Parkview Care and Rehabilitation Center, Inc.
September 29, 2016 Certification Survey

Standard Health Citations

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: September 29, 2016
Corrected date: November 25, 2016

Citation Details

Based on record review and staff interviews during a recertification survey, the facility did not ensure that, upon receipt from the Department of Health (DOH) of a notification of proposed disapproval of eligibility for employment of an employee, the facility did not allow an employee to provide direct care or supervision to residents until receipt of a final determination of eligibility for employment from the Department. This was noted for one Certified Nurse Assistant (CNA), out of five employees reviewed for Criminal History Record Check (CHRC), who was allowed to work for two shifts with direct resident contact after the facility received a notification letter from the DOH to hold the CNA's employment status in abeyance. The finding is: The facility received a hold in abeyance letter dated 1/27/16 from the DOH concerning a CNA which directed the facility to immediately remove the CNA from any position that involved direct care or supervision to residents until further notice, pending a final determination of eligibility for employment from the Department. During an interview with the facility Human Resource Director regarding Criminal History Record Check (CHRC) procedures at the facility on 9/29/16 at 10:30 AM, she stated that the CNA worked 3:00 PM - 11:00 PM shifts on Wednesday 1/27/16, and Thursday 1/28/16. The Human Resource Director stated that two people, she and the Administrator, were authorized to monitor the CHRC related communication from the DOH. The Human Resource Director stated that both she and the Administrator were on vacation on 1/27/16 and 1/28/16. The Administrator was interviewed on 9/29/16 at 10:45 AM and stated that, going forward, there will be more people assigned to monitor the CHRC related correspondence. 402.7(a)(2)(i)

Plan of Correction: ApprovedNovember 2, 2016

R808 Department Criminal History
I.Immediate Corrective Action
1.Educational Counseling given to Human Resources Coordinator who did not ensure that upon receipt from Department of Health of a hold in abeyance letter that employee was immediately taken off the schedule.
Date of completion: 10/20/16
II.Identification of Other
1.The facility respectfully states that all residents have the potential to be affected by these issues.
III.Systematic Changes
1.The Administrator and Human Resources Coordinator reviewed and revised the Criminal History Record Check Policy.
Date of Completion: 10/28/16
2. Human Resources Coordinator in-serviced by Administrator on the The Criminal History Record Check Policy.
Completion Date: 10/31/16
2.In the event the Human Resources Coordinator is not at work the administrator will complete daily checks.
IV.QA
1.The Administrator developed an audit to monitor compliance with daily Criminal History Record Checks.
2.Audits will be done daily by Human Resources Coordinator, in the event the Human Resources Coordinator is not at work the Administrator will complete checks
3.The outcome of this audit will be reported quarterly to the QA committee by the Human Resources Coordinator for 1 year.
V.The date for the correction and the title of the person responsible for the correction of the deficiency:
1. The Administrator is responsible for the correction of this deficiency by 11/25/16 and ongoing

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review during a recertification survey, the facility did not 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. This was noted for one randomly observed resident (Resident #227). Specifically, the facility did not ensure that the resident was dressed and covered properly during a recreation activity and lunch meals in the dining room on 9/22/16 and 9/23/16. The finding is: Resident #227 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had short and long term memory loss and severely impaired decision making skills. The MDS also documented, in the Activities of Daily Living (ADLs) section, that the resident required total assistance for transferring, bed mobility, dressing, locomotion, toilet use and personal hygiene. A Comprehensive Care Plan (CCP) dated 9/7/16, and titled ADLs, documented that the resident had self-care deficits as evidenced by decrease in abilities for dressing, grooming, feeding, bathing, toileting and personal hygiene tasks. Resident #227 was observed in the main Dining Room on 9/22/16 from 10:30 AM to 1:15 PM with approximately 60 to 80 residents in the room. The resident was seated in a recliner chair wearing a hospital gown with a sheet covering the lower part of his body. His legs and feet were resting on the elevated leg support attached to the chair. The resident received his lunch at approximately 12:15 PM. A Certified Nursing Assistant (CNA) moved the resident's recliner chair to a table and lowered the leg support. Upon lowering of the resident's legs, he was observed to move his legs in a circular motion. The resident continued to move his legs. The gown and sheet were displaced exposing the resident's legs, knees, thighs and brief for approximately 20 minutes until the end of the meal. Resident #227 was again observed in the dining room on 9/23/16 from 11:00 AM to 1:00 PM. The resident was seated in a reclining chair and it was observed that the resident's gown and sheet did not cover the resident's thighs, knees and legs before and during lunch. The unit Registered Nurse (RN) was interviewed on 9/23/16 at 1:30 PM. The RN stated that the resident's family wanted the resident to wear hospital gowns and only provided the facility with hospital gowns for the resident to wear. The RN stated further that the resident should have been covered. 415.5(a)

Plan of Correction: ApprovedNovember 2, 2016

F241 DIGNITY AND RESPECT OF INDIVIDUALITY
I.Immediate Corrective Action
1.The DNS identified CNA who was responsible for the ADL care of Resident #227. An educational counseling along with a 1:1 in-service regarding her responsibility to ensure that residents are dressed and covered properly as part of the residents daily grooming.
Completion Date: 10/20/16
2.A full house audit completed and there are no other residents identified that have a preference of wearing a hospital while out of OOB.
Completion Date: 10/28/16
II.Identification of Others
1.The facility respectfully states that all residents have the potential to be affected by these issues.
III.Systematic Changes
1.The DNS/Administrator reviewed the policy and procedure on dignity specifically with regard to resident?s dignity and respect to full recognition of his or her individuality and found it to be compliant.
Completion Date: 10/24/16
2.All staff will be in-serviced by the DNS/Designee. This in-service will include ensuring that the residents are dressed and covered properly at all times. A copy of the lesson plan and attendance will be filed for reference.
Completion date: 11/25/16
IV.Quality Assurance
1.The DNS developed an audit tool to track compliance of dignity specific to residents being dressed and covered properly at all times.
2.The audit will be conducted on 10 residents weekly by the RNS/designee x1 month then 5 residents weekly x3 months. Any issues identified will have immediate corrective actions. Findings will be submitted to the QA committee quarterly for evaluation and follow up as indicated.
V.The date for the correction and title of the person responsible for the correction of the deficiency:
1.The DNS is responsible for the correction of this deficiency by 11/25/16 and ongoing

