The Grand Rehabilitation and Nursing at River Valley
May 10, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 12, 2018

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 that an accurate assessment was conducted relating to urinary continence for 1 of 2 residents (#143) reviewed for urinary continence. Specifically, the resident was coded to be frequently incontinent on the most recent annual Minimum Data Assessment, which when compared to the prior quarterly assessment reflected an increase in the resident's level of incontinence. The corresponding Care Area Assessment summary noted that there was no change in the continence level and the resident's plan of care was not revised to reflect the decline in his level of bladder continence. The findings are: Resident #143 has medical conditions that include urolithiasis (the process of forming stones in the kidney, bladder, and/or urinary tract) with kidney stent. The Quarterly Minimum Data Set (MDS; a resident assessment instrument) dated 6/23/17 showed that the resident was occasionally incontinent of bladder, was toileted, and wheelchair bound. The Annual MDS dated [DATE] showed that the resident was frequently incontinent of bladder. This was not consistent with the corresponding Care Area Assessment summary (CAAs), an extension of the MDS that provides more in-depth information of areas/problems triggered by the MDS. The CAAs noted that the resident was occasionally incontinent of bladder as opposed to being frequently incontinent. The information from the assessment is used to develop appropriate goals and interventions for a resident and should accurately reflect the resident's status. The resident's current care plan addressing urinary continence revealed that the goal for the resident was to maintain continence during waking hours. Interventions to achieve this goal were to: check skin for impairment. encourage fluids during the day to promote prompted voiding responses; monitor for signs and symptoms/ of urinary tract infection, monitor and document, report to MD as needed any changes in incontinence and urology follow-up as ordered. This care plan did not accurately reflect the resident's level of urinary continence and included a plan to attempt to return the resident to his previous level of continence (occasionally incontinent) as possible as noted on the 6/23/17 MDS. The Certified Nurse Aide (CNA #2) assigned to the resident was interviewed on 5/9/18 at 2:00 PM. CNA #2 stated that the resident was able to use a urinal before and was able to toilet himself. CNA #2 stated that after he returned from the hospital in (MONTH) (YEAR), the resident was using a Hoyer lift and required total care. The resident is now able to pivot (turning while standing) with assistance but is not on a toileting program. The CNA care guide was revised on 4/23/18 to show that the resident could stand and pivot with the assistance of one person. The MDS Registered Nurse was interviewed on 5/9/18 at 2:10 PM regarding the accuracy of the CAAs for the Annual MDS and the lack of care plan revision to address the decline in the resident's urinary status. The MDS nurse concurred that the CAA summary was inaccurate and that the care plan did not address the need for returning the resident to a higher level of continence. The director of Rehabilitation Services was interviewed in the morning of 5/11/18 and stated that the resident is currently not strong enough to use the toilet but would be a future candidate for the toileting program. 415.11(b)

Plan of Correction: ApprovedJuly 18, 2018

1. Corrective Action ? 1. An in service was given to the MDS coordinators regarding assesing and reviewing medical records during the assessment period to ensure that the CAA summary reflects in the care plans. 2. The CAA summary that did not reflect the change in the resident?s level of urinary incontinence and the care plan for bladder incontinence were reviewed, corrected/modified and will be resubmitted. The MDS nurse was re-inserviced regarding assessing and reviewing medical records during assessment period of resident.
2. Residents at Risk for Same Practice ? All residents who have MDS done have been identified with the potential to be affected by the same deficient practice. Residents that had an MDS done within the last 90 days, will be reviewed to ensure accuracy.
3. Systemic Changes to Prevent Reoccurrence ? The MDS nurse will assess each resident, and review their medical records during the assessment period, to ensure that all changes are captured correctly. Also, during the CCP meeting, the MDS and the care plan will be reviewed by the MDS Coordinator and the IDT. The CNA care card will also be reviewed.
4. Monitoring of Corrective Action ? The MDS Coordinator will be responsible to audit no less than 10 comprehensive assessments monthly. The results of the audit will be presented to the QAPI committee meeting on a quarterly basis by the MDS Coordinator or her designee on a quarterly basis, ongoing. The audits will be kept in the DONs office in a binder labeled (YEAR) P(NAME) audits.
5. Person Responsible and Date of Completion ? 1. MDS Coordinator 2. 7/10/2018

FF11 483.20(b)(1)(2)(i)(iii):COMPREHENSIVE ASSESSMENTS & TIMING

REGULATION: §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during a recertification survey, the facility did not ensure that the initial comprehensive assessment for 1 of 5 residents (#125) reviewed for dental concerns addressed the need for dentures for the resident who is endentulous (having no teeth). The finding is: Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; an assessment instrument) dated 6/11/17 noted that the resident was edentulous. The resident was evaluated by the dentist in (MONTH) (YEAR) which was the only dental evaluation to date. The evaluation showed that the resident was at the facility for short term stay. The evaluation did not address the resident's need for dentures or her history of having dentures. The Annual MDS dated [DATE] also noted that the resident is edentulous. The corresponding Care Area Assessment Summary, an extension of the MDS that provides more in-depth information, noted that complications related to the resident's edentulousness included difficulty with oral intake and increased risks for infections. This summary did not address the need for dentures and noted that the resident was tolerating her current diet well (a regular diet). The resident was observed and interviewed on 5/2/18 at 2:27 PM. At that time she was noted to be edentulous. When asked if she had dentures, she stated that she left them behind. The Nurse Manager/Registered Nurse (UNM #1) was interviewed in the morning of 5/9/18 about an assessment for the resident that determined her need for dentures. UNM #1 stated that the resident's diet has been upgraded from a pureed diet to a regular diet. UNM #1then proceeded to review the (MONTH) (YEAR) dental evaluation. After this review, UNM #1 stated that an assessment for dentures was not done by the dentist because the resident was supposed to be at the facility for short term stay only. The resident was observed during the lunch meal on 5/9/18. She was served small slices of roast beef. She did not eat most of it and stated that she could not handle it. 415.11(a)(3)(iii)

