The Grand Rehabilitation and Nursing at Mohawk
November 16, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.15(f)(1):ACTIVITIES MEET INTERESTS/NEEDS OF EACH RES

REGULATION: The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure an ongoing program of activities was designed to meet the interests of 1 of 9 residents (Resident #17) reviewed for activities. Specifically, Resident #17's needs were not accommodated in order for the resident to attend meaningful activities. Findings include: Resident #17 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. She required extensive assistance with most activities of daily living (ADLs), and did not have any behavioral issues. The comprehensive care plan (CCP) dated 8/26/2016 documented the resident attended activities of her choice and she enjoyed special socials. Interventions included to provide her with independent leisure activities of her choosing upon request, provide stimulation such as television or radio, and provide a monthly activities calendar. During a resident interview on 11/15/2016 at 9:00 AM, she stated she liked the activities offered by the facility, and at times she was not able to actively participate in the activity. She stated her wheelchair was too large to fit through some of the doorways of the facility and they were looking at getting her a smaller chair. She stated at times she would observe the activity from outside the doorway. She stated she was not able to ambulate at this time as she did not have the proper shoes that would provide the ankle support she needed to safely walk. She stated she had a smaller wheelchair when she was admitted that worked just fine, and when she asked for that chair back, they said they could not find it. During an interview with the Director of Activities on 11/16/2016 at 9:40 AM, she stated the resident was not able to attend some of her activities of choice, as her wheelchair was too wide to fit through some of the doorways of the facility. She stated she would offer the resident activities she could do independently or she would set the resident up outside the doorway to observe the activity from there. She stated the physical therapy (PT) department was working on getting her a new wheelchair and that was initiated over a month ago. She stated the physical therapy department was also working on getting her new shoes so she would be able to walk into the activity. During an interview with the Director of Rehabilitation on 11/16/2016 at 9:50 AM, she stated she was aware the resident's wheelchair was too large for some of the doorways and they were working on getting her a smaller one. She stated the resident was evaluated by the occupational therapist for a smaller wheelchair and she understood there was a concern regarding the resident's skin integrity. The Director reviewed the resident's occupational therapy (OT) progress notes and stated she was unable to find the OT evaluation regarding her wheelchair. She stated the resident had plateaued in PT, as she did not have the proper shoes. She stated the facility was working on getting her the correct shoes that provided her with ankle support so she could ambulate safely. During an interview with occupational therapist #13 on 11/16/2016 at 1:30 PM, he stated he was notified of the resident's wheelchair being too large and he could not remember when that was. He stated he did not do an evaluation of the wheelchair, it was more of a casual conversation that he had with the resident regarding maintaining her skin integrity and needing the larger wheelchair. He stated the resident was able to walk into the activity if she wanted to and she refused that. He stated maybe they could have provided her with a smaller wheelchair just for the activity and then transfered her back to the larger chair when she was done. 10NYCRR 415.5(f)(1)

Plan of Correction: ApprovedJanuary 3, 2017

I. The following actions were accomplished for the residents identified in the sample:
Resident # 17
An Occupational Therapy screen has been completed and documented in the resident?s medical record. A wheelchair has been provided that allows entrance into all facility doorways and new shoes have been obtained to promote ambulation.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
All resident wheelchairs have been screened to ensure residents have no impediments passing through facility doorways. No other residents were identified.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Staff Development Coordinator has educated all therapy and activity staff on their responsibility to provide ongoing activities programs designed to meet the interests and the physical, mental, and psychosocial well-being of each resident and to care plan accordingly.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Three activity programs will be observed weekly for one (1) month and then monthly for two (2) months to ensure residents are attending activity programs, per their CCP, without impediments.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Activities Director

FF09 483.60(c):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. The pharmacist must report any irregularities to the attending physician, and the director of nursing, and these reports must be acted upon.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, it was determined for 6 of 19 residents (Residents #3, 4, 5, 9, 10, and 15) reviewed for physician orders, the facility did not ensure all residents' medication regimens were reviewed at least monthly by a licensed pharmacist. Specifically, for Residents #3, 4, 5, 9, 10 and 15, there was no documentation that medication regimens were reviewed monthly by the consulting pharmacist during (YEAR). Findings include: Licensed practical nurse (LPN) Assistant Manager #6 stated on 11/16/2016 at 10:00 AM that monthly pharmacy sheets/documentation were no longer completed at the facility and they had not been in some time. During an interview with the Director of Nursing (DON) on 11/16/2016 at 3:30 PM, she stated the pharmacist came to the facility on a monthly basis. The pharmacist who currently worked with the facility had started approximately 9/2016. She stated the pharmacist looked at every resident's medication regimen when in the facility. She stated the pharmacist kept track of the active residents and medication regimen reviews on her own, and the facility did not keep any documentation in the facility of the monthly reviews completed. During an interview with the acting consulting pharmacist on 11/16/2016 at 3:40 PM, she stated she had been consulting at the facility for 2 months. She stated she was able to run a report on her own of all residents in the facility and she reviewed every resident monthly. She stated she kept track and documented her monthly reviews on her personal work computer and she did not provide documentation to the facility. She stated she would notify nursing of any irregularities following the reviews. 1) Resident #4 had [DIAGNOSES REDACTED]. The 9/23/2016 comprehensive care plan (CCP) documented the resident was on 9 or more medications including medications for major depressive disorder, cardiovascular disease, renal disease, and chronic pain. The resident was at increased risk of abnormal bleeding and potential bruising related to anticoagulation therapy. The CCP documented the resident was at risk for side effects from her medications. Staff were to administer medications per order, monitor for signs and symptoms of adverse reactions and report to physician, monitor lab work as ordered, and monitor pharmacy review and reduce medications if possible. The resident would be maintained safely as evidenced by no adverse event related to medication regimen. The 10/29/2016 physician orders [REDACTED]. There was no documentation in the resident record that the resident's medication regimen was reviewed at least monthly by a licensed pharmacist in (YEAR). 2) Resident #15 had [DIAGNOSES REDACTED]. The 9/13/2016 comprehensive care plan (CCP) documented the resident had the potential for constipation, was at risk to fall, and had chronic pain related to multiple sclerosis. Staff were to administer medications per physician order, monitor effectiveness of medications, and report to physician for modifications as indicated. The 10/29/2016 physician orders [REDACTED]. There was no documentation in the resident record that the resident's medication regimen was reviewed at least monthly by a licensed pharmacist in (YEAR). 3) Resident #10 had [DIAGNOSES REDACTED]. A note to the attending physician/prescriber by the consulting pharmacist documented the resident's medications Tylenol and Norco (pain medications) were reviewed in 3/2016; Cymbalta (antidepressant) on 6/17/2016; and Omeprazole (anti-ulcer medication) on 8/24/2016. There was no documentation that the resident's entire medication regimen was reviewed by the consulting pharmacist on these dates. There were no further notes to attending physician/prescriber for (YEAR). The 10/11/2016 comprehensive care plan (CCP) documented the resident was at risk for constipation, was at increased risk of fractures related to osteoporosis, had potential for decreased cardiac output related to cardiovascular disease, had [DIAGNOSES REDACTED]. The resident was to receive medication per physician orders, once administered the medications were to be monitored for efficacy, and she would receive psychotropic medications without side effects. The physician orders [REDACTED]. The orders were signed by the attending physician on 11/17/2016. There was no documentation in the resident record that the resident's medication regimen was reviewed at least monthly by a licensed pharmacist in (YEAR). The resident's most recent monthly pharmacy review documented the resident's entire drug regimen was last reviewed by a pharmacist in 2014. 10NYCRR 415.18(c)(1)

Plan of Correction: ApprovedDecember 8, 2016

I. The following actions were accomplished for the residents identified in the sample:
Resident # 3,4,5,9,10 and 15
Documentation of the consulting pharmacist?s last monthly review has been obtained and entered into the resident?s medical records.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
Documentation of the consulting pharmacist?s last monthly review has been obtained and entered into the resident?s medical records.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility has developed a Drug Regimen Review policy. The consulting pharmacist and DON have been educated on this policy with emphasis on ensuring medical records contain documentation of monthly regimen reviews.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
A monthly review will be conducted for three (3) months to ensure drug regimen reviews are documented in each resident?s medical record.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Director of Nursing

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 6, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure food was stored, prepared, and served under sanitary conditions for the main kitchen. Specifically, the ice machine was unclean, staff facial hair was not properly restrained, 2 prep sinks did not have indirect drains, multiple tube feed cans were expired, and 1 can was dented. Findings include: On 11/14/2016, between 10:40 AM and 11:15 AM, a surveyor observed the following in the main kitchen: - The ice machine had visible black material inside of it that was easily wiped out with a paper towel. - A dietary staff member who had facial hair was working in the kitchen without a beard restraint. - There were 2 prep sinks that did not have indirect drains. - The emergency stock storage area contained cans of tube feed product that had expired 9 months prior, and there was a dented can of tube feed product. When interviewed in the kitchen on 11/16/2016 at 2:15 PM, the Dietary Manager stated: - The ice machine was cleaned every 6 months by maintenance and was also cleaned after the initial kitchen tour. - There were beard restraints available and staff with facial hair would wear beard guards. - The 2 prep sinks were used for cleaning and preparing foods for resident meals and maintenance would be contacted to address the drains. - The tube feed product in the emergency stock room was rarely used by the nursing home residents, as it was brought in with rehabilitation residents from outside facilities. There was potential for the tube feed product to be used by nursing home residents as a substitute in the event of a floor stock shortage. 10NYCRR 415.14(h)

