Northwoods Rehabilitation and Nursing Center at Moravia
March 31, 2017 Certification/complaint 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: March 31, 2017
Corrected date: May 30, 2017

Citation Details

Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 1 sampled employees (Employee #7), reviewed for failing the CHRC (Criminal History Record Check) was removed from work in a timely manner. Specifically, the facility did not remove Employee #7 from resident access timely when notified the employee failed the CHRC. Findings include: Review on 3/30/2017 of a printout from CHRC, printed 2/1/2017, showed documentation a Pending Denial Letter was issued to the provider on 10/7/2016. Review on 3/30/2017 of a Supervision Verification Form for 10/5/2016 through 10/9/2016, and Employee #7's timesheet, verified she worked on 10/8/2016 and 10/9/2016. When interviewed on 3/30/2017 at 4:00 PM, the Medical Records/Finance Officer stated Employee #7's letter came on a Friday, and she saw it on Monday. Employee #7 was suspended after her 10/9/2016 shift. She also stated she usually checked the staff negative determination letters on a daily basis. The facility's Verification of Credentials Policy and Procedure, dated 7/2007, documented until clearance is received from the NYSDOH (New York State Department of Health) on the new employee, the Department Supervisor charts daily on on the individual's CHRC log sheet. Once clearance is obtained, the CHRC log sheet is placed in the individual's personnel file in Human Resources. The policy did not provide direction for staff on how to address an employee with an unfavorable background check. 10NYCRR 402.7

Plan of Correction: ApprovedMay 25, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
No residents were affected by the deficient practice.
All residents had the potential to be affected by the deficient practice.
The facility has 2 staff members who can access CHRC system as Authorized Person's (AP's) . The Administrator is now the primary Human Resources staff and AP, while the Medical Records/Finance Officer is secondary/backup The policy on new employee credentialing has been revised and updated to include instructions on how to handle all the potential response letters from the CHRC system. All of the facility's AP's have been educated on the revised policy.
The Medical Records/Finance Officer or designee, will check the CHRC system daily for 2 weeks, then twice a week for 3 months to ensure that all CHRC letters have been reviewed and acted upon by the Administrator. The check on Friday will be done at the end of the work day, and the Friday check will be one of the twice a week reviews. Any letters found will be handled immediately.
Results of the audit will be reported monthly to the QA committee, with continuation determined by the committee, with a goal of 100% compliance.
The completion date is 5/30/2017. The Administrator is responsible for this P(NAME).

E3BP 402.7(a)(4):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: ...... (4) Where the criminal history information of a prospective employee reveals a charge for any felony, the Department shall hold the determination regarding a prospective employee's eligibility for employment in abeyance until the charge is finally resolved. Upon receipt of notification from the Department of the abeyance, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider before final resolution of the criminal charge.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 30, 2017

Citation Details

Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 1 sampled employees (Employee #6) reviewed for failing the CHRC (Criminal History Record Check) was removed from work in a timely manner. Specifically, the facility did not remove Employee #6 from resident access timely when notified the employee failed the CHRC. Findings include: Review on 3/30/2017 of a printout from CHRC, printed 2/1/2017, showed documentation a Hold in Abeyance Letter was issued to the provider on 8/3/2016. Review on 3/30/2017 of a Supervision Verification Form for 6/20/2016 through 8/8/2016, and Employee #6's timesheet, verified she worked the week of 8/7/2016 to 8/13/2016. When interviewed on 3/30/2017 at 4:00 PM, the Medical Records/Finance Officer stated Employee #6's letter came on a Wednesday, and she saw it on Monday. Employee #6 was suspended after her 8/8/2016 shift. She also stated she usually checked the staff negative determination letters on a daily basis. The facility's Verification of Credentials Policy and Procedure, dated 7/2007, documented until clearance is received from the NYSDOH (New York State Department of Health) on the new employee, the Department Supervisor charts daily on on the individual's CHRC log sheet. Once clearance is obtained, the CHRC log sheet is placed in the individual's personnel file in Human Resources. The policy did not provide direction for staff on how to address an employee with an unfavorable background check. 10NYCRR 402.7

Plan of Correction: ApprovedMay 25, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
No residents were affected by the deficient practice.
All residents had the potential to be affected by the deficient practice.
The facility has 2 staff members who can access CHRC system as Authorized Person's (AP's) . The Administrator is now the primary Human Resources staff and AP, while the Medical Records/Finance Officer is secondary/backup The policy on new employee credentialing has been revised and updated to include instructions on how to handle all the potential response letters from the CHRC system. All of the facility's AP's have been educated on the revised policy.
The Medical Records/Finance Officer or designee, will check the CHRC system daily for 2 weeks, then twice a week for 3 months to ensure that all CHRC letters have been reviewed and acted upon by the Administrator. The check on Friday will be done at the end of the work day, and the Friday check will be one of the twice a week reviews. Any letters found will be handled immediately.
Results of the audit will be reported monthly to the QA committee, with continuation determined by the committee, with a goal of 100% compliance.
The completion date is 5/30/2017. The Administrator is responsible for this P(NAME).

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not promote care for residents in a manner and an environment that maintained or enhanced each resident's dignity for 1 of 6 residents (Resident #2) reviewed for dignity. Specifically, Resident #2 was observed with unwanted long facial hair throughout survey. Findings include: Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The physician order [REDACTED]. The comprehensive care plan (CCP) updated 11/30/2016 documented the resident had an activities of daily living (ADLs) self-care deficit. Interventions included to provide a sponge bath when a full bath or shower cannot be tolerated, with total dependency on 2 staff to provide bath/shower on day shift every Tuesday and as necessary. The resident had total dependency on 2 staff for personal hygiene and oral care. Staff were to discuss any concerns regarding health with the resident, and report changes. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had full cognition. She required total assist of 2 with bathing, and did not refuse care during the assessment period. The 3/2017 certified nurse aide (CNA) task sheet (documents care) documented the resident received personal hygiene at least daily, and her skin was monitored daily. She was bathed every Tuesday and all but 1 Thursday during the month. The resident had facial hair on her chin that was about 0.5 centimeters in length: - On 3/29/2017 at 8:00 AM, 11:00 AM, 2:15 PM, and 4:15 PM; - On 3/30/2017 at 9:00 AM, 1:00 PM, and 4:00 PM; and - On 3/31/2017 at 10:30 AM. There was no documented evidence the resident refused to be shaved. When interviewed on 3/29/2017 at 11:00 AM, the resident stated she could brush her own teeth, wash her face and hands, and feed herself. She stated staff performed the rest of her care for her. She stated staff shaved her if she asked them to and she should not have to ask. She stated facial hair bothered her. When interviewed on 3/31/2017 at 10:30 AM, CNA #10 stated resident care instructions were in the CCP and on the Kardex (care instruction guide). CNA #10 stated baths or showers were usually given twice a week, and residents should be shaved daily unless they refused. She stated Resident #2 did not refuse hygiene, baths, or showers. When interviewed on 3/31/2016 at 11:20 AM, CNA #11 stated Resident #2 received a bed bath twice a week on Tuesday and Friday, she was capable to tell staff what she needed, and shaving was not documented in the CNA task sheet. She stated residents were to be shaved on bath day or when facial hair was noticeable, and staff were to inform a nurse if they were unable to shave the resident. She stated the facility was usually short staffed, there were days when staff did not have time to shave the residents, and the resident was not shaved unless she asked to be shaved. When interviewed on 3/31/2017 at 11:45 AM, licensed practical nurse (LPN) #12 stated female residents should not have facial hair unless they refused to be shaved. When interviewed on 3/31/2017 at 11:55 AM, the Director of Nursing stated noticeable female facial hair was unacceptable, and she expected residents to be shaved on bath day unless the resident refused. She stated there were no formal checks done on care the CNAs provided to residents. She stated there have been staffing issues lately, despite the facility trying to hire new staff or acquire agency personnel. 10NYCRR 415.5(a)