Plan of Correction: ApprovedJuly 18, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective Action ? 1. All nurses will be re-inserviced on assessing all residents for poor/loose fitting dentures upon admission and re-admissions 2. An in service was given to the Unit Clerks about notifying the Dentist and completing the weekly dental tracking tool audit. 3. Resident #125 was seen by the dentist, on 5/29/2018. The consultation stated that the resident was not an appropriate candidate for dentures but they will attempt to make one. The resident was seen by the dietitian and evaluated that the therapeutic diet remains appropriate and well tolerated. The CAA summary of the Annual MDS dated [DATE] was reviewed by the MDS Coordinator for accuracy and will be modified to address the resident?s need for dentures.
2. Residents at Risk for Same Practice ? All residents that are edentulous or have broken poor fitting dentures have the potential to be affected by the same deficient practice. An assessment of all residents that are in this category was done to ensure that no other residents were affected. None were identified. Residents that had a Comprehensive MDS done within the last 60 days, will be reviewed to ensure accuracy of the CAAs.
3. Systemic Changes to Reoccurrence ? Upon admission, all residents will be assessed for poor/loose fitting dentures by the Nurse completing the admission assessment. If noted upon assessment a referral will be made to be seen by the Dentist. Also, if noted upon assessment a referral will be entered into the shared drive int he computer under the dental weekly tracking audit tool. The Unit Clerks will be in serviced on this new procedure, The Dentist is on-site at the facility on a weekly basis. All referrals to the Dentist will be audited on a weekly basis by the Unit Clerk to ensure they have been seen by the Dentist within the two-week time frame. The Unit Manager for each unit will ensure that these residents are seen and follow up care is done when applicable. The admitting nurse will prepare consult for the dietitian to evaluate the need for the appropriate diet consistency. The MDS coordinator will assess each resident, and review their medical records during the assessment period, to ensure that that the CAA Summary of the comprehensive MDS reflects each resident?s functional capacity accurately.
4. Monitoring of Corrective Action ? The facility will develop an audit tool to ensure that all new residents are seen by the Dentist within 2 weeks if edentulous or with loose fitting/poor fitting dentures and that follow up care is provided as needed. The Unit Clerk will report the results of their audits on a weekly basis to the Unit Manager. The Unit Manager will report their audit findings to the DON who will report to the QAPI committee on a quarterly basis for a six-month period and ongoing as needed. The MDS coordinator will be responsible to audit no less than 10 comprehensive assessments monthly. The results of the audit will be presented to the QAPI committee meeting at least quarterly by the MDS Coordinator/designee until deemed not necessary. The audits will be kept in the DONs office in a binder labeled (YEAR) P(NAME) audits.
5. Person Responsible and Date of Completion ? 1. The DON/Designee 2. 7/10/2018

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not develop and implement comprehensive person-centered care plans with measurable goals, time frames and appropriate interventions to meet the needs 1 of 2 residents (#139) reviewed for pain, 1 of 1 resident reviewed for vision 465) and 1 of 5 residents (#138) reviewed for pressure ulcers. Specifically, Resident # 139 did not have a care plan in place to address pain and diabetic foot care problems and Resident # 465 did not have a care plan to address his vision needs. The findings are: 1. Resident #139 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment and screening tool) of 3/12/18 indicated that the resident had a BIMS (Brief Interview Mental Status) score of 15 out of 15 which indicated the resident was cognitively intact; required supervision of one staff member with bed mobility and eating; limited assist of 1 staff for transfers, and extensive assist of 1 staff for toilet use with activities of daily living(ADL). This MDs further documented that the resident received scheduled pain medication with indicator of pain (vocal complaint) 1-2 days during staff assessment for pain. The Physician order [REDACTED]. There was no care plan in place to address pain and discomfort which was caused by long toe nails at the time of the above admission assessment. The resident was interviewed on 5/4/18 at 2:00 PM and stated he has long toenails that cause discomfort when touched. The resident stated he was concerned and fearful of infection if his toenails become ingrown due to his diabetes. The Unit Nurse Manager (UMN #1) was interviewed on 5/7/18 at 10:30 AM and stated that it was the responsibility of the nurses and MDS Coordinators to initiate the care plans to address the residents' needs. The nurse manager was unable to locate a care plan addressing the resident's pain. The MDS Coordinator was interviewed on 5/7/18 at 12:00 PM and she stated the ground work for initiating care plans starts with MDS but it is the responsibility of the nurses on the unit to modify the care plans as needed. She stated that the care plan for pain should have been included in the comprehensive person-centered care plans with the prescribed pain medication. The MDS coordinator was unable to locate a pain care plan at that time. 2. Resident #465 had [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] indicated the resident had a BIMS score of 12 out of 15 which suggested the resident had moderately-impaired cognition and required limited assistance of 1 staff member with most aspects of activities of daily living (ADL). The Physician order [REDACTED]. An Optometry Consultation Note dated 4/27/18 revealed that the resident had floaters and dry eye syndrome and included directions to treat with Artificial Tears 1 drop two times daily in both eyes. There was no care plan in place to address vision problems related to dry eyes and the use of Artificial Tears. UNM #3 was interviewed on 5/11/18 at 10AM and stated the nurse managers and MDS Coordinators were responsible for initiating the care plans. UNM #3 was unable to locate a care plan for the resident's vision problems and the prescribed medication Artificial Tears. She stated that a vision care plan should have been put in place. 415.11(c)(1)

Plan of Correction: ApprovedJuly 18, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective Action ? 1. An in service was given to all RNs about updating care plans regarding pain upon admission and PRN as well as updating care plans regarding vision problems upon admission and PRN. 2. The residents that were identified with the deficient practice were assessed. Resident #139 with the long toe nails, that was causing discomfort, was seen by the podiatrist on 5/23/18 and the nails were trimmed. Resident #138 who has Diabetes had Diabetic foot care added to the resident?s plan of care and the care plans were updated with appropriate interventions. 3. Resident #465 care plans were updated to include vision and the need for artificial tears due to dry eyes.
2. Residents at Risk for Same Practice ? All residents have the potential to be affected by the same deficient practices. All residents who have the potential for pain are being evaluated q shift and prn as per protocol for objective and subjective data for pain. Residents that have a [DIAGNOSES REDACTED]. Residents with a [DIAGNOSES REDACTED]. This includes diabetic foot care. The CNA task in PCC will be updated to reflect any special changes.
3. Systemic Changes to Prevent Reoccurrence ? All residents will have a potential care plan for pain upon admission which will be initiated by the Unit Manager. An actual care for pain will be initiated if there are any indication or complaint of pain. 10 MARS, per unit, will be checked weekly to ascertain if residents are receiving pain medication and care plans are updated.
4. Monitoring of Corrective Action ? An audit tool will be developed to audit 10 chart, per unit, weekly to ensure compliance and appropriateness. The unit managers will initiate the care plans on admission and report the results of the audits which will be presented to the QAPI committee by the DON/designee at least quarterly for 6 months. The audits will be kept in the DONs office in a binder labeled (YEAR) P(NAME) audits.
5. Person Responsible and Date of Completion ? 1. DON/Designee 2. 7/10/2018

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(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. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 12, 2018