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during a recertification survey, the facility did not ensure that there was adequate indication for use of an antipsychotic drug, or gradual dose reduction of the antipsychotic drug when indicated, for one of six residents reviewed for unnecessary medications (Resident #177). Specifically, Resident #177 was administered an antipsychotic medication ([MEDICATION NAME]) for a [DIAGNOSES REDACTED]. Additionally, there was no documented evidence of attempted gradual dose reductions for [MEDICATION NAME] even though the resident displayed distressed behaviors, the same behaviors the resident displayed prior to the administration of the antipsychotic. The finding is: Resident #177 has a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the Resident's Brief Interview for Mental Status was 4 out of a possible 15 (severely impaired for cognition). The physician's orders [REDACTED]. Progress Note entries described resident behaviors as follows: A Progress Note dated 7/21/16 at 2:28 PM documented that the resident was on 15 minute visual checks for exit seeking behavior and disrobing. A Progress Note dated 7/25/16 at 2:53 PM documented the resident was alert with confusion, ambulating in hallway, resident observed going back into her room several times to change her clothes. A Progress Note dated 7/29/16 at 4:29 PM documented that the resident defecated in hamper in other resident's room, removed resident and toileted her. A Progress Note dated 8/02/16 at 2:23 PM documented the Resident was alert and responsive, went into another person ' s room and had an altercation. Resident stated to the Certified Nursing Assistant (CNA) that her hair was pulled, no visible signs of injury noted. The resident was brought to the dining room and made comfortable. Nurse Practitioner made aware and no new orders. A Progress Note dated 8/04/16 at 1:20 PM documented that the resident was on 15 minute checks for exit seeking and disrobing noted. The resident ambulates in hallway with supervision. A Progress Note dated 8/07/16 documented the resident continues on 15 minute checks, continues to wander in and out of resident rooms removing items. A Psychiatry Progress Note dated 8/16/16 at 11:20 AM documented that the resident was diagnosed with [REDACTED]. Resident is alert and confused. She was involved with a peer to peer altercation. No injury. A Progress Note dated 9/03/16 at 12:47 PM documented the resident was alert with confusion, out of bed ambulating in hallway with supervision, 15 minute checks in place for exit seeking behavior, no exit seeking behavior noted . Resident noted out of bed ambulating in hallway with a sheet wrapped around her waist, brought back to her room to change clothes. Resident # 177 resides on the secure unit in the facility. On 9/23/16 at 1:00 PM the resident was observed seated in a chair in the hallway outside the recreation room with five other residents. The five residents were observed yelling, banging their chairs with their hands at times. The five residents were seated with their chairs touching each other. Resident #177 was observed with her fingers in her ears. The resident was interviewed immediately. The resident stated that the hallway was noisy and she had to cover her ears. The Recreation Aide #1 (RA) was interviewed on 9/23/16 at 1:30 PM. The RA stated that she was the only RA on the unit and she was running a program. The RA stated that the resident's that are in the hallway cannot concentrate long enough to participate in the program that she was running. The Licensed Practical Nurse (LPN) Charge Nurse was interviewed on 9/26/16 at 1:00 PM. The LPN stated that at times the hallway on the unit is very noisy. We are at full capacity on this unit. The Psychiatrist was interviewed on 9/29/16 at 1:00 PM. The Psychiatrist stated that he was aware that the resident was exhibiting behaviors but did not realize that there was only a slight change in her behavior. The Psychiatrist stated he would try and taper her medication. The Director of Nursing Services (DNS) was interviewed on 9/29/16 at 1:30 PM. The DNS stated that she would work on the issue. 415.12(l)(1)

Plan of Correction: ApprovedNovember 2, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F329 Psych Consult Updated Care Plan
I.Immediate corrective Action
1.Resident #177 was evaluated by the psychiatrist for adequate indication for [MEDICATION NAME] use and documentation of attempted gradual dose reduction. Completion date: 10/20/16
2.The resident?s plan of care revised by the MDS coordinator and reviewed with the CCP team and resident?s family to discuss resident?s current status.
Completion date: 10/20/16
3.Full house audit competed each resident receiving [MEDICATION NAME] will have their medical record reviewed to check [DIAGNOSES REDACTED].
Completion Date: 11/11/16
II.Identification of others:
1.All residents are identified to have the potential to be affected by this deficiency.
III.Systemic Changes
1.The administrator, Medical Director and DNS reviewed the policy and procedure on [MEDICAL CONDITION] medication and found it to be compliant
Completion date: 10/28/16
2.All medical staff and licensed nurses will be in serviced by the DNS/designee on this policy with the focus on proper [DIAGNOSES REDACTED]. A copy of the lesson plan and attendance will be filed for reference.
Completion date: 11/25/16
IV.QA
1.The DNS/ MDS developed an audit tool to assure that residents on anti-psychotic medication have a proper [DIAGNOSES REDACTED].
2.This audit will be done by the DNS/ designee on residents who are on [MEDICATION NAME]. They will monitor 5 residents weekly x1 month then 10 residents monthly x 3 months. Any negative findings will be reported to the Administrator/DNS for immediate corrective action.
3.Audit findings will be presented to the QA committee quarterly for evaluations and follow up as indicated. The outcome of this audit will be quantified and reported to the quality assurance committee by the MDS coordinator/designee.
V.The date for the correction and the title of the persons responsible for the correction of the deficiency;
1.The DNS is responsible for the correction of this deficiency by 11/25/16 and ongoing.

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey, the facility did not utilize a resident positioning device to prevent potential accidents for one of one residents reviewed for accidents (Resident #70). Specifically, the facility did not follow the care plan instructions to feed the resident at a 90 degree angle to prevent aspiration. The finding is: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) Assessments dated, 4/23/16 and 7/1/16 documented that Resident #70 could not complete a Brief Interview for Mental Status (BIMS) and had severely impaired decision making skills. A Comprehensive Care Plan (CCP) for Dysphagia (impaired swallowing), last updated on 3/15/16, documented that the resident will observe aspiration/reflux precautions. Interventions included to alternate liquids and solids, sit upright 90 degrees during PO (by mouth) intake and 30-45 minutes after, take small bites and sips at slow pace. There were no specific assessments documented in the medical record regarding the recommended, safe angle for feeding the resident other than in the care plan for feeding at 90 degrees angle. The resident was observed being fed by a Certified Nurse Assistant (CNA) at a table in the dining room on 9/22/16 at 12:30 PM. The resident was seated in a Geri chair with the back inclined at 45 degrees angle. The CNA did not raise the back of the Geri chair to 90 degrees while feeding the resident the meal. The Assistant Director of Nursing (ADON) was interviewed 9/22/16 at 12:30 PM and stated that the resident cannot tolerate sitting upright/90 degree positioning. The ADON stated that she knows that the resident is comfortable at 45 degrees. She also stated that the resident's back should be pulled up against the back of the Geri chair and not sliding down. The CNA who fed the resident her lunch was interviewed on 09/22/16 at 12:45 PM and stated that she is not regularly assigned to feed the resident and did not get any specific instructions for feeding the resident. She stated that she has always seen the resident being seated and fed in this reclined position and she followed the same practice. The Resident was observed being fed by the same CNA at the table in the dining room on 9/23/16 at 12:30 PM. The resident was seated in a Geri chair with the back inclined at 45 degrees angle. The CNA did not raise the back of the recliner to 90 degrees while feeding the meal. The Occupational Therapist (OT) was interviewed on 09/26/16 at 12:48 PM and stated that the resident can be sat up during meals. The OT stated that she was told by Nurses that the resident is uncomfortable at a 90 degrees. She stated that she had not assessed the resident ' s ability or comfort level while sitting at a 90 degree angle. The OT then performed an assessment and documented in an OT assessment dated [DATE] that, resident was assessed for proper seating and positioning in a Geri chair for meal times. Resident was properly positioned at a 90 degree angle in a Geri chair. Resident is able to tolerate sitting up to 90 degree angle in Geri chair with close supervision for safety. 415.12(h)(1)

Plan of Correction: ApprovedNovember 2, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F323 FREE OF ACCIDENT HAZARDS/SUPERVISION DEVICES
I.Immediate Corrective Action
1.The Care plan team reviewed resident #70 medical record and revised residents plan of care to reflect residents current eating status based on last OT assessment
Completion Date: 10/27/17
2.The CNA assigned to resident #70 was given an educational counseling with emphasis on proper positioning during resident meals.
Completion Date: 10/20/16
3.Full house audit was completed by OT on residents who have a [DIAGNOSES REDACTED].
Completion Date: 11/11/16
4.All residents with a [DIAGNOSES REDACTED].
Completion Date: 11/11/16
II.Identification of Others;
1.The facility respectfully acknowledges that all residents have the potential to be affected by this deficiency.
III.Systemic Changes;
1.The DNS, OT and speech Therapist reviewed and revised the policy and procedure on General Feeding Procedure.
Completion Date: 10/28/16
2.In-service was given to all licensed nurses, CNA?s, Dieticians, OT & Speech on the General Feeding Procedure with emphasis on proper positioning during meals by the DNS/Designee. A copy of the lesson plan and attendance will be filed for reference.
Completion Date: 11/25/16
IV.QA
1.The DNS developed an audit tool to monitor compliance of positioning of residents with dx of Aspiration Risk during meals
2.Audit will be done by the DNS/designee on 5 residents weekly x1 month then 5 residents monthly x3 months. Any issues identified will have immediate corrective actions by the DNS and to be reported to the administrator.
V.The date for the correction and the title of the person responsible for the correction of this deficiency:
1.The DNS is responsible for the correction of this deficiency by 11/25/16 and ongoing

