Chasehealth Rehab and Residential Care
November 7, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (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: (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 (facility assessment implementation is Phase 2); (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. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure it maintained an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection for 2 of 13 sampled residents (Residents #8 and 9) and two additional residents (Residents #16 and 17). Specifically: - For Residents #6, 7, and 16, a nurse did not disinfect a shared glucometer (device for blood sugar testing) between residents; - For Residents #6, 7, 16, and 17, a nurse did not practice hand hygiene between residents; and - Resident #6 was observed with a Foley catheter drainage bag directly on the floor. Findings include: 1) The facility's handwashing policy dated 9/2016, documented hand washing was the most important single procedure to prevent the spread of nosocomial infections. Indications included washing before, during, and after preparation and delivery of medications, and before and after glove use. The facility's blood glucose testing policy revised 06/2013, documented the glucometer was cleaned after each use with a disinfectant wipe such as a Clorox wipe. Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired; she had diabetes and received insulin injections daily. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired; she had diabetes and received insulin injections daily. Resident #16 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #17 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 11/8/2017, licensed practical nurse (LPN) #12 was observed: - at 3:48 PM taking supplies for blood sugar testing out of the top drawer of the medication cart. She set them on top of the glucometer that was sitting directly on top of the cart without a barrier. She put gloves on, picked up her supplies, went in Resident #16's room, stated to him she was doing his fingerstick, and performed the fingerstick. - at 3:49 PM LPN #12 came out of the room, put the glucometer directly on top of the cart, threw the other supplies away and took her gloves off. With bare hands, she put the glucometer in the top drawer and pulled the resident's insulin pen out. She prepared the resident's insulin pen for injection, put gloves on and went into his room and administered the insulin. - at 3:52 PM LPN #12 came out of the room, put the insulin pen on top of the cart, threw her gloves away, opened the top drawer and put the insulin pen back in. - from 3:55 PM to 3:58 PM, LPN #12 opened the top drawer and took the glucometer out of the drawer and set it directly on top of the cart. She got the rest of her supplies out, put gloves on and took Resident #7, who was sitting in the hall, into her bedroom and did the fingerstick. She came out of the room, placed the glucometer directly on top of the cart, disposed of the other supplies and her gloves, opened the top drawer putting the glucometer in and taking the resident's insulin out. She drew the insulin up in a syringe, put gloves on and went into the resident's room and administered the insulin. She then came out of the room, bringing the resident back out, went to the cart, disposed of the supplies, took her gloves off and entered data into the e-MAR (electronic medication administration record). - from 3:59 PM to 4:03 PM, LPN #12 opened the top drawer, took the glucometer, out and placed it directly on the cart. She took out the rest of her supplies, put on gloves, picked up the glucometer and supplies and went to the activities office where Resident #6 was with an activities staff member. She performed the resident's fingerstick, went back to the cart, put the glucometer on top of the cart, and disposed of the supplies and gloves. She then opened the top drawer, put the glucometer away and pulled out Resident #6's insulin and prepared it for injection. She went back to the activities office and administered the resident's insulin. - at 4:04 PM, the LPN returned to the cart, she disposed of the insulin supplies and her gloves. She pulled out the second drawer of the cart, and pulled out a bottle of Senna (laxative) and poured 2 tablets in a medicine cup. She then took out [MEDICATION NAME] (laxative) and poured the power in a cup and mixed with juice. She crushed the pills and poured them into the [MEDICATION NAME] mixture, put gloves on and took it to Resident #17. She held the cup for the resident, and gave him sips at a time until it was gone. She then disposed of the cup and her gloves and went to the wall sanitizer in the hall and sanitized her hands for the first time. When interviewed on 11/8/2017 at 4:15 PM, LPN #12 stated she did not need a barrier for the glucometer as she kept it in her hand in the residents rooms and had gloves on. She stated it was not necessary to have a barrier when setting it on the cart. She stated there were wipes in the bottom drawer to clean the glucometer and she usually did that at the beginning and end of the shift. She stated she did not clean the glucometer between residents. She stated she did not use hand sanitizer or wash her hands between the 4 residents and it was not necessary as she wore gloves when doing [MEDICATION NAME] and administering medications. When interviewed on 11/9/2017 at 11:00 AM, the Director of Nursing stated when using a shared glucometer, the glucometer was to be cleaned with germicidal wipes after each use and between residents. She stated nothing dirty should be set on the medication cart and there should have been a barrier between the glucometer and the surface it was set on. She also stated hand hygiene was to be practiced between all resident even when using gloves. 2) Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired; she required extensive assistance with activities of daily living and had an indwelling catheter. The care card (care instructions) updated 8/3/17, documented the resident had a Foley catheter and required catheter care every shift and to empty the drainage bag as needed. During an observation on 11/8/2017 at 7:40 AM, the resident was in bed sleeping, the Foley drainage bag was uncovered and lying on the floor. During an observation on 11/9/2017 at 7:50 AM, the resident was lying on her bed, fully dressed in day clothes. The Foley drainage bag had very little urine and was lying flat on the floor mat next to the bed. During observation and interview on 11/9/2017 at 7:55 AM, licensed practical nurse (LPN) #14 walked into the room, walked on the floor mat stepping over the Foley drainage bag to talk to the resident. She was interviewed at that time and stated the Foley drainage bag should not be on the mat, it should be hanging from the bed frame and not touching the floor. 10NYCRR 415.19(b)(2)(4)

Plan of Correction: ApprovedDecember 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 441
Corrective action for resident found to have been affected by the deficient practice:
Resident #16 - Not applicable. Resident and family reviewed MOLST on 11/9/17 with RN Unit Manager and medical provider and made the decision for palliative care measures related to medical condition. On 11/19/17 resident passed.
Resident # 6, 7, & 17 - Residents was monitored for any acute signs and symptoms of infection. Their vitals, including temperatures, were taken every shift. No sign of infectious disease process was noted.
Resident # 6 & 7 - The Director of Nursing verified that the residents had their own individual glucometers and all glucometers were sanitized.
Resident # 6 - The Foley catheter bag was placed on the bed and a Foley cover was obtained for the catheter bag.
LPN # 12 - Received immediate infection control disciplinary action with counseling and education. Hand washing observational competency audit was completed to ensure understanding of education.