Plan of Correction: ApprovedMay 25, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of this facility to treat each resident with dignity and respect. Resident #2 is alert and oriented. Upon interview with the DOH regarding residents care and the expectations for facial hair removal, the DON provided education to the assigned CNA and the residents? facial hair was removed per her request.
Because all residents receiving assistance during ADLs have the potential to be affected by the cited deficiency, on 4/25 the DON/Designee reviewed and updated all CNA Kardexes to reflect the need to ask all residents daily if they would like to be shaved. Should a resident refuse removal of facial hair it will be documented in the residents? plan of care.
To enhance currently compliant operations and under the direction of the DON/Designee, all nursing staff will receive in-service training regarding state and federal requirements for facial hair. The training will emphasize the importance of the removal of facial hair and its impact on resident dignity.
A quality-assurance program will be implemented under the supervision of the Director of Nursing to monitor residents dignity with respect to facial hair. The DON/designee will perform the following systemic changes: weekly checking all residents who require assistance with shaving and to ensure facial hair is being removed. Any deficiencies will be corrected on the spot, and the findings of the QA checks will be documented and submitted at the monthly quality-assurance committee meeting for further review or corrective action. Initial auditing/reporting to be done for 3 months with continued auditing & reporting to be determined by the committee, with a goal of 100% compliance.
The Director of Nursing will be responsible.
Completion date is 5/30/2017.

FF10 483.12(a)(1):FREE FROM ABUSE/INVOLUNTARY SECLUSION

REGULATION: 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms. 483.12(a) The facility must- (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification and abbreviated surveys (NY 781), the facility failed to ensure 1 of 6 residents (Resident #3) had the right to be free from abuse. Specifically, Resident #3 suffered psychological abuse when another resident's behaviors kept her awake at night. Findings include: Resident #3 was readmitted to the facility on [DATE] after a total knee replacement, and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and she required limited to extensive assistance with activities of daily living (ADLs). A 3-page grievance letter dated 12/25/2017 documented the resident had concerns with another resident (Resident #11) in the room next to her's. Resident #11 yelled, screamed, used vulgar language, and was abusive to staff on 12/10, 12/11, 12/12, and 12/14/2016. Resident #11 had issues with the loudness of his television and was asked several times daily to turn it down and at night when others slept. Resident #3 wrote: she should not have to be subjected to Resident #11's abusive behavior; the environment felt hostile and uncomfortable for her; and she was asking for the facility's help. A grievance communication form dated 12/31/2016 documented the resident was awoken at 4:45 AM by Resident #11's yelling and swearing. There was no documented evidence the facility followed up with the resident to ensure her concerns were thoroughly addressed and the issue was resolved. The comprehensive care plan (CCP) revised 2/10/2017 documented the resident was at risk of having adjustment issues. Interventions included the resident would be helped to identify/recognize stressors, and staff would intervene and remove stressors when possible. A social services progress note dated 3/2/2017 at 10:07 AM documented the resident continued to have complaints regarding another resident who lived in the room next to her's. She was asked if she would d like to switch rooms to the other end of the hallway and she declined. She recently made more complaints that Resident #11 was disruptive at night and she could not sleep very well. The resident was asked again if she wanted to switch rooms, and she refused as she felt she should not be the one to move. The plan was the social worker would continue to address concerns with the resident and Resident #11. There was no documented evidence the social worker followed up with the resident to determine if her concerns were resolved. An occupational therapy note dated 3/3/2016 at 12:49 PM documented the resident called the therapist at 8:30 AM and stated she had been up all night and could not sleep due to a resident (Resident #11) in the next room yelling out. The note documented the resident might not be up to therapy, and something needed to be done or she would leave the facility. A review of Resident #11's record documented: - on 12/3/2016 at 1:54 PM, he cursed and made threats when told he would have to wait to go back to bed as staff were helping other residents. - on 12/26/2016, he received [MEDICATION NAME] 0.25 milligrams (mg) one time for increased anxiety. - on 1/5/2017 at 5:57 AM, he yelled give me some (expletive) OJ my sugar is low, and constantly rang his bell and yelled throughout shift. - on 2/12/2017 at 4:48 AM, he was awake in bed since 2 AM. He was yelling and sighing loudly and woke Resident #3 and another resident, who were very angry. The resident pushed his call bell every hour asking for food, had his television turned up to maximum volume, and woke Resident #3. He was compliant when asked to turn the television down and then would turn it up again. - on 2/14/2017 at 12:18 PM, he was screaming at the top of his lungs. - on 3/2/2017 at 12:34 PM, he was verbally aggressive with staff, swearing, calling residents names, and being disrespectful in the dining room. - on 3/28/2016 at 5:04 AM, he yelled and swore at staff. Resident #11's record did not document any behaviors from 12/4/2016 through 1/4/2017. During an interview on 3/30/2017 at 9:40 AM, Resident #3 stated: - Resident #11 was non-stop; he yelled and said horrific sexual things every day. - Resident #11 demanded food and medication at all hours of the night. - Resident #11 kept his television turned up to the highest volume at all hours of the day and night. - Resident #11 slept all day and was up all night. - The wall between her room and Resident #11's room was very thin and his yelling was like nothing she had heard before. - Other residents and family members also had complained of Resident #11's behavior in the past. - After she wrote a letter on 12/25/2016, the Administrator told her something would be done about Resident #11. - In the last week, the nurse practitioner gave her ear plugs to help block out Resident #11's noise. She stated nobody else offered or suggested interventions to reduce the amount of noise she had to listen to. - After she returned from knee surgery in January, she needed rest to help with her recovery and Resident #11 kept her awake most nights. She was observed crying during the interview, and she stated she felt very traumatized by the whole situation. On 3/13/2017 at 10:13 AM, physical therapist (PT) #13 stated in an interview that he was currently working with Resident #3 and she complained to him about Resident #11's behavior. He stated there were days when the resident was not in the mood for therapy as she had not slept the night prior. There were also times when she was not able to complete therapy due to lack of sleep. He stated he witnessed 2 instances where the resident cried when she spoke about Resident #11's behavior and he notified the social worker both times. On 3/31/2017 at 10:15 AM, licensed practical nurse (LPN) #14 stated in an interview when Resident #11 was in a bad mood, he continuously rang his call bell and his television was turned up to the maximum volume. She stated Resident #3 frequently complained of Resident #11's behavior, she lived in the room next door, and she had been complaining for a while now. She stated Resident #3 was emotional, related to all her medical issues, and Resident #11's behavior sent her over the edge emotionally. She stated Resident #3 spoke to management all the time about the issue. During an interview on 3/31/2017 at 12:15 PM, the facility's social worker stated she spoke with the resident in (MONTH) after complaints were made about Resident #11. She offered Resident #3 a room change at that time and the resident refused when it could not be guaranteed she would continue to have a private room. The facility had not considered ear plugs for Resident #3 to help with the noise and had not considered other options other than a room change to help her cope. She stated they were pursuing another placement for Resident #11 and no other facility had accepted him yet. She stated policy was to send residents with abusive behavior to the hospital for evaluation and Resident #11 was not sent. She stated both the Administrator and physician were aware and nothing was done. During an interview on 3/31/2017 at 1:30 PM, the Administrator stated they were trying to figure out what do with Resident #11. The facility wanted to discharge him and was having a hard time getting another facility to accept him. He stated he was not sure if anyone considered an inpatient behavioral treatment center for the resident. He also stated that Resident #3 did suffer from emotional trauma caused by Resident #11. 10NYCRR 415.4(b)(1)(i)

