M.M. Ewing Continuing Care Center
August 19, 2016 Certification 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: August 19, 2016
Corrected date: October 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one of three residents reviewed for activities for the cognitively impaired, the facility did not have an ongoing program of activities that addressed the resident's individual interests. Specifically, Resident #49 did not consistently receive preferred activities as specified in the care plan. This is evidenced by the following: Resident #49 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/31/16, includes that the resident has severe impairment of cognitive function and is dependent on staff for all locomotion. Additionally, preferences for daily activities listed on the assessment include listening to music, being around pets, spending time outdoors, participating in religious activities, and doing things with groups of people. Review of the resident's activity log from 5/27/16 to 8/17/16 included a total of one religious event, two outdoor events, one music event, and three massage therapy activities for the 12 week period. Review of the spiritual visit logs for the past two months revealed that the spiritual volunteers visit the unit several times a week spending approximately 1 to 2 hours and visiting approximately 40 residents. Review of the Activity calendars for 7/1/16 through 8/17/16 revealed that there were approximately 11 pet visits scheduled for all units and 12 outdoor activities (most involving music) that were scheduled on Resident #49's specific unit. In multiple observations made throughout the day shift, from 8/15/16 through 8/17/16, the resident was seen either in her recliner geriatric chair in front of the nursing station or resting in bed. A CD player was on her bedside stand but was not turned on over the course of the three days. On 8/17/16 at 11:00 a.m., an outdoor activity was going on in the courtyard right off the nursing station. Resident #49 was sitting in her chair in the hallway indoors during the activity. She did engage with staff when spoken to and was occasionally heard yelling out. When interviewed at that time, Licensed Practical Nurse (LPN) #1 stated that that the resident likes to go outside. LPN #1 said she did not know why the resident was not participating in the outdoor activity. She later stated that the resident's CD player located in her room should be on daily. When interviewed on 8/17/16 at 11:08 a.m., the Recreation Therapist stated that there was no reason why this resident was not included in the outdoor activity. The therapist stated that this resident does get a lot of spiritual visits. Review of the current facility policy, Recreation Therapy Activities, revealed that care plans address activities that are appropriate for each resident based on their comprehensive assessment. (10 NYCRR 415.5(f)(1))

Plan of Correction: ApprovedSeptember 9, 2016

Resident #49?s care plan was reviewed by Recreation Therapy Manager (RTM) and Interdisciplinary Team (IDT) for preferred activities and the activities preferences in the care plan are appropriate for this person.
The RTM reviewed all other cognitively impaired Resident?s care plans for activities preferences and their attendance at such activities and determined that they are receiving ongoing activities programs addressing their individual needs.
The policy on Recreation Therapy Activities and the procedure for recording attendance at recreation programs were reviewed and revised by the RTM. The RTM will update the resident personal preference books on each avenue.
The RTM will provide education to all nursing and recreation associates on recording attendance at rec therapy programs on and the use of resident preference book.
Using a standard audit tool, the RTM will audit recreation therapy attendance records to ensure that Residents who are cognitively impaired are attending programs based on their individual preferences, monthly for 3 months and then quarterly. Results of the audits will be presented to the Performance Improvement Committee for action if necessary.
Person responsible: Recreation Therapy Manager