Completion Date: 11/9/17
Responsibility: Director of Nursing
Identification and corrective action for residents having potential to be affected by the same deficient practice:
All residents that have an order for [REDACTED]. All residents without a glucometer will be provided one.
All medication carts will be audited to ensure sanitizing wipes are in place.
All residents with a Foley Catheter will be audited to ensure that they have a Foley cover over their Foley bag at all times and that it is not sitting directly on the floor, but rather hooked onto the edge of the bed/chair.
All current licensed nursing staff will have a hand washing and glucometer sanitizing competency completed. Based on results of each competency, individual education will commence.
Completion Date: 1/5/18
Responsibility: Director of Nursing
Systemic changes to ensure that the deficient practice does not recur:
The Director of Nursing reviewed the policy on infection control prevention, specifically in regards to hand washing, medication administration, and glucometer utilization. The policy was not revised.
The Director of Nursing reviewed the nursing general orientation agenda and revised it to include the Relias (computerized educational format) on hand washing, which includes a written test.
Licensed nursing will have yearly competencies on hand washing and glucometer sanitization. Re-education will be built on an individual basis depending on outcomes for the competency.
The yearly Foley Catheter competency was reviewed and revised to include infection control prevention techniques to include but not limited to placement of Foley Bag.
The facility purchased the Glow Germ and Glow Bar product to utilize during competencies.
Completion Date:1/5/18
Responsibility: Director of Nursing
Quality Assurance Performance Improvement Program to ensure that the deficient practice does not recur:
The facility will incorporate the deficient practice into the QAPI program.
10 (5 of the audits will include licensed nursing staff during medication administration) monthly random audits will be completed by designated individuals for all departments on hand hygiene. 10% of the monthly audits will be done without the knowledge of the staff and 10% will be done with the knowledge of the staff. If a staff member does not accurately complete hand washing, then they will be sent to the in-service department for re-education within 72 hours.
1 weekly random audit will be completed on infection control prevention for Foley Catheters, specifically noting the placement of the Foley Bag. If the audit identifies that the Foley Bag is not properly secured off the floor, individual re-education will be provided by the in-service department within 72 hours.
The results of all the compentencies listed in the plan of correction will be incorporated into the QAPI executive sessions.
The audits will be reviewed at the quarterly executive QAPI meetings at which time the frequency of the audits will be determined based on 100% threshold results.
Completion Date: 1/5/18
Responsibility: 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: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews conducted during the abbreviated survey (NY 997), it was determined for 1 of 4 residents reviewed for changes in medical condition (Resident #1), the facility did not consult with the resident's physician when there was a significant change in the resident's physical status. Specifically, Resident #1 had a fall with a [MEDICAL CONDITION] and the physician was not notified timely. Findings include: Resident # 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. She was readmitted [DATE] with a new [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required extensive assist for bed mobility, transfers, and toileting. The fall risk assessment dated [DATE] documented the resident was at low risk for falls. The comprehensive care plan (CCP) dated 9/27/2017 documented the resident had an activities of daily living (ADL) self care deficit related to the [MEDICAL CONDITION]. Interventions included therapy services as ordered by the physician and maintain toe touch weight bearing to her left leg. Nursing progress notes documented the following: -On 9/12/2017 at 5:50 PM the resident was found sitting on the floor on her buttocks at and stated she tripped on her slipper. She complained of pain in her left leg, the physician was notified, and an x-ray was ordered and obtained. -On 9/12/2017 at 11:17 PM the results of the x-ray returned and revealed a probable non-displaced impacted subcapital [MEDICAL CONDITION] femur. -On 9/13/2017 at 3:40 AM the resident was able to make her needs known, slept well without complaints of pain, and the results of the x-ray would be passed on to the oncoming staff. -On 9/13/2017 at 1:19 PM the physician evaluated the resident earlier that day and she was sent to the hospital at 10:00 AM for evaluation. There was no documented evidence the physician was notified of the x-ray results when they were first obtained. A message was left for registered nurse (RN) supervisor #2 to return surveyor's call on 11/9/2017 at 10:35 AM. There was no return call by the end of the survey. During an interview on 11/9/2017 at 11:08 AM, licensed practical nurse (LPN) #1 stated he worked the evening shift the day of the incident and he heard a thud, saw the resident on the floor, and notified RN supervisor #2. The resident initially denied injury and was assisted off the floor and to a chair with two staff and a gait belt. LPN #1 was unable to remember details and assumed RN supervisor #2 notified the physician and the resident's family. The x-ray results returned toward the end of the shift when he was about to leave and both he and LPN #3 saw the faxed results. There was also a phone call from the x-ray company confirming the staff received the faxed results. During an interview on 11/9/2017 at 11:45 AM, the Director of Nursing (DON) stated she would have expected the staff to communicate the x-ray findings when first obtained, no matter what time the results returned. During an interview on 11/9/2017 at 2:38 PM, LPN #3 stated she worked the night shift the day of the incident and was made aware of the resident's fall during report from LPN #1. The x-ray results returned at the change of shifts, while receiving report and the x-ray company called at 11:45 PM to confirm staff had received the faxed results. She stated based on her experience with this type of fracture, she did not think anything would be done about it and she knew the physician was coming in the morning. She did not notify RN supervisor #2, who had already left the building, and she did not think about notifying the on-call RN covering the night shift about the x-ray results. She stated not calling the physician was a poor decision on her part and she took full responsibility for the error. 10NYCRR 415.3(e)(2)(ii)(a)

