The Center for Nursing and Rehabilitation at Hoosick Falls
February 15, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.24(c)(1):ACTIVITIES MEET INTEREST/NEEDS EACH RESIDENT

REGULATION: §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (Resident #'s 7 and 37) of 3 residents reviewed for activities. Specifically, the facility did not ensure that Resident #'s 7 & 37 were provided with activities on an ongoing basis according to the residents' Comprehensive Care Plans and that activities provided met the residents' preferences. This is evidenced by: Resident #7: The resident was admitted to the nursing home on 9/20/14 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. Section F of the MDS documented the resident preferred listening to music, being around animals, doing things with groups of people, participating in favorite activities, and participation in religious activities or practices. An undated Comprehensive Care Plan (CCP) for Activities, documented to provide individualized 1:1 visits for socialization and reminisce 2 - 3 times per week, encourage resident to attend activities of interest; religious services, pamper yourself, and musical events. During observations on: 2/11/19 at 1:24 PM, the resident was in the dining room crying and was removed by staff; 2/12/19 at 10:43 AM, the resident was set up for breakfast in the hall across from the nursing station, at 10:58 AM, the resident had finished her meal; she kept picking up her empty drink glasses trying to drink from them and was complaining she was cold; the resident's breakfast tray was in front of her and clothing protector on until 11:35 AM. The resident was restless. At 11:42 AM, the resident was taken to the dining room for lunch. 2/13/19 at 9:35 AM, 10:46 AM, 12:15 AM, 1:09 PM, and 3:21 PM the resident was in bed. The lights were off. There was no music or TV. The resident was sleeping. CNA documentation listed the resident did not have breakfast or lunch. An Activity Attendance log for the 25 days between 1/14/19 - 2/12/19, documented that the resident took part in orientation and validation daily, attended coffee clutch on three occasions, 10 group activities with 4 of them occurring on the same day, 2 individual activities and one 1:1 visit. The log did not include were R's documented for any activities which woullllld indicate activities were offered and refused. An Activity progress note dated 2/6/19, documented that the resident continued to attend a few group activities throughout her day, a few weekdays mornings the resident attended coffee clutch; and she continues to receive one to one visits. During an interview on 2/13/19 at 4:20 PM, Registered Nurse (RN) #1 stated the resident loved music. During an interview on 2/14/19 at 9:05 AM, Activity Aid #4 stated the resident liked Christian music, socials, and music in general. Resident #37: The resident was admitted to the nursing home on 2/3/18 with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The resident had verbal and physical behaviors symptoms toward others. Section F of the MDS documented the resident's daily preferences were books, papers, and magazines to read, being around animals, doing things with groups of people, and participating in favorite activities. An undated Comprehensive Care Plan (CCP) for Activities, documented to offer alternate plan for activities as needed, encourage activities of interest, and to provide materials for independent leisure activities. He enjoyed war/military books and magazines, watching game shows and the Yankees. During observations on: 2/11/19 at 12:40 PM - 12:58 PM, the resident was in the small common area across from the nursing station asking for help; his wheelchair was locked. A staff member asked if he would like to go to bed, the resident said yes; the staff left and did not return. 2/12/19 from 10:27 AM - 11:30 AM, the resident was in the common area next to the nursing station; his wheelchair was locked. 2/13/19 from 9:34 AM - 10:47 AM, the resident was in the common area, at 12:56 PM the resident was brought from the dining room and placed in the common area, and at 3:20 PM he was in the common area. 2/14/19 at 10:27 AM, the resident was brought to the common area for breakfast and was taken to activities at 10:41 AM without having breakfast or fluids. There was no television, music, or individual activities in the area on any of these occasions. An Activity Attendance log for the 42 days between 1/1/19 - 2/12/19 documented that the resident took part in orientation and validation (orientation- letting residents know what day it is and weather can be done in a group setting, and validation is just checking on residents ensuring that they are still there) daily, attended coffee clutch (the activity person stands outside the door to the dining room and offers coffee to residents who are brought in, while waiting for breakfast) twice, music programs twice, had visitors on 10 occasions, and the hair dresser once. There were no R's documented for any activities that would indicate that they were offered and refused. Resident Services Activity Progress note dated 12/20/18, documented that the resident enjoyed spending time in his room on occasion where he is able to watch television and look through books he enjoys. The resident also enjoyed listening to music while in his room; he will continue to receive one to one visits where he enjoys chatting with staff. During an interview on 2/13/19 at 3:44 PM, CNA #2 stated they keep the resident at the desk because he can get aggressive and will try to get up; they keep him there to prevent falls. During an interview on 2/14/19 at 9:05 AM, Activity Aid #4 stated she did not know if the resident could unlock his wheel chair; she had never seen him do it. Interviews: During an interview on 2/13/19 at 12:33 PM, the Director of Resident Services/Activities stated that orientation entailed reorienting residents to time and place and Validation was acknowledging the resident and that they were still in the facility. Validation and Orientation could be done as part of a group and took approximately 5 minutes. They did not document how long an activity took place, but regular activities are approximately 30 minutes in length. During an interview on 2/14/19 at 9:05 AM, Activity Aid #4 stated some people refuse and she documents refused on the paperwork. When Activity Aid #6 did Coffee Clutch, she would stand outside the dining room door and made coffee for residents who were allowed to drink alone. During an interview on 2/14/19 at 11:32 AM, Activity Assistant /Resident Services stated that staff were supposed to offer activities, but most times residents refused; staff should have documented an R in the space for the activity if it is refused. During an interview on 2/15/19 at 11:26 AM, Activity Aid #6 stated she covered the entire building. They offer activities to all residents and know which one each resident liked by what they went to, on a repetitive basis. They write an R on the activity sheet for residents that refuse. There was no care plan for them to look at and she did not know how many 1:1 visits each resident was supposed to have. Coffee Clutch was not an organized activity, she just give the residents coffee. 10NYCRR 415.5(f)(1)

Plan of Correction: ApprovedApril 1, 2019

F679
Activities
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Resident #7 and 37 were affected. Their care plans and activity preferences were reviewed and updated as indicated.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The care plans and activity preferences of all residents were reviewed and updated as indicated.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
Education was provided to all employees about residents' Activities Care Plans and where to find them. Education included a review of the updated Activity Programs and documentation tools.
Employees educated about One to One activity programming and updated Activities Programming Policies. The Activities care plan binder available to all activity staff and for reference by all employees.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (IE: what quality assurance program will be put into practice)?
To ensure that residents needs and interests are being met, two audits will be conducted to ensure compliance as well as to continue educating staff. These audits are an Activities Audit Tool for activity involvement as well as a documentation audit.
The Activity Involvement Audit will monitor 7 residents 2 times a week for 4 weeks, then 10 residents bi-weekly for 3 months, then randomly as indicated.
An additional documentation audit will be conducted monitoring 14 residents for 4 weeks, then 14 residents bi-weekly for 3 months, then randomly as indicated.
Findings will be reviewed to ensure plans of care are being followed and residents? activity needs are being met. Additional education will be conducted with Activities staff and other employees as necessary based on observations and audits.
These audits will be reviewed at the facility?s QAPI meeting within the auditing period. Additional education and program enhancements as directed by the QAPI committee.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The Activities Director and/or designee will be responsible for correction of the deficiency.

FF11 483.21(a)(1)-(3):BASELINE CARE PLAN

REGULATION: §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during a recertification survey, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 2 (Resident #'s 316 and #7) of 8 residents reviewed for baseline care plans. Specifically, for Resident #316, the facility did not ensure a Baseline Care Plan (BCP) was completed within 48 hours of admission and for Resident #7, the facility did not ensure the BCP addressed the use of [MEDICAL CONDITION] medications. This is evidenced by: Resident #316: The Resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) had not yet been completed. The nursing admission assessment dated [DATE], documented the resident was alert and oriented to time, place, and person. During a record review on 2/14/19, the resident's baseline care plan was initiated on 2/7/19, but remained incomplete. The baseline care plan had not been completed within 48 hours of admission. During an interview on 02/14/19 at 2:28 PM, the Director of Resident Services (DRS) reviewed the baseline care plan for Resident #316 and stated the baseline care plan was not fully completed and lacked information pertinent to the resident's care needs. She stated the baseline care plan was lacking signatures of the interdisciplinary care team (IDT) as well as a completion date. The baseline care plan should include IDT signatures and a completion date to document it was completed within 48 hours of the resident's admission. During an interview on 02/14/19 at 2:52 PM, the Director of Nursing (DON) stated the facility did not have a policy and procedure for baseline care plans. The DON was aware the baseline care plan had to be completed within 48 hours of a resident's admission to the facility, but was not aware of the facility's procedure for completing baseline care plans. During an interview on 02/15/19 at 9:05 AM, Registered Nurse (RN) #3 stated baseline care plans were completed upon a resident's admission and she would expect to see the signatures of the IDT and a completion date on the baseline care plan within 48 hours of admission. Resident #7: The resident was admitted to the nursing home on 3/7/17 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was sometimes understood by others. Admission Physician (MD) Orders dated 3/7/17, documented that the resident was receiving [MEDICATION NAME] (an anti anxiety medication), and [MEDICATION NAME] (an antidepressant). The Baseline Care Plan did not include the resident's [MEDICAL CONDITION] medication. During an interview on 2/14/19 at 11:12 AM, Registered Nurse (RN) #3 stated that the baseline care plan should have addressed the resident's [MEDICAL CONDITION] medications. They are now using a new form that addressed [MEDICAL CONDITION]. 10NYCRR415.11

Plan of Correction: ApprovedMarch 14, 2019

F 655
Baseline Careplan
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Resident #7 was affected and has returned to the facility. It was confirmed that the resident has a current Care Plan in place. Resident #316 was affected and no longer resides at the facility.

