Hudson Valley Rehabilitation & Extended Care Center
June 21, 2017 Certification Survey

Standard Health Citations

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: July 31, 2017

Citation Details

Based on observation, interview and record review conducted during a recertification survey, it was determined for 2 of 3 nursing units (1st and 2nd Floors) that current acceptable standard of practice regarding storage of insulin injection was not followed. Specifically, multi-dose insulin pens of Humalog and Lantus insulin injections were opened, in use, and not dated. The findings are: 1. Observation of the 2nd Floor medication storage was conducted on 6/21/17 at 2:00 PM. An opened, undated, and in use multi-dose Humalog Insulin pen was found in the East Side medication cart. The medication Licensed Practical Nurse (LPN #1) was interviewed on 6/21/17, at the time of the observation, and stated that the resident who the insulin medication was assigned to, was relocated from another unit on 6/19/17 with the opened, and undated Humalog Insulin pen. 2. Observation of the 1st Floor med storage was conducted on 6/21/17 at 2:30 PM. An opened, undated, and in use multi-dose Lantus Solostar Insulin Pen was found in the East side medication cart. LPN #2 was interviewed on 6/21/17 at the time of the observation, and provided no explanation as to why the insulin was opened, in use, and not dated. The manufacturer of Humalog and Lantus insulins recommended that used (opened) and unrefrigerated insulin must be dated when opened and discarded after 28 days, even if the vials still contain the medicine. 415.18 (d)

Plan of Correction: ApprovedJuly 21, 2017

F431
415.14(h)
483.45(b)(2)(3)(g)(h) Drug Records, Label/Store Drugs and Biologicals
The facility will ensure that all drugs and biologicals will be labeled in accordance with current acceptable standards of practice regarding storage of insulin injections, specifically multi dose pens of insulin injections will be dated when opened and in use as evidenced by:.
1. The nurse on 1E and 2E units discarded the undated insulin pens, opened new ones and dated the pens as required. Both Nurses were reeducated on dating insulin pens when opened and the proper storage of insulin. These will be filed in their employee record. Completed: 7/14/17
2. All nursing unit storage room refrigerators where unopened insulin is stored was checked for insulin storage and all insulin and insulin pens were in compliance- labeled and dated per requirements. All medication carts were checked for insulin pens in use and placed in a separate compartment in the medication cart. All insulin pens were noted to be dated and in compliance with the 28 day storage limit. Completed: 7/19/17
3. All licensed nurses will be re-educated by the DNS and ADNS on storage and labeling of drugs and biologicals. The policy and procedure for the storage of drugs and biologicals with regards to insulin pens will be revised to reflect the changes as described above for observation and compliance of same. Completion: 7/31/17
4. Ten medication pass audits weekly will be done to include the observation of all insulin storage compartments in the medication rooms and carts to verify compliance is maintained with proper storage and labeling of unopened and opened insulin/insulin pens by the DNS and ADNS. All licensed staff with access to the medication storage rooms and carts will document every shift the compliance with the storage and labeling of insulin, in the Insulin Storage/Label Verification Log Book. The documentation will verify that all unopened insulin is in the medication room refrigerator insulin storage compartment. All opened, in use insulin pens are in the storage compartment in the medication carts and dated with the opened date and expiration date in accordance with the 28 day storage limit. Completion: 7/31/17 and on-going
5. Overall Responsibility: Director of Nursing


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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: July 31, 2017