FF09 483.15(h)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

Based on observation and staff interviews during a recertification survey, the facility did not ensure that one of four units (East unit) was maintained with a sanitary or homelike environment. Specifically, the East unit was toured throughout the survey and was noted to have hair and dust in residents' rooms and scuff marks on bedroom walls. The finding is: During the initial tour of the facility, and throughout the survey, the following was observed on the East unit: Room 492 had baseboards with dark black marks. The baseboard molding was full of hair and dust debris. Room 489 had baseboards that were covered with hair and dust. Room 480 was observed with a black substance surrounding the sink and the wall by the door had scuff marks. Room 481 had hair and dust accumulated behind the door. The Director of Housekeeping was interviewed on 9/29/16 at 1:00 PM and stated that he would take care of the situation. 415.5(h)(2)

Plan of Correction: ApprovedNovember 2, 2016

F253 Housekeeping & Maintenance Services
I.Immediate Corrective Action
1.Room 492 had baseboards with dark black marks. The baseboard was full of hair and dust debris. ? Cove base was replaced.
Date of completion: 10/20/16
Room 489 had baseboards that were covered with the hair and dust-Cove base replaced
Date of completion: 10/20/16
Room 480 was observed with a black substance surrounding the sink and the wall by the door had scuff marks-Sink was cleaned and wall by the door was painted
Date of Completion: 10/20/16
Room 481 had hair and dust accumulated behind the door- Hair and dust was removed and behind the door was cleaned
Date of Completion: 10/20/16
2.The Administrator, Director of Environment Services, Director of Maintenance made full house rounds to identify items cited in the SOD and in other locations to identify other areas in need of cleaning. Date of Completion: 10/27/16
II.Identification of Others
1.The facility respectfully states that all residents were affected by the deficient practice in the environment.
III.Systematic Changes
1.The Administrator, Director of Environmental Services, Director of Maintenance reviewed the facility policy On Sanitation and Preventative Maintenance and found it to be compliant.
Date of Completion: 10/24/16
2. All Maintenance and housekeeping staff will be in-serviced on the Sanitation and Preventative Maintenance Policy by Environmental Director.
Date of Completion: 10/31/16
2.The Administrator, Director of Environmental Services, Director of Maintenance will conduct weekly environmental rounds throughout the building.
IV.QA
1.Administrator developed an audit tool to track compliance.
2.Audits will be done initially throughout the facility and weekly x3 months and quarterly thereafter by the Environmental Director. Audits with negative findings will have immediate corrections implemented by the Environmental Director.
3.Audits will be reported to the QA committee for evaluation and follow up.
V.The date for the correction and the title of the person responsible for the correction of the deficiency:
1.The Administrator is responsible for the correction of this deficiency by 11/25/16 and ongoing.

FF09 483.25(i):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not provide services to ensure adequate nutrition and prevent weight loss for one of four residents reviewed for nutrition (Resident #176). Specifically, there is no documented evidence that the Physician assessed or addressed significant weight loss for resident. The findings are: Resident #176 has [DIAGNOSES REDACTED]. A review of the weight record revealed the following significant weight loss (defined as a weight loss of 5% or more in last month or 10% or more in last 6 months): [DATE]: 123 lbs. [DATE]: 122 lbs. [DATE]: 122 lbs. [DATE]: 122 lbs. [DATE]: 119 lbs. [DATE]: 117 lbs. [DATE]: 109 lbs. [DATE]: 109 lbs. [DATE]: 108 lbs. [DATE]: 108 lbs. [DATE]: 109 lbs. The resident lost 13 lbs. weight (10 %) in 1 month between [DATE] and [DATE]. A Registered Dietitian (RD) note dated [DATE] documented that resident had significant undesirable weight loss despite receiving Puree No Added Salt Diet, snacks twice a day, and 2 Cal HN supplement 4 oz 5 x day. The RD documented that the resident also received pancake syrup with each meal for improved palatability. She also documented that the resident mostly accepts a good amount of nutritional supplement but at times the resident's supplement intake is ,[DATE] or 0 %. The note further documented that the weight loss may be due to deceased intake, difficulty feeding at times due to resident being slow, resistive and with a tendency to clamp mouth. The RD documented that Nursing spoke with the resident's family member about a possible feeding tube (GT) and the family member was not in agreement at this time. The note documented further that the NP made aware of weight loss. NP notes dated [DATE], [DATE], [DATE], [DATE], [DATE] revealed no documented review of the resident's nutritional status/weight loss. Physician's notes dated [DATE] revealed no documented review of the resident's nutritional status/weight loss. Physician's notes dated [DATE] documented the residents current weight was 116.5 lbs. The physician's note indicated no significant weight loss was present. Physician's notes dated [DATE] revealed no documented review of the resident's nutritional status/weight loss. Physician's notes dated [DATE] documented the resident's current weight was 110 lbs. The physician's note indicated no significant weight loss was present. Physician's notes dated [DATE] documented current weight 108 lbs. The physician's note indicated no significant weight loss was present. A Minimum Data Set (MDS) assessment dated [DATE] documented a significant weight loss (defined as a weight loss of 5% or more in last month or 10% or more in last 6 months). The resident's family member was interviewed on [DATE] at 2:06 PM and stated that the resident had lost weight. The residents RD was interviewed on [DATE] at 2:06 PM and stated that the resident lost weight in June. The RD stated that the family member visits daily and helps feed the resident who is very difficult to feed. The RD stated that the family member was on vacation and the resident would not allow anyone to feed him and the resident lost weight. The RD also stated that the MD and NP were made aware of the weight loss. The Resident's Physician was interviewed on [DATE] at 3:03 PM and stated that the resident lost weight due to a metabolic situation related with prostrate [MEDICAL CONDITION]. He stated that he may not have documented weight loss. The Resident's Nurse Practitioner was interviewed on [DATE] at 2:00 PM and was unable to explain the lack of weight loss review in the medical record. 415.12(i)(1)

Plan of Correction: ApprovedNovember 2, 2016

F325 MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE
I.Immediate Corrective Action
1.MD reviewed medical record of #176 and documented on residents current weight status.
Date of Completion: 10/28/16
2.NP was given an education counseling by the DNS which emphasized that resident?s must receive a full comprehensive assessment including but not limited to assessing and addressing significant weight loss.
Date of completion: 10/20/16
3.The DNS and dietician completed a full house audit on all residents with significant weight loss to ensure the MD/NP assessed and addressed the significant weight loss.
Date of completion: 11/11/16
II.Identification of Other
1.The facility respectfully states that all residents have the potential to be affected by these issues.
III.Systematic Changes
1.The Administrator, DNS, and Dietician reviewed and revised the policy and procedure on weight loss.
Date of completion: 10/24/16
2.Physician, NP, dieticians and all clinical staff will be in-serviced by the DNS/designee on the policy and procedure on weight loss with emphasis on assuring proper documentation. A copy of the lesson plan and attendance will be filed for reference.
Date of completion: 11/25/16
IV.QA
1.The DNS developed an audit tool to track compliance with proper documentation on residents with significant weight loss.
2. The audit will be done by the Dietician on all residents with a significant weight loss x1 month then 5 residents monthly x1 year. Any QA issues will be immediately corrected and will be reported to the Administrator/DNS. Audit findings will be presented to the QA committee quarterly for evaluation and follow up as indicated.
V. The date for the correction and the title of the person responsible for the correction of the deficiency:
1.The Administrator is responsible for the correction of this deficiency by 11/25/16 and ongoing.