Plan of Correction: ApprovedDecember 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 157
Corrective action for resident found to have been affected by the deficient practice:
Resident #1 - A facility investigation commenced on the morning of 9/13/17, following the identification that an accident occurred involving the resident and the physician was not immediately made aware of the x-ray results that indicated a significant change in the residents status. The Medical Director was in house on the morning of 9/13/17 and was made aware of the results that showed a [MEDICAL CONDITION]. The resident was transferred to (NAME) Imogene Bassett Hospital following face to face evaluation of the Medical Director on 9/13/17 where the [MEDICAL CONDITION] was confirmed and the resident underwent [REDACTED]. Her plan of care was developed to indicate the change in her status and a comprehensive MDS with an ARD of 9/25/17 was completed to identify goals and approaches to return the resident to attain her highest practicable physical, mental, and psychosocial function. The resident remains in therapy on this day of 12/4/17 at the level of stand-by assist utilizing a walker. The resident has expressed that she feels increased comfort utilizing a walker so her plan of care will reflect the continued utilization of the walker. Her Physical Therapy discharge goal is set for 12/8/17. She has attained her goals in occupational therapy and has returned to her previous level of function, thus was discharged from the skilled occupational program on 11/29/17.
Completion Date:12/8/17
Responsibility: Director of Nursing
Identification and corrective action for residents having potential to be affected by the same deficient practice:
At the time of the investigation the facility audited 2 separate medical records of residents that had been involved in accidents which resulted in injury and required physician intervention. The facility determined that there was not a deficient practice as evidenced by the physician being notified to direct immediate plan of care interventions.
During the time of the investigation and licensed nursing staff re-education of the Notification of Physician policy the Director of Nursing and Medical Director put a temporary policy and procedure into place that indicated that all diagnostic testing results were to be called to the RN on duty/call and the RN was to call the physician to report all results of the said diagnostic test results.
The temporary policy indicating the RN must notify the physician of all diagnostic test results was changed back following full house licensed nursing education to indicate that any licensed nursing staff can notify the physician, but they must also notify the RN.
The facility will complete a full house audit with a look back of 60 days of all residents that have had accidents resulting in injury that required physician intervention to ensure physician notification at time of accident. The audit will also identify if the facility notified the physician of the results of any ordered x-ray testing following the accident.
Based on the results of the audit the facility will immediately notify the Medical Director of any diagnostic results not reported to the physician and follow the facility abuse protocol for reporting incidents/deficient practices to the NYS DOH.

Completion Date: 1/5/18
Responsibility: Director of Nursing
Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur the facility revised the policy regarding Physician Notification to identify that all licensed nursing staff are to notify the RN and physician of diagnostic test results.
The preliminary results of the investigation on 9/13/17 identified reasonable cause for a deficient practice had occurred thus the facility reported the incident to the NYS DOH.
Hiring a FT RN for the night shift M-F and continuing to advertise for a PT RN for S and S.
All licensed staff will be re-educated on the regulation that denotes notification of change, specifically the policy and procedure regarding physician notification involving residents that have had accidents resulting in an injury requiring physician intervention.

Completion Date: 1/5/18
Responsibility: Director of Nursing
Quality Assurance Performance Improvement (QAPI)Program to ensure that the deficient practice does not recur:
The facility has incorporated the deficient practice into the QAPI program. The facility will complete 100% full house audits of all residents that have had accidents with injury requiring physician ordered x-rays to identify if the facility notified the physician of the results of any ordered x-ray testing following the accident.
The audits will be reviewed at the quarterly executive QAPI meetings at which time the frequency of the audits will be determined based on results.

