Fieldston Lodge Care Center
October 25, 2017 Certification Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: January 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , staff interviews and record review , the facility did not ensure that a comprehensive person centered care plan that includes measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs was developed and implemented as evidenced by a resident with a physician's orders [REDACTED]. Resident # 64 . The finding is: Resident # 64 a admitted to the facility with Diagnoses: [REDACTED]. Review of the resident's medical record documented that on 08/23/2017 the resident was complaining of leg pains. The physician evaluated resident and ordered a Doppler study; a test that uses high-frequency sound waves to measure the amount of blood flow through your arteries and veins, usually those that supply blood to your arms and legs. The Doppler study of lower extremities was done and based on the results the physician ordered that an ace Velcro bandage be applied to bilateral lower extremities daily. Further review of the TAR ( treatment administration record ) from 08/30/2017 to 10/23/2017 reveals no documentation of the application of the ace bandage. The resident's current physician's orders [REDACTED]. Remove for hygiene and skin check . On 10/23/2017 at 12:00 PM the resident was observed in his room in bed dressed in hospital gown. He was observed with lower extremities slightly exposed with no ace bandage with Velcro. During the conversation, he stated I don't have any ace bandages. The MDS ( minimum data set ) assessment dated [DATE] identified the resident with a BIMS ( brief interview for mental status ) score of 15, alert , oriented to person, place and time. The resident requires assistance with 1 person with activities of daily living. Review of the comprehensive care plan reveals no documentation with measurable objective and time frame addressing the application of the ace bandage or the resident refusal of its application. The registered nurse unit manager (RN #1) was interviewed on 10/23/2017 at 4:46 PM. RN #1 stated, The resident refuses to use it. The CNA informed me he refuses it. RN#1 stated that there was no care plan written for the use of the ace bandage. She also stated that there is not documentation of the resident's refusal to wear ace bandage. 415.11 (c)(1)

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate corrective actions taken
A. Resident #64
1. As of 10/23/17, the resident was assessed by the RN Supervisor for need for use of ace bandage secondary to bilateral leg pains. The Nurse Practitioner (NP) was notified and performed evaluation on the resident. The order for ace bandage was discontinued by the Nurse Practitioner as the resident continued to refuse and that it was no longer indicated. He had no further complaint of leg pain. The resident remains with a score of 15 on (BIMS) brief interview for mental status and the discontinuation was discussed with him and he expressed understanding and agreement. This was reflected on his medical record.
2. The resident?s care plan on pain was reviewed and was updated to reflect the resident?s current status and the appropriate interventions. The care updated care plan also reflects the resident?s refusal and the measures in place to address his wishes.
3. As of 11/15/17, the nursing staff, licensed nurses and CNA's, were given in service regarding application of devices, ace bandage in particular, including proper documentation, care planning and addressing resident?s refusal to the application, if any.
II. Identification of other residents who have been potentially affected by the deficient practice and corrective actions to be taken
A. The Director of Nursing created a list of residents with physician orders [REDACTED]. The list will also be utilized for an audit on proper application of ace bandage on the residents, documentation on the residents medical records specifically treatment records or CNA accountability and the resident?s care plan.
Based on this list, the following will be done:
1. All residents with physician order [REDACTED].
a. If ace bandage is no longer clinically indicated, the order will be discontinued. Assessment findings will be documented on the resident?s medical records. The care plans of each of these residents will be reviewed and updated to reflect the resident?s actual and current status.
b. All residents with orders of ace bandage that will be determined to be clinically indicated will be individually observed if they are actually applied and signed off on the treatment record by the licensed nurse. Resident refusals will be documented and the Physician/NP/PA will be notified. The individualized care plans of each of these residents will be developed, reviewed and updated to reflect the indication of the ace bandage, the resident?s actual and current status and the interventions to address the refusal, if any.
2. Any identified non-compliance or deficient practice will be corrected accordingly based on facility policy.
3. A report will be presented during QA Committee meeting and a copy will be submitted to the Administrator.
III. Systemic changes to prevent recurrence of the same deficient practice.
A. The Director of Nursing will review, and revise if necessary, the facility?s policy and procedure on Comprehensive Resident Care Plans, to ensure that it is comprehensive, resident-centered and includes measurable objectives and time-framed to meet the resident?s medical and nursing and mental and psychosocial needs. The care plan should be individualized and specify the person responsible to carry out the intervention. Resident refusals to prescribed treatment or device, such as ace bandage, will be incorporated in the individualized care plan and will include measures to address the refusal. An in service will be given to the Interdisciplinary Team (IDT) members regarding this policy. Attendance record will be maintained on file for reference.
B. The Medical Director and Director of Nursing will also review, and revise if necessary, the facility?s policy and procedure on Physician order [REDACTED]. All physician-ordered treatments will be designated on the treatment flowsheet to be signed off by the administering licensed nurse. An in-service on this policy will be given to the physicians and licensed nurses. Attendance record will be maintained on file for reference.
IV. Monitoring of corrective actions to ensure the deficient practice will not recur.
A. The Director of Nursing will develop an audit tool to monitor compliance to the facility?s policy and procedure on Comprehensive Care Plans and Physician Orders, to ensure that the use of ace bandages and similar treatment devices are incorporated/included.
B. The audit will be conducted by the RN Managers/Supervisors monthly for three (3) months and then quarterly thereafter.
C. Any non-compliance identified will be corrected immediately.
D. Audit findings report will be presented to the Administrator and during the QA Committee meeting.
Responsible Person: Director of Nursing

