Cortland Park Rehabilitation and Nursing Center
August 23, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: (a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 25, 2017
Corrected date: October 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not provide the necessary services to maintain good nutrition and eating ability for 2 of 16 residents (Residents #4 and 6) observed for activities of daily living (ADLs). Specifically, Residents #4 and 6 required staff assistance for eating and were observed not receiving assistance. Findings include: 1) Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severe cognitive impairment, experienced symptoms of disorganized thinking and inattention, was non-ambulatory, and required extensive assistance with eating. The resident had a significant weight loss of 5% or more in the last month or 10% or more in the last 6 months, had a mechanically altered diet, and was at risk for skin impairment. The comprehensive care plan (CCP) updated 6/18/2017, documented the resident had limited ability to maintain activities of daily living (ADLs) related to cognitive and physical deficits and required assistance of one person for eating. The nutrition care plan updated 8/17/2017, documented the resident was at risk for weight loss/dehydration, was on a pureed diet, was to have fluids encouraged, and intakes monitored. A nutrition services note dated 8/10/2017, documented the resident triggered for a significant weight loss and her nutritional supplement was increased. Nursing progress notes dated 8/17 and 8/18/2017 documented the resident did not communicate her needs and staff were required to feed the resident as well as provide verbal cues during meals as she would only sit and look at her food. The following observations were made of the resident in the dining room on 8/21/2017: - At 6:09 PM the resident was reclined in her geri chair (a chair for positioning), facing sideways to the table. Two 8 ounce (oz) cups of liquid, 3 small bowls, covered with plastic lids, and a plate of pureed food were at her place at the table. A staff member was feeding the resident seated next to Resident #4. - Between 6:09 and 6:52 PM, the resident had not received assistance and had not attempted to feed herself. Licensed practical nurse (LPN) #15 was observed walking around the dining room with a clipboard and looking at each resident's meal, including Resident #4. - At 6:52 PM, a dietary aide removed the food items from the resident's place at the table and did not speak to her. The food and drinks had not been touched, the flatware remained clean and unused. - At 7:15 PM, 3 residents at the table were eating ice cream and Resident #4 did not have ice cream. LPN #11 was observed standing next to the resident. The vitals report for meal and fluid intake for 8/21/2017, documented the resident consumed 1-25% of her dinner. The Point of Care report (details the level of resident participation and staff assistance for ADLs) documented on 8/21/2017, the resident ate independently with supervision and set-up assistance during the evening shift. During an interview with LPN #11 on 8/21/2017 at 7:16 PM, she stated the resident needed to be fed by staff and she was unsure of the reason the resident had no ice cream. The following observations were made of the resident in the dining room on 8/22/2017: - From 12:17 PM to 12:52 PM, the resident received her meal and she made no attempt to feed herself, received no assistance from staff, and was not approached by any staff. - At 12:52 PM, an unidentified staff sat to feed the resident and the food was not reheated. At 12:57 PM the unidentified staff left the resident and CNA #10 sat to feed her. CNA #10 offered her one bite of food, which was refused, and he left the table. He returned at 1:12 PM, offered the resident some milk and left the table. - At 1:22 PM, the resident's dishes were removed. She had consumed a very small portion of her food (bites) and 2-3 oz of liquid from each of her two cups. During an interview with CNA #10 on 8/22/2017 at 1:55 PM, he stated the resident needed to be fed at times and was unaware how long her food was there before feeding her. He stated residents should be fed shortly after they receive their meals and all staff in the dining room were supposed to help residents who need assistance with feeding. When interviewed on 8/25/2017 at 10:20 AM, the Assistant Director of Nursing (ADON)/acting Unit Manager stated the resident needed to be fed by staff, and should be reassigned to the table where more residents who need assistance were seated. She stated, regardless of seating it was unacceptable she was not fed, all staff are responsible to assist in the dining room, and her food should have been reheated. 2) Resident #6 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 7/28/2017 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required assistance of 1 staff for eating. The comprehensive care plan (CCP) dated 11/17/2016, documented the resident was on a mechanical soft diet and required set-up assistance for eating. Interventions included to encourage to feed self and toilet more frequently due to increased incontinence. The resident profile (certified nurse aide care instructions) documented to provide extensive assistance of 1 staff with meals. The resident was observed in the dining room on 8/22/2017 and did not receive assistance with her meal from 12:15-1:15 PM. On 8/23/2017 the resident was observed with scrambled eggs and pancakes on her plate, a bowl of oatmeal and 3 cups with liquids. No assistance with eating was provided from 10:40- 11:38 AM when the food was removed. At 12:20 PM the resident remained sitting at the table and received her lunch tray. During an interview with CNA #10 on 8/22/2017 at 1:20 PM, he stated the resident ate slow and could feed herself. He stated staff should be assisting residents not long after they receive their meal. He stated he was unaware of how long her food had been sitting on her plate. During an interview with CNA #24 on 8/25/2017 at 9:40 AM, she stated the resident could feed herself, was a slow eater and needed verbal cueing. She stated all of the aides were responsible for making sure residents got fed. 10NYCRR 415.12(a)(3)