Citation Details

Based on observations and interview conducted during a recertification survey it was determined that the facility did not store food in accordance with professional standards for food safety practice. Specifically, leftover foods were unlabeled and illegibly dated and stored in the kitchen refrigerator; time and temperature controlled for safety (TCS) foods were not maintained at 41 degrees Fahrenheit (F) or less; and the dry storage room was not maintained in a sanitary manner. The findings Include: Observations and interviews were conducted during the initial tour of the kitchen between 10:00 AM and 11:00 AM on 4/30/18 and revealed the following: 1. One full stainless-steel pan of turkey sandwiches was unlabeled and undated, and one one-third full stainless-steel pan of turkey sandwiches was labeled with an illegible date. The Food Service Director (FSD) was interviewed at that time and stated that the dated label was not clear, and then proceeded to discard both pans of turkey sandwiches. 2. The dry storage room floor was heavily soiled with pieces of paper and cardboard; plastic cup lids were scattered on the floor; a large brownish-black colored spill visually estimated to be 24 x 12 inches was observed under a food storage rack; a reddish-brown spill was observed under the supplement rack; and the floor in general was heavily soiled with dirt and stains. Baseboards and walls were soiled with dirt. Four plastic storage racks were observed to be heavily soiled with blackish and brownish colored debris including dried, raised-to-touch accumulated debris. The FSD was interviewed at that time and stated that he did not know when the last time the racks were cleaned. He stated that the dry storage room floor cleaning schedule is for the floor to be swept and mopped every Wednesday. He stated he is the person responsible to make sure the cleaning was done and that the dry storage room floor was cleaned last Wednesday and that if something was spilled it should be cleaned up immediately. 3. A blackish-colored 4 round-shaped area was observed on the dry storage room floor and was wet and greasy to the touch. The area was directly beneath a partially exposed ceiling pipe. The pipe was covered with a foam wrap and there was an opening in the foam wrap. The FSD was interviewed at that time and stated that he was not aware of any leak in the dry storage room and further stated that he would inform maintenance. A follow-up Kitchen observation and interview was conducted on 5/04/18 between 11:30 AM and 12:00 PM. Egg salad and tuna salad sandwiches were being held on a cart in front of the tray line prior to tray line service. Temperatures were obtained by a kitchen staff for two tuna sandwiches, one of which was recorded at 50 degrees Fahrenheit (F) and the other at 60 degrees F. Additionally, the temperature for one egg salad sandwich was recorded at 50 degrees F. The Food Service Director was interviewed at that time and stated that the sandwiches had been put into the refrigerator about one and a half hours ago, and further stated that cold food temperatures are not being checked at the beginning of meal service unless there is a problem. A follow up observation of the dry storage room was conducted on 5/4/18 at 2:40 PM with the FSD present. At that time, a slow drip sound could be heard directly under the area of the ceiling pipe that remained partially exposed from its foam wrap. The Director of Maintenance (DOM) was called by the FSD to the dry storage room. The DOM was interviewed at 2:45 PM and stated that following the initial surveyor observation on 4/30/18, the FSD informed the DOM about a possible leak in a ceiling pipe in the dry storage room. The DOM stated that he repaired on the same day it was reported to him of a leak in the walk-in refrigerator line, and had left the insulation open to monitor for further leaking. The DOM further stated that the dripping was from a condensation as the insulation needs to be replaced. 415.14(h)

Plan of Correction: ApprovedJuly 18, 2018

1. Corrective Action ? 1. An in service was given to the dietary department about making sure all food kept in the refrigerator is properly and clearly dated, maintaining a clean kitchen and making sure sandwiches are being kept in the refrigerators until they are ready to be sent to the floors. 2. A date gun was purchased and all food in the refrigerators was relabeled. 2. Garbage was thrown away, racks were wiped down and the floor was mopped. 3. Necessary repairs were made to ensure the pipe doesn?t leak 4. Sandwiches are being kept in refrigerators until they are ready to be sent to the floors
2. Residents at Risk for Same Practice ? All residents have been identified with the potential to be affected by the same deficient practice.
3. Systemic Changes to Prevent Reoccurrence ? 1. An audit tool was created to check that all food is being properly labeled. This audit will be conducted for 1 year. 2. An audit tool was created to make sure the noted area is free of debris and spills. This audit will be conducted for 1 year. 3. An audit tool was created to observe the noted pipe. 4. An audit tool was created to check the temperatures of the sandwiches before being sent to the floors. This audit will be done prior to the meals and conducted for one year.
4. Monitoring of Corrective Action ? The results of the audit tools will be presented to the QA committee by the Director of Food Services or his designee on a quarterly basis for one year. The audits will be kept in the DONs office in a binder labeled (YEAR) P(NAME) audits.
5. Person Responsible and Date of Completion ? 1. Director of Food Services 2. 7/10/2018

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during a recertification survey, the facility did not ensure that the doses of antipsychotic medications were gradually reduced unless clinically contraindicated for 2 of 5 residents (#72 and #67 ) reviewed for unnecessary medications. Specifically, gradual dose reduction (GDR) of antipsychotic medications did not occur for these residents with the [DIAGNOSES REDACTED]. The findings are: 1. Resident #72 has [DIAGNOSES REDACTED]. A review of two of the psychiatric evaluations conducted by a Psychiatric Nurse Practitioner (NP) revealed the following notations about the resident: - 12/8/17 - Displaying more of a flat/blah effect, not sure if it is depression progressing or dementia, [MEDICATION NAME] (an antipsychotic medication) is being tapered. Tolerating this well but (resident) appears worsening mood. Recommendations made was to decrease [MEDICATION NAME] from 50 mg to 25 mg for 14 days then to 12.5 mg. (This was done on 12/25/17). - 3/5/18 - Noted to be delusional and depressed, not as sad appearing since last consultation (2/5/18). Frequently will say that her grandchildren are here and can not find them; as a result, becomes worried. The recommendation was to increase [MEDICATION NAME] (an antidepressant) to 75 mg. The (MONTH) (YEAR) care plan addressing the use of [MEDICAL CONDITION] medications (antipsychotic and antidepressants) related to the [DIAGNOSES REDACTED]. The interventions to achieve these goals included to educate the resident family/caregivers about risks, benefits and the side effects and/or toxic symptoms of [MEDICAL CONDITION] drugs; give medications ordered by physician; monitor/document side effects and effectiveness; and monitor/record occurrence of target behavior symptoms: irritability, change in appetite/sleep pattern, lethargy, inappropriate response to verbal communication, violence/aggression towards staff/others. Review of nursing notes following the psychiatric NP evaluation of 3/5/18 to the present, revealed no documented evidence of ongoing incidents of delusional thinking. According to the comprehensive person-centered care plan meeting note dated 4/5/18, the family reported that the resident was having visual hallucinations and requested that the resident have a psychiatric evaluation for a dose increase. The Psychiatric NP evaluated the resident on 4/6/18. This evaluation noted that the resident appeared to have progressed in dementia since last visit and was not having any delusion or hallucinations. The NP also noted that it was unclear if [MEDICATION NAME] was beneficial. The recommendation by the NP was to increase [MEDICATION NAME] to 75 mg. The nursing note of 4/11/18 documented that the family was spoken to regarding to decrease [MEDICATION NAME] as recommended by the Psychiatric NP. The family stated they did not want any gradual dose reduction with medications. The family reported that the resident was having visual hallucinations at times during their visits and felt that these hallucinations were increasing at times. This was discussed with the NP (a Family NP) who gave an order to place the resident back on previous dose of [MEDICATION NAME] (25 mg). The resident's primary designated representative was interviewed on 5/9/18 at 4:45 PM and stated that no one in the facility educated her on dementia care and on the use of antipsychotic medications including how behavioral symptoms are addressed and noting that they should be persistent and causing clinical decline or discomfort to warrant the continuation of medication therapy. The Psychiatric NP was interviewed on 5/9/18 at 2:25 PM. This interview revealed that she did not educate the family on the use of antipsychotic medications. She stated that this education would be done by the nursing staff. The Social Worker, UNM #1, and the Psychiatric NP were interviewed on 5/14/18 at 2:25 PM and revealed no evidence that the resident was exhibiting hallucinations/ delusional thinking other than what was reported by the family at the time [MEDICATION NAME] was reordered. This interview revealed no evidence that the family was provided any education by any member of the care planning team on dementia care and the use of antipsychotic medications. Additionally, the Psychiatric NP stated that she was not aware of the concern expressed by the family and the objection to further gradual dose reduction of the resident's medications.
2. Resident #67 has [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] coded the resident had moderately-impaired cognitive skills; had no behavior problems; and on antipsychotic, anti-depressant, and copied medications. The Psychiatric Evaluation Consultation Long Term Care Form dated 7/31/17 and signed by the Nurse Practitioner included depression, anxiety, crying, confusion, and [MEDICAL CONDITION] with prescription for Trazadone 50 mg po (by mouth) at hs (bedtime), [MEDICATION NAME] 0.5 mg po every 12 hours, [MEDICATION NAME] 5 mg every 12 hours, and [MEDICATION NAME] 100 mg po two times a day, and [DIAGNOSES REDACTED]. The plan was to decrease Trazadone 25 mg po hs for 7 days then discontinue, start [MEDICATION NAME] 7.5 mg po every bedtime for 7 days and then increase [MEDICATION NAME] to 15 mg by mouth every bed time and follow up in 3-4 weeks. The behavior care plan initiated on 12/7/16 included behaviors such as wandering, elopement risk, cognitive impairment, and mental illness (anxiety/pseudobulbar affect/depression/[MEDICAL CONDITION]). The Behavior Psychiatry assessment record of 1/31/17 documented that the family stated on two separate occasions that they do not want psych medication adjustments. During an interview in the morning of 5/8/18 with UNM #1, she stated she spoke with the resident's daughter today after the surveyor questioned if the family has been educated on use of psych medications and to confirm the documentation in the chart regarding psych medication dosage changes. UNM #1 stated the family does not want the medications increased or decreased at this time and that if the resident is seen by the psychiatrist the family would like to be notified and would consider changes if medical staff thinks it is needed. UNM#1 stated that the psychiatry evaluation dated 7/31/17 was the last that she was aware of and could not locate in the chart. She also said the resident is stable without behavior issues at that time. The resident's physician (MD) was interviewed on 5/10/18 at 1:30 PM and he stated that he recently spoke with the resident family and they requested a neurology consult to better understand the effect dementia could have on the resident. He said he has known this resident for many years as he cared for her in a previous facility. The MD stated that anytime her medications have been changed/tapered she has been re-hospitalized and that the resident has had long standing psychiatric behaviors with multiple hospitalization s in the past. The MD further stated that he had educated the family on the use of [MEDICAL CONDITION] medications. There was no evidence documented evidence in the resident's clinical record of this intervention and of any ongoing monitoring/GDR consideration for the use of these medications. The resident's family member was interviewed on 5/14/18 at 10:53 AM and stated that her mother has a history of [MEDICAL CONDITION] since childhood with escalating behaviors and that the resident has had multiple psychiatric hospital admissions when facilities she had been in could not handle her. This family member stated that she was open to psychiatric consults and medication adjustments, either up or down, if the team feels it is warranted as long as the facility lets her know of what is being done and the reason why. She stated further that her family had requested that her mom be seen by a neurologist to see if the medications may need to be changed to benefit her mother. 415.12(l)(2)(ii)