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: January 2, 2018

Citation Details

Based on observations and staff interviews during the recertification survey, the facility did not ensure that housekeeping and maintenance services were provided to maintain a sanitary and orderly and comfortable environment. Specifically, multiple areas on mulitple units were observed with walls, ceilings, furniture and blinds in disrepair. This was evident on 4 of 5 units during Environmental Observations. (2nd, 3rd, 4th, and 5th). The findings are: Multiple observations were conducted from 10/18/17 to 10/25/17 and the following was observed: On Unit 2: Discolored, dirty walls were observed in the Nursing station. In room 207, the nightstand was observed with mismatched drawers and there was a large hole in the bathroom door. On Unit 3: Floors in the chart room were observed to be badly scuffed, and there were unpainted areas on walls in the medication and chart room. In room 301, walls were stained with a brownish substance and the wall paper was torn in places. In room 305, torn, uneven wallpaper was observed above the window. On Unit 4: Floors in chart room were observed to be badly scuffed, and there were unpainted areas on walls in the medication and chart room. In room 401, a plastered unpainted patch was observed on the wall near the ceiling. Broken window blinds were also observed and the call bell cord was stained with a brownish/blackish substance. In room 402, a closet door was observed to be broken and the handle was missing on one of the dresser drawers. In room 403, torn wallpaper was observed on the walls. In room 406, missing baseboards were observed and there were unpainted areas on the lower walls. In room 407, mismatched dresser drawers were observed and handles for the 2nd and 3rd drawer were only affixed on one side. In addition, the closet door could not be closed and the wood at the base appeared damaged. In room 409, bubbled paint was observed in several areas on the ceiling. In addition, unbroken, unmatched dresser drawers were observed near bed A. In room 411, a large unpainted area in entryway facing the bed was observed. In addition, there were mismatched dresser drawer, a chipped floor tile, a loose plate on radiator, and the radiator cover did not lay flush with the unit. In room 414 broken window blinds were observed. There was a plastered, unpainted area on the ceiling near the window and dried plaster was noted on the window curtains. In addition, a badly chipped dresser was observed near bed C. On Unit 5 the following was observed: Multiple areas on the 5th floor day room walls were peeling and cracked and in general disrepair. In addition, the left corner wall area of the day room was covered with a large piece of blue plastic. In room 501, chipped and mismatched dresser drawers were observed and dresser drawers had broken handles. In room 516, torn wallpaper was observed. On 10/19/17 at 12:09 PM, Resident # 1 who resides in room 402 was interviewed and stated that the room is not cleaned unless the resident requests it to be cleaned. Once requested, they are told it would be cleaned the following day. The resident also stated that staff has been informed about the closet and the dresser drawer on multiple occasions, but it has not been repaired. On 10/25/2017 at 11:45 AM, resident #240 who resides in room 411 was interviewed. The resident stated that the room was in this condition upon their admission to the facility two weeks ago. The resident stated that this was not discussed with staff as they should know what the room looks like. On 10/25/2017 at 11:59 AM, the housekeeper assigned to unit 4 was interviewed. The housekeeper stated that issues in the residents rooms are written in the book at the nursing station, and sometimes maintenance is notified directly. The housekeeper also stated maintenance had been notified about room 411, a sink had been removed and the walls and floors needed to be repaired. On 10/25/2017 12:05 PM, the Director of Environmental Services (DES) was interviewed and stated that some painting needed to be done throughout the facility. The DES also stated that items are repaired as the department becomes aware, and all staff are supposed to put issues in the log books at the nursing station. The DES stated that the log books are reviewed during rounds. The DES also stated that a company is supposed to be coming in to do work on the floors, they do not have a start date.