FF09 483.25(a)(3):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 19, 2016
Corrected date: October 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for two (Residents #49 and #204) of three residents reviewed for Activities of Daily Living (ADL), the facility did not provide the necessary care and services to maintain personal hygiene. The issue involved a lack of fingernail care. This is evidenced by the following: 1. Resident #49 has [DIAGNOSES REDACTED]. Review of an activity assessment, dated 5/26/16, revealed that the resident's preferred activities included manicures. The Minimum Data Set (MDS) Assessment, dated 5/31/16, includes that the resident has severe impairment of cognitive function, requires extensive assist by staff for personal hygiene, and total dependence on staff for bathing. Review of the current Comprehensive Care Plan (CCP) and current Certified Nursing Assistant (CNA) Assignment sheet revealed that the resident has a self-care deficit and is totally dependent on staff for all aspects of ADLs. Neither document includes any mention of fingernail care. Review of the current unit shower schedule revealed that the resident receives a shower weekly on Fridays. Observations included the following: a. On Monday, 8/15/16, at 1:23 p.m., the resident was sitting in a reclining geriatric chair in the hallway. Multiple fingernails on both of the resident's hands were untrimmed and filled with black debris. b. On Tuesday, 8/16/16, at 4:18 p.m., the condition of the resident's fingernails had not changed. c. On Wednesday, 8/17/16, at 8:54 a.m. and again at 11:00 a.m. after getting dressed and out of bed, the resident's fingernails were in the same condition. The resident periodically put her hand in her mouth and sucked on her fingers. Licnesed Practical Nurse (LPN) #1 was notified of the condition of the resident's fingernails by the surveyor, stated that they were dirty and needed to be trimmed, and she would do it immediately. LPN #1 reported that the aides should look at the resident's fingernails daily and clean them as needed. LPN #1 described the resident's fingernails as pretty bad. When interviewed on 8/17/16 at 3:16 p.m., the Registered Nurse Assistant Nurse Manager (RN/ANM) stated that the primary aide should check the resident's fingernails daily. 2. Resident #204 has [DIAGNOSES REDACTED]. A MDS Assessment, dated 5/30/16, included that the resident has severe impairment of cognitive function and requires extensive assist of staff for personal hygiene. The current CCP and current CNA Assignment sheet both included that the resident has a self-care deficit related to his need for assist with all ADLs. Documentation on the ADL log included that the resident's last shower was on 8/12/16. During several observations made throughout the day shift from 8/16/16 through 8/18/16 at 9:30 a.m., the resident had multiple fingernails on both hands filled with brown debris. In an interview on 8/18/16 at 9:30 a.m., the RN/ANM stated that the resident's fingernails were dirty and needed to be cleaned. At 10:10 a.m. that day, CNA #1 stated that fingernails are trimmed on shower days but should be checked daily. Also, this resident is very cooperative and does not refuse care as far as she knows. (10 NYCRR 415.5(a))

Plan of Correction: ApprovedSeptember 9, 2016

Resident #49?s nails were cleaned and trimmed by CNA on 8/18/2016.
Resident #204?s nails were trimmed and cleaned by CNA on 8/18/2016.
All Residents? nails were inspected and cleaned and trimmed by a licensed professional if necessary on 8/20/2016.

Nail care is a Standard of Care for nursing professionals. The caregivers for Residents #204 and #49 received coaching from the DON.
RN Education Specialist and RN Nurse Managers reviewed Standards of Care specific to nail care with all licensed nursing associates.
Using a standard audit tool, weekly finger nail checks will be conducted by the RN/ANM or their designee on all residents for 1 month and then monthly for 3 months. Results of the audits will be presented to the Performance Improvement Committee for action if necessary.
Person responsible Director of Nursing