2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents who are admitted to the facility have the potential to be affected. An audit was conducted of the care plans for all residents admitted to the facility during the past 30 days. Care plans were updated as indicated.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?

The Admission and plan of care policies were reviewed and updated as indicated (or developed).
The initial care plan meeting process (?Meet and Greet?) was developed.
All clinical staff were educated on the baseline care plan process.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (ie: what quality assurance program will be put into practice)?
An audit of baseline care plans will be conducted for all new admissions weekly x 4 weeks. Random auditing of new admission baseline care plans will be conducted thereafter monthly x 3 months then randomly as indicated. Results will be reviewed by the facility QAPI committee.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The DNS and/or designee will be responsible for correction of the deficiency.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for 5 (Resident #'s 20, 23, 39, 51, and #166) of 16 residents reviewed. Specifically, for Resident #'s 20, 23 and #39, the facility did not ensure the [MEDICAL CONDITION] drug use care plans were resident specific; for Resident #39, the facility did not ensure a care plan was developed to address the resident's continuous oxygen use or anxiety; for Resident #51, the facility did not ensure the intervention for one to one time documented on the activities care plan was implemented; for Resident #166 the pain care plan did not include monitoring of the effectiveness of interventions. This was evidenced by: Resident #20: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to be usually understood, usually able to understand and with severly impaired cognitive skills. Physician Medication Orders signed on 2/9/19, documented the resident was to be given [MEDICATION NAME] (antipsychotic medication) 12.5 milligrams in the morning and 25 milligrams at bedtime for agitation and anxiety. The Comprehensive Care Plan (CCP) titled Potential for adverse side effects related to [MEDICAL CONDITION] drug use: [MEDICATION NAME]; the section titled; as evidenced by (specify behavior) was left blank. The goal documented the Resident will be free from adverse side effects and achieve maximum benefit. The interventions documented; monitor, assess and evaluate for effectiveness and/or adverse reaction. There was no indication regarding symptoms that should be monitored, what was to be assessed, or what the desired effectiveness was. Another intervention documented; monitor labs as ordered, without indication as to what labs would be used to monitor [MEDICATION NAME] use. During an interview on 02/15/19 at 9:36 AM, Nurse Manager #1 reported the care plan lacked the necessary information regarding monitoring and assessments, as well as resident specific and non-pharmacological interventions. Resident #39: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident to be understood, able to understand and had intact cognition. Physician Medication Orders signed on 2/1/19, documented the resident was to be given [MEDICATION NAME] (antianxiety medication) one milligram at bedtime for anxiety and oxygen at 2 liters per minute continuously via nasal cannula. The CCP titled Potential for Alteration in Respiratory Function related to [MEDICAL CONDITIONS], did not document resident specific interventions and did not address the resident's need for continuous oxygen. The CCP titled Potential for Adverse Side Effect related to [MEDICAL CONDITION] Drug Use - anxiety ([MEDICATION NAME]), documented; monitor, assess and evaluate for effectiveness and/or adverse reactions. There was no indication of what symptoms should be monitored, what was to be assessed, or what the desired effectiveness was. There was no CCP in the resident's medical record that addressed the resident's anxiety symptoms. During an interview on 02/15/19 at 9:36 AM, Nurse Manager #1 reported the care plans lacked resident specific interventions. Additionally, she reported the resident's anxiety was related to his [MEDICAL CONDITION] and there should be a care plan to address his needs. Additionally the care plan for chronic obsteructive [MEDICAL CONDITION] disease should have addressed his oxygen use. Resident #51: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had severely impaired cognition, could understand others and could make herself understood. The CCP for activities, last revised 1/11/19, documented the resident was to be provided with one to one visits for socialization and reminiscing at least one time per week and as needed (PRN). The monthly Activity Attendance Log for (MONTH) (YEAR) documented the resident received one to one time once on 12/23/18. The monthly Activity Attendance Log for (MONTH) 2019 did not document the resident received one to one time in January. The monthly Activity Attendance Log for (MONTH) 2019 documented the resident received one to one time once on 2/7/19. During an interview on 02/14/19 at 2:23 PM, the Director of Resident Services reviewed the Activity Attendance Logs for (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019 for Resident #51. She stated the resident should have received individualized one to one visits provided by activity staff at least one time a week according the resident's care plan. She stated based on the documentation it appeared the activity care plan was not being followed. 10NYCRR415.4(b)(1)(i)

Plan of Correction: ApprovedApril 1, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 656 Final
Comprehensive Care Plan
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Residents # 23, 51, and 166 were affected, they have either been discharged from the facility or deceased . Residents #20 and 39 were affected, their care plans have been reviewed and updated by the interdisciplinary team.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
An audit was conducted of the care plans for all residents who use psychoactive medications, have a psychological diagnosis, who have a [DIAGNOSES REDACTED]. Care plans for all residents using oxygen or residents receiving psychoactive medications were reviewed and updated as indicated. Weekly Risk Management meetings review each resident?s comprehensive care plan. Resident?s [MEDICAL CONDITION] medications gradual dose reduction reviews occur weekly.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
The Plan of Care and Psychoactive Medication policies were reviewed and updated or developed as indicated.
All residents' Activity Care Plans were reviewed and updated as indicated.
All clinical staff were educated on the care plan development process.
Formed a Comprehensive Person-Centered Care Plan Review Committee tasked with reviewing residents charts on admission and weekly thereafter. A Risk Management Committee formed and meets weekly.
Gradual Drug Reduction forms have been placed in individuals? charts and reviewed weekly.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (IE: what quality assurance program will be put into practice)?
Care plans audited for all residents who utilize psychoactive medications and all residents who are using oxygen performed weekly x4 weeks. Then twice a month x 3 months then randomly as indicated. Comprehensive Person-Centered Care Plan Review Committee and auditor findings will be reviewed by the facility's QAPI committee. Comprehensive Care Plans updated and training given as needed.
5. Date for completion and the title of the person responsible for correction of the deficiency.
[DATE]
The DNS and/or designee will be responsible for correction of the deficiency.

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly Medication Regimen Review (MRR) that included time frames for the different steps in the process. Specifically, the facility did not ensure there were time frames established for the steps in the MRR process concerning actions the pharmacist and facility needed to take when an irregularity that required urgent action to protect the resident was identified. This is evidenced by: Medication Monitoring: Medication Regime Review and Reporting with a date of 09/2008 documented: -Resident specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. -The pharmacist and nursing follow up on recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within a reasonable time frame. -If there is potential for serious harm and the attending physician does not concur, the Director of Nursing (DON) and pharmacist would contact the Medical Director. -For recommendations that do not require physician intervention, the DON will address the recommendations. During interview on 02/15/19 at 08:43 AM, the Administrator stated he did not realize time frames were required in the MMR review policy and procedure for each step in the process. He later provided a different copy of the MRR entitled, Drug Regime Review-Monthly. He stated he had been told this was the MRR policy that was currently being used. During an interview on 2/15/19 at 2:34 PM, the Minimum Data Set (MDS) Licensed Practical Nurse (LPN) stated the first time she saw the pharmacy policy was a little while ago when it was brought to her by the Administrator. She stated she was aware that the previous DON was starting to work on the policy. During an interview on 2/15/19 at 2:36 PM, the DON stated that the MDS coordinator was the person who took care of the pharmacy recommendations. Additionally, the DON stated that today was the first day she saw the policy; it was in the pharmacy binder but she never saw it until today. 10NYCRR415.18 (c)(2)