Plan of Correction: ApprovedMay 25, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
Incident was fully investigated. Appropriate actions were taken with identified resident in accordance with facility policy and procedures. Resident #3 has been safely discharged from the facility back to her home.
All residents have a right to be free from abuse, neglect, misappropriation of resident property, and exploitation, therefore all residents have a potential to be affected by the cited deficiency. A review of sample grievances over the last three months pertaining to such behavior has been conducted and determined that no other residents were affected by the cited deficiency.
The facility?s policy and procedure related to abuse, neglect, misappropriation of resident property and exploitation was reviewed and deemed adequate. All staff will receive in-service education on Abuse Prevention and Prohibition.
Audits of 50% sample of satisfaction surveys related to grievance resolution will be conducted by the administrator/designee x3 months. The audits will be presented to the QA committee monthly for three months and then periodically thereafter as determined by the committee, with a goal of 100% compliance.
The facility social worker is responsible for this P(NAME).
completion date is 5/30/2017

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 6 residents (Resident #4) received adequate supervision and assistance to prevent accidents. Specifically, Resident #4 fell and fractured a rib; she was not assessed by a qualified person, and there was no evidence she was properly supervised. Findings include: Resident #4 was admitted to the facility 7/2/2015 and had [DIAGNOSES REDACTED]. The Resident with Injury/Falls Policy, dated (MONTH) 2012, documented when a resident fell on the off-shifts, the LPN (licensed practical nurse) would check on the resident, and then call the RN (registered nurse) on-call for instructions. The resident was not to be moved until directions were given by the RN. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. She required one person assistance with transfers and walking, and she had 3 falls during the assessment period. The comprehensive care plan (CCP) revised 12/8/2016 documented the resident was at a high risk for falling. Interventions included keeping the call light in reach, a mat on the floor next to bed, and following the facility fall protocol. The CCP documented resolved (discontinued) interventions included a seat belt alarm (resolved 8/5/2016) and a bed alarm (resolved 12/8/2016). The Morse Fall Scale (fall risk assessment tool) dated 1/24/2017 documented the resident was at high risk for falling. The incident report dated 3/28/2017 at 1:15 AM, completed by LPN #15, documented the resident walked out of her room in socks, attempted to sit in a wheelchair, was found on her back in the hallway, and complained of right back pain. The report documented that LPN #15 and certified nurse aides (CNAs) #16 and 17 were working during the resident's fall. The undated CNA Kardex (direct care instructions) did not document the resident had bed or chair alarms in place. The radiological report dated 3/29/2017 documented the resident had an x-ray of her right ribs and the x-ray revealed a nondisplaced right lateral rib fracture. During a telephone interview on 3/31/2017 at 10:35 AM, CNA #17 stated that just prior to the resident's fall, she and CNA #16 were outside on a break and LPN #15 was the only other staff inside the building. She stated when she and CNA #16 came back inside, they found the resident on the floor outside her room and she complained of back pain. The resident stated to them that she was trying to go to the bathroom at the time she fell . CNA #17 stated she called out for LPN #15, who was down the hall at the nursing station. LPN #15 responded and did vital signs and made sure the resident could move all her limbs. She stated she did not witness LPN #15 calling the RN prior to moving the resident off the floor. She stated prior to the fall, CNA #16 had put the resident to bed and she currently had a floor mat and bed/chair alarm in place to prevent falls. She stated the bed alarm was sounding at the time they found the resident on the floor. During a telephone interview on 3/31/2017 at 11:30 AM, CNA #16 stated that she and CNA #17 were outside on a break and found the resident on the floor when they came inside. She stated the resident told her she was trying to find the bathroom; her bed alarm was sounding and she complained of back pain. She stated LPN #15 did vital signs, she and CNA #17 assisted the resident off the floor, and she did not see LPN #15 call the RN prior to getting the resident up. During an interview on 3/31/2017 at 1:55 PM, the Director of Nursing (DON) stated she was the on-call RN the night the resident fell . She did not know the resident fell until she came into work that morning. She stated the resident was moved without an assessment being completed and she immediately retrained LPN #15. She stated not more than 1 person was to be on break during the night shift, and she was not aware that both CNAs were on break at the time the resident fell . 10NYCRR 415.12(h)(2)

Plan of Correction: ApprovedMay 25, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of this facility to properly supervise all residents and that their environment remains as free of accident/injury hazards as possible. As for resident#4 she was assessed at a high risk for falls, she had a fall mat in place as well as a bed/chair alarm. The bed alarm was sounding at the time of the fall and there was an LPN on the unit.
The LPN was educated per facility policy that the RN is to be notified prior to moving any resident who has fallen on the off shift. Resident #4 was evaluated by the physician first thing in the morning and x-rays were obtained. The CNAs were educated on the facility policy to take breaks in shifts. The care card was updated to reflect the bed and chair alarm.
All residents have the potential to be affected by the cited deficiency. The DON reviewed the
Policy with the nursing staff to ensure that an RN was called regarding any falls on the off shift
prior to any transfer of resident from one surface to another. The policy on CNA breaks was also reviewed by the DON with all to reinforce the need for supervision of the residents.
To enhance currently compliant operations, the DON implemented a log of incidents which includes a check list attached to each incident report ensuring their completeness, including contact with the on-call staff as required. The reports are logged by the DON/designee and check list is verified for completeness. The log and check lists will be maintained by the DON/ designee.
A QA audit will be implemented under the supervision of the DON to monitor resident incident reports for completion. The DON/designee will be monitoring each incident report (100%) and the findings reported on a monthly basis to the QA committee x 3 months. Any deficiencies will be corrected on the spot, and findings of the quality assurance checks will be documented and submitted at the monthly quality assurance committee meeting for further review or corrective action. The committee will determine continued auditing and reporting, with a goal of 100% compliance.
The Director of Nursing is responsible for this P(NAME).
Completion date is 5/30/2017.

