Bedford Center for Nursing and Rehabilitation
November 9, 2018 Certification Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews during the recertification survey, the facility did not ensure that the comprehensive care plan (CCP) was revised to reflect resident care needs and that the CCP was prepared by an interdisciplinary team, which included participation of the resident. Specifically, (1) the facility did not review and revise a resident's care plan to reflect application of heel booties while resident is in bed (resident #163); (2) a resident was not able to participate in the care planning process. This was evident for 1 of 2 residents reviewed for Pressure Ulcer (Resident #163), and for 1 of 5 residents reviewed for Participation in Care Planning (Resident #53) out of a total Investigation sample of 35 residents. The finding is: 1) Resident #163 was initially admitted to the facility on [DATE], with a most recent re-admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident is ventilator dependent, alert, and non- verbal. The resident required total care for all activities of daily living. [DIAGNOSES REDACTED]. The Braden Scale for predicting pressure sore risk dated 09/21/18 documented the resident is very high risk for skin breakdown. The Braden Scale for predicting pressure sore risk dated 10/07/18 documented resident is high risk for skin breakdown. A Nursing note dated 9/21/18 documented that redness was noted on both resident's heels, back, and sacrum. A physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) for potential for pressure ulcer, last reviewed on 10/10/18, did not reflect application of heel booties while resident is in bed among the interventions documented. The CCP for potential/actual impairment to skin integrity, last reviewed on 10/10/18, did not reflect application of heel booties while resident is in bed among the interventions documented. On 11/09/18 at 10:25 AM, the Registered Nurse (RN #1) was interviewed. RN # 1 stated that part of her job responsibilities is to review and revise care plans if a resident has a new [DIAGNOSES REDACTED]. RN #1 stated that the resident's care plans for potential pressure ulcer and skin breakdown were completed on 9/10/18. The Care plans were not revised to reflect application of heel booties. RN #1 further stated that the care plans for skin integrity do not mention anything about applying heel booties while in bed. RN #1 stated that usually, when there is a readmission, the care plans are updated to reflect new orders. RN #1 further stated that when the resident returned to the facility on [DATE], the care plan for skin integrity and pressure ulcer should have been updated by the RN on duty. On 11/09/18 at 11:49 AM, RN #5 was interviewed. RN #5 stated that her job responsibilities include supervising the unit and supervising charge RNs, LPNs and CNAs. RN #5 stated that she confirms Doctors' orders, communicates with Doctors, and updates care plans. RN # 5 stated that if a resident returns from the hospital and there is a new [DIAGNOSES REDACTED]. If there are no new orders, we would revise the care plan quarterly. RN # 5 further stated that when a resident is being readmitted to the facility; the nurse who is admitting the resident is supposed to revise the care plan to reflect the new orders. The resident's care plan should have been revised to reflect application of booties while in bed. The care plan should always get revised if there are any new orders or new diagnoses.
2) Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's policy Care Planning -Interdisciplinary Team reviewed 5/2017 documented: the Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The policy further documented that the resident, resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. The Care Plan Conference Summary shall be completed during the conference and include all attendees signatures. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS documented the resident participated in the assessment. On 11/05/18 at 9:34 AM, the resident was interviewed. The resident stated she has not been included in her care plan for the past year. The facility provided the Care Plan Conference Summary document dated 5/16/18 and 8/22/18; which showed the designated area to be signed by the resident/representative was blank. On 11/08/18 at 03:00 PM, an interview was conducted with Register Nurse (RN #8) who stated that after a care plan meeting has ended, each staff who attended the meeting must document a care plan. On 11/07/18 at 03:31 PM, an interview was conducted with the Social Worker (SW) and Social Worker Director (SW Dir.). The SW stated two weeks prior to care plan meetings written invitations are physically handed to the residents, and the residents are also asked where the meeting should be held. The resident's response of yes or no is documented on a sheet that is not kept. A copy of the invitation is kept, but the facility does not have a tracking system verifying delivery to the residents. The SW department presented two out of four requested Care Plan Conference Summary (of who attended the meeting) dated 5/16/18 (blank) and 8/22/18 (resident refused to sign). The document date 8/22/18 was scanned into the EMR (Electronic Medical Record) on 8/23/18, and the scanned version was blank in the area where the resident/representative is designated to sign. On 11/08/18 on 12:11 PM, the SW was interviewed. The SW stated, he dropped the ball and must have the form signed by the resident or document why the resident was not able to sign. The SW stated moving forward, a system to monitor issuance of invitation letters and to ensure that resident/representative signatures or reason not signed is completed on the Care Plan Conference Summary at the end of each care plan meeting will be developed. 415.11 (c) (2) (i-iii)

Plan of Correction: ApprovedDecember 13, 2018

Corrective Actions for Residents Identified:
? Resident # 163 ? heel booties were immediately applied, care plan was updated and involved staff was in-serviced.
? Resident # 53- care plan conference was held on 11/7 at bedside, resident participated and signed ?Care Plan Conference Summary? as attestation of participation
Residents At Risk:
? All residents have the potential to be affected by this practice.
? ? The audit of all care plans for residents with new intervention,diagnoses, medication/treatment change or change in order is being conducted to ensure all interventions are reflected on care plan and accountability record.
? The audit of invitation to participate in a CCP meeting for the past 3 months is being conducted. Any indication of missing invite will be addressed immediately by providing invitation to participate in the nearest CCP meeting
Systemic Changes:
? All Social Service department employees were re-educated on ?Care Planning- Interdisciplinary Team? policy and procedure.
? The audit tool was developed to monitor compliance with invitations and participation.
? All RN?S are being re-educated on periodic care plan review and revision guide with emphasis to ensure timely reflection of new interventions on care plan and accountability record
? The audit tool was developed for monitoring compliance with review and revision of care plan
Monitoring Of Corrective Actions:
? On a weekly basis for one quarter, ADNS or designee will audit care plan for residents readmitted to the facility and residents with the change in status to ensure compliance
Any outstanding issues will be addressed immediately and reported to DNS
? On a monthly basis DNS or designee will report findings to Administrator
? On a quarterly basis DNS or designee will report findings to QAPI Committee
? QAPI Committee to determine if further action is required
? On a Monthly basis for one quarter, the director of social service or designee will audit invitation to participate in a CCP meeting care plan for residents readmitted to the facility to ensure compliance
Any outstanding issues will be addressed immediately and reported to Administrator
? On a quarterly basis Social Service or designee will report findings to QAPI Committee
? QAPI Committee to determine if further action is required