Completion Date: 1/5/18
Responsibility: Director of Nursing

FF10 483.45(f)(2):RESIDENTS FREE OF SIGNIFICANT MED ERRORS

REGULATION: 483.45(f) Medication Errors. The facility must ensure that its- (f)(2) Residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure 2 of 15 sampled residents (Residents #6 and 7) and 1 additional resident (Resident #16) reviewed for medications were free of significant medication errors. Specifically; Residents #6, 7, and 16 had orders for fingersticks (blood sugar monitoring) insulin to be administered before meals according to a sliding scale (amount of insulin administered is determined by fingerstick reading). Resident #6 received insulin 1 hour and 40 minutes before the meal; Resident #7 received insulin 1 hour and 6 minutes before the meal; and Resident #16 received insulin 2 hours and 6 minutes before the meal. Findings include: 1) Resident #16 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. On 11/8/2017, licensed practical nurse (LPN) #12 was observed from 3:48 PM to 3:52 PM. During this time she took the glucometer into the resident's room, performed blood sugar testing, came out and got the resident's insulin. She took the insulin in the room, administered it, and returned to the medication cart. The treatment administration record (TAR) dated 11/2017, documented the insulin was to be given at 4:30 PM and on 11/8/2017 the resident received 4 units. The resident was observed on 11/8/2017: - at 4:55 PM in his bed sleeping; - at 5:15 PM, an activities aide was coming out of his room and said Resident #16 was not feeling well. The resident was in bed, his mouth was very dry and his speech was very soft and difficult to understand. The registered nurse (RN) Manager came to the room and the resident said he wanted to get out of bed and into his recliner; - at 5:25 PM, a certified nurse aide and the RN Manager went in the room to get the resident up; - at 5:45 PM, the resident was asked if he was offered dinner and he said no. When asked if he would eat if they brought him something he said something soft; - at 5:46 PM, the resident's tray was the only one left on the cart and the staff on the unit were in the small dining room feeding residents; - at 5:52 PM, the surveyor asked LPN #13 why Resident #16's tray was not served. She stated the RN Manager was in the room with him earlier and she thought the RN Manager was going to serve him. LPN #13 got up and took the tray to the resident; and - at 5:58 PM, LPN #13 started to assist the resident with his meal. 2) Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired; she had diabetes and received insulin injections daily. The current physician's orders [REDACTED]. On 11/8/2017, licensed practical nurse (LPN) #12 was observed from 3:59 PM to 4:03 PM. She took the glucometer (instrument for blood sugar reading) and supplies to the activities office where Resident #6 was with an activities staff member. She performed the resident's fingerstick, went back to the cart, prepared the insulin for injection. She went back to the activities office and administered the resident's insulin. The resident was observed on 11/8/2017: - at 4:53 PM with an activities aide wheeling her towards the solarium (small dining room on the unit); - from 5:12 PM to 5:30 PM in the hallway TV lounge yelling, swearing, and talking inappropriately with activities staff sitting with her; - at 5:30 PM she was taken to the solarium; and - at 5:43 PM, the resident received her supper and was fed by staff. 3) Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired; she had diabetes and received insulin injections daily. The physician's orders [REDACTED]. On 11/8/2017, licensed practical nurse (LPN) #12 was observed from 3:55 PM to 3:58 PM. During this time, she took the resident from the hall TV lounge to her bedroom with the glucometer and supplies and performed blood sugar testing. She came out of the room, prepared the resident's insulin, went back in the room, administered the insulin, and brought the resident back out to the TV lounge. The resident was observed on 11/8/2017: - at 4:34 PM at the dining room table with her clothing protector on. A dietary server was at her table taking orders; - at 4:50 PM all resident's were seated at Resident #7's table waiting to be served; and - at 5:04 PM the resident was served her food and her drinks (honey thickened liquids) came soon after. When interviewed on 11/8/2017 at 6:10 PM, LPN #12 stated when insulin was ordered to be given before meals, it was ideal to give it 15 to 20 minutes before the meal. She stated she did her insulin injections between 4:15 PM and 4:30 PM. She stated they started taking residents to the dining room at 4:30 PM and dinner started at 4:45 PM in the main dining room. She did not know when trays were served on the unit. She stated giving insulin an hour or more before a meal was too long and it should be given closer to the meal. When interviewed on 11/9/2017 at 11:00 AM, the Director of Nursing (DON) stated when insulin was ordered to be given before meals, it should be given within a half hour of the meal. She stated giving insulin at 4:00 PM was too early for the residents that ate on the unit and was all right for the residents that ate in the main dining room. She stated the residents that went to the main dining room arrived at 4:30 and were given drinks when they arrived. She stated if the resident was on thickened liquids, they could have a drink if the nurse was in the dining room. She stated the resident who ate on the unit got insulin at 4:30 PM and their dinner trays came at 5:00 PM. She stated she was unaware the trays were not served until after 5:30 in the solarium. 10NYCRR 415.12(m)(2)

Plan of Correction: ApprovedDecember 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 333
Corrective action for resident found to have been affected by the deficient practice:
Resident #16 - Not applicable. Resident and family reviewed MOLST on 11/9/17 with RN Unit Manager and medical provider and made the decision for palliative care measures related to medical condition. On 11/19/17 resident passed away.
Resident #6 - Director of Nursing and RN Unit Manager reviewed insulin times in comparison with resident's scheduled meal times. No changes were made to the insulin or meal times. Resident was monitored to ensure no adverse effects.
Resident #7 - Director of Nursing and RN Unit Manager reviewed insulin times in comparison with resident's scheduled meal times. No changes were made to the insulin or meal times. Resident was monitored to ensure no adverse effects.
Completion Date: 11/8/17
Responsibility: Director of Nursing
Identification and corrective action for residents having potential to be affected by the same deficient practice:
The facility will audit all resident's orders/medication administration records that have a [DIAGNOSES REDACTED]. The audit will denote the times that the sliding scale insulin coverage is scheduled versus the time of meal service. All residents that are found to have insulin times scheduled at a time not conducive to when they receive their meals will have time adjustments to their medication administration record.
The facility will update the policy and procedure for diabetic protocol, specifically noting that all residents with a [DIAGNOSES REDACTED].
Completion Date: 1/5/18
Responsibility: Director of Nursing
Systemic changes to ensure that the deficient practice does not recur:
The Director of Nursing reviewed the policy and procedure for diabetic protocol and revised it to include that each resident with diabetes on a sliding scale insulin will have required documentation to verify that they received their meal within the peak time of the administration of the insulin, and if not, then a small protein snack was provided based on the diabetic protocol.
The facility will educate all licensed staff to the change in policy and procedure.
The facility will contract for a Diabetic Educator to come into the building to provide all licensed nursing staff with diabetic education, including but not limited to sliding scale insulin peak times. The educational content will be utilized for all new hires and annually with diabetic competency exams for all licensed nursing staff.
The facility will post on each medication cart, a reference sheet that indicates all insulin peak times.
Completion Date: 1/5/18
Responsibility: Director of Nursing
Quality Assurance Performance Improvement Program to ensure that the deficient practice does not recur:
The facility will incorporate the deficient practice into the QAPI program.
All new residents with a [DIAGNOSES REDACTED].
All new licensed nursing staff on hire will have an observational competency audit completed on diabetic sliding scale insulin administration, including but not limited to insulin peak times, administration, and infection control. Based on the results of the observational competency audit further education will be provided if the licensed nurse did not perform at 100% accuracy. The observational competency audit will then be repeated within 72 hours.
All licensed nursing staff will have a yearly observational competency audit completed on diabetic sliding scale insulin administration, including but not limited to insulin peak times, administration, and infection control. Based on the results of the observational competency audit further education will be provided if the licensed nurse did not perform at 100% accuracy. The observational competency audit will then be repeated within 72 hours.
The medical record audits will be reviewed at the quarterly executive QAPI meetings at which time the frequency of the audits will be determined based on 100% compliant threshold being met.
The observational competency audits will continue as part of general orientation and yearly education for all licensed nursing staff.
Completion Date: 1/5/17
Responsibility: Director of Nursing