Plan of Correction: ApprovedDecember 1, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate corrective action taken:
1. As of [DATE], all immediate corrective actions to address housekeeping and maintenance issues identified during the DOH re-certification survey have been completed. Below is the summary of corrective actions taken:
a. On the 2nd floor
The walls of the nursing station were thoroughly cleaned with cleaning solution.
The nightstand draws in room 207 were remedied and the bathroom door was repaired.
b. On the 3rd floor
On [DATE] the floor of the chart room was stripped and waxed and the walls in the medication and chart room were painted.
In room 301 the walls were cleaned with cleaning solution and the wallpaper repaired.
c. On the 4th floor
On [DATE] the floor of the chart room was stripped and waxed and the walls of the medication and chart room painted.
The wall in room 401 was painted and the call bell cord cleaned with cleaning solution.
The closet door and dresser door handle in room 402 were repaired on [DATE].
The wallpaper in room 403 was repaired and baseboards were installed in room 406 and the lower walls painted.
The dresser in room 407 was repaired and remedied and the closet door repaired (and wood at base replaced).
The ceiling in room 409 was repaired and painted.
In room 411 the entryway wall was painted and the dresser, floor tile and radiator repaired.
On [DATE] new blinds were ordered from Home Depot for room 414. The ceiling near the window was painted and the window curtain was cleaned. On [DATE] the dresser for the C bed was remedied .
d. On the 5th floor
On [DATE] the day room wallpaper that was in disrepair was removed and the walls were painted. On [DATE] the Administrator contacted and contracted Prestige Point Design to update/renovate the day room including the walls. The blue plastic was removed from the left corner wall area of the day room.
The dresser in room 501 was repaired and remedied .
In room 516 the wallpaper was repaired.
2. The completion of the above actions was confirmed by the Administrator and the Environmental Services Director and inspected by our Directed Plan of Correction Consultant for compliance.

Identification of other residents who have been potentially affected by the deficient practice and corrective actions to be taken:
1. A facility-wide environmental rounds will be conducted done by the Administrator and Environmental Services Director to identify issues with sanitary, orderly and comfortable interior.
2. Results and findings of the environmental rounds will be recorded and filed for reference. Any non-compliance will be addressed and corrected by plan of correction date.
3. A report of all identified and corrected issues will be presented to the consultant to be inspected for compliance.

Systemic changes to prevent recurrence of the same deficient practice:
1. The Director of Maintenance and Housekeeping will perform daily rounds to check the communication book and ensure that recorded issues are addressed in a timely and satisfactory manner.
2. The job responsibilities and functions of the housekeeping and maintenance departments will be reviewed and revised to ensure that responsibilities are followed and ensure a sanitary and orderly and comfortable environment. All parties will be educated on the revisions and responsibilities.
3. All non-minor repairs will be recorded and presented to the Administrator to be spot inspected for compliance.
4. On [DATE] the Administrator contacted and contracted Prestige Point Design to inspect all wallpapers in the facility to assess and repair/replace, if necessary.
5. All maintenance and housekeeping employees will be given in-service education by the Directed Plan of Correction Consultant on the requirements of code 483.15(h)(2) Housekeeping and Maintenance Services as it pertains to job description and requirements of said staff.
6. The consultant will conduct competencies of all housekeeping and maintenance staff, and provide education and demonstration as part of the department?s general in-service program.
7. The Policy and Procedure for Housekeeping and Maintenance will be reviewed and revised, as needed. Additionally, the job descriptions for Housekeeping and Maintenance will be reviewed and revised, as needed.
Monitoring of corrective actions to ensure the deficient practice will not recur:
1. The Administrator will develop an audit tool to monitor compliance within the Housekeeping and Maintenance umbrella. The audit will be done by department head for three (3) months and quarterly thereafter. All identified non-compliance will be addressed and corrected accordingly. The findings will be presented to the QA Committee meeting and to the Administrator.
2. The Environmental Services Director will perform spot checks on remedied issues from communication book weekly for four weeks then monthly thereafter. Any issues not resolved satisfactorily will be readdressed and the responsible employee held accountable.
3. The findings will be presented to the QA Committee meeting and to the Administrator.
4. The Directed Plan of Correction Consultant will develop audit tools for an independent quarterly audit of the facility. His finding will be presented to the Administrator for review and will be presented to the QA Committee meeting.

Responsible Person: Environmental Services Director / Consultant
A copy of all requested documents, as well as a copy of this plan of correction has been mailed to the Department of Health.

