Warren Center for Rehabilitation and Nursing
February 24, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure a comprehensive care plan (CCP) was developed for each resident to meet medical, nursing, and psychosocial needs as identified in the comprehensive assessment for 1 (Resident #80) of 16 residents reviewed. Specifically, for Resident #80, the residents clinical record did not include a Comprehensive Care Plan (CCP) for the care and treatment of [REDACTED]. Resident #80: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment and was rarely able to understand or be understood. A physician's orders [REDACTED]. A review of the electronic Medication Administration Record [REDACTED]. During an interview on 2/23/17 at 11:00 am, the Registered Nurse Manager (RNM) stated the resident had increasing anxiety issues due to declining health and should have had a CCP in place to address the anxiety, with non-pharmacological interventions as well as PRN [MEDICATION NAME] use. The RNM was unable to locate a CCP addressing these concerns. During an interview on 2/24/17 at 11:30 am, the Director of Nursing (DON) reported the resident should have had a CCP for anxiety and PRN [MEDICATION NAME] administration and he did not. 10NYCRR 415.11(c)(1)

Plan of Correction: ApprovedMarch 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #80 is no longer at the facility.
2. All residents currently receiving antianxiety medications have the potential to be affected. All current prn antianxiety medication orders have been reviewed to ensure a care plan is in place.
3. All resident's with antianxiety medication orders in (MONTH) and march have had their care plans reviewed to ensure they have a care plan for care and treatment of [REDACTED]. Staff will be educated on the PRN orders policy.
4. Audits will be conducted by the Director of Nursing/designee for all new prn antianxiety medications five days a week for four weeks, then weekly for four weeks, then monthly x2.
Results of audits will be presented to the QA committee for review and will continue until otherwise directed by the committee.
5. The Director of Nursing is responsible for continued compliance.

