Bethany Gardens Skilled Living Center
October 10, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.24(a)(1)(b)(1)-(5)(i)-(iii):ACTIVITIES DAILY LIVING (ADLS)/MNTN ABILITIES

REGULATION: §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 12, 2018
Corrected date: December 11, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure for 1 of 5 residents (Resident #58), reviewed for activities of daily living (ADL), that each resident was provided the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless unavoidable. Specifically, Resident #58 was discharged from physical therapy (PT) and occupational therapy (OT) with a plan to maintain his current level of function by receiving services in the restorative nursing program (RNP); the resident did not receive the planned services. Findings include: Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident's cognition was moderately impaired; he required extensive assistance with all ADLs except eating which required supervision and set up, and he did not ambulate. The resident profile (care instructions) dated 8/8/2018, documented the resident ate by himself after set up, had a wheelchair propelled by staff for mobility, was non-ambulatory, required a mechanical lift for transfers and toilet use, and was incontinent at times. He required extensive assistance for bathing, bed mobility, dressing and grooming. The PT discharge summary dated 9/7/2018, documented the resident had reached maximum potential. Discharge recommendations included encouraging the resident to participate in activities of interest to promote socialization and active lifestyle; and the resident was also to participate in the RNP. The RNP was to facilitate the resident to maintain his current level of performance and to prevent decline. The summary documented that development and instruction was completed with the interdisciplinary team for AROM (active range of motion). The OT discharge summary dated 9/7/2018, documented the resident had achieved his highest practical level. Discharge recommendations included a reacher, low bed, and restorative nursing for PROM (passive range of motion) and AROM. The RNP was to facilitate the resident to maintain his current level of performance and to prevent decline. The summary documented that development of and instruction was completed with the interdisciplinary team for AROM and PROM. The comprehensive care plan (CCP) updated 9/21/2018, documented the resident was discharged from skilled services on 9/7/2018 and to see the discharge summary for full details. The resident's ADL plan was not updated to include AROM/PROM; the ADL status was unchanged from the resident profile dated 8/8/2018. When observed and interviewed on 10/09/18 at 1:49 PM, the resident was sitting in his wheelchair with a Hoyer (mechanical lift) pad under him. He stated was not getting PT or OT services anymore and was unsure why. When interview on 10/11/2018 at 11:43 PM, certified nurse aide (CNA) #8 stated she took care of resident, he no longer went to PT, and she was not sure if he was seen by the restorative aide. On 10/11/18 at 12:25 PM, the Director of Therapy #9 stated they did not have a RNP policy. She stated the program was for residents to be seen by a therapy/rehab aide after discharge from skilled services to maintain their level of function. She said when the resident was discharged from therapy, if the therapist wanted the resident to have some type of continuing program such as ROM, bed mobility, or ambulation, the rehab aide was trained by the therapist on the resident's needs. The rehab aide would then schedule to see the resident 3-5 times a week and complete the recommendations. She stated if there was a decline or problem the aide reported it to nurse manager or therapist and the resident would be re-evaluated. She stated the rehab aide documented their activities on the kiosk (electronic medical record). When interviewed on 10/11/18 at 1:00 PM, rehab aide #12 stated she saw the residents for the RNP and documented the number of minutes she worked with each resident in the kiosk. She stated she took over this responsibility 9/24/18 and had not seen Resident #58. She stated she got a notebook that the previous rehab aide used and that was how she knew who to see. She stated she was not given information on the resident and did not know Resident #58 was on the program until the Director of Therapy and physical therapist (PT) #10 told her a few minutes ago. When interviewed on 10/11/18 at 1:06 PM, PT #10 stated the discharge plan was to provide AROM in the RNP. He said he wrote a plan for the aide (no longer at the facility) to administer and she documented in a book. He said the plan was verbalized to the aide and a written plan was given to her. He stated he was unable to find a copy of the plan he wrote. He said the resident was not highly motivated and needed a lot of encouragement to perform ROM. He stated the resident preferred not to be bothered and required maximum encouragement to perform exercises. The resident was put in the program to maintain his current level of function. When interviewed on 10/11/2018 at 2:15 PM, occupational therapist (OT) #11 stated when a resident was discharged from OT she consulted the rest of the interdisciplinary team to see if continuing a restorative nursing program was necessary. She stated then she would communicate with the RNP aide verbally and in writing as to the resident's needs. She stated the previous rehab aide had been in and out a bit and she was not sure what happened. She stated she put the resident on the program and he should have received the RNP services. When interviewed on 10/12/18 at 11:23 PM, registered nurse (RN) Manager #13 stated the therapy department was responsible for updating the ADL care plan and the RNP. She stated she did not know if the rehab aide had seen the resident for ROM. She stated the resident would benefit from the program. 10NYCRR 415.12(a)(1)

Plan of Correction: ApprovedNovember 7, 2018

I) Immediate Plan of Correction:
1. Resident #58 was re-evaluated by PT on 10/16/2018. After Evaluation, Resident # 58 was recommended for Skilled Physical Therapy Services.
2. Recommendations were implemented into the Residents CCP.
3. Policy & Procedure on Follow-up Care after Discharge from Restorative Rehabilitation to LTC was reviewed & revised. In addition, all Therapy Staff were educated on this Policy & Procedure on 10/12/18.
II) Identification of Others:
1. Facility respectfully submits that all LTC residents have been identified as having the potential of being affected by the same practice.
2. The Director of Therapy will perform a full in-house audit to identify other residents that may have been affected by the same practice.
3. Immediate corrective actions will be taken to ensure that each resident is being provided with the necessary care and services to ensure that a residents abilities in activities of daily living do not diminish unless unavoidable. These recommendations will be added & implemented to each individual CCP as needed.

III) Systemic Changes:
1. The Director of Therapy has implemented a Rehabilitation-Aide-Program formerly known as a Restorative Nursing program. If recommendations are made by Therapists for Rehab.-Aide-Program, all appropriate interventions & documentation, will be provided to Rehab.-Aide for each individual resident and included in their CCP.
2. Director of Therapy will educate all Direct Care Staff, current & new hires, on Policy & Procedures regarding follow up care after discharge from rehabilitation to LTC annually or as needed.
3. All LTC Residents will be screened quarterly by Clinicians to assess if current program remains appropriate, and Care-Plans will be reviewed and updated as appropriate at this time.
IV) QA Monitoring:
1. The Director of Rehabilitation or Designee will audit 10% of residents discharged to a follow-up care program weekly x2 months to verify program implemented is being followed through and that patient is tolerating program. Threshold for compliance is to be at 95%. These audits will be reviewed at quality assurance meetings.
2. All Audits with negative findings will have corrective actions implemented, retraining or counseling to staff responsible if needed.
V) Responsible Party & Expected Date of Completion:
1. Director of Therapy or Designee
2. Expected Date of Completion: 12/11/2018


FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 12, 2018
Corrected date: December 11, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey, for 1 of 22 residents (Resident #142) reviewed for comprehensive care plans (CCP), the facility did not develop a comprehensive person-centered CCP to meet the resident's needs. Specifically, for Resident #142 the Minimum Data Set (MDS) and admission fall risk assessments were not completed accurately and the resident was not care planned for falls; the CCP was not revised to include recommended fall interventions after the resident fell ; the resident fell again and sustained injuries. Findings include: The facility's fall policy dated 7/2017, documented the resident's CCP was to be updated with interventions to reflect the event, and the event was to be documented on the 24-hour report. Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired. The resident required extensive assistance of 2 for bed mobility, transfers, dressing, toilet use, hygiene, and bathing. He required limited assistance of 1 for walking and supervision with set-up for eating. The MDS documented the resident had no falls in the past 6 months and received physical and occupational therapies (PT/OT). The admission fall risk assessment dated [DATE] documented the resident had: - intermittent confusion, poor recall, judgement, safety awareness; - no falls in the past 3 months; - impaired mobility and required assistance with toilet use; and - required use of an assistive device for walking. It was determined he was not at risk for falls. The resident's care plan dated 8/17/2018 documented the resident used a wheelchair and ambulated in therapy only. He required extensive assistance of 1 for bed mobility and extensive assistance of 2 with a rolling walker for transfers. He was not care planned for risk of falling. The physician's history and physical dated 8/20/2018 documented the resident was admitted for physical therapy (PT) and occupational therapy (OT) after an episode of profound weakness. The resident was doing well and was discharged from the facility after having rehab for a fractured pelvis secondary to a fall. He went home and 2 days later was admitted to the hospital with [REDACTED]. The plan was to return home after rehabilitation. The nursing progress note dated 8/25/2018 at 5:02 PM, documented the resident was found on the floor in his room. The resident stated he did not know how he got there and stated he hit his head on the nightstand. No injuries were noted and the resident was assessed and assisted back to bed. He was reminded to use the call bell and neurological checks were initiated. An incident report dated 8/25/2018 documented at 4:50 PM, the resident was found on the floor in his room. The incident report was signed off as reviewed on 8/27/2018 by the interdisciplinary team and the Director of Nursing (DON). The review documented the resident was found on the floor, the call bell was not on, and the plan of care was followed. New interventions included encouraging the use of the call bell for assistance and to offer floor mats. The CCP did not contain any documentation or interventions for fall risk following the 08/25/18 fall. The incident report dated 8/28/2018 at 2:00 AM documented the resident was found on the floor next to his bed with skin tears on the right wrist and left elbow, and bumps on the head and right eye. The incident was reviewed by the interdisciplinary team on 8/28/2018 and determined the care plan was followed and new interventions included floor mats, a low bed, and medical to follow. A nursing progress note dated 8/28/2018 at 8:27 AM, documented the resident was found on the floor at 2:00 AM by a certified nurse aide (CNA) who heard a loud noise. He was face down next to the bed and said he rolled out of it. The incident report dated 8/28/2018 at 8:45 AM, documented the resident was found kneeling on the floor with his elbows on the bed. The incident was reviewed by the interdisciplinary team on 8/29/2018 and determined the care plan was followed and interventions included medical to see due to increased confusion and ? floor mats. The RN progress note dated 8/28/2018 at 6:05 PM, documented the resident was found kneeling to the left side of his bed with elbows on the bed at 8:45 AM. The resident stated he did not know what happened and he fell . He was assessed and returned to bed. A fall assessment completed 8/30/2018 at 11:45 AM, documented the resident was at risk for falls. The resident's care plan was updated 8/30/2018 and documented the resident was at risk for falls due to recent falls and the goal was to have no further falls. Interventions included a low bed, call bell within reach, and bilateral floor mats. When interviewed on 10/12/2018 at 9:49 AM, RN #22 stated he assessed the resident on 8/28/2018 at 2:00 AM when he fell out of bed. He stated the resident's bed was in the low position and he did not remember the resident having floor mats. When interviewed on 10/12/2018 at 11:25 AM, RN Manager #13 stated the resident did not trigger as a fall risk when she assessed him on admission and he was not care planned for falls. She stated he was at the facility before after fracturing his pelvis and she thought it was more than 3 months before his admission on 8/17/2018. She stated she was unaware of the fall on 8/25/2018 and he did not have floor mats. She stated she did not update the care plan to include fall interventions until 8/30/2018 and it should have been updated after the first fall on 8/25/2018. When interviewed on 10/12/2018 at 12:30 PM, the physician stated the resident was at high risk for fall and he would have expected a care plan to include falls. When interviewed on 10/12/2018 at 1:20 PM, the DON stated to determine the care plan was followed, they looked at the care plan and the interventions that were in place. She stated on the statement forms completed by the LPN and CNAs the last question asked about interventions in place. She reviewed the incident forms from the falls on 8/25 and 8/28/2018 and stated they did not fill them in correctly. She stated fall interventions were added to the care plan after he had falls and should have been updated 8/25/2018. She stated on the 8/28/2018 incident report for the fall at 8:45 AM she wrote ? floor mats as she was not sure if he had them. 10NYCRR 415.11(c)(2)(iii)

Plan of Correction: ApprovedNovember 6, 2018

1. Immediate Corrective Action:
Resident #142 was discharged from (NAME)any Gardens on 8/31/18.
2. Identification of Others:
Facility respectfully submits that all current and future residents had the potential to be affected by this deficient practice. As a result the facility will:
? Complete a full house audit on comprehensive care plans to ensure all residents have the appropriate plan of care and that the plan of care is being followed by staff.
? Re-education will be conducted for all RN Nurse managers/Supervisor staff on care plans and ensuring correct plan of care is documented for each resident.
3. Measures & Systemic Changes:
The facility will conduct the following in order to prevent this practice from occurring in future:
? Review the education-process for all RN Nurse managers/Supervisor staff for implementing care plans specific to each resident.
? Ensure all care plans are implemented/revised with appropriate interventions within a timely manner. All new admissions/re-admissions fall risk observations will be reviewed by Interdisciplinary Team in morning report to assure accuracy. MDS fall history assessment will be reviewed for accuracy in initial care plan meeting.

4. QA Monitoring:
The Nurse Managers will audit 10% of care plans monthly to ensure plan of care is individualized for each resident. Threshold compliance is 95%. This information will be gathered and reviewed monthly at the Quality Assurance meeting. Audits will be audited monthly for six months, at that time it will be referred to the Quality Assurance Committee for further guidance if needed.
5. Responsible Party and Expected Date of Completion:
The Director of Nursing or Designee is responsible for correction of this deficient practice and the expected completion date is (MONTH) 11th, (YEAR).

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 12, 2018
Corrected date: December 10, 2018

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure 1 of 2 employees (Employee #2) who received negative determination letters from their CHRC (Criminal History Record Check) was immediately removed from direct resident care or supervision. Specifically, the facility did not remove Employee #2 from resident access when notified the employee failed the CHRC. Findings include: The facility's 12/2010 Criminal History Record Check Policy documented that all prospective non-licensed staff that may be employed or used to provide direct care to residents undergoes a criminal history investigation by the Federal Bureau of Investigation. Upon receipt of the CHRC report, the facility must review it to determine the applicant's suitability for employment. If the CHRC revealed a Pending Denial (30-days to submit rehabilitation evidence), then the facility is prohibited from hiring this individual and will be advised of the same. Any individual deemed not employable must be removed from direct care immediately. Review on 10/10/2018 of a printout from CHRC, dated 8/1/2018, showed documentation a Pending Denial Letter was issued to the provider on 8/22/2017 for Employee #2. On 10/10/2018, the facility provided Employee #2's personnel record for review during survey. A Pending Denial Letter dated 8/22/2017 was in the record and documented the employee's eligibility for employment was denied by the New York State Department of Health. On 10/10/2018, Employee #2's job description as a dietary aide was reviewed and documented the employee was responsible for: - assisting in serving the meals, cold and hot beverages to the residents; - delivering the PM and HS (bedtime) nourishments as assigned; - setting the dining room tables for meals; and - cleaning the dining rooms. Review on 10/11/2018 of a Provisional Supervision Form for 7/31 through 8/23/2018, documented Employee #2 worked 1 day (8/23/2018) after the facility received the Pending Denial Letter. On 10/10/2018 at 3:05 PM, Business Officer #1 stated in an interview that Employee #2 began working as a provisional employee on 7/31 through 8/23/2018. The employee's Pending Denial letter was dated 8/22/2018 and she continued to work in the facility on 8/23/2018 on the day shift and several hours into the evening shift. Business Officer #1 stated she was the primary person responsible for checking the CHRC website, she was on duty on 8/22 and 8/23/2018, and was not sure why she missed the Pending Denial Letter for 2 days before removing Employee #2 from duty. 10NYCRR 402.7