FF09 483.20(b)(2)(ii):COMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE

REGULATION: A facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a significant change means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 19, 2016
Corrected date: October 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Resident #82) of two residents reviewed for urinary incontinence, the facility did not identify that a resident had a significant change in two or more areas of his physcial and mental condition. The issue involved the lack of a Comprehensive Significant Change Minimum Data Set (MDS) Assessment completed for a resident with multiple documented declines in physical and mental well-being. This is evidenced by the following: Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] following a hospital stay for cardiac complications, and again on 6/27/16 after a hospital stay for a corneal ulceration, new onset hallucinations, and [MEDICAL CONDITION] activity. A Comprehensive Adminission MDS Assessment, dated 4/20/16, included that the resident had a moderate impairment of cognitive function, had moderately impaired vision (limited but able to identify objects), minor symptoms of depression, no history of hallucinations or delusions, was independent with bed mobility, was always continent of bladder function, and had some balance problems during transitions and walking but was able to steady self without assist. Review of several quarterly MDS Assessments (6/15/16 and 7/16/16) following the two hospital stays, revealed that the resident was now severely cognitively impaired, had severe vision loss (no vision or only sees light), suffered increased symptoms of depression, hallucinations, and delusions, required extensive assist from staff to move around in bed, was always incontinent of urine, and was no longer able to steady himself when transitioning with staff assist. In a Physical Therapy evaluation, dated 7/11/16, the therapist wrote that this resident was being evaluated for a decline in ambulation and decreased strength and endurance. He noted that this was the resident baseline function at this time, and due to that and refusals, the resident would not be picked up for physical therapy. In a medical progress note, dated 7/12/16, the physician wrote that the resident is having recurrent cardiac episodes of unresponsiveness, which resolve, but that the resident has not returned to baseline and is most likely terminal. Medications were adjusted as needed for the resident's comfort, and the chaplain was notified. His prognosis is grim. Review of the Occupational Therapy discharge summary, dated 7/19/16, revealed that therapy was being discontinued due to a change in medical status requiring increased level of assistance in all Activities of Daily Living. The resident passed away on 8/7/16. Review of the resident's care plan in place at the time of death revealed that it did not include any goals and/or interventions related to end of life care. Interviews conducted on 8/19/16 included the following: a. At 9:57 a.m., the Registered Nurse (RN) Corporate Compliance, who oversees the MDS Assessments, and the MDS Coordinator, stated that if the resident had two areas of decline, they would qualify for a significant change MDS Assessment. They added that technically this resident would qualify for a significant change, but he was receiving therapy and was making progress. b. At 11:17 a.m., the RN Manager stated that they discuss any changes in morning report with the whole disciplinary team. Then the MDS nurses review those changes and decide if a significant change MDS Assessment should be done. Review of the current Resident Assessment Manual revealed that criteria for significant change included the following: a. a decline in the resident's status that will not normally resolve itself without intervention by staff, b. impacts more than one area of the resident's health status, c. requires interdisciplinary reviews and/or revision of the care plan. When a resident's status changes and it is not clear whether the resident meets the guidelines, the facility may take up to 14 days to determine whether the criteria are met. (10 NYCRR 415.11(a)(3)(ii))

Plan of Correction: ApprovedSeptember 13, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 82 expired on [DATE].
No further action possible as of [DATE].

[DATE] ? MDS Coordinator reviewed quarterly MDS? completed in (MONTH) for other Resident's to assess whether criteria for significant change was met without corrective action required. Interdisciplinary team will review and discuss each Resident who meets criteria for a Significant Change MDS and the MDS Coordinator will complete them as necessary.
[DATE] ? Director of Clinical Quality in-serviced interdisciplinary team regarding significant change determination using RAI manual as a reference.
[DATE] The Director of Clinical Quality implemented a procedure to incorporate and facilitate interdisciplinary team discussions regarding resident's who meet significant change criteria to daily morning huddles. Interdisciplinary team present at morning huddle include MDS nurse, Nurse Manager, Social Work, Recreation Therapist, Physical Therapist, Director of Nursing and the Director of Clinical Quality.

RN MDS Coordinator will audit current MDS? for significant change using RAI manual and note whether criteria has been met and no omission has occurred x 3 mos. Results of the audits will be presented to the Performance Improvement Committee for action if necessary.
Person Responsible: Director of Clinical Compliance