FF10 483.24(a)(1):TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS

REGULATION: (a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews conducted during the recertification survey, it was determined the facility did not provide services to maintain or improve the ability for 1 of 8 residents (Resident #5) to carry out activities of daily living (ADLs). Specifically, Resident #5 was not provided with assistance as needed for eating. Findings include: Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 9/8/2017 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance for all ADLs, and was on a mechanically altered diet. The nutrition assessment dated [DATE] documented the resident's meal intakes averaged 50-75% with adaptive equipment and needed encouragement and cueing from staff. The resident care instructions dated 10/24/2017 documented the resident was on a regular, mechanically altered diet, with nectar thickened liquids, required set up and limited assistance as needed. The resident utilized a 1/2 built up tray, spork, scoop plate, and cups with lids and straws. The resident's ADL summary for 10/27/2017-11/9/2017 documented the resident: - received supervision and set up help for 3 meals; - received limited assistance of one person for 12 meals; - received extensive assistance of one person for 14 meals; and - was totally dependent on staff for 9 meals. The comprehensive care plan (CCP) updated 10/24/2017 documented the resident was at risk for nutritional alteration and dehydration, was on a mechanically altered diet, and required encouragement to feed self, verbal cueing and minimal assistance using adaptive equipment. The speech therapy progress note dated 11/7/2017 documented the resident benefited from verbal prompts as well as tactile cues to regulate pace and bolus (bite) size. The speech therapy progress note dated 11/8/2017 documented the resident required corrective positioning as well as verbal cues to sustain appropriate positioning through the meal. She benefited from environmental modifications/set up as well as varying levels of staff assistance to encourage the resident's self-feeding. The following observations were made on 11/7/2017 in the main dining room: - at 12:08 PM, the resident was seated in a stationary chair, leaned to the right, and had a pillow partially placed on her right side. She had her lunch meal which consisted of pureed foods, two 6 ounce cups with plastic wrap over the tops, and straws placed through the plastic wrap; - at 12:10 PM, the resident held her spork, a napkin was stuck to it, and the resident dropped her spork on the floor; - at 12:17 PM, the resident continued to lean to the right, was not eating, a regular spoon was placed in her food, and the resident's right hand was in a bowl of pureed food; - at 12:22 PM, the resident attempted to hold the spoon and was unable; - at 12:27 PM, certified nurse aide (CNA) #23, seated to the left of the resident, while feeding another resident, handed the resident a cup in her left hand; - at 12:29 PM, the resident's left hand was in her food; - at 12:32 PM, the resident had not yet consumed any of her food and had not been provided assistance; - at 12:36 PM, CNA #24 wiped the resident's face and handed her a cup. The resident brought the cup with a straw halfway to her mouth, held the straw, removed it, placed it on her food, and placed her hand in her food; - at 12:39 PM, she attempted to drink from the cup through the hole in the top of the plastic wrap covering the cup; and - at 12:46 PM, CNA #24 stated to the resident you really didn't eat anything, and CNA #23 (who was still seated next to the resident assisting another resident) stated she had a little ginger ale. CNA #24 then removed the resident's tray without offering assistance. During an observation on 11/7/2017 at 12:54 PM, the resident's meal ticket documented R-90 (refused 90%). CNA #24, who collected the tray and marked the ticket, was not observed at the resident's table offering assistance or verifying meal refusal. The resident's ADL summary for amount eaten on from 10/27/2017 to 11/9/2017 documented the resident: - ate 0-25% of 4 meals; - ate 26-50% of 8 meals; - ate 51-100% of 28 meals; and - refused 1 meal (11/7/2017, as documented refused by CNA #24). When interviewed on 11/9/2017 at 12:10 AM, CNA #23 stated the resident needed minimal to extensive assistance, depending on the day. She stated the resident should be fed if she was not feeding herself or appeared sleepy. She allowed staff to feed her and was not known to refuse meals or assistance. The CNA stated she was seated next to the resident during lunch on 11/7/2017 while feeding another resident. She could not recall if the resident had difficulty feeding herself, if she assisted the resident, or if the resident refused. She stated the resident should have been offered assistance with feeding if the resident's hands were in her food. When interviewed on 11/9/2017 at 12:25 PM, registered nurse (RN) Unit Manager #9 stated the resident had good and not so good days where she may need more assistance. The resident should be offered assistance of feeding and/or encouragement if she was not feeding herself. 10NYCRR 415.12(a)(iv)