Responsible person: director of Nursing and director of social service

FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, during the recertification survey, the facility did not ensure that residents with limited mobility received appropriate services and assistance to maintain or improve mobility. Specifically, residents at risk for contractures with an order for [REDACTED].#25 and #103). The findings are: 1) Resident #25 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. On 11/05/18 at 6:55 AM, 11/05/18 at 8:30 AM, 11/05/18 at 11:39 AM, and 11/06/18 at 9:22 AM, Resident #25 was observed lying in bed in his room without bilateral hand rolls in place. A Comprehensive Care Plan (CCP) dated 2/13/18 and updated on 9/11/2018 documented that Resident #25 was issued bilateral hand rolls for contracture management. The goal of the CCP is that the resident will not develop complications from use of device and to promote prevention of contractures or further deformities. The interventions document that staff are to apply splint/device as ordered, assess quarterly and as needed, monitor skin integrity, and have physical/occupational therapy screen the resident as needed. The resident's current physician's orders [REDACTED]. The day and evening shift are to remove the hand rolls during hygiene care and perform a skin check. The hand roll order was initiated on 4/11/2018. The Treatment Administration Record (TAR) dated 11/2018 documented bilateral hand rolls are to be present at all times for contracture management. The day shift and evening shift signed the TAR to indicate they performed hygiene/skin checks. The Brace/Splint Nursing Rehab Program Form dated 11/2018 documented that the resident has bilateral hand rolls at all times. Every day and evening shift is to perform hygiene and skin checks. The section for CNA Initials on the 7-3 shift does not reflect signatures for 11/3 and 11/4/2018. The 3-11 shift does not reflect any signatures for 11/1, 11/2, 11/3, 11/4, 11/6, and 11/7/2018. On 11/08/18 at 12:17 PM, the Certified Nursing Assistant (CNA #1) was interviewed. CNA #1 has worked with Resident #25 since 6/2018. He assists the resident by providing total care with all activities of daily living. CNA #1 stated that the resident has hand rolls in place to prevent tightening of his hands. CNA #1 stated that he always places hand rolls in Resident #25's bilateral hands after providing care. The resident is unable to remove the hand rolls on his own without assistance from staff. The hand rolls are only to be removed during care and then placed back into the resident's hands once care is done. 2) Resident #103 was admitted to the facility on [DATE] and has a [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented that the resident had severely impaired cognition and required total assistance with all activities of daily living. Observations were made of Resident #103 in his room on 11/05/18 at 6:55 AM, 8:30 AM, and 11:38 AM, 11/06/18 at 9:51 AM, and 11/07/18 at 9:38 AM. Each time, the resident was observed without bilateral hand rolls in place. The hand rolls were observed to be on the resident's bedside table near the wall and out of reach of the resident. The Comprehensive Care Plan (CCP) dated 2/13/18 and revised 9/17/18 documented that the resident was been issued bilateral hand rolls for contracture management. The goal is that resident will not develop complications from use of device and to promote prevention of contractures or further deformities. The documented interventions are to apply the splint device as ordered, assess quarterly and as needed, monitor skin integrity, and physical/occupational therapy screen as needed. The most current physician's orders [REDACTED]. Hand rolls are to be removed for hygiene and skin checks on the day and the evening shifts. The Treatment Administration Record (TAR) dated 11/2018 documented the presence of bilateral hand rolls to be applied for contracture management every day and evening shift. Remove hand rolls for hygiene/skin checks. The day and evening nurses signed the TAR daily. The Brace/Splint Nursing Rehab Program Form dated 11/2018 documents that the resident has bilateral hand rolls at all times. Every day and evening shift is to perform hygiene and skin checks. The section for CNA Initials on the 7-3 shift does not reflect signatures for 11/6 and 11/7/18. The 3-11 shift does not reflect any signatures for 11/1, 11/2, 11/3, 11/4, 11/5, and 11/7/2018. An interview was conducted with the assigned Certified Nursing Assistant (CNA # 2) on 11/08/18 at 11:06 AM. CNA #2 has worked with resident for a long period of time. She is aware that hand rolls were ordered for the resident. According to CNA #2, the resident will only keep the hand rolls on for 5-10 minutes at a time. He has a behavior of wiping his hands along his body, removing the hand rolls. CNA #2 must reapply the resident's hand rolls several times a day. The resident does not currently have hand rolls in place because he has already removed them. CNA #2 stated that she will apply the hand rolls to the resident's hands again once the housekeeper is done mopping the floor in the resident's room. She stated that the physician's orders [REDACTED]. CNA #2 stated that she has informed the Occupational Therapist (OT) regarding the resident's behavior of removing the hand rolls. On 11/08/18 at 11:46 AM, an interview was conducted with the Director of Rehabilitation Services (DORS). The resident is not currently receiving restorative occupational therapy services. Resident #103 was originally evaluated on 1/24/18 and 2 occupational therapy screens were completed on 6/29/18 and 9/12/18. If nursing staff communicated to the therapists that the resident had any non-compliant behaviors or issues with using devices, the occupational therapist would document this in their notes. There are no documented behaviors regarding non-compliance or difficulty with hand roll usage for Resident #103. An interview was conducted with the charge nurse of the resident's unit, RN #3, on 11/08/18 at 12:24 PM. Once the physician has ordered hand rolls to be in place, the RNs are responsible for documenting on the TAR regarding device usage and whether it is in place. RN #3 has not been made aware of any behaviors that would cause Resident #103 to not have the hand rolls in place. 415.12(e)(2)

Plan of Correction: ApprovedDecember 13, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified:
? Residents # 25 and # 103- handrolls were applied. Orders for handrolls for both residents were revised to ensure they are always in place, except for hygiene, on all shifts.
Residents At Risk:
? All residents with splint/device to promote prevention of contractures or further deformities have the potential to be affected by this practice.
? The audit of all residents with an order for [REDACTED].

Systemic Changes:
? All nursing staff is being in-serviced on:
- Contracture management and use of splint/device
- Importance of following MD orders for splint/device application
? All RNs are being in-serviced on ensuring all splint/device interventions are listed on CNA Accountability
? All CN As are being in-serviced on timely reporting of resident?s non-compliance with splint/device to nurses
? All CN As Are being in-serviced on properly documenting splint/device application, specifically on nursing restorative program form.
? The audit tool was developed for monitoring compliance with splint/device application

Monitoring Of Corrective Actions:
? On a weekly basis for one quarter, DNS or designee will audit 5 residents with an order for [REDACTED].
Any outstanding issues will be addressed immediately and reported to Administrator
? On a monthly basis DNS or designee will report findings to Administrator
? On a quarterly basis DNS or designee will report findings to QAPI Committee
? QAPI Committee to determine if further action is required
Responsible person: Director of Nursing

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not maintain a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a staff member was observed without personal protective equipment (PPE) in the room of a resident on transmission based precautions. This was evident for a random observation on 1 of 5 resident units (Unit 2). The finding is: 1) The facility Infection Control Guidelines for All Nursing Procedures policy dated 1/2018 documents that staff should wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. On 11/08/18 at 11:22 AM, a Respiratory Therapist (RT) was observed in room [ROOM NUMBER] leaning over a resident with gloves on her hands. A sign was observed on the door of room [ROOM NUMBER] that documented Instructions for all personnel and visitors - STOP - contact precaution - wear gown and gloves. A cart containing PPE items (masks, gloves, and gowns) was observed directly outside of room [ROOM NUMBER]. The RT in the resident's room was not wearing a gown. The RT began gathering supplies near the resident's bedside. She then removed her gloves and walked out of the resident's room and used hand sanitizer in the hallway. An interview was conducted on 11/08/18 at 11:22 AM with the RT. The RT stated that PPE equipment should be used when entering room [ROOM NUMBER]. The RT stated that she knows that she should have had a gown in place when entering the resident's room to provide any type of care. On 11/09/18 at 12:03 PM, an interview was conducted with the facility Assistant Director of Nursing Services (ADNS)/ Infection Control Coordinator. The ADNS stated that PPE is to be used for residents on contact precautions. Every staff member and visitor entering the room must put on the ordered PPE. A sign is used to inform each person entering the room of the specific precautions. Infection control in-services are provided quarterly and as needed to update staff and to reinforce adhering to the policies. All staff are provided with the in-service, and all staff must adhere to the infection control policies. 483.80