FF09 483.20(b)(1):COMPREHENSIVE ASSESSMENTS

REGULATION: The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. A facility must make a comprehensive assessment of a resident's needs, using the resident assessment instrument (RAI) specified by the State. The assessment must include at least the following: Identification and demographic information; Customary routine; Cognitive patterns; Communication; Vision; Mood and behavior patterns; Psychosocial well-being; Physical functioning and structural problems; Continence; Disease diagnosis and health conditions; Dental and nutritional status; Skin conditions; Activity pursuit; Medications; Special treatments and procedures; Discharge potential; Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS); and Documentation of participation in assessment.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 19, 2016
Corrected date: October 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined that for one (Resident #78) of one resident reviewed for hospice care, the facility did not code the Resident Assessment Instrument, including the Minimum Data Set Assessment, correctly. The issue was inaccurate coding regarding hospice care. This is evidenced by the following: Resident #78 has [DIAGNOSES REDACTED]. The resident was first admitted to hospice for advanced dementia, pneumonia, and failure to thrive on 2/26/16. A Minimum Data Set (MDS) Assessment, dated 3/4/16, significant change assessment included that the resident was not receiving any specialized program under Section O. The MDS Assessment, dated 6/4/16, quarterly MDS, does not indicate the resident is receiving specialized services. When interviewed on 8/19/16 at 10:45 a.m., the Nurse Assessment Coordinator stated she knew the resident was on Hospice. She must have missed checking it on the MDS Assessment, and she would send in corrections for the (MONTH) (YEAR) and (MONTH) (YEAR) assessments. (10 NYCRR 415.11(a)(1))

Plan of Correction: ApprovedSeptember 9, 2016

For Resident #78
08/19/16 a modification was made of
MDS? dated 3/4/16 and 6/4/16 under section O0100K to include hospice care
services.

08/19/16 ? One additional resident is on hospice services in facility. MDS was reviewed by Director of Clinical Quality, and found to be coded appropriately.
Coding of MDS for residents on hospice services will be verified by compliance department.
Residents on hospice services will have every MDS assessment audited by the Director of Clinical Compliance until 100% compliance in coding of section O0100K is reached x 3 mos. Results of the audits will be presented to the Performance Improvement Committee for action if necessary.
Person Responsible: Director of Clinical Compliance