Plan of Correction: ApprovedNovember 5, 2018

1) Immediate Corrective Action:
i. The identified Employee was terminated on: 08/24/18.
ii. The Director of Human Resources (HR) conducted a review of the file for Employee # 2 to assure that all required certifications, screenings, on-line checks, and NYS-DOH (CHRC) Criminal History Record Check have been entered & processed as required.
iii. The Director-of-HR also performed an immediate check of all current in-house employees of the CHRC site to check for any results, negative or otherwise.
iv. Human Resource Director will be counseled by the Administrator on the importance of performing CHRC back-ground checks properly & as required by applicable law.
v. Education & Counseling will be kept on file.
2) Identification:
i. The Facility respectfully submits that although the residents were potentially affected by this deficiency, no residents were affected as a result these findings.
ii. In order to prevent this occurrence in the future, the HR-Manager / Designee will ensure that each new employee, whom requires finger-printing, will be entered into the CHRC-System upon the application & hiring process. Purpose is to ensure that no individuals who are currently employed by (NAME)any Gardens or any new-hires, have any access to direct-care or in-direct care with residents.
iii. Human Resources will work together with other Dept.-Heads & IDT members as necessary in order to set up an education / In-Service for the CHRC Policy & Procedure as well as, Observation-Sheets. Purpose is to monitor & observe the new employee, as necessary, while awaiting the CHRC results. Facility will act accordingly if prospective-employees? results are found to be negative.
3) Systemic Changes:
i. The Policy & Procedure for CHRC will be reviewed & revised if necessary. P & P will be revised to include that website will be checked twice daily, for at least the first month.
ii. The Director-of-HR or Designee will develop a Program & Schedule to review & ensure that all in-house employee CHRC records are reviewed and any required action will be taken by the Facility if necessary. This is to ensure Facility is in compliance.
iii. All findings will then be logged into a Designated-Binder for which is to be reviewed by the Administrator or Designee as needed.
iv. The Director of Human Resources will ensure a Designee or back-up to perform these tasks should it be necessary.
4) Monitoring of Corrective Actions:
i. The Facility will develop an Audit-Tool which will include the findings of the Program & Schedule review as mentioned in previous Section. This includes audits of all new hires who may require Observation by HR-Manager or Designee (i.e. Department Head)
ii. The mentioned audits & reviews, including Policy & Procedure for checking the CHRC, will be conducted daily for the first month, on a weekly basis for the next two months, monthly for the next quarter and bi-monthly for the remainder of the year.
iii. The HR-Director or Designee, will report all audit findings to the QA / QAPI Committee, which are conducted at least quarterly, or as needed. At the conclusion of the meeting, the IDT or Committee will determine if any additional auditing or further action is needed.
5) Responsible Party & Expected Completion Date:
i. Director of Human Resources or Designee
ii. Expected Date of Completion is: 12/10/18