Plan of Correction: ApprovedOctober 13, 2017

F 312: ADL Care Provided for Dependent Residents:
A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was not bed as evidenced by: based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not provide the necessary services to maintain good nutrition and eating ability for 2 of 16 residents (Residents #4 and #6) observed for activities of daily living. Residents #4 and #6 required staff assistance for eating and were observed not receiving assistance.
Seating arrangements for both resident #4 and resident #6 have been changed to have them positioned next to another resident requiring assistance with eating to allow staff members to assist each resident requiring assistance. Staff who care for resident #4 and resident#6 will be educated on proper positioning and set-up for meals assistance. Care plans have been changed for residents #4 and #6 for them to be seated next to a staff member to assist them with meal consumption.
This deficient practice could affect all residents who require staff assistance to meet adequate nutrition. A facility wide review of residents that require assistance with eating was performed to ensure they were appropriately placed for staff to provide assistance or cueing to complete their meals. CNA care profiles were reviewed for accuracy for ADL Care. The facility ADL policy was reviewed and the Nurse Educator will in-service all nursing staff on proper position, meal set-up, as well as ensure food temps are maintained. Residents intake and weights will be monitored. Two additional tables have been ordered for repositioning of residents on the Whispering Pines unit to ensure proper supervision of residents during meals.
An audit tool was developed to ensure that this practice is monitoring and residents are fed by the Nurse Managers, Nursing Supervisors, Nurse Educator, and Director of Nursing. The completed audit will be given to the Director of Nursing and will be discussed with the Education Coordinator to ensure that education takes place with those who perform deficient practice. The acceptable threshold for compliance when conduction audits is 95%. The acceptable audit will be performed three times each week by the Nurse Management Team. The Nurse Educator is responsible to begin (MONTH) 25, (YEAR).
The Director of Nursing will review all audits performed weekly and results will be reported to the Quality Improvement meeting. The Quarterly Quality Improvement meeting results will be discussed with the Corporate Officer as well as the Medical Director.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 25, 2017
Corrected date: October 16, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the resident environment was maintained in a sanitary and orderly manner for 3 of 3 units (Maplewood unit, Parkside unit and Whispering Pines unit). Specifically; the facility's walls, floors, ceilings, baseboard heaters, and sinks were not maintained. Findings include: On 8/22/2017 at 10:00 AM, a surveyor on the Maplewood unit observed a wall in the main dining room was delaminating/peeling. On 8/22/2017, between 11:10 AM and 11:51 AM, a surveyor on the Parkside unit observed: - a wall in bathroom shared by rooms 310 and 311 was damaged; - a wall behind the toilet in the bathroom used by room 307 had peeling paint, and there was water dripping from a pipe with a puddle on the floor. - there was a rust like colored stain on the shower room floor; and - the nursing station granite counter top was loose and when moved in certain ways sharp points were created. On 8/22/2017, between 12:01 PM and 12:19 PM, a surveyor on the Whispering Pines unit observed: - in room 219, the end piece of the radiator was missing and there was metal exposed; - the bathroom used by room 209 had a loose wall sink and was out approximately 1 inch from the wall; and - the bathroom used by room 203 had a missing wall tile. On 8/23/2017, between 9:15 AM and 9:20 AM, a surveyor on the Whispering Pines unit observed: - the base of a suction machine in the dining room was rusty/unclean; and - the walls of the dining room had loose wood trim with a finishing nail exposed and sharp edges. On 8/23/2017, between 9:20 AM and 9:24 AM, a surveyor on the Parkside unit observed: - the shower room radiator cover was loose; and - there was a stained ceiling tile in the dining room. On 8/23/2017 at 9:27 AM, a surveyor on the Maplewood unit observed the shower room had a cracked wall tile. Resident Room Environmental Checklists documented: -6/27/2017 the bathroom door frame in Room 307 was in need of painting and walls needed repair and paint; -7/5/2017 the heater cover was missing and the baseboard heating required repair in Room 219 and the bathroom floor/wall tile needed replacement in room 203. Under Director's initials the areas were blank. When interviewed on 8/23/2017 at 1:38 PM, the Director of Environmental Services stated he was not aware of the issues identified during survey, and he relied on other staff within the facility to make him aware of the issues. In room 307 a bucket had been placed behind the toilet to catch the dripping water from a leak. The water spilled onto the wall peeling the paint. He also stated neither the Housekeeping Director or himself was made aware of this leak. Facility rounds are done on a weekly basis, with every room checked quarterly. 10NYCRR 415.5(h)(2)