Plan of Correction: ApprovedDecember 8, 2016

I. The following actions were accomplished for the residents identified in the sample:
The inside of the ice machine was immediately cleaned.
The staff member not wearing a facial hair restraint was instructed to immediately wear one.
All expired tube feeding supplies and dented cans were discarded immediately.
The Director of Maintenance contacted local plumbing vendor to inspect the existing drain and to submit a quote to replace with an indirect drain.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
All ice machines were inspected for cleanliness.
All staff members with facial hair were instructed to wear facial hair restraints.
Maintenance installed the indirect drain in the prep sink area.
All emergency stock items were inspected to ensure there were no expired dates or dented cans.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The dietary dress code policy has been reviewed and revised to reflect the use of facial hair restraints and all dietary staff has been educated on this change.
Checking emergency stock items for expired dates and dented cans has been added to the weekly kitchen audit.
A full kitchen review revealed no other needs for an indirect drain.
Dietary staff have been educated on the need to clean the inside ledge of the ice machine during scheduled weekly cleaning.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Weekly audits will be conducted for one (1) month and then monthly for (2) months to ensure the inside ledge of the ice machine is clean, emergency storage area is free from expired items and dented cans, and facial hair restraints are used.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Food Service Director

FF09 483.25(e)(2):INCREASE/PREVENT DECREASE IN RANGE OF MOTION

REGULATION: Based on the comprehensive assessment of a resident, the facility must ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure 2 of 4 residents (Residents #9 and 15) reviewed for range of motion (ROM) received the appropriate treatment and services to improve, and/or to prevent a decrease in ROM. Specifically, Residents #9 and 15 did not receive ROM as care planned. Findings include: 1) Resident #9 had [DIAGNOSES REDACTED]. The active certified nurse aide (CNA) instructions initiated 4/8/2016 documented active range of motion (AROM) was to be provided to the resident twice daily, 10 repetitions each, to all joints of bilateral upper and lower extremities with care. The comprehensive care plan (CCP) dated 7/5/2016 documented the resident was on a maintenance nursing program for transferring related to a decreased motivation to perform. Interventions included to explain safety techniques and procedures prior to assisting, report changes to restorative nurse, participate in transfer program, and to remain on program for ambulation. The maintenance nursing progress note dated 8/23/2016 documented the resident continued on the maintenance nursing program for transferring and ambulation monthly. The resident was transferred 8 times that month with minimal assistance of 1 staff. The resident ambulated 8 times that month with minimal assist with rolling walker, and ambulated 2-6 feet during those times. An 8/27/2016 physician order, with original order date of 11/6/2015, documented the resident was to receive AROM twice a day (BID) with 10 repetitions to all joints of bilateral lower extremities with care. In addition, 10 repetitions of AROM/PROM (passive ROM) would be provided to all joints of bilateral upper extremities with care. An 8/31/2016 occupational therapy (OT) quarterly assessment documented AROM/PROM continued to be within functional limits to both upper extremities. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact; required limited assistance with bed mobility and personal hygiene, transferred with extensive assistance, and did not reject evaluation of care. The MDS documented the resident did not have impairment to his upper extremities and had impairment on both sides of his lower extremities. The resident had not participated in a restorative nursing program for range of motion, ambulation, or transfers during the assessment period. The physician orders [REDACTED]. The resident was to ambulate as tolerated 30 feet with minimal assistance of 1 with a rolling walker, with a second staff to wheelchair follow. The CCP was updated on 9/15/2016 to reflect the 9/15/2016 physician orders. A 9/15/2016 physical therapy (PT) quarterly assessment documented to continue with maintenance for ambulation/transfers and exercise daily ROM to all 4 extremities, 10 repetitions at least once per day as tolerated. The CCP was updated on 9/22/2016 and documented the resident transferred with minimum assistance of 2 with a rolling walker, and to continue maintenance nursing plan of care. A physician order [REDACTED]. A nursing progress note dated 9/28/2016 documented the resident remained on a maintenance program for transferring and ambulation. The note documented the resident transferred 13 times, and ambulated 13 times from 2-13 feet. The ambulation goal was documented as 30 feet. The 9/2016 maintenance nursing record documented the resident transferred 13 times and ambulated 13 times 2-14 feet. It was documented 1 time the resident was not able to ambulate. There was no further documentation for the remaining 17 days of the month why ambulation and transferring were not offered or performed. There was no documentation on the maintenance nursing record or in the resident record that AROM/PROM were provided as ordered. The 10/2016 maintenance nursing record documented the resident transferred 17 times and ambulated 17 times 4-8 feet. The resident's ambulation goal remained 30 feet. It was documented on the record 1 time the resident was unable to transfer. There was no further documentation on the record that ambulation and transferring was offered or performed. There was no documentation on the maintenance nursing record or in the resident record that AROM/PROM were provided as ordered. The CCP dated 11/6/2016 documented the resident was to receive AROM to all joints of both lower extremities with care, and AROM/PROM to the right shoulder with care twice daily. A maintenance nursing progress note dated 11/1/2016 documented the resident transferred and ambulated 16 times that month. The resident ambulated between 2-14 feet, and the ambulation goal remained 30 feet. The 11/2016 - 11/16/2016 maintenance nursing record documented the resident transferred 8 times, and ambulated 8 times 2-8 feet. There was no documentation on the maintenance nursing record or in the resident record that AROM/PROM were provided as ordered. The resident was observed seated at the dinner meal with adaptive silverware on 11/16/2016 from 5:56 PM - 6:37 PM. During an interview with licensed practical nurse (LPN) Assistant Manager #6 on 11/16/2016 at 10:00 AM, she stated if a resident required AROM/PROM it would be documented in the CNA kiosk (record system), and CNAs would be prompted to complete this for the assigned resident. During an interview with CNA #9 on 11/16/2016 at 10:15 AM, he stated the resident stood while in the room with staff, and was walked with a walker towards the in-room bathroom and back to his bed. He was not aware of any further range of motion or ambulation that was to be provided. He stated if it had been provided, it would be recorded in the CNA kiosk and would show in the resident's record. He stated if a resident was on a maintenance program, this would be completed by a designated rehabilitation team and would not be completed by CNAs. He was not aware of a maintenance plan in place for this resident. During an interview with occupational therapist #13 on 11/16/2016 at 12:55 PM, he stated the resident had orders in place for ROM. He stated PROM was to be provided to the right shoulder, and AROM to both lower extremities. OT #13 reviewed a 8/31/2016 therapy screen note that the resident was not picked up by OT/PT, and AROM was recommended to be continued. He stated the purpose of ROM was to maintain the resident's abilities regardless of the resident's current abilities. He stated ROM would prevent further decline. He stated the resident had a cognitive impairment and would not initiate ROM on his own behalf, and staff would have to offer/encourage range of motion. He stated the resident had a decline in functioning between 3/2016 and 8/2016, and ROM should have been continued. During a follow up interview with OT #13 on 11/16/2016 at 2:25 PM, he stated if there was a physician order [REDACTED]. During an interview with LPN Maintenance program coordinator on 11/16/2016 at 2:30 PM, she stated a resident was placed on/recommended for the maintenance program by the therapy department and goals/type of maintenance would be coordinated by PT/OT. She stated the maintenance program staff kept paper documentation for all residents on program. The maintenance program staff did not work with residents daily, and were normally scheduled on a Monday - Friday basis. She stated at times staff would need to assist with resident care, would call in, did not have time to complete all residents on the program, were short staffed, or would be pulled for other duties. She stated this was often why maintenance records had gaps/dates that services were not provided. The LPN stated if the resident had a decline, therapy was to be notified. She stated if not all services were able to be provided, the CNAs in the maintenance program would try to make sure each resident on the program was walked first. She stated Resident #9 was on a transfer and ambulation program. She stated he did not receive this daily, and when reviewing the 11/2016 record, it was noted the maintenance staff had been pulled for other duties on the resident units. She stated there was no documentation AROM/PROM were to be provided to the resident. 2) Resident #15 had [DIAGNOSES REDACTED]. The 9/17/2014 physician orders, active on 10/29/2016, documented 10 repetitions of active range of motion (AROM)/passive range of motion (PROM) were to be provided to the resident's bilateral shoulders and left elbow daily with care. The certified nurse aide (CNA) care instructions, initiated 2/18/2015 and active through (YEAR), documented the resident required extensive assistance for bathing, bed mobility, dressing and hygiene. The resident was totally dependent on staff with use of a Hoyer (mechanical) lift for transferring. The resident was to receive 10 repetitions of AROM/PROM to all extremities twice daily (BID) with care. There was no documentation the CNA care instructions were updated to reflect specific areas of ROM to the shoulders and left elbow as specified in the physician orders. The 11/6/2015 physician orders, active on 10/29/2016, documented the resident was to receive 10 repetitions of AROM/PROM to all joints of both lower extremities with care. The comprehensive care plan (CCP) dated 9/13/2016 documented the resident had a self care deficit with activities of daily living (ADLs). The goal was for the resident to maintain current ADL performance status as evidenced by not requiring increased support to complete tasks over the course of the next review period. Staff were to provide 10 repetitions of nursing AROM/PROM to all joints of both lower extremities with care twice a day. There was no documentation on the CCP regarding ROM to the upper extremities. There was no documentation in the resident record that any AROM/PROM was provided to the resident from 8/2016 - 11/14/2016. The resident was observed on 11/15/2016 at 10:15 AM, seated in his wheelchair leaning to the left, and attempting to position himself upright with his left arm. During an interview with licensed practical nurse (LPN) Assistant Manager #6 on 11/16/2016 at 10:00 AM, she stated if a resident required AROM/PROM, it would be documented in the CNA kiosk and CNAs would be prompted to complete this. She stated the resident was not documented in the computer to complete ROM. She stated the resident did participate in a walking group that was coordinated by a nurse running the maintenance nursing program. During an interview with CNA #10 on 11/16/2016 at 10:30 AM, he stated he thought the resident participated in therapy, he did his own thing, and he did not have to provide/encourage any additional ROM for the resident. During a telephone interview with CNA #11 on 11/16/2016 at 10:51 AM, he stated the resident required assistance of 2 staff with turning in bed, a Hoyer lift for transferring, and assistance with dressing/bathing. He stated he was not sure if the resident had ROM ordered. He stated if the resident did, it would show up on the CNA kiosk, and staff would be prompted to offer/provide ROM. During an interview with occupational therapist #13 on 11/16/2016 at 12:55 PM, he stated all residents had ROM orders in place. He stated ROM would be reviewed if necessary on all resident quarterly screens. The therapy department did not receive feedback if a resident was not able to complete goals or if ROM was not being completed. He stated the resident was receiving therapy in 8/2016 and was discharged on [DATE]. He stated the resident had been placed on a therapy program at that time for decrease in posture and inability to feed himself related to a significant deficit to his right side. OT #13 reviewed the resident's record and he stated the resident had a physician order [REDACTED]. He stated the resident was active and it was important to encourage/offer ROM to a resident. He stated the physician order [REDACTED]. During an interview with LPN Maintenance program coordinator on 11/16/2016 at 2:30 PM, she stated a resident was placed on/recommended for the maintenance program by the therapy department and goals/type of maintenance would be coordinated by PT/OT. She stated the maintenance program staff kept paper documentation for all residents on program. The maintenance program staff did not work with residents daily, and were normally scheduled on a Monday - Friday basis. She stated at times staff would need to assist with resident care, would call in, did not have time to complete all residents on the program, were short staffed, or would be pulled for other duties. She stated this was often why maintenance records had gaps/dates that services were not provided. The LPN stated if the resident had a decline, therapy was to be notified. She stated if not all services were able to be provided, the CNAs in the maintenance program would try to make sure each resident on the program was walked first. She stated the resident was not on the maintenance nursing program and there was no documentation that AROM/PROM were to be provided to the resident. 10NYCRR 415.12

