Eddy Village Green
February 8, 2018 Certification/complaint Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 6, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure the care plan was evaluated for effectiveness and revised to include the changing goals and needs for one (1) resident (Resident #91) of five (5) residents reviewed for careplans. Specifically, for Resident #91, the Care Plan for Alteration in Elimination; Elder has an Indwelling Foley, was not revised after the elder pulled her foley out (indwelling urinary catheter) causing gross hematuria (blood in the urine). This is evidenced by: Resident #91: This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was severely impaired for cognition and sometimes understood others. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Medical Provider Note dated 11/14/17 at 1:50 pm, documented resident had gross hematuria which could be traumatic in nature as there may have been pulling by the resident. Foley flushes, and urine culture and sensitivity were ordered as resident is vulnerable to UTI's. Nurses Note dated 11/14/17 at 2:15 pm, documented the foley catheter was changed and flushed with 30 cc of normal saline due to hematuria.[MEDICATION NAME](an antibiotic) was started for 7 days. Medical Provider Note dated 11/15/17 at 9:43 am, documented the resident still had hematuria. Nurses Note dated 11/15/17 at 10:24 am, documented resident had multiple clots and discomfort and nurses had difficulty flushing the foley catheter. Bleeding was extensive around the foley despite it being changed this morning. Bleeding cannot be controlled with family agreeing to have resident sent to the hospital. Nurses Note date 11/15/17 at 2:58 am, documented resident had returned from the hospital. Foley was replaced and flushed. Nurses Note dated 11/15/17 at 8:31 pm, documented hematuria continued despite flushing once. Nurses Note dated 11/16/17 at 4:01 am, documented hematuria persists. Foley flushed as ordered. Health Status note dated 11/16/17 at 11:18 am, documented the resident continued with gross hematuria. Hemacrit and hemoglobin dropped since labs taken on 11/13/17 due to blood loss. Nurses Note dated 11/16/17 at 12:23 pm, documented the resident's family decided to send her back to the hospital. Health Status notes dated 11/18/17 at 4:08 pm, documented the resident returned from the hospital with temperature of 101.2. During hospital stay elder diagnosed with [REDACTED]. Hospice consult was recommended to the family. Health Status Notes dated 11/20/17 at 11:15 am, documented the urologist stated hematuria was caused by trauma from pulling foley catheter out. Family declined hospice services at this time. Care Plan of Alteration in Elimination, Elder has an Indwelling Foley Care Plan, revised on 12/09/17, revealed no documented evidence of the resident having pulled out her foley causing gross hematuria. There also was no documented evidence of an intervention to flush the foley catheter with 30 cc of normal saline every 2 hours as needed for hematuria, per physician's orders [REDACTED]. There also was no documented evidence that the care plan goal was updated. During an interview on 2/05/18 at 2:36 pm, Registered Nurse Manager (RNM) #5 reviewed the careplan and stated it should have been updated to include the resident's history of hematuria and intervention to follow the physician's orders [REDACTED]. RNM #5 stated using the Stat Lock, used to secure foley tubing to resident's upper leg, is in the standards of care. She stated the resident was wearing it when she pulled out her foley stating she's a pretty strong woman. 10NYCRR415.11(c)(2)(i-iii)

Plan of Correction: ApprovedMarch 8, 2018

Resident #91: CCP has been updated to reflect the history of hematuria and interventions for prevention.
All Elders have the potential to be affected by this deficiency. Education will be provided to all members of the CCP team regarding person-centered care planning and the importance of Elder-specific goals and interventions.
All care plans will be reviewed and updated to insure that they are Elder-specific.
16 care plans per month will be audited for 3 months and reported to the QAPI committee monthly to insure the care plan accurately reflects the Elder's current clinical status and that the CCP is Elder-specific. After three months, QAPI committee will determine need for future monitoring.
Responsible Party: Director of Nursing