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 12, 2018
Corrected date: December 11, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure each resident's drug regimen must be free from unnecessary drugs for 2 of 7 residents (Resident #69 and 193) reviewed for unnecessary medications. Specifically, Resident #69 had orders for as needed [MEDICAL CONDITION] medications and those medications were not reviewed timely to determine if the medications could be discontinued. Resident #193 had orders for as needed (PRN) antipsychotic medication ([MEDICATION NAME]) and there was no documentation of non-pharmacological interventions attempted prior to the medication administration and no parameters to specify when the medication was to be given. Findings include: 1) Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The nursing admission progress note dated 10/5/2018 at 4:30 PM documented the resident arrived at the facility at 3:30 PM and was alert, able to make needs known, and was cooperative with care. The initial care plan dated 10/5/2018 documented the resident had behavioral symptoms due to a history of dementia with Sundow[DIAGNOSES REDACTED] (change in behavior in the evening hours). The goal was to make the resident calm and comfortable in his new surroundings and he would be cooperative with care. Interventions included: - giving evening medications at 6:00 PM for compliance; - redirecting the resident when he became behavioral; - involving the family in the resident's care; and - attempting to keep the resident on a routine towards the evening when his confusion increased. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The registered nurse (RN) Supervisor's progress note dated 10/5/2018 at 7:05 PM documented the resident was walking in the hallway attempting to go in other residents' rooms. When staff tried to redirect, the resident became belligerent and combative. He attempted to push past staff into another resident's room and was placed in a wheelchair and taken to his room. He did not want to stay there and was taken to the lounge. The resident thought staff were keeping him at the facility against his will and he wanted to go home. The resident's wife came in and the resident settled after she arrived and stayed for a while. The licensed practical nurse (LPN) progress note dated 10/5/2018 at 10:13 PM documented the resident was alert and confused. He walked out of his room several times and went into other residents' rooms. He was combative with staff and threatened staff on several occasions. The supervisor was notified and the resident was given [MEDICATION NAME] at 6:30 PM as ordered without effect. The resident offered no complaints. The MAR indicated [REDACTED]. The nursing progress note dated 10/6/2018 at 10:09 PM documented the resident was alert, confused, and able to make his needs known. He refused his meal and was given [MEDICATION NAME] at 7:00 PM as ordered, with effect. He did not have any behavior issues noted, denied pain, and had no complaints. The MAR indicated [REDACTED]. The nursing progress note dated 10/7/2018 at 10:12 PM documented the resident was given [MEDICATION NAME] at 8:00 PM for wandering in the hallways unassisted. The physician's progress note for 10/8/2018 documented the resident was placed on [MEDICATION NAME] while at the hospital and needed it for the first few days of his admission. The plan was to continue and monitor the need, try [MEDICATION NAME] at bedtime, and if the resident slept adequately, he would try to discontinue the [MEDICATION NAME]. The resident was interviewed on 10/9/2018 at 11:10 AM, he was alert and cooperative and stated he had pneumonia and was at the facility for strengthening with a plan to go home. The resident was observed on 10/10/18 at 09:07 AM in his room. He stated he felt good and had no complaints. The MAR indicated [REDACTED]. There was no documentation in the nursing progress notes for the shift. On 10/11/2018 at 3:15 PM, certified nurse aides (CNA) #3 and #4 were interviewed and stated they were full-time CNAs on the unit and knew Resident #193. CNA #3 stated she worked on 10/5/2018 when the resident was admitted and he was very calm at the time. She stated around 6 or 7 PM on the evening of admission he became very agitated, then his wife came in and he was fine. CNA #4 stated she worked on 10/6/2018 the day shift and the evening shift until 9 PM. She stated in the morning he was out of it, they found him on his knees and then he laid on the floor. They got him up and put him back to bed. She stated she got report from the overnight shift that he had to be medicated for being combative. She said during the evening he came out of his room with a hat, gloves, jacket, and shoes on and was ready to leave. CNA #4 brought him back to his room and talked him into staying and turned on the television. She said he came out for dinner and was fine. When interviewed by telephone on 10/11/18 at 3:30 PM, LPN #5 stated the resident had dementia with behaviors. He said the resident was fine during the day and in the evening his behaviors increased due to Sundow[DIAGNOSES REDACTED]. He said the family wanted the resident to have the television and lights on until he fell asleep at night to avoid sundowning behaviors. He said the resident wandered out of his room and into other rooms and they had to get him in a wheelchair to take back to his room. He stated the first night (10/5/18) the resident was aggressive and told the CNA they were going to get into a tangle. He went in and out of other rooms and became aggressive when they tried to get him back to his room. The supervisor was called and it took 2 CNAs, himself, and the supervisor to get him into a wheelchair and back to his room. Later, he walked out of his room and went into an empty room and used the bathroom. The staff got him back to his room and the RN Supervisor told LPN#5 the resident had a PRN order for [MEDICATION NAME]. He said he gave the resident the [MEDICATION NAME] and by the time he left the resident was in his room and was not behavioral. LPN #5 stated the next night, 10/6/18, the resident was calmer. He stated the resident was not aggressive and seemed agitated and was wandering. He stated the resident was also not using his call bell to get assistance for the bathroom and was going into the bathroom by himself. He said staff tried to redirect him and reminded him to use his call bell. He stated he gave the resident [MEDICATION NAME] as a measure to calm him down. LPN #5 said on 10/7/18 he gave the resident [MEDICATION NAME] to enable the CNAs to give the resident a shower. He stated the resident's wife was in and wanted to give him a shower. He told the wife she was not allowed to shower the resident and the CNAs would give the shower. He said the resident's behaviors also included being non-compliant with using his call bell, and he was resistive to going back to his room when he was wandering in the hall. When interviewed by telephone on 10/11/2018 at 3:50 PM, LPN #6 stated she was told in report on 10/10/2018 that the resident had a PRN order for [MEDICATION NAME] for behaviors and often needed it in the evening. She stated she was in the dining room and while the residents were waiting for dinner, he kept trying to get out of his wheelchair. She stated she gave the [MEDICATION NAME] before the dinner arrived and when dinner came he refused it and kept pointing to a lady and asking what was wrong with her. She stated he wanted to go back to his room and the CNA took him back. When asked what interventions she tried before giving the [MEDICATION NAME], she stated she repeatedly told the resident to sit down. When interviewed on 10/11/2018 at 4:10 PM, RN Supervisor #7 stated [MEDICATION NAME] as a PRN should only be used if the resident was combative and putting other residents at risk or if the resident was so fearful and the cycle could not be broken. She stated when a resident was combative or acting out, redirection, reassurance, calling the family, or diverting attention by giving food or drink would be interventions to try prior to giving [MEDICATION NAME]. She stated on 10/5/2017 she admitted the resident to the facility and he was calm and appropriate at the time. She stated later in the evening he started wandering, was confused and combative. She stated they were unable to redirect the resident, he was going into other resident's rooms and thought they were holding him prisoner. She stated they gave him [MEDICATION NAME] and called the family. The family came later and stayed with him. She stated she was unaware of the resident needing [MEDICATION NAME] after that night. She stated she worked 10/10/2018 and did not hear anything about the resident's behavior, only that he refused to use Bi-pap (breathing apparatus). When interviewed on 10/12/2018 at 11:10 AM, RN #13 Manager stated the resident had a PRN order for [MEDICATION NAME] that was started in the hospital and she expected other interventions to be tried before giving [MEDICATION NAME]. She stated it was appropriate to give if the resident was going to cause harm to himself or others and all other interventions were tried. She stated wandering, non-compliance with the call bell, and not sitting down were not acceptable reasons to give [MEDICATION NAME]. When interviewed on 10/12/2018 at 12:30 PM, the physician stated he did not like to use antipsychotics and if the resident came from the hospital he did not want to discontinue it abruptly. He stated antipsychotics should be used as a last resort if there was the potential for harming self or others. He stated the resident came with a PRN order for [MEDICATION NAME] and he expected it to be used after other interventions were tried. 2) Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired, she had physical behavioral symptoms directed towards others (hitting, kicking, scratching) and she had other behavioral symptoms not directed towards others (disrobing, disruptive sounds). The 3/16/17 comprehensive care plan (CCP), updated 7/25/18, documented the resident had intermittent [MEDICAL CONDITION], and could be aggressive and combative at times. Interventions included to provide a quiet, non-hurried environment and monitor negative interactions with staff and other residents. On 10/11/2018, the resident's record was reviewed on survey and documented: - A 9/18/2018 physician assistant (PA) note. The resident had increased behaviors. She was being treated for [REDACTED]. - A 9/18/2018 physician order [REDACTED]. - A nursing progress note date 9/26/2018 at 2:27 PM, written by licensed practical nurse (LPN) Manager #14, the resident was seen by medical and [MEDICATION NAME] was added every 6 hours PRN for agitation, anxiety and combativeness. - A 9/26/2018 physician order [REDACTED]. The resident's record did not document a rationale for the extended timeframe (23 days) of both PRN medications and did not document a specific duration the medications would be used. On 10/12/2018 at 11:20 AM, LPN Manager #14 stated in an interview the resident's behavior consisted of being combative, obsessing about using the bathroom, and she stripped and yelled at times. She stated she was aware of the new regulation for PRN [MEDICAL CONDITION], the time limit was 14 days and was not aware the resident had two current orders for [MEDICAL CONDITION] that exceeded 14 days. She stated liquid [MEDICATION NAME] was added on 9/26/2018 because the resident occasionally would not swallow pills. She was not aware the order written for [MEDICATION NAME] tablets on 9/18/2018 was not discontinued and should have been. On 10/12/2018 at 12:15 PM, the Medical Director stated the PA (physician assistant) that prescribed the resident's medication was not available for interview. He stated he was aware that PRN [MEDICAL CONDITION] needed to be reviewed after 14 days, nursing was responsible to alert medical when 14 days were up, and he was not aware the resident's medications had not been re-evaluated. 10NYCRR 415.12(l)(2)

Plan of Correction: ApprovedNovember 6, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate Corrective Action:
Resident #193?s PRN [MEDICATION NAME] was discontinued on (MONTH) 12th, (YEAR).
Resident #69?s [MEDICATION NAME] ordered was reviewed by medical and re-ordered for 14 days. Medical will re-evaluate resident on (MONTH) 26th, (YEAR).
Agency Nurse was removed from schedule and currently is no longer working at (NAME)any Gardens for failure to follow policy.

2. Identification of Others:
Facility respectfully submits that all current and future residents have the potential to be affected by this deficient practice. As a result:
? The facility will complete a full in-house audit on all PRN [MEDICAL CONDITION] orders to ensure all residents with PRN [MEDICAL CONDITION] have a 14 day end date.
? Re-education to all RN/LPN staff regarding the [MEDICAL CONDITION] Medication Policy and the documentation needed for all non-pharmacological interventions prior to a PRN [MEDICAL CONDITION] medication being administered.
3. Measures/ Systemic Changes:
The following steps will be taken:
? The Nurse manager/Supervisor will review any new or revised order at the time the order is given to ensure all PRN [MEDICAL CONDITION] medications have a 14 day end date.
? The physician will be notified of any discrepancy found to ensure accuracy of all orders.
? Re-education will be given annually and with any changes to all RN/LPN staff on the process of entering orders in the EMAR system with a 14 day end date for all PRN [MEDICAL CONDITION] medications and the documentation needed for all non-pharmacological interventions prior to a PRN [MEDICAL CONDITION] being administered.
4. QA Monitoring:
The Nurse Managers will audit all PRN [MEDICAL CONDITION] medication orders entered into the EMAR system on their units weekly. Threshold for compliance is 95%. This information will be gathered and reviewed monthly at the Quality Assurance meeting. PRN [MEDICAL CONDITION] orders will be audited weekly for 3 months, at that time it will be referred to the Quality Assurance Committee for guidance.
5. Responsible Party and Expected Date of Completion:
The Director of Nursing or Designee is responsible for correction of this deficient practice and the expected completion date is (MONTH) 11th, (YEAR).