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

Based on observations and interviews conducted during a recertification survey, the facility did not promote care for the resident's in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full respect of their individuality for residents on two (2) of two (2) units and in two (2) of two (2) dining rooms. Specifically: the facility did not ensure that residents' meals were served in the dining rooms at the same time at each table; that residents' were served beverages as requested; that a dining room alarm did not sound multiple times interrupting the resident's dining experience; that facility staff did not feed several residents while standing; that clothing protectors were not piled in the middle of the dining room tables limiting resident space during dining; and that one resident, who sat alone at a dining room table was not served their meal last. Additionally, the facility did not ensure that resident confidential information was not displayed on facility computer screens unattended by facility staff. This was evidenced by: Finding #1: The facility did not ensure that residents' meals were served at the same time at each table in the dining rooms, that residents' were served beverages as requested; that a dining room alarm did not sound multiple times interrupting the resident's dining experience; that facility staff did not feed several residents while standing, that clothing protectors were not piled in the middle of the dining room tables limiting resident space during dining; and that one resident, who sat alone at a dining room table was not served their meal last. Dining room between South/West and North/East nursing units: A lunch meal observation was conducted on 2/21/17 at 12:10 pm. Observations revealed that each resident at a table were not served their meals at the same time. At one table the first resident was served at 12:15 pm, and the last resident was served at 12:30 pm. During this time, residents at other tables were being served, and trays were being taken out of dining area to be delivered to resident rooms. Clean clothing protectors were piled up in the middle of the tables while residents were eating their lunch meal, limiting the amount of space for each resident while he/she ate their meal. At another table, a resident was observed dozing in his chair with his food uncovered. Facility staff did not make any attempts to awaken the resident for the entire meal period. Two staff members observed feeding other residents at the same table, did not provide assistance to this resident. At another table, a facility staff person was standing up while feeding/assisting a female resident. The staff person would then go to a nearby table, kneel down, and feed a resident at that table. She went back and forth between the two tables during the meal. Main dining hall for residents of South/West and North East nursing units: During an observation for a noon meal conducted on 2/21/17 at 12:00 pm, residents were observed in the main dining room at 12:00 pm, with clothing protectors on. The first tray was served at 12:25 pm, and the last tray was severed at 12:58 pm. Residents were heard complaining of hunger. Observations at this time revealed that residents at one table were not served their meals at the same time. There were three staff members passing trays in the dining area while residents at 6 tables were observed watching residents at 4 tables beginning their meal. A Certified Nursing Assistant (CNA) #1 was taking trays out to residents on the unit while residents in the dining room had not yet been served, and the residents' were watching other residents around them beginning to eat. During the passing of trays, the door to the main kitchen, alarmed for over 1 minute several times, from 12:35 pm until 12:58 pm, disturbing the residents who had begun eating. Many of the residents observed were startled each time the alarm sounded. One resident stated I wish they would stop that damn alarm from sounding. The last resident (at table #11) to receive her meal stated several times, I'm starving, I don't know what is taking so long. Two residents that were served first, at two separate tables, were asleep with their food trays uncovered, before staff were able to prompt them awake to begin their meal. One male resident requested another beverage at 12:35 pm, and had not yet received the beverage by 1:00 pm. This resident's wife arrived and requested a beverage a second time. Licensed Practical Nurse (LPN) #1 and CNA #2 were observed talking amongst themselves about personal work issues, unrelated to the residents care needs, while the residents were eating. During an observation for a morning meal conducted on 2/22/17 at 8:00 am, some residents were observed sitting in the main dining room with clothing protectors on. Three facility staff members began serving trays at 8:15 am, and the last tray was served at 8:40 am to a resident at table #10 who was sitting alone. This resident was observed sitting alone, looking around, watching other residents eating around her at table #'s 8, 9, and #11. The resident was not served a beverage until her tray was passed at 8:40 pm, and the resident became anxious by the time her tray came. CNA #1 was observed taking trays out of the dining area to residents in their rooms and halls, before everyone was served in the dining room. Finding #2: North/East and South/West Unit The facility did not ensure that confidential resident information was not displayed on facility computer screens unattended by facility staff. During an observation on 2/23/17 at 11:00 am, a medication cart was observed in the hallway on the North/East unit. A computer with an Electronic Medical Record (eMAR) was observed to be open to a residents medical chart. The opened eMAR was left unattended for 20 minutes. The eMar was open to a residents information while there were residents and families in the hallway, passing by the medication cart while it was unattended. During an observation on 2/23/17 at 2:35 pm, a computer on the South/West unit at the nurses station displayed confidential resident information. There were no staff members in the immediate vicinity while the computer screen was open to progress notes for a male resident. A family member visiting a resident was observed sitting behind the desk using the phone, where the computer was open displaying confidential resident information. A unit LPN was shown the computer, identified the problem, and turned the computer off. Interviews: During an interview on 2/21/17 at 12:55 pm, a resident at table #11 stated that the meals are getting later everyday. She further stated we don't have enough people. It was getting better and now it is getting bad again. She further stated my people at my table are eating and I'm starving. She stated it makes her hungrier when others are eating and she has to watch. The resident also stated the alarm by the kitchen door goes off about three to four times during their meals because the kitchen door is open. She stated it startles me, I wish they would take that out. During an interview on 2/21/17 at 1:10 pm, the Licensed Practical Nurse (LPN) stated the residents are served from the kitchen using their meal tickets. She stated most of the residents in the main dining room are independent and only need queuing during the meal after there meals are set up. She stated there was a delay in getting the noon meal going today and wasn't sure why. She stated that the meal was late today and that they did the best they could with the staff they had. She stated they try to rotate the way they serve the tables every meal, so that the same resident is not last each time. She further stated the residents that are sleeping are supposed to be woken up as soon as the food is put in front of them, so there food doesn't get cold. The LPN stated they have tried different ways to serve the residents, but that it is a work in progress and if there are not enough staff people, they do end up waiting. The LPN stated that the alarm that went off during the meal was a preset alarm that goes off if the door between the kitchen and the dining room is open for too long. She also stated this happens because the door is open while they are serving food during meals, because the door is open and they have to keep resetting the alarm. She stated the residents do complain about it at times and wasn't sure if anyone had done anything to correct this. During an interview on 2/21/17 at 1:30 pm, CNA #1, who passed trays to the hall and rooms, stated that she helps pass trays in the dining room at the beginning of the meal, and when half of the people have their trays she starts to bring trays to the residents that eat in the hall or their room. She stated that most days someone has to wait and that the staff does the best they can. She further stated the Registered Nurse Manager (RNM) or LPN decides who will be in the dining rooms. During an interview on 2/21/17 at 1:45 pm, CNA #2 stated the LPN and she were talking about the new policy that the facility has concerning uniforms. She stated the staff is not happy with the choices and would prefer to use their own uniforms. She further stated that it was not appropriate to be talking about this during the resident's meal time. She stated she was not sure why it took so long for the residents to be served, but that she thinks there is never enough help and that contributes to delays with meals and care. During an interview on 2/21/17 at 2:00 pm, a resident's wife requested to speak with this writer and stated her husband always has to wait for his food when eating in the main dining room. She stated he was upset, because he had asked for another juice a half hour before he got it. She stated the resident's meals have frequently been late and that there is not enough help. She stated that she has talked with the administrator about the long wait at meal times as have other family members, but that nothing has been done. She stated weekends are the biggest problem. During an interview on 2/22/17 at 10:00 am, RNM #1 stated that the assignments for the dining room are done according to staffing. She stated an LPN needs to be in the dining room for resident safety. She stated she wasn't aware there had been a delay with resident's getting served. She also stated staff should not be carrying on private conversations during the meal time. She stated the resident in the main dining room who was sitting alone, frequently gets upset and that the staff should have given her a drink if she had to wait so long for her meal. She further stated that staff members who feed residents need to be sitting next to the resident when assisting them and that it is not appropriate for a staff member to stand while feeding. She also said she was going to review the proper dining room protocol with staff, because this is not acceptable, even if they are short staffed. During an interview on 2/23/17 at 11:00 am, LPN #2 stated the eMAR is never supposed to be left open. She stated the facility educates them on privacy policies and that when a nurse leaves the medication cart, the computer is to be closed to prevent others from viewing personal private information of the residents'. During an interview on 2/23/17 at 3:00 pm, LPN #1 on the South/West unit stated she did not know who left the computer open with the resident's information accessible and turned off the computer. She stated the resident's family member was behind the desk making a call, and there was the possibility that the residents information was seen, but she could not be sure. She further stated that residents family members should not be behind the desk at the nurses station, but that this does happen and that is why it is so important to have all electronic records closed if a nurse is not present. During an interview on 2/23/17 at 3:15 pm, the Director of Nursing (DON) stated the computers should be closed at all times when a nurse is not physically present and using them. She stated that staff would need to be reeducated on the importance of this. 10 NYCRR 415.5(a)