FF09 483.25(d):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: Based on the resident's comprehensive assessment, the facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during a recertification survey, the facility did not ensure that one of three residents reviewed for urinary incontinence was assessed to determine possible contributory factors for a decline in urinary continence in order to potentially restore, or prevent further decline in, urinary continence (Resident #196). Specifically, Resident # 196 had a decline in urinary continence and there was no documented assessment to determine the reason. The finding is: Resident #196 was admitted on [DATE] with [DIAGNOSES REDACTED]. An Admission Nursing assessment dated [DATE] documented that the resident was continent of urine at all times and assisted by staff with toileting needs. A Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS also documented that the resident was continent of urine. A Comprehensive Care Plan (CCP) dated 4/15/16 documented that the resident was continent of bladder. The CCP documented on 5/31/16 that the resident had occasional incontinence of urine at times and to continue the plan of care. An MDS assessment dated [DATE] documented that the resident had a BIMS score of 11 (moderately impaired cognition). The MDS also documented that the resident was occasionally incontinent of urine. A Certified Nursing Assistant (CNA) Accountability Record (CNAAR) dated (MONTH) (YEAR) documented that the resident was occasionally incontinent of urine. A Medical Progress Note (MPN) dated 6/11/16 documented NO under the question: Is the resident incontinent? The MPN was inconsistent with the CCP and the CNAAR documentation of the resident being occasionally incontinent of urine. There was no documented evidence that the interdisciplinary team, Physician, Nurse Practitioner (NP) or other person assessed the resident's change in urinary continence or considered possible contributory factors in an attempt to restore previous content status or prevent further decline. Additionally, the CCP was not revised to reflect the change. The NP is responsible for the plan of care for the resident. An interview was held with the Registered Nurse (RN) MDS Coordinator on 9/28/16 at 9:30 AM. The RN reviewed the medical record and stated that there was no documented evidence that the plan of care was revised to reflect the current status of the resident's urinary incontinence. An interview was held with the NP on 9/28/16 at 10:00 AM. The NP reviewed the MPN and provided no explanation of why the documentation was inaccurate and did not reflect the resident's current continence status. 415.12(d)(2)

Plan of Correction: ApprovedNovember 2, 2016

F315 NO CATHETER, PREVENT UTI, RESTORE BLADDER
I.Immediate Corrective Action
1.Resident #196 is no longer in the facility therefore facility is unable complete a new bladder assessment to determine contributory factors for decline in urinary continence.
2.NP received an educational counseling by Medical Director to ensure that the NP understands that when a resident has a decline that an accurate bladder assessment is complete.
Completion date: 10/20/16
3.MDS nurse received educational counseling on the importance of the resident?s plan of care to reflect all urinary changes.
Completion date: 10/20/16
4.Full house audit completed by MDS Coordinator on all residents identified on the MDS as having a change in urinary continence in the past two months to ensure that the physician documented the decline appropriately and the medical status is reflected in the care plan.
Completion Date: 11/11/16
II.Identification of Others
1.All residents are identified to have the potential to be affected by this deficiency.
III.Systemic Changes
1.The DNS and Medical Director reviewed the facility policy and procedure on Bladder Assessment which was found to be complaint.
Completion Date: 10/28/16
2.All Medical Staff and licensed nurses will be in-serviced by the DNS/Designee on the Bladder Assessment policy. A copy of lesson plan and attendance will be filed for reference.
Completion Date: 11/25/16
IV.QA
1.The DNS developed an audit tool to monitor facility compliance and accuracy with bladder assessment and care plans of all residents with changes in urinary continence.
2.The MDS RN will audit 10 residents weekly x1 month then monthly thereafter for 3 months. Any negative findings will have immediate corrective action referred to the DNS and Medical Director for review. Findings will be submitted to the Quality Assurance Committee quarterly for evaluation and follow up as indicated.
V.The date for the correction and the title of the person responsible for the correction of the deficiency:
1.The DNS is responsible for the correction of this deficiency by 11/25/16 and ongoing.

FF09 483.75(f):NURSE AIDE DEMONSTRATE COMPETENCY/CARE NEEDS

REGULATION: The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and staff interviews during a recertification survey, the facility did not ensure that a Certified Nursing Assistant (CNA) demonstrated competency in skills related to resident safety for one randomly observed resident (Resident #177). Specifically, during a tour of the East unit, Resident # 177 was observed lying in her bed supporting the left side of her body with her left elbow attempting to eat her breakfast of large pieces of French Toast with her right hand. Additionally, there was a wire on the floor at the foot of the bed which could have been a tripping hazard. The finding is: Resident #177 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 4 out of a possible 15 (severely impaired cognition). The MDS also documented that the resident was able to ambulate in the room with supervision. An observation on 9/27/16 at 12:10 PM revealed that the resident was observed ambulating by herself in her room and the hallway. Resident #177 was observed on 9/28/16 at 9:00 AM in her room lying in her bed supporting the left side of her body with her left elbow attempting to eat her breakfast of large pieces of French Toast with her right hand. The CNA was interviewed immediately and stated that she had placed the food tray on the resident ' s over bed table and left the room. Additionally, the CNA stated that she did not set up the breakfast tray. The CNA stated when she had left the room and did not see the wire on the floor at the foot of the bed. The Licensed Practical Nurse (LPN) was interviewed on 9/28/16 at 9:05 AM. The LPN stated that the CNA should have had the head of the bed raised. The wire that was at the foot of the bed should have been removed. 415.26(c)(1)(iv)

Plan of Correction: ApprovedNovember 2, 2016

F498 NURSE AIDE DEMONSTRATE COMPETENCY/CARE PLANS
I.Immediate Corrective Action
1.The CNA received an educational counseling resident #177 who did not ensure proper positioning during meals and who did not provide a safe environment for resident by DNS
Completion Date: 10/20/16
2.A full house audit was done on proper positioning during meals and that the environment was free of any hazards.
Completion Date: 10/20/16
II.Identification of other Residents
1.The facility respectfully acknowledges that all residents have the potential to be affected by the deficient practice.
III.Systemic Changes
1.The Administrator and DNS reviewed the policy and procedure on General Feeding Policy and environmental hazards and found it to be compliant.
Completion Date: 10/28/16
2.All nursing staff and Speech will be In-serviced by DNS on the General Feeding policy. A copy of the lesson plan and attendance will be filed for reference
Completion Date: 11/25/16
3.All staff will be in-serviced by the DNS/Designee on environmental Hazards. A copy of the lesson plan and attendance will be filed for reference
Completion Date: 11/25/16

IV.QA Monitoring:
1.An audit tool was developed by the DNS to assure that residents are properly positioned during meals and environmental hazards.
2.The audit will be conducted by the DNS/designee on 5 residents weekly x1 month then 5 residents monthly x3 months. Any issues identified will have immediate corrective action by the DNS and will be reported to the administrator.
Findings will be submitted to the Quality Assurance Committee quarterly for evaluation and follow up as indicated.
V.The date of correction and the title of the person responsible for the correction of this deficiency.
1.The DNS is responsible for the compliance of this deficiency by 11/25/16 and ongoing.