Plan of Correction: ApprovedJuly 18, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective Action ? 1. An in service was given to the Unit Managers and Social Workers about educating the families and residents regarding the risks vs benefits of [MEDICAL CONDITION] medications as well as what GDR is and why they are attempted. 2. Resident #72 & #67 were seen by the medical practitioner. The families of the noted residents will be educated to understand the risks vs benefits of [MEDICAL CONDITION] medications, what are gradual dose reduction and why they are attempted. The resident/family wishes/desires will be respected as requested.
2. Residents at Risk for Same Practice ? All residents who are on a daily [MEDICAL CONDITION] drug regimen have the potential to be affected by the deficient practice.
3. Systemic Changes to Prevent Reoccurrence ? The medical director, unit managers and social workers will be provided re-education on the need to provide education to residents/families and/or next of kin on risks vs benefits of [MEDICAL CONDITION] medications. A form will be created for all residents and/or families to sign that they were educated and understand the risks vs benefits of [MEDICAL CONDITION] medications. All residents/families and/or next of kin who are on a daily [MEDICAL CONDITION] medication will be educated to understand what gradual dose reduction are and why they are attempted. They will be given the opportunity to express their wishes prior to any GDR attempt. The social worker will inform the resident/next of kin of any changes to the plan of care and document responses in the chart. The pharmacy consultant will include in his monthly reports any issues with GDRs.
4. Monitoring of Corrective Action ? an audit tool will be developed to monitor 5 charts, per unit, weekly on (a) documentation of education to resident/next of kin on risk vs benefits (b) GDR attempted (c) Resident/next of kin: Agreed/disagreed. Results of the audit tool will be presented to the QAPI committee at least quarterly for 6 months or until deemed not necessary by the QAPI committee. The audits will be kept in the DONs office in a binder labeled (YEAR) P(NAME) audits.
5. Person Responsible and Date of Completion ? Director of Social Services/designee 2. 7/10/2018

E3BP 402.9(b)(2):RESPONSIBILITIES OF PROVIDERS; REQUIRED NOTIF

REGULATION: Section 402.9 Responsibilities of Providers; Required Notifications. ...... (b) Notifications. A provider must immediately, but within no later than 30 calendar days after the event, notify the Department, and document such notification occurred, when: ...... (2) any employee who was subject to, and underwent, a criminal history record check in accordance with this Part is no longer employed by the provider.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 12, 2018

Citation Details

Based on record review and interview conducted during a recertification survey, the facility did not notify the Department of Health (DOH) within the required 30 calendar day period that multiple prospective employees subjected to criminal history record check (CHRC) and were not employed by the facility, were not removed from the system, in order to terminate further exchange of information related to the prospective employees who had negative determination findings. The finding is: The facility CHRC review was conducted on 5/14/18 and revealed that 3 of the 4 prospective employees (#1, #2, and #3), who underwent CHRC, for whom the facility was notified of the negative determinant findings, were not hired by the facility, or removed from the CHRC system. There was no documented evidence, upon review, or upon request, that the facility notified the DOH that the prospective employees were not hired by the facility, or were removed from the system within the required 30 calendar day period following receipt of the negative letters on 5/9/17 for Prospective employee #1, 5/10/17 for Prospective employee #2, and on 9/27/17 for Prospective employee # 3. This was required in order to terminate further exchange of information related to these prospective employees who underwent CHRC and were not hired by the facility. The Human Resources (HR) Director was interviewed on 5/14/18 at 10:15 AM and stated that the previous HR Director who was responsible for submitting the termination information to DOH CHRC system had not submitted them. The Acting Administrator (AC) was interviewed on 5/14/18 at 10:52 AM and stated that the previous HR Director did not perform her job. The AC stated she should have removed them from the CHRC system. 402.9(b)(2)