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, it was determined for 1 of 6 residents (Resident #4) reviewed for abuse/neglect, for 2 of 5 new employees (Employees #2 and 3) reviewed for abuse prevention orientation, and for 5 of 5 new employees (Employees #1, 2, 3, 4, and 5) reviewed for reference checks, the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated. Specifically: - Resident #4 was not assessed by a qualified professional following a fall and the investigation was not thorough or complete. - For Employees #2 and 3, abuse prevention orientation was not complete. - For Employees #1-5, there was no documentation that reference checks were completed. Findings include: 1) Resident #4 was admitted to the facility 7/2/2015 and had [DIAGNOSES REDACTED]. The Resident with Injury/Falls Policy, dated (MONTH) 2012, documented when a resident fell on the off-shifts, the LPN (licensed practical nurse) would check on the resident, and then call the RN (registered nurse) on-call for instructions. The resident was not to be moved until directions were given by the RN. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. She required one person assistance with transfers and walking, and she had 3 falls during the assessment period. The comprehensive care plan (CCP) revised 12/8/2016 documented the resident was at a high risk for falling. Interventions included keeping the call light in reach, a mat on the floor next to bed, and following the facility fall protocol. The CCP documented resolved (discontinued) interventions included a seat belt alarm (resolved 8/5/2016) and a bed alarm (resolved 12/8/2016). The Morse Fall Scale (fall risk assessment tool) dated 1/24/2017 documented the resident was at high risk for falling. The incident report dated 3/28/2017 at 1:15 AM, completed by LPN #15, documented: - The resident walked out of her room in socks, attempted to sit in a wheelchair, was found on her back in the hallway, and complained of right back pain. - The incident did not involve a self-toileting attempt. The section to determine the last time the resident was toileted was blank. - The actions taken to prevent further incidents included the resident was re-oriented to her room and bathroom, and current interventions were bed and chair alarms. The section to determine if bed/chair alarms were functioning at the time of the incident was blank. - Certified nurse aides (CNAs) #16 and 17 were working at the time of the resident's fall. There were no CNA statements attached to the report. - There was no evidence of abuse, neglect, or mistreatment. The undated CNA Kardex (direct care instructions) did not document the resident had bed or chair alarms in place. The radiological report dated 3/29/2017 documented the resident had an x-ray of her right ribs and the x-ray revealed a nondisplaced right lateral rib fracture. During a telephone interview on 3/31/2017 at 10:35 AM, CNA #17 stated that just prior to the resident's fall, she and CNA #16 were outside on a break and LPN #15 was the only other staff inside the building. She stated when she and CNA #16 came back inside, they found the resident on the floor outside her room and she complained of back pain. The resident stated to them that she was trying to go to the bathroom at the time she fell . CNA #17 stated she called out for LPN #15, who was down the hall at the nursing station. LPN #15 responded and did vital signs and made sure the resident could move all her limbs. She stated she did not witness LPN #15 calling the RN prior to moving the resident off the floor. She stated prior to the fall, CNA #16 had put the resident to bed and she currently had a floor mat and bed/chair alarm in place to prevent falls. She stated the bed alarm was sounding at the time they found the resident on the floor. She stated that nobody spoke with her after the incident to determine if the care plan was followed and she was not asked to provide a statement. During a telephone interview on 3/31/2017 at 11:30 AM, CNA #16 stated that she and CNA #17 were outside on a break and found the resident on the floor when they came inside. She stated the resident told her she was trying to find the bathroom; her bed alarm was sounding and she complained of back pain. She stated LPN #15 did vital signs, she and CNA #17 assisted the resident off the floor, and she did not see LPN #15 call the RN prior to getting the resident up. She stated the LPN asked her what happened and what she had seen. She stated the resident had been toileted recently prior to the fall and LPN #15 did not ask her the last time the resident was toileted. During an interview on 3/31/2017 at 1:55 PM, the Director of Nursing (DON) stated she was the on-call RN the night the resident fell . She did not know the resident fell until she came into work that morning. She stated the resident was moved without an assessment being completed and she immediately retrained LPN #15. She stated she was not aware staff statements were not obtained, and they should have been to determine if the care plan was followed. She also stated not more than 1 person was to be on break during the night shift, and she was not aware that both CNAs were on break at the time the resident fell . 2) Reference Checks/Abuse Orientation On 3/30/2017, a review of the personnel folders for Employees #2 and 3 revealed that abuse orientation documentation was not present. On 3/30/2017, a review of the personnel folders for Employees #1, 2, 3, 4, and 5 revealed that reference checks were not completed. When interviewed on 3/30/2017 at 9:30 AM, the Administrator stated reference checks were not completed for Employees #1, 2, 3, 4, and 5. When interviewed on 3/30/2017 at 3:40 PM, the Administrator stated abuse orientation was part of the new employee orientation and a new employee orientation packet was made for an employee upon hire. He also stated after the orientation packet was completed, there was a monthly orientation led by various staff including the Administrator, the Maintenance Director, the Nursing Manager, and others. He was not aware Employees #2 and 3 did not have documentation regarding abuse orientation in their personnel folders. 10NYCRR 415.4(b)(1)(ii)

Plan of Correction: ApprovedMay 25, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
Item #1:
It is the policy of this facility to thoroughly investigate all accidents and incidents. As for resident#4, she was assessed at a high risk for falls and she had a fall mat in place as well as a bed/chair alarm. The bed alarm was sounding at the time of the fall and there was an LPN on the unit.
The LPN was educated per facility policy that the RN is tobe notified prior to moving any resident who has fallen on the off shift. Resident #4 was evaluated by the physician first thing in the morning and x-rays were obtained. The CNAs were educated on the facility policy to take breaks in shifts.
All residents have the potential to be affected by the cited deficiency. The DON reviewed the
Policy with the nursing staff to ensure that an RN was called regarding any falls on the off shift
prior to any transfer of resident from one surface to another. The policy on CNA breaks was also reviewed by the DON with all to reinforce the need for supervision of the residents.
To enhance currently compliant operations, the DON implemented a log of incidents which includes a check list attached to each incident report ensuring their completeness. The reports are logged by the DON/designee and check list is verified for completeness. The log and check lists will be maintained by the DON/ designee.
A QA audit will be implemented under the supervision of the DON to monitor resident incident reports for completion. The DON/designee will be monitoring each incident report (100%) and the findings reported on a monthly basis to the QA committee x 3 months. Any deficiencies will be corrected on the spot, and findings of the quality assurance checks will be documented and submitted at the monthly quality assurance committee meeting for further review or corrective action. The committee will determine continued auditing and reporting, with a goal of 100% compliance.
The Director of Nursing will be responsible for this P(NAME).
Completion date is 5/30/2017
Item #2:
Employee #2 is no longer employed. Employee #3 completed the missing abuse orientation documentation.
Reference checks were completed for all new hires from the last 4 months that are still employed by the facility.

All personnel files for new hires during the last 4 months that are still employed were reviewed for missing resident abuse training. No other incidents were found. Also, reference checks were completed for these employees.
The Administrator has been reeducated by the facility operator regarding the need to review orientation paperwork to include the abuse, neglect, mistreatment, misappropriation and exploitation training, as well as the requirement to complete reference checks. A policy has been implemented whereby new employees should not be entered in to the scheduling software until it is confirmed that reference checks are complete.
The Medical Records/Finance Officer/designee will review a 50% sample of new hire personnel files each month to verify abuse training and reference check documentation is present. The audits will be presented to the QA committee monthly for three months and then periodically thereafter as determined by the committee, with a goal of 100% compliance.
The Administrator will be responsible for this P(NAME).
Completion date is 5/30/2017.