Plan of Correction: ApprovedDecember 13, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified:
? Respiratory Therapist (RT) observed in room [ROOM NUMBER] was in-serviced on ?Infection Control Guidelines? policy and procedure on 11/8
Residents At Risk:
? All residents have the potential to be affected by this practice.
Systemic Changes:
? All Staff are being in-serviced on ?Infection Control Guidelines? Policy and Procedure
? The use of PPE competency evaluation on all staff is being conducted
? The use of PPE competency evaluation on all staff will be conducted upon hire and annually
? The audit tool was developed to monitor compliance with PPE use
Monitoring Of Corrective Actions:
? On a weekly basis for one quarter, ADNS or designee will observe 3-5 staff members for proper PPE use and adherence to Infection Control policy.
Any outstanding issues will be addressed immediately and reported to DNS
? On a monthly basis DNS or designee will report findings to Administrator
? On a quarterly basis DNS or designee will report findings to QAPI Committee
? QAPI Committee to determine if further action is required
Responsible person: Director of Nursing

FF11 483.10(f)(10(i)(ii):PROTECTION/MANAGEMENT OF PERSONAL FUNDS

REGULATION: §483.10(f)(10) The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds. (i) The facility must not require residents to deposit their personal funds with the facility. If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section. (ii) Deposit of Funds. (A) In general: Except as set out in paragraph (f)( l0)(ii)(B) of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund. (B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interest-bearing account, or petty cash fund.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, during the recertification survey, the facility did not ensure that the resident's right to manage his or her financial affairs was maintained. Specifically, two residents stated that the facility does allow them to withdraw more than fifty dollars each month from their personal accounts. This was evident for 2 of 3 residents reviewed for personal funds (Resident #s 13 and 138). The findings are: The facility's policy Resident Funds, reviewed 4/2018, documented: residents will be entitled to access their funds 24 hours/7 days a week at the facility. 1) Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had intact cognition. During the initial interview on 11/05/18 at 11:11 AM, the resident stated she can only withdraw fifty dollars a month. The resident stated if it runs out I will do without for the rest of the month. On 11/09/18 at 12:50 AM a follow up interview with resident #13 was conducted. The resident stated that she can only withdraw a total of fifty dollars every month. The resident further stated she previously attempted to withdraw an additional $10 within that same month but was not allowed. Resident #13 Funds ledger showed consistent monthly withdrawals of $50 between (MONTH) (YEAR) through (MONTH) (YEAR). On 8/8/18 a total of $50 was debited with a remaining balance of $261.50; on 09/06/18 a total of $50 was debited with a remaining balance of $261.50; and on 10/8/18 total of $50 was debited with a remaining balance of $262.17. 2) Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented the resident had intact cognition. On 11/05/18 at 10:27 AM, an interview was conducted with the resident who stated that she could not withdraw more than fifty dollars a month. Resident #138 Funds ledger showed monthly withdrawals of less than or equal to $32 between (MONTH) (YEAR) through (MONTH) (YEAR). On 8/9/18 a total of $20 was debited with a remaining balance of $682.37; on 09/05/18 a total of $20 was debited with a remaining balance of $717.37; on 10/4/18 total of $20 was debited with a remaining balance of $742.09. On 11/09/18 at 09:36 AM, an interview was conducted with the Medicaid Coordinator (MC). The MC stated residents receive fifty dollars a month from Medicaid, and the residents can withdraw that amount each month even if the residents' balance is greater than fifty dollars. The MC stated she believed Medicaid regulations limited withdrawals to fifty dollars, but there is a misunderstanding by residents who have stated only fifty dollars can be withdrawn each month. The MC stated for large withdrawals, the resident is asked questions related to the need for the amount and how the money will be used to determine if the money would just be stored in the resident's room rather than being used. The MC stated that residents would not be denied their funds. On 11/09/18 at 01:04 PM, an interview was conducted with the Administrator (Admin.). The Administrator stated residents can withdraw any amount from their personal funds, and he was not aware of the fifty dollar withdrawal limit to residents or why staff were asking how the funds would be used when residents requested larger funds. The Admin. stated a staff member would be directed to inform each cognitively intact resident with an account (verbally and in writing) that all residents are entitled to withdraw any amount based on needs or wants without limitation. 415.26(h)(5)

Plan of Correction: ApprovedDecember 13, 2018

Corrective Actions for Residents Identified:
? Residents # 13 and # 138 were informed by administrator that they can withdraw more than $50.00 a month from their personal funds account.
Residents At Risk:
? All residents with personal funds account have the potential to be affected by this practice
? All residents with personal funds accounts received written notification on their right to withdraw personal funds in any amount based on their needs or wants without limitation.
Systemic Changes:
? Medicaid Coordinator was in-serviced by the administrator on resident?s right to manage financial affairs, including withdrawal of money form their accounts without limitation.
? All nurses, social service and recreation staff are being in-serviced by the in-service coordinator on resident?s right to manage financial affairs
? The audit tool was developed to monitor amount of funds withdrawn by residents from their accounts
Monitoring Of Corrective Actions:
? Once a month basis for one quarter, Assistant Administrator or designee will interview 5 to 10 residents of their awareness regarding personal funds
? On a weekly basis for 3 months, Medicaid Coordinator or designee, will provide the administrator with the report of personal funds withdrawal
? On a monthly basis Medicaid Coordinator or designee will report findings to Administrator
? On a quarterly basis Medicaid Coordinator or designee will report findings to QAPI Committee
? QAPI Committee to determine if further action is required
Responsible person: Administrator or designee