Plan of Correction: ApprovedJanuary 9, 2017

I. The following actions were accomplished for the residents identified in the sample:
Resident # 9 and 15
A therapy screen has been complete and the current ROM plan has been reviewed without revision and will now be performed by the resident?s primary CNA to allow for ROM to be performed daily as ordered. CNA Nursing Instructions and care plans were reviewed to ensure accuracy.
The resident?s primary CNAs have been re-educated on documenting ROM in the EMR prior to the end of their shift. The supervisors have been re-educated on ensuring all CNA documentation, including ROM, is complete in the EMR prior to the end of their shift.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
All resident ROM plans have been reviewed and found accurate. CNA Nursing Instructions in the EMR and care plans were reviewed to ensure accuracy.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s Range of Motion (ROM) policy has been reviewed and revised to give direction for CNAs to document ROM in the EMR prior to the end of their shift. All CNAs have been educated on this policy by the SDC and all Supervisors have been educated on ensuring all CNA Documentation, including ROM, is complete in the EMR prior to the end of their shift by the SDC. This education will be integrated into General Orientation and annual mandatories.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
CNA Nursing Instruction documentation will be reviewed weekly for one (1) month and then monthly for two (2) months to ensure CNAs are documenting range of motion per the nursing instructions in the EMR.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Director of Nursing

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification and abbreviated surveys (NY 554), it was determined for 1 of 19 residents (Resident #19) reviewed for abuse/neglect, the facility did not ensure all alleged violations involving abuse were thoroughly investigated. Specifically, the facility did not ensure Resident #19 was provided with adequate safety from the accused after the investigation determined the resident was verbally abused. Findings include: The resident had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 4/11/2016 documented the resident had the potential to withdraw from interacting with residents/others and had verbal conflicts with residents/staff. The CCP documented no interventions exist for this problem. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. The resident required extensive assistance for most activities of daily living (ADLs), and he did not have any behavioral problems. The physician progress notes [REDACTED]. Nursing progress notes for 7/6/2016 included: - At 7:49 PM, licensed practical nurse (LPN) #8 documented the resident was seen while in the dining room taking his tablemate's thin (normal consistency) water and drinking it. The LPN documented he removed the water from the table and the resident became very irate and agitated. The LPN documented he advised the resident he needed to calm down or leave the dining room immediately. The nursing Supervisor was notified by another LPN on the unit and the Supervisor went to talk to the resident. - At 9:05 PM, an LPN documented the resident was caught drinking thin liquid water in the dining room tonight by LPN #8. The resident became visibly angry and went to his room. Staff would continue to monitor the resident for pain and behaviors. There was no documentation in the medical record from the nursing Supervisor regarding the incident on 7/6/2016. A concern/grievance from dated 7/7/2016 documented the resident went to physical therapy and was very concerned and upset about an incident with evening nurse. The resident stated his drink was frozen and when he asked LPN #8 to fix it, a confrontation arose and he was kicked out of the dining room. The resident stated he was degraded in front of all those people. The investigation outcome concluded that LPN #8 spoke to the resident in a tone that could be interpreted as verbal abuse. The LPN received a reprimand and suspension. Staff, including LPN #8, were re-educated on abuse. The form was signed off by the Director of Nursing (DON), social worker and the Administrator on 7/14/2016. A physician order [REDACTED]. A summary of the investigation completed by the DON on 7/12/2016 documented it was determined LPN #8 used a tone that was considered verbally abusive toward the resident. The DON documented the immediate interventions included the resident was offered food and drink when it was determined he had not eaten for two meals, and statements from staff and the resident were obtained. The DON documented the plan of correction included the LPN was suspended for using a verbally abusive tone of voice, and upon his return he would be re-educated on the facility's verbal abuse policy and demonstrate understanding. The LPN was instructed to have a second staff member present during any interactions with the resident. The DON documented a follow-up on the summary that staff were re-educated on abuse and the resident was updated on 7/12/2016 that his complaint had been investigated. During a record review of Employee #8's personnel file on 11/14/2016 at 1:45 PM, there was no documented evidence the employee was suspended during the investigation, was re-educated on abuse/neglect, and there was no documented evidence the employee was to be supervised when having any interaction with Resident #19. On 11/16/2016 at 9:25 AM, the DON stated she was unable to locate the resident's investigation and she would keep looking. On 11/16/2016 at 1:35 PM, social worker #14 stated she was aware of the incident with the resident on 7/6/2016 and he had been very upset about it. She stated she would check in on the resident from time to time. She stated she thought the LPN was not supposed to have any contact with the resident after the incident. She stated she had the investigation report in her office. During an interview with LPN Assistant Unit Manager #6 on 11/16/2016 at 12:05 PM, she stated she was the Unit Manager for Resident #19's unit at the time of the incident. She stated she thought the LPN was suspended, and could not recall if his suspension was during or after the investigation. She was not aware of any plan for the resident regarding the LPN requiring to have another staff member present during any interaction with the resident. During an interview with the DON on 11/16/2016 at 2:55 PM, she stated when a investigation was initiated at the time of a complaint regarding abuse, they would ensure the resident was safe from the accused employee. The employee would be suspended pending the outcome of the investigation. She stated the investigative process would be initiated by the nursing supervisor and they would be responsible for obtaining staff statements. She stated LPN #8 was suspended, and she could not locate the documentation to show what days he was suspended and would keep looking. She stated she would also provide the surveyor with documentation the LPN and all staff were re-educated on the abuse policy. The DON was interviewed a third time on 11/16/2016 and stated she was unable to provide documentation the LPN was suspended during the investigation, that he was re-educated, or that all other staff were re-educated on the abuse policy. 10NYCRR 415.4(b)(3)(4)

Plan of Correction: ApprovedDecember 8, 2016

I. The following actions were accomplished for the residents identified in the sample:
Resident # 19
LPN #8 was re-educated on the facility?s Abuse Policy, received written disciplinary action for the incident on 7/6/16 and is no longer employed by the facility. The previous has been documented and is on file in the employee?s personnel record.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
The past three months of Grievance/Concern forms have been reviewed to ensure proper documentation is present to support facility actions.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s Grievances policy has been reviewed without revision. The Administrator and DON have been re-educated on their responsibility to ensure that all documentation is present to support corrective actions.
All staff has been re-educated on the facility?s Abuse Policy with emphasis on understanding the definition of verbal abuse.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
All Grievance forms will be reviewed monthly for three (3) months to ensure documentation is present to support corrective actions.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Administrator