Plan of Correction: ApprovedOctober 2, 2017

F253 Housekeeping & Maintenance

The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was not evident during the state inspection secondary to:
? Maplewood Unit
On Maplewood a wall in the main dining room was delaminating/peeling.
Shower room has a cracked wall tile.
? Parkside Unit
o Bathroom wall shared between room 310 and 311 was damaged.
o Bathroom in room 307 had peeling paint behind the toilet and water was dripping from a
pipe with a puddle on the floor.
o Shower room in Parkside Unit noted a rust like colored stain on the room floor.
o Nursing station in Parkside Unit granite counter top was loose and when moved in certain ways sharp points were created.
o Shower room radiator cover was loose
o Stained ceiling tile in the dining room.
? Whispering Pines
o Suction machines in dining room was rusty/unclean
o Walls in the dining room had loose wood trim with a finishing nail exposed and sharp edges.
Resident Room Environmental Checklists documented bathroom door frame in room 307 was in need of paint and walls needing repair and paint; the heater cover was missing and the baseboard heating required repair in room 219 and the bathroom floor/wall tile needed replacement in room 203. Facility did not ensure that the resident environment was maintained in an orderly manner on all three units.
The following corrections were made:
? Maplewood Unit
o Delaminated/peeling wall covering was glued and reattached.
o Shower room cracked tile was removed and replaced with intact wall tile and re-grouted.
? Parkside Unit
o Bathroom wall shared between room 310 and 311 was repaired and repainted.
o Bathroom in room 307 dripping from pipe was repaired and wall behind the toilet was repaired and painted. Door frame painted.
o Parkside unit shower room floor grout was removed, cleaned and re-grouted.
o Nursing station in Parkside unit granite counter top was reinforced with additional supports and gap caulk.
o Shower room radiator cover was re-enforced with additional anchors to ensure its stability.
o Stained ceiling tile in the dining room was replaced.
? Whispering Pines
o Suction machine in dining room was replaced with a rust free and clean unit.
o Loose wood trim in dining room was re-enforced and any exposed nails/sharp edges it created was nailed further into the wood.
- Room 209 loose wall sink was tighten.
o Room 217 & 219 heater cover is fixed and baseboard heating cover repaired and painted.
o Room 203 bathroom floor and wall tile are replaced.
All residents have the potential to be affected by the same deficient practice. An in-house audit of all ancillary spaces and offices will be completed by (MONTH) 27, (YEAR). An in-house audit of all resident rooms will be completed by (MONTH) 4, (YEAR). All staff will be in-serviced to document any deficiency and when to call maintenance on call to address immediate issues after hours. This will also be expressed more so with Housekeeping staff since they are in rooms daily. Maintenance staff responsibilities are reassigned by their specialty to improve outcomes. An existing audit tool was modified to list all the areas in a resident room and added ancillary spaces and offices. Housekeeping will continue to conduct weekly audits and updated the results on a form setup in the computer for review. The Maintenance Director will review the update data daily and any maintenance discrepancies will be delegated to the appropriate specialist. All tasks will be reviewed weekly by the Director and bi-weekly by a designated representative to ensure the resident environment is maintained in a sanitary and orderly manner.
An Environmental room rounds audit sheet was modified to better identify areas of need and who and when corrected the deficit as well as completed by. This form is now saved in the computer under an all user drive. Housekeeping and maintenance directors or designated representative will complete 10% of the facility census audits weekly to ensure environmental deficiencies are updated. The Maintenance Director will review the site daily to ensure his staff are given the latest update to complete. Each maintenance worker will have their own updated audit sheet/book provided by the director. Then the Maintenance Director will review his/her staff progress weekly to ensure accountability and plan for the week ahead. The threshold for compliance is 95% because there are things that might require capital improvement authorization. The administrator or designated representative will review the audit sheets bi-weekly to hold the department accountable as well as ensure materials and supplies are provided to complete the work.

The Director of Maintenance and Director of Housekeeping will provide the audits weekly to the administrator and quantify for the quality assurance improvement meetings for timeliness and performance compliance.
The date of correction is (MONTH) 16, (YEAR) and the Director of Maintenance, Director of Housekeeping and Administrator are the responsible individuals for the correction of this deficient practice.