Citation Details

Based on observation and interview conducted during a recertification survey, the facility did not ensure safe food storage and handling of resident food brought in by visitors and family members. Specifically the refrigerators on 4 of 5 resident units (1 East, 3 West, 2 East, and 2 West) contained foods that were either unlabeled, undated, or expired. Additionally, there was no temperature monitoring of food being reheated on the resident units. The findings include but are not limited to: All the refrigerators on the resident units were observed between 11:30 AM and 12:00 noon on 6/15/17. The following were observed: 1. Unit 1 East: A container of pasta and sausage was labeled and dated 6/4/17. The LPN (Licensed Practical Nurse) was interviewed at that time and stated that the container may have been mislabeled. A Certified Nursing Aide (CNA) was interviewed at that time and stated she would throw it away. The CNA stated that after two days, things need to be thrown out if the foods were not properly labeled. When asked who is responsible in checking the refrigerators, the LPN stated the night shift checks and that food can be kept for 24 hours. The unit RN manager and the LPN were interviewed on 6/15/17 at 11:35 AM regarding how they heat up the food for the residents. They stated they have a microwave. When asked who checks the temperature to make sure the food has been reheated properly they stated they understood, but no one really checks. The Food Service Director was interviewed on 6/20/17 at 2:30 PM and stated that the policy is that food can be stored on the unit refrigerators for 72 hours and that foods were not supposed to be reheated on the units. 2. Unit 3 West: Multiple containers of food items including jelly, mayonnaise, salad dressing, and coffee creamer were not dated. The LPN stated she was unsure how long things can be stored in the refrigerator. 3. Unit 2 West: A clear plastic container labeled fish cake and a plastic container of unknown food had a name but no date were found in the freezer. Additionally, a chef salad dated 6/14/17 and a Styrofoam container of meat and rice dated 6/7/17 were found. The unit Registered Nurse (RN) manager stated that food can be kept for 72 hours. 415.14(h)

Plan of Correction: ApprovedJuly 21, 2017

F37
415.5(B)(1-3) 483.60 (I)(1)-(3) Food Procure, Store/Prepare/Serve ? Sanitary
The facility will ensure safe food storage and handling of resident food brought in by visitors and family members. This is evidenced by:
1. Unit 1E container dated 6/4/17 was thrown out. Jelly, mayonnaise packets, salad dressing, coffee creamer packets were removed from the refrigerators on 3W. The undated fishcake container, the chef salad of 6/14/17 and rice and meat container dated 6/7/17 on 2W were discarded. Completion: 6/21/17
2. All units were checked again and no other findings were found at that time. Completion: 6/22/17
3. The policy was reviewed and updated to include new labels, reheating foods and use of thermometers and storage of prepared condiments (expiration date of the products). Completion: 7/14/17
Date labels and disposable thermometers are available at the refrigerators to ensure items are dated, names of residents are on them and that reheated items are at the right temperature. Completion: 7/19/17
All nursing and dietary staff will be educated on the revised resident food storage, labeling and reheat policy. Completion:7/31/17
Residents will be informed of the policy via next Resident Council meeting. Families will be notified of policy through the admissions process, mailings and handouts at the reception desk.
Completion: 7/31/17
4. Current pantry refrigeration audits will be updated to include changes made to policy. Three random audits at varying times will be conducted weekly for three months to assure compliance and as directed by the QAPI committee thereafter. Results of the audits will be communicated to the QAPI team.
Completion: 7/31/17 and on-going
5. Overall Responsibility: Assistant Director of Nursing

FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: July 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure for 1 of 2 residents (#229) reviewed for choices that the medical provider was informed of the resident's request to discontinue, alter or start a new form of treatment to maintain the resident's health and well-being. Specifically, the medication Licensed Practical Nurse did not inform the resident's attending physician in a timely manner of the resident's request to stop a medication ([MEDICATION NAME]; a stool softener) for early intervention and attempt to conduct further assessment or investigation to determine the reason for the resident's refusal of the medication. The findings are: Resident #229 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment tool) of 6/12/17 indicated the resident scored 12 out of 15 on the BIMS (Brief Interview for Mental Status; used to measure memory recall and orientation) which suggested that the resident had no cognitive impairment. This MDS further revealed that the resident was always incontinent of bowel. The physician's orders [REDACTED]. The most common adverse effect of the pain medications is constipation. The comprehensive care plan (CCP) for Elimination of 6/21/17 had a goal that the resident will have spontaneous bowel movement three times weekly during the next 90 days. Interventions to achieve this goal included, but are not limited to monitor bowel pattern every shift and record, monitor bowel pattern for need for intervention and notify the physician, monitor for signs and symptoms of constipation, and administer [MEDICATION NAME] 100 mg every 12 hours and monitor for effectiveness and adverse effects such as weakness, dizziness, and excessive bowel activity and report to the physician for early intervention. The Medication Administration Record (MAR) for period 6/01/17 to 6/30/17 revealed that on 6/10/17 at 9:00 PM, 6/11/17 at 9:00 AM, 6/15/17 at 9:00 AM and on 6/17/17 at 9:00 PM, [MEDICATION NAME] was encircled which suggested that this medication was not given. Further review of the MAR and the Nurses Notes inclusive of the above dates when [MEDICATION NAME] was not given, revealed no documented evidence that the resident refused or the reasons why the medication was not given. The resident's bowel log summary revealed that the resident had medium to extra large amount of stools from 6/8/17 to 6/21/17, except for 6/19/17 when the resident had no bowel movement. This bowel log did not describe the consistency of the stools. The resident was interviewed on 6/15/17 at 3:00 PM. When asked if the staff includes him in decisions about medications and treatments, the resident stated he keeps telling the staff that the stool softener is giving him diarrhea and he wants it to be discontinued. The resident stated that he keeps having to pick it out of the medication cup containing all his other medications. The LPN (Licensed Practical Nurse) who occasionally gives medications to the resident was interviewed on 6/21/17 at 10:15 AM and stated that she was aware that the resident did not want the medication. She stated that he probably gets it because he is on pain medications. When asked if she informed anyone that the resident wants the medication stopped, she stated she had told the nurse who took over for her on the evening shift but she couldn't remember who it was. There was no documented evidence that any referral was made to the attending physician following four episodes of the resident's possible request to stop the medication for early intervention, and (2.) an assessment or an attempt to interview the resident as to why he wants the medication stopped, were conducted. The unit RN manager and the LPN charge nurse were interviewed on 6/21/17 at 10:20 AM and they stated that the issue had not been brought to their attention. The unit RN manager stated that she would speak to the resident and offer him alternatives. The DON was interviewed on 6/21/17 at 11:30 AM regarding the resident's discussion with the LPN about stopping the stool softener. The DON stated the LPN should have spoken to the doctor about it to find out if the medication was still necessary or alternatively, she could have told the unit RN manager. Further review of the CCP for Elimination revealed that on 6/21/17, the physician discontinued the [MEDICATION NAME] per resident's request. 415.3(e)(2)(ii)(b)

Plan of Correction: ApprovedJuly 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F157 483.10(g)(14) The facility will ensure that proper Notification of Changes in resident care or treatments are communicated immediately to the resident or representative, when the physician needs to discontinue an existing form of treatment, or to commence a new form of treatment. This is evidenced by:
1. Resident #229 was admitted for short term post acute care on 6/5/17 with the order for twice daily [MEDICATION NAME]. [MEDICATION NAME] was discontinued once nursing was told by surveyor that he told her he feared getting diarrhea from it on 6/21/17. The attending MD arrived the same day the concern came up and he was asked to review the [MEDICATION NAME] order by nursing when they told him the resident did not want it and refused it 4 times during his stay. He reviewed the MAR and agreed to discontinue the [MEDICATION NAME].
Completed: 6/21/17
2. The facility will review all resident MAR (Medication Administration Records) for documentation of refusals, discuss with resident as appropriate the reason for the refusals if not stated or clear, and MD will be notified of the refusals to determine if further intervention is necessary and the outcome will be documented in the medical chart.
Completion: 7/31/17
3. The nurses were counseled and filed on refusals of medications and ascertaining why they are refusing when they are vague about the refusals so an intervention can be initiated if necessary with the MD/NP.
Completed: 7/21/17
Refusal of medication policy was updated/revised to address notification of refusal and changes as appropriate.
Completion: 7/21/17
4. Reeducation will be provided to the nursing department on communication of resident refusals of medications that may come up so that nurse in collaboration with the MD /NP can review the request with the resident and implement an immediate change in the plan of care if indicated.
Completion: 7/31/17
5. All new resident medication records and five existing resident medication records will be audited per unit with emphasis on resident to refusal of medication per policy and evaluate physician notification and interventions taken if any and documentation (progress note, care plan change) of same. Audits will be conducted monthly for three months and as directed by the QAPI Committee thereafter until compliance is established. All findings will be reported to the QAPI committee.
Completion: 7/31/17 and on-going
Overall Responsibility: Director of Nursing Services