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: June 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification and abbreviated surveys (NY 533), it was determined the facility did not ensure residents were provided with the necessary services to maintain optimal physical well-being for 2 of 10 residents (Residents #6 and 8) reviewed for quality of care. Specifically: - Resident #6's medical record lacked documented evidence that changes in her medications were re-evaluated to determine effectiveness. - Resident #8's medical record lacked documented evidence his behaviors were monitored when the dosage of his anti-anxiety medication was changed. Findings include: 1) Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], and updated 5/14/2016, documented the resident's cognition was intact and she required extensive assistance for all activities of daily living (ADLs) except eating. She had an indwelling urinary catheter (tube to drain the bladder) and a [MEDICAL CONDITION] (surgical opening through the abdomen for stool elimination). The resident's comprehensive care plan (CCP), initiated 9/9/2015 with all revisions through discharge from the facility on 6/27/2016, did not document any interventions for pain management. The nursing note dated 4/15/2016 at 10:46 AM documented laboratory blood work was drawn. The nurse practitioner (NP) progress note dated 4/15/2016 documented the resident was being treated for [REDACTED]. The plan was to continue treatment with [MEDICATION NAME] (antibiotic) for UTI with ESBL (extended-spectrum beta-lactamases, resistant bacteria). The NP documented the resident had [DIAGNOSES REDACTED] (low potassium) with [MEDICAL CONDITION] (swelling), a [MEDICAL CONDITION] bladder and chronic Foley catheter (tube to drain the bladder), and acute and [MEDICAL CONDITION]. The note documented a plan for aggressive medication management due to the high creatinine level. The plan included discontinuing [MEDICATION NAME] (medication to decrease muscle spasms of the bladder and the frequent urge to urinate), discontinue [MEDICATION NAME] (antidepressant), discontinue [MEDICATION NAME] (for muscle spasms), and decreasing [MEDICATION NAME] (nerve pain medication) to 300 mg (was on 400 mg) three times a day. The note documented significant medication changes were made and some kind of stabilization should be seen in the next couple days or weeks. The plan was to follow her very closely and monitor vital signs. A laboratory report dated 4/20/2016 documented the resident's creatinine level was 1.7 mg/dL. A nursing progress note dated 4/20/2016 at 3:32 PM documented the resident complained of increased bladder spasms and anxiety. A new order was received from the physician for [MEDICATION NAME] (anti-anxiety medication) as needed. The physician progress notes [REDACTED]. She was seen for a UTI and pemphigoid (rare skin disease with fluid-filled blisters). He documented the medications the resident was taking included [MEDICATION NAME] 1 mg every 6 hours as needed for spasm or anxiety. He did not document how the resident was adjusting to the medication changes made on 4/15/2016. The Medication Administration Record [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. A nursing progress note dated 5/6/2016 at 4:55 PM documented the resident returned from the hospital. There were no nursing notes documenting when or why the resident went to the hospital. The physician progress notes [REDACTED]. The note documented the resident developed pain on readmission in the anterior lower abdomen radiating down both legs, it was unusual due to her [MEDICAL CONDITION] and she had not had feeling in her legs before. She was being treated with [MEDICATION NAME] (narcotic pain reliever) 5 mg every 4 hours on a regular basis, which was giving pain relief. The resident was also noted to be on [MEDICATION NAME] 300 mg three times a day, which did not appear to be affecting the pain. (There was no physician order for [REDACTED]. A physician order dated 5/9/2016 documented [MEDICATION NAME] sulfate solution 20 milligrams/milliliter (mg/ml), give 0.25 ml (5 mg) by mouth every 4 hours as needed for pain. A laboratory report dated 5/11/2016 documented the resident's creatinine level was 1.2 mg/dL (within normal limits). The (MONTH) (YEAR) MAR indicated [REDACTED]. The physician progress notes [REDACTED]. The resident developed acute pain 2 to 3 weeks ago, in the back radiating down the right leg, and was very uncomfortable. She continued on [MEDICATION NAME] 5 mg every 4 hours as needed for pain and felt comfortable. The plan was to add [MEDICATION NAME] (narcotic pain reliever) 50 microgram (mcg) patch and give the [MEDICATION NAME] 5 mg as needed for pain. The NP progress notes: - On 6/3/2016, documented the resident was seen for her continued UTI, [DIAGNOSES REDACTED], and follow up for a toe wound. She was also seen for chronic decubitus ulcers of her ishium (part of hip bone) and buttocks, and the plan was to continue current treatments. The note did not document regarding pain. - On 6/10/2016, documented the resident suffered from chronic pain issues. She was getting [MEDICATION NAME] 75 mcg patch and [MEDICATION NAME] for breakthrough pain. The plan was to discontinue the [MEDICATION NAME] and increase the [MEDICATION NAME] to 100 mcg/hr and change patch every 72 hours. The 6/2016 MAR indicated [REDACTED]. The NP progress note dated 6/17/2016 documented the resident suffered from chronic pain issues. The plan was to increase the resident's [MEDICATION NAME] to 150 mcg/hr every 72 hours. The 6/2016 MAR indicated [REDACTED]. There were no NP or physician progress notes [REDACTED]. Physician orders documented: - On 6/23/16: [MEDICATION NAME] 15 mg IR (immediate release) tablet every 4 hours as needed for breakthrough pain. - On 6/24/16: [MEDICATION NAME] mg ER (extended release [MEDICATION NAME]) every morning and at bedtime. - On 6/26/16: [MEDICATION NAME] sulfate solution 20 mg/ml, give 0.25 ml (5 mg) by mouth every 4 hours as needed for breakthrough pain. On 3/29/2017 at 11:00 AM, the resident's records were requested including all physician and NP progress notes. On 3/30/2017, the Director of Nursing (DON) #20 was asked if there were any physician progress notes [REDACTED]. At 4:30 PM, the surveyor was told they were unable to find any physician notes after 6/17/2016. During a telephone interview on 3/30/2017 at 3:58 PM, licensed practical nurse (LPN) #19 stated she started working at the facility in (MONTH) (YEAR) and the resident suffered a lot of pain. She stated the resident was on a [MEDICATION NAME] and continued to have pain. During a phone interview on 3/31/2017 at 9:15 AM, the former Director of Nursing (DON) #21 stated she worked at the facility when the resident was there. She stated the resident initially did not have pain and came back from the hospital towards the end of her stay with a lot of pain. She stated the resident was medically complicated and paraplegic. She had a non-healing wound, frequent UTIs, and would become septic requiring hospitalization . She stated the resident was on a high dose of [MEDICATION NAME] for years and it was discontinued related to her kidney function when her creatinine level was elevated. She thought the resident was started on [MEDICATION NAME] at that time. She did not remember any changes in the resident's [MEDICATION NAME] and stated when medication changes were re-evaluated it was documented in the nursing or physician progress notes [REDACTED]. She stated the resident did not return to the facility as her family was not happy with her care. She also stated she would have expected to see pain interventions in the care plan. During a telephone interview on 3/31/2017 at 10:45 AM, the NP stated the resident was taken off [MEDICATION NAME] and put on [MEDICATION NAME] due to a high creatinine level. He stated he made many medication changes and the medications were continuously re-evaluated. He did not know if the resident had another creatinine level drawn after the medication changes were made. He stated he would wait 3 to 6 months to order labs after changing medications. He stated they were on top of the resident's medications and he switched her from [MEDICATION NAME] to [MEDICATION NAME] for pain and did not consider previously discontinued non-narcotic medications prescribed for spasms and pain. During a telephone interview on 3/31/2017 at 1:05 PM, the physician stated he agreed with the NP's decision to change the resident's medications due to her renal function. He stated he was not necessarily aware of all the changes, as the dictated notes were not always put in the chart timely. He thought her pain was well controlled with the [MEDICATION NAME] and [MEDICATION NAME]. He also said if the resident's discomfort was not being controlled and her creatinine level went down, he would have consider adding back some of her medications. 2) Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. The resident required supervision for most activities of daily living (ADLs) except for personal hygiene for which he required limited assistance, and toilet use for which he required extensive assistance. He received anti-anxiety medication daily. The physician admission orders [REDACTED]. The physician progress notes [REDACTED]. The resident was alert and ambulated with a walker to the exam room. The note documented the resident was doing well given his circumstances, and would be re-evaluated in 2 months and as needed. The physician order dated 1/27/2017 documented the resident's [MEDICATION NAME] was changed from 1 mg twice a day to 1 mg in the morning for [MEDICAL CONDITION]. There were no physician or nursing notes on this date to document why the resident's medication was decreased. A nursing note dated 2/2/2017 documented the resident's [MEDICATION NAME] was decreased on 1/27/2017 without negative effect. The nurse practitioner (NP) progress note dated 2/2/2017 documented the resident was monitored closely for a history of agitation and aggressive episodes. He did not appear to be anxious or depressed, and he took [MEDICATION NAME] 1 mg in the morning for [MEDICAL CONDITION]. She did not document a gradual dose reduction (GDR) was in progress. Nursing progress notes dated 2/3/2017 to 3/16/2017 did not document any behavioral changes for the resident. The NP progress note dated 3/16/2017 documented the resident was seen for increased agitation and aggression. She documented he was making comments and gestures that he was going to shoot people and had been mumbling to himself over the past few days. The resident's [MEDICATION NAME] was increased to 1 mg twice a day. The physician's order dated 3/16/2017 documented to change [MEDICATION NAME] to 1 mg twice a day for [MEDICAL CONDITION]. The resident was observed: - On 3/29/2017 at 6:40 AM, seated in the TV lounge watching the news. - On 3/30/2017 at 8:10 AM, he received his morning medications including [MEDICATION NAME] 1 mg. - On 3/30/2017 at 2:25 PM, he was sitting on his bed with 2 large plastic bags packed with some of his belongings. When interviewed, he stated he was leaving to go home today. Review of the medical record on 3/30/2017 at 4:30 PM did not show documentation the resident's behavior was monitored after the change in [MEDICATION NAME] dosage. During an interview on 3/31/2017 at 11:20 AM, licensed practical nurse (LPN) #3 stated the resident's medication was decreased in (MONTH) (YEAR) and the resident started coming out of his room more, and was more abusive towards his family. She stated the medication was increased per the family's request. She stated she did not document any behavior changes, as there were none. During an interview on 3/31/2017 at 11:45 AM, the NP stated she was not sure who decided to decrease the resident's [MEDICATION NAME], and she was not sure she knew a GDR had been done when she saw him on 2/2/2017. She stated on 3/16/2017, the Director of Nursing (DON) reported to her the resident was aggressive and agitated and the [MEDICATION NAME] was increased. She stated the Medical Director often made the decision when residents should have a GDR. During an interview on 3/31/2017 at 12:15 PM, the DON stated the process for doing GDRs was: - a committee consisting of the Medical Director, Administrator, DON, and consulting pharmacist met once a month; - the Medical Director made recommendations; - the Nurse Manager (vacant position starting mid-February (YEAR)) called the NP or the attending physician with the Medical Director's recommendation and received a telephone order for the change. The DON stated when a telephone order was received, the order and conversation should be documented in the nursing progress notes. She stated the LPN (medication nurse) should be documenting behaviors in the nursing progress notes and the certified nurse aide (CNA) should be documenting on the behavior flowsheet. The DON reviewed the record with the surveyor and stated documentation was lacking. She stated she expected nursing staff to document when medication changes were made and any changes in behaviors. 10NYCRR 415.12