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: August 25, 2017
Corrected date: October 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, observation, and interview conducted during the recertification and abbreviated surveys (NY 361), it was determined the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 2 of 13 residents reviewed for abuse (Residents #3 and 13). Specifically, there was no documentation investigations were thorough and complete to rule out abuse, neglect, or mistreatment when: Resident #13 alleged being bullied by staff and Resident #3 had an elopement event and interventions were not implemented timely to prevent reoccurrence. Findings include: 1) Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severe cognitive impairment, required extensive assistance for activities of daily living (ADLs), and walked with the use of a walker. The comprehensive care plan (CCP) initiated 4/10/2017 and updated 6/5/2017, documented the resident was at risk for falls, and at risk for wandering and elopement. Interventions included a Wanderguard (alarming system to alert of elopement attempts), a chair alarm to all chairs and placement verified every shift. Nursing progress notes documented on 5/22, 5/24, 5/30, 5/31, 6/24, 6/30, and 7/1/2017 the resident attempted to exit both interior unit doors, the door to the parking lot, attempted to remove her Wanderguard and verbalized her desire to leave. An incident report dated 7/2/2017, documented at 6:45 PM, the resident went through the alarmed doors to the Parkside unit, pulled the fire alarm on the Parkside unit and exited the building. Maintenance technician #23 arrived in the parking lot, found the resident, and there were two CNAs approximately 25 yards behind her. Corrective actions taken to prevent reoccurrence included bed and chair alarms to be secured to surfaces, resident's room changed for closer staff supervision, and maintenance inspection of the unit doors. Egress times on the internal unit doors were changed from 15 seconds to 30 seconds. The summary did not address if the care planned chair alarm was in use or the reasons for the lack of response to the unit door alarm when the resident exited the unit and the building. The CCP updated 7/2/2017, documented the resident was at risk for wandering and elopement, had exited the facility unassisted, and had a history of [REDACTED]. She understood the Wanderguard system and had the ability to read signs and follow directions. Interventions included existing bed and chair alarms to be secured to surfaces to prevent the resident from removing them and Wanderguard placement and function was to be checked each shift. An incident report dated 7/5/2017 at 4:20 PM, documented the resident went out the first set of doors to the parking lot when aides caught up with her. Care plan interventions in place at the time were documented as the Wanderguard and proper footwear. A Witness statement documented the resident was found in the parking lot by a visitor and another statement documented she was in the doorway. There was no documented statement from the visitor who found her. Interventions included a hall monitoring schedule had been put into place to prevent any further attempts to exit the building. A nursing progress note dated 7/5/2017 at 10:27 PM, documented at the start of the shift, the resident was hitting the door with her walker. At 4:40 PM, the resident had eloped out the door by the parking lot, a visitor caught the resident on the outside of the door and brought her back inside. The resident profile (certified nurse aide care instructions) last updated 8/8/2017 did not include bed/chair alarms and did not include any information regarding other interventions for the resident's exit seeking behaviors or details about her ability to release alarmed doors. When interviewed on 8/24/2017 at 5:20 PM, LPN #6 stated the resident should be supervised any time she was up. She stated when the resident eloped on 7/2/2017, the unit door alarm was not heard and has since been adjusted to be louder. She stated the exit door from the unit to the parking lot was not able to be heard if staff are in the kitchen/dining room area. The LPN left the kitchen and activated the exit door alarm while the surveyor remained in the kitchen. The alarm was not heard, and the ADON and another surveyor arrived to confirm the alarm was sounding. The LPN stated she had reported this to administration as this was a concern. She stated the hall common area needed monitoring because residents can get out quickly and this was not always possible due to the various needs of the residents throughout the shift. On 8/25/2017 at 10:05 AM, LPN #5 stated in an interview she was not certain if the resident was to have a chair alarm, and chair alarms can be moved from seat to seat for those residents who require them. During an interview on 8/25/217 at 10:10 AM, the Director of Nursing (DON) stated an investigation was done to seek root cause of the incident and to establish interventions to prevent reoccurrence. Investigations included witness statements from anyone involved, including non-staff, and all staff assigned to the area/shift of occurrence. For elopement investigations, she would look at staff response to alarms, proper functioning of doors and alarms, staff whereabouts, and if current interventions were used at the time. The investigations for the 7/2/2017 elopement and 7/5/2017 for the near elopement were not complete due to lack of all witness statements, lack of documentation regarding use of the chair alarm, and lack of clarification of conflicting witness statements. Hall monitoring and secured chair/bed alarms were put in place following the 7/2/2017 elopement event. She was unaware of any issues regarding the egress times on the doors or interventions not in place following the incidents. On 8/25/2017 at 10:20 AM, the Assistant Director of Nursing (ADON) stated interventions for the resident's exit seeking were the Wanderguard and supervision in the common area. No chair alarm was used and if it was on the care plan it should be in place. 2) Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact and required extensive assistance with transfers and ambulation, had no behaviors and had adequate ability to hear. The social work progress note dated 4/13/2017 at 4:19 PM, documented the resident was cognitively intact, pleasant, cheerful and accepting of placement. The social work progress note dated 4/18/2017 at 2:11 PM, documented the staff reported concerns with the resident's behavior such as self-ambulating and refusing medications. The resident also reported some concerns with transition to the new facility. The grievance form, completed on 4/18/2017 by the social worker, documented the resident requested to meet with the social worker on 4/17/2017 after feeling threatened and bullied by licensed practical nurse (LPN) #1 on the evening of 4/16/2017. The resident stated no one came when she rang her call bell and LPN #1 saw her self-ambulating in her room towards the bathroom. The LPN yelled at her and told her to go back to bed. The resident told the LPN she was going to the bathroom and the LPN continued to yell at her. The LPN entered the resident's room, leaned into her personal space and put her face to the resident's ear and stated she would continue to yell until the resident got back to bed. The resident's roommate thought the resident was being abused and called the police. The resident told the social worker she was unable to take her medication after that as she was too upset, had difficulty breathing, and was unable to swallow. The grievance form documented another nurse (LPN #2) came in and helped the resident after LPN #1 left. The form documented the Nurse Manager was responsible for investigating the grievance. The social worker documented for her follow-up actions, she met with the resident's roommate and the roommate did not remember the situation for calling the police. The social worker documented she educated the staff and provided a brief social history. Social worker #3 was interviewed on 8/23/2017 and stated when a resident filed a grievance, she documented the the resident's statement on a grievance form and sent a copy to the Nurse Manager, Director of Nursing (DON), and the Administrator. She stated the grievances became the responsibility of the Nurse Manager after she talked to the resident. When asked specifically about the grievance for Resident #13, she stated the resident was new and she and the staff did not know each other. She said she thought it was LPN #1's first time taking care of the resident and she was yelling as she thought the resident was hard of hearing. She stated she gave the grievance form to the Nurse Manager to investigate and she shared the resident's social history with the staff. She stated she was not involved in the investigation and did not know the results of the investigation. On 8/24/2017 at 8:10 AM, social worker #3 came to the surveyor with a statement from the registered nurse (RN) Manager #4 regarding the grievance. She stated she found it in the resident's file and had not previously looked at it. The statement documented the resident came out of her room independently and was yelling in the hall for pain medication and gingerale. The statement documented the interaction took place in the hall and the resident had already been taken to the bathroom. RN #4 documented LPN #1 stated she did not yell and had to get close to the resident's ear for her to hear. When interviewed on 8/24/2017 at 10:35 AM, RN #4 stated she interviewed LPN #1 about the incident and counseled her and did not have her write a statement. She stated she did what she thought needed to be done and passed the investigation on to the DON, Administrator, and social worker #3. When interviewed on 8/24/2017 at 11:05 AM, the DON stated she was unaware of the incident. The DON was given the statement written by RN #4 and stated RN #4 determined abuse did not occur and that was why she was not notified. She stated the investigation should have included statements from other staff on duty and from other residents as the resident was definitely upset and felt bullied and a thorough investigation was not done. 10NYCRR 415.4(b)