FF10 483.10(f)(1)-(3):SELF-DETERMINATION - RIGHT TO MAKE CHOICES

REGULATION: (f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. (f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. (f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: July 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure the resident's right to make choices about aspects of her life that are significant for 1 of 2 residents reviewed for choices (#22). Specifically, Resident #22's preferences to have an assistive positioning device (half siderail) to be in place while she's out of bed, and to keep her room hot, were not considered provided that the resident's safety and well-being were compromised. The findings are: Resident #22 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS; a resident assessment tool) dated 10/29/16 indicated that resident had a Brief Interview for Mental Status score (BIMS; used to measure memory recall and orientation) of 15 out of 15 which suggested that the resident had independent and reasonable decision-making skills and had no behavior issues. The resident was interviewed on 6/19/17 at 11:30 AM and was asked if the staff treats you with respect and dignity, the resident stated that the assigned Certified Nurse Aide (CNA) was not friendly. According to the resident, she asked the CNA to leave the half side rails up on her bed because they help her to get into bed. The CNA told the resident that the side rails should be down when she is not in bed. The resident further stated she likes her room hot. The CNA told her that the CNAs will pass out if the room was too hot. The CNA was interviewed on 6/21/17 at 10:15 AM and stated that she has been trained that the side rails have to be down when residents are out of bed and that it's for safety reasons. When asked about the heat in the resident's room, the CNA stated that it's been an ongoing issue with the resident and that the unit Registered Nurse (RN) manager and the Director of Nursing (DON) had been involved as well. She stated that the resident leaves the heat on while she is in the room but when the resident leaves, she goes back in and turns it off to cool it off a little. When the resident comes back she turns it back on. The RN unit manager was interviewed at that time and stated that the resident has her own room for that very reason. The DON was interviewed further on 6/21/17 at 11:00 AM and stated that the side rails should be down when the resident is out of bed since the reason for the side rails is for bed mobility and the resident is not in bed. The DON stated it has nothing to do with safety and that if a resident wants the side rails to be kept up they can be kept up. The DON stated further that every resident is initially evaluated for the use of side rails and if a resident requests to have the side rails left up they will be reevaluated to determine if it is safe to do so. The unit RN unit manager was interviewed on 6/21/17 at 11:20 AM and stated that she was unaware that the resident had requested that the side rails be left up when the resident is out of bed. When asked if the CNA ever mentioned this to anyone she stated she had not. She stated that the assigned CNA should have reported this issue so the resident can be evaluated to have the side rails up when out of bed. 415.5(b)(1-3)

Plan of Correction: ApprovedJuly 21, 2017

F242 483.10(f)1. The facility will ensure that the resident right to make choices about his/her life that are significant to the resident are addressed. This is evidenced by:
1. Resident #22 was immediately interviewed by the RN nurse manager when she was made aware of the resident request. The RN discussed with the resident why she wanted them up when out of bed. Resident was then evaluated by the nurse for the side rails to be up when she was out of bed. The resident was given the benefits and risks of having them up while out of bed, reminded of her history of attempting to get back in bed without assistance and potential for falling and injury. Resident #22 stated she understood. Her care plan was updated to reflect change.
Completed: 6/21/17
2. The facility will continue its ongoing effort to reassess all residents with side rails, the appropriateness of side rail use and reason to use or not use, resident?s choice as appropriate and documented education is provided to the resident on the risk and benefits of use. Care plans of residents will be completed and updated accordingly to reflect this in their plan of care. Completion: 8/18/17

3. The C.N.A. was counselled verbally on 6/21/17 and formally counselled and filed by DNS on how to deal with refusals or choices and preferences (room hot, rails up when out of bed) that differ from the plan of care, communication with the nurse to address the resident issues and choices by residents.
Completion : 7/11/17