FF10 483.90(i)(4):MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

REGULATION: (i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: January 2, 2018

Citation Details

Based on observations, record review and staff interviews during a recertification survey, the facility did not ensure an effective pest control program was maintained. Specifically residents and staff reported that roaches were observed several occasions in various places, like rooms, pantry areas and day rooms. Roaches were also observed by the State Agency (SA) during the initial tour of a resident's room. This was evident in Room 504 on Unit 5. Findings are: The facility policy on pest control dated 2/21/2017 documented that the facility will implement a program that will follow a comprehensive approach to pest control. The resident rooms should be treated while the resident is away. There were evidence of roaches in the resident's bedroom and no effective pest control in place. On 10/19/2017 at 12:30 PM, during the initial visit to the resident's room. The resident reported to the State Agency that there were roaches in the room. The resident further stated that she had reported the incident to the housekeeping staff several times, but nothing was done about it, and no exterminator ever visited her room. During the interview the SA observed a roach, crawling on the floor of the resident's room. The SA did not observe any traps or pest control devices in resident's room. On 10/24/17 at 1:00 PM an interview was conducted with the housekeeping staff assigned to unit 5. The housekeeper stated that residents sometimes complain that they have roaches in their rooms, and we notify the maintenance director and write on the pest control logs. The housekeeping staff also stated that the housekeeping director is responsible for contacting the exterminator. On 10/25/2017 11:30 AM an interview was conducted with the Registered Nurse (RN#2) manager. The RN #2 sated that staff have reported to him about the roaches and they notify the housekeeping staff. He also stated that they log it in the Pest control service log book . Then the house keeping will call the exterminator. Although the exterminator come every Monday and go to specific places and also make rounds. On 10/25/2017 11:45:17 AM an interview was conducted with the Housekeeping and maintenance director. He stated that the exterminator comes every Monday and work on the concerned areas but mostly on the common areas like the day room and the pantry areas, and tubs. The maintenance director could not explain the reason why the exterminating system is not effective. A review of pest control log book, dated from 2/2017 to 10/23/17 documented the extermination of the following areas day rooms, pantries. No documented evident that the exterminator went to resident rooms, or specifically to room 504. 10/25/17 at 2:00 PM, an attempt made to contact the pest control technician but unavailable 415.29(h)(4)

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate corrective action taken:
1. On 10/23/17 J&B Pest Control performed a full clean out of room 504, as well as adjacent rooms 503 and 505.
2. On 10/23/17 housekeeping did a thorough cleaning of rooms 503, 504, and 505.
3. Additionally, on 10/23/17 J&B Pest Control performed a thorough inspection and treatments of all rooms and hallways of Unit 5.
Identification of other residents who have been potentially affected by the deficient practice and corrective actions to be taken :
1. On 10/25/17 environmental services did a full inspection of all areas of the facility, and ensured that any areas and resident rooms of concern were recorded in the pest control log.
2. On 10/30/17 J&B Pest Control did a complete treatment of [REDACTED].

Systemic changes to prevent recurrence of the same deficient practice :
1. Policy and Procedure for facility Pest Control Program to be reviewed and revised as needed by the Administrator.
2. On ll/16/17 housekeepers and managers were in-serviced on Policy and Procedure for the Pest Control Program, including the use of the pest control log.
3. On 11/17/17 a new system of communication was put into place with J&B Pest Control. Going forward, the technician must meet and communicate with the Facilities Director, or surrogate, on the date of service.
Monitoring of corrective actions to ensure the deficient practice will not recur:
1. J&B will present a record of all areas inspected and treated on service calls.
2. Additionally, the facility will receive a quarterly report from J&B Pest Control on the effective status of the Pest Control Program.
3. This report will be reviewed by the Environmental Services Director and will be presented to the QA committee quarterly.
Responsible Person: Environmental Services Director

FF10 483.35(g)(1)-(4):POSTED NURSE STAFFING INFORMATION

REGULATION: 483.35 (g) Nurse Staffing Information (1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law) (C) Certified nurse aides. (iv) Resident census. (2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. (3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. (4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: October 25, 2017
Corrected date: January 2, 2018

Citation Details

Based on observations and staff interviews conducted during the Recertification completed 10/25/17, the facility did not ensure that nurse staffing information was posted daily and in a prominent place readily accessible to residents and visitors. The findings are: During multiple observations by multiple surveyors during the Recertification survey conducted 10/18/17-10/25/17 the nursing staffing data was not observed posted at any location throughout the facility. An interview conducted with the Assistant Director of Nursing (ADN) on 10/25/2017 at 12:23 PM, who stated that the nurse staffing is kept in the nursing office and in a binder at the desk and residents can ask the security guard or the nursing supervisor. The ADN then proceeded to the front desk where an unlabeled black binder was located which contained staffing schedules and not nurse staffing postings. An interview was conducted with the Director of Nursing on 10/25/2017 at 12:32 PM, who stated that the nurse staff posting should be at the front desk or on the first floor where staff sign in by the time-clock. The DNS then went on to state that staffing should be posted next to survey results however it was not located there at this time. The DNS also stated that the staffing is usually completed by the staffing coordinator who has been on leave for the past two weeks and so may have been overlooked. The DNS stated that the coordinator would be contacted to find out where the completed forms are kept. On 10/25/2017 at 1:45 PM, the DNS returned with a binder labeled Daily Staffing Binder which is kept in Nursing office. The most recent staffing posting in the binder was dated 2/5/17.