Plan of Correction: ApprovedOctober 13, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F225: Investigate/Report Allegations/Individuals:
The facility must 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 no later than two (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 twenty-four (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 stated law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Evidence must be in place that all alleged violations are thoroughly investigated, measures are in place to prevent potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress, and results of investigation are reported 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 five (5) working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. This was not met as evidence by: based upon record review, observation, and interview conducted during the recertification and abbreviated surveys, it was determined the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 2 of 13 residents reviewed for abuse. There was no documentation that investigations were thorough and complete to rule out abuse, neglect, or mistreatment based on resident #13 alleged being bullied by staff and resident #3 had an elopement event and interventions were not implemented timely to prevent reoccurrence.
1) Resident #3 had an elopement event on 7/2/2017; at which time the resident exited through alarmed doors to the Parkside unit, pulled the fire alarm on the Parkside unit, and exited the building. Corrective actions at the time of the event included: securement of bed and chair alarms to surfaces, room changed for closer supervision, and maintenance inspection of the unit doors with egress times changed from fifteen (15) seconds to thirty (30) seconds. Resident #3 made another attempt to leave the facility unattended on 7/5/2017 at which time a visitor intervened at the door and assisted staff to bring resident back to the unit. Corrective action at the time of the event included: a hall monitoring schedule was put in place to prevent further attempts to by any resident to leave the facility. Resident #3 has had no further successful attempts to leave the facility unattended as of 9/22/2017. Update #3 care plan to involve her in activities of her choosing. Continue the use of the wanderguard and educated staff of change of alarm activation to the Whispering Pines dining room.
2) Resident #13 requested an audience with the social worker on 4/17/17 and stated she felt ?threatened and bullied? by licensed practical nurse #1. The social worker completed the grievance form on 4/18/2017 and stated she forward a copy to the DON, Unit Manager, and Administrator. An investigation was completed by the unit manager and counseled LPN #1. On 8/24/2017, the social worker interviewed six additional residents as well as resident #13. Resident #13 stated ?her needs are met and has no known concerns with staff or care at this time.? She report ?she is not fearful of anyone or anything and feels comfortable and safe in her environment. Social Services will monitor for psychosocial needs.
The deficient practice could affect all residents who are at risk for elopement and any resident complaining of allege violations involving resident rights. A facility wide review was performed on all residents that require the use of a Wanderguard and alarm usage. A list of these residents was completed and a spread sheet/audit form was developed so these residents could be monitored. Staff in-servicing of proper monitoring of wanderguard system and the proper use and monitoring of safety alarms will be completed by (MONTH) 6, (YEAR) by Education Coordinator, Nicole Vanderhoff, RN and on-going for all nursing staff. The facility purchased a ?Sounder (Siren)? to add to the existing Wander guard system with a loudness of 101db. This unit will be installed in the unit dining area were most staff and residents gather. Resident #3's care plan has been updated to offer resident activities of her choosing when exit seeking such as items to read, puzzles, and one to one visits as these are things she likes to do. On [DATE], (YEAR), the social worker interviewed six residents to ensure any alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported. The six residents from the same unit where LPN #1 would have care for them were interviewed by the Social Worker Director. As well as six from Maplewood and six from Whispering Pines. Each concluded that there needs were met and have no known concerns with their care. Each reported they are not fearful of anyone or anything and feels comfortable and safe in their environment. All staff were in-serviced on Abuse Prohibition Protocol by the Education Coordinator, Nicole Vanderhoff, RN including the DON and Administrator. Elopement risk is determined by the EMR profile and the facility maintains an elopement risk blinder that is updated daily with change and elopement status. All nursing staff have been educated on elopement assessment are completed on all residents at time of admission, quarterly, annually and with any increase in wandering or attempts at exit seeking activity. Continue the use of the wanderguard and educated staff of change of alarm activation to the Whispering Pines dining room.

Changes have been made to the facility?s Resident/Visitor-Incident/Accident Report to prompt the licensed nursing staff to obtain useful information necessary for a thorough investigation. These changes include: If equipment was in place and functioning properly, an interview log which requires that all staff on the unit be interviewed and a written statement obtained, the name of any non-employee witnesses and a written statement from that person, a check list of all interventions in place to prevent the event prior to the event and were these interventions in place at the time of the event with instructions to notify the Administrator and Director of Nursing if not. The Interdisciplinary Team is to review Accident and Incident reports with each morning meeting. Facility Grievance/Complaint Policy was revised to reference policy Freedom from Abuse, Neglect, and Exploitation. As well as to include any grievance that involves alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator and/or Director of Nursing or both.
An audit tool was developed for the monitoring of wanderguards and personal safety alarms to ensure that this practice will be monitored by the Nurse Managers, Nurse Educator, and Director of Nursing. The completed audit will be given to the DON and will be discussed with the education coordinator to ensure that education takes place with those who perform deficient practice. The audit will be performed weekly by the Nurse Management Staff. Maintenance has added on their PM list to check and verify daily all Wanderquard sound systems in the facility. The threshold for compliance is 100% to ensure all residents with wandersguards and personal safety alarms are in order. The Education Coordinator is responsible-to begin 9/27/17 and ongoing. An audit tool was developed for ensuring timely process of notifying the appropriate personnel, timeliness completion of the grievance and was the Administrator and Director of Nursing notified immediate for all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property. Acceptable threshold for compliance is 100%.
All Accident and Incident reports will be reviewed by the Director of Nursing or designee to ensure that all sections are complete. The Director of Nursing will discuss findings with the Education Coordinator to ensure that education takes place with those who perform deficient practice. The Director of Nursing is responsible-to begin 9/25/17 and is on-going. Grievance audit tool will be reviewed bi-weekly by the Director of Social Services and reviewed monthly by the administrator.
The Director of Nursing and Director of Social Services will review all audits performed weekly and results will be reported to the Quality Improvement meeting. The Quarterly Improvement meeting results will be discussed with the Corporate Officer as well as the Medical Director.