Plan of Correction: ApprovedJuly 18, 2018

1. Corrective Action ? 1. An in service was given to the HR Coordinator about terminating from the CHRC within the required 30 calendar day period following receipt of any negative letters. 2. All employees who no longer work for the facility are terminated from the CHRC and going forward all prospective employees who no longer work for the facility will be terminated from the CHRC within the required 30 calendar day period following receipt of any negative letters.
2. Residents at Risk for Same Practice ? All residents have been identified with the potential to be affected by the same deficient practice.
3. Systemic Changes to Prevent Reoccurrence ? 1. An audit tool was created to ensure that all prospective employees who no longer work for the facility will be terminated from the CHRC within the required 30 calendar day period following receipt of any negative letters
4. Monitoring of Corrective Action ? The results of the audit tools will be presented to the QA committee by the Human Resources Coordinator or her designee on a quarterly basis for one year. The audits will be kept in the DONs office in a binder labeled (YEAR) P(NAME) audits.
5. Person Responsible and Date of Completion ? 1. Human Resources Coordinator 2. 7/10/2018

FF11 483.25(a)(1)(2):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- §483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, conducted during a recertification survey, the facility did not ensure that treatment and services to correct visual impairment were provided in a timely manner for 1 of 4 residents (#45) reviewed for vision. Specifically, the resident did not receive the eyeglasses that was recommended by the optometrist and which was ordered physician. The findings are: Resident # 45 has [DIAGNOSES REDACTED]. An Optometry Evaluation report dated 8/21/17 documented that the resident had Tortuosity and Myopia of both eyes, and bifocal glasses were ordered. An Optometry Evaluation dated 12/1/17 revealed that glasses were re-ordered. The Annual Minimum Data Set (a resident assessment and screening tool) of 2/5/18 indicated that the resident had impaired vision, sees large print, but not regular print in newspapers and books, and had no corrective lens. The 2/16/18 Impaired Vision Care Plan documented that the resident had impaired vision related to the aging process and [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The resident was interviewed on 4/30/18 at 1:12 PM and he stated that he needed glasses to read. The resident stated that the facility doctor was notified of his request for glasses and that the doctor would consult the eye doctor so he could get his glasses. The resident stated that he had a pair of glasses a long time ago but it got broken, and never received a new one. The resident was observed on multiples occasions, throughout the survey, including the initial interview, as indicated above, as well as on 5/7/18, at 2:52 PM, 5/11/18, at 10:50 AM, 5/14/18 at 11 AM, and other times, without glasses. There was no documented evidence found or produced by the facility, upon request, indicating that the glasses that should have been re-ordered as documented on the 12/1/17 Optometry Evaluation Report was re-ordered or received. The Unit Nurse Manager (UNM #2) was interviewed on 5/11/18 at 10:32 AM and stated that the resident was supposed to receive new glasses after being seen by the optometrist in (MONTH) (YEAR). UNM #2 stated that the resident had glasses that got broken, but it was supposed to be re-ordered in (MONTH) (YEAR), but no one followed it up. UNM #2 stated that it was the nurse manager's responsibility to follow up when glasses or anything are ordered by the eye doctor. UNM #2 further stated that she could not find any evidence that the resident received the ordered glasses. The resident was further interviewed on 5/11/18 at 10:50 AM and stated that he never received his glasses. The resident stated he was not informed by anyone that the glasses were ordered. UNM #2 was interviewed again on 5/14/18 at 11:00 AM and she stated that she contacted the eye doctor on 5/11/18 and he ordered the glasses, which should been received in 2 weeks. The Medical Director (MD) was interviewed on 5/14/18 at 1:10 PM and stated that the resident did not complain of any eye issues to him. The MD stated that when orders are placed in the computer, the eye doctor would come to examine the residents, and it is the nurse's responsibility to follow up with recommendations. A Nurse Practitioner, present in the facility, was interviewed on 5/14/18 at 1:46 PM and stated that she also covers the resident but the resident never complained of vision problems or requested glasses. 415.12 (3) (b)

Plan of Correction: ApprovedJuly 18, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective Action ? 1. An in service was given to the clinical nursing staff including the CNAs about ensuring that eye glasses are in place and in good condition for residents who need or use. 2. Resident #45 received a new pair of eyeglasses from the Optometrist on 5/11/18.
2. Residents at Risk for Same Practice ? All residents who wear or were recommended to wear eyeglasses have been identified with the potential to be affected by the same deficient practice. A review will be done of all residents who have an order or was recommended to wear eye glasses to ensure that they have the glasses in place or in process.
3. Systemic Changes to Prevent Reoccurrence ? An audit tool will be created to ensure that the resident have the eye glasses as in place as recommended by the Optometrist. All residents with eye glasses will be checked each shift by the CNA to ensure that the resident?s glasses are in place. All missing/broken glasses will be reported to the nurse manager who immediately will get an order for [REDACTED].
4. Monitoring of Corrective Action ? An audit tool will be developed to check that the resident?s glasses are in place and in good condition. This will be done by the CNA and reviewed at least weekly by the managers. Results of the audits will be presented to the QAPI committee by the Unit Managers or their designees at least quarterly for one year or until deemed not necessary by the QAPI committee. The audits will be kept in the DONs office in a binder labeled (YEAR) P(NAME) audits.
5. Person Responsible and Date of Completion ? Unit managers 2. 7/10/2018