Plan of Correction: ApprovedDecember 5, 2017

F 311
Corrective action for resident found to have been affected by the deficient practice:
Resident #5 - The resident will be evaluated by occupational and speech therapy to ensure the plan of care regarding eating maintains/attains the resident's highest practicable level of function. Upon completion of the evaluation, the Director of Nursing and Director of Therapy Services will develop educational sessions for all certified and licensed nursing staff that identifies the activities of daily living interventions for eating to ensure the resident maintains and/or attains her highest practicable mental, physical, psychosocial well being.
Completion Date: 1/5/18
Responsibility: Director of Nursing
Identification and corrective action for residents having potential to be affected by the same deficient practice:
The facility will audit all residents who need assistance at meals for a 72 hour period to identify the following eating interventions are being carried forth per the individuals plan of care:
Level of Assist; Positioning; Adaptive Equipment; Consistency.
Any residents that are found to not be eating at their highest practicable level with the current plan of care, interventions will be re-evaluated by occupational and speech therapy. Based on the professional therapist recommendations, the plan of care will be maintained and/or revised and full house education will commence with all certified and licensed nursing staff.
If it is determined that the resident is not being provided interventions based on their plan of care, the certified and/or licensed staff working with them at the time will be provided immediate education.
Completion Date: 1/5/18
Responsibility: Director of Nursing
Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the facility therapy department will re-educate all certified and licensed nursing staff on activities of daily living eating interventions used within the facility to maintain and/or attain a residents highest practicable level of functioning.
The facility will develop and implement on hire and yearly competencies to all certified and licensed nursing staff on facility interventions utilized for eating to maintain and or attain a residents highest practicable level of functioning.
The facility will implement a policy that a licensed nursing staff must be present within the dining room during scheduled meal times to ensure that residents are being providing interventions based on their plan of care. All staff will be educated on the change in the policy and procedure.
Completion Date: 1/5/18
Responsibility: Director of Nursing
Quality Assurance Performance Improvement (QAPI) program to ensure that the deficient practice does not recur:
The facility will incorporate the deficient practice into the QAPI program.
Random audits will be assigned and completed to designated individuals.
The audit will identify random residents who need assistance at meals and identify if the following eating interventions are being carried forth per the individuals plan of care:
Level of Assist, Positioning, Adaptive Equipment, Consistency.
The audits will be completed on at least 10% of random meals in a monthly period. Immediate corrective action will occur based on findings.
The audits will be reviewed at the quarterly executive QAPI meetings at which time the frequency of the audits will be determined based on a 100% threshold for compliance being met.
Completion Date: 1/5/18
Responsibility: Director of Nursing

Standard Life Safety Code Citations

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 7, 2017
Corrected date: January 5, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not maintain an exit discharge pathway for 1 of 9 exits (nursing modular emergency exit). Specifically, the external pathway was not a hard packed surface. Findings include: On 11/6/2017 at 5:17 PM a surveyor, with the Director of Environmental Services present, observed the nursing modular emergency exit exterior pathway was grass/not hard packed surface. The pathway had an approximate 150 foot section to the community center parking lot, and a 50 foot section to the existing paved walkway towards the school that was grass. During an interview on 11/7/2017 at 5:17 PM, the Director of Environmental Services stated the exit discharge pathway for the nursing modular emergency exit had sections of grass/not hard packed surface. 2012 NFPA 101 19.2.7 CMS Survey and Certification Letter 05-38 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 20, 2017

K 271
Corrective action for area found to have been affected by the deficient practice:
The facility will pour a hard packed surface from the hard packed paved fenced in area by the nursing modular, approximately 50 feet to the existing paved hard packed surface, towards the school. The facility maintenance staff will prepare the ground and lay the forms that are being loaned to the facility by the Village of New Berlin. A local cement company will pour the concrete, utilizing an additive for quick drying. The local cement company noted the facility can lay the concrete in colder weather as long as there is a barrier that prevents the ground from frosting during the drying process.
Completion Date: 1/5/18
Responsibility: Director of Environmental Services
Identification and corrective action for areas having potential to be affected by the same deficient practice:
The facility will perform an audit of all emergency exits to ensure that each exit has an external, hard packed surface. Any exit that does not have a external hard packed surface will have one installed.
Completion Date: 1/5/18
Responsibility: Director of Environmental Services
Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the facility will install a hard packed all-weather surface from the nursing modular emergency exit to the pathway that connects to the school. The facility will adjust the evacuation plan to denote that if the nursing modular emergency egress is utilized the evacuation will be to the school. The facility will train all staff of the change in the evacuation plan and perform table top drill exercises to ensure competency of all staff in the change. Training will then occur on hire and at least annually there after with ongoing exercises and evaluation of the current plan for effectiveness.