FF09 483.40(b):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: The physician must review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; write, sign, and date progress notes at each visit; and sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during a recertification survey, the facility did not ensure that the physician reviewed the resident's total program of care for two of three residents reviewed for Physician Services (Residents #176 and #206). Specifically, 1) There was no documented evidence that the physician reviewed or assessed weight loss for resident #176. 2) There was no documented evidence that the Nurse Practitioner (NP) assessed a decline in Resident #206's sacral pressure ulcer from a stage two to a stage three. The findings are: 1) Resident #176 has [DIAGNOSES REDACTED]. A review of the weight record revealed the following significant weight loss (defined as a weight loss of 5% or more in last month or 10% or more in last 6 months): 3/2/16: 123 lbs. 4/7/16: 122 lbs. 4/21/16: 122 lbs. 5/4/16: 122 lbs. 5/6/16: 119 lbs. 5/27/16: 117 lbs. 6/10/16: 109 lbs. 6/22/16: 109 lbs. 7/27/16: 108 lbs. 8/23/16: 108 lbs. 9/26/16: 109 lbs. The resident lost 13 lbs. weight (10 %) in 1 month between 5/4/16 and 6/10/16. NP notes dated 5/13/16, 6/29/16, 6/30/16, 7/9/16, 7/22/16 revealed no documented review of the resident's nutritional status/weight loss. Physician's notes dated 5/9/16 revealed no documented review of the resident's nutritional status/weight loss. Physician's notes dated 5/27/16 documented the residents current weight was 116.5 lbs. The physician's note indicated no significant weight loss was present. Physician's notes dated 6/14/16 revealed no documented review of the resident's nutritional status/weight loss. Physician's notes dated 7/2/16 documented the resident's current weight was 110 lbs. The physician's note indicated no significant weight loss was present. Physician's notes dated 7/28/16 documented current weight 108 lbs. The physician's note indicated no significant weight loss was present. A Minimum Data Set (MDS) assessment dated [DATE] documented a significant weight loss (defined as a weight loss of 5% or more in last month or 10% or more in last 6 months). The resident's family member was interviewed on 9/22/16 at 2:06 PM and stated that the resident had lost weight. The residents Registered Dietitian (RD) was interviewed on 09/27/2016 at 2:06 PM and stated that the resident lost weight in June. The RD stated that the family member visits daily and helps feed the resident who is very difficult to feed. The RD stated that the family member was on vacation and the resident would not allow anyone to feed him and the resident lost weight. The RD also stated that the MD and NP were made aware of the weight loss. The Resident's Physician was interviewed on 09/27/2016 at 3:03 PM and stated that the resident lost weight due to a metabolic situation related with prostrate [MEDICAL CONDITION]. He stated he may not have documented weight loss. The Resident's Nurse Practitioner was interviewed on 9/27/16 at 2:00 PM and was unable to explain the lack of weight loss review in the medical record. 2) Resident #206 has [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident's cognition was intact. The MDS also documented that the resident was assessed to be free of pressure ulcers. An MDS dated [DATE] documented a BIMS score of 13, also indicating that the resident's cognition was intact. The MDS further documented that the resident was assessed to be free of Pressure ulcers. A Nursing Progress Note (NPN) completed by an RN dated 9/3/16 documented that the resident was assessed to have a Stage 2 pressure ulcer on the sacrum. A NPN dated 9/6/16 documented that a pressure ulcer was observed on the sacrum measuring 1.2 centimeters by 1 cm by 0.1 cm and had 50 % slough and 50% granulation. The NPN also documented that the NP was made aware of the finding and ordered a treatment of [REDACTED]. An NP Medical Progress Note (NPMPN) dated 9/6/16 documented that the resident had a skin opening and to apply [MEDICATION NAME] to the affected areas. The MPN had no documentation of the description of the open area or where it was located. An interview was held with the NP on 9/28/16 at 10:15 AM. The NP could not explain why there was no documented evidence in the medical record that an assessment was completed on 9/6/16 of the resident's Stage 3 pressure ulcer. The NP stated that the LPN wound Nurse assessed the pressure ulcer and informed him. An interview was held on 9/28/16 at 12:45 PM with the Licensed Practical Nurse (LPN) wound nurse. The LPN wound nurse stated that on 9/6/16 she assessed the pressure ulcer on the Sacrum and staged the pressure ulcer as a stage 3 with 50% slough. The LPN wound nurse also stated that she informed the NP that the resident had a Stage 3 pressure ulcer and that Hydrogel should be used. The LPN stated that the NP did not assess the resident's pressure ulcer. 415.12(b)(2)(iii)

Plan of Correction: ApprovedNovember 2, 2016

F386 PHYSICIAN VISITS-REVIEW CARE/NOTES/ORDERS
I.Immediate Corrective Action
1.NP assessed and documented on resident #176 weight status
Completion date: 10/31/16
2.NP assessed and documented on resident #206 sacral pressure ulcer decline which went from a stage two to a stage three.
Completion date: 10/31/16
3.A care plan meeting was held for resident #176 and resident #206 to assure that the issues that were reassessed above were documented properly on their care plans.
Completion date: 10/28/2016.
4.The NP was given an educational counseling by the medical director/DNS which emphasized the importance of documenting on residents medical changes.
Completion date: 10/20/16
5.A full house audit was conducted by the DNS/designee on 1) any resident who had a significant weight loss in the last 30 days and 2) any resident who has a stage three pressure ulcer to assure that proper medical documentation is present.
Completion Date: 11/11/16
II.Identification of other Residents
1.The facility respectfully acknowledges that all residents have the potential to be affected by the deficient practice.
III.Systemic Changes
1.The Administrator/ DNS reviewed the policy and procedure for weight loss and pressure ulcers and found it to be compliant.
Completion date: 10/28/16
2.In-service was given to all medical staff by DNS on the policy for weight loss and pressure ulcers. A copy of the lesson plan and attendance will be filed for reference.
Completion Date: 11/25/16
IV.QA Monitoring:
1.The DNS developed audit tools to assure that the physician/NP assess and document weight loss and a change in pressure ulcers.
2.Audits will be done by the DNS/designee on 5 residents weekly for 1 month and 5 residents monthly x3 months. Any issues identified will have an immediate corrective action by the DNS and reported to the administrator.
Findings will be submitted to the Quality Assurance Committee quarterly for evaluation and follow up as indicated.
V.The date of correction and the title of the person responsible for the correction of this deficiency.
1.The DNS is responsible for the compliance of this deficiency by 11/25/16 and ongoing

FF09 483.15(g)(1):PROVISION OF MEDICALLY RELATED SOCIAL SERVICE

REGULATION: The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews during a recertification survey, the facility did not ensure that one of one residents reviewed for social services received services that maintained or improved her ability to manage her everyday physical, mental and psychosocial needs (Resident #118). Specifically, Resident #118 brought concerns regarding a room change and about durable medical equipment (portable oxygen) for trips outside the facility to her Social Worker's (SW) attention and the resident ' s concerns were not addressed timely. The finding is: Resident #118 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 15/15, which is suggestive of intact cognition. Additionally, the MDS documented, under the section for Functional Rehabilitation Potential, that the resident believed that she is capable of increased independence in at least some activities of daily living. Resident #118 was interviewed on 9/23/16 at 10:00 AM. The resident stated that she felt like a prisoner in the facility. The resident stated that she had spoken to the Social Worker (SW) on three occasions about moving to a semiprivate room. Additionally, the resident requested information about portable oxygen. The resident stated that she would like to go out to visit her son and required portable oxygen. The SW was interviewed on 9/23/16 at 10:30 AM. The SW stated that she had not had a chance to get back to the resident about either of the issues. The Director of Nursing Services (DNS) was interviewed on 9/23/16 at 11:00 AM. The DNS stated that the SW should have communicated the information that the resident needed portable oxygen. 415.5(g)(1)(i-xv)