Plan of Correction: ApprovedNovember 24, 2017

I. Immediate corrective actions taken:
A. After identification of the deficient practice of no posted nurse staffing information during the recertification survey, on 10/25/17 ?Nursing Daily Staffing? form was immediately posted on the designated area in the lobby.
II. Identification of others:
A. All residents, families and visitors were potentially affected by the deficient practice.
III. Systemic changes:
A. On (MONTH) 25, (YEAR), a policy entitled ?Nursing Daily Staffing? was developed to detail the procedure and the responsible person. According to the policy,
1. The ?Nursing Daily Staffing? form is initiated by the night supervisor after he/she has checked the actual working staff at the start of the morning shift. The form also specifies the day?s census.
2. The supervisor will then display the completed form in the designated area in the lobby, which is visible to everyone entering the building, particularly residents, families and visitors. The form is filled out for the succeeding shifts by the RN Supervisor who checked the actual working staff of that particular shift.
3. A new form is displayed daily and the previous form is removed. Old forms are placed in a binder in the nursing office and the forms are to be retained for eighteen months, as per regulations.
B. A copy of the policy and procedure was given to each responsible person and was followed by an in-service about the policy. Attendance record is maintained on file for reference.
IV. Monitoring of corrective actions to ensure the deficient practice will not recur.
A. An audit tool was developed by the Director of Nursing to establish compliance of the nursing supervisors.
B. Daily audits has been ongoing since (MONTH) 25, (YEAR) to ensure that posting the Nursing Staffing Information is being followed per regulation and per facility policy.
C. The daily audit will be done for one (1) month until (MONTH) 25, (YEAR), then weekly for four (4) weeks, then monthly thereafter.
D. Any non-compliance will be corrected and addressed in a timely fashion.
E. Audit findings report will be presented to the Administrator and during the QA Committee meeting.
Responsible Person: Director of Nursing

FF10 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i):QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS

REGULATION: (g) Quality assessment and assurance. (1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (g)(2) The quality assessment and assurance committee must : (i) Meet at least quarterly and as needed to coordinate and evaluate activities such as identifying issues with respect to which quality assessment and assurance activities are necessary; and (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. (i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: January 2, 2018

Citation Details

Based on observation, record review and interview, the facility did not ensure the Quality Assurance committee (QA) effectively identified quality deficiencies and implemented plans of correction for identified deficiencies, including monitoring the effect of revised action plans. Specifically, the corrective plans of actions that were implemented were not effective, and as a result, repeated deficiency in housekeeping and maintenance services were identified during the recertification survey of 10/25/17. (Reference F-253) Findings are: Please refer to findings at F253 of the recertification survey of 10/25/17: Based on observation and interview, the facility did not ensure effective housekeeping and maintenance were maintained. Specifically, multiple areas and multiple floors observed with torn wallpaper, multiple dresses in the resident's room badly chipped and with broken handles, the resident's rooms were dirty and had mismatched paint, chipped tiles, badly scuffed floors, loose plate on radiator, and radiator cover not flush in front. The Plan of Correction submitted by the facility with a completion date 9/9/16 documented the following: The Director of Maintenance and Housekeeping developed a system to improve communication of housekeeping issues such as environmental cleanliness, state of repair of unit floors, floors, walls, furniture, bed, chair, cabinets etc. The system utilizes a customized communication book which provides the specific action and outcome. The Director of Maintenance/Housekeeping will perform daily rounds to check the communication book, and will acknowledge any reported issue. And all employees were given in-service education regarding the communication system. The corrective plan of corrections were not effective. Based on interview of staff and residents and observations by the SA the facility did not provide evidence that their corrective action plan has been effectively implemented and monitored. This is evidenced by several rooms still have furniture in disrepair; areas on multiple units observed with peeling plaster, paint, stained walls, etc. On 10/25/17 at 3:22PM, an interview conducted with the Administrator who stated that the QA committee meets every quarterly and as needed. He further stated that all the department heads including the Director of Maintenance/Housekeeping are also involved in the QA. The administrator stated that he decides what each discipline will do their quality measures on. Recently Maintenance Department checked radiators. Additionally, is unaware of any plan of corrections that are currently not effective, because as part of last year's deficiency was that the facility replaced the old black marble/composition book with a new maintenance book and maintenance is supposed to write down what needs to be fixed and double checks that the books are filled out correctly. Furthermore, the Administrator stated we got 80 new dressers for the resident rooms for the 2nd and 6th floors.