FF11 483.10(e)(3):REASONABLE ACCOMMODATIONS NEEDS/PREFERENCES

REGULATION: §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, during the recertification survey, the facility did not ensure that residents received services that accommodated the resident's needs and preferences. Specifically, the call light were not kept within reach of the resident. This was evident for 1 of 5 residents reviewed for the Environment (Resident #13). The findings are: The facility's policy and procedure Call Light Use Of reviewed 8/2017 documented the purpose to assure the call system is in proper working order, including bedside and emergency call lights (in bathrooms). The facility's procedure included guidance to check all call bells daily, be sure all call bells are in residents reach, and call bells that are malfunctioning, resident should be provided with a portable bell. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required extensive assistance of one person assist for bed mobility and toilet use, and the resident required limited assistance of one person for transfers. On 11/05/18 at 11:51 AM and 11/6/18 at 12:50 pm, the surveyor observed the resident's bathroom call light. The call bell's pull string with a black knob on the end was detached from the call light's metal lever/switch. The call light's pull string was hanging on a piece of curved metal just below the call light's metal lever. On 11/08/18 at 02:48 PM, an interview was conducted with Certified Nursing Assistant (CNA #7) currently assigned to the resident. CNA #7 stated the resident usually uses the call light at the bedside to alert staff when assistance is needed to use the bathroom. The resident waits at the bathroom door for staff. CNA #7 stated that the call light in the resident's bathroom was working properly; the CNA and surveyor walked into the resident's bathroom and observed that the pull string with black knob was detached from the metal lever of the call light. CNA #7 stated she was not aware that the pull string was not attached to the call light. She then proceeded to test the call light by pushing down on the metal lever and stated it was working. CNA #7 was asked, if the resident is on the toilet and needs assistance, can the resident use the call light, and the CNA responded no. CNA #7 also placed the black knob with string unto the metal lever and stated that the black knob will not stay on. On 11/08/18 at 03:01 PM, an interview was conducted with CNA #8 who was previously assigned to the resident for (MONTH) (YEAR). CNA #8 was asked to observe the call light in the resident's bathroom, and CNA #8 returned and stated that the call light is working. The CNA was asked if the resident is on the toilet and needs assistance, would she be able to use the call light. CNA #8 responded No. CNA #8 also stated she was not aware that the pull string with black knob was not attached to the call light. The surveyor observed CNA #8 informing Registered Nurse (RN #8) about the resident's call light. On 11/08/18 at 03:45 PM, RN #8 was interviewed. RN #8 stated she routinely visits each resident in their room and test the bedside call lights. She further stated she checked the resident's call light today. RN #8 stated she usually does not check bathroom call lights of residents and was not aware of the issue with the resident's bathroom call light. RN #8 stated the maintenance department was contacted about the matter. In a follow up interview on 11/09/18 at 12:05 PM with RN #8, it was clarified that during morning visits with residents, RN #8 observes if the call lights are within reach of the residents and asks the residents if the call lights are working. RN #8 stated CNAs are responsible for spills, broken items, ensuring appropriate room temperature, heater is working, and other issues in residents' rooms. RN #8 stated that the nursing staff is responsible for determining that call lights work. 415.5(e)(1)

Plan of Correction: ApprovedDecember 13, 2018

Corrective Actions for Residents Identified:
? Resident # 13- bathroom call light was repaired on 11/9/18.
Residents At Risk:
? All residents have the potential to be affected by this practice
? All bathroom all lights throughout facility were checked for proper function. No issues were found

Systemic Changes:
? All nursing staff is being in-serviced by the in-service coordinator on facility policy ?Call Light-Use Of? with emphasis on checking bathroom call lights in addition to bedside call light
? An audit tool was developed for monitoring compliance
Monitoring Of Corrective Actions:
? On a weekly basis for 3 months, DNS or designee, will conduct the audit of at least 5 random rooms for proper bathroom call light function
? On a monthly basis DNS or designee will report findings to Administrator
? On a quarterly basis DNS or designee will report findings to QAPI Committee
? QAPI Committee to determine if further action is required
Responsible person: Director of Nursing

FF11 483.90(g)(2):RESIDENT CALL SYSTEM

REGULATION: §483.90(g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. §483.90(g)(2) Toilet and bathing facilities.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, during the recertification survey, the facility did not ensure that a resident was adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. Specifically, a resident was observed on multiple occasions without an operating call bell in place. This was evident for 1 of 5 residents reviewed for the Environment out of an initial pool of 40 residents (Resident #67). The findings is: The facility's Call Light, Use Of Policy and Procedure dated 8/2017 documented the purpose to assure call system is in proper working order. The policy further documented that staff are to position the call bell conveniently for the resident to use, check all call bells daily and report any issues to the charge nurse immediately, and if the call bell is malfunctioning, provide the resident with a portable bell. Resident #67 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had severely impaired cognition. On 11/05/18 at 6:55 AM, 11/06/18 at 10:01 AM, and 11/07/18 at 9:46 AM, Resident #67 was observed in his bed with no call bell attached to the wall. There was no observed call bell cord hanging from the call bell unit on the wall behind the resident's bed. No other call bell system or manual bell was observed in the resident's room. The call bell light in the hallway above the resident's door was not lit. The Risk For Falls Comprehensive Care Plan (CCP) initiated on 3/5/2018 and updated on 8/30/2018 documents that resident #67 is at moderate risk for falls due to gait and balance problems, incontinence, and the resident being unaware of safety needs. Goals-Will be free of falls through review date. The CCP further documents that the interventions to prevent falls includes ensuring that the resident's call light is within reach and encouraging the resident to use it for assistance as needed. An interview was conducted with the resident's Certified Nursing Assistant (CNA), CNA #1, on 11/07/18 at 12:15 PM. CNA #1 has worked in the facility since 2/2018 and has worked directly with the resident since 6/2018. CNA #1 confirmed that there is no call bell present in the resident's room. He stated that normally, the call bell is placed close to all residents. CNA #1 stated that the resident can ambulate independently, and he believed this was the reason that the resident did not have a call bell in his room. CNA #1 stated that he believes that the resident has not had a call bell in place since he first started working with the resident in 6/2018. He did not inform the nurses or other staff about the resident's missing call bell cord and button. CNA #1 assists the resident with bed baths and toileting. The resident can get out of bed, walk to the door of his room, and wave to staff members to indicate whether he needs something. CNA #1 states that the resident will mainly go to his door and wave for staff when he requires the assistance of the respiratory therapist (RT). CNA #1 states that he believes it is his responsibility to ensure that a call bell is present in each resident's room and to ensure that the call bell is placed within the resident's reach. He stated that he learned in school that the call bell needs to be placed near the resident after providing care in order for residents to communicate with staff if they need something. CNA #1 further stated that he had been in-serviced at the facility regarding alarms, abuse, and infection control but not specifically regarding call bell use. He does not recall whether he was trained and/or ever in-serviced regarding the call bell policy in the facility. CNA #1 stated that his training included shadowing another CNA from the 3rd floor for one day to be competent in providing care to residents. On 11/07/18 at 12:33 PM, an interview was conducted with Registered Nurse (RN), RN #1. She has been a nurse with facility since 6/2018 and a nurse on the resident's unit since 6/2018. RN #1 stated that she is familiar with Resident #67 and she does not believe he uses the call bell. The resident is near the nursing station and staff check on him very often. RN #1 could not recall seeing the resident ring the call bell; however, she stated that the resident would know how to use the call bell if it were placed next to him. She stated that the resident has a behavior of letting the staff know that there is a concern when they conduct their rounds of the unit. RN #1 was not aware that Resident #67 did not have a call bell and/or call bell cord in his room. She will ensure that the Maintenance Department will be contacted to address the fact that the resident does not have a call bell button and cord present. RN #1 was not aware of any physician's orders [REDACTED]. Generally, if the call bell is not functioning, or if it is detached from the wall, the call light above the resident's door will light up and stay on. In addition to the call light above the resident's door, every shift is responsible for completing daily rounds which includes taking note of any issues with call bells or the call bell system. The charge nurse and a RN on the unit are responsible for environmental rounds that are to be completed several times per month. A form with the environmental assignment to be completed is handed out to the charge nurses and RNs by the nursing administration. Environmental rounds were completed on the previous Monday. RN #1 was part of the environmental rounds last Monday and stated that Resident #67 had no observed issues with his call bell. RN #1 stated that every resident is supposed to have their own call bell. She further stated that only residents who are alert and oriented will be able to use the call bells; however, all residents should have a call bell present in their room. Even if the resident has cognitive impairments, a call bell should still be present. An interview was conducted with the Director of Maintenance (DOM) on 11/09/18 at 11:51 AM. He has worked with the facility for approximately 11 months. The DOM stated that the maintenance department is responsible for maintaining all call bells. He personally performs weekly environmental rounds and checks every resident room, common areas, and bathrooms that have call bells. The last weekly check was performed on the resident's unit last Thursday. During rounds, every bell is pressed and the lights are checked to ensure they light up when a call button is pressed, and the general presence of call bell cords are ensured. If the call bell station is malfunctioning, the DOM will try to trouble shoot the issue or will call CCI (the call bell consulting company). The DOM found it hard to believe that Resident #67's call bell light and an audible sound were not triggered by the resident's call bell cord not being in the wall. This is the first time that a resident's cord had ever been out of the wall without any alarms sounding. Whenever there is an issue with call bells, the nursing staff will either call the maintenance department and/or use the maintenance log books located on each floor to ensure communication of the issue. There has been no communication from the nursing staff regarding Resident #67's call bell. On 11/09/18 at 12:17 PM, an interview was conducted with RN #2. He has been with the facility since 1995. RN #2 stated that the CNA #1 reported that there was no call bell in the resident's room following his interview with the SA. RN #2 is not the person that staff would normally contact for call bell issues; however, CNA #1 chose to contact him in this particular case. RN #2 was first made aware of the fact that Resident #67 did not have a call bell cord in his room on 11/7/18. No other issues or reports were made regarding any residents not having a call bell cord or functioning call bell. RN #2 asked maintenance department for a call bell cord and went directly to Resident #67's room to insert the cord in the wall. Once the cord was inserted into the wall, it was pressed and was determined to be functional. A maintenance worker was also sent to the resident's room to ensure that the call bell is functioning properly. RN #2 stated that this is the first time that he has ever encountered a resident who had a cord missing and that the alarm did not sound or go off. 483.90(g)(1)(2)