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 12, 2018
Corrected date: December 11, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY 753), the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #29) reviewed for falls. Specifically, Resident #29 had a lap buddy (a lap cushion used in a wheelchair to aid in fall prevention) and was left unsupervised with the lap buddy released and the resident sustained [REDACTED]. Findings include: The facility's Restraint Use policy dated 5/2018 included the definition of a physical restraint is a device or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the body. Types of restraints included seatbelts, trays, and tables that the resident cannot easily remove and which prevent the resident from rising. The policy did not include parameters for release of the restraint and supervision when not in use. Resident #29 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 5/25/2018 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment with disorganized thinking and inattention. The resident exhibited behaviors of wandering one to three days during the assessment period and required extensive assistance for most activities of daily living (ADLs). The resident had one fall without injury and two or more falls with injury since admission or since the prior assessment. The fall risk assessment dated [DATE] documented the resident had 3 or more falls in the last 3 months, had impaired mobility, balance problems while standing and walking, and was at risk for falls. The restraint assessment dated [DATE] documented the resident had a chair alarm 05/14/18 to 05/18/18. Instructions included to remove every 2 hours and at meal time. Reasons for the use of the seatbelt were poor impulse control and no safety awareness. Physician orders [REDACTED]. The comprehensive care plan (CCP) dated 5/23/2018 documented the resident had a lap buddy due to unsafe attempts to self-ambulate and not asking for help. The lap buddy was to be released every 2 hours and as needed for toileting, meals and ambulation. The resident was not to be left unattended in his wheelchair without the lap buddy in place. The resident care profile (care instructions) dated 5/23/2018 documented the resident had a lap buddy, to release it every 2 hours, as needed, for toileting, meals, and ambulation. The incident and accident report dated 6/16/2018 documented the resident was found on the floor at 09:50 AM in front of the elevator and had a [MEDICAL CONDITION] and hematoma (a collection of blood under the skin). The resident was sent to the emergency department and admitted with a subdural hematoma (a collection of blood on the brain's surface). Follow up interventions noted a possible change to an alarming seatbelt and to educate staff to replace the lap buddy if the resident was unattended. Staff statements included: - Licensed practical nurse (LPN) #17 noted she was on break and returned when she heard the page for a Supervisor to the unit; - CNA #16 noted she was told the resident fell and she assisted CNA #15 in taking the resident to the bathroom before the incident; - Occupational therapy aide #20 noted another resident notified her in the hall of the resident's fall and she went to get help. The undated investigation summary prepared by the Director of Nursing (DON) documented on 06/16/2018, the resident was brought to the dining room and placed at the table; his lap buddy had been removed; staff assisted other residents, and the resident got up, walked down the hall, and fell near the elevator door frame. The DON and Assistant Director of Nursing (ADON) reviewed camera footage and noted staff did not replace the lap buddy after returning the resident to the dining room and left the resident unsupervised. CNA #15 was disciplined and stated she was unaware the lap buddy was to be put back on as the resident was at the table. The hospital discharge summary dated 6/19/2018 documented the resident was admitted to the hospital on [DATE] with left temporal subarachnoid hemorrhage (bleeding in the space that surrounds the brain). The resident had left parietal scalp swelling and surgical staples. A physician's orders [REDACTED]. The resident was observed: - On 10/09/18 at 12:02 PM, eating lunch in the dining room, his seatbelt on in the wheelchair; and - On 10/10/18 at 08:59 AM, in the dining room eating breakfast with his seatbelt on in the wheelchair; The resident's family member was interviewed on 10/09/18 at 01:31 PM and stated the primary reason the resident was admitted to the facility was due to his ongoing falls at home. He had no safety awareness and was not steady on his feet. She stated he would impulsively stand without assistance at any given time and this was the reason he was now utilizing the alarming seat belt. He used to have a lap buddy, but he would remove it and did not care for it. During an interview on 10/12/18 at 10:30 AM, CNA #16 stated when the resident fell on [DATE], she was assisting another resident and CNA #15 had gone on break, she was unaware of the LPN's location at the time. She stated any resident with a restraint (lap buddy) needed to be supervised when the restraint was released. She stated CNAs were not always able to directly supervise residents and nurses and activities staff also helped. Resident #29 was to be checked often, and if his lap buddy was not in place, he needed to have direct supervision. CNA #15 stated during an interview on 10/12/18 at 10:40 AM, she took the resident to the bathroom after breakfast, did not replace his lap buddy, and placed him at the table in the main dining room. She stated she thought the resident could not have his lap buddy while at the table and she knew he required supervision when the lap buddy was off. She stated LPN #17 was just outside the dining room talking with LPN #18 and she (CNA #15) went on break. She stated she should have told LPN #17 she was leaving the floor and the resident was in the dining room without his lap buddy. She was one of 2 CNAs on the day shift that day and she knew the resident required supervision. When interviewed on 10/12/18 at 12:30 PM, the DON stated she reviewed the video footage after the resident's fall. She observed the resident was brought back into the dining room by CNA #15 after breakfast. LPN #17 was just outside the dining room and LPN #18 joined her, and they left down the stairwell to go on a break. CNA #15 had left just before the LPNs and did not communicate with them she was leaving or the resident was at the table without the lap buddy. CNA #16 was on the other side of the unit caring for residents. Resident #29 was observed to push back his wheelchair from the table, stand, and walk out of the dining room, toward the elevator and appeared to stumble over his feet. The DON stated the resident walked at a quick pace and only minutes had elapsed from being seated to walking down the hall. CNA #16 was still in a resident's room and the resident fell forward and hit his head. The expectation was for staff to supervise residents anytime a restraint was released and CNA #15 should have told someone she left resident unattended without his lap buddy and was leaving the unit. The DON stated even if the resident profile did not specify to provide constant supervision while the lap buddy was off, the standard for CNA practice would be to provide supervision anytime a restraint was released. 10NYCRR 415.12(h)(2)

Plan of Correction: ApprovedNovember 2, 2018

1. Immediate Corrective Action:
Resident #29 was sent to Rome ED for evaluation on (MONTH) 16th, (YEAR) and returned to the facility on (MONTH) 22nd, (YEAR).
CNA was disciplined for failure to follow plan of care on 6/25/18.

2. Identification of Others:
Facility respectfully submits that all current and future residents had the potential to be affected by this deficient practice. As a result the facility will:
? Complete a full house audit on all Accidents and Incidents to ensure comprehensive care plans and CNA care instructions for all residents have the appropriate plan of care and that the plan of care is being followed by all nursing staff.
? Re-education on the Restraint Policy was completed for nursing staff by (MONTH) 6th, (YEAR).
3. Measures & Systemic Changes:
The facility will conduct the following in order to prevent this practice from occurring in future:
? Review the education-process for all new hires on the Accident and Incident Policy and the Restraint Policy and how to follow the plan of care for each resident in the care instructions.
? Re-education will then be given annually and as needed to all nursing staff of the understanding of the Restraint Policy, care plan reviews and CNA care instructions.
4. QA Monitoring:
The Nurse Managers will audit all Accident and Incident reports on their units. The Accident and Incident reports will be reviewed in morning report to ensure compliance. Any accident or incident involving a resident with a restraint will be investigated thoroughly to ensure the proper supervision was provided. Threshold for compliance is 95%. This information will be gathered and reviewed at the Quality Assurance meeting. Accident and Incidents will be audited at least weekly for 3 months, at that time it will be referred to the Quality Assurance Committee for guidance.
5. Responsible Party and Expected Date of Completion:
The Director of Nursing or Designee is responsible for correction of this deficient practice and the expected completion date is (MONTH) 11th, (YEAR).