Plan of Correction: ApprovedMay 25, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of this facility to provide residents with appropriate medications and continued assessment and follow up regarding effectiveness. This is to include effective as well as ineffective. Resident #6 was continuously being followed by the NP for complaints of pain with changes made to her pain medication regimen.
Because all residents have the potential to be affected, the facility will implement a pain policy in collaboration with the Medical Director to indicate the steps/interventions required for pain management prior to implementation of Narcotic therapy. Once the policy is written and approved all staff will be in serviced in regards to pain management and its implementation, this to include the Physician and the NP. All residents are currently monitored for pain each shift. Any increased complaints of pain are then reported to the RN for assessment. A monthly QA audit will be completed and reported to the QA committee with a threshold expectation of 100%.
Resident # 8 had a [DIAGNOSES REDACTED]. He had a GDR recommended by the physician and the dose was changed. In both of these cases, the surveyor alleged that documentation was lacking. Resident #6 had been discharged from the facility on 6/27/16, to the hospital, and did not return. Nursing staff was educated by the DON the importance of documenting residents? behavior after any mood stabilizing medication change.
Because all residents on mood stabilizing medications are potentially affected by the cited deficiency, all residents on mood stabilizing medications will be reviewed and nursing staff reeducated to document any behavior changes or not for any resident with a reduction in his/her medications. The reeducation will reinforce the importance of documentation with regards to any medication dosage change.
To enhance currently compliant operations and under the direction of the DON/Designee the facility will revise the gradual dose reduction team meeting to include care plan updating and CNA task documenting to include any noted changes in residents behavior. Facility nurses will be notified of any dosage reductions and be required to document q shift on any noted behavior changes. If there are no changes in behavior they are still required to document ?no change in behavior?.
A quality ?assurance program will be implemented under the supervision of the DON to monitor the documentation. The DON/Designee will perform the following systemic changes: randomly checking 50% of the residents who had medication changes during the week and monthly to ensure the documentation is being completed. Any deficiencies will be corrected immediately, and the findings will be documented and submitted at the monthly quality assurance committee meeting for further review and suggested corrective actions for 3 months, with continued auditing and reporting determined by the committee, with a goal of 100% compliance.
The Director of Nursing will be responsible for this P(NAME).
Completion date is 5/30/2017.

FF10 483.10(j)(2)-(4):RIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES

REGULATION: (j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. (j)(3) The facility must make information on how to file a grievance or complaint available to the resident. (j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents? rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident?s grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident?s concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents? rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents? rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification and abbreviated surveys (NY 781), it was determined the facility did not support residents' rights to voice grievances for 1 of 2 residents (Resident #3) and assure that after receiving a complaint/grievance, the facility actively sought a resolution and kept the resident appropriately apprised of progress toward resolution. Specifically, Resident #3 voiced grievances and efforts were not made timely to resolve her concerns. Findings include: Resident #3 was readmitted on [DATE] after a total knee replacement and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and she required limited to extensive assistance with activities of daily living (ADLs). A social services progress note dated 3/2/2017 at 10:07 AM documented the resident continued to have complaints regarding another resident who lived in the room next to her's. She was asked if she would d like to switch rooms to the other end of the hallway and she declined. She recently made more complaints that Resident #11 was disruptive at night and she could not sleep very well. The resident was asked again if she wanted to switch rooms, and she refused, as she felt she should not be the one to move. The plan was the social worker would continue to address concerns with the resident and Resident #11. There was no documented evidence the social worker followed up with the resident to determine if her concerns were resolved. On 3/30/2017 at 9:40 AM, Resident #3 stated in an interview: - Resident #11 was non-stop; he yelled and said horrific sexual things every day. - Resident #11 demanded food and medication at all hours of the night. - Resident #11 kept his television turned up to the highest volume at all hours of the day and night. - Resident #11 slept all day and was up all night. - The wall between her room and Resident #11's room was very thin and his yelling was like nothing she had heard before. - Other residents and family members also had complained of Resident #11's behavior in the past. - After she wrote a letter on 12/25/2016, the Administrator told her something would be done about Resident #11. - In the last week, the nurse practitioner gave her ear plugs to help block out Resident #11's noise. She stated nobody else offered or suggested interventions to reduce the amount of noise she had to listen to. - After she returned from knee surgery in January, she needed rest to help with her recovery and Resident #11 kept her awake most nights. She was observed crying during the interview, and she stated she felt very traumatized by the whole situation. On 3/30/2017 at 12:00 PM, the facility's grievance reports were reviewed by the surveyor, and contained a grievances from Resident #3 and a grievance from an unsampled resident. Resident #3's grievances included: - A 3-page letter dated 12/25/2017 that documented the resident had concerns with another resident (Resident #11) in the room next to her's. Resident #11 yelled, screamed, used vulgar language, and was abusive to staff on 12/10, 12/11, 12/12, and 12/14/2016. Resident #11 kept his television on loud and was asked several times daily to turn it down and at night when others slept. The letter documented Resident #3 believed she should not have to be subjected to Resident #11's abusive behavior. The environment felt hostile and uncomfortable for her, and she was asking for the facility's help. - A grievance communication form dated 12/31/2016 documented the resident was awoken at 4:45 AM by Resident #11's yelling and swearing. There was no documented evidence the facility followed up with the resident to ensure her concerns were thoroughly addressed and the issue was resolved. During an interview on 3/31/2017 at 12:15 PM, the facility's social worker stated: - She spoke with the resident in (MONTH) after she made complaints about Resident #11. - The Administrator spoke with Resident #11 about facility rules. - She met monthly with Resident #11 to discuss calming choices. - She never heard Resident #11's television on loudly and while others complained about it in the past, she had not heard any recent complaints. - Most complaints were about Resident #11's mouth. - She offered Resident #3 a room change and the resident refused when she could not be guaranteed a private room (as she currently had). - The facility did not consider ear plugs for Resident #3 to help with the noise. - The facility did discuss headphones for Resident #11 to listen to the television, and the resident or his family needed to purchase the headphones. - Resident #11 was offered a psychological evaluation and he refused. - The facility was pursuing other placement for Resident #11 and no other facilities had accepted him. She stated they did not consider in-patient hospitalization for behaviors. During an interview on 3/31/2017 at 1:30 PM, the Administrator stated they were trying to figure out what do with Resident #11. The facility wanted to discharge him and was having a hard time getting another facility to accept him. He stated he was not sure if anyone considered an inpatient behavioral treatment center for the resident. 10NYCRR 415.3(c)(1)(ii)

Plan of Correction: ApprovedMay 25, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of the facility to actively seek resolution to resident grievances and keep the residents appropriately apprised of progress toward resolution. Resident #3 has since been safely discharged from the facility back to her home.
Because all residents have a right to voice grievances and expect resolution to their grievances, all residents have the potential to be affected by the cited deficiency. A review of sample grievances over the last three months was conducted and determined that no other residents were affected by the cited deficiency.
The facility?s policy and procedure related to grievance reporting was reviewed and deemed adequate. Specifically, the grievance report contains a line prompting the person completing the form to document follow-up with the complainant within seven days. The social worker will receive in-service training reinforcing this point to ensure it does not occur again. It will also be incorporated into the resident rights portion of the employee new hire and annual in-services.
Audits of a 50% sampling of facility grievances will be conducted monthly by the facility?s social worker/designee. The audits will be presented to the QA committee monthly for three months and then periodically thereafter as determined by the committee, with a goal of 100% compliance.
The facility social worker/designee will be responsible.
completion date is 5/30/2017.