Plan of Correction: ApprovedMarch 28, 2017

1. There were no residents identified as affected.
2. All resident's eating in both dining rooms have the potential to be affected.
All residents have the potential to be affected by open unattended computer screens.
Maintenance will adjust the times for the kitchen door alarm so that it will not alarm during meals.
Signs have been applied to the nurses station to indicate that the phone is for employees only and where to find a public phone.
3. Resident council will determine in which order meals will be delivered to the dining room.
The Director of nursing has reviewed and revised the dignity policy and the dining experience which will include:
*Residents will be offered clothing protectors as they are entering the dining room to wear. Clothing protector have been removed from the tables
*Residents will be encouraged to sit at tables with other residents unless their preference is to sit alone
*Beverages will be served while waiting for meals: As a resident enters the dining room they will be offered a beverage of their choice according to their diet
*Meals will be delivered to all residents at one table before serving another table unless otherwise directed by the resident council
*The employee will always sit when feeding a resident and re approach any resident not eating or sleeping during meals
* The resident is the focal point during dining service
* The employee will refrain from personal conversation with each other
All employees will be in-serviced:
* Report any alarms sounding during a meal
* Lock or close all unattended computer screens
* Direct all visitor/families to the nearest public phones
4. The main dining room alarm will be monitored for sounding during meals, five days a week for four weeks, then weekly x4, then monthly 2 months
The director of nursing/designee will audit unattended/unlocked computer screens five days a week for four weeks then weekly x4 weeks then monthly x2.
The director of nursing/designee will use the Meal/audit tool to include a breakfast, lunch and dinner meal for five days a week for four weeks, then weekly x4 weeks then monthly x2.
The director of nursing/designee will monitor the dining room to indicate if an alarm sounds during meals to include a breakfast, lunch and dinner meal for five days a week for four weeks, then weekly for four weeks then monthly x2.
The results of the audits will be brought to the QA committee and will continue until otherwise directed by the committee.
5. The DON will be responsible for the continued compliance.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview it was determined during the recertification survey that the facility did not ensure each residents' drug regimen was free from unnecessary drugs in 3 (Resident #'s 35, 80 and #81) of 8 residents reviewed. Specifically: For Resident #35, the facility did not ensure that adequate monitoring was completed to determine the effectiveness of antipsychotic medication on an as needed (prn) usage; For Resident #'s 80 and 81, as needed anti-anxiety medications were administered without adequate documentation of the symptoms the resident was experiencing, consideration/use of non-pharmacological interventions, and without adequate monitoring for effectiveness. Resident #35: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident had difficulty being understood by others and has difficulty with understanding others. The Mood/Behavior section assessed no hallucinations or delusions within 7 days of completion of the MDS. The medication section of the MDS also assessed the resident to receive antipsychotic medications each of the last 7 days for the assessment period. The Comprehensive Care Plan for [MEDICAL CONDITION] medications related to behavioral disturbances revised on 12/12/16, listed interventions such as give medication ordered by the physician and monitor/document side effects and effectiveness. The Comprehensive Care Plan for the resident exhibits behavior symptoms revised on 12/7/16, documented no behaviors specific to this resident. Under the Intervention Section the intervention listed to document all behaviors. The Medication Administration Record [REDACTED].) give 1 tablet by mouth every 12 hours as needed (prn) for [MEDICAL CONDITION]/delusions/paranoia on the the following dates; 2/2/17 [MEDICATION NAME] tablet 5 mg by mouth given at 12:06am the chart code E indicated the medication was effective. 2/7/17 [MEDICATION NAME] tablet 5 mg by mouth given at 4:28pm the chart code I indicated the medication was ineffective. 2/21/17 [MEDICATION NAME] tablet 5 mg by mouth given at 7:02pm the chart code E indicated the medication was effective. Progress notes for the following dates indicated that no behavior description was available prior to the resident receiving the medication and/or no description of behavior after administration to determine full effectiveness of the medication was available: 2/2/17 12:06am - no description of behavior the resident was displaying prior to him receiving the [MEDICATION NAME] 5 mg. and no description of behaviors after the resident received the medication. 2/7/17 - the resident was administered [MEDICATION NAME] 5 mg. by mouth at 4:28 pm and the medication was found to be ineffective. An e-Mar Medication Administration Note on 2/7/17 at 6:31pm, documented that [MEDICATION NAME] 5 mg was given and the prn mediation was found to be ineffective. No other description of the resident's behavior was available to explain the behaviors the resident was exhibiting that made the medication ineffective. 2/21/17 7:02pm - no description of the behavior the resident was displaying prior to receiving the [MEDICATION NAME] 5 mg. and no description of behaviors after the resident received the medication. A Medication Administration Note dated 2/21/17 at 10:02pm documented that the prn medication was effective. During an interview on 02/24/17 at 10:45 am, the Licensed Practical Nurse (LPN) stated she would administer medications to the resident such as [MEDICATION NAME] 5 mg for changes of mental status when directed by the nursing supervisor. The LPN stated that she was documenting whether the medication was effective or ineffective and was not aware that additional information was needed to describe the behaviors the resident was displaying. During an interview on 2/24/17 at 10:30 am the Registered Nurse Unit Manager (RNUM) stated that the Medication Administration system will only offer two options for the follow-up status of medications such as antipsychotic's, that being effective or ineffective. The RNUM stated that effective or ineffective are not very descriptive to the physician to monitor the resident's response to or need for the medication. During interview on 2/24/17 at 10:00 am, the Director of Nursing (DON) stated that the resident sundown's in the afternoon at which time he becomes louder, attempts to stand from wheelchair, and may attempt to throw things. The DON stated that vague terms such as effective or ineffective are open to interpretation. The DON stated that she is not seeing 100% compliance from the nursing staff marking effective or ineffective and don't follow-up with more descriptive documentation. Resident #80: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severe cognitive impairment and was rarely able to understand or be understood. A physician's orders [REDACTED]. A review of the electronic Medication Administration Record [REDACTED]resident anxious, climbing from bed stripping). There were no documented attempts to use non-pharmacological interventions and all administrations lacked adequate monitoring for effectiveness. During an interview on 2/23/17 at 10:45 am, Licensed Practical Nurse (LPN) reported she administered [MEDICATION NAME] when the resident showed signs of anxiety such as attempting to climb out of bed or yelling out and she should have documented the behaviors. The LPN further reported that the aides would attempt to toilet or walk the resident prior to her medicating and that she should have documented the interventions. LPN did not know the resident's behaviors after being medicated should have been documented rather than just documenting effective or ineffective. During an interview on 2/24/17 at 11:30 am, the Director of Nursing (DON) reported the QA Committee had audited the medical records for documentation related to PRN medications for behaviors. They found the documentation insufficient and educated the nurses. Upon review of the documentation for this resident the DON stated, further education and follow up is needed due to the continued insufficient documentation and monitoring of effectiveness. Resident #81: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severe cognitive impairment and was sometimes able to understand usually understood. A physician's orders [REDACTED]. A review of the electronic Medication Administration Record [REDACTED]. There was no documentation of non-pharmacological interventions. The symptoms documented as the reason for administering [MEDICATION NAME] were anxiety, family requested, or comfort care. Follow-up was documented as resting or sleeping for four administrations and effective for the remaining eight administrations. During an interview on 2/24/17 at 11:30 am, the Director of Nursing (DON) reported the QA Committee had audited the medical records for documentation related to PRN medications. They found the documentation insufficient and educated the nurses. Upon review of the documentation for this resident the DON stated, further education and follow up is needed due to the continued insufficient documentation and monitoring of effectiveness. 10NYCRR415.12(l)(1)