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate corrective action taken:
1. The findings from the recertification survey of [DATE] were reviewed and immediate corrective action was taken.
2. All specified issues from the survey were reinspected to ensure compliance.
3. The communication book that was implemented was reviewed by environmental services to ensure that all recorded issues were remedied and inspected for compliance.
4. Environmental Services Director was reeducated and in-serviced on the [DATE] Plan of Correction and the QA responsibilities.
5. The Administrator will review regulation 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i) QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS.
Identification of other residents who have been potentially affected by the deficient practice and corrective actions to be taken:
1. A facility-wide environmental rounds will conducted done by the Administrator and Environmental Services Director to identify issues with sanitary, orderly and comfortable interior.
2. Results and findings of the environmental rounds will be recorded and filed for reference. Any non-compliance will be addressed and corrected immediately.
3. QA audit tools from quarterly QA meeting were reviewed by the Administrator to ensure compliance with facility and P(NAME) responsibilities.
Systemic changes to prevent recurrence of the same deficient practice:
1. QA audit tools will be reviewed with each department to ensure both the utilization and efficacy of the facility QA program.
2. The job responsibilities and functions of the housekeeping and maintenance departments will be reviewed and revised to ensure that responsibilities are followed and ensure a sanitary and orderly and comfortable environment. All parties will be educated on the revisions and responsibilities.
3. On [DATE] the Administrator contacted and contracted Marcelo (company) to begin a floor maintenance and cleaning program in the facility.
4. On [DATE] the Administrator contacted and contracted Prestige Point Design to inspect all wallpapers in the facility to assess and repair/replace, if necessary.
Monitoring of corrective actions to ensure the deficient practice will not recur:
1. The Administrator will develop an audit tool to monitor compliance within the Housekeeping and Maintenance umbrella. The audit will be done by department head monthly for three (3) months and quarterly thereafter. All identified non-compliance will be addressed and corrected accordingly. The findings will be presented to the QA Committee meeting and to the Administrator.
2. The Environmental Services Director will perform spot checks on remedied issues from communication book weekly for four weeks then monthly thereafter. Any issues not resolved satisfactorily will be readdressed and the responsible employee held accountable.
3. The findings will be presented to the QA Committee meeting
and to the Administrator.
Responsible Person: Environmental Services Director

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: January 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , staff interviews and record review during the recertification survey, the facility did not ensure that services are provided in accordance with a physician's orders [REDACTED]. The resident was observed by the SA not wearing the appliance. Upon interview the resident stated he did not have appliance. Resident # 64 . The finding is : Resident # 64 a [AGE] years old admitted to the facility with [DIAGNOSES REDACTED]. The MDS ( minimum data set ) assessment dated [DATE] identified the resident with a BIMS ( brief interview for mental status ) score of 15, alert, oriented to person, place and time. Resident requires assistance of 1 person with activities of daily living. Review of the resident's medical record documented that on 08/23/2017 the resident was complaining of leg pains. The physician evaluated resident and ordered a Doppler study; a test that uses high-frequency sound waves to measure the amount of blood flow through your arteries and veins, usually those that supply blood to your arms and legs. The Doppler study of lower extremities was done and based on the results the physician ordered that an ace Velcro bandage be applied to bilateral lower extremities daily. On 10/23/2017 at 12:00 PM , the resident was observed in his room in bed dressed in hospital gown. He was observed with lower extremities slightly exposed with no ace bandage with Velcro. During the conversation, he stated I don't have any ace bandages. The resident's current physician's orders [REDACTED]. Remove for hygiene and skin check . Further review of the TAR ( treatment administration record ) from 08/30/2017 to 10/23/2017 revealed no documentation of the application of the ace bandage . The CNA (certified nursing assistant ) assigned to the resident was interviewed on 10/25/2017 at 1:54 PM and stated I have not applied any ace bandage on him,because it is not on my accountability . The certified nursing assistant (CNA#1) assigned to the resident was interviewed on 10/25/2017 at 1:54 PM. CNA #1 stated, I have not applied any ace bandage on him,because it is not on my accountability sheet. The certified nursing assistant accountability record (CNAAR) from 08/30/2017 to 10/23/2017 did not include instructions to apply ace Velcro bandage. RN #1 was interviewed on 10/23/2017 at 4:46 PM. RN #1 stated, The licensed nurses picks up the orders and transcribed it on the TAR and CNAAR . When asked why was this not done, there was no answer. 415.11 (c)(3)(ii)