FF11 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 12, 2018
Corrected date: December 11, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure the services provided were consistent with professional standards of quality for 1 of 3 residents reviewed for accidents. Specifically, Resident #142 sustained a fall and neurological checks were not done accurately and according to policy, the physician was not notified timely, and falls were not communicated so that interventions could be implemented. The resident subsequently had a change in condition and altered mental status and was hospitalized . Findings include: The facility's neurological assessment policy dated 10/2010, documented a resident was to have neurological assessments following an unwitnessed fall or after a fall with a suspected head injury. The neurological assessment flow sheet documented assessments were to be done every 15 minutes x 4, then every 30 minutes x 4, then every 1 hour x 4, then every 4 hours x 2, and then every 8 hours x 2. The facility's fall policy dated 7/2017 documented the attending physician was to be immediately notified, the resident's comprehensive care plan (CCP) was to be updated with interventions to reflect the event, and the event was to be documented on the 24-hour report. Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired. The resident required extensive assistance of 2 for bed mobility, transfers, dressing, toilet use, hygiene, and bathing. He required limited assistance of 1 for walking and supervision with set-up for eating. The MDS documented the resident had no falls in the past 6 months. A hospital discharge summary dated 5/30/2018 documented the resident was admitted to the hospital on [DATE] for a fractured pelvis. A hospital discharge summary dated 8/17/2018 documented the resident was admitted to the hospital on [DATE] for generalized weakness and leukocytosis (high white blood cell count, infection) without fever. The summary also documented the resident had a recent [MEDICAL CONDITION] ramus and acetabulum (pelvic bone where the head of the femur meets). The admission fall risk assessment dated [DATE] documented the resident had no falls in the past 3 months and determined he was not at risk for falls. (He was previously at the facility for rehabilitation after the fractured pelvis.) The resident's care plan dated 8/17/2018 documented the resident used a wheelchair and ambulated in therapy only. He required extensive assistance of 1 for bed mobility and extensive assistance of 2 with a rolling walker for transfers. The care plan did not document the resident was at risk for falls. The physician's history and physical dated 8/20/2018 documented the resident was admitted for physical therapy (PT) and occupational therapy (OT) after an episode of profound weakness. The resident was doing well and was discharged from the facility previously after having rehab for a fractured pelvis. He went home and 2 days later was admitted to the hospital with [REDACTED]. The plan was to return home after rehabilitation. The nursing progress note dated 8/25/2018 at 5:02 PM, documented the resident was found on the floor in his room. The resident stated he did not know how he got there and stated he hit his head on the nightstand. No injuries were noted and the resident was assessed and assisted back to bed. He was reminded to use the call bell and neurological checks were initiated. The incident report dated 8/25/2018 documented at 4:50 PM, the resident was found on the floor in his room. It was not documented if the physician was notified. The neurological assessment flow sheet documented the resident was given Tylenol for pain at 6:15 PM. The neurological assessments were done from 8/25/2018 at 5 PM until 7:45 AM on 8/26/2018, the last 2 assessments to be done every 8 hours were not documented. There were no updates made to the care plan to protect the resident from further falls. The incident report dated 8/28/2018 documented at 2:00 AM, the resident was found on the floor in his room. It documented a note was left in the physician's book for minor injuries. The report documented 2 bumps on the resident's head measuring 1/2 x 1/2 inch and 1-1/4 inch circle. He also had 2 skin tears measuring 1/2 x 1/2 inch and 2-1/4 x 1-1/4 inches. The neurological assessment flow sheet documented neurological checks were done every 15 minutes from 2:00 AM to 2:45 AM. There were no checks done from 2:45 AM to 4:45 AM and it was documented the resident was sleeping. A nursing progress note dated 8/28/2018 at 8:27 AM, documented the resident was found on the floor at 2:00 AM by the certified nurse aide (CNA) who heard a loud noise. The resident was face down next to the bed and said he rolled out of it. The neurological assessment was benign, his grips were equal and strong, range of motion was good, his pupils were equal and reactive to light, there was no pain and no change in mental status. He had 2 skin tears, and on the upper right aspect of his head had a 1-1/4 inch circle/bump slightly raised and tender to touch. Above his right eye was a 1/2 inch circle/bump raised and tender to touch. He was transferred safely back to bed, rechecked numerous times, and had no change in mental status. The resident was not on the 24-hour report (shift to shift nursing communication) for falling on 8/28/2018 at 2:00 AM. The incident report dated 8/28/2018 at 8:45 AM, documented the resident was found kneeling on the floor with his elbows on the bed. It was not documented when the provider was notified. Neurological checks were documented per protocol from 8:45 AM to 3:30 PM and noted the resident's level of consciousness as alert at every check. A nursing progress note dated 8/28/2018 at 2:39 PM, documented the resident was lethargic throughout shift and fell at 8:45 AM. The neurological assessment flow sheet dated 8/28/2018 for the fall at 8:45 AM was discontinued at 7:30 PM and did not document the last 3 checks to be done. The resident was not on the 24-hour report (shift to shift nursing communication) for falling on 8/28/2018 at 8:45 AM. There was no further documentation in the resident's record regarding the head injuries (bumps) he sustained when he fell on [DATE] at 2:00 AM. The physician assistant (PA) progress note dated 8/29/2018 documented the resident was seen for follow-up of the emergency room visit on 8/27/2018 for abdominal pain with tenderness, and diaphoresis (profuse sweating). He was diagnosed in the emergency room with a UTI and started on an antibiotic. The note did not document the resident's falls. A hospital discharge summary dated 9/13/2018 documented the resident was admitted to the hospital on [DATE]. His discharge [DIAGNOSES REDACTED]. When interviewed on 10/12/2018 at 9:49 AM, RN #22 stated he assessed the resident on 8/28/2018 at 2:00 AM when he fell out of bed. He stated he was the floor nurse and the RN Supervisor that night. He stated he did not call the physician that night as there was no change in the resident's mental status. He said he wrote a note in the physician book and gave a verbal report to the next shift. He completed the incident report and put it in the box in the nursing office. He said all incidents should be put on the 24-hour report and he did not remember if he put the resident on the report. He stated if the resident was sleeping, he would not wake for neurological checks. If there was a major injury such as bleeding, a change in physical or mental status, pain, or a behavioral change he would wake the resident for neuro checks. He said the resident had no change in condition and the bumps on his head did not worsen. When interviewed on 10/12/2018 at 11:25 AM, RN Manager #13 stated she was unaware of the resident's fall on 8/25/2018 and he should have had floor mats put into place after the fall. She stated she was unaware of the resident's falls on 8/28/2018 until a day or 2 later. She stated the resident should have been woken for neurological checks during the night and the nurse's documentation on 8/28/2018 was conflicting. She stated the resident could not be both alert and lethargic. She stated the medical provider saw the resident on 8/29/2018 and was aware of his falls. She stated the physician should be notified of any falls with injury. When interviewed on 10/12/2018 at 12:30 PM, the physician stated he was usually notified immediately of falls. He stated it depended upon the fall if they needed to call during the night. If there was an injury, the physician expected to be notified. He stated he was aware the resident had falls and did not know how often. He was not sure if he knew the resident hit his head. He stated it was difficult to assess the resident as some days he presented better than others and progressively got weaker. The resident ended up with a subdural hematoma and it could not be determined when it started. He stated the resident was at high risk for falls on admission as he was at the facility before for a fractured pelvis and had a history of [REDACTED]. When interviewed on 10/12/2018 at 1:20 PM, the DON stated the physician should be notified immediately of any fall with injury. She stated during the night they could wait until morning if there was no injury. She said for major injuries the resident would be sent to the hospital and with other injuries the physician was notified. She stated the resident should be woken for neurological checks if he hit his head. She could not tell from the incident report if the provider was notified on 8/25/2018 as the box was checked for the physician and there was no time or date documented. For the incident on 8/28/2018 at 2:00 AM, the physician should have been notified and the resident should have been put on the 24-hour report, and the resident should have been woken for neuro checks. She stated the nurse taking care of the resident on 8/28/2018 on the 7:00 AM to 3:00 PM shift had conflicting information on the neuro check sheet and her progress note as the resident could not be both lethargic and alert at the same time. 10NYCRR 415.11(c)(3)(i)