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: February 8, 2018
Corrected date: April 6, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews during a recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 5 of 35 residents. Specifically, the facility did not ensure a person-centered care plan was developed for Resident #18 related to actual verses potential alteration in skin integrity for a deep tissue injury; for Resident # 173; communication care plan was not person-centered and Resident #180 actual elopement comprehensive care was not in place with interventions specific to prevent the chance of future elopements. Resident #18 The Resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented the resident as usually understood and usually understands, and severely impaired cognitively, as well as, a documented facility acquired unstageable pressure ulcer suspected of deep tissue injury. Wound care tracking dated 10/27/17, documented a suspected deep tissue injury to left heel. Wound care follow-up visit dated 12/20/17, documented left heel deep tissue injury, measuring 1cm x 1cm was improving and 12/26/17 documented deep tissue injury had resolved. Potential alteration in skin integrity care plan was initiated on 2/18/15 and revised on 10/27/17 related to the deep tissue injury to left heel, however, the focus of the care plan was not changed to reflect an actual alteration in skin integrity. The goal of the care plan documented skin will remain intact through next review, initiated on 2/18/ 15 and revised on 2/5/18. Of the interventions included in the care plan, there were two that were initiated on 10/27/17; blue padded pillow to end of bed against footboard to protect heels and transfer to recliner in living room after breakfast and lunch and do not elevate legs of recliner. The remaining interventions were all initiated in (YEAR) and (YEAR), including skin integrity standard of care. The skin integrity standard of care documented reposition every 2-3 hours, this was not included on the care card. During an interview on 2/6/18 at 11:16 am, Registered Nurse #1 stated the focus of the care plan should have documented an actual alteration in skin integrity and the goal of care plan should have reflected a measurable goal related to the deep tissue injury on the resident's heel. She also stated the interventions were not resident specific. Resident # 173 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented no speech, rarely/never understood and rarely/never understands and severely impaired cognitively. Alteration in communication care plan, initiated on 10/14/15, documented intervention as see communication standard of care, dated initiated 10/14/15. The Communication Standard of Care documented: 1) ensure access to and encourage use of hearing aide, 2) keep hearing aide in good working order, 3) break tasks into steps, 4) provide adequate response time, 5) alter environment to prevent sensory overload or deprivation as appropriate, 6) if resident does not understand, rephrase rather than repeat, 7) reinforce approaches with family, 8) speak slowly while facing resident, 9) ask simple yes or no questions, 10) speak into ear with the best hearing as needed, 11) seek information from regular caregiver that may be helpful in understanding gestures or phrases and 12) pair verbal interaction with gestures and object cues as needed. During an interview on 2/6/17 at 9:03 am the Director of Nursing stated the communication care plan should have been resident specific. Resident #180 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident with understanding others and being understood by others. The resident was assessed with [REDACTED]. The MDS also assessed the resident to have demonstrated wandering behaviors for 4-6 days of the look back period. Progress notes dated 1/18/18 documented the resident eloped house # 7 by holding down the exit bar of the front door. The Certified Nursing Assistant (CNA) reported the door alarmed immediately and the CNA followed the resident outside. The resident moved very quickly making his way down the side walk and to the parking lot. The Director of the Alzheimer's care unit saw the resident and CNA and convinced the resident to get into her car and drove him back to house #7. The Comprehensive Care Plans (CCP) documented no CCP specific to the issue of elopement. No entry could be identified for the use of the Global Positioning System (GPS) device the resident was wearing to determine the resident's placement should he elope again. No entry could be found for the frequency of checking the resident while in the house. During interview on 02/06/18 at 09:41 AM the Acting Registered Nurse Manager (RNM) of house #7 stated there was no CCP dealing with elopement. The RNM stated there should have been. The use of the Wander alert is an intervention under safety awareness care plan. The frequency of resident checks of every 30-60 minute checks was not written on a care plan or care card. Items in care card include interventions to keep the resident busy. The resident is also wearing a GPS tracking device that is in place should elope the house, after which the the nurses will call 911 to alert the police who will then come to the site and use the tracking device to find out exactly where the resident is . During interview on 02/08/18 at 8:58am, the Director of Nursing ( DON) stated elopement is incorporated into safety CCP including wanderguard and other areas in the CCP activities diversion. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedMarch 8, 2018

Resident # 18- opportunity to correct the care plan has passed - it reflects the current state of a healed injury and her current risk for alteration in skin integrity.
Resident #173-the safety care plan has been updated to reflect specific elopement risk and interventions, including the GPS device.
Resident #173 - the standard of care will be updated to delete # 10. In this instance, neither ear is better for Elder, rather, slow, clear speech facing the Elder is most effective. This strategy is also outlined in the standard of care.
Resident #180 - CCP safety section has been updated to reflect Elder's elopement risk and interventions in place.
All Elders have the potential to be affected by this deficiency. Education will be provided to all members of the CCP team regarding person-centered care planning and the importance of Elder-specific goals and interventions.
All care plans will be reviewed and updated to insure that they are Elder-specific.
16 careplans per month will be audited for 3 months and reported to the QAPI committee monthly to insure the care plan accurately reflects the Elder's current clinical status and that the CCP is Elder-specific. After three months, QAPI committee will determine need for future monitoring.
Responsible Party: Director of Nursing

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: February 8, 2018
Corrected date: April 6, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that foods time/temperature controlled for safety (TCS foods), formerly identified as potentially hazardous foods, be cooled to 41 degrees Fahrenheit (F) within 6 hours provided the food is cooled from 135F to 70F within the first two hours of cool. Specifically, in 15 of 16 residential houses, TCS foods were not cooled safely, food contact and non-food contact surfaces and floors were not clean, and/or cabinetry was in disrepair. This is evidenced as follows. Observations on 01/30/2018 revealed that at 10:49 am, roast turkey cooling in the House 7 refrigerator was 85F; at 11:07 am roast turkey in the House 5 refrigerator was 54F; and roast turkey cooling in the House 8 refrigerator was 61F. On 02/01/2018 at 2:12 pm, baked ziti cooling in the House 1 refrigerator was 113F. Observations on 01/30/2018 from 10:49 am through 11:26 am and again on 02/01/2018 from 1:34 pm through 2:57 pm revealed that in Houses 1, 2, 3, 4, 5,6, 7, 8, 10, 12, 14, 16, 19, 21, 22, and 24 microwave ovens, electric hand mixers, cabinets, electric timers, gaskets on refrigerator or freezer doors, and/or floors under refrigerators were soiled with food particles or dust. In Houses 5, 12, 14, and/or 16 the laminate interiors of cabinet were peeling and/or the doors to cabinetry would not close shut. The Food Service Director stated in an interview conducted on 02/01/2018 at 3:03 pm based on the findings above he will review cooling procedures with staff and that the established cleaning process needs to be more closely monitored to ensure it is followed. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.40(b), 14-1.110, 14-1.170