Standard Life Safety Code Citations

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 23, 2017
Corrected date: October 16, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure delayed egress locking arrangements was maintained for 1 of 10 emergency exit doors (main kitchen dry storage room). Specifically, the main kitchen dry storage room emergency exit door was secured with an unapproved device. Findings include: On 8/21/2017 at 6:49 PM, a surveyor in the main kitchen dry storage room observed an emergency exit door. This door's panic hardware was locked in the open position and would not latch. There were brackets installed on the wall on both sides of the door and a metal bar leaning on the wall near the door. When interviewed 8/21/2017 at 6:49 PM, the Food Service Director stated the metal bar was placed on the emergency exit door at night when the kitchen staff leaves. When interviewed 8/22/2017 at 11:34 AM, the Director of Environmental Services stated the main kitchen dry storage room emergency exit door was last checked in (MONTH) (YEAR), and this door was not included on the facility emergency exit door list. He stated the bar was placed at night for security reasons and did not know it was not allowed. He also could not find any work orders for this door, and could not find any documentation that this door had been checked since (MONTH) (YEAR). When interviewed 8/22/2017, between 12:50 PM and 1:07 PM, the Food Service Director stated he did not know how long the panic bar for this door had been locked in the open position, and does not have a key to unlock the panic bar. 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 28, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 222 NFPA 101 Egress Door
The facility needs to ensure delayed egress locking arrangements is maintained on all doors. It was observed that the facility, specifically, the main kitchen dry storage room emergency exit door was secured with an unapproved device. A new door with an approve device in accordance with 7.2.1.6.2 was ordered on [DATE] and will be installed as soon as it arrives.
The Maintenance department surveyed all of the facility doors with an access-controlled egress locking arrangement to ensure it is in accordance with 7.2.1.6.2. having the potential to be affect by the same deficient practice. A new audit tool was developed to inspect all exterior egress door for the following:
1. Door Labels & Fire Rating
2. Positive Latching
3. Door Bottom/Weather seal
4. Window intact
5. No holes or surface breaks in door or caulk
6. All Hardware in proper working order
7. No missing parts
8. Self-closing device operational
9. Magnetic locks intact
10. No Interference from Aux hardware
11. Door Signage Fastened correct/ <5% door area
All other doors that had the potential to be affected by the deficient practice were corrected. The maintenance staff will be educated on the function and use of the new form. It is used as part of maintenance PM checklist and all exterior doors will be inspected monthly for all of the above for potential deficiencies.

Exterior Egress Door Inspection Log was developed and added as part of maintenance monthly PM schedule. Maintenance staff will be educated on the function, use of the new form, and how to identify a malfunction as well as ensure an access-controlled egress locking arrangement is in accordance with 7.2.1.6.2. A special Main Entry Door Weekly PM Check was developed because its function is different than all other Exterior Egress Doors. The following areas added on the checklist are:
? Tracks cleaned on both sets of doors
? Breakaway checked on both sets of doors
? Check sensors for debris (clean if necessary)
? Check doors for proper operation (after cleaning and checks)
Maintenance Director will audit the department PM log weekly for the Main Entrance door and monthly, and Quarterly for all other Exterior doors to ensure all egress locking arrangements are approved and operational in accordance with 7.2.1.6.2. The administrator and/or designated representative will review all logs monthly and quarterly to ensure compliance.
The Maintenance Director is responsible for the deficient practice and to be completed by [DATE], (YEAR)

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 23, 2017
Corrected date: October 16, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not maintain electrical equipment in accordance with National Fire Protection Agency (NFPA) 99. Specifically, a mixer in the main kitchen had a damaged plug. Finding include: On 8/21/2017 at 6:15 PM, a surveyor in the main kitchen observed the cord sheathing of a plug for a floor-type mixer was damaged and there were exposed wires. The outlet the mixer was plugged into was approximated 3 inches from the floor. When interviewed 8/21/2017 at 6:50 PM, the Food Service Director stated he was not aware the cord for the floor type mixer was damaged, or how long it had been damaged. When interviewed 8/22/2017 at 11:37 AM, the Director of Environmental Services stated he was not aware the cord for the floor type mixer was damaged. He also stated that no work orders had been made to correct this issue, so he could not determine how long the cord had been damaged. 2012 NFPA 99: 10.3 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 27, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 921 NFPA 101 Electrical Equipment ? Testing and Maintenance
The facility needs to ensure 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. The facility did not maintain electrical equipment in accordance with NFPA 99. Specifically, a mixer in the main kitchen had a damaged plug. The plug was immediate repaired the same day.
All other equipment have the potential to sustain damage plugs. The maintenance department inspected all other electrical equipment in the kitchen to ensure 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.
An Outlet Tension Test log was modified to include Kitchen (Dietary) equipment plugs/cords with the annually/quarterly testing. The Maintenance staff will be re-educated of the modified form and taught how to inspect equipment cords and plugs. Kitchen staff will be re-educated on how to remove a plug from an outlet to prevent damage, how to identify a damage cord/plug and when and who to report. Any plugs or cords that are damaged, frayed/sheathing or bent will be replaced immediate to ensure 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.

Maintenance Director will audit the ?Outlet Tension Test log? monthly, quarterly and annually to ensure all cords and plugs in the kitchen are maintained in accordance with NFPA 10.3. The administrator and/or designated representative will review logs monthly and annually to ensure compliance.
The Maintenance Director is responsible for the deficient practice and to be completed by [DATE], (YEAR).

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 23, 2017
Corrected date: October 16, 2017