Completion Date: 1/5/18
Responsibility: Director of Environmental Services
Quality Assurance Performance Improvement program to ensure that the deficient practice does not recur:
The identified issues will be incorporated into the facility QAPI program to ensure the deficient practice does not recur. The facility will perform bi-annual audits on all external emergency exit pathways to ensure they are maintained as hard and packed surfaces.
Completion Date: Ongoing
Responsibility: Director of Environmental Services

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: January 5, 2018

Citation Details

Based on interview conducted during the recertification survey, it was determined the facility did not ensure an emergency generator remote annunciator was properly installed. Specifically, the emergency generator was not connected to a remotely installed alarm annunciator. Findings include: During interview on 11/7/2017 at 8:43 AM, the Director of Environmental Services stated there was an generator annunciator panel in the boiler room (where the generator was located), and the facility did not have a remote generator annunciator with 24-hour coverage. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 20, 2017

K 916
Corrective action for areas found to have been affected by the deficient practice:
The facility will be hiring a local electrician to install a remote alarmed annunciator panel that is storage battery powered for the sole facility emergency generator located in the facility boiler room. The panel will be located in the facility hallway located by the employee entrance, kitchen entrance, and Director of Environmental Services office to ensure it is readily observed by operating personnel.
Date of Completion: 1/5/2018
Responsibility: Director of Environmental Services
Identification and corrective action for areas having potential to be affected by the same deficient practice:
The facility concluded that there is no other emergency generator in the facility that would require a remote alarmed annunciator panel.
Date of Completion: 11/8/2017
Responsibility: Director of Environmental Services
Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur the facility Director of Environmental Services, Assistant Director of environmental Services, and Administrator have been re-educated on K 916 to ensure any future generators installed will have a remotely installed alarm annunciator with 24 hour coverage. The facility has updated the Loss of Power policy and procedure to identify the annunciator panel location and instructions on how to read it. All facility staff will be educated on the revision of the Loss of Power policy change.
Date of Completion: 1/5/2018
Responsibility: Director of Environmental Services and Administrator
Quality Assurance Performance Improvement program to ensure that the deficient practice does not recur:
The identified issue will be incorporated into the QAPI program to ensure the deficient practice does not recur. The facility Environmental Service Director and Assistant will audit the installation of the annunciator panel and continue to monitor it's function on a regular basis to ensure it indicates alarmed conditions of the emergency generator. Random competencies will be completed to ensure facility staff understanding of the function of the annunciator panel.
Date of Completion: Ongoing
Responsibility: Director of Environmental Services

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: January 5, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the fire rating for 1 of 1 hazardous area was maintained (mechanical room). Specifically, the mechanical room had unsealed wall penetrations. Findings include: On 11/7/2017 at 12:26 PM, a surveyor observed the mechanical room/corridor wall had an unsealed data wire penetration. During an interview on 11/7/2017 at 4:50 PM, the Director of Environmental Services stated the data wire was connected to the time clock and it was installed at least 7 years ago. He stated he was not aware of the unsealed wall penetration in the mechanical room. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 20, 2017

K 321
Corrective action for area found to have been affected by the deficient practice:
The facility sealed the hole caused by the data wire penetration from the mechanical room to the corridor with red fire rated caulk that has at least a 2 hour fire resistance rating.
Date of Completion: 11/8/2017
Responsibility: Director of Environmental Services
Identification and corrective action for areas having potential to be affected by the same deficient practice:
The facility will perform an audit of the following areas (note: the facility does not have all noted hazardous areas identified in K 321) within it's building to ensure that there is no unsealed penetrations: Boiler/maintenance room, soiled linen rooms, and combustible storage rooms (over 50 square feet). All unsealed penetrations identified will be sealed with red fire rated caulk that has at least a 2 hour fire resistance rating.
Date of Completion: 12/22/2017
Responsibility: Director of Environmental Services
Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the Director of Environmental Services will enhance the policy and procedure with regards to the responsibility of contractors when performing work within the facility to include K 321 regulations. All future contractors performing services within the facility that have a potential to cause or disrupt vertical openings will be educated on the policy. All new hire and current maintenance staff will be educated on the enhanced policy.

Date of Completion: 1/5/2018
Responsibility: Director of Environmental Services
Quality Assurance Performance Improvement program to ensure that the deficient practice does not recur:
The identified issue will be incorporated into the QAPI program to ensure that the deficient practice does not recur. Audits will be performed on all areas that have a potential for vertical opening penetrations in the identified locations listed above on a yearly basis and as needed following any contractors that are in the facility or facility maintenance staff performing services that may result in vertical penetrations or a disruption with areas that have vertical openings.
Date of Completion: Ongoing
Responsibility: Director of Environmental Services

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 7, 2017
Corrected date: January 5, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility's exit discharge lighting was not maintained for 2 of 9 emergency exits (nursing modular emergency exit, emergency exit #4). Specifically, the exit discharge for the above mentioned emergency exits were not arranged so that failure of any single lighting fixture would not leave the area in darkness. Findings include: On 11/7/2017, between 1:00 PM and 1:19 PM, a surveyor observed the nursing modular emergency exit and emergency exit #4 exterior discharge pathways lacked any lighting fixtures. During an interview on 11/7/2017 at 5:10 PM, the Director of Environmental Services stated there were no light sources outside of the nursing modular emergency exit and emergency exit #4. 2012 NFPA 101: 19.2.8 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 20, 2017

K281
Corrective action for area found to have been affected by the deficient practice:
Illumination that is capable of automatic operation without manual intervention was added to the nursing modular emergency exit, South stairwell emergency exit, corner of facility by the South stairwell (directed towards path along south of building), the garden shed in the center of the walkway between the facility and school, and the corner of the school building. The lighting that was added provides illumination to the entire emergency egress path from the facility to the school building.
Completion Date: 11/16/17
Responsibility: Director of Environmental Services