Plan of Correction: ApprovedMarch 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Residents numbered 80 and 81 are no longer at the facility. Resident number 35 has had the prn [MEDICATION NAME] discontinued.
2. All residents receiving prn antianxiety and antipsychotic medications have the potential to be affected. All current residents receiving antipsychotics/antianxiety medications will be reviewed for documentation of symptoms, non-pharmacological interventions as well as effectiveness.
3. The PRN orders policy was reviewed and revised to include the documentation required for prn medication administration: Symptoms, non-pharmacological interventions and effectiveness when medication is administrated. Staff will be educated regarding the PRN orders policy and revisions.
4. Audits will be conducted by the Director of Nursing/designee for the appropriate documentation related to all prn (antipsychotics/antianxiety) medications. This will be done dailyx5, then weekly x 4 then monthly x 2.
Results of the audits will be presented to the QA committee for review and will continue until otherwise directed by the committee.

5. The DON will be responsible for compliance.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

Based on observation, record review, and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that automatic dishwashing machine are to operate in accordance with the manufacturer's instructions, and food is to be stored in a manner that precludes cross-contamination. Specifically, the automatic dish washing machine was not rinsing in accordance with the manufacturer's instructions, and ready-to-eat foods were not stored safely. This was evidenced as follows: The main kitchen was inspected on 02/21/2017 at 9:00 am. The automatic dish washing machine was rinsing at 150 degree Fahrenheit (F) and zero (0) parts per million (ppm) of available chlorine at fifty (50) pounds per square inch (psi) water flow pressure. Raw pork was stored above ready-to-eat packaged food in the walk-in refrigerator. The automatic dish washing machine instructions were reviewed on 02/21/2017. These instructions state that the final rinse is to be 180 F or 50 ppm available chlorine with a water flow pressure between 15 and 25 psi. The Director of Food Services stated in an interview conducted on 02/21/2017 at 9:00 am, that she did not know why the automatic dishwashing machine was not sanitizing, something must need repair, and the raw food stored above ready-to-eat food must have been an oversight. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.43(c), 14-1.110

Plan of Correction: ApprovedMarch 29, 2017

1. There were no residents identified in this deficient practice.
2. All current residents have the potential for being affected. The necessary part for the dishwasher has been ordered and will be installed upon arrival. The ready to eat packaged food was immediately removed and discarded upon finding.
3. The policy and procedure for sanitary conditions for food storage was reviewed and revised to include the storage of raw meat. Education will be provided to all dietary staff regarding the revised policy. The policy and procedure titled dishwashing was reviewed and revised. Education regarding the dishwashing policy will be provided to dietary staff.

4. Audits will be conducted by the Dietary Supervisor/designee to include temperatures during the rinse cycle of the dishwasher. Audits will also be conducted regarding the storage of raw and cooked meat. Three times daily x7 days for four weeks, then daily x 7 days for four weeks then weekly x4 weeks then monthly x2. An audit will be conducted to measure the water flow pressure on the dishwashing machine daily x7 days for four weeks, then weekly x4 weeks, then monthly x2.
Audits will be brought to the QA committee for review and will continue until otherwise directed by the committee.
5. Dietary Supervisor will be responsible for compliance.