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review conducted during a recertification survey, the facility did not ensure that care and treatment were provided to promote healing of existing pressure ulcers and prevent development of new pressure ulcers for 2 of 5 (#138 and #62) residents reviewed for pressure ulcers. Specifically, for Resident #138, there was no ongoing monitoring and assessment of the resident's skin in accordance with the written care plan including timely implementation of pressure relieving measures including off loading and turning and positioning to heal or prevent development of further pressure ulcers. For Resident #62, there was no comprehensive person-centered care plan with appropriate and timelt interventions to address prevention of pressure ulces at the time the MDS was initiated for this resident at risk at the time of admission. The findings are: 1.Resident #138 was admitted on [DATE] and has [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment and screening tool) with reference date of 2/21/18 indicated that resident has no cognitive impairment; required extensive assistance of 2 persons for bed mobility, transfers and toileting and limited assist of 1 person for eating. This MDS documented that the resident had a Stage 1 or greater, a scar over bony prominence pressure ulcer and was asssessed as high risk for developing pressure ulcers; an unhealed pressure ulcer at Stage 1 or higher; and one Stage 2 pressure ulcer. According to this MDS, pressure reducing devices to chair and bed were initiated. The care plan for At Risk for Impaired Skin Integrity related to immobility and incontinence initiated on 2/14/18 had a goal that the resident's skin will remain intact throughout the review period. Interventions to achive this goal included to apply moisturizer as needed to the skin, apply protective/preventive skin care, avoid prolonged sitting, ensure frequent weight shifts and monitor skin condition daily during care and report changes. The interventions listed did not include specific and appropriate measures with time frames to address the treatment and healing of the existing pressure ulcer. Additionally, there was no indication that pressure relieving measures for the right heel and sacral area were initiated at the onset following identification of this resident to be at risk for developing pressure ulcers. Furthermore, there was no documented evidence that daily monitoring and ongoing assessment of the pressure ulcer was conducted between of 2/14/18 and 3/1/18. A review of the facility investigation report revealed that on 3/1/18, pressure ulcers were noted on the right heel to be a deep tissue injury measuring 4.5 cm x 4.5 cm, and a Stage 2 pressure ulcer to the sacrum measuring 2 cm x 2 cm. The care plan for At Risk for Impaired Skin Integrity was updated on 3/5/18. The interventions did not address the presence of the right heel pressure ulcer. The care plan was then revised on 3/13/18. It was not until this date that the interventions including the use of pressure relieving devices was added while the resident was in bed and on the wheelchair. Turning and repositioning was not listed as one of the interventions on both of these care plans. A wound assessment note dated 3/22/18 showed that on that date, the sacrum wound measured 2.5 cm x 2.6 cm x 0.3 cm with moderate exudate (fluid seeping from the wound), and the right heel wound measured 4.4 cm x 4.2 cm with exudate. On 3/23/18 the CNA (Certified Nursing Assistant) care guide showed that turning and positioning had been initiated. Off loading of the heels was not included as an intervention. The Unit Nurse Manager (UNM #1) was interviewed on 5/11/18 at 10:00 AM and was asked about the resident's Stage 2 pressure ulcer present on admission. UNM #1 responded by saying, What pressure ulcer, he did not have a pressure ulcer. The resident's clinical record was then reviewed with UNM #1 and stated there was a pressure ulcer measuring 2 cm x 3 cm on that document which she had signed but she does not remember this wound. UNM #1 stated she obviously would have looked at him and put him on wound monitoring. She stated further that she must have noted it on admission and did not get back to it. UNM #1 stated that the RN is responsible for assessing the resident's skin on admission and the LPN is responsible for putting in orders. She was unable to locate treatment orders or any documentation for wound monitoring or tracking. During an interview conducted on 5/7/18 at 12:00 PM with the MDS Coordinator, she said that the ground work for care plans is started by the MDS department but it is the responsibility of the nurses to modify the care plans as needed and on a timely manner. The assigned 3-11 shift Licensed Practical Nurse (LPN #1) was interviewed on 5/9/18 at 4:55 PM and stated that on 3/1/18, a CNA (#1) reported that the resident had a wound to the coccyx. She stated that she received an order for [REDACTED].#1 stated that after she noted the coccyx wound on 3/1/18, she put in a request for an air mattress and after noting the heel wound on 3/1/18 she put a request in for heel booties, and to off load heels when in bed. LPN #1 stated that these interventions were not in place prior to 3/1/18. She stated there were no reasons for these interventions to be in place because this resident had no skin issues. (The 2/21/18 MDS assessed the resident to be at risk for developing pressure ulcers.) The assigned Certified Nurse Aide (CNA #2) was interviewed on 5/14/18 at 10:35 AM and she stated that she does not remember if she was ever told to turn and position the resident every 2 hours. CNA #2 added that she does not remember if the resident was being turned on any schedule. A wound observation was conducted with the unit nurse on 5/14/18 at 1:30 PM. The sacral wound measured 1.0 cm x 0.5 cm x 0.2 cm with a small amount of exudate and the right heel wound measured 0.7 cm x 0.6 cm x 0.1 cm with exudate, there was no odor or obvious signs of infection.
2. Resident #62 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] showed that the resident was severely cognitively impaired, required extensive assistance with bed mobility, had poor appetite, had no pressure ulcers, at risk for developing pressure ulcers, had a pressure reducing device for the bed, and was not on a turning and positioning schedule. There was no care plan initiated addressing the prevention of the development of pressure sores at the time of this initial MDS for this at risk resident. An at risk pressure ulcer plan of care was developed on 9/21/17 with the following interventions: frequent incontinent care, monitor intake and record, monitor changes in skin status, monitor labs, and apply moisture to skin as needed. This care plan was revised on 9/28/18 to reflect the presence of a blister to the right heel measuring 3.4 cm x 3.2 cm. The interventions to promote wound healing at that time were to use Skin Prep (a pad that protects the skin) to the heels daily and to off load heels. It was not until 11/8/17, 25 days after the resident was admitted , that the CNA care guide showed that a turning and positioning schedule was initiated for the resident. The facility's investigation of this pressure sore showed that the pressure ulcer discovered on 9/18/17 was noted on the right heel to be a deep tissue injury (or a blister filled with fluid) measuring 3 cm x 3 cm. The investigation documented that at the time of discovery new interventions were planned for the resident to include off loading the heel and that the resident was severely debilitated, had bilateral [MEDICAL CONDITION] of the lower extremities, and decreased sensation to area of wound. The conclusion was that this wound was unavoidable due to the resident's condition and medical problems. This investigation did not address what measures were in place prior to 9/18/17 to prevent the development of pressure sores in light of the fact that the resident's condition described in the investigation put him at high risk for breakdown to his lower extremities. A wound observation was conducted in the morning of 5/14/18. The wound was clean, there were no signs of infections and no drainage. Following this observation, the Director of Nursing was interviewed on 5/14/18 about the lack of timely interventions to prevent the development of pressure sores to the resident's heels at the time of his admission and about the delay in the development of a preventive care plan as noted above. She stated that the nurse manager who was responsible was for updating and implementing preventive measures was terminated because of her failure to develop care plans. 415.12(c)(1)(2)

Plan of Correction: ApprovedJuly 18, 2018

1. Corrective Action ? 1. An in service was given to the RN staff regarding correct skin assessment and initiating a care plan on Potential or actual skin integrity with appropriate interventions for the specified area(s) affected. 2. Both residents # 138 &# 62 had the preventative measures put in place, 1) Heel lift; air mattress 2) The CNA task in PCC were updated to include turning and positioning every 2-3 hours, the MDS was reviewed 3) The nurses that were directly involved with the care of these residents were re-educated on caring and preventative measures of resident with PU, or resident that are high risk for impaired skin integrity. 4) The MDS coordinator was also re-inserviced on assuring measures are in place before completing the initial MDS 5) Nurses continued to assess the wound daily, medical practitioner weekly, to ensure appropriate treatment and preventative measures continues as needed.
2. Residents at Risk for Same Practice ? Residents that have been identified on admission as high risk for impaired skin integrity, or residents who requires assistance of more than 1 person in bed mobility, and incontinent residents, have the potential to be affected by this deficient practice
3. Systemic Changes to Prevent Reoccurrence ? The wound care specialist nurse will have a reeducation program on:
a) Assessing residents for potential/actual impaired skin integrity on admission and readmission
b) Preventative care
c) Appropriate equipment to use and when
d) Special cushions
e) Treatments and a review of the present preventative protocol.
2) All newly developed impaired skin integrity, and new admissions that were assessed to be high risk will be discussed in the daily morning meeting. A plan of care will be developed with appropriate interventions. The CNA task in PCC will also be updated to reflect the care plan
The admission nurse will ensure that all residents on admission are skin integrity are assessed thoroughly on admission
The wound care team will ensure that the resident?s skin integrity will be documented accurately during weekly wound rounds
4. Monitoring of Corrective Action ? 1. The charge nurse will monitor daily during dressing changes for preventative measures that were put in place, correct any negative findings, and report to the unit manager. 2. The unit managers will perform random checks of their unit to ensure compliance and report weekly to the ADNS compliance/ non-compliance. 3. The MDS coordinator/Designee will audit 50% of initial MDS care plans of residents that are high risk, or who have impaired skin integrity, to ensure care plans and interventions are appropriate. Findings will be reported to the ADNS monthly. The ADNS will compile a monthly report from managers and MDS coordinator and send to the DNS, who will report findings quarterly to the QAPI meeting. The audits will be kept in the DONs office in a binder labeled (YEAR) P(NAME) audits.
5. Person Responsible and Date of Completion ? 1. DON 2. 7/10/2018