Identification and corrective action for areas having potential to be affected by the same deficient practice:
A full facility grounds audit was completed to ensure exit discharge lighting is maintained for all emergency exits and exterior discharge pathways are lit on a continuous operation or automatic operation without manual intervention. Any emergency exit or exterior discharge path of egress without illumination that is continuous or automatic has had lighting installed.
Completion Date: 11/16/17
Responsibility: Director of Environmental Services
Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the facility developed an Environmental service policy and procedure that specifically denotes that all emergency exits will have a illumination at the point of egress that are continuously operating or capable of automatic operation without manual intervention. The facility will educate all staff to the policy and procedure to ensure that the illumination is functional at all times.

Completion Date: 1/5/2018
Responsibility: Director of Environmental Services
Quality Assurance Performance Improvement program to ensure that the deficient practice does not recur:
The identified issues will be incorporated into the facility QAPI program to ensure the deficient practice does not recur. The facility will perform bi-monthly and as needed audits on all external emergency exit lighting to ensure that illumination is continuously in operation or the automatic operation is functional without manual intervention.
Completion Date: Ongoing
Responsibility: Director of Environmental Services

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: January 5, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the building's automatic sprinkler system was maintained in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems, for one isolated area (second floor nursing station). Specifically, the flow pattern of a sprinkler head near the second floor nursing station was blocked by spackle on the deflector. Findings include: On 11/7/2017 at 3:33 PM, a surveyor near the second floor nursing station observed a sprinkler head with dried spackle on its deflector. This spackle would affect the flow pattern of the sprinkler head. During an interview on 11/7/2017 at 4:52 PM, the Director of Environmental Services stated the second floor sprinkler head was installed during the 2013 sprinkler renovation project, and that he was not aware of the spackle on its deflector. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 20, 2017

K 353
Corrective action for areas found to have been affected by the deficient practice:
The facility cleaned the second floor nurses station sprinkler head of all spackle on the deflector so the flow pattern of the sprinkler head was no longer compromised.
Date of Completion: 11/8/2017
Responsibility: Director of Maintenance

Identification and corrective action for areas having potential to be affected by the same deficient practice:
The facility will audit every sprinkler head within the building to ensure the sprinkler heads are maintained, specifically the flow of pattern of a sprinkler head is not compromised by spackle or other debris on the deflector. Any sprinkler head found to be compromised by spackle and/or debris on the deflector will be cleaned.
Date of Completion: 12/22/2017
Responsibility: Director of Environmental Services
Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur the facility will educate all maintenance staff yearly and on hire, and contractors to the importance of ensuring the sprinkler system is maintained, specifically that the flow pattern of a sprinkler head is not compromised because of spackle and/or other debris.

Date of Completion: 1/5/2018
Responsibility: Director of Environmental Services
Quality Assurance Performance Improvement program to ensure that the deficient practice does not recur:
The identified issue will be incorporated into the QAPI program to ensure the deficient practice does not recur. The facility will perform yearly and as needed after any work is completed near sprinkler heads, an inspection audit of all facility sprinkler heads for spackle and/or debris.

Date of Completion: Ongoing
Responsibility: Director of Environmental Services

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during the recertification survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for 1 of 2 emergency stairwells (south stairwell). Specifically, the south stairwell had an unsealed penetration. Findings include: On 11/7/2017 at 4:00 PM, surveyor in the south emergency stairwell observed an unsealed two inch sprinkler pipe penetration into resident room [ROOM NUMBER]. During an interview on 11/7/2017 at 4:53 PM, the Director of Environmental Services stated the unsealed sprinkler line was installed during the 2013 sprinkler renovation project, and he was not not aware of the unsealed sprinkler line penetration. 2012 NFPA 101: 19.3.1, 8.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 311
Corrective action for area found to have been affected by the deficient practice:
In the south emergency stairwell the facility filled the unsealed penetration around the vertical two inch sprinkler pipe that went into room [ROOM NUMBER] with fire rated red caulk to ensure at least 2-hour fire resistance.
Date of Completion: 11/7/2017
Responsibility: Director of Environmental Services
Identification and corrective action for other areas having potential to be affected by the same deficient practice:
The facility will perform a full house audit of all areas that have a potential for vertical penetration openings, specifically the piping for the sprinkler system, to ensure that the vertical openings are properly enclosed. Any vertical penetration openings found will be filled with red fire caulk that has a fire resistance rating of at least 2 hours.
Date of Completion: 12/22/2017
Responsibility: Director of Environmental Services
Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the Director of Environmental Services will enhance the policy and procedure with regards to the responsibility of contractors when performing work within the facility to include K 311 regulations. All future contractors performing services within the facility that have a potential to cause or disrupt vertical openings will be educated on the policy. All new hire and current maintenance employees will be educated on the enhanced policy.
Date of Completion: 1/5/2018
Responsibility: Director of Environmental Services
Quality Assurance Performance Improvement program to ensure that the deficient practice does not recur:
The identified areas will be incorporated into the facility QAPI program. Audits will be performed on all areas that have a potential for vertical opening penetrations on a yearly basis and as needed following any contractors and/or facility maintenance staff that are in the facility performing services that may result in vertical penetrations or a disruption with areas that have vertical openings.
Date of Completion: Ongoing
Responsibility: Director of Environmental Services