Plan of Correction: ApprovedApril 10, 2019

F-756
Drug Regime Review
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The facility's Consulting Pharmacist and DNS updated the policy and procedure, titled ?Drug Regimen Review-Monthly Policy #PHNY02?, with specific time frames for the different steps in the monthly drug regimen review process. Policy PHNY02 was reviewed and approved by the Administrator, Medical Director, Director of Nursing, and Consultant Pharmacist. The policy was made effective immediately and distributed to the nursing managers and prescriber.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The facility?s consulting pharmacist reviewed all outstanding drug regimen review recommendations to insure compliance with the time frames in the updated policy.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
The facility convened a committee consisting of the Administrator, Medical Director, Director of Nursing, and Consultant Pharmacist and found the revised policy to be acceptable.
The policy ?Drug Regimen Review?Monthly? (#PHNY02) states the following: ?Any irregularities of an urgent nature shall be communicated by the Consultant Pharmacist immediately upon discovery to the Director of Nursing and/or Nursing Supervisor for immediate notification and action of the attending physician or licensed designee for action as soon as possible, but no later than midnight of the following day after the issue has been identified.?
Education was provided to all nurses on the management of medication recommendation(s) processes.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (ie: what quality assurance program will be put into practice)?
The facility shall monitor compliance with the policy on a monthly basis. The Consultant Pharmacist will supply a summary report each month to the facility administrator and director of nursing listing each drug regimen review finding for the prior month. The summary report will be used as a checklist to insure that the drug regimen review findings have been answered in the time frames specified in the policy. The findings of the audit will be reported to the QAPI committee monthly for 3 months.
Additional training about timely response to urgent medication irregularities provided as needed.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The Consulting Pharmacist, DNS, and/or designee will be responsible for correction of the deficiency.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on observation and interview during the recertification survey, the facility did not ensure equipment and food thermometers were maintained in accordance with professional standards of food safety; and that the chemical sanitizer in the three compartment sink was at the proper concentration. This is evidenced by: Finding #1 During an observation on 2/11/19 09:40 AM, the chemical santizer in the three comparment sink tested at 100ppm at 70 degrees Farenheit. During an interview on 2/11/19 at 9:42 AM, the Food Service Director (FSD) stated the chemical santizer was below the expected concentration. She is unaware of any issues and states there was likely too much water added today to dilute the sanitizer. Finding #2 During an observation on 2/11/19 at 09:12 AM, the freezer located in the kitchen dining room did not have a thermomter. During an observation on 2/11/19 at 9:17 AM, the freezer located on Unit B did not have a thermometer. During an observation on 2/11/19 at 9:21 AM, the freezer located on Unit A did not have a thermometer. During an interview on 2/11/19 at 9:23 AM, the Food Service Director stated thermometers should be in each freezer, and she would take care of it. 10 NYCRR 415.14 (h)

Plan of Correction: ApprovedApril 1, 2019

F812
Food
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
No affected residents were identified. Audit of refrigerators completed facility-wide. Thermometers placed in all freezers.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected. The presence of thermometers in freezers will be verified by scheduled audits. Pot wash third sink temperature and sanitizer concentration verified by scheduled audits.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
Food preparation and service policy was updated to include thermometers kept in all freezers.
A daily log of 3rd compartment rinse sink temperature and sanitizer concentration implemented. Temperature and concentration maintained per manufacturer recommendation.
Education was provided to dietary regarding proper pot wash sink sanitizer temperature and concentration.
Facility freezers were audited for thermometers.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (ie: what quality assurance program will be put into practice)?
An audit of three compartment sanitizer sink temperatures will be conducted x 5 weekly x 4 weeks, then monthly x 3 months then randomly as indicated.
Facility?s freezers audited for thermometers once monthly and then quarterly as needed.
Findings will be reviewed by the facility's QAPI committee.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The Food Services Manager and/or designee will be responsible for correction of the deficiency.

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based staff interview and the Legionella Sampling and Water Management Plan (WMP) review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Part 4, Protection Against Legionella, Section 4-2.3 requires that environmental assessments be updated annually. Section 4-2.4 requires that by (MONTH) 1, (YEAR) facilities shall adopt and implement a Legionella culture sampling and management plan for their potable water systems with the initial Legionella sampling at periods not exceeding 90 days prior to annual sampling. This is evidenced by: Specifically, the facility did not develop a WMP, did not test for Legionella, and did not maintain a current Legionella Environmental Assessment Form (EAF) as required by New York State regulation. When requested on 02/14/2019, the facility could not provide a Legionella WMP, Legionella testing records, and a current EAF. The Facilities Manager stated in an interview conducted on 02/14/2019 at 3:15 PM, that he was not aware an EAF was required, he will develop a WMP, and will have the potable water system tested as required. 415.19(a)

Plan of Correction: ApprovedMarch 18, 2019

415.19 Infection Control
I210, SS=F
Allegation: The facility did not develop a Water Management Plan (WMP), did not test for Legionella, and did not maintain a current Legionella Environmental Assessment Form (EAF) as required by New York State regulation.
I. Immediate Corrective Actions
The facility?s Water Management Plan was developed, reviewed, and approved by the QAPI committee to include water testing for Legionella at periods less than 90-days for 1-year and water testing annually thereafter. Test results recorded on Legionella Environmental Assessment form and DOH form 5222 completed. Vendor agreement and testing schedule established with first test samples completed on or before (MONTH) 16, 2019.
Known dead end pipes removed by outside plumber on or before (MONTH) 14, 2019. Infection control for Engineering Department policy was reviewed and updated as indicated.
II. Identification of other residents
Though no harm occurred, potentially all residents were potentially at risk of harm from this deficient practice.
III. Systemic Changes
Outside Legionella testing vendor contracted and testing appointments set. The QAPI committee found the revised water management plan and vendor credentials to be acceptable on or before (MONTH) 16, 2019.
IV. QA Monitoring
Upon completion of initial water testing series, Director of Maintenance or designee will monitor the effectiveness of the water management plan through testing results and update annually, the Environmental Assessment form, DOH-5222. Findings reported to QAPI committee on a quarterly basis, the first year. Environmental Assessment form, DOH-5222, updated, water testing performed, and results reported to facility's QAPI Committee annually thereafter. Water Management Plan to be updated as indicated.
Responsible parties: Director of Maintenance or designee

FF11 483.70(a)-(c):LICENSE/COMPLY W/ FED/STATE/LOCL LAW/PROF STD

REGULATION: §483.70(a) Licensure. A facility must be licensed under applicable State and local law. §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. §483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, (YEAR) Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in areas with gas fuel fired equipment. This is evidenced as follows. Observations on 02/15/19 at 10:30 AM, revealed fuel burning appliances in the main kitchen (gas stove) and laundry room (clothing dryers). Carbon monoxide detection was not provided in these areas. The Facilities Director stated in an interview on 02/15/2019 at 10:30 AM, that he was unaware that carbon monoxide protection was missing in the kitchen and laundry. 483.70 (b); (YEAR) International Fire Code, Section 915

Plan of Correction: ApprovedMarch 14, 2019

F836
License, Carbon monoxide, (CO)
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
No affected residents were identified.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected. CO testing was conducted and no concerns were noted.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
CO monitors were wired into the electrical system by licensed electricians.
Education was provided to all staff regarding functioning of the monitors and expectations for response.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (ie: what quality assurance program will be put into practice)?
An audit of CO monitor functioning will be conducted annually and as indicated by alarm monitoring vendor. Results will be reviewed by the facility Safety/Quality committee.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The Maintenance Director and/or designee will be responsible for correction of the deficiency.