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: February 24, 2017
Corrected date: April 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview during the recertification survey, it was determined that the facility did not conduct the minimum required background checks on new employees. The State Operations Manual paragraph 483.13(c)(1) states that facilities may not employ individuals with a finding entered into the State nurse aide registry (NAR) concerning abuse, neglect, mistreatment of [REDACTED]. Specifically, NAR checks were not conducted prior to hiring on 1 of 5 new employees reviewed. This is evidenced as follows: The personnel files for the MDS (Minimum Data Set) Coordinator was reviewed on 02/21/2017. This review revealed that the MDS Coordinator was hired on 02/15/2017, and the required NAR check was not performed as of the date of this survey review, six days after being hired. The Director of Nursing stated in an interview conducted on 02/21/2017 at 2:35 pm, that after consulting with the responsible staff persons, she does not know why a NAR for the MDS Coordinator was not performed. The facility policy Registry of Nurse Aides was reviewed on 02/22/2017. This policy does not state that all employee applicants will be subject to a NAR check before on the hire date of hire. 10 NYCRR 415.4(b)(1)(ii)

Plan of Correction: ApprovedMarch 28, 2017

1. No residents were identified as being affected. The Nurse aide registry check has been completed for the MDS coordinator.
2. All residents have the potential to be affected. The human resources director has been counseled and reeducated.
3. Education provided to the human resource director regarding the Registry of nurse aides policy. The policy was reviewed and revised to include all new hires be check through the nurse aide registry before start date.
4. Audits will be conducted by the administrator/designee for all new hires for 30 days then five new hires a month for 6 months.
The results of the audits will be presented to the QA committee and will continue until otherwise directed by the committee.
5. The administrator will be responsible for compliance.

FF10 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18):NOTICE OF RIGHTS, RULES, SERVICES, CHARGES

REGULATION: (d)(3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. 483.10(g) Information and Communication. (1) The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. (g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes - (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) [483.10(g)(4)(ii) will be implemented beginning November 28, 2017 (Phase 2)] (iii) Information regarding Medicare and Medicaid eligibility and coverage; [483.10(g)(4)(iii) will be implemented beginning November 28, 2017 (Phase 2)] (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; [483.10(g)(4)(iv) will be implemented beginning November 28, 2017 (Phase 2)] (v) Contact information for the Medicaid Fraud Control Unit; and [483.10(g)(4)(v) will be implemented beginning November 28, 2017 (Phase 2)] (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives: (i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and (ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community. (g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. (g)(16) The facility must provide a notice of rights and services to the resident prior to or upon admission and during the resident?s stay. (i) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. (ii) The facility must also provide the resident with the State-developed notice of Medicaid rights and obligations, if any. (iii) Receipt of such information, and any amendments to it, must be acknowledged in writing; (g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in paragraphs (g)(17)(i)(A) and (B) of this section. (g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident?s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility?s per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility?s per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident?s date of discharge from the facility. v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

Based on medical record review and staff interview during the recertification survey, it was determined that the facility did not ensure that residents and/or their designated representative were notified (2-day notifications) about their right to appeal the discontinuation of Medicare. This was evident for two (2) out of three (3) sampled residents reviewed for the Notice of Medicare Provider Non-Coverage (Residents #'s 82 and 83). This is evidenced as follows: The Notice of Medicare Provider Non-Coverage for Resident #82 was reviewed on 02/22/2017. This document recorded that rehabilitative services for Resident #82 were to end on 12/07/2016, and that the resident was so notified on 10/06/2016. The Notice of Medicare Provider Non-Coverage for Resident #83 was reviewed on 02/22/2017. This document recorded that rehabilitative services for Resident #83 were to end on 12/14/2016 and that the resident was so notified on 12/13/2016. The Administrator and Director of Admissions stated in an interview conducted on 02/22/2017 at 9:10 am, that Resident #82 was admitted for rehabilitative services on 12/02/2016 and could not have possibly signed their The Notice of Medicare Provider Non-Coverage on 10/06/2016, and that they did not know why Resident #83 was not given a 2-day notification. 10 NYCRR 415.3 (g)

Plan of Correction: ApprovedMarch 20, 2017

1. Residents number 82 and 83 have been discharged from the facility.
2. All resident's with Medicare coverage have the potential to be affected.
3. All residents that have been cut from Medicare in the months of (MONTH) and (MONTH) (YEAR) be reviewed to ensure they have received the appropriate Medicare cut letter. Any found that are not in compliance will be reissued.
4.MDS coordinator was hired, educated and designated to issue all two day notices moving forward.
5. Audits will be conducted by the administrator/designee five days a week for four weeks then weekly x4 then monthly x2.
The results of the audit will be brought to the QA committee and will continue until otherwise directed by the committee.
6. The administrator will be responsible for continued compliance.