FF09 483.10(b)(11):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in §483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in §483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 565), it was determined for 1 out-of-sample resident (Resident #20), the facility did not inform the resident's interested family members when there were changes in the resident's physical status with the need to alter treatment. Specifically, the facility did not inform the resident's next of kin (designated representative) when changes were made to the resident's medications, in response to a reported abnormal potassium blood level. Findings include: Resident #20 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. The resident had additional active [DIAGNOSES REDACTED]. The MDS documented the resident's life expectancy was greater than 6 months. The nursing progress note dated 7/10/2016 documented the physician was in to assess the resident after a fall. New orders were posted, including [MEDICATION NAME] ([MEDICATION NAME], a diuretic/water pill) x 1 now, and then daily. The physician orders [REDACTED]. The physician orders [REDACTED]. The 7/2016 MAR (Medication Administration Record) documented the resident received 20 mg [MEDICATION NAME] on 7/10/2016 and 7/11/2016. The facility investigation documented that on 7/11/2016 at approximately 8:00 AM, Resident #20 was treated for [REDACTED]. During the investigation, the Director of Nursing (DON) was notified at approximately 2:20 PM by RN (registered nurse) Nurse Manager #15 that there was an identified issue between the early morning verbal report she had received from the lab (with a low potassium value), and the hard copy of the lab report that was sent over (with a high potassium value). The hard copy of resident's lab results dated 7/11/2016 at 8:03 AM documented: - Potassium level was high at 5.9 mEq/L (milliequivalents/Liter, unit of measure) (normal = 3.5 - 5.1). - Sodium level was critically low at 119 mEq/L (normal = 136 - 145). The printed font of the sodium level was in bold font, and the letters LP were listed after 119. - Chloride level was low at 84.0 mEq/L (normal = 98.0 - 107.0). The physician orders [REDACTED]. A BMP was ordered to be drawn on 7/12/2016. RN Nurse Manager #15's nursing progress note dated 7/11/2016 at 3:54 PM documented she was called to the resident's bedside due to respiratory distress, and a Code Blue (emergency code response) was called at 2:35 PM. The progress note documented the resident's son was notified of the situation and transfer. The resident's medical record did not contain documented evidence the resident's family was notified that the facility was provided erroneous lab values for the resident, or that the resident received potassium chloride based upon the report. The hospital ED (emergency department) and Medical Decision progress notes dated 7/11/2016 documented the resuscitative efforts were halted at 3:27 PM, as it appeared the resident had no meaningful response to endotracheal intubation (insertion of a flexible tube into the trachea to maintain an airway), defibrillation (electric shock to the heart), 3 doses of [MEDICATION NAME] (vasoconstrictive, increases cardiac output), and at least 45 minutes of resuscitative support. The resident was pronounced dead at 3:27 PM. During an interview with RN Nurse Manager #15 on 7/14/2016 at 10:15 AM, she stated she knew the resident's family was notified the resident became worse, but she did not know what was told to her family, as the ADON (Assistant Director of Nursing) called the resident's family. RN Nurse Manager #15 stated she was not sure if the outcome of the facility's investigation would be reported to the resident's family. During an interview with the ADON on 7/29/2016 at 3:31 PM, he stated he had called the resident's family and informed them that the resident had a [MEDICAL CONDITION]. The ADON stated he did not inform the resident's family that the facility was provided erroneous lab values for the resident, or that the physician ordered potassium chloride based upon the lab values received, as an investigation was being conducted by the facility and he did not know what the outcome of the investigation was. The ADON stated that per facility policy, RN Nurse Manager #15 should have informed the resident's family that the facility was provided erroneous lab values for the resident, and the physician ordered potassium chloride based upon the lab values received. During an interview with the Administrator on 8/2/2016 at 11:10 AM, he stated he did not believe the resident's family was notified the facility was provided erroneous lab values for the resident, or the physician ordered potassium chloride based upon the lab values received. He thought it was because he felt the nurse was more concerned about the condition of the resident. When asked if he felt the resident's family should have been notified, the Administrator stated he was not sure, as the facility treated the resident based upon the lab results reported to the facility. 10NYCRR 415.3(e)(2)(ii)(a)

Plan of Correction: ApprovedJanuary 9, 2017

I. The following actions were accomplished for the residents identified in the sample:
Resident # 20
A full investigation has been completed related to the incident involving potassium lab values reported to the facility for this resident on 7/11/16. The resident?s representative has been informed of the investigative outcome and the need to change medications in response to an abnormal laboratory value. This communication has been documented in the resident?s medical record.
Documentation in the resident?s medical record over the past 30 days has been reviewed to ensure the family was appropriately notified if there was a need to change medications in response to a reported abnormal laboratory value.

II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
Documentation in all resident?s medical records over the past 30 days has been reviewed to ensure residents/representatives were appropriately notified if there was a need to change medications in response to a reported abnormal laboratory value.

III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s Notification of Significant Change policy was reviewed without revision. All licensed nurses have been re-educated on this policy with emphasis on their responsibility to notify residents/representatives if there is an alteration to the treatment plan as a result of an abnormal laboratory value and document this communication in the progress notes.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
All laboratory reports will be reviewed weekly for three (3) months to ensure residents/representatives are notified appropriately if there is an alteration to the treatment plan as a result of an abnormal laboratory value.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Director of Nursing


FF09 483.75(h):OUTSIDE PROFESSIONAL RESOURCES-ARRANGE/AGRMNT

REGULATION: If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (h)(2) of this section. Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and the timeliness of the services.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, it was determined for 1 of 19 sampled residents (Resident #17), the facility did not ensure services were furnished to residents by a person or agency outside of the facility when necessary. Specifically, Resident #17 was not assisted with transportation to an appointment and the appointment was not rescheduled timely. Findings include: Resident #17 had [DIAGNOSES REDACTED]. The pulmonology consult note dated 2/1/2016 documented the resident had an office visit accompanied by a nurse from the nursing home, history of OSA (obstructive sleep apnea, pauses in breathing while sleeping) and asthma, used an autoPAP machine (treats sleep apnea), and scheduled a 3 month follow-up appointment for 5/2/2016 at 12:30 PM. The physician progress notes [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition, an active [MEDICAL CONDITION] (lung) diagnosis, and had total dependence on staff for locomotion off the unit. A nursing progress note dated 11/8/2016 documented the resident requested a follow-up pulmonology appointment and the nurse called to schedule the appointment. During a record review on 11/15/2016, there was no documented evidence the resident was seen by the pulmonologist after 2/1/2016. During a resident interview on 11/15/2016 at 9:00 AM, she stated she was supposed to follow up with her pulmonologist and that had not happened. She stated she thought she had not seen the pulmonologist in almost a year. She stated she had asked several people and had not yet received an answer. During an interview with the unit secretary on 11/16/2016 at 7:40 AM, she stated she had recently been assigned the task to coordinate resident's outside appointments for the facility. She stated when a resident returned from an outside appointment, she would be notified by an email from the Unit Manager if the resident needed a follow up scheduled. She stated she was not aware of any upcoming pulmonologist appointments for the resident. The secretary reviewed the appointment calender for 5/2016 and stated the resident was scheduled for a follow up appointment with the pulmonologist on 5/2/2016, and the calender stated the resident did not go as there was no transportation available. She continued to review the calender and stated she did not see that the 5/2/2016 appointment was rescheduled. She stated if there was no transportation available that day, the appointment should have been rescheduled. During an interview with licensed practical nurse (LPN) Assistant Unit Manager #6 on 11/16/2016 at 12:05 PM, she stated she was the Unit Manager for the resident's unit through 11/2016. She stated if transportation was not available for an appointment, she would expect to be notified and the resident's appointment would have been rescheduled. 10NYCRR 415.26

Plan of Correction: ApprovedJanuary 9, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample:
Resident # 17
The resident had the [MEDICAL CONDITION] appointment rescheduled and went to the appointment on 12/1/16. A review of the medical record revealed there was no other appoints in need of rescheduling. An appointment tracking log has been created to improve communication from nursing to the Unit Secretary?s and ensure appointments needing rescheduling are rescheduled timely.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
A review of cancelled appointments from the last three (3) months was conducted to ensure they were rescheduled appropriately.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s Appointment Scheduling policy was reviewed without revision and an appointment tracking log has been created to identify those appointments that need to be rescheduled. All Unit Secretary?s have been re-educated by the SDC on their responsibility to identify appointments needing to be rescheduled using the Appointment Tracking Logs and to ensure they are promptly rescheduled. Additionally, this education has been added to the new hire orientation for all Unit Secretary?s.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
The facility?s appointment tracking log will be reviewed monthly for three (3) months to ensure cancelled appointments are rescheduled promptly.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Director of Nursing