FF09 483.15(a):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 19, 2016
Corrected date: October 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Meadows) of five units reviewed for dining, the facility did not promote a dignified dining experience. Issues included a resident being fed by staff who were facing the another resident (Residetn #66), residents who did not receive assistance to eat for 27 minutes (Residents #66 and #95), and a delay in residents receiving their food for 30 minutes while the food carts sat in the hall within their line of vision (Residents #31, #113, #180 and #211.) This is evidenced by the following: 1. Resident #66 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/29/16, describes the resident with severely impaired cognitive skills. The current Certified Nursing Assistant (CNA) care sheet includes that the resident requires one person physical assistance due to being totally dependent while eating. During an observation on 8/15/16 at the mid-day meal, CNA #1 sat between Resident #66 and another resident, feeding one, and then the other. CNA #1 had her back turned mostly to this resident. She fed the resident with her arm turned backwards, as she did not turn her body to face the resident. Additionally, the food carts arrived on the unit at 12:34 p.m. and 12:40 p.m. This resident was brought into the dining room at 12:46 p.m. The resident sat, calling out, and sucking on her fingers until 1:13 p.m., when staff began to feed her. 2. Resident #95 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/6/16, describes the resident with severely impaired cognitive skills. Documentation on the 7/16/16 Comprehensive Care Plan shows the resident has had significant weight loss. Interventions include to allow the resident sufficient time to complete meals and assist the resident with feeding as needed. Instructions on the current CNA care sheet include to feed the resident, who is totally dependent while eating. During an observation on 8/17/16, food trays were being passed at 12:56 p.m. The resident's tray was set before him and uncovered at 1:03 p.m. At 1:12 p.m., a recreation staff person asked the resident if he needed help. The resident did not reply, looking about the room. At that time, all the other residents in the room were eating. No one assisted the resident to eat until 1:23 p.m. 3. During an observation on 8/17/16, the two food carts were delivered to the Meadows unit at 12:26 p.m. and 12:27 p.m. At 12:47 p.m., the surveyor entered the Dining Room. There were 23 residents present and no staff. Residents #31, #113, #180, and #211 began to shout at the surveyor, asking where was their food, where were the staff, This is awful, and they could see the food carts sitting there, why can't they have it? A recreation staff person came out of the office. During an interview at that time, she said she did not know the protocol for giving the residents food. At 12:49 p.m., the Registered Nurse Assistant Nurse Manager came out of the kitchenette and said they were not allowed to give the resident's any food trays until all residents were present in the dining room. Staff began to pass trays to the residents at 12:56 p.m. Recreation Therapists #1 and #2 assisted passing the trays but did not assist with feeding any of the residents. Resident #113 was observed to receive her tray at 12:57 p.m. on 8/17/16. The CNA asked the resident if she was hungry, and the resident replied, Are you kidding!? During an interview on 8/17/16 at 1:04 p.m., Resident #31 said this has been occurring for awhile, the residents just sit and wait for the food. Interviews conducted on 8/17/16 included the following: a. At 1:18 p.m., Recreational Therapist #2 said she is also a CNA. She said her responsibilities include setting up trays, calling the kitchen for additional food, and on occasion, feeding residents if they need extra help. b. At 1:26 p.m., Recreational Therapist #1 said she is also a CNA, and usually staff are waiting for the carts when they come. She said she did hear the residents yelling about their food, but she was concentrating on doing work in the office. She said Resident #95 did not respond when she asked him if he needed help. She did not think that she could feed him, and was unsure who she could feed. Interviews conducted on 8/18/16 included the following: a. At 9:19 a.m., Licensed Practical Nurse #1 said Residents #31, #113, #180, and #211 are all residents that are able to make their needs known. b. At 1:55 p.m., CNA #1 said it is normal that they feed two residents at the same time. The rule is that all the residents are supposed to be in the dining room before they are allowed to pass out any of the trays. c. At 2:11 p.m., CNA #2 said there are five CNAs that work each day. Two CNAs go to lunch between 11:30 a.m. and noon, and the other three go from noon to 12:30 p.m. The CNAs that are left have to get residents up and bring them to the dining room. Some days they are told to wait for all the residents to be in the dining room, and some days they are told to start to feed residents. She said it was not unusual to have to assist three residents at the same time. This makes her feel very frustrated because it is difficult to do. She also said that in the past year, she has seen the recreation staff help feed residents only twice. There are some nurses that will come and help them feed the residents, but most do not. Interviews conducted on 8/19/16 included the following: a. At 8:33 a.m., CNA #3 said she has never seen any of the recreational therapy staff feed a resident, and only on 8/17/16 has she even seen them pass trays. She said that occasionally a nurse will help them feed residents. She also said she has to feed two residents at the same time and feels like she is neglecting one. Sometimes she feeds a resident who is coherent, and one who is not, and she always feels neglectful to the resident who is not. She said they always have to have at least one CNA to toilet residents and help with trays for residents eating in the hall or their rooms. She said they were told not to serve the trays until all the residents are in the dining room, and they have to get all the residents up to bring to the dining room first. She said she did not realize that Resident #95 was not being fed until she finished feeding Resident #211. b. At 8:51 a.m., CNA #4 said they give out trays to the residents that can feed themselves first, then they sit between two residents and feed them. Some of the nurses help and some do not, and the recreational therapy staff do not normally help at all. She said one of the reasons that they struggle is because they have a lot of residents that require two people to assist them in getting out of bed for lunch. There was a meeting approximately two weeks ago where they were told they could feed residents and not wait for all the other residents, but not all the staff attended that meeting. c. At 9:48 a.m., LPN #2 said nurses are supposed to help with lunch time, pass trays, and feeding. Usually it is just her and the CNAs. They do feed two residents at the same time, and the recreation staff do not help them with the meals. The CNAs toilet residents and get them up, and they are supposed to wait until all the residents are in the dining room before they pass out the trays. She said it is not dignified to feed two residents at the same time and was taught to feed one resident at a time. She said there are 14 residents that require assistance to eat, and 27 residents that require two staff to get them up. d. At 10:57 a.m., the Registered Nurse Manager and Director of Nursing said ideally they would like all the residents in the dining room, as they do not want one eating and others not eating. They do see that the flow is not good, and ideally only one resident should be fed by one staff. However, in order for timeliness and number of residents that need to be fed, you may have to feed two at the same time. They stated that this could be done without compromising each resident's dignity. (10 NYCRR 415.5(a))

Plan of Correction: ApprovedSeptember 9, 2016

Resident #66 received assistance and consumed her meal.
Resident #95 received assistance and consumed his meal.
Resident?s #31, #113, #180, #211 received and consumed their meals approximately 1:00pm.