Plan of Correction: ApprovedNovember 2, 2016

F250 PROVISION OF MEDICALLY RELATED S(NAME)IAL SERVICE
I.Immediate Corrective Action
1.Resident #118 will be moved to a two bedded room.
Completion date: 10/31/16
2. The social worker was given an educational counseling by Administrator regarding resident #118 requested room change and not addressing resident?s concerns.
Completion Date: 10/20/16
3. Social worker was also given an education counseling by the administrator on the importance of addressing resident #118 concerns about DME for trips outside the facility.
Completion Date:10/25/16
4. The social workers compiled a list of all residents in the last 30 days who have requested a room change and a list of all residents in the last 30 days who requested medical equipment. These lists will be utilized to assure that the resident?s needs are being met in a timely manner and proper documentation is done on an individual need.
Completion date: 10/28/16
II. Identification of Others
1. The facility respectfully acknowledges that all residents have the potential to be affected by this deficient practice.
III. System Changes
1. The Administrator, DNS and social workers review the policy and procedure on Resident?s Rights and found it to be compliant.
Completion date:10/27/16
2. The social workers will be in-serviced on resident rights and the importance of timely responses to resident requests by the Administrator. A copy of the lesson plan and attendance will be filed for reference.
Completion date: 11/25/16
IV. QA
1. The Administrator developed an audit tool to assure that resident?s needs were being met in a timely manner and that proper documentation is in the medical record.
2. This audit will be conducted by the social worker/designee on 5 residents weekly X 1 month then 5 residents monthly X 3 months. Any quality assurance issues will be reported to the administrator/DNS for immediate corrective action.Audit findings will be presented to the QA committee quarterly for evaluation and follow up as indicated. The outcome of this audit will be quantified and reported to the Quality Assurance Committee by the social worker/designee.
V. The date for the correction and the title of the person responsible for the correction of the deficiency:
1. The Administrator will be responsible for the correction of this deficiency by 11/25/16 and ongoing

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews during a recertification survey, the facility did not ensure that one of three residents reviewed for participation in care planning was invited to a Comprehensive Care Plan Meeting (Resident #224). The finding is: Resident #224 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 13 out of a possible 15, which indicated intact cognition. The MDS indicated that the resident had no behavior problems. A Comprehensive Care Plan (CCP) dated 8/15/16 documented the resident's BIMS score was 13. A CCP goal identified that the resident will be maintained at the current level of cognition. During an interview conducted on 9/22/16 at 11:28 AM with Resident #224, he stated that he did not recall being invited to his care plan meeting and would have liked to attend. A Social Service note dated 8/30/16 documented that an Initial CCP meeting for the resident was held on 8/30/16, and that the resident did not participate in the meeting because the resident declined. The family was notified of the CCP meeting and did attend. It was further documented that the multidisciplinary team goals for the resident were reviewed and accepted by all participants. The Interdisciplinary Care Plan (ICP) Meeting sign-in sheet dated 8/30/16 for the Initial Assessment revealed the resident's family attended the meeting. A MDS Note dated 9/1/16 documented that the initial care plan meeting was held on 8/30/16, family was present and that the Plan of Care was reviewed and accepted. There was no documented evidence that the resident was apprised of the goals that were reviewed in the meeting. An interview was conducted on 9/27/16 at 11:45 AM with the Registered Nurse (RN) MDS Coordinator regarding who updates the resident about the plan of care and goals after a CCP meeting is held on their behalf. The RN stated that he did not recall speaking to the resident after the CCP meeting. The RN stated that the resident was not apprised of his plan of care and goals after the CCP meeting and that he should have been. A subsequent interview was conducted on 9/27/16 at 2:00 PM with Resident #224. The resident stated that he recalled that his family attended a meeting and that, when the Social Worker (SW) spoke with him, he was given the impression that he did not need to be in the meeting because his family was attending. Additionally, the resident further stated that no one appraised him of the plan of care and goals after the meeting. During an interview conducted on 9/28/16 at 11:30 AM the SW stated that the MDS Coordinator is usually the one that updates the resident regarding the plan of care after the meetings. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedNovember 2, 2016

F280 Right to Participate Planning Care
I.Immediate Corrective Action
1.Care plan meeting held for resident #224 to review all aspects of his care.
Completion Date: 10/21/16
2.Social worker was given an educational counseling by the Administrator concerning the care plan process specifically that the social worker did not inform resident of his plan of care and goals after the meeting that family attended and that resident declined to attend.
Completion date: 10/20/16
3.A list of all residents who have a BIM score greater than 10 for the last 3 months was compiled by the MDS coordinator. A CCP meeting was held with each resident to assure their plan of care was reviewed with each resident
Completion date: 11/25/16
II.Identification of others:
1.The facility respectfully acknowledges that all residents have the potential to be affected by this deficient practice

III.System changes
1.The administrator,DNS,MDS coordinator reviewed & revised the policy and procedure on care planning.
Completion Date: 10/24/16
2.All clinical staff will be in serviced by the DNS/designee on the importance of ensuring that the resident participates in the care plan meeting or is informed of their plan of care soon after if they did not attend. A copy of the lesson plan and attendance will be filed for reference
Completion Date: 11/25/16
IV.QA
1.The DNS developed an audit tool to assure that the resident is invited and participates and / or is aware of the resident?s plan of care. This audit will be conducted by the social workers/ designee on any resident who is due for a care plan meeting x1 month then 10 residents monthly x3 months.
2.Any quality assurance issues will be reported to the administrator/DNS for immediate corrective action. Audit findings will be presented to the QA committee quarterly for evaluation and follow up as indicated. The outcome of this audit will be quantified and reported to the quality assurance committee by the social worker.
V.The date for the correction and the title of the persons responsible for the correction of the deficiency;
1.The DNS is responsible for the correction of this deficiency by 11/25/16 and ongoing.

FF09 483.20(k)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during a recertification survey, the facility did not ensure that injection sites for insulin administration were documented as ordered by qualified nurses for one of six residents reviewed for unnecessary medications (Resident #84). The finding is: Resident #84 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score was 13, which indicated intact cognition. The MDS also indicated that the resident had no mood or behavior problems and required assistance of one staff member for all areas of Activities of Daily Living. A Comprehensive Care Plan (CCP) for DM dated 10/19/15 documented that the resident had elevated blood glucose level secondary to [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Inject 40 unit subcutaneous (SQ) once daily at bedtime for DM. The order instructed to record the injection site. A Review of the Resident's Medication Administration Record (MAR) revealed the injection site for insulin administrations were not being documented on the MAR for the months of July, (YEAR) to September, (YEAR) as ordered by the Physician. During an interview conducted on 9/28/16 at 10:06 AM with the day shift Licensed Practical Nurse (LPN), she stated that, after administering insulin, the site of injection should be documented on the MAR as ordered. An interview was conducted on 9/28/16 at 10:15 AM with the Registered Nurse (RN) Supervisor. The RN stated that when an order is given with specification to document dose and site, all nurses are not educated on how to add documentation for the injection site and dose in the Medication Administration Record. 415.11(c)(3)(ii)