Plan of Correction: ApprovedMarch 8, 2018

Cooling of food: All food that was not cooled correctly was discarded during survey.
This deficiency has the potential to impact all Elders on campus.
Training will be provided to all Shahbazim related to proper food cooling. Facility procedure has been modified including all food storage containers used for cooling will be 2 quarts or smaller.
Audits will be conducted in all 16 houses weekly for four weeks. Any houses at 100% compliance will be audited monthly for three months. Any house below 100% compliance will continue to be re-educated and audited weekly until they reach 100% compliance and then will be audited monthly for 3 months.
Responsible Party: Manager, Dining Services
Sanitation: The areas identified during inspection have been cleaned.
This deficiency has the potential to impact all houses and Elders.
Shahbazim will be re-educated to cleaning protocols and schedules. Cleaning under refrigerators have been added to the Housekeeping Dept. cleaning schedule.
Weekly audits will be conducted in all houses for sanitation and reported to QAPI committee monthly for three months. QAPI committee will recommend future audit frequency.
Responsible Party: Manager, Dining Services
Kitchen cabinetry: An audit is being conducted and repairs underway. Replacement cabinet doors will be ordered as needed.
Responsible Party: Manager, Facilities

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: February 8, 2018
Corrected date: April 6, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews during a recertification survey and complaint (NY 842) investigation, the facility did not ensure an environment that was free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents for 3 (#67, #148, #173) of 9 residents reviewed. Specifically, for Resident # 67 the facility did not take adequate precautions to prevent an elopement; for Resident #148 the facility did not provide identification of the correct diet order to prevent the resident from choking and for Resident #173, the facility did not ensure the head of his bed was maintained at 45 degrees, at all times, per physician's orders [REDACTED]. This was determined by: Resident #67 Resident # 67 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident was usually able to understand, usually understood, had severely impaired cognitive skills, a wander/elopement alarm was used daily and wandering behavior occurred 1-3 days during the assessment time period. Incident Report documented a video was watched to determine the sequence of events leading to the elder's elopement on 10/30/17. At 4:25 pm 3 Shabazz were in the house, 1 in the kitchen preparing dinner and 2 in elder's rooms. The elder walked directly to the front door and held the crash bar for 15 seconds to gain egress to the outside. A Shabazz came into the living room to close the shades, noticed the elder outside and instantly went out to bring her into the house. The elder was outside unattended for 40 seconds. Front door crash bar was tested after the incident and it did make an audible buzz as it was designed to do but it was not heard by staff inside the house. The I & A summary also documented, review of recent wander risk assessment indicated resident was indeed a candidate for a wander tag but one was not applied. The Wander Assessment documented if answer to A is yes, any additional yes response increases risk for wandering or exit-seeking behavior, so institute/modify care plan to reflect findings. On the Wander Assessments completed on 9/5/17 and 6/5/17 the answers to A and 5/6 questions were yes, however, a wander tag was not initiated. Employee statements obtained by the facility during their investigation documented the following; Shabazz #1 reported she was in bedroom [ROOM NUMBER], no mention of hearing the alarm. Shabazz #2 reported she was closing living room window shade and saw resident outside No mention of hearing the alarm. Shabazz #3 reported she was in the kitchen, no mention of hearing the alarm. The LPN reported she was coming into house through the back door, saw elder and Shabazz walking toward back door from front of house. Alarm to front door was sounding. During an interview on 1/31/18 at 10:08 AM Shabazz #1 reports she was in room [ROOM NUMBER] with the door closed, helping an elder. She did not hear the alarm. When alarm is heard all staff should check the doors and check all elders. Upon request, Shabazz #1 opened the front door to set off alarm, although it was not loud, it could be clearly heard from the kitchen, dining room and living room areas of the house During an Interview on 02/08/18 at 08:53 AM with the facility Administrator and DON. It was reported that immediately after the incident the door alarm was tested and it did sound as it should. Both believe the staff did not hear the alarm due to noises in the house (television, blender, kitchen noises). Maintenance checked the alarm and the volume could not be turned up and no other actions were attempted to modify the door alarm system. Both the Administrator and DON agree they could further pursue increasing the volume of the alarm. The DON reported that all wander assessments were reviewed for accuracy and new protocols were implemented, although she did not believe the nurse assessing the resident for elopement risk was negligent for not putting a Wanderguard on because the resident had never attempted or verbalized desire to leave the facility. Resident #148 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 6/30/17 assessed that the resident understands, was understood and had severely impaired cognitive ability. It identified the resident needed supervision and set up help for eating. A Nurses Note on 7/21/17 at 11:48 pm documented the Elder was at a luncheon in Building 300 when she took a drink of water and began coughing forcefully. When writer arrived, the Elder was sitting in the hallway stating something was stuck in her throat. Lung assessment was moist and crackles. Elder continued to cough and follow directions to deep breathe. She leaned forward and I did some cupping to her back and she continued to cough up moist clear thick secretions. At 1:55 pm Elder was brought back to the house And the SLP (Speech Language Pathologist came and said there was definitely solid in the Elders esophagus. Suction was done with clearing noted. The Elder stated she did not feel anything in her throat. The Accident and Incident (I and A) Report of 7/21/17 documented the elder was at a luncheon in Building 300 and began coughing forcefully. Reported feeling as though something was stuck in her throat. Speech Therapist was called for assistance. The Elders airway was clear, she was breathing normally, but a food bolus was palpated in her throat. Speech Therapist, Registered Nurse(RN) and