Citation Details

Based on interview conducted during the recertification survey, it was determined the facility did not ensure the emergency generator remote annunciator was properly installed for the generator. Specifically, the emergency generator was not connected to a remotely installed alarm annunciator. Findings include: During an interview on 8/23/2017 at 9:41 AM, the Director of Environmental Services stated he thought what the facility had was compliant. He stated if the generator had an issue a message would be sent his phone and the Administrator's phone. He was not aware a hard-wired generator panel was required. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 7, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 916 NFPA 101 Electrical Systems ? Essential Electric System
The facility needs to ensure a remote annunciator that is a storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hardwired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g. building information system) is not to be substituted for the alarm annunciator in accordance with 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99). During an interview with the Director of Environmental Services states generator issue messages are received through the phone and the administrator is notified through that same process as well. In accordance with NFPA 99 (YEAR) version states the following:
6.4.1.1.18.2 ? The following annunciation shall be provided at a minimum:
1. For Level 1 EPS, local annunciation and facility remote annunciation, or local annunciation and network remote annunciation.
2. For Level 2 EPS, local annunciation.
We have a letter dated (MONTH) 25, (YEAR), from the City of Cortland, Fire Department, Code Enforcement signed by(NAME)Knickerbocker, Deputy Fire Chief/Director of Code Enforcement stating the following:
City of Cortland uses the New York State Uniform Code, (YEAR) addition of NFPA 99 for the installation of generators associated with health care facilities. More specifically section 6.4.1.1.18 of NFPA 99 allows local and network monitoring of standby generators.
The Cortland Park facility provides network monitoring which meets the minimum as required by this standard.
Under the guidelines of NFPA 99 (YEAR) version 6.4.1.1.18.2 level 1 EPS allows local annunciation and facility remote annunciation, or local annunciation and network remote annunciation. The facility already has local annunciation and as the surveyor noted during an interview with the Director of Environmental Services received messages through the phone known as network remote annunciation. The Administrator and all maintenance personnel have access to mobile notification of the generator status through mobile devices.
Adding a Kiosk and fixing it nearby the nursing unit provides an additional backup through network monitoring. The Kiosk will be anchored to the wall with AC adapter. The Kiosk has UPS battery backup of 15 mins. The Kiosk will link by direct line (Ethernet) or Wi/Fi to ensure continuity. The internet sever has two internet services, one by Spectrum cable and the other fiber optics. The sever has a two hour battery back-up.
Policy and procedures will be developed to ensure the annunciator is monitored every shift. The maintenance department, nursing supervisor and/or delegated individual will document daily the status and function of the generator to mitigate any risk associated with the upgrade. If any chance the system is compromised the maintenance department will initiate the repairs until the generator system is fully functional. If the repairs can not immediate resolve the problem and the generator is inoperable for more than 4 hours then an emergency generator will be acquired to maintain emergency backup. In accordance with the Nursing Home Incident Reporting Manual, dtd (MONTH) (YEAR), ?The facility must report planned and unintentional loss of service for ?electricity ? ?[MEDICATION NAME] or expected to last 4 or more hours.
Considering the server has a battery backup, the internet services are provided by two sources, the Kiosk is connected to the generator via mobile and Wi/Fi as well as it has AC & DC power minimize any risk to the health and safety of the facility occupants.

The facility request approval and acceptance of City of Cortland Fire Department Code Enforcement approval of network monitoring which meets the minimum as required by this standard 6.4.1.1.18 of NFPA 99 (YEAR) version.
The facility completed DOH -5223 Waiver/Equivalency Request and submitted it for consideration.

K307 NFPA 101:EXIT SIGNAGE

REGULATION: Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 23, 2017
Corrected date: October 16, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure exit signs were displayed in accordance with National Fire Protection Association (NFPA) 7.10 requirements for 1 isolated location (main kitchen). Specifically, the main kitchen lacked an exit sign. Findings include: On 8/21/2017 at 7:08 PM, a surveyor in the kitchen observed there was an emergency exit door in the dry storage room. The surveyor in the main kitchen looked towards the dry storage room area and could not find an exit sign to indicate there is an emergency exit in the adjoining room. During an observation and concurrent interview on 8/22/2017 at 2:30 PM, the Director of Environmental Services stated after the surveyor pointed out there were no exit sign to direct staff through the dry storage room to the emergency exit door, he agreed an exit sign at this location was required. 2012 NFPA 101: 19.2.10.1, 7.10 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 27, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 293 Exit Signage
2012 Existing
Accordance to the findings based on observations and interview conducted during the recertification survey, it was determined the facility did not ensure exit signs were displayed in accordance with NFPA 7.10 for 1 isolated location lacked an exit sign. After researching NFPA 19.3.2.1.5 Hazardous Area forbids those areas to be used as part of an egress. The door in question leads into a dry storage area which is considered as a Hazardous Area due to combustibles. Doors shall swing in the direction of egress if serving:
? An exit enclosure
? A high hazard content area
? More than 50 occupants
The door in reference does not swing in the direction of egress in accordance with 7.2.1.4.2. The door in question does not swing into the hazard area as define in NFPA as an Egress. 19.2.6.2.1 States the travel distance between any point in a room and an exit shall not exceed 150ft. There is an exit sign within 150 ft. between any point in a room that leads into the hallway and it swings into the hallway. We will install a ?No Exit? sign in accordance with 7.10.8.3.1 because of the above reference.

The Maintenance department surveyed all of the facility Egress and doors to ensure it is in accordance with NFPA 7.10 having the potential to be affect by the same deficient practice.
An audit was developed to ensure all exits that have the potential to be affect by the deficient practice are inspected. All Egress and doors are inspected to ensure the appropriate exit signs are displayed in accordance with NFPA 7.10. Maintenance staff will be educated with NFPA 7.10 and the PM checklist function. The doors will be checked on a weekly basis to ensure all signs are either illuminated or recognizable.
The audit tool will be added as part of the facility maintenance PM weekly rounds. Maintenance staff will be educated on the function, use of the new form and NFPA 7.10 as well as how to identify any malfunctions.
Maintenance Director will audit the department PM log weekly, monthly, and quarterly to ensure all egress doors with exit signs are identified and are illuminated as well as those doors requiring signage of ?No Exit.? The administrator and/or designated representative will review the logs monthly and quarterly to ensure compliance.
The Maintenance Director is responsible for the deficient practice and to be completed by [DATE], (YEAR)

K307 NFPA 101:FIRE ALARM SYSTEM - OUT OF SERVICE

REGULATION: Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 23, 2017
Corrected date: October 16, 2017