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident?s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician?s, nurse?s, and other licensed professional?s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review conducted during the recertification survey and abbreviated survey (Case #NY 017), the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. Specifically, for one (1) (Resident #69) of sixteen (16) residents reviewed, a physician's orders [REDACTED]. This was evidenced by: Resident #69: The resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was able to make herself understood and could understand others. The Policy and Procedure (P&P) for Electronic Health Record Medication Orders dated (MONTH) (YEAR), documented telephone orders must be recorded immediately in the resident's eMar by the person receiving the order and must include the date and time of the order. A physician's orders [REDACTED]. Check placement and function every shift. The Comprehensive Care Plan (CCP), for use of an alarmed lap belt related to poor safety awareness, with an effective date of 1/10/17, documented interventions of evaluating continuing risk/benefits of the alarmed lap belt, alternative to and need for ongoing use. An observation on 2/22/17 at 9:30 am, revealed the resident was seated in her broda chair without an alarmed lap belt at the nurses station while supervised by CNA #1. During an interview on 2/22/17 at 9:35 am, CNA #1 stated the resident will sometimes become anxious when seated with the alarm belt in place. She stated the staff will not always attach it for this reason. When the surveyor asked to see the seat belt, CNA #1 was unable to find it on the broda chair. CNA #1 then went into the resident's room to look for another seat belt, but could not find one. During an interview on 2/22/17 at 12:00 pm, the Registered Nurse Manager (RNM) stated after the resident destroyed her seat belt, a replacement should have been put on her chair. Review of a nurses note dated 2/17/17 at 5:16 pm, documented the alarmed seat belt had been discontinued after the resident took it off and destroyed the safety device by ripping it apart. A review of physician's orders [REDACTED]. During an interview on 2/22/17 at 2:20 pm, the agency Registered Nurse Supervisor stated after the resident destroyed the seat belt on 2/17/17 at approximately 6:00 pm, the Director of Nursing told her to notify the physician and an on-call doctor was notified. The RN Supervisor did not enter an order to discontinue it into the computer as she was not aware that this was protocol. During an interview on 2/23/17 at 8:00 am, the Director of Nursing (DON) stated she told the nurse supervisor to call the doctor to discontinue the order. The DON stated the order should have been transcribed into the resident's physician's orders [REDACTED]. 10NYCRR415.22(a)(1-4)

Plan of Correction: ApprovedMarch 20, 2017

1. Resident number 69 had the alarmed lap belt discontinued.
2. All residents that have had the lap belts discontinued have the potential for being affected. All residents with lap belts have had their orders reviewed and no problems have been found.
3. The policy and procedure for electronic health medication orders was reviewed and no changes were made. Staff will be reeducated regarding the policy. A log was created for Supervisors to indicate all telephone orders that are obtained and staff was educated on how to accurately complete the log.
4. Audits of all telephone orders will be conducted by the Director of Nursing/designee to ensure the order was transcribed five times daily for four weeks, then once weekly for four weeks then monthly x2.
Results will be presented to the QA committee for review and will continue until otherwise directed by the QA committee.
5. The DON is responsible for compliance.

FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (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 24, 2017
Corrected date: April 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey and abbreviated survey (Case #NY 017), the facility did not ensure the comprehensive care plan (CCP) was developed and updated to include implemented interventions and tasks which were an accurate representation of actual experiences for one (1) resident (Resident #69) of 16 residents. Specifically, the facility did not ensure the CCP for the resident's At Risk for Falls Careplan was revised to include interventions and tasks being provided by staff on a daily basis. This is evidenced by: Resident #69: The resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was able to make himself understood and could understand others. The Policy and Procedure (P&P) for the Care Planning Process with a revision date of 7/2016, documented the registered nurse (RN) will create, revise and update all goals and interventions. In addition, Care Plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. Review of Incident and Accident Reports and Facility Investigations for (MONTH) (YEAR) and (MONTH) (YEAR) documented: -Resident fell on [DATE] at 2:15 am when, she lost her balance when attempting to ambulate herself from her broda chair. Resident leaned to the left and fell striking her face on the hoyer lift. The resident sustained [REDACTED]. Resident is impulsive with poor safety awareness. -Resident fell on [DATE] at 9:30 am, when she was self transferring and grabbed the wall. She slid down to the floor with no injury noted. -Resident was walking down the hall with the Certified Nursing Assistant (CNA), when the resident lowered herself to the floor on 2/04/17 at 11:15 am, with no injury sustained. -Resident fell on [DATE] at 6:30 pm, when she was found sitting on the floor by her chair at the nurses station with no injury sustained. Resident was noted to be impulsive with decreased safety awareness as she attempted to stand and lost her balance. -Resident fell on [DATE] at 10:10 am, when she tipped her chair sideways by holding onto the siderails in the hall and fell with the chair sustaining no injury. -On 2/20/17 at 7:15 am, a CNA discovered a large bruise to the resident's left buttock and left hip consistent with a recent fall, X-ray ordered by the physician with no further injury noted. During observations on multiple occasions, staff were observed providing the resident with coffee, newspaper to read and were engaging her in conversation as she was being supervised and allowed to accompany a staff member on the unit. The resident was noted to respond positively to these interventions. Review of the resident's At Risk for Falls Careplan did not reveal these individualized interventions. There was also no documented evidence that the interventions provided by staff on a daily basis, were evaluated to determine their effectiveness. During an interview on 2/22/17 at 2:22 pm, the Nurse Manager, who is a Licensed Practical Nurse (LPN), stated the Director of Nursing (DON) and Assistant Director of Nursing (ADON) develop and revise the careplans for her unit. During an interview on 2/24/17 at 8:20 am, the DON stated that the individualized interventions provided by staff on a daily basis should have been added to the resident's At Risk for Falls Care Plan. The DON stated she concentrates on resolving interventions and did not ensure these interventions were part of the careplan, but stated they should have been added. When an inquiry was made to determine if these interventions were listed on the care card, the DON stated no. The DON responded that she did not know the care card and care plans should match. 10NYCRR415.11(c)(2)(i-iii)