Plan of Correction: ApprovedDecember 13, 2018

Corrective Actions for Residents Identified:
? Resident # 63- bedside call light cord was inserted on 11/7/18 and checked for proper functioning. Based on review of call bell check it was functioning earlier, however resident pulled it out of the wall.

Residents At Risk:
? All residents have the potential to be affected by this practice
? All call bells throughout facility were checked for proper function. No issues were found

Systemic Changes:
? All nursing staff is being in-serviced on facility policy ?Call Light-Use Of? with emphasis on daily call bell check and reporting of issues
? An audit tool was developed for monitoring compliance with regulation

Monitoring Of Corrective Actions:
? On a weekly basis for 3 months, DNS or designee, will conduct the audit of at least 5 random rooms for call bell presence and functioning.
Any immediate issues will be reported to Director of Maintenance and the Administrator
? On a monthly basis DNS or designee will report findings to Administrator
? On a quarterly basis DNS or designee will report findings to QAPI Committee
? QAPI Committee to determine if further action is required
Responsible person: Director of Nursing

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, during the recertification survey, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Specifically, during multiple observations, a resident was observed in bed without heel booties in place as ordered. This was evident for 1 of 2 residents reviewed for Pressure Ulcer(Resident #163). The finding is: Resident #163 was initially admitted to the facility on [DATE], with a most recent re-admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident is ventilator dependent, alert, and non- verbal. The resident required total care for all activities of daily living. [DIAGNOSES REDACTED]. On 11/05/18 at 09:45 AM, 11/06/18 at 10:47 AM and 03:43 PM, 11/07/18 at 09:51 AM and 12:47 PM, 11/08/18 at 9:50 AM, and 11/09/18 at 10:24 AM, the resident was observed in bed with no heel booties in place. The Braden Scale for predicting pressure sore risk dated 09/21/18 documented the resident is very high risk for skin breakdown. The Braden Scale for predicting pressure sore risk dated 10/07/18 documented resident is high risk for skin breakdown. A Nursing note dated 9/21/18 documented that redness was noted on both resident's heels, back, and sacrum. A physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) for potential for pressure ulcer, last reviewed on 10/10/18, did not reflect application of heel booties while resident is in bed among the interventions documented. The CCP for potential/actual impairment to skin integrity, last reviewed on 10/10/18, did not reflect application of heel booties while resident is in bed among the interventions documented. The Nursing Notes from 09/21/18 to 11/09/18 did not document application of heel booties while resident is in bed. The CNA Accountability sheets from (MONTH) 1, (YEAR) to (MONTH) 8, (YEAR) did not document application of heel booties while resident is in bed. On 11/08/18 at 03:59 PM, the Certified Nursing Assistant (CNA #3) was interviewed. CNA #3 stated that the charge Nurses inform CNAs of any changes in the resident's plan of care. CNA #3 stated that the charge nurses would explain to the CNAs what they are responsible for. CNA #3 further stated that she does skin checks daily, and if she sees any changes in resident's skin condition, she would inform the charge nurse so that the RN can assess the resident. On 11/09/18 at 10:30 AM, the Licensed Practical Nurse (LPN #1) was interviewed. LPN #1 stated that the resident's personal aide is always there monitoring her. LPN #1 stated that she checks to ensure that the personal aide is doing what she is supposed to be doing. LPN #1 stated that if the personal aide is doing something she is not supposed to be doing, we would correct it. LPN #1 stated that the application of heel booties while resident in bed is an active order, and the resident should have heel booties on when she is bed. LPN #1 stated that she is not sure why the resident is not wearing booties. LPN #1 further stated that she will talk to the personal aide to ensure the resident wears the heel booties while she is in bed. On 11/09/18 at 10:25 AM, the Registered Nurse (RN #1) was interviewed. RN #1 stated that on a daily basis, she checks the electronic Medical Record (EMR) to see if there are any new orders, pending orders and labs results. RN #1 stated that she confirms orders and then she carries the orders out. RN #1 stated that at the beginning of the shift, she gets shift report from the nurses on the previous shift. The nurses on the previous shift also inform her about any new orders. RN #1 further stated that she is not sure why the resident is not wearing the heel booties while in bed. RN # 1 further stated that since there is an active order for application of heel booties, the resident should be wearing the heel booties while in bed. RN #1 stated that she recently informed the personal aide that heel booties must be applied while the resident is in bed. On 11/09/18 at 10:52 AM, RN #4 was interviewed. RN #4 stated that the previous shift would inform the incoming shift about any new orders or pending orders. RN # 4 stated that when a doctor puts in new orders, we have to confirm it. If an order is active that means it was confirmed. RN #1 stated that the application of heel booties is an active order and the resident is supposed to have heel booties on while she is in bed. RN #4 stated that the resident has a personal aide so the aide should put it on. RN #4 further stated that it is nursing staff's responsibility to ensure that all physician's orders [REDACTED]. The application of heel booties should be on the CNA task/responsibilities, but the heel booties are not on the current CNA Accountability sheet. RN # 4 further stated that going forward, she will ensure the resident is wearing heel booties while she is bed. On 11/09/18 at 11:49 AM, RN #5 was interviewed. RN #5 stated that her job responsibilities include supervising the unit and supervising RNs, LPNs and CNAs. RN #5 stated that she confirms physician's orders [REDACTED]. RN # 5 stated that after a doctor puts in an order, the nurse checks the order and confirms the order. Once the order is confirmed, the nurse informs the nurse on duty to carry it out. If it falls under CNA tasks, she would add it to their tasks. RN # 5 stated that since the resident has an order for [REDACTED]. RN # 5 further stated that she recently explained to the nurses and personal aide that the heel booties should be on while the resident is in bed. RN # 5 stated that going forward, staff will ensure that all Doctor's orders are carried out. 415.12 (c) (1)