FF09 483.25:PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification and abbreviated surveys (NY 565), it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable well-being for 2 of 20 residents (Residents #17 and 20) reviewed for quality of care. Specifically, Resident #20 had laboratory (lab) blood work drawn and the facility did not ensure the system to consistently monitor lab values was implemented to ensure appropriate care and services were rendered. Resident #17 was planned to have legs wrapped and a wrist splint and was observed without them. Findings include: The facility Lab Test Ordering and Monitoring policy dated ,[DATE] included: - The nurse manager/supervisor would fill out the daily lab worksheet, and a a copy would be provided to the nurse practitioner. - The nurse manager/supervisor would review the lab results with the physician/nurse practitioner, and check off on the daily lab work sheet. - Nursing staff would document all lab results and communication with the physician/nurse practitioner related to labs in the progress notes. The policy included a copy of the Daily Lab Work Sheet, which was a sheet of paper with a table with four columns. The columns were entitled: Resident, Labs Ordered, Received?, and MD/NP (medical doctor/nurse practitioner) reviewed? There was a space at the top of the table for the date. 1) Resident #20 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. The resident had additional active [DIAGNOSES REDACTED]. The MDS documented the resident's life expectancy was greater than 6 months. The nursing progress note dated [DATE] documented the physician was in to assess the resident after a fall. New orders were posted, including [MEDICATION NAME] ([MEDICATION NAME], a diuretic/water pill) x 1 now, and then daily. The physician orders [REDACTED]. The physician orders [REDACTED]. The ,[DATE] MAR (Medication Administration Record) documented the resident received 20 mg [MEDICATION NAME] on [DATE] and [DATE]. The hard copy of the resident's lab results dated [DATE] at 8:03 AM documented: - Potassium level was high at 5.9 mEq/L (milliequivalents/Liter, unit of measure) (normal = 3.5 - 5.1). - Sodium level was critically low at 119 mEq/L (normal = 136 - 145). The printed font of the sodium level was in bold font, and the letters LP were listed after 119. - Chloride level was low at 84.0 mEq/L (normal = 98.0 - 107.0). The physician orders [REDACTED]. A BMP was ordered to be drawn on [DATE]. The facility investigation documented that on [DATE] at approximately 8:00 AM, Resident #20 was treated for [REDACTED]. During the investigation, the Director of Nursing (DON) was notified at approximately 2:20 PM by registered nurse (RN) Nurse Manager #15 that there was an identified issue between the early morning verbal report she had received from the lab (with a low value), and the hard copy of the lab report that was sent over (with a high value). The facility investigation documented the following timeline for [DATE]: - Around 8:00 AM, RN Nurse Manager #15 received a call from the lab to report a critical value for potassium at 2.9 for Resident #20. - RN Nurse Manager #15 immediately notified the nurse practitioner (NP) #17 of the lab value. - NP #17 stated she assessed Resident #20 immediately and place a one-time order for potassium chloride 40 mEq and notified licensed practical nurse (LPN) #16 of the new order. - LPN #16 administered the potassium chloride to the resident. - At 2:00 PM, NP #17 was completing her rounds and assessments of residents in the facility and did a follow-up on the lab results for Resident #20. It was then the NP discovered that the hard copy of the resident's lab results showed a potassium level of 5.9 for the resident that morning. - The NP went to assess Resident #20, and during NP #17's assessment, the resident went into [MEDICAL CONDITION] and CPR (cardiopulmonary resuscitation) was initiated. RN Nurse Manager #15's Employee Statement dated [DATE] documented that at approximately 8:00 AM that day, the lab called to report a critical lab value for Resident #20, which was a potassium level of 2.9. RN Nurse Manager #15 documented that she notified NP #17, who was on the unit. At approximately 2:20 PM, RN Nurse Manager #15 received a phone call from the NP, who stated she received the (hard copy) lab report for the resident and her potassium level was 5.9, not 2.9. At 2:30 PM, RN Nurse Manager #15 went to the resident's room. The resident was sitting up in bed, her eyes were closed, and her hands were cyanotic (bluish tint). The NP requested the process to be started to transfer the resident to the emergency department (ED). The hospital ED and Medical Decision progress notes dated [DATE] documented the resuscitative efforts were halted at 3:27 PM, as it appeared the resident had no meaningful response to endotracheal intubation (insertion of a flexible tube into the trachea to maintain an airway), defibrillation (electric shock to the heart), 3 doses of [MEDICATION NAME] (vasoconstrictive, increases cardiac output), and at least 45 minutes of resuscitative support. The resident was pronounced dead at 3:27 PM. NP #17's typed statement for [DATE] documented: - Around 8:00 AM, the resident was seen for skin rounds. - About 8:15 AM, the NP was notified by RN Nurse Manager #15 that she received a call from the lab that the resident's potassium was 2.9. - The NP ordered 40 mEq potassium chloride for the resident and it was administered at 8:30 AM by LPN #16. - The NP texted the physician at 8:24 AM and notified him of Resident #20's low potassium, the medication ordered, a repeat BMP for [DATE], and that the resident gained weight and it would be rechecked on this date. The NP documented the physician thanked her, and gave no further orders. - The NP asked RN Nurse Manager #15 for the actual copy of the resident's lab report during morning report and RN Nurse Manager #15 did not yet have it. - Between 2:00 PM - 2:10 PM, the NP approached RN Nurse Manager #15 in the first floor office about the resident's lab results. RN Nurse Manager #15 looked through her papers and stated that the report was on her desk on the third floor. The NP went to the third floor and reviewed the labs, and discovered the verbal lab report from the morning was wrong. - The NP called RN Nurse Manager #15 to verify the report, and RN Nurse Manager #15 stated the potassium was 2.9. - The NP stated the resident's sodium was 119, a panic low value, and the resident was assessed. The fax Transmission Verification Report for the resident's [DATE] lab values was dated [DATE] at 8:24 AM. The report was initialed and copy was written on the report. On [DATE] at 4:30 PM, the DON stated the initials and handwriting were those of the NP. The facility investigation concluded that the phone call received from the lab on [DATE], stating that the resident's potassium level was 2.9, resulted in the ordering and administration of the potassium supplement. Additionally, the printed lab results were not reviewed timely, until after 2:00 PM on [DATE]. During an interview with RN Nurse Manager #15 on [DATE] at 10:15 AM, she stated: - She went to look for the hard copy of the resident's lab results prior to going to morning report scheduled for 9:00 AM, and the labs were not on the unit. - The procedure for lab results was that the labs were faxed to the fax machines on the units, and if there was a problem with the fax machine, the results defaulted back to the fax machine on the first floor. - She was told the fax machine on the unit was out of toner. - The telephone result she was provided for the resident's potassium was 2.9, and there was no way that she misunderstood the value, as she repeated it back. - She requested a faxed copy, and provided the lab the fax number, not knowing the fax machine was not working. - She was notified by NP #17 that the hard copy of Resident #20's lab results was on her desk. - She did not follow the facility's Lab Test Ordering and Monitoring policy and there was no Daily Lab Work Sheet filled out for [DATE]. During an interview with NP #17 on [DATE] at 3:11 PM, she stated she saw the resident three times on [DATE]. The NP stated that she was informed by RN Nurse Manager #15 that Resident #20's potassium was 2.9, and supplemental potassium was ordered and administered. The NP stated she wanted to see the hard copy of the resident's labs, as there might be other things going on with the resident that could be identified by looking at the other lab values. The NP stated she ordered potassium for the resident and was told it was administered at 8:30 AM. The NP stated at 8:34 AM, she texted the physician to see if there was anything else he wanted for the resident. The NP stated she asked RN Nurse Manager #1 prior to morning report if she had the hard copy of the labs, and she did not. The NP stated she proceeded with her day. She saw RN Nurse Manager #15 sitting in the office, who informed her there were a lot of lab reports upstairs. The NP stated she went upstairs, reviewed the resident's labs, and identified the resident's potassium was 5.9. The NP stated that when she saw the resident's labs, she knew the resident needed to be sent to the hospital, as the resident's sodium was low and the facility could not properly administer the resident fluids. The NP described the lab reports she found as a loose pile of papers next to the computer. The physician stated during an interview on [DATE] at 4:00 PM, there was no proof that the resident's potassium level caused the death of the resident, as a potassium of 5.9 is not life-threatening, and her sodium level was more critical. The DON stated during an interview on [DATE] at 4:30 PM, the process for receiving labs was that the Receptionist received the labs via fax from the lab between 8:00 AM - 8:30 AM, and then faxed them to the respective units. The DON stated the Receptionist received confirmation that the fax that was sent (with the resident's lab results) was received. It was later discovered that something on the fax was not working on Resident #20's unit, and the fax did not print. The DON stated the toner cartridge was out. When asked how this happened, the DON stated she did not know, as she had a supply person who keeps an eye on it. The DON stated she did not know anything about faxes defaulting to the first floor if they did not go through. During an interview with the facility Receptionist on [DATE] at 3:06 PM, she stated that the process for lab faxes was that the fax would be sent to her, and she would fax the results to the units. The Receptionist stated she did not know if a fax did not go through if it defaulted back to the first floor. During an interview with the Administrator on [DATE] at 11:10 AM, he stated he was not aware there was a problem with the unit's fax machine until the incident occurred with Resident #20. 2) Resident #17 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition and required extensive assistance with dressing, toileting, personal hygiene, and bathing. LEG WRAPS Physician orders [REDACTED]. Wrap the right upper leg only with one foam roll. Remove the wraps daily at 5:30 AM to have them washed, and re-apply at 10:00 AM. The comprehensive care plan (CCP) dated [DATE] documented the resident required ACE (compression) wraps applied daily to both lower legs to help control excess fluid accumulation. She required assistance with the leg wraps, as she could not do them herself. The ,[DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On [DATE] at 4:50 PM, the resident was observed in bed without the wraps on her legs. The resident stated frequently the leg wraps were not put on by the nurse, as the nurse would tell her she did not have time to do them. The resident stated frequently the certified nurse aides (CNAs) would put them on her and they were supposed to be applied by the nurse. She stated she needed the leg wraps to get out of bed, as the wraps controlled the swelling and provided her with protection against the metal on the wheelchair. During an interview with licensed practical nurse (LPN) #4 on [DATE] at 1:15 PM, she stated when she applied the leg wraps to the resident it was a lengthy process, and on [DATE] she did not have time to apply them. HAND SPLINT A nursing progress note dated [DATE] documented the nurse practitioner (NP) saw the resident for complaints of left wrist pain and swelling. There was a new order obtained for a registered nurse (RN) to apply a padded splint in the morning, apply ACE wrap daily, and the LPN could remove it at bedtime (8:00 PM). The physician order [REDACTED]. The ,[DATE] MAR indicated [REDACTED] - On [DATE], the RN was to apply padded splint to the right wrist and the LPN would remove at 8:00 PM, and will re-evaluate splint for effectiveness on [DATE]. - On [DATE], the order for the padded splint to the right wrist was re-initiated at 8:23 AM to be applied at 9:00 AM by an RN and removed by an LPN. There was no documented evidence the splint was applied at 9:00 AM. - On [DATE] at 9:00 PM, an LPN documented the removal of the right wrist splint was not performed. On [DATE] at 4:50 PM, the resident was observed in bed without a splint on her right hand. The resident stated she had pain in the right hand from tendinitis and the splint helped control the pain. She stated the splint had not been applied over the weekend and had not been done that date either. She stated there was not an RN on during the weekend, so it was not completed. The NP note dated [DATE] documented an RN would wrap the resident's right wrist daily with a splint and ACE bandage, which would be applied in the morning and removed at bedtime. During an interview with RN Unit Manager #1 on [DATE] at 1:45 PM, she stated the resident received a splint on the right arm to control pain and tingling she experienced. She stated she spoke with the resident the week before, and the resident had reported to her the splint was helping with the pain. She stated the order was discontinued on [DATE] (Friday) and re-initiated by the NP on [DATE] (Monday), as there was not an RN to apply the splint over the weekend. She stated she did not know why it had not been applied on [DATE]. During an interview with the NP on [DATE] at 2:05 PM, she stated the order for the right arm splint was discontinued on [DATE], as there was not an RN to apply the splint on the weekend. 10NYCRR 415.12