Plan of Correction: ApprovedMarch 29, 2017

1. Resident #69 has had the CCP for at risk for falls revised to include interventions and tasks being provided by staff on a daily basis.
2. All residents that are at risk for falls have the potential to be affected. All residents that are at risk for falls will have their care plans reviewed and updated to include interventions and tasks being provided by the staff on a daily basis. These interventions will initially be identified at morning meeting and then reviewed at care plan meetings to review appropriateness and new interventions.
3. CCP policy has been reviewed and revised to include adding interventions specific to the resident. Staff will be educated regarding the revisions to the policy.
4. All residents with falls will have their care plans audited by the Director of Nursing/designee for specific interventions five days weekly for four weeks then weekly for four weeks then monthly x2.
Results of audits will be presented to the QA committee for review and will continue unless otherwise directed by the committee.
5. The DON will be responsible for the continued compliance.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

Based on staff interview and record review during the recertification survey, it was determined that the facility did not exercise the emergency generators as required by adopted regulations. NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.4 requires that emergency power standby systems (emergency generator), including all appurtenant components, shall be inspected weekly and exercised under load for 30 minutes at least monthly. Specifically, the primary emergency generator (generator #5) was not being exercised monthly under load and during 4 of the last 12 months, the secondary emergency generator was not exercised under load conditions for at least 30 minutes. This is evidenced as follows: The test logs for the emergency generators were reviewed on 02/24/2017. No records were available for survey review documenting that generator #5 is being exercised under load for 30 minutes per month. For the secondary generator, the (MONTH) (YEAR) load test was conducted for 25 minutes, the (MONTH) (YEAR) test was conducted for 27 minutes, (MONTH) (YEAR) test for 27 minutes, and the (MONTH) (YEAR) load test was conducted for 25 minutes. The Maintenance Supervisor stated in an interview conducted on 02/24/2017 at 10:30 am that maintenance for generator #5 is provided by an outside contractor and that he did not know the secondary generator had to be exercised under load for 30 minutes per month. 42 CFR 483.70 (a) (1); 2010 NFPA 110 8.4; 10 NYCRR 415.29, 711.2(a)(1); 1999 NFPA 99 3-4.4.1, 3-4.4.2; 1999 NFPA 110 6-4

Plan of Correction: ApprovedMarch 20, 2017

1. No residents were identified as being affected. Generator #5 and the secondary emergency generator were both exercised under load conditions for at least 30 minutes each.
2. All residents have the potential for being affected. There were other no other potential areas that were affected by this. These are the only 2 emergency generators.
3. A new monthly audit tool will be utilized for the Administrator to review the monthly generator logs and sign off only if at least a 30 minute load test was conducted for each of the 2 emergency generators.
4. The new load test audit tool will be reviewed monthly at QAPI and any issue identified will be addressed immediately. The audits will be done for 6 months.
5. The director of maintenance will be responsible for compliance.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

Based on record review and staff interview during the recertification survey, it was determined that the facility did not maintain the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm Code 2010 edition section 14.2.1.2.3 requires that defects and malfunctions shall be corrected. Specifically, the defective smoke detectors were not replaced. This is evidenced as follows: The fire alarm testing reports were reviewed on 02/24/2017. The Inspection Report (testing report) dated 10/26/2016, documented that the smoke detectors in room on the 12 South Unit and the nurse station on the Northeast Unit needed replacement. No records were provided that documented that these smoke detectors were replaced. The Maintenance Supervisor stated in an interview conducted on 02/24/2017 at 10:30 am, that the repairs were not ordered to replace the smoke detectors. 42 CFR 483.70 (a) (1); 2012 NFPA 1019.6.1.3; 2010 NFPA 72 14.2.1.2.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-1.1.2

Plan of Correction: ApprovedMarch 20, 2017

1. No residents were identified as being affected. The identified smoke alarms will be repaired.
2. All residents have the potential for being affected. A full review of the last fire alarm testing report was reviewed and no other items were noted as needing to be repaired or replaced.
3. The Maintenance Director will bring each new quarterly/bi-annual/annual fire system testing reports to the Administrator to review. A tracking tool will be created to note the date of the test and any items identified as needing repair. The tracking tool will be updated as repairs are completed.
4. The repair tracking tool will be reviewed each month at QAPI and any outstanding items will be addressed. This will be continued for 12 months.
5. The director of maintenance will be responsible for compliance.

K307 NFPA 101:FIRE DRILLS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

Based on staff interview and record review during the recertification survey, it was determined that the staff were not familiar with the basic response to fire. NFPA 101 Life Safety Code 2012 edition section 19.7.2 requires that the basic response to fire shall include rescuing occupants involved in the fire, closing doors to confine fire, and training employees in the use of a code phrase to insure the transmission of an alarm when the individual who discovers a fire must immediately go to the aid of an endangered individual (code phrase for fire). Specifically, 4 of 7 staff interviewed were not familiar with the correct procedure used when an endangered individual requires immediate aid in a fire emergency. This is evidenced as follows: The facility emergency fire procedure was reviewed on 02/21/2017. The policy requires that upon discovery of fire, staff persons are to announce Code Red and the location, rescue endangered persons, and close the door to the room in which the fire is located. The Activities Director did not know to announce the code phrase for fire and to rescue endangered persons when interviewed on the basic response to fire on 02/21/2017 at 11:30 am. Certified Nursing Assistant #1 did not include closing the door to the fire room after rescuing endangered persons when interviewed on the basic response to fire on 02/21/2017 at 10:50 am. Maintenance Employee #1 did not include closing the door to the fire room after rescuing endangered persons when interviewed on the basic response to fire on 02/21/2017 at 11:20 am. Dietary Employee #1 did not include announcing the code phrase for fire and closing the door to the fire room after rescuing endangered persons when interviewed on the basic response to fire on 02/21/2017 at 11:20 am. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.2.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.7.2.3