Physician Assistant (PA) discussed suction of food bolus or send to emergency room . Suctioning provided and the food bolus was successfully cleared. The Investigation Summary started on 7/21/17 documented: The Elder was transported by the house Guide to the Culinary Luncheon. The Elder was served a regular diet. The Elder was being supervised and shortly after the Elder started eating she started coughing. The RN at the luncheon went to assist the Elder and the House RN was called to come assist. The Elder was coughing and had increased mucous secretions, but was able to maintain her airway and continue to talk. The Elder was noted to be served the incorrect diet. The Elder is on a modified diet (NDD3), all meats should be ground. At the luncheon the Elder received chicken cut into small pieces. The Guide failed to communicate to the Culinary Instructors or Servers at the luncheon that the elder needed to be served a NDD3 diet which requires all meat to be ground. The house RN noted the elder to be occasionally coughing. The house RN percussed the Elder's back and the elder was able to expectorate mucous with noted flecks throughout the secretions. The Speech Language Pathologist assessed the Elder was coughing due to food being stuck in her throat. The house RN provided oral suctioning. The Elder tolerated it well. Food particles were suctioned along with mucous and the remaining food appeared to be cleared from her throat. During interview on 1/31/18 at 8:00 am the Director of Nurses (DON) said the role of House Guides was like a nurse manager, they do the schedule, have other duties and the specific Guide was also an educator for house culture. She stated dietary was at other food activities to help guide the diets for the Elders, but they are not at the Culinary Luncheon. She stated the Shabbaz go through a week of culinary training, when they finish they hold a luncheon. She stated there was no process in place prior to the luncheon (on 7/21/17) to ensure appropriate diets were served; since then they have a specific written procedure. During interview on 2/6/18 at 4:10 pm the Food Service Director (FSD) said during the incident with the Elder he did ask the Guide if the resident had any diet restrictions and she said no. The FSD stated that they relied on verbal confirmation from the person bringing the resident to the Luncheon; because there was no written process to follow. For the Luncheons it was usually a staff member in the class who would bring the Elder to the luncheon; this was an unusual circumstance. The FSD stated it was their expectation that anyone bringing an Elder to a food function would check the swallow guide and diet roster (Information on the diet the Elder needed) for that Elder. During interview on 2/7/18 at 9:57 am the Guide, who had brought the Elder to the luncheon, stated she should have looked at the swallow guide for the Elder before bringing her to the luncheon, but did not. She stated now they must bring the actual paperwork to the luncheon for the Elder. Resident #173 The Resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented no speech, rarely/never understood and rarely/never understands, and severely impaired cognitively and extensive assistance with eating. On 1/30/18 at 1:58 pm, observed Licensed Practical Nurse (LPN) #2 leaving resident's room after administering medications, upon immediate entry to room, the head of the bed was positioned at approximately 25-30 degrees and resident had fluid in his mouth that was drooling out the left side of his mouth. Observed a sign at the head of the resident's bed that documented: HOB (head of bed) at 45 degrees at all times. Reported to staff, Shabaz (Certified Nursing Assistant) immediately entered the room and put the HOB up to 45 degrees and encouraged the resident to swallow what was in his mouth. Resident spit out liquid into a washcloth. Medical order dated 3/29/17 documented head of bed at 45-degree angle, at all times. Diet order dated 8/3/17 documented regular diet, mechanical soft texture and nectar consistency. Care card in the resident's closet documented elevate head of bed at 45-degree angle at all times. Care plan, initiated 3/29/17, documented impaired breathing as evidence by dyspnea as the focus and will be comfortable with breathing as the goal of the care plan. The interventions were 1) to elevate head of bed at 45-degree angle, at all times and 2) offer emotional support and reassurance as necessary. During an interview on 1/30/18 at 2:11 pm, Shabazz #1 stated she put the resident back to bed at approximately 1 pm. When asked who is responsible to be sure the head of the bed is positioned at 45 degrees she stated: I guess we are, meaning the Shabaz. During an interview on 1/30/18 at 2:14 pm, LPN #2 stated the head of the bed needs to be at least 45 degrees for the resident so he won't choke and he does tend to keep food and fluid in his mouth. She stated that next time she will be sure the HOB is at 45 degrees and have him open his mouth to be sure he has swallowed all the liquids administered. 10 NYCRR 415.12(h)(2)

Plan of Correction: ApprovedMarch 8, 2018

Resident #67: After the elopement, the Elder had a wander tag applied. This deficiency was identified as a risk to all Elders on campus. All Elders were re-assessed for elopement risk after all RNs received re-education to completing the elopement assessment.
Resident #148: Opportunity for correction has passed, although corrective action was issued to the staff member who served the Elder the regular diet and she was re-inserviced.
This incident has the potential to affect all Elders attending culinary luncheons.
On 7/21/2018 changes were made to improve the process for safety for culinary luncheons. Staff escorting Elders to luncheon are required to bring a copy of the Diet Roster and Swallow Guide to the luncheon. There have been no further incidents at the culinary luncheons.
This process will be audited for the next three culinary luncheons and reported to the QAPI committee following the luncheon. QAPI committee will determine the need for future auditing.
Responsible Party: Manager, Dining Services
Resident # 173: The staff member was re-educated to the instructions for Resident # 173 and the standard of care for medication administration and HOB elevation. This issue has the potential to impact all Elders.
All nursing staff and Shahbazim will be re-educated to maintain the head of the bed at 45 degrees for administration of medications and per care plan instructions.
Visual audits will be done in weekly in at least four houses for four weeks (covering all 16 houses). Results will be reported to the QAPI committee, who will determine the need for continued auditing depending on the results reported.
Responsible Party: Director of Nursing