FF11 483.60(c)(1)-(7):MENUS MEET RESIDENT NDS/PREP IN ADV/FOLLOWED

REGULATION: §483.60(c) Menus and nutritional adequacy. Menus must- §483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure menus met nutritional needs of the residents in accordance with recommended guidelines, and were reviewed by the facility's dietitian for nutritional adequacy. Specifically, the facility did not ensure pasta alfredo was served to residents on a pureed diet at the correct consistency; that 3 oz of protein was planned and served to the residents; and that an alternate protein source was served to Resident #16. This is evidenced by: Finding #1 During an observation on 2/14/19 at 12:09 PM, a portion of pureed pasta alfredo was not the same consistency as the other pureed items (pureed asparagus, pureed shrimp cocktail, and pureed strawberries) on a test tray provided in the sanctuary. The pureed pasta alfredo was thicker than applesauce consistency. During an observation on 2/14/19 at 12:55 PM, a portion of pureed pasta alfredo was on a residents plate after the resident left the main dining room. The pureed pasta alfredo was thicker than applesauce consistency. During an interview on 2/14/19 at 1:00 PM, the Speech Language Pathologist (SLP) stated the consistency of the pureed pasta alfredo is too thick, she would expect it to be thinned more. During an interview on 2/14/19 at 1:03 PM, the Food Service Director (FSD) stated the consistency of the pasta alfredo served to the residents was incorrect, and it should have been thinned to applesauce consistency like the asparagus was. Finding #2 The week 2 cycle menu with a start date of Sunday, 2/10/19 listed the Thursday (2/14/19) lunch meal as Fettuccine(NAME) Shrimp Cocktail, Asparagus, and Chocolate Covered Strawberries. During an observation on 2/14/19 at 12:40 PM, the steam table service was observed in the main dining room. Three shrimp were observed being placed in a ring around a cup with cocktail sauce and being delivered to the residents. During an interview on 2/15/19 at 8:47 AM, the Registered Dietitian (RD) stated they usually plan a 3 oz portion for protein. She entered 5-6 pieces of shrimp for the lunch meal on 2/14/18 to ensure 3 oz of protein, however the Food Service Director (FSD) decided they were going to give three shrimp instead. The FSD writes the menu and asks the RD for input. She states some meals have been adjusted, however the full menu has not been reviewed for nutritional adequacy. During an interview on 2/15/19 at 10:12 AM, the FSD stated she was aware of the 3 oz standard for protein after discussing with the dietitian. Finding #3 Resident #16 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had cognitive impairment, could understand others and make himself understood. A quarterly nutrition assessment dated [DATE], documented a hospital [DIAGNOSES REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. A nutrition progress note dated 1/25/19, documented a weight loss of 8 pounds (lbs) over the past month, a BMI of 17.5, and a puree, nectar thick diet. The week 2 cycle menu with a start date of Sunday, 2/10/19 listed the Thursday (2/14/19) lunch meal as Fettuccine(NAME) Shrimp Cocktail, Asparagus, and Chocolate Covered Strawberries. During an observation on 2/14/19 at 12:06 PM, the resident was observed with pureed pasta alfredo on his plate. The resident's meal ticket did not include shrimp. The resident's plate did not include shrimp. During an interview on 2/15/19 at 8:47 AM, the Registered Dietitian stated residents that dislike seafood should should have recieved an alternate protein. She stated they had difficulty with the meal yesterday. 10 NYCRR 415.14 (c)(1-3)

Plan of Correction: ApprovedApril 10, 2019

F803
Menus and nutritional adequacy
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Resident #16 was affected. The resident?s nutritional status and menus were reviewed and the menus were updated to offer chicken as a replacement for fish per resident preference to meet identified nutritional needs. The menu planning software was reviewed for all residents' likes and dislikes and preferences updated to prevent future occurrence.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The nutritional status of menus reviewed for all residents and updated on or by (MONTH) 9, 2019. The RD analyzed each meal using the facility's nutrition management program to assess amount of protein offered in each meal to assure balance. Protein requirements based on age and gender were evaluated using Dietary Reference Intake (DRI) standards from the Food and Nutrition Board, Institute of Medicine.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
Resident's food preferences will be identified during admission interview. Resident's food preferences will be entered into the menu software, updated when menus change, a significant health change event, and during quarterly assessments. A Meal Audit tool was created and used to verify meal protein content, protein substitute for dislikes, and proper food consistency.
Dietary and nursing staff educated about portion control and the menu selection process.
Education was provided to dietary employees to ensure the standard of applesauce like consistency for all puree food items.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (ie: what quality assurance program will be put into practice)?
Audits of all menus conducted for the entire 3-week cycle to verify that food consistencies, protein substitutes, and portion sizes are consistent with DRI standards in order to ensure that meals are nutritionally adequate. Any time that a meal is altered or added to the cycle menu, the RD will assess its nutritional adequacy.
To ensure that a nutritionally equivalent and alternate food time is provided as a replacement, the facility will audit twenty percent of the residents with meal dislikes weekly for 4-weeks, then once a monthly for 3-months, and when menus change. Corrections made as needed.
An audit will be performed assessing puree consistency weekly for 4-weeks, then once a monthly for 3-months, and when menus change.
Findings will be reviewed by the facility's QAPI committee and further enhancements made as directed.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The Food Service Director and/or designee will be responsible for correction of the deficiency.

FF11 483.15(d)(1)(2):NOTICE OF BED HOLD POLICY BEFORE/UPON TRNSFR

REGULATION: §483.15(d) Notice of bed-hold policy and return- §483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e)(1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure written notice which specifies the duration of the bed-hold policy, was provided to the resident and the resident representative at the time of transfer for hospitalization . This was evident for 1 (Resident #40) of 1 resident reviewed for hospitalization . Specifically, there was no documented evidence the resident and the resident's representative were notified in writing of the bed hold policy when the resident was admitted to the hospital. This is evidenced by the following: Resident #40: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident was understood, could understand, and had intact cognitive skills. Nurse's Notes documented the resident was sent to the hospital on [DATE] and returned to the facility on [DATE]. There was no documentation that written notification was sent to the resident or resident's representative informing them of the bed-hold policy upon discharge. During an interview on 2/15/19 at 11:25 AM, the Director of Nursing reported written notification of bed-hold policy upon discharge was not being done. 10NYCRR 415.3(h)(4)(i)(a)

Plan of Correction: ApprovedApril 1, 2019

F 625 Final
Bed-hold Notice
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Resident #40 was affected and has returned to the facility with no negative outcome to the resident. The facility's Bed-Hold Policy, now part of the admission packet, reviewed with residents and their family members during admission.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents transferring from the facility have the potential to be affected. An audit was conducted of all residents transferred over the past 30 days. Notice of residents' rights regarding the facility's Bed-hold Policy mailed to families. All nurses and social services employees will be educated on resident rights related to bed-holds, the proper use of the Bed-Hold form, the location of the form on the units.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
The Bed-hold policy was developed and distributed to residents and their families.
All nurses and social workers were educated on the Bed-hold policy, the location and use of the Bed-hold form.
The Bed-hold form was presented and reviewed with resident council and Bed-hold Policy was added to the admission packet.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (i.e.: what quality assurance program will be put into practice)?
Bed-hold forms are used when patients/residents go to the hospital for emergencies. Charts of all patients/residents sent to the hospital will be audited for Bed-hold form use once a week x 4 weeks. Then once a month after that x 3 months, then randomly thereafter. Results will be reviewed by the facility QAPI committee. Additional education provided as needed.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The Social Worker and/or designee will be responsible for correction of the deficiency.

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure that written notification was provided to the resident, the resident's representative, and a representative of the Office of the State Long-Term Care Ombudsman, of the resident's transfer or discharge and the reasons for the move for 1 (Resident #40) of 1 resident reviewed for hospitalization . Specifically, there was no documented evidence the resident, the resident's representative, or the Ombudsman were notified in writing by the facility when the resident was admitted to a hospital from the facility. This is evidenced by: Resident #40: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident was understood, could understand, and had intact cognitive skills. Nurse's Notes documented the resident was sent to the hospital on [DATE] and returned to the facility on [DATE]. There was no documentation that written notification was sent to the resident, resident's representative, or Ombudsman regarding the facility-initiated discharge of the resident. During an interview on 2/15/19 at 9:00 AM, the Director of Resident Services reported that previously the Ombudsman notifications were sent in bulk, now they are sent individually. Unable to provide documentation of notification for this hospitalization . During an interview on 2/15/19 at 11:25 AM, the Director of Nursing reported written notification to the resident and representative was not being done and Ombudsman notification was not sent for this hospitalization . 10NYCRR415.3 (h)(1)(iii)(a-c)

Plan of Correction: ApprovedApril 1, 2019

F 623 Final
Resident Transfer and Discharge Notice
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Resident #40 was affected and has returned to the facility. The Resident Transfer and Discharge Policy and Resident Transfer and Discharge form updated to the regulation, 42 CFR 483.15.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents who are transferred or discharged from the facility have the potential to be affected. All nurses and social services will be educated on resident transfer and discharge rights, the proper use of the Resident Transfer and Discharge form, the location of the form on the units, and the Resident Transfer and Discharge Policy. Education to include required notification of the Ombudsman and resident's family members of resident transfers or discharges.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
The Resident Transfer and Discharge policy and the Resident Transfer and Discharge form were developed and employees trained on resident rights regarding transfers and discharges and the required notifications.
The Resident Transfer and Discharge form was reviewed with resident council; and reviewed with resident's families on (MONTH) 12, 2019.
The Resident Transfer and Discharge form will be used with each resident transfer or discharge, and family members and Ombudsman notified.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (IE: what quality assurance program will be put into practice)?
Resident's charts will be audited for proper notification of resident transfer and discharge rights after a resident transfers or discharges from the facility. Chart audits performed once a week x 4 weeks, then once a month x 3 months, then randomly thereafter. Audit findings will be reviewed by the facility's QAPI committee and practices enhanced as directed.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The Social Worker and/or designee will be responsible for correction of the deficiency.