Plan of Correction: ApprovedDecember 13, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified:
? Resident # 163 ? heel booties were immediately applied and involved staff was in-serviced.
Residents At Risk:
? All residents at high risk for developing pressure ulcers have the potential to be affected by this practice.
? The audit of all residents with an order for [REDACTED].
Systemic Changes:
? All nursing staff are being in-serviced on the importance of preventative measures being in place when ordered
? The audit tool was developed for monitoring compliance with preventative measures

Monitoring Of Corrective Actions:
? On a weekly basis for one quarter, ADNS or designee will audit 5 residents with an order for [REDACTED].
Any outstanding issues will be addressed immediately and reported to DNS
? On a monthly basis DNS or designee will report findings to Administrator
? On a quarterly basis DNS or designee will report findings to QAPI Committee
? QAPI Committee to determine if further action is required
Responsible person: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 9, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that the doors to resident rooms were maintained free of impediments to closing in their door frames. Reference is made to the doors to a number of resident rooms that were obstructed by waste baskets. The findings include: On (MONTH) 5 and (MONTH) 6, (YEAR), between 10:00 AM and 3:00 PM, it was observed that the doors to a number of resident rooms were obstructed by waste baskets placed in front of the door leaves, examples were : doors to room #'s 427, 420, 325 and 212. On (MONTH) 16 (YEAR) at approximately 11:00 AM, the facility's Maintenance Director stated that the doors that were held open by means of waste baskets will be adjusted to stay open and will be maintained free of impediments to closing in their door frames. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedNovember 30, 2018

I. Immediate Corrective Action
The maintenance department conducted a survey of all doors of residents? rooms to ensure that they were properly functioning and free of impediments to closing in their door frames. They corrected the ones that were found to be self-closing.
II. Identification of Other Residents
The facility respectfully states that residents could potentially be affected by this deficient practice.
III. Systemic Changes
Maintenance department will be in-serviced to closely monitor proper functionality of all doors. Physical inspections will be conducted quarterly to ensure full compliance.
IV. QA Monitoring
The maintenance director or designee conducted a survey of the entire facility quarterly to ensure all rooms are free of obstructions. This report has been done by the maintenance staff and will be submitted to the QA committee for a review.
Responsible Party: Director of Maintenance

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 9, 2019

Citation Details

Based on observation amd staff interview, it was determined that the facility did not ensure that means of egress were maintained free of all impediments to full instant use in case of fire or other emergency. Reference is made to the flooded exit discharge area immediately outside the basement exit door leading towards the parking lot area. The findings include : On (MONTH) 5 and (MONTH) 6, (YEAR), between 10:00 AM and 3:00 PM ,it was observed that the exit discharge area immediately outside of the exit door from the basement, leading towards the parking lot area,was heavily flooded with rain water. The flooded area was not drained to maintain it free of impediment to the free and safe usage by the facility occupants during fire or other emergency. On (MONTH) 16, (YEAR), at approximately 12:00 PM ,the facility's Maintenance Director stated that exit discharge area was flooded due to malfunctioning of the drainage pump installed for maintaining it free of any standing water. The Director further stated that the needed repairs of the drainage pump were being done to remove the standing water from the exit discharge area . 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedNovember 30, 2018

I. Immediate Corrective Action
The facility retained the services of a plumbing contractor to repair the pump for the storm drain system to prevent flooding from rain water.
II. Identification of Other Residents
The facility respectfully states that residents could potentially be affected by this deficient practice.
III. Systemic Changes
Maintenance department will be in-serviced on the proper inspection requirements confirming that all pumps are functioning properly . The facility will implement an audit procedure for inspection of all electric pumps on a quarterly basis.
IV. QA Monitoring
The facility will conduct an inspection for all electric pumps to the drain system on a quarterly basis. This report will be done by the Director of Maintenance or his designee and submitted to the QA committee for review.
Responsible Person: Director of Maintenance

K307 NFPA 101:HVAC

REGULATION: HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 9, 2019

Citation Details

NFPA 90 A refers to NFPA 80 - Standard for Fire Doors and Other Opening Protective : Section 19.2.3.2 states that the damper access panel shall be labeled with the words Fire Damper in letters not less than 1 inch (25 mm) in height. This standard is not met as evidenced by: Based on observation and staff interview, it was determined that that the facility did not ensure that the damper access panels were labeled with letters required under 19.2.3.2, NFPA 80. Reference is made to the access panels to fire dampers installed in connection with the ventilation duct systems in the basement electrical room. The findings include : On (MONTH) 5 and (MONTH) 6, (YEAR), between 10:00 AM and 3:00 PM, during the recertification survey of the facility, it was observed that the facility had provided fire dampers in connection with ventilation duct systems of the facility. The access panels to the fire dampers located at the duct opening, in the main electrical room, in the basement were not labeled as required under NFPA 101-19.2.3.2, and NFPA 80. On (MONTH) 16, (YEAR), at approximately 12:4 PM , the facility's Maintenance Director stated that that access panels to all dampers,will be labeled with words Fire Dampers in accordance with NFPA 80. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 90A 2010 NFPA 80

Plan of Correction: ApprovedNovember 30, 2018

I. Immediate Corrective Action
The maintenance department conducted a review of all fire dampers and made sure they were labeled properly.
II. Identification of Other Residents
The facility respectfully states that no resident were affected by this occurrence.
III. Systemic Changes
Maintenance department will be in-serviced to ensure all fire dampers are labeled. A thorough review of all fire dampers will be conducted and reported by the Director of Maintenance.
IV. QA Monitoring
The facility conducted an inspection for all fire dampers ensure the labeling is there at all times. This report will be done by the Director of Maintenance or his designee and submitted to the QA committee for a review.
Responsible Party: Director of Maintenance