FF10 483.10(e)(2)(i)(1)(i)(ii):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- (i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 30, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure a safe, clean, comfortable, and homelike environment for 1 of 1 dining rooms. Specifically, the dining room building floor was cracked/uneven in multiple locations. Findings include: On 3/29/2017 at 7:15 AM, a surveyor observed the dining room building floor had a 15 foot x 1 foot uneven crack and a 47 foot x 8 foot section of the floor was cracked/uneven. When interviewed on 3/30/2017 at 1:51 PM, the Environmental Services Director stated there was a project estimate done last year on 3/7/2016 by a third party vendor for the replacement of the dining room flooring, and he verbally requested an updated proposal from the third party vendor this year on 3/7/2017. On 3/30/2017 at 1:51 PM, review of a third party vendor Project Estimate dated 3/7/2016 showed documentation of the estimate as described by the Environmental Services Director. 10NYCRR 415.5(h)(1)

Plan of Correction: ApprovedMay 25, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of this facility to maintain a safe, clean, comfortable, and homelike environment in accordance with 10NYCRR 415.5(a) and 483.10(e)(2)(i)(ii)
The facility is obtaining estimates from 3-4 3rd party vendors to replace the floor in said dining room to obtain compliance with 10NYCRR. We expect to have a signed contract in place by the compliance date, however, the work may not be complete by then depending on their work schedule. A time limited waiver request will be submitted to the DOH BEAR for completion of the work, once a vendor is chosen.
An inspection will be conducted monthly to ensure flooring is maintained in such a way to be compliant with 10 10NYCRR 415.5(a) and 483.10(e)(2)(i)(ii)
The inspection results will be reviewed by the QA committee monthly for 3 months and then periodically thereafter as determined by the committee.
Completion date: 5/30/2017
Responsible party: Environmental Service Director or Designee

FF10 483.40(b)(1):TX/SVC FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES

REGULATION: 483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that- (b)(1) A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 781), the facility did not ensure for 1 of 5 residents (Resident #11) reviewed for behaviors, that appropriate treatment and services were provided for mental and psychosocial behaviors. Specifically, Resident #11 had his behavior medications discontinued; he was not notified of the change, he continued to exhibit anxiety and other behaviors, and he was not re-evaluated. Findings include: Resident #11 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, his mood was stable, he had no behaviors, and he required extensive assistance with activities of daily living (ADLs). The 5/20/2015 comprehensive care plan (CCP) was revised on 3/7/2017 and documented the resident had a behavior problem related to yelling out and sexually inappropriate behaviors. He also had a mood problem related to depression and anxiety. Interventions included: administer medications as ordered; report to physician episodes of feeling sad, changes in sleep pattern, or changes in psychomotor skills; encourage to express feelings; monitor behavior episodes and attempt to determine underlying cause; and document behaviors. The nursing progress note dated 12/3/2016 at 1:54 PM documented the resident cursed and made threats when told he would have to wait to go back to bed, when staff were helping other residents. The nursing administration note dated 12/26/2016 at 3:35 PM documented the resident received [MEDICATION NAME] (anti-anxiety medication) 0.25 milligrams (mg) one time for increased anxiety. The note did not describe the resident's behavior. The physician note dated 1/4/2017 documented the resident was seen for anxiety. The resident would begin [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] daily, and he would be followed up in 2 months. The resident's record did not document any behaviors from 12/4/2016 through 1/3/2017 to show indication for behavior medications being prescribed. The physician orders dated 1/4/2017 documented the resident was prescribed [MEDICATION NAME] 37.5 mg at bedtime for depression, and [MEDICATION NAME] 0.25 mg as needed once daily for anxiety. The nursing progress note dated 1/5/2017 at 5:57 AM documented the resident yelled, Give me some (expletive) OJ my sugar is low, and he constantly rang his bell and yelled throughout the shift. The (MONTH) (YEAR) and (MONTH) (YEAR) medication administration records (MAR) documented the resident received as needed [MEDICATION NAME] 7 times from 1/4 through 2/1/2017. Nursing progress notes documented the resident: - On 1/4/2017 at 7:45 PM, requested and received [MEDICATION NAME]. - On 1/7/2017 at 7:47 AM, requested [MEDICATION NAME] due to increased anxiety from headache. - On 1/12/2017 at 3:51 AM, requested [MEDICATION NAME] for increased restlessness. - On 1/18/2017 at 2:22 AM, requested [MEDICATION NAME] for increased anxiety. - On 1/23/2017 at 7:28 AM, requested [MEDICATION NAME] for anxiety of unknown origin. - On 1/28/2017 at 6:42 AM, requested [MEDICATION NAME] for anxiety and shortness of breath. - On 2/1/2017 at 11:24 PM, requested [MEDICATION NAME] for increased anxiety. All administrations of [MEDICATION NAME] were documented as effective in relieving the resident's symptoms. The nurse practitioner (NP) note dated 2/2/2017 documented the resident was seen for a regulatory visit. The resident displayed no signs of depression or anxiety, and [MEDICATION NAME] and [MEDICATION NAME] were discontinued. The note documented the resident would have a trial without these medications and nonpharmacological means would be used. The resident's nursing progress notes documented: - On 2/7/2017 at 1:24 AM, he felt like his blood sugar was low. The blood sugar was checked and was within normal limits. The resident was upset that his anxiety medications were taken away. - On 2/12/2017 at 4:48 AM, he was awake in bed since 2 AM asking for a nerve pill. He was yelling and sighing loudly and woke 2 other residents, who were very angry. The resident pushed his call bell every hour asking for food, had his television turned up to maximum volume and again woke another resident. He was compliant when asked to turn the television down and then would turn it up again. - On 2/14/2017 at 12:18 PM, he was screaming at the top of his lungs and stated he was unable to breathe. The resident was transferred and admitted to the hospital (2/14-2/22/2017). The hospital admission history and physical dated 2/14/2017 documented the resident had been feeling more anxious over the last week and was taken off his anxiety medications. There was no documented evidence the resident was referred to medical for evaluation of his medication regime after his medications were discontinued and his behaviors continued. The physician note dated 3/1/2017 documented that no anxiety or depression was seen. The resident's progress notes documented: - A nursing progress note dated 3/2/2017 at 12:34 PM: he was verbally aggressive with staff, swearing, calling residents names, and being disrespectful in the dining room. He was seen by the social worker and the Director of Nursing (DON) to address this issue. - A social worker note dated 3/7/2017 noted that the social worker, physical therapist, nursing and Administrator had a conversation with the resident on 3/2/2017. The resident had been talked to continuously about his inappropriate language and disruption in the dining room. He continued to disrupt the entire facility with his yelling out, inappropriate language, and constant picking at the other residents in the dining room. The team discussed a 30-day notice and a referral was made. All staff were to monitor behavior and intervene as necessary. -A nursing progress note dated 3/28/2016 at 5:04 AM: the resident yelled and swore at staff when he asked for an anxiety pill and one could not be given due to no physician order. He called 911 for shortness of breath and was transferred to the hospital. During an interview on 3/31/2017 at 10:15 AM, licensed practical nurse (LPN) #14 stated when the resident was in a bad mood, he continuously rang his call bell and turned his television up to the maximum volume. She stated the resident had [MEDICAL CONDITION], which caused his anxiety, and until recently he always had a medication for anxiety. She stated when he had anxiety and asked for his medication, it was effective. She stated he was on a routine dose of [MEDICATION NAME] (anti-anxiety) for a long time, and that was discontinued for [MEDICATION NAME], and then [MEDICATION NAME] was recently discontinued. She stated that after the [MEDICATION NAME] was discontinued, the resident's behaviors worsened and the NP was made aware. She stated that medications get discontinued all the time and the residents were not always notified. She stated the reason medications were discontinued was not discussed with nursing and they had no way to notify the residents of changes because of this. During a telephone interview on 3/31/2017 at 11:50 AM, NP #18 stated she did not know the resident well enough to discuss his behaviors, as she had only worked for the facility since (MONTH) (YEAR). She stated that [MEDICATION NAME] typically took about 6 - 8 weeks for effectiveness and she was unsure if she was aware that both medications were only ordered 1 month prior to her discontinuing them. She stated she only looked at the signs and symptoms the resident displayed during her assessment to determine if a medication could be discontinued. She stated that she or nursing discussed with the resident when a medication was discontinued. She did not recall whether she discussed it with the resident on 2/2/2017. She stated that when she discontinued a medication, she only followed up with a resident when staff later noted a change in their behavior. She did not recall being notified of a change in Resident #11's behavior. During an interview on 3/31/2017 at 12:15 PM, the facility's social worker stated the resident was very depressed and she met monthly with him to talk. The resident was very demanding of anyone that walked by his door. He screamed, yelled, and was also disruptive in the dining room. She stated the resident was not currently on a medication for depression and he refused a psychological evaluation. She stated she was not aware the resident's as needed anxiety medication was discontinued in (MONTH) (YEAR). She stated if she was aware, she would have referred the resident back to medical for an evaluation. During a telephone interview on 3/31/2017 at 1:00 PM, the attending physician stated the resident was anxious and depressed, and he was rude to other residents and staff. He tried to give the resident medications to modify his behaviors and referred him to psych. He stated he expected to see results from [MEDICATION NAME] 6 - 8 weeks after he prescribed it, and he was not aware the NP discontinued it. He stated he would have waited to see results and would gradually reduce the medications to see if symptoms returned. He stated he expected to be notified when a resident's behaviors returned or worsened, and he would have put the resident back on behavior medications had he known. 10NYCRR 415.12(f)(1)