Plan of Correction: ApprovedDecember 8, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample:
Resident # 17
A physician assessment has been conducted and there has been no negative outcome from the lack of applying lower extremity leg wraps or right hand splint.
The right hand tendinitis has resolved and the splint has been discontinued.
LPN #4 has received disciplinary action for failing to follow a physician order [REDACTED].
Resident #20
A full investigation has been completed related to the incident involving potassium lab values reported to the facility for this resident on 7/11/16. The toner cartridge was replaced immediately when it was noted to be empty and a maintenance check was conducted to ensure proper functioning.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
All MARs for leg wraps and hand splints have been reviewed to ensure there is documentation to indicate they are being applied. Observations have been conducted to ensure all leg wraps and hand splints are applied as ordered.
During the above noted investigation for Resident #20, the past 30 days of lab reports were reviewed to ensure appropriate orders were obtained as indicated.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s Medication Administration policy has been reviewed without revision. All licensed nurses have been re-educated on this policy with emphasis on their responsibility to apply leg wraps and splints per physician order [REDACTED].
The facility?s Lab Test Ordering and Monitoring policy was reviewed and revised to include instruction for all verbal lab results to be reported to two (2) staff members to ensure accurate communication and documented on the Reported High/Low Panic Lab Value form. All licensed nurses have been educated on the revised Lab Test Ordering and Monitoring policy.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Five (5) random audits will be completed weekly for one (1) month and then monthly for two (2) months to ensure leg wraps and hand splints are applied per the physician order.
All verbal laboratory results documented on the High/Low Panic Lab Value form will be compared to the hard copy report daily for three (3) months to ensure accuracy.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Director of Nursing

FF09 483.20(d)(3), 483.10(k)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey, it was determined for 1 of 19 residents (Resident #17) reviewed for care planning, the facility did not offer the resident the right to participate in the planning of care. Specifically, Resident #17 was not provided with appropriate accommodations to attend her comprehensive care plan (CCP) meeting. Findings include: Resident #17 had [DIAGNOSES REDACTED]. The CCP initiated on 9/17/2014, active in 9/2016, documented the resident had the potential for discharge planning; had the ability to make care decisions; was alert and oriented to person, place, and time; and continued to make decisions in her daily plan of care. The CCP updated on 5/19/2015 documented to encourage the resident to set her own goals and adhere to them and provide education to the resident and her family/friends. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and she required extensive assistance for most activities of daily living (ADLs). The social service progress note dated 9/8/2016 documented the interdisciplinary team met for the resident's quarterly care conference. It did not document the resident was in attendance for the meeting. During an interview with social worker #14 on 11/16/2016 at 12:35 PM, she stated the resident was not present for her CCP meeting, as her wheelchair did not fit through the conference room door. The social worker stated she could not remember why the CCP meeting was not held in the resident's room. The social worker also reported staff were supposed to follow up with the resident after the meeting. She stated she was not sure if the resident's health care proxy was invited to the meeting. She stated she would follow up with the resident and her family regarding the outcome of the 9/8/2016 CCP meeting. During interview with the resident on 11/16/2016 at 1:00 PM, she stated she was unaware the CCP meeting was held in 9/2016, and stated there was no follow-up with her or her health care representative. The resident stated staff were supposed to reschedule the CCP meeting and let her know when that would be held. She stated this had not occurred to date, and if the CCP meeting was held on 9/8/2016, it was without her. 10NYCRR 415.11(c)(2)(ii)

Plan of Correction: ApprovedJanuary 9, 2017

I. The following actions were accomplished for the residents identified in the sample:
Resident # 17
A CCP meeting was held on 12/15/16 with resident #17 in attendance.
A wheelchair has been provided that allows entrance into all facility doorways.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
A review of all the most recent CCP Invitations has been conducted to ensure each resident/representative was offered the right to participate in the planning of care. No other residents were identified.
III. The following system changes will be implemented to assure continuing compliance with regulations:
All Social Workers have been re-educated by the Staff Development Coordinator on the facility?s responsibility to allow residents/representatives to participate in the CCP meetings and their responsibility to issue written CCP Invitations prior to the meeting informing the resident/representative of their right to participate in the planning process, the date/time of the care conference and the facility contact information if they are unable to attend but request follow-up after the care conference. Social Workers have been re-educated on their responsibility to contact those residents/representatives requesting follow-up and document outcomes in the medical record.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
All CCP Invitations will be audited monthly for three (3) months to ensure each resident/representative was offered the right to participate in the planning of care.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Director of Nursing

FF09 483.25(k):TREATMENT/CARE FOR SPECIAL NEEDS

REGULATION: The facility must ensure that residents receive proper treatment and care for the following special services: Injections; Parenteral and enteral fluids; Colostomy, ureterostomy, or ileostomy care; Tracheostomy care; Tracheal suctioning; Respiratory care; Foot care; and Prostheses.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not ensure 1 of 1 residents (Resident #4) reviewed for oxygen use received proper treatment and care related to specialized services. Specifically, the facility did not adequately monitor and ensure Resident #4 received the correct liter (L) flow of oxygen at the specified time. Findings include: Resident #4 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) initiated 9/2/2015 documented the resident had cardiovascular disease, and interventions included to administer oxygen as ordered. Resident nursing instructions dated 7/11/2016 documented the resident used oxygen only at night. Physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. She required extensive assistance with dressing, personal hygiene and bathing, and she required oxygen therapy. The resident was observed in bed sleeping on 11/15/2016 at 8:05 AM. The resident had a nasal cannula placed in her nares and the oxygen concentrator was delivering 4L of oxygen. The resident was observed in bed sleeping on 11/16/2016 at 7:20 AM with the nasal cannula in place and the oxygen concentrator was delivering 4L of oxygen. During an interview with certified nurse aide (CNA) #2 on 11/16/2016 at 7:32 AM, she stated the CNAs were not allowed to touch the resident's oxygen, and it was managed by the licensed practical nurses (LPNs). On 11/16/2016 at 1:40 PM, the resident was observed in bed sleeping with the nasal cannula in place and the oxygen concentrator delivering 4L of oxygen. Registered nurse (RN) Unit Manager #1 was present and stated she would check the resident's physician orders. LPN #3 was interviewed on 11/16/2016 at 1:40 PM and stated she did not apply the resident's oxygen on her when she went to bed and thought it may have been the other nurse on the unit. LPN #4 was interviewed on 11/16/2016 at 1:42 PM and stated she did not put the resident's oxygen on her and had not been near the resident's room. During an interview with RN Unit Manager #1 on 11/16/2016 at 1:52 PM, she stated it was the responsibility of the LPN to turn the oxygen on and off for residents and ensure the oxygen was delivered at the ordered dose. She stated the CNA had applied the oxygen on the resident when she put her down for a nap, and the resident was only supposed to have the oxygen on at night. She stated when the oxygen was in place, the resident was to receive 2L of oxygen as ordered by the physician. 10NYCRR 415.12(k)(6)

Plan of Correction: ApprovedDecember 8, 2016

I. The following actions were accomplished for the residents identified in the sample:
Resident #
The resident?s oxygen flow was adjusted to 2L as ordered when identified to be at 4L. The resident experienced to negative outcome.
The CNA that applied the oxygen was educated on the facility?s policy to have oxygen applied by a licensed nurse.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
An audit was conducted on all residents receiving oxygen to ensure it is being administered as directed by the physician.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s Oxygen Administration policy was reviewed without revision. Licensed nurses have been re-educated on this policy with emphasis on their responsibility to ensure oxygen is being administered during their shift as directed by the physician. CNAs have been re-educated on this policy with emphasis on oxygen only being applied by the licensed nurse.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Five (5) random audits will be conducted weekly for one (1) month and then monthly for two (2) months to ensure oxygen is being administered as ordered by the physician.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Director of Nursing