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 6, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during a recertification survey, the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection in 4 of 16 houses inspected. Specifically: 1. The facility did not ensure infection control was maintained during the performance of a glucose monitoring procedure. 2. The facility did not ensure proper infection control practices were maintained while administering eye drops to a resident. 3. The facility did not ensure proper disposal of a used insulin syringe. 4. The facility did not ensure hand hygiene was consistent with accepted standards of practice. This is evidenced by: Testing Procedure Policy for performing Blood Glucose (BG) dated 12/2/15 documents: 1. Wash hands and or disinfect with alcohol gel. Apply clean gloves. 3. Wash resident's hands with soap and water if soiled and dry completely, use an alcohol wipe to clean the fingertip, allow to air dry completely. 12. Place lancet on the side of the resident's finger. 13. Activate lancet. Dispose of the used device in the Sharps container. 17. Touch the tip of the test strip to the drop of blood. 19. Remove test strip dispose of it in sharps container. Procedure notes documented: Clean the meters after each resident use with a disinfectant wipe. Finding # 1 House 2 During observation on 02/06/18 at 11:43 am, the Licensed Practical Nurse #1(LPN) was performing a finger stick (FS) on elder # 9, using a multi-use glucometer (a machine used to test blood glucose (BG) level). She placed items needed for testing (glucometer with strip inserted, open alcohol prep pad, and tissue) on the Elder's chair. No barrier was used. She donned gloves, performed the procedure, touching the elders hand and the back of the elder's chair. Without removing the gloves, she placed the glucometer on the top of the medication cart before cleaning it, opened the medication cart, disposed of the lancet and test strip in the sharps container, inside the drawer, by picking up the sharps container and setting it back down in the drawer that contained other supplies. She then removed her gloves. No cleaning of the medication cart or top of the cart was observed before returning it to the medication room. During interview on 02/06/18 at 11:58 am, LPN #1 stated she should have removed her gloves and sanitized her hands before going into the medication cart. She she should have put a paper towel or tissue on the medication cart before setting the glucometer on the cart. During interview on 02/07/18 at 09:30 am, the Registered Nurse Staff Educator (RNSE) stated following the infection control procedure while performing a BG, using the multiple use glucometer, is taught to every nurse when hired and reeducation done annually. Maintaining infection control is very important especially with multiple use equipment. The nurse performing the procedure should clean the glucometer before placing it on the medication cart or clean the surface where it was placed after words. Once the Elder's FS was done, the LPN's gloves should have been removed and hands sanitized before getting anything out of a medication cart. She stated once the glucometer is brought in the Elder's room it is considered contaminated and needs to be cleaned. During interview on 02/07/18 10:30 am, the Infection Control Registered Nurse (ICRN), stated LPN # 1 should have removed the sharps container from the medication cart before performing the FS, or removed the soiled gloves and sanitized her hands before going into the cart to dispose of the used lancet and test strip. Finding # 2 House # 16 Medication Administration: Eye Drops policy and procedure, dated 10/07, documented use a tissue to remove excess drops on the resident's face and use a new tissue if drops are needed in the other eye. During observation on 1/30/18 at 10:43 am, Licensed Practical Nurse #2 (LPN) donned clean gloves and administered eye drops into each eye of an Elder. She gave the Elder one tissue to wipe both eyes. LPN #2 then poured the Elder a glass of water without removing gloves. She then administered another set of eye drops, using same tissue and then removed gloves and sanitized hands. During interview on 1/30/18 at 10:46 am, LPN #2 did not recognize the infection control issue concerning the use of the same tissue for both eyes; after explanation, she recognized water pitch handle was contaminated because she did not remove her gloves and wash her hands after the administration of the first set of eye drops. Finding #3 During observation on 2/6/18 at 11:35 am, a used insulin syringe was found laying on the counter in the nurses office. The needle was retracted in its sheath but not capped. During interview on 2/6/17 at 11:36 am LPN # 4 stated she got distracted and left the syringe there. During interview on 02/07/18 10:30 am, the ICRN, stated that all sharps (example: syringes and lancets) should be disposed of immediately before leaving the elders room in the sharps container. She stated there were sharp containers in the medication cart. There should be no reason for a used syringe to be left on a counter anywhere for any reason. Finding #4 House #14 The Facility's Policy and Procedure on Hand Hygiene, revised 1/22/18, documented hands should be washed before donning gloves and after removing gloves, between elder contact, handling contaminated items and after contact with medical equipment in the elders' room. The Policy documented to cleanse hands as promptly and thoroughly as possible between patient contacts and after contact with potentially contaminated equipment or environmental surfaces. During observation of a medication pass on 02/01/18 at 8:15 am, the Registered Nurse (RN) #1 began by opening the elder's medication cabinet and pouring the medication without first washing her hands. She placed the medication in the elder's cabinet and without washing her hands, proceeded to another elder's room where she opened the medication cabinet and poured the medication. She opened a [MEDICATION NAME] ER capsule, did not wash her hands, and poured the medication. She then returned the medication to the cabinet in the room. RN #1 went to the medication room, opened the narcotics cabinet for two medications. Without washing her hands, the RN gave the elder her narcotic medication. The RN did not perform hand hygiene during the medication process. She then returned to the first elder's room, opened the medication cabinet without first washing her hands, opened a capsule of neurotin, washed her hands and gave the elder her medication. During an interview on 2/06/18 at 8:50 am, RN #1 stated she should have washed her hands during the medication pass of the two elders. During an interview on 2/06/18 at 11:40 am, Registered Nurse Manager (RNM) #2, stated nurses should use the hand sanitizer before they start the medication pass and in between elders. She stated, if the nurses go into the medication room, they should wash their hands before leaving. She stated the nurses know they are supposed to wash their hands. During an interview on 2/07/18 at 9:40 am, the Infection Control Preventionist, who is the Assistant Director of Nurses (ADON), stated staff have been placed on heightened awareness to perform hand hygiene and to use standard precautions. She is re-evaluating new procedures for inservicing staff on policy and procedure for performing hand hygiene. Finding #5: House #22 During an observation on 02/06/18 at 11:55 am, RN #3 administered a tube feeding for to an elder. Without washing her hands or wearing gloves, she checked for placement by listening for installation of air and drawing syringe back for residual. She then donned gloves without washing her hands and proceeded with priming the pump and starting the tube feeding. She changed gloves without washing her hands and applied [MEDICATION NAME] to the elder's face. She took off her gloves checked the elder for itchiness and replaced her clothes before finally washing her hands. During an interview on 2/06/17 at 12:10 pm, RN #3 stated she should have washed her hands after changing gloves and stated she usually wears gloves when she checks for placement. During an interview on 02/06/18 at 3:25 pm, RNM #4 stated handwashing or using hand sanitizer should take place before and after hanging tube feed. The RN stated nurses should err on side of caution and use hand sanitizer throughout the procedure. 10NYCRR415.19(b)(4)