Plan of Correction: ApprovedNovember 2, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 282 SERVICES BY QUALIFIED PERSONS/PER CARE PLAN
I.Immediate Corrective Action
1.The medication record was reviewed for resident #84 and the injection site was added for proper documentation.
Completion Date: 10/20/2016
2.The DNS identified the nursing staff responsible for not documenting resident #84 injection site. The nurses involved received educational counseling by the DNS/Designee for failing to follow the physician orders [REDACTED].
Completion Date: 10/20/2016
3.A full house audit was conducted by the DNS on any resident who receives insulin to assure that the licensed nurse is documenting the site of the injection.
Completion Date: 10/28/2016
II.Identification of other Residents
1.The facility respectfully acknowledges that all residents have the potential to be affected by the deficient practice.
III.Systemic Changes
1.The DNS reviewed and revised the policy and procedure on medication administration.
Completion Date: 10/28/2016
2.In-service was given to all licensed nurses on insulin administration focusing on documentation of the injection site. A copy of the lesson plan and attendance will be filed for reference.
Completion Date: 11/25/16
IV.QA Monitoring:
1.The DNS developed an audit tool to monitor compliance with the facility policy on documenting insulin injection site as ordered by the physician.
2.Audits will be done by the DNS/designee on 10 residents weekly for 1 month then monthly thereafter 3 months. Any negative findings identified will have immediate corrective action and be referred to the DNS for review. Audits results will be presented to the QA committee quarterly for evaluation and follow-up.

V.The date for the correction and title of the person responsible for correction of this deficiency:
1.The Director of nursing will be responsible to ensure correction of this deficiency by 11/25/16 and ongoing

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: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey, the facility did not ensure that one of three residents reviewed for pressure ulcers received services that met professional standards of nursing practice for assessment (Resident #206). Specifically, the facility did not ensure that a Registered Nurse (RN) completed assessment of a pressure ulcer for a Stage 3 pressure ulcer. The findings are: 1) Resident #206 has [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident's cognition was intact. The MDS also documented that the resident was assessed to be free of pressure ulcers. Additionally, an MDS dated [DATE] documented a BIMS score of 13, again indicating intact cognition. The MDS also documented that the resident was assessed to be free of pressure ulcers. A Nursing Progress Note (NPN), signed by a Licensed Practical Nurse (LPN) dated 9/6/16, documented that a nosocomial (facility acquired) pressure ulcer was observed on the resident ' s sacrum measuring 1.2 centimeters (cm) by 1 cm by 0.1 cm and had 50 % slough (an indicator of non-viable tissue) and 50% granulation (an indicator of healing tissue). The NPN also documented that the Nurse Practitioner (NP) was made aware of the finding and ordered a treatment of [REDACTED]. Reference below from the American Association of Nurse Assessment Coordination dated 4/29/16: In New York State LPNs cannot assess, so although they can measure a pressure ulcer, they cannot stage as this would be outside their scope of practice and considered assessing.Staging a pressure ulcer is completing an assessment. LPNs can measure and describe what the pressure ulcer looks like. Staging and/or saying the wound has improved or deteriorated is assessing, and only RNs can do that. Reference from The National Pressure Ulcer Advisory Panel the Scope and Standards of Nursing Practice (2010): Registered Nurses are expected to assess the patient's skin, stage the wound and implement an individualized plan of care based on the patient needs. Due to licensed practical nurse state practice act restrictions, wounds that have the appearance of a pressure ulcer should be inspected and described by Registered Nurses. The Registered Nurse needs to identify and stage the pressure ulcer. An interview was held with the LPN Wound Nurse on 9/28/16 at 12:45 PM. The LPN stated that the sacrum pressure ulcer was discovered on 9/3/16 and was assessed as a Stage 2 by the Wound Physician and the LPN wound nurse. The LPN also stated that she assessed the pressure ulcer on 9/6/16 and staged the sacral pressure ulcer as a Stage 3 with 50% slough. The LPN stated that she informs the Physician about the treatment needed and then the Physician orders [REDACTED]. In a subsequent interview conducted on 9/28/16 at 12:49 the LPN stated that she received in-depth training from the wound care Physician on Staging of pressure ulcers. The LPN further stated that she also received training on staging pressure ulcers from a consultant from the maker of an enzymatic [MEDICATION NAME] agent used in the treatment of [REDACTED]. 415.11(c)(3)(i)

Plan of Correction: ApprovedNovember 2, 2016

F281 SERVICES PROVIDED MEET PROFESSIONAL STANDARDS
I.Immediate Corrective Action
1.The DNS reviewed Resident #206 medical record and did a complete assessment of his sacral Stage 3 pressure ulcer.
Completion Date: 10/26/16
2.An educational counseling was given to the LPN to assure she understands her scope of practice concerning pressure ulcers.
Completion Date: 10/25/16
3.Full house audit completed to ensure any resident with Stage 3 pressure ulcer has a completed assessment by an RN. 10/31/16
II. Identification of Others
1.All residents are identified to have the potential to be affected by this deficiency.
III. System Changes
1.The administrator and DNS reviewed the policy and procedure for wound care and found it to be compliant.
Completion date: 10/28/16
2.All RN?s and LPN?s will be in-serviced on the wound care policy by the DNS/designee with emphasis on standards of nursing practice. A copy of the lesson plan and attendance will be filed for reference.
Completion Date: 11/25/16
IV. QA
1.The DNS developed an audit tool to monitor compliance of pressure ulcer assessments and documentation completed by an RN.
2.The audit will be conducted by the DNS/designee on 5 residents weekly X one month and then 5 residents monthly. Any negative findings will have immediate corrective action by the DNS and will be reported to the Administrator. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as indicated.
V. The date for correction and the title of the person responsible for the correction of the deficiency:
1. The DNS is responsible for the correction of this deficiency by 11/25/16 and ongoing.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during a recertification survey, the facility did not ensure that treatment and services to promote healing, and to prevent development of new pressure ulcers, were provided for one of three residents reviewed for pressure ulcers (Resident #206). Specifically, Resident #206 was assessed on 9/6/16 by a Licensed Practical Nurse (LPN) for a nosocomial (facility acquired) pressure ulcer and there was no documented evidence that the Nurse Practitioner (NP) or other qualified health professional completed an assessment of the pressure ulcer. The finding is: Resident #206 has [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident's cognition was intact. The MDS also documented that the resident was assessed to be free of pressure ulcers. An MDS assessment dated [DATE] documented a BIMS score of 13, also indicating intact cognition. The MDS further documented that the resident was assessed to be free of pressure ulcers. A Nursing Progress Note (NPN) dated 9/3/16 documented that the resident was assessed by the Registered Nurse ( RN) Supervisor to have a Stage 2 pressure ulcer on the sacrum. A Comprehensive Care Plan (CCP) titled Skin Breakdown dated 9/3/16 documented a Stage 3 pressure ulcer to the sacrum. The CCP also documented new interventions as follows: Initiate wound rounds weekly. Apply treatments as ordered by the Physician and to monitor for infection or changes to the pressure ulcer. A Medical Progress Note (MPN) dated 9/6/16 documented that the resident had a skin opening and to apply [MEDICATION NAME] to the affected areas. The MPN had no documentation of the description of the open area or where it was located. A Nursing Progress Note (NPN), signed by a Licensed Practical Nurse (LPN) dated 9/6/16, documented that a nosocomial pressure ulcer was observed on the resident ' s sacrum measuring 1.2 centimeters (cm) by 1 cm by 0.1 cm and had 50 % slough (an indicator of non-viable tissue) and 50% granulation (an indicator of healing tissue). The NPN also documented that the Nurse Practitioner (NP) was made aware of the finding and ordered a treatment of [REDACTED]. A Wound Report completed by the LPN, who is the designated wound nurse, and wound Physician dated 9/15/16 documented that the resident had a pressure ulcer to the Sacrum measuring 1.5 cm by 1.0 cm by 0.1 cm. The Wound Report also documented that the pressure ulcer was a Stage 3 and that Hydrogel is to continue although Santyl (a [MEDICATION NAME] agent) would be preferred. An interview was held with the Nurse Practitioner (NP) on 9/28/16 at 10:15 AM. The NP was not aware of why there was no documented evidence in the medical record that an assessment of the resident ' s pressure ulcer was completed on 9/6/16 by a qualified health professional, The NP stated that the LPN wound Nurse assessed the pressure ulcer and informed her. An interview was held on 9/28/16 at 12:45 PM with the Licensed Practical Nurse (LPN) wound nurse. The LPN wound nurse stated that, on 9/6/16, she assessed the pressure ulcer on the Sacrum and staged the pressure ulcer as a Stage 3 with 50% slough. The LPN wound nurse also stated that she informed the NP that the resident had a Stage 3 pressure ulcer and that Hydrogel should be used. The LPN stated that the NP did not assess the resident's pressure ulcer. The Wound Care Physician was not available for comment. 415.12(c)(2)