Plan of Correction: ApprovedMarch 20, 2017

1. No residents were identified as being affected. All staff at the facility will be in-serviced regarding the facility?s fire procedure.
2. All residents have the potential for being affected. Competency tests will be conducted for other safety and emergency procedures to ensure that staff are aware of the facility procedures.
The new orientation process will be reviewed to ensure that all safety and emergency procedures are included.
3. Each month, for 6 months, the Facility will conduct random competencies of the facility?s fire procedure. The Random competencies will be done across all departments. A report will be generated showing percentage of compliance.
4. Each month?s fire procedure competencies report will be reviewed at QAPI to measure the percentage of staff that are knowledgeable in the facilities fire procedure. The reports will continue for 6 months.
5. The director of nursing will be responsible for compliance.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.5.2.2 requires that smoke barriers shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. Section 8.3.5 requires that penetrations and miscellaneous openings in smoke barrier walls shall be protected by an approved firestop system or device. Specifically, openings in 1 of 1 smoke barriers observed were either not sealed or not filled with the appropriate materials. This is evidenced as follows. The North Wing smoke barrier wall (wall) was inspected on 02/23/2017 at 1:40 pm. The length of the wall did not meet the underside of the roof by a -inch space. In the corridor, nurse manager office, electrical room, kitchenette, and lounge, the pipes penetrating the wall were either not sealed, had deteriorating construction joint compound, or were not sealed with an approved fire stop system. The Maintenance Supervisor stated in an interview conducted on 02/23/2017 at 3:15 pm, that he was not aware of the penetrations found. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5, 8.5.2.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedMarch 20, 2017

1. There were no residents identified as being affected. The issues identified in the smoke barriers during the re-survey on 2/23/17 will be filled with appropriate fire stop material per code.
2. All residents have the potential for being affected. A physical inspection of the smoke barriers at the facility will be conducted to ensure that all other areas are in compliance. Any area found non-compliant will be filled with appropriate fire stop material per code.
3. The facility will identify each fire and smoke barrier as well as the vertical opening. The facility begin a new policy that will require every contractor and outside vendor scheduled to work on one of the identified walls or vertical openings to notify the maintenance director of exactly what work will be performed and note every hole and penetration done they intend to make. After the work is completed the contractor/ outside vendor will show the Maintenance Director the exact places of the holes which will then be recorded in a new tracking log. The maintenance director will supervise the filling of each hole and penetration with appropriate fire stop material per code and then update the log with the details of the fire stop material used.
4. The new penetration tracking log will be brought to the monthly QAPI meeting for review for 6 months. Any outstanding items will be addressed.
Additionally, every quarter the Administrator and Maintenance Director will conduct a physical inspection of the holes and penetrations per the tracking log to ensure compliance. The physical inspection will also be noted in the log. The physical inspections will be done for 4 quarters.
5. The director of maintenance will be responsible for compliance.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2017
Corrected date: April 24, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.6.2 requires that the walls to vertical openings, such as stairwells, have a 1-hour fire resistance rating and be continuous from floor to roof. Table 8.3.4.2 requires that the doors to stairwells with a 1-hour fire resistance rating have doors with a 1-hour fire resistance rating. Specifically, the stairwell walls were not continuous and the door did not have a label indicating a 1-hour fire resistance rating. This is evidenced as follows: The stairwell was inspected on 02/23/2017 at 2:30 pm. An 8-inch hole, a 3-inch hole, and a 1-inch hole were found for piping and ventilation ductwork; and the door was not a labeled fire door. The Maintenance Supervisor stated in an interview conducted on 12/12/2016 at 1:30 pm, that the door and penetrations found were from the original construction. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1.1, 8.6.2, 8.3.3.1, Table 8.3.4.1; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1

Plan of Correction: ApprovedMarch 20, 2017

1. No residents were identified as affected. The holes identified in the stairwell during the re-survey on 2/23/17 will be filled with appropriate firestop material per code. The door to the vertical opening will be replaced with a door that carries the fire rated label.
2. All residents have the potential for being affected. The remaining area of the vertical opening was inspected for inspections, there were no other vertical openings in the facility.
3. The facility will identify each fire and smoke barrier as well as the vertical opening. The facility begin a new policy that will require every contractor and outside vendor scheduled to work on one of the identified walls or vertical openings to notify the maintenance director of exactly what work will be performed and note every hole and penetration done they intend to make. After the work is completed the contractor/ outside vendor will show the Maintenance Director the exact places of the holes which will then be recorded in a new tracking log. The maintenance director will supervise the filling of each hole and penetration with appropriate fire stop material per code and then update the log with the details of the fire stop material used.
4.The new penetration tracking log will be brought to the monthly QAPI meeting for review for 6 months. Any outstanding items will be addressed.
Additionally, every quarter the Administrator and Maintenance Director will conduct a physical inspection of the holes and penetrations per the tracking log to ensure compliance. The physical inspection will also be noted in the log. The physical inspections will be done for 4 quarters.
5. The director of Maintenance will be responsible for compliance.