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate corrective actions taken
A. Resident #64
1. As of 10/23/17, the resident was assessed by the RN Supervisor for need for use of ace bandage secondary to bilateral leg pains. The Nurse Practitioner (NP) was notified and performed evaluation on the resident. The order for ace bandage was discontinued by the Nurse Practitioner as the resident continued to refuse and that it was no longer indicated. He had no further complaint of leg pain. The resident remains with a score of 15 on (BIMS) brief interview for mental status and the discontinuation was discussed with him and he expressed understanding. This was reflected on his medical record.
2. The resident?s care plan on pain was reviewed and was updated to reflect the resident?s current status and the appropriate interventions. The care updated care plan also reflects the resident?s refusal and the measures in place to address his refusal.
3. As of 11/15/17, the nursing staff, licensed nurses and CNA's, were given in service regarding application of devices, ace bandage in particular, including proper documentation, care planning and addressing resident?s refusal to the application, if any.
II. Identification of other residents who have been potentially affected by the deficient practice and corrective actions to be taken
A. The Director of Nursing created a list of residents with physician orders [REDACTED]. The list will also be utilized for an audit on proper application of ace bandage on the residents, documentation on the resident?s medical records/treatment records or CNA accountability and the resident?s care plan.
Based on this list, the following will be done:
1. All residents with physician order [REDACTED].
a. If ace bandage is no longer clinically indicated, the order will be discontinued. Assessment findings will be documented on the resident?s medical records. The individualized care plans of each of these residents will be reviewed and updated to reflect the resident?s actual and current status.
b. All residents with orders of ace bandage that will be determined to be clinically indicated will be individually observed if they are actually applied and signed off on the treatment record by the licensed nurse. Resident refusals will be documented and the Physician/NP/PA will be notified. The care plans of each of these residents will be developed, reviewed and updated to reflect the indication of the ace bandage, the resident?s actual and current status and the interventions to address the refusal, if any.
2. Any identified non-compliance or deficient practice will be corrected accordingly based on facility policy.
3. A report will be presented during QA Committee meeting and a copy will be submitted to the Administrator.
III. Systemic changes to prevent recurrence of the same deficient practice.
A. The Director of Nursing will review, and revise if necessary, the facility?s policy and procedure on Comprehensive Resident Care Plans, to ensure that it is comprehensive, resident-centered and includes measurable objectives and time-framed to meet the resident?s medical and nursing and mental and psychosocial needs. The care plan should be individualized and specify the person responsible to carry out the intervention. Resident refusals to prescribed treatment or device, such as ace bandage, will be incorporated in the individualized care plan and will include measures to address the refusal. An in service will be given to the Interdisciplinary Team (IDT) members regarding this policy. Attendance record will be maintained on file for reference.
B. The Medical Director and Director of Nursing will also review, and revise if necessary, the facility?s policy and procedure on Physician order [REDACTED]. All physician-ordered treatments will be designated on the treatment flowsheet to be signed off by the administering licensed nurse. An in-service on this policy will be given to the physicians and licensed nurses. Attendance record will be maintained on file for reference
IV. Monitoring of corrective actions to ensure the deficient practice will not recur.
A. The Director of Nursing will develop an audit tool to monitor compliance to the facility?s policy and procedure on Comprehensive Care Plans and Physician Orders, to ensure that the use of ace bandages and similar treatment devices are incorporated/included.
B. The audit will be conducted by the RN Managers/Supervisors monthly for three (3) months and then quarterly thereafter.
C. Any non-compliance identified will be corrected immediately.
D. Audit findings report will be presented to the Administrator and during the QA Committee meeting.
Responsible Person: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 24, 2017
Corrected date: December 23, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that a horizontal sliding exit door was free of a locking mechanism. Reference is made to a keyed lock on the sliding door at the main lobby. The Finding is: On (MONTH) 18 (YEAR) at approximately 12:45 pm during the recertification survey, a horizontal sliding door in the main lobby that led to the outside of the building was equipped with a keyed locking mechanism. The facility must ensure that all exit doors are free of impediments in the event of emergency. In an interview with the Maintenance Director on (MONTH) 18, (YEAR) at approximately 12:50 pm, he stated that this mechanism will be removed immediately. 711.2(a)(1) NFPA 101 2012: 19.2.1

Plan of Correction: ApprovedNovember 9, 2017

Immediate corrective action taken:
1. On 10/19/17 the Environmental Services Director removed the mechanism from the horizontal sliding door.
Identification of others:
1. The Environmental Services Director will inspect and ensure that all exit doors are free of impediments.
2. Any issues requiring corrective action will be corrected immediately.
Systemic changes:
1. The Environmental Services Director will review code 711.2(a)(1) and NFPA 101 2012: 19.2.1 to ensure compliance of the regulations.
2. The policy and procedure for Life Safety Code will be reviewed and revised as needed by the Environmental Services Director.
QA monitoring:
1. The Environmental Services Director will ensure that facility is inspected quarterly for compliance with regulation 711.2(a)(1) and NFPA 101 2012:19.2.1 and any negative finding will have corrective actions implemented.
2. Audit finding will be presented and reviewed by the Administrator, with follow up as needed.
Responsible Person: Environmental Services Director