Reeducation will be provided to the nursing department on communication of resident choices(change or preference from the current care plan) that may come up so that nurse in collaboration with the MD /NP can review the request with the resident and implement an immediate change in the plan of care if indicated. Reeducate the IDT to address these choices and any choices as indicated at scheduled care plan meetings. Stop and Watch, an Interact tool, will be reeducated to all nursing staff to use as a communication tool to alert IDT of any refusals or choices that are new or is a change in the current plan of care that a resident is communicating with them.
Completion: 7/31/17
4. Five random audits will be conducted on all units for side rail use and the resident choice for same as applicable monthly. All results and modifications will be presented to the QAPI Committee for review for three months and quarterly until compliance is established.
Completion: 7/31/17 and on-going
5. Overall Responsibility: Director of Nursing Services

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 18, 2017

Citation Details

2011 NFPA 96 11.2.1 Inspection, Testing, and Maintenance of fire -Extinguishing Systems. 11.2.1 * Maintenance of the fire-extinguishing system and listed exhaust hoods containing a constant or fire actuated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. Based on observation and interview, the facility did not ensure that all components of the hood extinguishing system in the kitchen were properly maintained in that the exhaust hood cleaning was not serviced semi-annually, as per NFPA 96. This is evidenced by the service report for the hood duct that was dated 11/10/16. The findings are: During a tour of the kitchen conducted on 6/20/2017 at approximately 11:45 AM, it was noted that the last hood exhaust cleaning took place on 11/10/16. A current service report of the system was not provided by the facility. In an interview at the time of the findings, the Director of Facilities stated that the exhaust system was recently serviced. He further stated that he will contact the vendor to obtain the report. 2012 NFPA 101: 19.3.2.5.1 2011 NFPA 96: 11.2.1 * 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 18, 2017

K324-2011
2012 NFPA 101: 19.3.2.5.1
2011 NFPA 96: 11.2.1 *
10 NYCRR 711.2(a)(1)
The facility will insure that all components of the hood extinguishing system in the kitchen are properly maintained in that the exhaust hood cleaning is serviced semiannually per NFPA 96 as evidenced by:
1. The kitchen exhaust hood was cleaned on 6/29/17 by Sani Systems. Completion: 6/29/17
2. There are no other kitchen hoods that require cleaning. Completed: 6/30/17.
3. A calendar reminder has been set up as a reminder to have the hood cleaned every 6 months with both the Maintenance Director and Dietary Manager. The next 6 month cleaning has already been scheduled with the hood cleaning company. Findings will be reported to the QAPI committee for the next meeting. completed: 7/31/17
4. Any findings of the recent service will be reported to the QAPI committee for the next meeting and any future service and findings. Completion by: 7/31/17 and on-going.
5. Overall responsibility: Maintenance Director

K307 NFPA 101:ELECTRICAL SYSTEMS - MAINTENANCE AND TESTING

REGULATION: Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 18, 2017

Citation Details

Based on observation, interview, and record review, the facility did not provide documentation that the non hospital-grade electrical receptacles installed in resident care rooms on 3 of 3 resident floors were tested at intervals not exceeding 12 months in accordance with NFPA 99. The findings are: On 6/19/17 at approximately 11:15 AM, the maintenance documentation for the facility's non hospital- grade electrical receptacles was not provided. In an interview at the time of the findings, the Director of Facilities stated that he does not have the documentation that the electrical outlets are inspected and tested . 2012 NFPA 99: 6.3.4.1.3 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 19, 2017

K914-
2012 NFPA 99: 6.3.4.1.3
10 NYCRR 711.2(a)(1)
The facility will insure that Electrical systems maintenance and testing are in accordance with NFPA 101 and will be inspected and tested as evidenced by:
1. The facility created an outlet preventative maintenance log to include all non-hospital grade electrical receptacles which includes GFI outlets for inspection and testing. Completion: 6/26/17.
2. All electrical receptacles including GFI outlets in the facility were inspected and tested . Completed: 6/30/17.
3. An preventative maintenance order and audit was created for monthly inspection and testing of all outlets including GFI outlet receptacles. The results will be recorded on the logs. All maintenance staff will be educated on this requirement and the expectations of the PM. Completed: 7/14/17
4. Audits for GFI outlets will be conducted monthly and all other outlets annually. Any findings and any corrections made from auditing will be reported to the QAPI committee for three months and continue as part of the preventative maintenance program thereafter. Completion: 7/31/17 and on-going.
5. Overall responsibility: Maintenance Director.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 18, 2017