The Registered Dietitian (RD) and Diet Technician conducted observations in dining rooms on STU, Pines, Lakeview, and Gardens using the QIS Surveyor Guidance for Dining Observation, specifically looking at timeliness of assistance with eating and proper positioning of Associate to Resident while providing assistance with eating, and timely delivery of meals to Residents in relation to food cart arrival on avenue. No trends were identified.
The CNA assisting Resident #66 received coaching from the RNM regarding positioning of herself in relation to the Resident while assisting them with their meal. Dining procedures were reviewed and revised by the DON, RNM, and Dietitian in order to establish an effective process for timely meal delivery.
All licensed nursing associates and recreation therapy associates will receive in-service education on meal service and assisting a Resident while eating.
Using the QIS dining observation tool, the RD or her designee will conduct monthly audits for three months then quarterly. Results of the audits will be presented to the Performance Improvement Committee for action if necessary.

Person responsible: Director Of Nursing.

FF09 483.20(k)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: The services provided or arranged by the facility must meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 19, 2016
Corrected date: October 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that for one (Resident #204) of five residents reviewed for unnecessary medications, the facility did not provide services in accordance with professional standards of quality. The issues involved medications not given as per physician orders [REDACTED]. Resident #204 has [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED] a. [MEDICATION NAME] was given after a meal (as opposed to before) from 90 minutes up to 6 hours (10:13 p.m.) after the scheduled dose on 13 of 31 opportunities. b. [MEDICATION NAME] was given 98 minutes up to 5 hours (10:13 p.m.) after the scheduled dose on 14 of 31 opportunities. c. [MEDICATION NAME] was administered on one occasion despite the resident's blood pressure being 98/50. Review of the afternoon and evening nourishment schedule revealed the resident was not scheduled to receive a snack in the evening or before bed. Review of meal cart delivery time to the unit revealed the dinner carts are delivered between 5:00 p.m. to 5:30 p.m. Review of nursing progress notes for the same time period revealed a lack of refusals by the resident for the above identified medications. In an interview on 8/18/16 at 9:30 a.m., the Registered Nurse/Assistant Nurse Manger (RN/ANM) stated that the resident's [MEDICATION NAME] should have been held due to a low blood pressure. Also, if the physician orders [REDACTED]. She said that if a medication is ordered to be given with food, it is usually scheduled around meal times. The RN/ANM said that there is no way to tell if those late doses were given with food and the administration times are too late. She stated that this resident does not get a scheduled snack in the evening. When interviewed on 8/19/16 at 11:11 a.m., the covering Registered Nurse Manager stated that medications need to be given as ordered. She added that if a resident refuses a medication, staff would document it in the progress notes and attempt later. The current facility policy, Techniques for Medication Administration, includes that routine medications shall be given within one hour before and after the time due with the exception of daily, weekly, and monthly medications. (10 NYCRR 415.11(c)(3)(i))

Plan of Correction: ApprovedSeptember 9, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #204 was assessed by RN and NP was notified of the administration of [MEDICATION NAME] outside of parameters and [MEDICATION NAME] with no side effects noted.
The medication regimen for Resident #204 was reviewed by the Consultant Pharmacist and Nurse Practitioner (NP) on 9/7/2016. [MEDICATION NAME] order was changed and it does not need to be given with food.