FF09 483.25(a)(2):TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS

REGULATION: A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 1 of 12 residents (Resident #17) reviewed for activities of daily living (ADLs), the facility did not ensure residents were given appropriate treatment and services to maintain or improve their ADL abilities. Specifically, Resident #17 was not assisted getting shoes timely and the resident was unable to ambulate as planned. Findings include: Resident #17 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 10/14/2015 documented to ensure the resident had adequate footwear. The physician progress notes [REDACTED]. The 7/1/2016 physical therapy (PT) quarterly assessment documented the resident was unable to propel her wheelchair because of her size and the size of the wheelchair. The PT note documented the resident was waiting for custom made shoes and would need skilled PT once the resident received her shoes. A nursing progress note dated 8/10/2016 documented the orthotics company was contacted to see if they could provide services. The face sheet had been faxed to them for review regarding the resident's need for custom fitting shoes to aid in her ambulation. A nursing progress note dated 8/16/2016 documented a representative of the orthotics company would be in the facility to size the resident for properly fitting shoes on 9/23/2016. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. She required total dependence on staff for locomotion on and off the unit, and limited assistance walking in her room and in the corridor. A nursing progress note dated 9/26/2016 documented Hangar Orthotics was in last week to do casts of bilateral feet and ankles and would then make shoes to assist the resident with ambulation. The CCP updated 10/6/2016 documented the resident remained on program for transfer, would allow certified nurse aides (CNAs) to transfer her once in a while, and she would not ambulate with the CNAs as scheduled as she was still waiting for her shoes. A nursing progress note dated 10/11/2016 documented the resident had not been transferring or ambulating with the CNAs that month, due to it not being safe as she could not walk until she got her shoes. The note documented the shoes had been ordered. The social services progress note dated 10/25/2016 documented a discharge planning meeting was conducted 10/24/2016, and the resident was still waiting for her shoes. During an interview with the resident's health care proxy (HCP) on 11/14/2016 at 4:30 PM, she stated the resident had been waiting several months to get the proper shoes so she would be able to walk and be discharged . During an interview with the resident on 11/15/2016 at 9:00 AM, she was observed in bed without any socks or shoes on. She stated she had been waiting seven months for the facility to get her the proper shoes so she would be able to safely walk. She stated the shoes she had now were too soft and did not provide her feet with any support. During an interview with the Director of Activities on 11/16/2016 at 9:40 AM, she stated the resident was not able to attend some of her activities of choice, as her wheelchair was too wide to fit through some of the doorways of the facility. She stated the PT department was working on getting her new shoes so she would be able to walk into the room where the activity was held. During an interview with the Director of Rehabilitation on 11/16/2016 at 9:50 AM, she stated the resident required shoes that provided ankle support. She stated the original orthotics company had sent the wrong ones and they were currently working with another company. She stated the resident would be receiving skilled PT for ambulation once the resident's shoes arrived. During an interview with licensed practical nurse (LPN) Assistant Unit Manager #6 on 11/16/2016 at 12:05 PM, she stated she was the Unit Manager for the resident's unit until two weeks ago. She stated the plan for the resident was once she got the correct shoes, she would be more mobile and be able to be discharged back into the community. During an interview with social worker #14 on 11/16/2016 at 12:35 PM, she stated she had been working on getting the resident her shoes for about 4 months. She stated the original orthotics company sent the wrong ones, and she went back and forth with that company several times. She stated that they then just went with another company, which was in the process of making the correct shoes. 10NYCRR 415.12(a)(2)

Plan of Correction: ApprovedDecember 8, 2016

I. The following actions were accomplished for the residents identified in the sample:
Resident # 17
New shoes have been obtained to promote ambulation and PT for ambulation was provided.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
A review of all residents has been conducted and there are no other residents in need of shoe orthotics.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility has developed a relationship with a new orthotics company to prevent future delays in obtaining shoe orthotics for residents.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
All ordered shoe orthotics will be audited weekly for the next three (3) months to ensure they are obtained timely.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Director of Nursing

FF09 483.25(c):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 2 of 5 residents (Residents #4 and 7) reviewed for pressure ulcers, the facility did not ensure care was provided that prevented residents from developing pressure ulcers and/or did not ensure residents with pressure ulcers received the necessary treatments and services needed to promote healing and prevent pressure ulcers from worsening. Specifically, Resident #4 had a skin impairment identified and there was no documented evidence the impairment was assessed by a qualified professional and a treatment to promote healing was implemented timely. Resident #7 developed pressure ulcers they were not assessed by a qualified professional, and treatment to promote healing was not implemented timely. The weekly skin assessments were inconsistent and it was unclear if the resident had preventative pressure relief in place prior to the development of the pressure ulcers. Findings include: 1) Resident #4 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) effective 9/2/2015 documented the resident was at risk for skin breakdown related to decreased mobility. Interventions included the certified nurse aide (CNA) would complete a skin evaluation daily during care and report any abnormalities to the nurse, and turn and reposition every 2 hours while in bed. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and she required extensive assistance with most activities of daily living (ADLs). The MDS documented the resident did not have any pressure ulcers and was at risk for the development of pressure ulcers. A licensed practical nurse (LPN) progress note dated 9/21/2016 at 9:55 AM documented he was notified by a CNA the resident had an open area on her bottom that contained a small amount of red drainage. There was no documented evidence the resident's open area was assessed by a qualified professional, the physician was notified, or a treatment order was obtained until 9/26/2016. A nursing progress note written by registered nurse (RN) Supervisor #7, dated 9/26/2016, documented the resident was seen by the skin team for shearing to her right buttock that measured 6.6 centimeters (cm) x 3.2 cm. The base of the wound contained 50% granulation tissue (pink healing tissue), 25% slough (moist dead tissue) and 25% necrotic tissue (dead black tissue). The treatment initiated was to apply Santyl (enzymatic [MEDICATION NAME] ointment) to the wound bed and covered with a protective dressing daily. A skin tracking sheet initiated on 9/26/2016 documented the resident had shearing to her right buttock that measured 6.6 cm x 3.2 cm. The base of the wound contained 50% granulation tissue, 25% slough, and 25% necrotic tissue. Preventative measures included turning and repositioning. During a skin observation on 11/16/2016 at 7:32 AM, the resident was assisted onto her left side with the assistance of 2 CNAs. The resident had a reddened intact area on her right buttock. While pointing to the reddened area on the right buttock, CNA #2 stated that was where the area used to be. During an interview with LPN #5 on 11/16/2016 at 11:58 PM, he stated he would report any skin breakdown to the nursing supervisor. He stated he remembered finding the area on the resident's right buttock, and could not remember if he notified the nursing supervisor. He stated he may not have. During an interview with LPN Assistant Unit Manager #6 on 11/16/2016 at 12:05 PM, she stated she would expect the LPNs to notify the Unit Manager or nursing Supervisor if any skin breakdown was observed. She stated an assessment would be completed by the RN, a skin tracking sheet would be initiated, the physician would be notified, and a treatment order would be obtained. During an interview with the 2 PM - 10 PM RN Supervisor #7 on 11/16/2016 at 12:25 PM, he stated if an LPN observed skin breakdown during his shift, he would expect to be notified. He stated he would assess the skin and document his assessment, call the physician, and initiate a treatment. He stated he assessed the area on the resident's buttocks on 9/26/2016 during skin rounds. He could not remember how he was notified the resident had an area on her buttock. He stated the area was not pressure related as it was shearing. 2) Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired and he required extensive assistance for all activities of daily living (ADLs) except for eating. The MDS documented the resident did not have any weight loss and did not have any pressure ulcers. The resident was at risk for the development of pressure ulcers and required pressure reducing device for bed and chair. The Braden scale assessment dated [DATE] documented the resident was at moderate risk to develop pressure sores. The Wound and Skin Record dated 9/10/2016 documented the resident had an Unstageable pressure ulcer (full thickness skin loss) in the left heel area. A physician order [REDACTED]. A late entry dietary weekly skin note dated 9/23/2016 documented the resident was seen by the skin team the week before and during the current week, and had an Unstageable pressure ulcer on his left heel. There was no documentation that a complete and thorough assessment of the pressure ulcer on the left heel was completed by a qualified professional. The 9/27/2016 dietary weekly skin note documented the resident was seen on skin rounds and the Unstageable pressure ulcer on the left heel was worse. There was no documentation that a complete and thorough assessment of the pressure ulcer on the left heel was completed by a qualified professional. An update to the certified nurse aide (CNA) care instructions dated 10/6/2016 at 2:56 PM documented the resident was to be turned and positioned every 2 hours daily. The dietary note dated 10/7/2016 documented the resident was seen by the skin team and the Unstageable pressure ulcer on the left heel had worsened. There was no documentation that a complete and thorough assessment of the pressure ulcer on the left heel was completed by a qualified professional. A licensed practical nurse (LPN) progress note dated 10/24/2016 at 1:35 PM documented while the CNA was assisting with care, the resident was found to have two open areas on his sacrum (lower back area). A border foam dressing was applied per nurse manager. Will continue to monitor. There was no documented evidence the area was assessed by a qualified professional and a complete and thorough assessment of the open areas on his sacrum was completed. There was no documented evidence a treatment was ordered until 10/27/2016 to promote healing of the two open areas. An RN progress note dated 10/27/2016 documented the resident was seen for wounds on coccyx (tailbone area) and the nurse practitioner (NP) was in to assess the resident for his Stage II (partial thickness skin loss) pressure area. A new order was received for Hydrogel (moist absorbent dressing) and a dry sterile dressing (DSD) daily and as needed (prn). The note also documented an air mattress was placed on the bed and a positioning wedge was put in place. A physician order [REDACTED]. CNA care instructions updated 10/28/2016 documented to place a Vector cushion (adjustable for skin protection and positioning) in the Broda chair (tilt and recline positioning wheelchair) with Dycem (non-slip material) under the cushion for pressure relief and comfort. The occupational therapy (OT) progress note dated 10/28/2016 documented the resident had an open area on his sacrum and a Vector cushion was added to his Broda to assist with wound healing. OT recommended to continue using the air mattress and positioning wedge to promote side-lying for assisting with wound care. A skin tracking sheet initiated on 11/2/2016 documented the resident had: - An Unstageable pressure ulcer on his left outer foot measuring 1.5 centimeters (cm) x 1 cm and N/A was documented under the section asking if the pressure ulcer had worsened; - A Stage II pressure ulcer on his coccyx that measured 1.5 cm x 0.5 cm; and - An Unstageable pressure ulcer on his left heel that measured 0.9 cm x 0.9 cm and the wound bed contained black/necrotic tissue. During a skin observation on 11/16/2016 at 10:38 AM, the resident had a Stage II pressure ulcer on his coccyx that measured 1.5 cm x 0.5 cm x 0.5 cm. The wound bed was moist and pink and the surrounding skin was macerated (moisture-damaged). On the left outer heel, the resident had a deep tissue injury that measured 1.0 cm x 1.0 cm and the skin was intact. On the left outer foot, there was an Unstageable pressure ulcer that measured 4.0 cm x 1.5 cm and the wound bed was partially covered with black necrotic tissue. The Director of Nursing (DON) stated during the observation there was a lapse in the documentation, as the weekly skin rounds were not being completed because they did not have an NP until just recently. The DON stated she thought the air mattress, heel booties, and the turning and repositioning schedule was initiated after the resident developed the pressure ulcers. During an interview with LPN Assistant Unit Manager #6 on 11/16/2016 at 12:05 PM, she stated she would expect the LPNs to notify the Unit Manager or Nursing Supervisor if any skin breakdown was observed. She stated an assessment would be completed by the RN, a skin tracking sheet would be initiated, the physician would be notified, and a treatment order would be obtained. During an interview with RN #7 on 11/16/2016 at 12:25 PM, he stated if an LPN observed skin breakdown during his shift, he would expect to be notified. He stated he would assess the skin and document his assessment, call the physician, and initiate a treatment. He stated he assessed the area on the resident's buttocks on 9/26/2016 during skin rounds and could not remember how he was notified the resident had an area on her buttock. He stated the area was not pressure related as it was shearing. 10NYCRR 415.12(c)(1)(2)

Plan of Correction: ApprovedJanuary 3, 2017

I. The following actions were accomplished for the residents identified in the sample:
Resident # 4
As noted on the CMS-2567, the skin area on the right buttock has resolved.
LPN #5 has been re-educated on his responsibility to report any new areas of skin breakdown to the RN supervisor.
Resident # 7
A RN assessment has been completed on all current areas of skin breakdown, current treatments are in place for the left heel, left lateral foot and the sacral wound is healed. The care plan to prevent skin breakdown has been reviewed and updated.