Plan of Correction: ApprovedMarch 8, 2018

LPN#1 will be re-educated to all of the deficient infection control processes identified by the surveyor.
LPN # 2 will be re-educated to all deficient practices identified by the surveyor.
LPN # 4 will be re-educated regarding appropriate disposal of syringes
RN #1 will be re-educated regarding the handwashing policy.
RN #3 will be re-educated regarding the handwashing policy
This deficient practice has the potential to impact all licensed nurses.
All licensed nursing staff will receive education to appropriate infection control practices.
Visual audits will be performed by nursing management staff to observe inflection control practices found deficient during survey. 16 observations per month will be performed and results will be reported to the QAPI committee for 3 months. Further monitoring will be determined by the QAPI committee.
Responsible Party: Assistant Director of Nursing/Infection Control Specialist

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 6, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey, the facility did not maintain drugs and biologicals labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary standards, and expiration date when applicable for 7 of 16 nursing units (houses) inspected. Specifically, inspection of medication storage cabinets located in the resident rooms revealed a number of expired (outdated) medication whose expiration date had expired. Additionally, the facility did not ensure the safe and secure storage of medications with 2 observations of medication carts being unlocked and unattended. In House 21 there were unlabeled eye drops in the medication cart. This is evidenced by the following: Finding #1: House 7 On 1/31/18 at 2:48pm, the medication cabinet storage areas of House 7 rooms 2, 4, 9, and 11 revealed the following: [MEDICATION NAME] 3 milligrams (mg) expired 8/20/17. [MEDICATION NAME] 5 mg. expired expired 9/22/17. [MEDICATION NAME] 50 mg. expired 12/25/17. [MEDICATION NAME] 3 mg. expired 11/2017. Vitamin D 3 expired 9/5/17. The Licensed Practical Nurse stated she would discard the medications or return to the pharmacy for a credit. Finding #2: House 5 On 2/6/18 at 10:23AM the medication cabinet storage area of House 5 room [ROOM NUMBER] revealed: [MEDICATION NAME] extended release 5 mg expired on 11/25/17. The Licensed Practical Nurse stated she would discard the medications or return to the pharmacy for a credit. During interview on 2/8/18 at 9:00am the Director of Nursing (DON) stated medications when they are being administered should be checked for the expiration date. The DON stated that if the medications are expired they should be removed and discarded or returned to the pharmacy for credit if available. The night shift is responsible for auditing for expired medications and removing from the medication storage cabinet. Finding #3: House 12 On 1/31/18 at 10:35am the medication cart was observed unlocked and unattended. A bottle of Senna (laxative) was observed on the top of the medication cart. During interview on 1/31/18 at 11:10am LPN #3 stated she should not have left the medication cart unlocked and unattended. Finding # 4: House #2 During an observation on 2/06/18 at 11:30 am, in House 2, the medication cart was found to be unlocked and unattended in the hall between the nurses office and in the room to right of front door. LPN #1 was in the room with an elder. During an interview on 2/06/18 at 11:35 am, LPN#1 stated the elder was yelling and she should have locked the medication cart before attending to the elder. During an interview on 02/06/18 at 03:35 pm, Registered Nurse Manager (RNM) #4 stated the medication cart should always be locked if not within eye sight. Finding 5: House 21 During observation on 2/6/18 at 12:30 pm, in House 21, the medication cart had 3 bottles ([MEDICATION NAME]) of unlabeled eye drops which were out of their boxes. There was a fourth bottle of unlabeled eye drops out of its box in a corner of the Medication Cart. During interview on 2/6/18 at 12:32 pm the House LPN #4 stated the bottles of eye drops were for the Elder in room [ROOM NUMBER]. She said she did not know who the fourth bottle of eye drops belonged to. During interview on 2/6/18 at 12:33 pm the RNM #4 stated the eye drops should not be in the medication cart unlabeled. 10NYCRR 415.18(e)(1-4)