FF11 483.60(i)(3):PERSONAL FOOD POLICY

REGULATION: §483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure their policy regarding foods brought to residents by family and other visitors included information on the safe and sanitary storage, ans handling and consumption of food. Specifically, the facility does not provide information for family and other visitors on safe food handling practices or safe reheating of food that is brought in to residents. This is evidenced by: The policy and procedure (P&P) titled Food Brought in by Family/Visitors dated 3/22/18 documented the process for food handling once brought into the facility. The policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. During an interview on 2/15/19 at 10:07 AM, Admissions Coordinator #10 stated no food safety information is included in the admission packet. During an interview on 2/15/19 at 10:23 AM, the Food Service Director (FSD) stated there was no food safety policy or education (regarding food safety) provided to families at this time. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedApril 10, 2019

F813
Personal Food Policy
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Though no affected residents were identified as being affected by this practice, the facility's Personal Food Policy was sent to all resident's families. Follow up calls to verify receipt of facility's Food Policy completed on or before (MONTH) 16, 2019.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents who have food brought in have the potential to be affected. An audit was conducted to identify personal food in the facility. Food items lacking dates and labels discarded.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
A Personal Food Policy was developed and added to the Admission packet (MONTH) 18,2019.
The Personal Food Policy provides details of proper personal food labeling, storage, shelf-life, handling, reheating of food items by facility employees, and food disposal criteria.
A copy of the policy was mailed or hand delivered to the families of all residents on (MONTH) 12, 2019. Follow up calls to confirm facility's food policy received made on or before (MONTH) 16, 2019.
Education was provided to all staff regarding the Personal Food Policy and proper handling and disposal of personal food items.
Facility's Personal Food Policy was presented to and reviewed with resident council on (MONTH) 9, 2019.
An audit tool created to ensure that all personal food is properly labeled, dated, and stored by family members. Food service employees monitor units' refrigerators daily. Food found without proper labeling will be discarded.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (i.e.: what quality assurance program will be put into practice)?
To verify adherence to the Personal Food Policy, an audit of food products stored in the resident refrigerators will be conducted daily. Out of date items and potentially hazardous food lacking labels will be discarded. Findings will be reviewed by the facility's QAPI committee. Family members violating the Personal food Policy will be educated as needed.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The Food Services Director and/or designee will be responsible for correction of the deficiency.

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview during a recertification and abbreviated survey (Case #NY 783), the facility did not ensure that based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice to maintain the highest practicable physical well-being for one (1) (Resident #167) of one (1) residents reviewed. Specifically, Resident #167 was found guarding and not moving her right arm and did not receive appropriate and timely treatment to relieve pain of a fractured arm. This is evidenced by: Resident #167: The resident was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician note dated 4/18/17, documented the resident had advanced Alzheimer's requiring assistance of skilled level of care for safety, supervision, and medication. She is incontinent and her cognitive performance status is so poor, she requires hands on assistance with Activities of Daily Living (ADL's). A Nurses Note dated 11/16/17 at 1:15 PM, documented the resident was guarding her right arm. When her right arm was moved by staff, the resident expressed great pain. The resident had a history of [REDACTED]. The physician was notified and ordered [MEDICATION NAME] to be started and to recheck her blood pressure in an hour. The resident's daughter was called and stated she did not want the resident sent to the hospital. A Nurses Note dated 11/16/17 at 2:10 PM, documented [MEDICATION NAME] was given and the resident was in a little less pain. Blood pressure was 130/82. A Nurses Note dated 11/16/17 at 10:50 PM, documented the resident was guarding her right arm with all movement and stated she had shoulder pain. The resident used her fingers but would not lift or move her shoulder. She was leaning to the left when walking and her gait was unsteady. A wheelchair was used for transfer. [MEDICATION NAME] was given at 7:00 PM. A Nurses Note dated 11/17/17 at 7:00 AM, documented the resident did not have non-verbal complaints of pain. She was leaning to her left side on her elbow. Her right arm had swelling and purple discoloration. It was warm to the touch. Discolored area measured 11 centimeters (cm) x 8.5 cm. The resident had complaint of pain on palpation along with pain with movement. A call was placed to her daughter. physician's orders [REDACTED]. Apply sling to right upper arm for comfort and place bilateral mats to the bedside. A Nurses Note dated 11/17/17 at 10:55 AM, documented result of an x-ray to the resident's right shoulder revealed a proximal humeral fracture. A Nurses Note dated 11/17/17 at 2:30 PM, documented a complete body assessment was performed. The resident's right deltoid had discoloration and red/purple discoloration on her right bicep area. The resident continued to complain of discomfort to her right humerus area upon palpation. The sling was intact. A Nurses Note dated 11/17/17 at 2:30 PM, documented the resident's daughter was made aware of the fracture and plan of care was discussed. The daughter would like non-surgical interventions along with treatment of [REDACTED]. A Nurses Note dated 11/17/17 at 5:00 PM, documented the physician was in to see the resident for her right humerus fracture. The physician wrote an order to follow up with orthopedics and to take [MEDICATION NAME] (a narcotic pain medication) 5/325 milligram (mg) three times a day as needed (PRN). Resident Incident Report was dated 11/17/17 at 7:00 AM with a description of incident of discoloration and swelling noted to right upper arm with pain. During a phone interview on 02/15/19 at 10:45 AM, Registered Nurse #5 had a difficult time remembering the resident. She then stated the resident was frail, but did not remember that the resident sustained [REDACTED]. During an interview on 02/15/19 at 10:54 AM, Registered Nurse Manager (RNM) #3 on the B Unit stated if she was the nurse who saw the resident guarding and not using her arm, she would have done a full assessment of the resident, and would have contacted the physician with findings. When the physician responded with an order for [REDACTED]. The pain scale would be used when the resident complained of pain and if the pain was not controlled, she would reach out to the physician. Using the current measures used in the nursing home, she would reach out to the physician and if time elapsed, she would immediately send a fax to the physician. If she did not hear back in a short amount of time for the injury of unknown origin, she would have called the physician back. During an interview on 02/15/19 at 10:26 AM, the Director of Nursing (DON) stated she would assess the resident and if she felt the need for an x-ray she would call the physician, and get an order for [REDACTED]. She would have given one dose of Tylenol to see if it helped. As the physician ordered narcotic pain medication in the evening, the DON stated the x-ray result was probably either faxed or called in. The nurse would usually wait until the physician got back to her. The physician probably got back to the nurse after business hours. The DON stated she would have followed up if she did not hear from the physician in a short amount of time. The nurses should have been more aggressive knowing the resident fractured her arm. 10 NYCRR 415.12 .,

Plan of Correction: ApprovedApril 1, 2019

F684
Quality of Care/Pain
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Residents #167 affected and does not reside in the facility at this time.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
An audit was conducted of the pain management for all residents. No concerns were noted.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
The process for pain management was evaluated and updated to include q-shift pain assessments in addition to those conducted with administration of pain medications.
The Medication administration, Physician notification, and Skin Care policies were reviewed and updated as indicated.
All nursing staff were educated on the evaluation/assessment of pain and pain management.
?Stop and Watch? process was reviewed.
All staff were educated on the ?Stop and Watch? process.
Formed a committee to assess At Risk residents for interdisciplinary review.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (IE: what quality assurance program will be put into practice)?
All residents have the potential for pain, 14 random residents audited once a week x 4 weeks, then monthly x 3 months then randomly as indicated. Results will be reviewed by the facility's QAPI committee.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The DNS and/or designee will be responsible for correction of the deficiency.