The licensed nurse who administered the [MEDICATION NAME] was counseled by the DON on medication administration techniques.
Medication Administration records (MAR) are being reviewed by the RNM and or RN/ANM on each avenue for timely administration and medications administered within parameters.
The Policy for Techniques for Medication Administration was reviewed and revised by the DON and Director of Clinical Compliance.
Medication administration is a professional standard of care and all licensed nurses will receive in-service education on the policy for Techniques of Medication Administration and the professional standard of medication administration from the RN Education Specialist.
Using a standard observation audit tool for medication administration, the RN Staff Development or her designee will complete monthly observations of medication administration for 3 monthly then quarterly. In addition, audits of the MAR for timely administration of medication and parameters will be conducted by the Director of Clinical Compliance monthly for 3 months then quarterly. Results of the audits will be presented to the Performance Improvement Committee for action if necessary.

Person responsible: Director of Nursing


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

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 19, 2016
Corrected date: October 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 713-1.3 Nursing units. Each nursing unit shall include the following service areas and shall meet the following minimum requirements: (j) Each resident bedroom shall have direct access to an outside exposure. Windowsills shall not be higher than three feet above the finished floor, and shall be above grade. Based on observations and interviews, it was determined that for two (Lakeview, STU-Skilled Transitional Unit) of five resident sleeping units, the facility did not maintain compliance with New York State building construction standards for existing nursing homes. Specifically, windows in resident rooms were secured in the closed position. This is evidenced by the following: 1. Observations in the presence of the Director of Facility Services on 8/15/16 at 1:30 p.m. revealed the window in Resident room [ROOM NUMBER] (STU) would not open. The window was approximately 5 feet wide x 5 feet tall. There was a pull/push mechanism at the base of the window and two locking mechanisms at the top of the window. Further observations throughout the STU revealed that all resident room windows were of this type, and the windows in Rooms # , # , and # could not be opened. In an interview at that time, a nurse stated that all the windows were this way, and they have never been able to open them. Also when interviewed at that time, a member of the Maintenance Department reported that the two locks at the top of the window had to be adjusted using a wrench for the window to open. 2. Observations on 8/17/16 from approximately 2:00 p.m. to 2:15 p.m. revealed that the windows throughout the Lakeview Unit were the same type as those found on the STU. In an interview at that time, the Nurse Manager stated that none of the windows open. In another interview at that time, the Facility Services Project Manager reported that the STU and Lakeview Units were part of the building's original construction in 1971. (10 NYCRR: 713-1.3(j))

Plan of Correction: ApprovedSeptember 14, 2016

Director of Facilities (DF) identified 19 windows on STU and 19 windows Lakeview that are unable to open without a tool. The windows were installed during original construction and the existing frames will not accept nor can the frame assemblies be altered to have window insect screens. In addition, keeping windows closed helps maintain HVAC regulated temperatures. Residents are at no risk of adverse effects from windows remaining closed and each room is supplied with a mixed fresh outside air and condition air from AHU system. Each Resident has access to an enclosed courtyard for fresh air if they so desire. It is cost prohibitive to replace all of these windows. Facility will submit a waiver request for the windows, to Albany, on 9/16/2016.
DES services and maintenance personal inspected all windows in resident sleeping units and those on Gardens,(NAME)and Pines were found to be able to open without a tool.
DES reviewed with all staff that the windows should be able to open without the use of a tool. Facility is submitting a waiver request for windows on STU and Lakeview to Albany on 9/16/2016. In the event that the waiver request is not accepted, facility will need to contract with a company to replace windows, which would be cost prohibitive.
DES will monitor the progress of the waiver application to ensure that there is a response from Albany on the waiver. DES will provide Administrator and the Performance Improvement Committee with a report on the status of the waiver for action if necessary.
Person Responsible: Director of Facilities

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 19, 2016
Corrected date: October 18, 2016