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 9, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that all exit discharge areas were illuminated in accordance with section 7.8. Reference is made to the lack of illumination at the exit discharge from exit stair East,at the main floor level. The findings include: On (MONTH) 5 and (MONTH) 6, (YEAR), between 10:00 AM and 3:00 PM,during the re-certification survey, it was observed that a lighting unit was lacking at the exit discharge location from exit stairway East,at the main floor level. On (MONTH) 16, (YEAR), at approximately 2:30 PM, the facility's Maintenance Director stated that the lighting fixture at the exit discharge from East stair was removed for some exterior maintenance work. The Director further stated that all exit discharges will be provided and maintained to provide required illumination in accordance with 7.8. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedNovember 30, 2018

I. Immediate Corrective Action
The maintenance department conducted a review of all exit lighting. All light fixtures were found to be operational and compliant with regulations. The lighting unit that was previously removed by construction at the exit stairway east on the main floor level was reinstalled.
II. Identification of Other Residents
The facility respectfully states that residents could potentially be affected by this deficient practice.
III. Systemic Changes
Maintenance department will be in-serviced on the proper inspection requirements for lighting. The facility will conduct inspections for all outside lighting as well as exit and entrance lighting every quarter.
IV. QA Monitoring
The facility will conduct an inspection for all exit lighting and outside lighting on a quarterly basis. This report will be done by the director of maintenance or his designee and submitted to the QA committee for a review.
Responsible Party: Director of Maintenance

K307 NFPA 101:SMOKE DETECTION

REGULATION: Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 9, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that the open spaces to the corridor were provided with a smoke detection system as per 2012 NFPA 101 19.3.6.1 Reference is made to the waiting areas off the lobby that were open to the egress corridors, and lacked a smoke detection system. The findings include : On (MONTH) 5 and (MONTH) 6, (YEAR), between 10:00 AM and 3:00 PM, during the recertification survey of the facility, it was observed that the main floor waiting area was open to the exit access corridor. These open areas lacked the required smoke detection systems per 2012 NFPA 19.3.6.1. On (MONTH) 16, (YEAR), at approximately 1:00 PM, the facility's Maintenance Director stated that that all areas open to the egress corridor will be provided with the required smoke detection system. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedNovember 30, 2018

I. Immediate Corrective Action
The maintenance department conducted a review of all open areas for smoke detector coverage. Alburden Electric Co was contracted and installed smoke detectors on the main floor waiting area.
II. Identification of Other Residents
The facility respectfully states that residents could potentially be affected by this deficient practice.
III. Systemic Changes
Maintenance department will be in-serviced on the proper inspection requirements for smoke detectors. Changes will include implementation of smoke detector inspections on a quarterly basis.
IV. QA Monitoring
The facility will conduct an inspection for all smoke detectors on a quarterly basis. This report will be completed by the director of maintenance or his designee and submitted to the QA committee for review.
Responsible Party: Director of maintenance

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 9, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7 and NFPA 13. Reference is made to the lack of sprinklers or obstructed sprinklers in a number of areas in the building, examples include : In the residents dayrooms, the recessed areas containing electronic charting units lacked sprinkler coverage; sprinklers were lacking under the greater than four feet wide overhang/duct system, in the laundry area; sprinklers were lacking under the overhang, in the main kitchen; obstructed sprinklers by the 12 inches high soffits in the electrical rooms, on first floor and 5th floor,sprinklers obstructed by the solid type of curtains in a number of centralized shower areas; lack of sprinklers in the shower stall, off the Director of Maintenance office, in the basement; and lack of sprinklers under the overhang located in the food Director's office, off the kitchen area. The findings include: On 11/05 and 11/06, (YEAR), between 10:00 AM and 3:00 PM, during the recertification survey, it was observed that automatic sprinklers were lacking or the sprinklers were obstructed in a number of areas of the building, so as not to provide coverage for the entire protected area. in accordance with NFPA 13, examples includes but not limited to the following : (1) In the dayrooms/dining rooms, on the resident floors, ,the recessed areas containing electronic data entry units, lacked sprinkler coverage; The existing sprinklers in the vicinity of the recessed areas were were obstructed by the turn of walls so as not to provide coverage for the entire protected area. (2) In the basement, sprinklers were lacking under the greater than four feet wide overhang/duct enclosure in the laundry area. (3) In the electrical panel rooms, on resident floors, the existing sprinklers were obstructed by an approximately 12 inches high soffits , so as not to provide coverage for the entire protected area. (4) In the basement; sprinklers were lacking under the large overhang containing miscellaneous stored items, in the main kitchen ( 5) In the food service director's office, off the kitchen area, sprinklers were not provided under the overhang/low ceiling containing stored items. (6) Sections of dressing areas, in the centralized shower areas of the nursing units lacked sprinkler coverage. The existing sprinklers were obstructed by the solid type curtains provided at door openings leading to the dressing area, and did not to provide coverage for the entire protected area. (7) The shower stall off the Director of maintenance office, in the basement, lacked sprinklers (8) The recessed alcove storing supply carts area off the centralized whirlpool/bathing areas, on the 2nd floor and first floor, lacked sprinklers. On 11/06/18, at approximately 1:30 PM, the facility's Director of Maintenance stated that the sprinkler company will be contacted to evaluated and provide sprinklers in all areas of the building in accordance with NFPA 13. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedNovember 30, 2018

I. Immediate Corrective Action
Our facility continously inspects and tests the sprinkler system by our in-house staff with a hired licensed sprinkler contractor. Our maintenance director and licensed contractor conducted a survey of the entire facility and they will add heads to all missing sprinkler coverage areas.
II. Identification of Other Residents
The facility respectfully states that residents could potentially be affected by this deficient practice.
III. Systemic Changes
Maintenance department will be in-serviced on the proper procedures of inspecting and maintaining all aspects of the sprinkler system. A new system of inspections of sprinkler coverage will be thoroughly conducted on a quarterly basis.
IV. QA Monitoring
The facility will conduct an inspection of the sprinkler system and sprinkler heads on a quarterly basis. This report will be done by the Director of Maintenance or his designee and submitted to the QA committee for review.
Responsible Party: Director of Maintenance

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 9, 2019

Citation Details

Section 7.2.2.5.3, states that enclosed, usable space within exit enclosures shall be prohibited, including under stairs, unless otherwise permitted by 7.2.2.5.3.2. This requirement is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that the exit stairways did not contain a properly separated enclosed usable space, with an entrance within the stairway as per 7.2.2.5.3.2. Reference is made to the enclosed storage space within exit stairway East, at the basement level, that had an entrance from within the stairway. . The findings include : On (MONTH) 5 and (MONTH) 6, (YEAR), between 10:00 AM and 3:00 PM, during the recertification survey of the facility, it was observed that the facility had constructed an enclosed storage space within exit stairways East, at the basement level. The storage space was noted storing maintenance items for air handing equipment. The enclosed storage space had an entry door from within the exit stairway. On (MONTH) 16, (YEAR),at approximately 12:15 PM, the facility's Maintenance Director stated that enclosed used space contained with exit stairways East, at the basement level will be emptied out and the entry door to the space will be sealed to prevent any further use. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedNovember 30, 2018