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on observations and interviews during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner that promoted his or her quality of life while dining in 1 of 2 designated dining areas. Specifically, the facility did not ensure residents had a dignified dining experience in the Sanctuary dining area of the facility. This is evidenced by: During an observation in the Sanctuary dining area on 02/12/19 at 8:15 AM, two residents were positioned away from the dining table while fed by staff. During an observation in the Sanctuary dining area on 02/14/19 at 12:04 PM, a resident was facing away from the table while fed by staff. During an observation in the Sanctuary dining area on 02/15/19 at 08:23 AM, one staff member was standing to feed a resident who was positioned facing away from the table. During an interview on 02/15/19 at 8:26 AM, Registered Nurse (RN) #4 stated staff standing over residents to feed them was likely due to staff convenience. During an interview on 02/15/19 at 8:40 AM, Registered Dietitian (RD) #8 stated staff should be seated and residents should be facing the table when fed. She stated staff have reported it is easier for them to feed the residents when they are facing away from the table. During an interview on 2/15/19 at 11:28 AM, the Director of Nursing (DON) stated she was not aware of dignity issues in the dining room. She stated staff should have been sitting when feeding the residents, and residents should be facing the table while dining. 10 NYCRR 415.3 (c)(1)(i)

Plan of Correction: ApprovedApril 1, 2019

F550
Resident Rights/Dignity in Dining
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Though affected residents were not identified, CNA's responsible for feeding residents in the Sanctuary have been instructed about resident's rights to assure a dignified dining experience.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected. Meal observation audits were conducted for 3 meals for a period of 3 days. Any compromises to residents' dignified dining experience were addressed with the staff member(s) involved.
3. What measure(s) will be put in place or what systematic changes will you make to ensure that the deficient practice does not reoccur?
Dining policy was reviewed and updated as indicated. Employees were trained and sensitized to resident rights to a dignified dining experience.
4. How will the corrective actions be monitored to ensure that the deficit practice does not reoccur (ie: what quality assurance program will be put into practice)?
Five meal service practices per week observed for 4 weeks, then 3 times weekly for 1 month, 2 times weekly for 2 months, and finally periodically as indicated. Findings will be reported to and reviewed by the facility's QAPI committee. Re-education and redirection to assure residents have a dignified dining experience given as needed.
5. Date for completion and the title of the person responsible for correction of the deficiency.
April 16, 2019
The DNS and/or designee will be responsible for correction of the deficiency.

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on observation, record review and staff interview during the recertification survey, the facility did not protect cooking facilities in accordance with adopted regulations. NFPA 17A Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2009 Edition Section 7.2 requires monthly owner's inspections. Specifically, the kitchen fire suppression system was not inspected monthly. This is evidenced as follows. The inspection tag on the kitchen fire suppression system was checked on 02/14/2019. The inspection tag documented the last semi-annual testing was conducted during (MONTH) (YEAR), and a monthly owner's inspection was not recorded for (MONTH) 2019. The kitchen fire suppression system tests reports were reviewed on 02/15/2019. Records were not available for survey review documenting the required monthly owner's inspection. The Facilities Manager stated in an interview conducted on 02/14/2019 at 10:25 AM, that he did not know the kitchen fire suppression system required monthly owner's inspections. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.2.5.5; 2009 NFPA 17A 7.2; 10 NYCRR 415.29; 2000 NFPA 101 19.3.2.6, 9.2.3; 1998 NFPA 17A 5-2

Plan of Correction: ApprovedMarch 14, 2019

K 324, SS=E, 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.1, 8.5; 10 NYCRR 415.29, 711.2(a) (1); 2000
NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3 Kitchen Facilities
Allegation: The kitchen fire suppression system tests reports were reviewed on 02/15/2019. Records were not available for survey review documenting the required monthly owner's inspection.
I. Immediate Corrective Actions
The facility?s Director of Maintenance or designee will inspect the Ansul System on a monthly basis and document findings on or before (MONTH) 16, 2019.
II. Identification of other residents
Though no residents were affected by this deficient condition, the potential to affect all residents existed.
III. Systemic Changes
A calendar reminder created for the Director of Maintenance as a reminder to inspect the Ansul System monthly.
IV. QA Monitoring
Findings of these inspections will be reviewed during the facility's QAPI committee monthly for 3-months, then quarterly for 1-year. Audits annually thereafter.
Responsible parties: Director of Maintenance or designee.

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: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that PCREE is tested and inspected prior to being placed in service and is maintained with consideration of the owner's manual. Section 10.5 requires that instruction/maintenance manuals be accessible and that a record shall be maintained of required tests. Specifically, PCREE was not maintained as prescribed in the owner's manual, instruction/maintenance manuals were not accessible, and a log was not kept of all testing. This is evidenced as follows. Observations 02/14/2019 at 1:30 PM and again on 02/15/2019 at 9:30 AM and 10:15 AM revealed that oxygen concentrator (concentrator) 3514 was in use and situated 5-inches from a chair, concentrator 3535 was in use and situated 4-inches from a bed, and concentrator 7859 was in use situated 3-inch from a bed; and nebulizers 5723, 5827, and 6472 were not in use and plugged into an electrical outlet. Suction machines were found ready-for-use on the crash carts on the A-Unit, B-Unit, and main dining room. Review of the oxygen concentrator owner's manual on 02/15/2019 revealed that while in use, the concentrator is to be situated at least 6-inches from walls, draperies, or other objects. Observation on 02/14/2019 at 1:45 PM in resident room [ROOM NUMBER] revealed an nebulizer was plugged into an electrical outlet and was not in use. Review of the nebulizer owner's manual on 02/15/2019 revealed that the power cord is to be unplugged from the electric outlet immediately after using. The Director of Nursing stated in an interview conducted on 02/15/2019 at 11:00 AM, that staff have not been provided education on the safe use of PCREE as outlined in the owner's manuals. When requested on 02/15/2019, the suction machine instruction manual and log of suction machine testing could not be provided. The Facilities Manager stated in an interview on 02/15/2019 at 11:45 AM, that he could not find the suction machine instruction manual nor any records of suction machine testing. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3, 10.5; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedMarch 20, 2019

K 921, SS=E, 42 CFR 483.70 (a) (1); 2010 NFPA 110 8.3.8
NFPA 101 Electrical Equipment - Testing and Maintenance
Allegation: Based on observation, employee interview, and record review during the recertification survey, Patient care-related electrical equipment PCREE was not maintained as prescribed in the owner's manual, instruction/maintenance manuals were not accessible, and a log was not kept of all testing.
I. Immediate Corrective Actions
A facility-wide audit/assessment completed to ensure of all patient care-related electrical equipment (PCREE) has been inspected as required per chapter 10 of the 2012 edition of NFPA 99. Moving forward, all new PCREE tested and inspected prior to being placed in service. PCREE maintained and service log kept by an outside vendor. Safe operation labels placed on all PCREE in accordance with the owner's manual and adopted regulations and employees trained on proper operation and placement on or before (MONTH) 27, 2019. Log maintained of PCREE trained employees. PCREE owner's manuals stored in offices of Purchasing, Maintenance, and Director of Nursing.
II. Identification of other residents
Though no residents were affected by this deficient condition, the potential to affect many residents existed.
III. Systemic Changes
All new PCREE and personal electric equipment will be tested and inspected prior to being placed in service. PCREE maintained by an outside vendor. Service log kept by outside vendor and service record reported to facility's Director of Maintenance annually. Safe operation labels placed on all new PCREE in accordance with the owner's manual and adopted regulations. New employee orientation to include PCREE placement and operation. Employees will be retrained as needed about the proper operation and placement of PCREE. Log of employees trained about PCREE operation and placement kept by Director of Maintenance. Current owner's manuals located and maintained in Maintenance, Purchasing, and Nursing offices.
IV. QA Monitoring
Upon installation of the safe operation labels on all PCREE and training of employees on the proper operation and placement of PCREE, the Director of Maintenance, or designee will verify proper operation and placement of PCREE and personal electric equipment as required by manufacturer and 2012 NFPA codes, on a monthly basis. Findings reported monthly and Service log reviewed annually by QAPI committee. Additional education provided, PCREE maintenance completed, and owner's manuals updated as needed.
Responsible parties: Director of Maintenance, or designee.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide emergency power as required by adopted regulations. NFPA 99 Health Care Facilities Code 2012 edition section 6.4.1.1.17 requires that the emergency power source (emergency generator) is to include a remote annunciator that is storage battery powered and provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. Specifically, the emergency generator did not include a remote annunciator at a regular work station. This is evidenced as follows. Observations on 02/14/2019 at 12:05 PM, revealed that the emergency generator remote annunciator is in the maintenance office. The maintenance office was not staffed at the time of the observation. The Facilities Director stated in an interview on 02/14/2019 at 12:05 PM, that the emergency generator remote annunciator is in an area that is not normally monitored. 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.4.1.1.17; 10 NYCRR 415.29, 711.2(a)(1); 1999 NFPA 99 3-4.4.1.1.15