Plan of Correction: ApprovedNovember 2, 2018

1. Immediate Corrective Action:
Resident #142 was discharged from (NAME)any Gardens on 8/31/18.

2. Identification of Others:
Facility respectfully submits that all current and future residents have the potential to be affected by this deficient practice. As a result:
? The facility will complete a full in-house audit on Accident and Incident reports to ensure all residents have the appropriate care plan in place and that the plan of care is being followed by RN/LPN staff, all reports have documentation that the medical provider was notified in a timely manner, all neurological assessments are completed as per policy and all accidents and incidents are documented on the 24 hour report sheet.
? 24 hour report sheet revised to add a section designated for Accident and Incidents.
? All Nurse mangers/Supervisors will be re-educated on the Accident and Incident policy and procedure, including Neurological Assessment policy and procedure and Fall policy.
3. Measures/ Systemic Changes:
The following steps will be taken:
? The Nurse manager/Supervisor will notify the medical provider, either by phone or face to face, of any new accident or incident and document on the Accident and Incident report. The medical provider will be notified of all incidents with injury at time of incident.
? The Nurse managers will review any new accident or incident report to ensure compliance, including neurological assessment form.
? The Nurse manager/Supervisor will document all Accident and Incidents on the 24 hour report sheet.
? Re-education will be given annually and with any changes to all RN/LPN staff on the Accident and Incident policy and procedure, Neurological Assessment policy and Fall policy and procedure.
4. QA Monitoring:
The Nurse Managers will audit all Accident and Incident reports on their units. The Accident and Incident reports will be reviewed in morning report to ensure compliance. Threshold for compliance is 95%. This information will be gathered and reviewed at the Quality Assurance meeting. Accident and Incidents will be audited at least weekly for 3 months, at that time it will be referred to the Quality Assurance Committee for guidance.
5. Responsible Party and Expected Date of Completion:
The Director of Nursing or Designee is responsible for correction of this deficient practice and the expected completion date is (MONTH) 11th, (YEAR).

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 10, 2018
Corrected date: December 9, 2018

Citation Details

Based on record review and interviews during the Life Safety Code survey, the facility did not ensure the generator testing was maintained. Specifically, the monthly load test was not conducted at 30% or greater of the generator capacity and no fuel quality test was performed annually, as required. Findings include: Review on 10/9/2018 of the generator load test reports dated from 9/29/18 and 10/3/18 showed the tests were not conducted at equal to or greater than 30% of the generators' capacity (175 kilowatt). There were no load tests performed at greater than 30%. Specifically, the documented load testes were calculated to be 10.6% of the total kilowatt value. When interviewed on 10/9/2018 at 3:35 PM, the Facility Director stated he was not aware the generator was not running at 30% or greater during load tests. He stated the generator vendor did not review their monthly load tests when conducting their annual inspection. Review on 10/9/2018 of the semi-annual maintenance tests dated from 1/31/2018 to 7/2/2018 performed by the generator vendor did not indicate an annual load bank test or an annual fuel quality test had been performed. When interviewed on 10/9/2018 at 3:35 PM, the Facility Director stated no load bank tests or fuel quality tests have ever been performed on the generator. 2012 NFPA 99: 6.4.4.1.1.3 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 1, 2018

K 918:
1) Immediate Corrective Action:
a. The Director of Environmental Services or Designee will contact vendor to schedule a load-bank test & Fuel Quality-Test. Expected Completion Date for this:
b. Maintenance Staff will be counseled by Administrator or Designee on the importance of ensuring the load-bank test & Fuel Quality tests are conducted as required.
c. A review of the applicable NFPA-99-Codes, pertaining to load-bank test & Fuel Quality test will be conducted.
d. Documentation of the counseling & education will be kept on file.
2) Identification:
a. The Facility respectfully submits that although residents were potentially affected by this deficiency, no residents were affected or harmed as a result of these findings.
b. The Director of Environmental Services or Designee will identify & record the proper measurement for generator-load testing. This is to ensure these tests are being conducted at 30% or greater of the generator-capacity. Purpose is also to ensure compliance.

c. Should any further issues regarding this matter arise, If generator test load is lower, adjustments will be made as needed. Also, vendor contacted if necessary to address & correct any issues to ensure compliance.
3) Systemic Changes:
a. The Director of Environmental Services or Designee will review & revise the Policy & Procedure as needed to ensure proper monitoring & measurements of the generator capacity to ensure the load-bank tests & fuel-quality tests are being performed.

b. The Facility will also develop a Preventive Maintenance Program & Schedule. This will consist of scheduling the load-bank tests & the Fuel-Quality-tests within required time-frame.

c. Findings of these measurements & readings will be logged in a Designated Binder which will be reviewed by the Administrator or Designee.
4) Monitoring of Corrective Actions & Quality Assurance:

a. The Facility will also develop an Audit Tool which will include the findings / readings of the mentioned tests above. These will also be will be reviewed by the Administrator or Designee as needed.

b. The Director of Environmental Services or Designee will complete audits on a bi-weekly basis for the first month, on a monthly-basis for the next quarter and then quarterly thereafter for remainder of the year.

c. Any further corrective Action will be implemented if necessary. The Administrator or Designee will report all findings to the QA / QAPI Committee during its quarterly or as needed-meetings. At the end of each QA / QAPI Meeting, a determination will be made by the Committee if any further corrective-actions or additional-auditing is needed.
5) Responsible Party & Expected Completion Date:

a. Administrator, Director of Environmental Services Director or Designee

b. Expected date of completion: 12/08/2018

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 10, 2018
Corrected date: December 9, 2018

Citation Details

Based on record review and interview conducted during the Life Safety Code survey, the facility's fire alarm system was not inspected in accordance with the requirements of National Fire Protection Association (NFPA) 72. Specifically, the elevator recall, the alternate elevator recall, and the remote LED indicator was not inspected annually, as required. Findings include: Review on 10/10/2018 of the facility's fire alarm system inspection reports, dated 1/12/2018 and 7/13/2018, indicated the elevator recall, the alternate elevator recall, and the remote LED indicator were not inspected annually, as required. On the fire alarm inspection report dated 7/13/2018 it indicated 1 of 1 elevator recall, 1 of 1 alternate elevator recall, and 1 of 1 remote LED indicator was not inspected. During an interview on 10/10/2018 at 9:45 AM, the Facility Director stated he was unaware of the items not getting inspected. He further stated after contacting the vendor that the prior Environmental Services Supervisor told the vendor it was ok to not have the missing items inspected. 2012 NFPA 101: 19.3.4.1, 9.6.1.5 2010 NFPA 72: 14.1, 14.3.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 1, 2018

K-345:
1)Immediate Corrective Action:
a. Maintenance Staff will be counseled and in-serviced on the importance of testing the Fire Alarm System & complying with necessary requirements as needed. This includes review of any applicable sections of NFPA 70, National Electric Code & also NFPA 72, (National Fire Alarm & Signaling Code).
b. Director of Environmental Services will set up a schedule to ensure that the Fire Alarm System Inspection Reports (Specifically the Elevator Recall, Alternate-Recall, & Remote LED Indicator) are reviewed, updated if necessary and inspected as required.
c. Director of Environmental Services will contact vendor to ensure the inspection & testing is performed and completed up-to date & in compliance. Expected Completion date is: 12/09/18