II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be effected by this practice:
All residents have received a full body skin assessment by a Registered Nurse to ensure all areas of breakdown are identified and properly assessed by a qualified professional, areas of breakdown are documented on a Weekly Skin Tracking sheet, and and current physician treatment orders and care plans are in place.
All resident care plans have been reviewed to ensure preventative skin measures are in place to promote healing.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s Skin Integrity policy has been reviewed and revised to include a Pressure Investigation form to determine if preventative pressure ulcer relief interventions were in place prior to the development of the pressure ulcer and a Wound Assessment/Notification form to document that a RN assessment has been complete, the treatment was initiated timely and the plan of care has been updated.
The DON has been re-educated by the Administrator on the revised Skin Integrity policy and her responsibility to complete a Pressure Ulcer Investigation on all new nosocomial pressure ulcers to ensure preventative measures were in place.
All RNs have been re-educated by the Staff Development Coordinator (SDC) on their responsibility to complete a Wound Assessment/Notification form for all new pressure ulcers documenting their initial assessment, that the treatment was initiated and the plan of care has been updated.
All RNs have been re-educated by the SDC on their responsibility to complete weekly assessments for all pressure ulcers and document the assessment on the Weekly Skin Tracking sheet.
All LPNs have been re-educated by the SDC on their responsibility to report any new areas of skin breakdown to the RN supervisor/nurse manager.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Pressure Ulcer Investigations and Wound Assessment/Notification forms for all new nosocomial pressure ulcers will be reviewed daily (Monday-Friday) for three (3) months during morning meeting to ensure compliance with the facility?s revised policy.
Weekly Skin Tracking sheets will be audited weekly for three (3) months to ensure a RN assessment has been completed and treatments are in place to promote healing.
CNA documentation will be audited weekly for three (3) months to ensure all identified areas are reported timely to the RN supervisor to allow for assessment and treatment orders to be obtained.
Audit results will be reported to the QA Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: 1/6/17
Responsibility: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 18, 2016
Corrected date: January 6, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure all exit discharges provided a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation for 1 of 6 exits (ground floor/adult day care exit stairwell). Specifically, the ground floor/adult day care exit stairwell exterior exit discharge pathway was too steep/not level. Findings include: On 11/18/2016 at 4:50 PM, a surveyor observed that the ground floor/adult day care exit stairwell exterior exit discharge pathway, which was a means of egress for the ground floor and the adult day care program, was not a level walking surface with respect to changes in elevation. The slope perpendicular to the direction of travel had a steeper ratio then the required 1 inch rise to 4 foot run, a 2% grade. The slope perpendicular to the direction of travel for this exit pathway was 1 foot rise to approximately 9 foot run, approximately an 11% grade. The height distance from exit door to bottom of pathway was 11 feet, and the distance from exit door to bottom of pathway was 96 feet. During an interview on 11/18/2016 at 4:57 PM, the Plant Operations Manager stated he did not consider the ground floor/adult day care exit stairwell exterior exit discharge pathway to be a level walking surface, and during fire drills and disaster drills he had never attempted to take a person with a physical disability down that pathway. During an interview on 11/18/2016 at 5:20 PM, the Administrator stated he could not ensure there would not be any persons with physical disabilities on the ground floor. 2012 NFPA 101 19.2.7, 7.1.7 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedDecember 30, 2016

The Administrator will engage with an outside professional to design and build a compliant plan which will meet the Code requirements for the adult day care exit stairwell exterior exit discharge pathway. Due to the upcoming change in season/weather, the anticipated date of completion will be (MONTH) 30, (YEAR). The Bureau of Architecture and Engineering Review (BAER) waiver form will be submitted for review on (MONTH) 3, (YEAR) by the Administrator via mail.
The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
The affected staff/residents will be specifically located within our Adult Day Health Care program. The exterior exit discharge pathway is considered a secondary exit and has not been used due to the slope and uneven surface.
The Director of Plant Operations and/or designee has kept the ground floor/ adult day care exterior exit discharge pathway free of debris in accordance with State regulations in the event of a fire or evacuation.
The Director of Plant Operations has completed exterior audit of all exit doors and respective pathways to ensure all surfaces are level and within the slope requirement.
The following system changes will be implemented to assure continuing compliance with regulations:
Upon completion of any physical plant renovations, recommended by outside contractors, which meets Life Safety Code regulations, the facility will initiate periodic fire drills using the ground floor/adult day care exit stairwell exterior exit discharge.
The Director of Plant Operations has educated all maintenance staff on keeping the exterior exit discharge pathway clear of obstructions in the event of a fire/evacuation.
The facility?s compliance will be monitored utilizing the following quality assurance system:
The facility has developed a QA audit tool to monitor and ensure all emergency exits all level and within the slope requirement are conducted on a monthly basis for three (3) months to ensure accuracy.
Audit results will be reported to the QA committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Responsible Party: Director of Plant Operations

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 18, 2016
Corrected date: January 6, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure all smoke barrier doors were smoke resistant for 1 of 8 smoke barriers observed (first floor north end smoke barrier). Specifically: the first floor north end smoke barrier double doors were not smoke resistant. Findings include: On 11/18/2016 at 11:35 AM, a surveyor observed the first floor north end smoke barrier double doors had a 1/8 inch gap between them, and were not smoke resistant. During an interview on 11/18/2016 at 5:05 PM, the Plant Operations Manager stated he thought the first floor north end smoke barrier double doors had less of a gap, and had he realized this issue, he would have installed a side sweep between the doors. 2012 NFPA 101 19.3.7.6 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedDecember 8, 2016

A door sweep was installed by maintenance 11-30-16 between the first floor north end smoke barrier double doors to correct the 1/8 gap inch gap noted.
The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
The maintenance has completed a full house audit of smoke barrier doors for any possible existing penetrations and none were found at this time.
The following system changes will be implemented to assure continuing compliance with regulations:
The Director of Plant Operations has educated all the maintenance staff on the smoke barrier doors.
The Director of Plant Operations will be conducting monthly audits to inspect all smoke barrier doors for gaps.
The facility?s compliance will be monitored utilizing the following quality assurance system:
The facility has developed a QA audit tool to monitor and ensure the checks for the smoke barrier doors are conducted on a monthly basis for three (3) months to ensure accuracy.
Audit results will be reported to the QA committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Responsible Party: Director of Plant Operations

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: November 18, 2016
Corrected date: January 6, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure that smoke barriers were constructed to a 1/2 hour fire resistance rating for 3 of 4 smoke barriers observed (second floor south barrier, third floor south barrier, and fourth floor smoke barrier). Specifically, these floors had unsealed penetrations. Findings include: On 11/18/2016 between 11:50 AM and 12:25 PM, a surveyor observed the following smoke barriers had unsealed penetrations: - The second floor smoke barrier over the double smoke doors had an unsealed 1/2 inch hole with a cable and three data wires passing through it. - The third floor smoke barrier over the double smoke door had an unsealed 1/2 inch hole with a cable and three data wires passing through it. - The fourth floor smoke barrier over the double smoke doors had an unsealed 1/2 inch hole with two cables and 11 data wires passing through it on one side of the barrier, and a 4 inch x 7 inch section of pushed in/damaged sheetrock on the other side. During an interview on 11/18/2016 at 5:10 PM, the Plant Operations Manager stated he was not aware of the unsealed holes in the observed smoke barrier walls. He stated that since the last federal survey on 9/1/2015, the facility had checked the smoke walls after wire installation and other work was completed. 2012 NFPA 101 19.3.7.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedDecember 8, 2016

The second, third, and fourth floor smoke barrier penetrations identified were immediately sealed on by the maintenance department on 11-16-16.
The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
The maintenance has completed a full house audit of fire walls for any possible existing penetrations and none were found at this time.
The following system changes will be implemented to assure continuing compliance with regulations:
The Director of Plant Operations has educated all the maintenance staff regarding smoke barrier penetrations.
The Director of Plant Operations and/or designee will be conducting monthly audits to include any areas that are interrupted by contract work or by the facility staff.
The facility?s compliance will be monitored utilizing the following quality assurance system:
The facility has developed a QA audit tool to monitor and ensure the checks for the smoke barriers are conducted on a monthly for three (3) months to ensure accuracy.
Audit results will be reported to the QA committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.
Responsible Party: Director of Plant Operations