Plan of Correction: ApprovedMarch 14, 2019

K 916, SS=E, 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.1, 9.1.2; 2011 NFPA 54 9.3; 10
NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 54
NFPA 101 Electrical Systems - Essential Electric System, Alarm Annunciator
Allegation: The emergency generator did not include a remote annunciator at a regular work station.
I. Immediate Corrective Actions
The facility?s Director of Maintenance or designee will install an annunciator panel at Unit A nurses? station and employees on all shifts trained on procedures or before (MONTH) 16, 2019.
II. Identification of other residents
Though no residents were affected by this deficient condition, the potential to affect all residents existed.
III. Systemic Changes
Hard wired, with battery back-up, and located at the Unit A nurses station, the annunciator panel will inform all employees of a generator malfunction. Employees trained to telephone and page the on-call maintenance technician after-hours to notify of any issues.
IV. QA Monitoring
Upon installation of the annunciator panel, Director of Maintenance or designee will verify all employees understand the annunciator functions on a weekly basis. Record reported monthly to QAPI committee for 3-months and quarterly thereafter. Additional education provided as needed.
Responsible parties: Director of Maintenance, or designee.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on staff interview and record review during post survey review, the facility did not maintain the emergency generator as required by adopted regulations. NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.8 requires that a fuel quality test shall be performed at least annually using tests approved by ASTM standards. Specifically, there were no fuel quality tests performed within the past year. This is evidenced as follows. The emergency generator inspection and maintenance records were reviewed on 02/09/2019. The inspection report dated 02/15/2019, did not include a fuel quality test. No other records were available for review documenting a fuel quality test was performed on the emergency generator fuel reserve. The Facilities Manager stated in an interview on 02/15/2019 at 9:40 AM, that he cannot find documentation of a fuel quality test for (YEAR). 42 CFR 483.70 (a) (1); 2010 NFPA 110 8.3.8

Plan of Correction: ApprovedMarch 14, 2019

K 918, SS=E, 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.4.1.1.17; 10 NYCRR 415.29, 711.2(a) (1); 1999 NFPA 99 3-4.4.1.1.15
NFPA 101 Electrical Systems - Essential Electric System, Maintenance and Testing
Allegation: The inspection report dated 02/15/2019, did not include a fuel quality test. No other records were available for review documenting a fuel quality test was performed on the emergency generator fuel reserve.
I. Immediate Corrective Actions
The facility?s Director of Maintenance or designee will test the generator fuel quality on or before (MONTH) 16, 2019.
II. Identification of other residents
Though no residents were affected by this deficient condition, the potential to affect all residents existed.
III. Systemic Changes
The updated agreement with the vendor now includes fuel quality testing at least annually.
IV. QA Monitoring
The Director of Maintenance, or designee will report fuel quality testing results to QAPI committee on or before (MONTH) 16, 2019, and annually thereafter.
Responsible parties: Director of Maintenance, or designee.

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 more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, in the past year, the facility did not conduct community-based drills, facility-based drills, or a tabletop drill, or experience an actual event that would activate the emergency plan. This is evidenced as follows. A review of the Emergency Plan on 02/14/2019, revealed that the facility did not conduct a community-based drill, facility-based drill, or a tabletop drill and did not experience an actual event that would activate the emergency plan. The Administrator stated in an interview conducted on 02/14/2019 at 11:15 AM, that the facility did not conduct any of the required emergency preparedness drills. 42 CFR: 483.73(d)(2)

Plan of Correction: ApprovedMarch 14, 2019

E 039, SS=F, CFR: 483.73(b) (8)
EP Testing Requirements
Allegation: A review of the Emergency Plan on 02/14/2019, revealed that the facility did not conduct a community-based drill, facility-based drill, or a tabletop drill and did not experience an actual event that would activate the emergency plan.
I. Immediate Corrective Actions
Facility?s Safety committee and community emergency personnel reviewed and updated the facility?s emergency management plan. The facility will participate in a full-scale exercise and additional full-scale and tabletop exercise on or before (MONTH) 16, 2019.
II. Identification of other residents
Though no residents were affected by this deficient practice, the potential to affect all residents existed.
III. Systemic Changes
Facility to participate with assistance from Southern Vermont Health Care in tabletop exercise and full-scale exercise with community emergency personnel on or before (MONTH) 16, 2019 and complete two (2) emergency evacuation exercises annually.
IV. QA Monitoring
Upon completion of the tabletop exercise and full-scale exercise with staff, Administrator or designee will monitor the effectiveness of the emergency management plan through staff interview and provide outcomes to the facility's QAPI committee on a semi-annual basis. Additional education will be provided as needed.
Responsible parties: Administrator or designee.

K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

REGULATION: Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, the facility did not provide education on the safety guidelines, usage, and risks associated with the handling of medical oxygen cylinders. This is evidenced as follows. When requested on 02/15/2019, the facility could not provide records or documentation that facility staff received training on the safety guidelines and usage requirements associated with oxygen cylinders. The Director of Nursing stated in an interview on 02/15/2019 at 1:35 PM, that she could not find a record of training on the risks and use of oxygen cylinders and she will include information on the dangers of oxygen cylinders in the staff training. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedMarch 18, 2019

K 926, SS=E, 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3, 10.5; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3
NFPA 101 Gas Equipment - Qualifications and Training of Personnel
Allegation: The facility did not provide education on the safety guidelines, usage, and risks associated with the handling of medical oxygen cylinders.
I. Immediate Corrective Actions
All employees responsible for the handling of medical oxygen cylinders have been educated about associated risks of medical oxygen cylinders and the safe handling of medical gas cylinders per the facility's policy and procedures on or before (MONTH) 16, 2019.
II. Identification of other residents
Though no residents were affected by this deficient condition, the potential to affect many residents existed.
III. Systemic Changes
All new employees responsible for handling medical oxygen cylinders will be trained on the associated risks and safe handling of medical gas cylinders.
IV. QA Monitoring
Upon educating employees about the safe handling practices for medical oxygen cylinders by Director of Maintenance or designee, proper handling of medical oxygen cylinders verified on a monthly basis for 3-months, then quarterly. Findings reported to QAPI committee quarterly. Additional education provided as needed.
Responsible parties: Director of Maintenance, or designee.

LOCAL, STATE, TRIBAL COLLABORATION PROCESS

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years (annually for LTC facilities). The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the facility did not engage with State and Federal emergency preparedness (EP) officials in collaborative planning for an integrated emergency response. This is evidenced as follows. A review of the Emergency Plan on 02/14/2019 revealed that the facility did not document local emergency preparedness officials' involvement in the development of the facility emergency plan. The Administrator stated in an interview on 02/14/2019 at 8:45 AM, that he was not involved in the development of the emergency plan and does not know if local emergency preparedness officials were contacted or involved in the development of the emergency plan. 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedMarch 14, 2019

E009 Local, State, Tribal Collaboration Process
Allegation: A review of the Emergency Plan on 02/14/2019, revealed that the facility did not document local emergency preparedness officials' involvement in the development of the facility emergency plan.
I. Immediate Corrective Actions
The facility?s Emergency Plan was reviewed and updated by the facility's Safety committee and community emergency personnel on or before (MONTH) 16, 2019, to include comprehensive collaboration with local emergency planning authorities.
II. Identification of other residents
Though no harm occurred, potentially all residents were potentially at risk of harm from this deficient practice.
III. Systemic Changes
Staff educated on or before (MONTH) 16, 2019, by Administrator or designee regarding facility?s updated the All Hazards Risk Assessment with collaboration from local community emergency authorities.
IV. QA Monitoring
Upon completion of initial education with staff, Administrator or designee will monitor the effectiveness of the emergency management plan through staff interview and provide outcomes to the facility's QAPI committee on a semi-annual basis. Additional education will be provided as needed. Emergency plan to be updated as indicated.
Responsible parties: Administrator or designee

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan did not include provisions detailing their role for the care and treatment of [REDACTED]. This is evidenced as follows. A review of the Emergency Plan on 02/14/2019, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Administrator stated in an interview on 02/14/2019 at 10:45 AM, that county emergency preparedness officials will be contacted and the Emergency Plan will be revised to include provisions outlining their role for care at an alternate care site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedMarch 14, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E026, SS=E, 42 CFR: 483.73(b)(6)
Roles Under a Waiver Declared by Secretary
Allegation: A review of the Emergency Plan on 02/14/2019, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED].
I. Immediate Corrective Actions
The facility?s emergency management plan reviewed and updated on or before (MONTH) 16, 2019, by facility QAPI committee and community emergency personnel to include updated and site-specific policies and procedures to include an updated communications plan. Administrator and Director of Maintenance attended a Rensselaer County Emergency Planning meeting (MONTH) 19, 2019. A meeting scheduled at the facility with community emergency planning agents (MONTH) 20, 2019. Dr.(NAME)Sottolano, Lead for Healthcare Preparedness and Response, the key note presenter. Administrator has begun a dialogue with Rensselaer County Emergency Planning Coordinator to develop mutual aid agreements. Administrator and Director of Maintenance are now active with SVHC?s Emergency Preparedness Committee which meets monthly.
II. Identification of other residents
Though no residents were affected by this deficient practice, the potential to affect all residents existed.
III. Systemic Changes
Staff on all shifts will be educated on or before (MONTH) 16, 2019, by the Administrator or designee regarding facility?s updated policy about the facility role and responsibilities under 1135 waiver.
The Facility convened a Safety committee consisting of the Administrator, Maintenance Director, Director of Nursing, and Director of Housekeeping, and found the revised emergency plan to be acceptable.
IV. QA Monitoring
Upon completion of the initial education with staff, Administrator or designee will monitor the effectiveness of the emergency management plan through staff interview and provide outcomes to facility's QAPI committee monthly for 3-months and then semiannually. Additional education will be provided as needed.
Responsible parties: Administrator or designee.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.15.1 requires automatic sprinkler protection in concealed spaces of exposed combustible construction, such as above suspended ceilings. Specifically, automatic sprinkler protection was not provided in areas of combustible construction above suspended ceilings. This is evidenced as follows. A spot check of the sprinkler system was conducted on 02/14/2019 at 11:45 AM. Combustible construction, wood framing for curtain rods was found above the suspended ceilings in resident room [ROOM NUMBER] and the A-Unit shower room. Sprinkler protection was not found in these areas. The Facilities Manager stated in an interview on 02/14/2019 at 11:45 AM, the wood above the suspended ceilings as it is not fire retardant-treated wood, it will be removed. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.4.1.1.1, 8.6.5.2.2.1, 8.15.1