Citation Details

Based on observation and interview, the facility did not ensure that hazardous areas were protected by an enclosure that is separated from other spaces by smoke partitions. This was evidenced by doors to storage rooms in the basement that did not latch upon self - closing and or damaged smoke partition walls that will not resist the passage of smoke. The findings are: During the life safety tour of the basement on 6/20/17 between the hours of 11:00 AM - 2:30 PM, the following issues were noted: - At approximately 11:15 AM, a tour of the housekeeping storage room was conducted. Upon testing of the corridor door to the room, it was noted that the door did not latch upon self-closing. The door rested on the frame. - At approximately 11:35 AM, a tour of the laundry room was conducted and it was noted that the door did not latch upon self-closing. The door rested on the frame. This was also noted for the corridor door to the clean linen storage room. - At approximately 11:40 AM, the soiled linen room was toured and 3 of 4 smoke partition walls were noted to be damaged. In an interview at the time of the findings, the Director of Facilities stated that the doors to the storage rooms are checked monthly. He further stated that the doors and walls to the storage rooms will be repaired to resist the passage of smoke. 2012 NFPA 101: 19.3.2.1, 19.3.2.1.2*, 19.3.2.1.3, 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJuly 18, 2017

K321-
2101 NFPA 101:19.3.2.1, 19.3.2.1.2*, 19.3.2.1.3
The facility will insure that hazardous area enclosures are maintained in accordance with NFPA 101.

1, The Housekeeping door and the laundry door was repaired on 6/20/17.
The soiled linen room walls and ceilings repairs were completed. Damage resistant wall coverings were added to the walls in the soiled utility room to reduce any further damage. Completion: 6/30/17
2, The rest of the building was inspected and no further issues were found. Completed 7/12/17.

3, An preventative maintenance work order and audit was created to check that all identified hazardous area door enclosures in the facility are maintained to be done on a monthly basis. All maintenance staff will be re-educated on the requirements and expectations. Completion: 7/18/17
4, Audits will be conducted weekly and as indicated thereafter to the QAPI committee. All findings and corrective measures will be reported to the QAPI committee for three months as directed by the QAPI committee. Completion 7/31/17 and on going.
5, Overall responsibility: Maintenance Director.

K307 NFPA 101:SMOKING REGULATIONS

REGULATION: Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 18, 2017

Citation Details

Based on observation and interview, it was determined that the facility did not ensure that smoking areas in the facility were equipped with self-closing metal containers in accordance with NFPA 101 19.7.4. Reference is made to the 2 smoking towers that were observed in the designated smoking area. The findings are: On 6/20/17 during the annual recertification survey at approximately 1:20 PM, it was observed that there were nine people smoking. Five people were smoking in the smoking shed and there was one smoking tower available and four people were smoking outside the smoking shed with one smoking tower available. However, it was noted that the smoking towers were not being used and ashes were being dumped on the ground. The required ashtrays of non combustible material and safe design and metal container with self-closing cover devices into which ashtrays can be emptied were lacking and not provided in the smoking area. In an interview at the time of the finding, the Director of Facilities acknowledged that the smoking towers were not in use by the smokers. He further stated that the required ashtrays will be provided. 2012 NFPA 101: 19.7.4 711.2(a) (1)

Plan of Correction: ApprovedJuly 18, 2017

K741-
2012 NFPA 101: 19.7.4
711.2(a)(1)

The facility will ensure that smoking regulations are in accordance with NFPA 101 19.7.4, and equipped with self-closing metal containers evidenced by:
1. Additional Ash trays meeting the code were purchased. The Resident smoking area was swept after the surveyor noted ashes being dumped on ground by the Geri-Aide who supervises the smoking area and keeps the area clean through out the day. Completed: 6/21/17.
2. There are no other Resident designated smoking areas as the facility property is otherwise smoke-free. Completion 6/21/17.
3. New additional compliant ash trays (4) were purchased and installed on 7/3/17. The Geri-Aides that supervises the smoking area will be educated on the use of the ash trays, that they are used safely and that all Residents using the area will have access to an ash tray while smoking. Residents smoking will be educated on using the ash trays provided and not throwing ashes and butts on the ground. Completion 7/31/17.
4, A weekly visual random audit will be conducted and documented to assure the use of ash trays in the smoking area. The findings will be reported to the QAPI committee monthly for three months to insure compliance. Completion: 7/31/17 and on going.
5, Overall responsibility: Maintenance Director.