Citation Details

Based on observations made during the Life Safety Code Survey, it was determined that for one (Lakeview) of five resident sleeping units, the facility did not properly maintain exiting and egress. Specifically, exit discharge pathways lacked handrails where ramps were present and a ramp was too steep. The findings are: 1. Observations in the presence of the Director of Facility Services on 8/16/16 at 1:30 p.m. revealed the slope of the exit discharge pathway from exit door #43 (Lakeview Unit) was a drop in elevation of 7 inches over a 4-foot section. A section of this pathway dropped 2 1/4 inches over 20 inches of linear distance. The measurements were obtained using a 4-foot level and a tape measure. Further observations revealed the exit discharge door (#43) opened directly to a downward sloping pathway (there was no level landing outside the door), and the ramp section of this exit discharge pathway lacked handrails. The total length of the ramp from exit door #43 was 16 feet. 2. Observations in the presence of the Director of Facility Services on 8/16/16 at 1:35 p.m. revealed an approximately 16-foot long downward sloping ramp section of the sidewalk, comprising a portion of the exit discharge pathway from exit door #42 (Lakeview Unit) that lacked handrails. 3. Observations in the presence of the Director of Facility Services on 8/16/16 at 1:40 p.m. revealed an approximately 30-foot long downward sloping ramp section of the sidewalk, comprising a portion of the exit discharge pathway from exit door #44 (Lakeview Unit) that lacked handrails. (10 NYCRR: 415.29(a) (2), 711.2(a) (1); 2000 NFPA 101: 19.2.1, 7.1.6.3, 7.2.1.3, 7.2.2.4.2, 7.2.5.4, 7.2.5.2(b))

Plan of Correction: ApprovedSeptember 14, 2016

Facility will contract with a genaral contractor to install a new sidewalk and handrail systems at door #43, and hand rail systems at doors #42, and #44.

Director of Facilities (DF) surveyed the entire exterior of the Facility to ensure that all the emergency exit sidewalks met standard and they do.

The installed sidewalk at door #43 will have a compliant slope (no steeper than 1 in 12) and handrail systems shall remain permanently affixed and in good repair.
DF or his designee will conduct audits consisting of visual inspection of the sidewalks and handrails monthly for 3 months then periodically thereafter to ensure they are in good repair. Results of the audits will be presented to the Performance Improvement Committee for action if necessary.
Person Responsible: Director of Facilities

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Corridors are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.) 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 19, 2016
Corrected date: October 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the Life Safety Code Survey, it was determined that for one (Gardens) of five resident sleeping units, the facility did not properly maintain corridor walls. Specifically, spaces were not separated from the egress corridor by doors and walls, and the spaces did not meet an exception allowing the spaces to be open to the corridor. The findings are: Observations in the presence of the Director of Facility Services on 8/15/16 from approximately 11:20 a.m. to 11:28 a.m. revealed an approximately 7.5-foot x 6-foot space that was not separated from the egress corridor and was located adjacent to the smoke barrier doors across from bathing area room [ROOM NUMBER] (Gardens Unit). The space lacked a smoke detector and was being used for the storage of several wheelchairs and a stationary shelving unit containing pads and wheelchair accessories. Additionally, there was an approximately 7.5-foot x 6-foot space that was not separated from the egress corridor and located adjacent to Resident room [ROOM NUMBER] (Gardens Unit). The space lacked a smoke detector and was used as a sitting area for residents. (10 NYCRR: 415.29(a) (2), 711.2(a) (1); 2000 NFPA 101: 19.3.6.1)

Plan of Correction: ApprovedSeptember 9, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility will contract with a fire system contractor to install smoke detectors in the spaces across from bathing area room # and resident room [ROOM NUMBER].
Director of Facilities (DF) surveyed the entire facility and found two other areas that potentially may not meet the STANDARD.
Facility will contract with a fire system contractor to install smoke detector?s in these two areas.

The installed smoke detectors will be added to the annual inspection and certification that is completed at the facility by a contracted fire system specialist. The inspection results will be reviewed by DF and Administrator to ensure that STANDARD is met.
Using a standard audit tool, the DF or his designee will review the fire system inspection and certification reports with Administrator to ensure that the smoke detectors are on the report. Results of the audits will be presented to the Performance Improvement Committee for action if necessary.
Person Responsible: Director of Facilities