Plan of Correction: ApprovedMarch 8, 2018

All med cabinets were audited and all expired medications discarded.
This deficiency has the potential to impact all residents.
Medication storage areas will be inspected monthly and expired medications appropriately discarded.

All medication bottles will be kept in their properly labeled boxes. Nurses will receive re-education to these expectations.
Audits will be conducted on 16 medication and treatment cabinets and 4 med rooms monthly and reported to QAPI for three months. The need for additional auditing will be determined by the QAPI Committee.
Responsible Person: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 6, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not protect the cooking facilities in in accordance with the adopted regulations. NFPA 101 Life Safety Code 2012 Edition section 19.3.2.5.3(5)(a) requires that residential cooking equipment used to prepare meals for 30 or fewer persons shall be permitted to be open to the corridor provided that the cooktop is protected with a fire suppression system listed in accordance with UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Commercial Cooking Equipment, or is tested and meets all requirements of UL 300A, Extinguishing System Units for Residential Range Top Cooking Surfaces, in accordance with the applicable testing document's scope. Specifically, meals were prepared utilizing cooktops not located under required automatic fire suppression systems. This is evidenced as follows. Observations in House 14 on 01/30/2018 at 9:55 am revealed that pancakes were being prepared on a residential portable griddle in the kitchen center island countertop. Automatic fire suppression was not provided over the griddle. Shabaz #8 stated in an interview conducted on 02/07/2018 at 12:35 pm that on the occasion when elders request pancakes for breakfast, the pancakes are cooked on a portable griddle placed on the kitchen center island. Shabaz #9 stated in an interview conducted on 02/07/2018 at 12:35 pm that on the occasion when elders request pancakes for breakfast, the pancakes are cooked on a portable griddle placed on the kitchen center island. Shabaz #10 stated in an interview conducted on 02/07/2018 at 12:35 pm that on the occasion when elders request pancakes for breakfast, the pancakes are cooked on a portable griddle placed on the kitchen center island. Observations on 02/07/2018 in the late morning through the early afternoon revealed that no automatic fire suppression is provided over the kitchen center islands. 42 CFR 483.70(a)(1); 2012 NFPA 101 19.3.2.5.3(5)(a)

Plan of Correction: ApprovedMarch 8, 2018

House 14 staff has been educated to only use the griddle under the fire suppression hood.
This deficiency has the potential to impact all houses.
All Shahbazim will be re-educated to use all heat-producing cooking equipment (griddles and waffle makers for example) only directly under the kitchen hood, where the fire suppression system is located.
Visual audits will be conducted during meal times and reported to the QAPI committee monthly for three months. The QAPI committee will determine the need for further auditing.
Responsible Party: Manager, Dining Services

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: February 8, 2018
Corrected date: April 6, 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 99 Standard for Health Care Facilities 2012 Edition section 10.2.3.6 and The Centers for Medicare and Medicaid Services notice from the Director of the Survey and Certification Group S&C 14-46-LSC permits the use of Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL -1 to power patient care-related electrical equipment and Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment. Specifically, non-compliant power strips were used to power non-patient care electrical devices in patient care areas in 3 of 35 rooms observed. This is evidenced as follows. Observations on 02/07/2018 at 10:00 am revealed that personal electronics were powered with non-compliant power strips in resident rooms [ROOM NUMBER]. The Facilities Manager stated in an interview conducted on 02/07/2018 at 1:30 pm that power strips are not allowed in elders' rooms and Shahbaz are to notify maintenance housekeeping when found. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.3.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedMarch 8, 2018

The extension cords found during survey were removed or replaced with UL1363-compliant power strip.
This deficiency has the potential to impact all resident rooms.
Shahbazim will be re-educated on the need to report the presence of extention cords or power strips to the Facilities Dept.
All Elder rooms will be inspected for the presence of non-compliant power strips and any noncompliant strips will be removed or replaced with UL1363- compliant strips.
Monthly audits of 16 resident rooms per month will be completed and reported to the QAPI committee monthly for three months. The QAPI committee will determine the need for further auditing.
Responsible Party: Manager, Facilities

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: Widespread
Severity: Potential to cause minimal harm
Citation date: February 8, 2018
Corrected date: April 6, 2018

Citation Details

Based on employee interview and record review during the recertification survey, the facility did not develop maintenance protocols in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition Section 10.5.6 requires that records and a log shall be maintained of the tests and associated repairs or modifications of all patient-care electrical equipment. Specifically, the facility did not record all testing and repairs for all patient-care related electrical equipment. This is evidenced as follows. The facility maintenance policies and records were reviewed on 02/08/2018. A log of tests for every PCREE was not available for survey review. The Director of Clinical Engineering stated in an interview conducted on 02/08/2018 at 9:30 am that the facility has inspected and tested all PCREE in accordance with NFPA 99 but has not generated test records, only repair records for these devices. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.5.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedMarch 7, 2018