I. Immediate Corrective Action
The maintenance department emptied all contents from the storage area. Entry door to the space was sealed to prevent any further use of the area.
II. Identification of Other Residents
The facility respectfully states that no resident were impacted by this occurrence.
III. Systemic Changes
Maintenance department will be in-serviced on the proper inspection requirements for storage.
IV. QA Monitoring
The facility will audit and inspect to ensure that changes were done according to regulations.
Responsible Party: Director of Maintenance

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 9, 2019

Citation Details

NYCRR 713-2.1(d) Heating and ventilating system shall comply with the following : (2)(i): (i) Outdoor air intakes shall be located as far as practical but not less than 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vent stacks, or from areas which may collect vehicular exhaust and other noxious fumes. The bottom of outdoor air intakes serving central systems shall be located as high as practical but not less than six feet above ground level or if installed above the roof, three feet above roof level. This requirement is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that the outdoor air intakes were located at least twenty five feet from any exhaust ventilating systems and the plumbing vent stack. located at least twenty five feet from the exhaust outlets and from the plumbing stack. Reference is made to the air intakes for the central handling equipment installed on the roof of the building that were located less than twenty five feet from any exhaust ventilation fan units and the plumbing vent stacks . The findings are: On (MONTH) 5 and (MONTH) 6, (YEAR), between 10:00 AM and 3:00 PM, it was observed that the facility had installed the central air handling equipment units on the roof. of the building. An interview with the facility staff revealed that the central heating and air conditioning unit were recently installed to serve resident corridors on all resident floors.The air intake for the central and west air handling units were located approximately 10 feet from the toilet exhaust fans and from the plumbing vent stacks. The air intakes for the central air handling equipment cannot be closer than twenty five feet from any exhaust ventilating systems or from any plumbing vent stack. . On (MONTH) 16, (YEAR), at approximately 11:00 AM , the facility's Maintenance Director stated that the central air handling equipment units were installed as replacements for the old air handling equipment. The Director further stated that the company responsible for the installation and maintenance of these units will be contacted to re-design the air intakes for all central air handling equipment so as to be a minimum of twenty five feet from any exhaust ventilating systems and from any the plumbing vent stack. NYCRR 713-2.21(d)(2)(viii) : A manometer shall be installed across each filter bed serving central air systems. This requirement is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that a manometer were installed across all filter beds serving the central air handling equipment located on the roof of the building. The findings include: On (MONTH) 5 and (MONTH) 6, (YEAR), between 10:00 AM and 3:00 PM, it was observed that the facility had installed a number of central air handling system equipment units on the roof of the building. These air handling equipment units were provided with rows of throw-in type filter segments. Manometers were lacking across the filter beds of these air handling system equipment units. On (MONTH) 16, (YEAR), at approximately 11:15 AM , the facility's Maintenance Director stated that that the company responsible for maintaining the central air handling units will be contacted to install the required manometers across across filter beds of all central air handling equipment units the building NYCRR 713-2.22 (g) : (g) Nurse's calling system shall comply with the following : (1) A call button shall be provided at each resident bedside, which calls to the nurse's station. Two call buttons serving adjacent beds may be served by one calling station. Calls shall register with the floor staff and shall activate a visible signal in the corridor at the resident's door, in the clean workroom, in the soiled workroom, and in the nourishment station of the nursing unit. In multi-corridor nursing units, additional visible signals shall be installed at the corridor intersections. In rooms containing two or more calling stations, indicating lights shall be provided at each station. Nurses' calling systems that provide two-way voice communication shall be equipped with an indicating light at each calling station with lights and remain lighted as long as the voice circuit is operating. This requirement is not met as evidenced by: Based on observation, staff interview and testing of the nurses' calling system, it was determined that the facility did not ensure that nurses call system is designed and maintained to active a visible signal in the clean workroom in the soiled workroom, and in the nourishment station of the nursing unit. Reference is made to the lack of functional visual signals in the clean workroom, soiled workroom, and in the nourishment station (pantry) of the nursing unit upon activation of the nurses' calling system by the residents. The findings include: On (MONTH) 5 and (MONTH) 6, (YEAR), between 10:00 AM and 3:00 PM , it was observed that although, the the facility had designed the nurse's call system to activate a visible signal in all required areas, nurses' call system, , did not activate a visible signals, when tested , in the nourishment station ((pantry), in the clean workroom or in soiled workroom of the 6th floor, 5th floor, 4th floor and the 3rd floor nursing units. On (MONTH) 16, (YEAR), at approximately PM , the facility's Maintenance Director stated that the existing nurses' calling system was old and obsolete and hard to get spare parts for the burnt out signals.The Director further stated the facility is in the process of installing a new upgraded nurses calling system in all nursing units that could comply with the required visible signals in all areas of the nursing units.

Plan of Correction: ApprovedDecember 3, 2018

NYCRR 713-2.1(d)
I. Immediate Corrective Action
The facility retained the services of a HVAC contractor to ensure that the intake vent is 25 feet from any exhaust outlets.
II. Identification of Other Residents
The facility respectfully states that residents could potentially be affected by this deficient practice.
III. Systemic Changes
Maintenance department will be in-serviced on the proper inspection of HVAC units. They will be moved to the proper location and safety will be ensured.
IV. QA Monitoring
The facility will audit and inspect to ensure that changes were done according to regulations.

Responsible person: Director of Maintenance

NYCRR 713-2.21(d)(2)(viii):
I. Immediate Corrective Action
The facility retained the services of a HVAC contractor to install a manometer across each filter
bed serving our central air systems. After further investigation the facility learned that each unit has a pre-installed digital manometer.
II. Identification of Other Residents
The facility respectfully states that no residents were affected by this occurrence.
III. Systemic Changes
Maintenance department will be in-serviced on the proper inspection of HVAC unit.
IV. QA Monitoring
The facility will audit and follow up to ensure that proper changes were implemented according to regulations.
Responsible Person: Director of Maintenance
NYCRR 713-2.22 (g)
I. Immediate Corrective Action
The facility retained the services of CCI to upgrade our current call-bell system. We will install the duty station in all mentioned areas.
II. Identification of Other Residents
The facility respectfully states that residents could potentially be affected by this deficient practice.
III. Systemic Changes
Maintenance department will be in-serviced on the proper inspection of the call-bell system. Following the installation of the new call-bell system, the facility will continuously monitor proper functionality of the system.
IV. QA Monitoring
The maintenance director or designee will conduct a survey of the entire facility on a quarterly basis to ensure all call-bells are functioning correctly. This report will be done by the director of maintenance or his designee and submitted to the QA committee for review.
Responsible Party: Director of Maintenance