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: June 21, 2017
Corrected date: August 18, 2017

Citation Details

2012 NFPA 101 7.2.2.5 Enclosure and Protection of Stairs 7.2.2.5.3* Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Based on observation and interview, the facility did not ensure that the stairways were used in accordance with NFPA 101. Reference is made to 2 large storage bins stored at the bottom landing in 1 of 3 stairwells. During the life safety code survey conducted on 6/20/17 at approximately 11:05 AM, an examination of the center stairwell revealed 2 large bins of paper for shredding, stored at the bottom landing of the center stairwell near the emergency exit. In an interview at the time of the findings, the Director of Facilities stated that he was unable to find a storage space for the bins. He further stated that the bins will be removed. 2012 NFPA 101: 19.2.1 711.2 (a)(1)

Plan of Correction: ApprovedJuly 19, 2017

K225
2012 NFPA 101 7.2.2.5 Enclosure and Protection of Stairs
The facility will ensure that stairways are used in accordance with NFPA 101 and will not be used for any purpose that may interfere with egress as evidenced by:
1. The Paper bins were removed immediately and stored in the housekeeping storage area. Completed: 6/20/17
2. No other stairwells had stored items under them in the building. Completed: 7/14/17
3. The Housekeeping and maintenance staff will be reeducated that they can not store the paper bins or any items under the stairwells and where the appropriate location is that they can be stored. Completion: 7/31/17
4. The stairwells will be checked randomly and varying times noting date and time each week to assure no storage is placed under stairwells. Findings will be reported to the QAPI Committee for three months. Completion: 7/31/17 and on-going
5. Overall Responsibility: Housekeeping Manager

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 18, 2017

Citation Details

713-1.3 Nursing Units (b) A nurse's call system that can register a call from each resident's bedside, toilet, and bathing facilities to the nurse's station. The call system shall also register a visual signal at each resident's doorway, the clean room, soiled workroom and nourishment station on the nursing unit. Based on observation and interview, the facility did not ensure that a nurse call system able to register a visual signal was installed in all nourishment stations. Reference is made to the nourishment room located on 3 of 3 resident floors. The findings are: On 6/19/17 and 6/20/17 during the life safety survey between the hours and 11:00 AM - 2:30 PM, a tour of the nourishment rooms located on the resident floors (1-3) revealed that the rooms lacked a nurse call system that would register a visual signal upon activation of the system. In an interview at the time of the findings, the Director of Facilities stated that the nurse call system was not previously installed in the rooms. He further stated that a call bell system will be installed in the rooms if required. 10 NYCRR 711.2(a)(1), 713 -1.3(b)

Plan of Correction: ApprovedJuly 19, 2017

713-1.3 Nursing Units
10 NYRCC 711.2(a)(1), 713-1.3 (b)
The facility will ensure that a nurse's call system that can register a call from each nourishment station on the nursing unit as evidenced by:
1. A nurse's call system able to register a visual signal will be installed in the five nourishment rooms located on units. Completed: 8/15/17
2. There are no other nourishment stations on any of the nursing units. Completed: 6/21/17
3. The Preventative Maintenance schedule for call bell system and annunciator panel boxes will include to check the the nurse call system in nourishment rooms. All Maintenance staff will be informed of the update that includes the nourishment rooms. Completed: 7/14/17
4. Maintenance will continue to check call bell units including the nourishment stations per policy. AN audit will be conducted monthly for proper functioning and operation of call bell stations for three months to assure they are working properly.
Completed: 8/18/17 and on-going
5. Overall responsibility: Maintenance Director