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 10, 2018
Corrected date: July 19, 2018

Citation Details

Based on observation, interview, and record review, the facility did not ensure that the non patient care related electrical equipment was visually inspected in accordance with NFPA 99. Reference is made to the lack of documentation of the visual inspections for all non-patient care related electrical equipment in use in resident rooms. The findings are: During the life safety recertification survey conducted on 5/7/18 and 5/8/18 between 11:20 AM - 3:00 PM, a tour of resident rooms throughout the facility revealed that inspection stickers were not provided on the residents televisions, clocks or radios as evidence of a visual inspection. There was no other documented evidence of visual inspections of non-patient care related electrical equipment provided. In an interview at the time of the findings, the Director of Maintenance stated that the televisions in resident rooms are provided by the facility. He further stated that visual inspections are being conducted, however the inspections were not documented. The Director of Maintenance stated that he will ensure that the visual inspections of the personal electrical equipment will be documented. 2012 NFPA 101 2012 NFPA 99: 10.4.2.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMay 28, 2018

1) Corrective Action ? 1. The Director of Maintenance or their designee is inspecting each personal electrical device to assess for safety. 2. Each device will be tagged with a label indicating the inspection has been completed.
2) Residents at Risk for Same Practice ? All residents who utilize personal electrical devices have been identified with the potential to be affected by the same deficient practice.
3) Systemic Changes to Prevent Reoccurrence ? 1. Upon admission the Director of Admissions will notify the Director of Maintenance or their designee about any new admissions. 2. Within 24 hours of notification the Director of Maintenance or his designee will meet with the resident and request all electrical devices for inspection. 3. The Director of Maintenance or his designee will assess each device for safety and each device will be tagged with a label indicating the inspection has been completed. 4. The facility will create an audit tool was with the resident name, room number and electrical devices. 5. The Director of Maintenance or his designee will inspect the devices on an annual basis.
4) Monitoring of Corrective Action - The results of the audit tools will be presented to the QA committee by the Director of Maintenance or his designee on a quarterly basis for one year.
5) Person Responsible and Date of Completion ? 1. Director of Maintenance. 2. 7/8/2018.

EP TESTING REQUIREMENTS

REGULATION: *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: May 10, 2018
Corrected date: August 26, 2018

Citation Details

Based on documentation review and interview, the facility did not provide documentation of staff roles and participation, or review and analysis, of drills that had been conducted. Reference is made to external and internal reports for which direct actions taken by staff, analysis of the facility's response, and staff attendance sheets were not provided. The findings are: Internal and external exercise drills to test the facility's emergency preparedness plan were reviewed during the recertification survey on 5/7/18 at approximately 10:40 AM. Reports provided for an external drill conducted on 3/8/18 and an internal drill conducted on 1/10/18. However, neither report included specific staff roles, signed and dated staff attendance sheets, or a facility analysis of the drills. In an interview at the time of the findings, the Director of Maintenance stated that he will include staff participation, roles and the facility's analysis in future reports. 483.73(d)(2)

Plan of Correction: ApprovedMay 28, 2018

1) Corrective Action ? The facility will conduct an internal drill and external drill that will consist of the drills as well as an audit tool for specific staff roles, an audit tool for staff signatures of attendance and an audit tool for the facility analysis of each drill.
2) Residents at Risk for Same Practice ? All residents have been identified with the potential to be affected by the same deficient practice.
3) Systemic Changes to Prevent Reoccurrence ? Audit tools were created to identify specific staff roles, staff signatures and a facility analysis.
4) Monitoring of Corrective Action ? The results of the audit tools will be presented to the QA committee by the Director of Maintenance or his designee on a quarterly basis for one year.
5) Person Responsible and Date of Completion ? 1. Director of Maintenance. 2. 7/8/2018.

K307 NFPA 101:FIRE DRILLS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 10, 2018
Corrected date: July 19, 2018

Citation Details

Based on documentation review and interview, the facility did not ensure that fire drills are conducted at varying times. This was evidenced by 4 of 4 required quarterly drills for the Evening shift and 3 of 4 drills on the Night shift that were not performed at varying times. The findings are: On 5/7/18 at approximately 10:15 AM, a review of the facility's fire drill logs for the past 12 months was conducted. It was noted that 4 of 4 Evening fire drills that were conducted between 5/2017 - 2/2018 took place between 3:15 PM - 3:45 PM, and 3 of 4 Night fire drills conducted between 9/2017 - 3/2018 took place between 11:00 AM - 11:50 AM. In an interview on 5/8/2018 approximately 11:15 AM, the Acting Administrator stated that he will notify the vendor to conduct drills at varying times on the shifts mentioned. 2012 NFPA 101: 19.7.1.26 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 28, 2018

1) Corrective Action ? All fire drills will be held at various times to ensure appropriate simulation.
2) Residents at Risk for Same Practice ? All residents have been identified with the potential to be affected by the same deficient practice.
3) Systemic Changes to Prevent Reoccurrence ? An audit tool was created to monitor the dates and times of the facility fire drills to ensure they occur at different times.
4) Monitoring of Corrective Actions ? The results of the audit tools will be presented to the QA committee by the Director of Maintenance or his designee on a quarterly basis for one year.
5) Person Responsible and Date of Completion ? 1. Director of Maintenance. 2. 7/8/2018.

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 10, 2018
Corrected date: July 19, 2018

Citation Details

2012 NFPA 99: 11.6.5 Special Precautions - Storage of Cylinders and Containers. 11.6.5.1 Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Based on observation and staff interview, the facility did not ensure that full and empty oxygen cylinders stored within the same room were segregated. Reference is made to the main oxygen storage room within a basement storage room. The finding is: On 5/8/2018 at approximately 11:25 AM, a tour of the main oxygen storage room in the basement revealed that the oxygen cylinders in the room could not be readily identified as full or empty due to the lack of signage segregating the full and empty tanks. In an interview at the time of the findings, the Director of Maintenance stated that he will provide signs to separate the full and empty oxygen cylinders. 2012 NFPA 99: 11.6.5.1, 11.6.5.2, 11.6.5.3 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMay 28, 2018