Plan of Correction: ApprovedNovember 2, 2016

F314 TREATMENT/SERVICES TO PREVENT/ HEAL PRESSURE SORES
I.Immediate Corrective Action
1.The NP reviewed Resident #206 medical record and did a complete assessment of his sacral Stage 3 pressure ulcer.
Completion Date: 10/31/16
2.Educational counseling given to NP by medical director to ensure that NP understands the importance of completing pressure ulcer assessments.
Completion Date: 10/20/16
3.Full house audit conducted on all residents with pressure ulcers to ensure that an assessment was completed.
Completion Date: 11/11/16
II. Identification of Others
1. All residents are identified to have the potential to be affected by this deficiency.
III. System Changes
1.The administrator and DNS reviewed the policy and procedure for Pressure Ulcers and found it to be compliant.
Completion Date: 10/28/16
2. All medical staff will be in-serviced on this policy by the DNS with emphasis on importance of pressure ulcer assessment when a pressure ulcer develops or deteriorates. A copy of the lesson plan and attendance will be filed for reference.
Completion date: 11/25/16
IV. QA
1.The DNS developed an audit tool to monitor compliance of pressure ulcer assessment and documentation.
2.The audit will be conducted by the DNS/designee on 5 residents weekly X one month and then 5 residents monthly. Any negative findings will have immediate corrective action by the DNS and will be reported to the Administrator. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up follow up as indicated.
V. The date for correction and the title of the person responsible for the correction of the deficiency:
1. The DNS is responsible for the correction of this deficiency by 11/25/16 and ongoing.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Where Alcohol Based Hand Rub (ABHR) dispensers are installed: o The corridor is at least 6 feet wide o The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms) o The dispensers shall have a minimum spacing of 4 ft from each other o Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet. o Dispensers are not installed over or adjacent to an ignition source. o If the floor is carpeted, the building is fully sprinklered. 18.3.2.7, CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

Life Safety Code does not allow for the storage of more than 10 gallons of Alcohol Based Hand Rub (ABHR) in a single smoke compartment outside of a storage cabinet. Based on observation and staff interview, the facility failed to ensure that Alcohol Based Hand Rub was not stored in excess of 10 gallons within a single smoke compartment. This was observed in the basement of the facility. The findings are: On 9/22/2016 between the hours of 9am and 2pm during the recertification survey, the following was observed: In the storage room in the basement, Alcohol Based Hand Rub (ABHR) was observed being stored outside of a fire rated cabinet. There were 14 full boxes of ABHR solution. Each box contained 6 Liters of ABHR. This amount exceeds the allowed 10 gallons per smoke compartment. In an interview at approximately 11:20am with the Director of Maintenance, he stated he would relocate the hand sanitizers to different smoke compartments to meet the code. CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623

Plan of Correction: ApprovedOctober 28, 2016

K211 Where Alcohol Based Hand Rub dispensers are installed
I.Immediate Corrective Action
1.All Alcohol Based hand rub was immediately relocated to the shed outside of the facility for storage.
Completion Date: 10/20/16
2.Full house audit completed by Environmental Director to ensure there are no Alcohol based hand rub being stored inside the facility.
Completion Date: 10/20/16
II.Identification of Others
1.The facility respectfully states that all residents have the potential to be affected by these issues.
III.Systematic Changes
1.The Administrator and Environmental Director reviewed and revised the policy and procedure on Proper Storage of Alcohol Based Hand Rub.
Completion Date: 10/25/16
2.In-service given to all housekeeping staff by the Environmental Director on the policy and procedure on Proper Storage of Alcohol Based Hand Rub. A copy of the lesson plan and attendance will be filed for reference.
Completion Date: 10/27/16
IV.QA
1.The Environmental Director developed and audit tool to monitor compliance to ensure no more than 10 gallons of Alcohol Based Hand Rub is stored in a single smoke compartment and that no alcohol based hand rub is being stored outside a storage cabinet.
2.The audit will be conducted by the Environmental Director daily x1 month and 1x weekly thereafter x1 year. Any negative findings identified will have immediate corrective action and be referred to Administrator for review. Audit findings will be presented to the QA committee for evaluation and follow up as indicated.
V.The date for the correction and title of the person responsible for the correction of the deficiency:
1.The Administrator is responsible for the correction of this deficiency by 11/25/16 and ongoing

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 25, 2016

Citation Details

1999 NFPA 13:5-6.3.4 Minimum distance between sprinklers. Sprinklers shall be spaced not less than 6ft (1.8m) on center Based on observation and staff interview, the facility failed to ensure that sprinklers were not located less than six feet apart. This was observed on 1 of 4 units in the facility, including the basement. The findings are: On 9/22/2016 between the hours of 8:30am and 2pm during the recertification survey, the following was observed: Sprinklers were noted to be within 6 feet of each other. Locations include, but are not limited to: 1) Resident bathroom on the West Unit 2) The laundry room in the basement In an interview with the Director of Maintenance at approximately 9:30am, he stated he will see if the sprinkler can be removed. In an interview with the Director of Maintenance at approximately 10:45am, he stated they used to store laundry bins when the facility did laundry on site. He further stated that might be why there are so many sprinklers in the room.

Plan of Correction: ApprovedOctober 28, 2016

K062 Required automatic sprinkler systems are continuously maintained in reliable operating conditions and are inspected and tested periodically
I.Immediate Corrective Action
1.Sprinkler company contacted to remove sprinklers in the resident bathroom on West unit and the laundry room in the basement that was noted to be within 6 feet of each other.
Completion date: 11/11/16
2. Full house audit completed by Director of Maintenance and Sprinkler company to ensure all sprinklers are located within six feet apart.
Completion date: 11/11/16
II.Identification of Others
1.The facility respectfully states that all residents have the potential to be affected by these issues.

III.Systematic Changes
1.The Administrator and Director of Maintenance reviewed and revised the policy and procedure on Fire Sprinkler System Testing and Inspection.
Completion date: 10/25/16
2.The maintenance staff will be in-serviced by the Director of Maintenance on the policy and procedures with emphasis on the requirements on the distance of sprinklers and a copy of the lesson plan and attendance will be filed for reference.
Completion date: 10/26/16
IV.QA
1. The Director of maintenance developed and audit tool to monitor compliance to ensure sprinklers are not located less than six feet apart.
2.The audit will be conducted by the maintenance director/designee on all sprinklers monthly x3 months and quarterly thereafter. Audit findings will be presented to the QA committee for evaluation and follow up as indicated.
V.The date for the correction and the title of the person responsible for the correction of the deficiency:
1.The Administrator is responsible for the correction of this deficiency by 11/25/16 and ongoing.