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, the facility failed to communicate proper fire procedures to all facility staff during the loss of the fire alarm system for 2 of 12 fire zones within the building (zone 6 and zone 10). Specifically, the facility failed to properly institute a fire watch when a part of the fire alarm system became non-functional for more than 4 hours for zone 6, and the facility failed to contact the Department of Health when a fire watch was instituted for zone 10. Findings include: 1) Zone 6 On 8/21/2017 at 7:25 PM, a surveyor behind the Maplewood unit nursing station observed the fire alarm control panel (fire alarm control panel) had a system trouble in zone 6. On 8/22/2017 at 8:44 AM and 12:36 PM, a surveyor behind the Maplewood unit nursing station observed the fire alarm control panel had a system trouble in zone 6. During an interview on 8/22/2017 at 12:36 PM, the Director of Environmental Services stated: - he was not aware of the system trouble in zone 6; - he could tell based on the visual alarm there was a faulty smoke detector within that zone; - this system trouble would not affect other zones within the building; and - nurses knew to look at the fire alarm control panel for warning lights when they walk into that area of the Maplewood nursing station. During an interview on 8/22/2017 at 12:36 PM, the Director of Nursing stated: - she was not aware of the system trouble in zone 6; - nurses typically do not look at the fire alarm control panel unless there is an audible alarm; and - she was not aware of any facility policy/procedure stating nurses were required to look at the fire alarm control panel. On 8/22/2017, during record review of an 8/22/2017 fire watch log, a surveyor observed that a fire watch was started on 8/22/2017 at 1:00 PM. During an interview on 8/22/2017 at 2:47 PM, the Director of Environmental Services stated he identified the faulty smoke detector and reset the fire alarm panel by 2:00 PM. During an interview on 8/23/2017 at 10:14 AM, maintenance worker #23 stated: - he checked the fire alarm control panel every morning at approximately 6:55 AM; - once a trouble signal audible alarm was silenced on the fire alarm control panel, it does not re-alarm until another trouble signal triggers the audible alarm; - the fire alarm control panel was located in an area that is out of site behind the Maplewood unit nursing station; - staff will not look at fire alarm control panel unless an audible alarm is going off; - he had trained other facility staff to look at the fire alarm control panel when they heard an audible alarm; - if a staff person heard an audible alarm he/she was to dial 911 and the maintenance department was to be notified; - the morning of 8/21/2017, there was no system trouble in zone 6 on the fire alarm control panel; - he did not check the fire alarm control panel on the morning of 8/22/2017 because he was asked to do another task and never got back to it; - he was not aware of the trouble signal prior to the surveyor identifying it on the fire alarm control panel. During an interview on 8/23/2017 at 11:30 AM, the Administrator stated: - no one was allowed to silence the audible alarm of the fire alarm control panel; - if a supervisory visual alarm was seen, a staff person should call maintenance; - he was not aware the system trouble in zone 6 was ignored and/or not seen for approximately 18 hours; - he knew fire watch should be implemented if a component of the fire alarm system was down for more than 4 continuous hours; and - he knew to contact the Department of Health if the facility went on fire watch. On 8/23/2017, during record review of the facility's Fire Procedures last reviewed 4/19/2017, a surveyor observed a section that stated Any fire protection system (fire alarm, etc.) that is out of service and the building is occupied is required to establish a fire watch. 2) Zone 10 On 8/22/2017, during record review of an 8/30/2016 fire alarm event, a surveyor observed that a fire watch was initiated after 10:30 PM. On 8/23/2017, during record review of a 8/30/2016 fire watch log, a surveyor observed that a fire watch was started on 8/30/2016 at 11:00 PM and ended on 9/1/2016 at 1:00 PM. During an interview on 8/23/2017 at 1:25 PM, the Administrator stated the 8/30/2016 fire watch was not called into the Department of Health. 2012 NFPA 101: 19.7.2.1, 9.6.1.6 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 27, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 346 NFPA 101 Fire Alarm System ? Out of Service
The facility needs to ensure when there is a fire alarm system alert and/or out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction should be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown unit the fire alarm system has been returned to service. On [DATE], (YEAR), at 7:25am it was observed by the surveyor that the fire alarm control panel had a system trouble in zone 6. A button to silence the trouble was activated without notifying the proper authority. On [DATE], (YEAR), the surveyor observed a fire watch log was started on at 11:00pm and ended on 9/1/2016 at 1:00pm. The DOH was not notified of the watch that extended pass 4 hours in a 24-hour period. The facility purchased a plastic cover and it was placed over the supervisory buttons which were accessible to anyone is now only accessible to maintenance personal. The Administrator and Director of Maintenance were re-educated on the requirements from the Nursing Home Incident Report Manual dated (MONTH) (YEAR) on when to report Physical Plant Issues/Loss of Service. It states one of the following elements must be present for an incident to be reportable to the NYS DOH:
? Loss of service [MEDICATION NAME] or expected to last 4 or more hours
? There is no back-up system in place; or
? The back-up system fails to work
? Planned or unexpected events that may affect resident care.
This issue has the potential to affect the whole facility. The maintenance department continue with their daily monitoring and it is their first responsibility of the day regardless of other duties.

The maintenance daily operating log has been modified to include fire alarm panel check to ensure no alarms are activated. This responsibility has been designated to a specialty technician and the maintenance director will inspect the log daily to ensure compliance. A cover was purchased and placed over the alarm acknowledge buttons to prevent an accidental acknowledgement by unauthorized staff. A sticker was affixed to the panel stating any alarms must be notified to Maintenance immediate.

The Maintenance Director will audit the department operating log on a daily, weekly, monthly and quarterly basis. The administrator and/or designated representative will review the logs monthly and quarterly to ensure compliance. He will bring the results and any issues to the monthly QAPI & quarterly QA meetings.
The Maintenance Director is responsible for the deficient practice and to be completed by [DATE], (YEAR).