2) Identification:
a. The Facility respectfully submits that although residents were potentially affected by this deficiency, no residents were affected or harmed as a result of these findings.
b. The Director of Environmental Services / Designee will conduct rounds to see if any other mentioned-areas needed inspection. Results will be documented in a designated log.
c. Should any further issues regarding this matter arise, it will be addressed and corrected to ensure compliance.
3) Systemic Changes:
a. The Administrator, Director of Environmental Services or Designee will develop a Preventive Maintenance Program & Schedule to ensure that all the mentioned-areas are reviewed and inspected as necessary in order to ensure compliance.
b. The findings will then be logged in a Designated Binder which will be reviewed by the Administrator or Designee as needed.
4) Monitoring of Corrective Actions & Quality Assurance:
a. The facility will develop an Audit-Tool which will include the findings the of rounds to identify & ensure that the Fire Alarm System Inspection & the Elevator Recall, Alternate-Recall, & Remote LED Indicator are all up-to date and in compliance.
b. The Director of Environmental Services will complete audits on a bi-weekly basis for the first month, on a monthly-basis for the next quarter and then quarterly thereafter for remainder of the year.
c. Any further corrective Action will be implemented if necessary.
d. The Administrator or Designee will report all findings to the QA / QAPI Committee during its quarterly or as needed-meetings. At the end of each QA / QAPI Meeting, a determination will be made by the Committee if any further corrective-actions or additional-auditing is needed.
5) Responsible Party & Expected Completion Date:
a. Administrator, Director of Environmental Services Director or Designee
b. Expected date of completion: 12/09/2018

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 10, 2018
Corrected date: December 9, 2018

Citation Details

Based on observations and interview during the Life Safety Code survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 2 isolated areas (basement corridor and education room) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2 which states Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, both areas contained both quick response and standard response sprinkler heads. Findings include: 1. When observed on 10/9/2018 at 1:53 PM, there were 2 quick response sprinkler heads and 2 standard response sprinkler heads located within the basement corridor. 2. When observed on 10/9/2018 at 2:18 PM, there were 2 quick response sprinkler head and 2 standard response sprinkler heads located within the education room. When interviewed on 10/9/2018 at 2:18 PM, the Facility Director stated he did not know about the mixed sprinkler heads in both areas. He stated in 2014, new heads were added to the branch from the west stairwell leading into the basement. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 1, 2018

K-351:
1) Immediate Corrective Action:
a. Maintenance Staff will be counseled and in-serviced by the Administrator or Designee on the importance of ensuring that the correct and proper sprinkler-head types in the identified areas of Basement Corridor & Education-Room(s) are in place.
b. A vendor will be contacted to come to the Facility to check the identified area(s). Will schedule a date to perform the project if needed. Expected Date of Project Completion: 12/09/18
c. A review of the applicable sections in NFPA-13 & NFPA 101, pertaining to Standard for Installation of Sprinkler Systems will be conducted by the Administrator or Designee with the Maintenance staff.
d. Documentation of the counseling & education will be kept on file.
2) Identification:
a. The Facility respectfully submits that although residents were potentially affected by this deficiency, no residents were affected or harmed as a result of these findings.
b. The Director of Environmental Services or Designee will form a Team & rotation-schedule to perform rounds to check these identified areas, including the Basement Corridor & Education-Room & other identified rooms which pertain to these types of sprinkler-heads. Purpose is to ensure that they are properly installed according to applicable NFPA codes, Standard for Installation of Sprinkler Systems code.
3) Systemic Changes:

a. The Director of Environmental Services or Designee, will develop a Preventive Maintenance Program & Schedule. Will implement to the team. Purpose of performing rounds is to ensure the identified areas mentioned above or any other identified area which may need installation for the proper-sprinkler-heads are in compliance with the applicable NFPA Code(s).

b. The findings will then be logged in a Designated Binder, which will be reviewed by the Administrator or Designee as needed.

4) Monitoring of Corrective Actions & Quality Assurance:

a. The facility will develop an Audit-Tool which will include the findings of rounds mentioned above. This is to include any new identified areas that need to change the Sprinkler-Head types in identified rooms or other areas if necessary.
b. The Director of Environmental Services will complete audits / rounds on a bi-weekly basis for the first month, on a monthly-basis for the next quarter and then quarterly thereafter for remainder of the year.

c. Any further corrective Action will be implemented if necessary.

d. The Administrator or Designee will report all findings to the QA / QAPI Committee during its quarterly or as needed-meetings. At the end of each QA / QAPI Meeting, a determination will be made by the Committee if any further corrective-actions or additional-auditing is needed.
5) Responsible Party & Expected Completion Date:
a. Administrator, Director of Environmental Services Director or Designee

b. Expected date of completion: 12/09/2018

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 10, 2018
Corrected date: December 9, 2018

Citation Details

Based on observations and interview conducted during the Life Safety Code Survey, the facility did not properly maintain smoke barrier doors for one isolated area (3rd floor dining room west smoke barrier door). Specifically, the 3rd floor dining room west smoke barrier door was not able to self close when tested . The findings include: When observed on 10/9/2018 between 11:40 AM and 12:45 PM, the 3rd floor dining room west smoke barrier door was not able to self close, as required. When tested by the surveyor the door became stuck on the floor and had to be pulled closed. While attempting to pull the door closed it again became stuck on the floor approximately six inches prior to full closure. When interviewed on 10/9/2018 at 11:40 AM, the Environment Services Supervisor stated smoke barrier doors were checked monthly at each fire drill. 2012 NFPA 101: 19.3.7.8, 8.5.4.1, 8.4.3.4 2010 NFPA 80: 6.3.1.7.1 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 6, 2018

K 374:
1) Immediate Corrective Action:

a. Adjustments were made to the mentioned 3rd Floor-Dining-Room, West Smoke-Barrier Door. This included immediate removal of the specified door; 1/8th of an inch was removed from the bottom of the door to clear for the new floor; door was also further checked if any other adjustments were needed before placing back to original spot. 3rd-Floor-Dining-Room, West Smoke-Barrier Door now closes freely.

b. Maintenance Staff will check all Smoke Barrier Doors on the identified Unit, to ensure that they are able to properly self-close.

c. Maintenance Staff will be counseled and in-serviced by the Administrator or Designee on the importance of ensuring that Smoke Barrier Doors are able to properly self-close upon testing or at other times when they need to close.

d. A review of the applicable code(s) in NFPA-80 & NFPA-101, pertaining to Smoke Barrier Doors, will be conducted by the Administrator or Designee with the Maintenance staff.

e. Documentation of the counseling & education will be kept on file.
2) Identification:
a. The Facility respectfully submits that although residents were potentially affected by this deficiency, no residents were affected or harmed as a result of these findings.

b. The Director of Environmental Services or Designee will form a Team & rotation-schedule to perform Environmental-Rounds to check & ensure that the Smoke Barrier-Doors are able to properly self-close. Purpose is to ensure Facility is in compliance.

c. Should any further issues regarding this matter arise, it will be addressed and corrected to ensure compliance.
3) Systemic Changes:

a. The Director of Environmental Services or Designee, will develop a Preventive Maintenance Program & Schedule and implement to the team. This will include performing rounds, as mentioned above, to ensure that the Smoke Barrier Doors are able to self-close properly.

b. The findings will then be logged in a Designated Binder, which will be reviewed by the Administrator or Designee as needed.
4) Monitoring of Corrective Actions & Quality Assurance:

a. The facility will develop an Audit-Tool which will include the findings of rounds performed for purpose mentioned above. This will be kept in an identified-binder.

b. The Director of Environmental Services will complete audits on a bi-weekly basis for the first month, on
a monthly-basis for the next quarter and then quarterly thereafter for remainder of the year.

c. Any further corrective Action will be implemented if necessary.

d. The Administrator or Designee will report all findings to the QA / QAPI Committee during its quarterly or as needed-meetings. At the end of each QA / QAPI Meeting, a determination will be made by the Committee if any further corrective-actions or additional-auditing is needed.
5) Responsible Party & Expected Completion Date:

a. Administrator, Director of Environmental Services Director or Designee

b. Expected date of completion: 12/08/2018