Plan of Correction: ApprovedMarch 18, 2019

K 351, SS=D, 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.2.5.5; 2009 NFPA 17A 7.2; 10 NYCRR
415.29; 2000 NFPA 101 19.3.2.6, 9.2.3; 1998; NFPA 17A 5-2
NFPA 101 Sprinkler System - Installation
Allegation: Automatic sprinkler protection was not provided in areas of combustible construction above suspended ceilings.
I. Immediate Corrective Actions
The facility?s Director of Maintenance or designee will remove combustible materials from the space above ceilings as required on or before (MONTH) 16, 2019.
II. Identification of other residents
Though no residents were affected by this deficient condition, the potential to affect many residents existed.
III. Systemic Changes
A thorough assessment of combustible materials present in the space above ceilings has been completed. Combustible materials will not be stored or used in the space above ceilings.
IV. QA Monitoring
The removal of or fire-rated coating of all combustible materials present in the space above ceilings reported to facility's QAPI Committee monthly for 3-months, then quarterly. Random audits above ceilings for combustible materials performed semi-annually. Combustible materials will not be used in the space above ceilings; if found, will be removed or risk mitigated immediately.

Responsible parties: Director of Maintenance or designee.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 Edition Section 8.3.5.6.3 restricts the installation of metal electrical boxes in smoke barrier walls when the required fire resistance of the smoke barrier wall is reduced. Section 8.5 requires that smoke barriers shall be continuous from floor to the underside of the roof and through all concealed spaces, and penetrations and miscellaneous openings be sealed with materials capable of maintaining the smoke rating of the smoke barrier wall. Specifically, in 1 of 1 smoke barriers observed, metal boxes were not fire protected, the wall was not continuous, and the fire-resistance rating was not maintained. This is evidenced as follows. The A-Unit smoke barrier wall (wall) was inspected on 02/14/2019 at 11:20 AM. In resident room 108 a 6-foot length of 6-inch by 4-inch spaces where the wall meets the underside of the roof were found were filled with joint compound which is not a fire-rated material. In resident rooms 106 and 109, the spaces around 4 pipes each in the bathrooms were not sealed. In the corridor, one 2-inch unsealed hole and two ½-inch holes were found. The common wall between resident rooms 106 and 108 had 4 metal electrical boxes within 2-feet of each other on opposite sides of the wall. The Director of Maintenance stated in an interview conducted on 05/24/2018 at 3:15 pm, that he will repair and seal the areas found. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5.6.3, 8.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedMarch 19, 2019

K 372, SS=E, 42 CFR 483.70 (a) (1); 2012
NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.4.1.1.1, 8.6.5.2.2.1,8.15.1
NFPA 101 Subdivision of Building Spaces - Smoke Barrier
Allegation: The A-Unit smoke barrier wall (wall) was inspected on 02/14/2019 at 11:20 AM. In
resident room 108 a 6-foot length of 6-inch by 4-inch spaces where the wall meets the underside
of the roof were found were filled with joint compound which is not a fire-rated material. In
resident rooms 106 and 109, the spaces around 4 pipes each in the bathrooms were not sealed.
In the corridor, one 2-inch unsealed hole and two ½-inch holes were found. The common wall
between resident rooms 106 and 108 had 4 metal electrical boxes within 2-feet of each other
on opposite sides of the wall.
I. Immediate Corrective Actions
The facility?s Director of Maintenance or designee will seal smoke barrier penetrations with 2-hour fire-rated material on or before (MONTH) 16, 2019.
II. Identification of other residents
Though no residents were affected by this deficient condition, the potential to affect many residents existed.
III. Systemic Changes
A thorough assessment of the facility?s smoke barriers has been completed and future penetrations sealed to complete work.
IV. QA Monitoring
Upon completion of smoke barrier project, Director of Maintenance or designee will verify future smoke barrier penetrations properly sealed through direct observation. Findings submitted to facility's QAPI committee monthly for 3-months, then quarterly. Future smoke barrier penetrations will be properly sealed as needed with 2-hour fire-rated material. Random checks smoke barriers completed semi-annually and penetrations sealed.
Responsible parties: Director of Maintenance, or designee.

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

REGULATION: Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on observation, record review, and staff interview during the recertification survey, the facility did not maintain equipment using gas or related gas piping in accordance with adopted regulations. NFPA 54, National Fuel Gas Code 2011 Edition Section 9.3 requires that Type II gas dryers provide outside air for fuel combustion (make-up air). Specifically, adequate make-up air was not provided for gas dryers. This is evidenced as follows. Observations of the laundry room on 02/15/2019 at 10:15 AM, revealed 2 fuel fired gas clothes dryers and no provision for make-up air. Record review of the clothes dryer installation manual on 02/15/2019, revealed that a total 432 square inches of free openings for make-up air be provided for fuel combustion for the two dryers. The Facility Director stated in an interview on 02/15/2019 at 10:15 AM, that the laundry does not have a vent for the make-up air and he will install a vent. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.1, 9.1.2; 2011 NFPA 54 9.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 54

Plan of Correction: ApprovedMarch 18, 2019

K 511, SS=E, 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5.6.3, 8.5; 10 NYCRR 415.29,
711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3
NFPA 101 Utilities - Gas and Electric
Allegation: Observations of the laundry room on 02/15/2019, at 10:15 AM, revealed 2 fuel fired gas clothes dryers and no provision for make-up air. Record review of the clothes dryer installation manual on 02/15/2019, revealed that a total 432-square inches of free openings for make-up air be provided for fuel combustion for the two dryers.
I. Immediate Corrective Actions
The facility?s Director of Maintenance or designee hired an HVAC contractor to install a louvered air duct and build an enclosure supplying the manufacturer recommended amount of make-up air on or before (MONTH) 16, 2019.
II. Identification of other residents
Though no residents were affected by this deficient condition, the potential to affect all residents existed.
III. Systemic Changes
Permanent installation of ducting providing sufficient make-up air for two fuel fired gas clothes dryers.
IV. QA Monitoring
Upon installation of ducting to supply required make-up air, the Director of Maintenance, or designee will report to QAPI committee. Future gas dryer installations will meet the manufacturer recommended make-up air requirement.
Responsible parties: Director of Maintenance, or designee.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 16, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls including rated ceiling assemblies shall be fire-sealed. Specifically, the basement rated ceiling was not continuous and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. Observations of the maintenance shop on 02/14/2019 at 12:10 PM, revealed ten 4-inch unsealed penetrations for piping and two 6-inch holes in the ceiling assembly. The Facilities Manager stated in an interview conducted on 02/14/2019 at 12:10 PM, that he will fire-seal the holes found in the ceiling. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.1, 8.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3

Plan of Correction: ApprovedMarch 14, 2019

K 311, SS=E, 42 CFR: 483.73(d)(2)
NFPA 101 Vertical Openings ? Enclosure
Allegation: Observations of the maintenance shop on 02/14/2019 at 12:10 PM, revealed ten 4-inch
unsealed penetrations for piping and two 6-inch holes in the ceiling assembly.
I. Immediate Corrective Actions
The facility?s Director of Maintenance or designee will seal, with at least 1-hour, fire-rated material, vertical openings on or before (MONTH) 16, 2019.
II. Identification of other residents
Though no residents were affected by this deficient condition, the potential to affect many residents existed.
III. Systemic Changes
A thorough assessment of the facility?s vertical openings has been completed and future openings sealed before work determined complete.
IV. QA Monitoring
Upon completion of vertical opening enclosures, Director of Maintenance, or designee will verify future vertical openings properly sealed through direct observation and document. Findings reported to the facility's QAPI committee monthly for 3-months, then on a quarterly basis. Additional vertical openings will be properly sealed as needed.
Responsible parties: Director of Maintenance, or designee.