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 24, 2017
Corrected date: December 23, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10 NYCRR 415.29(a)(2) Physical Enviornment The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public. Life Safety from fire and other hazards. Nursing homes shall comply with section 711.2(a) of this Title. Based on observations and staff interview, it was determined that the facility did not ensure that the physical environment was kept in good functional order as evidenced by peeling paint, peeling wall paper and broken baseboards.This was observed on 3 out of 6 floors. The Findings are: On (MONTH) 18 (YEAR) and (MONTH) 19 (YEAR) between the hours of 10:00 am and 02:30 pm during the recertification survey of the facility, the following observations were made concerning the physical environment: 1. The first floor pantry area near the rehab area, a radiator was observed with peeling paint and rust. 2. A wall with bare plastered and unpainted areas was observed in a first floor corridor. Also, the wall paper was peeling. 3. room [ROOM NUMBER], the wall was observed with bare plastered and unpainted areas. 4. room [ROOM NUMBER], the wall paper was ripped. 5. room [ROOM NUMBER], the baseboard was broken. In an interview with the Maintenance Director on (MONTH) 19 (YEAR) at approximately 12:00 pm, he stated that these concerns will be corrected.

Plan of Correction: ApprovedNovember 9, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate corrective action taken:
1. On 11/07/17 the radiator was remediated and subsequently repainted.
2. On 11/09/17 the first floor corridor wall was painted. Additionally, on 11/07/17 the Administrator contacted and contracted Prestige Point Designs to replace the aforementioned wallpaper.
3. On 11/07/17 the wall in room [ROOM NUMBER] was painted and finished.
4. On 11/08/17 the wallpaper in room [ROOM NUMBER] was repaired. Additionally on 11/07/17 the Administrator contacted and contracted Prestige Point Design to replace said wallpaper.
5. On 11/07/17 the Administrator contacted and contracted Prestige Point Design to replace the baseboard in room [ROOM NUMBER].
Identification of others:
1. The Environmental Services Director will review NYCRR 415.29 (a)(2) section 711.2(a) to review and re-educate himself on standard facility physical environment requirements. The Environmental Services will thoroughly search and identify any areas of the facility that are not in compliance with section 711.2(a) and take corrective action.
2. Any issues identified will be corrected and completed by plan of correction date.
3. A report of all identified and corrected issues will be presented to the Administrator to be inspected for compliance.
Systemic changes:
1. The policy and procedure for physical plant will be reviewed and revised by the Environmental Services Director, if needed. There will be a quarterly inspection by Environmental Services to ensure compliance with the regulations.
2. The maintenance staff will be in-serviced on the policy and procedure by the Environmental Services Director.
QA monitoring:
1. The Environmental Services Director will inspect the facility physical plant quarterly for compliance, and any negative finding will have corrective actions implemented.
2. Audit finding will be presented and reviewed by the Administrator, with follow up as needed.
Responsible Person: Environmental Services Director

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

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 24, 2017
Corrected date: December 23, 2017

Citation Details

713-3.25 Electrical Requirements. (d) All spaces occupied by people, machinery, equipment within buildings, approaches to buildings, and parking lots shall have lighting commensurate with intended use. Residents' rooms shall have general lighting and night lighting. A reading light shall be provided for each resident. At least one light fixture for night lighting shall be switched at the entrance to each resident room. All switches for control of lighting in resident areas shall be of the quiet operating type. Based on observations and staff interview, it was determined that the facility did not ensure that all nursing supply and mechanical closets were equipped with minimal lighting in accordance with 713-3.25. This was evidenced by the absence of electrical lighting in the rehab and linen closets. This was noted on 2 of 6 floors. The Findings are: On (MONTH) 19 (YEAR) during the recertification survey of the facility, the following closets were observed without any illumination: 1. Linen closet on the second floor. 2. Respiratory closets on the second floor. 3. Mechanical closet in the beauty salon on the third floor. 4. Rehab closet located on the third floor. On (MONTH) 19 (YEAR) at approximately 11:00 am, the Maintenance Director stated that these closets do not have any illumination and the facility will provide illumination in these closets.

Plan of Correction: ApprovedNovember 9, 2017

Immediate corrective action taken:
1. On 11/02/17 the Environmental Services Director installed illumination in the listed observed areas.
Identification of others:
1. The Environmental Services Director will conduct a walkthrough of the facility to ensure compliance with regulation 713-3.25 (d).
2. The Environmental Services Director will identify any areas not in compliance with regulation 713-3.25 (d) and take corrective action.
Systemic changes:
1. Regulation 713-3.25 (d) will be reviewed by the Environmental Services Director to review and re-educate himself on standard facility physical requirements.
2. The policy and procedure for physical plant will be reviewed and revised by the Environmental Services Director, if needed.
QA monitoring:
1. The Environmental Services Director will ensure that the facility physical plant is inspected quarterly for compliance, and any negative finding will have corrective actions implemented.
2. Audit finding will be presented and reviewed by the Administrator, with follow up as needed.
Responsible Person: Environmental Services Director