A log will be developed and maintained for each PCREE to track all inspections and repairs.
This deficiency has the potential to impact all PCREE on campus.
Status of the log will be reported to QAPI for three months. The need for further monitoring will be determined by the QAPI committee.
Responsible Party: Manager, Facilities

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: February 8, 2018
Corrected date: April 6, 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 training program did not include training in emergency preparedness policies and procedures to volunteers, consistent with their expected roles. This is evidenced as follows. A review of the Emergency Plan on 02/05/2018 revealed the training program did not include training in emergency preparedness policies and procedures to volunteers, consistent with their expected roles. The Administrator and Facilities Manager stated in an interview conducted on 02/05/2018 at 12:30 pm that the Emergency Plan will be revisited and revised to include training in emergency preparedness policies and procedures to volunteers. 42 CFR: 483.73(d)(1)(i)

Plan of Correction: ApprovedMarch 8, 2018

This deficiency impacts all(NAME)Village Green volunteers.
Training will be provided to all active volunteers regarding their roles and responsibilities in the Emergency Preparedness plan. Going forward, training will be included in the new volunteer orientation and provided to volunteers annually.
A report will be made to the QAPI committee in (MONTH) (YEAR), and placed on the QAPI calendar annually.
Responsible Party: Manager, Therapeutic Recreation

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: February 8, 2018
Corrected date: April 6, 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 communication plan of the Emergency 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 02/05/2018 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 02/05/2018 at 12:30 pm that the Emergency Plan has not been communicated to residents or their families. 42 CFR: 483.73(c)(8)

Plan of Correction: ApprovedMarch 8, 2018

A brochure describing the Emergency Preparedness plan will be developed and sent to all family members. Going forward, it will be included in the Admission packet of information provided to family members.
A report will be made to the QAPI committee in (MONTH) (YEAR), and placed on the QAPI calendar annually.
Responsible Party: Administrator

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 6, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition section 8.6.5.1.2 permits particular limitations on obstructions to the sprinkler system discharge pattern. Specifically, the automatic sprinkler system was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows. Observations of the sprinkler system was conducted on 02/07/2018 at 1:00 pm and again on 02/08/2018 at 11:30 am revealed that light fixtures obstructed the automatic sprinkler spray area in the Standish Community Center storage closet and the House 10 pantry. The Facilities Manager stated in an interview on 02/07/2018 at 1:30 pm that noting the sprinkler obstructions, he will move the lights in the Community Center closet. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.5.1.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-13.3.2

Plan of Correction: ApprovedMarch 7, 2018

The lights in the Standish community building and House 10 pantry have been relocated.
This deficiency could impact all house pantries.
House pantries will be assessed to look for sprinkler obstructions and lights moved where necessary.
A report will be provided at the (MONTH) QAPI committee summarizing the findings and corrective actions.
Responsible Party: Manager, Facilities

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: February 8, 2018
Corrected date: April 6, 2018

Citation Details

Based on staff interview and review of inspection records during the recertification survey, the automatic sprinkler system was not tested and maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 edition section 5.3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Section 4.3 requires that records shall be made for all inspections, tests, or maintenance; the organization that performed the work; the results; and the date. Specifically, no records were maintained documenting that the sprinkler system gauges were replaced or checked for calibration in the past 5 years. This is evidenced as follows. The sprinkler system inspection records for building 9 (Standish Community Center) and House 12 dated from 02/07/2013 through 11/22/2017 were reviewed on 02/08/2018. No records were available documenting that the sprinkler system gauges were replaced or checked for calibration during this 5-year period. The Facilities Manager stated in an interview conducted on 02/08/2018 at 12:00 pm that no building sprinkler system gauges were checked or replaced within the past 5 years but the sprinkler system testing company is currently on-site to replace the gauges. 2012 NFPA 101 9.7.5; 2011 NFPA 25 4.3, 5.2.1.1.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.6; 1998 NFPA 25 1-8, 2-2.1.1, 2-4.1.8

Plan of Correction: ApprovedMarch 7, 2018

The Standish community Center and House 12 sprinkler system gauges have been replaced.
This deficiency has the potential to impact all buildings.
The gauges for the entire sprinkler system in all buildings have been replaced. A sticker will be added with the replace date in the future.
A formal report will be presented to the QAPI committee in (MONTH) (YEAR).
Responsible Party: Manger, Facilities

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 6, 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 in mechanical rooms were not continuous and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. Observations on 02/07/2018 at 10:00 am revealed unsealed holes and penetrations in the rated ceilings in the mechanical rooms in Houses 08, 10, 12, 16, 19, and 22 The Facilities Manager stated in an interview conducted on 02/07/2018 at 1:30 pm that he will seal the holes found in the ceilings. 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: ApprovedMarch 7, 2018

The unsealed holes have been rectified in the areas noted during survey.
This deficiency has the potential to be found in all mechanical rooms.
All mechanical rooms have been checked and patched where needed
Mechanical rooms will be inspected monthly for three months and reported to the QAPI committee. The QAPI committee will determine the need for further reporting.
Responsible Party: Manager, Facilities