1) Corrective Action ? 1. A sign was immediately posted in the oxygen storage room to ensure a clear delineation between the full and empty tanks. 2. An audit was conducted in the oxygen storage room to ensure there was no comingling of full and empty oxygen tanks. None were noted.
2) Residents at Risk for Same Practice ? All residents that utilize oxygen have been identified with the potential to be affected by the same deficient practice.
3) Systemic Changes to Prevent Reoccurrence ? An audit tool was created by the facility to ensure all oxygen rooms are clearly labeled and full and empty tanks are kept separated.
4) Monitoring of Corrective Action ? The results of the audit tools will be presented to the QA committee by the Director of Maintenance or his designee on a quarterly basis for one year.
5) Person Responsible and Date of Completion ? 1. Director of Maintenance. 2. 7/8/2018.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 10, 2018
Corrected date: July 19, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2011 NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems Chapter 5 Sprinkler Systems 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). 5.4 Maintenance. 5.4.1 Sprinklers. 5.4.1.4* A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. 5.4.1.4.1 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. 5.4.1.6 * A special wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. 5.4.1.6.1 One sprinkler wrench shall be provided for each type of sprinkler installed. Chapter 8 Fire Pumps 8.3* Testing 8.3.1. Frequency 8.3.1.2* Electric- motor driven fire pumps shall be operated monthly. 8.3.2.3 The electric pump shall run a minimum of 10 minutes. 8.3.2.8 The pertinent visual operations or adjustments specified in the following checklists shall be conducted while pump is running: (2) Electrical system procedures as follows: (a) Observe the time for motor to accelerate to full speed (b) Record the time controller is on first step (for reduced voltage or reduced current starting) (c) Record the time pumps runs after starting (for automatic stop controllers). Based on observation and staff interview, the facility did not ensure that the automatic sprinkler system installed in required areas was maintained in accordance with NFPA 25. Reference is made to the following: 1. Sprinklers were noted with paint, plastic, debris, calcification, ice and a green oily substance. 2. Lack of documentation for the required testing of the electric driven fire pump. 3. Spare recessed heads were not observed and additional spare sprinkler heads were not stored in a metal cabinet. The findings are: During the recertification survey on 5/7/18 and 5/8/18 between the hours of 10:00 AM and 3:00 PM, a life safety tour of the facility was conducted and the following issues with the sprinklers were noted: 1. Sprinklers were noted with paint, plastic, debris, calcification, ice and a green oily substance. - On 5/7/18 at approximately 11:30 AM, a tour of the dining room on 5 East revealed a green oily substance on the pendent style sprinkler in the recreation closet within the room. - On 5/7/18 at approximately 2:05 PM, a tour of resident room [ROOM NUMBER] revealed paint on two of two sidewall sprinklers in the room. - On 5/7/18 at approximately 2:40 PM, a tour of the kitchen revealed calcification on the sprinkler in the walk-in freezer. - On 5/7/18 at approximately 2:53 PM, a green oily substance was noted on 1 of 2 sprinklers in the closet located near the Director's office for the adult day health care program. - On 5/8/18 at approximately 10:35 AM, a green oily substance was observed on on 1 of two sprinklers in the recreation room. - On 5/8/18 at approximately 10:40 AM, a tour of the dentist's office revealed debris between the prongs of one of two sprinklers in the room. This was also noted on the sprinkler in the corridor near the Rehab. room. - On 5/8/18 at approximately 11:00 AM, ice was noted on the sprinkler in a walk in freezer located in a basement storage room. - On 5/8/18 at approximately 11:45 AM, plastic was observed on 1 of 5 sprinklers in the clean linen room. In an interview at the time of the findings, the Director of Maintenance stated that the sprinklers are checked quarterly by the vendor, and currently the facility does not have a preventative maintenance schedule for the sprinklers. He further stated that a preventive maintenance schedule will be implemented and the vendor will be contacted to replace the sprinkler heads noted. 2. Documentation was missing for the electric driven fire pump. On 5/7/18 during the life safety tour of the facility, it was noted that the sprinkler system was equipped with an electric driven fire pump. The facility's sprinkler maintenance documentation was reviewed at approximately 10:25 AM the same day. Although documentation was provided for annual fire pump tests (dated (MONTH) (YEAR) and (MONTH) 5, (YEAR)), there was no documentation provided for the required monthly churn tests for a six month period between (MONTH) (YEAR) to (MONTH) (YEAR). In an interview during the exit conference conducted on 5/8/18 at approximately 3:15 PM, the Director of Maintenance stated that the electric driven fire pump had been leaking and the vendor was constantly on site to repair the leak. 3. Spare recessed heads were not observed and additional spare sprinkler heads were not stored in a metal cabinet. On 5/8/18 at approximately 11:30 AM a tour of the sprinkler room in the basement was conducted and revealed that spare recessed heads were not provided. Recessed sprinklers were installed throughout the Rehab room. Although spare sprinkler heads (side wall and pendent style) were stored in a wall mounted metal cabinet in the room, additional spare heads ( 5 sidewall and 7 pendent style) were stored on top of the wall mounted metal cabinet. In an interview at the time of the findings, the Director of Maintenance stated that the vendor will be contacted to provide an additional storage cabinet for the spare sprinklers heads. He further stated that spare recessed sprinklers will also be obtained from the vendor. 2012 NFPA 101 2011 NFPA 25: 5.2.1.1.1, 5.4, 8.3, 8.8.5.1.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMay 28, 2018

1) Corrective Action ? 1. The vendor was contacted to come and replace all noted dirty sprinkler heads. 2.The vendor was also contracted to conduct monthly fire pump testing and report the results to the Director of Maintenance. 3. The vendor was made aware of the lack of replacement sprinkler heads and has replaced the spare inventory to ensure there are enough spare heads for each category of sprinkler heads in the facility
2) Residents at Risk for Same Practice ? All residents have been identified with the potential to be affected by the same deficient practice.
3) Systemic Changes to Prevent Reoccurrence ? 1. An audit tool was created to do monthly sprinkler head inspections to ensure they are clean. 2. An audit tool was created to ensure the results of the fire pump inspections are being received and put in the binder. 3. An inventory list was created to keep track of how many spare sprinkler heads are available.
4) Monitoring of Corrective Action ? The results of the audit tools will be presented to the QA committee by the Director of Maintenance or his designee on a quarterly basis for one year.
5) Person Responsible and Date of Completion ? 1. Director of Maintenance. 2. 7/8/2018.

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: May 10, 2018
Corrected date: July 19, 2018

Citation Details

713-3.10 Physical Therapy Facilities Physical therapy facilities shall include and comply with the following: (a) Treatment areas shall have space and equipment commensurate with all approved programs including, but not limited to, thermotherapy, diathermy, ultrasound, and hydrotherapy. Provision shall be made for cubicle curtains around each individual treatment area, handwashing facility (ies) (one lavatory or sink may serve more than one cubicle), and facilities for the collection of soiled linen and other material. Based on observation and interview, the facility did not ensure that a privacy curtain was provided around a treatment area. Reference is made to the lack of a privacy curtain around the mat platform style treatment table in the Rehab room. The findings are: On 5/8/18 at approximately 10:30 AM, a tour of the Rehab room was toured and revealed that a privacy curtain was not installed or provided around the mat style treatment table used for providing treatment to individual residents. In an interview at the time of the finding with the physical therapist aide, he stated that the residents perform leg stretch exercises and are always dressed with long pants or shorts, and therefore a privacy curtain was not needed. 10 NYCRR 713-3.10 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 28, 2018

1) Corrective Action ? A privacy curtain will be installed around the treatment table.
2) Residents at Risk for Same Practice ? All residents who use the rehab room treatment table have been identified with the potential to be affected by the same deficient practice.
3) Systemic Changes to Prevent Reoccurrence ? A daily audit tool will be created by the facility to ensure that the privacy curtain is in place.
4) Monitoring of Corrective Action - The Director of Rehab will present the results of the audit tool to the QA committee on a quarterly basis for one year.
5) Person Responsible and Date of Completion ? 1. Director of Rehab. 2. 7/8/2018.