Plan of Correction: ApprovedMay 25, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.

It is the policy of this facility to provide resident with appropriate treatment and services to correct assessed problems and to assist in maintaining highest level of functioning while maintaining both mental and psychosocial well-being.

Resident #11 received follow up care by a physician on 3/31/17 and has since had his medications adjusted appropriately to address his assessed conditions.

Because all residents with a diagnosed mental disorder or psychosocial adjustment difficulty can be affected by the cited deficiency the director of nursing reviewed the charts of all residents with these [DIAGNOSES REDACTED].

A gradual dose reduction (GDR) meeting is held monthly with representation from nursing, medical, pharmacy and social work. A log will be created of all activity recommended at the meeting and must be reviewed the following month for documented results of the GDR. Any changes recommended must be discussed with the resident. Any [MEDICAL CONDITION] medication changes made outside the GDR meeting must be communicated to the social worker and nursing staff in order to ensure behavior documentation, and added to the meeting log. The nurse involved with the medical provider ordering the medication change will be responsible for notification and logging of the change. The log will be reviewed by the provider prior to any medication change. The rounding nurse will be responsible for its review with the practitioner. Each morning in the clinical morning report all disciplines will review the GDR log to be sure each discipline has been informed of any changes. All licensed staff will be educated on the new policy and procedure.

The GDR log which will include any medication reduction suggestions/orders either as a result of the GDR meeting or outside of the meeting, will be reviewed monthly by the Director of Nursing to ensure that the effectiveness of the medication change has been evaluated. The results of the review will be reported to the QA committee monthly for 3 months, with further reporting to be determined by the committee. Threshold to be reached is 100% compliance.

The Director of Nursing is responsible for this P(NAME).

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 19, 2017

Citation Details

Based on record review and interview during the recertification survey, it was determined the facility did not develop maintenance policies and provide records of all testing and repairs of all patient-care electrical equipment in accordance with National Fire Protection Association (NFPA) 99 for 2 pieces of equipment (electric beds and resident televisions). Specifically, both electric beds and resident televisions did not have maintenance policies, and maintenance/safety inspections were not documented. Finding include: 1) Electric Beds Review of equipment policies, on 3/30/2017 between 11:10 AM and 12:44 PM, revealed the facility did not have a maintenance/safety policy for electric beds. At the time of the review, the Environmental Services Director presented a surveyor with an electric bed policy created on 3/29/2017, the first day of the survey. When interviewed on 3/30/2017, between 11:10 AM and 12:44 PM, the Environmental Services Director stated electric beds were being checked during weekly rounds and it was not documented. 2) Resident Televisions Review of equipment policies, on 3/30/2017 between 11:10 AM and 12:44 PM, revealed the facility did not have a maintenance/safety policy for resident televisions. When interviewed on 3/30/2017, between 11:10 AM and 12:44 PM, the Environmental Services Director stated the facility practice was to check televisions when they were brought into the facility, and the facility did not have documented evidence the checks were completed. 2012 NFPA 99: 10.5.2.1, 10.5.6 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedApril 20, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of this facility to perform tests on all fixed and portable patient-care related equipment (PCREE) as required by NFPA 11 10.3, as well as any system consisting of several electrical appliances demonstrates compliance with NFPA 99.
Electrical equipment instructions and maintenance manuals will be kept on file and made readily available. The information provided by the manufacture that includes details as required by NFPA 101 10.5.3.1.1 will be considered in the development of a program for electrical equipment maintenance. This information will be logged and a record of electrical equipment tests, repairs, and modifications will be maintained for a period of time to demonstrate compliance in accordance with the facilities policy.
The log created as required will be reviewed by the QA committee monthly for 3 months and then periodically thereafter as determined by the committee.
Completion date: 5/19/2017
Responsible party: Environmental Service Director or Designee

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: April 21, 2017

Citation Details

Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure that fire drills were held at unexpected times and under varying conditions on 1 of 3 shifts (night shift) in (YEAR), as required. Specifically, the night shift fire drills for all four quarters of (YEAR) were not conducted at varying times. Findings include: Review of fire drill reports on 3/29/2017 at 3:45 PM documented night shift fire drills were conducted on the following dates and times: - on 2/29/2016 at 11:30 PM; - on 5/31/2016 at 11:30 PM; - on 8/19/2016 at 11:05 PM; and - on 11/30/2016 at 11:30 PM. Review of the fire drills did not indicate drills were conducted at varying times during the night shift. When interviewed on 3/30/2017 at 4:15 PM, the Environmental Services Director stated he was not aware the times of the night shift fire drills were not varied. 2012 NFPA 101: 19.7.1 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedApril 18, 2017

No residents were affected by the deficient practice.
All residents could have been affected by the deficient practice.
The Environmental Services Director has been educated on the requirement to conduct fire drills at varying times on each shift, as per NFPA 101. Drill times will be varied on each shift every quarter.
The Administrator will review the fire drill records monthly for 6 months,to ascertain that the drills have been held at varying times on each shift. Results of the review will be reported to the QA committee monthly, with continued review to be determined by the committee.
The completion date is 4/21/2017. The Administrator is responsible for this P(NAME).

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

REGULATION: Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 19, 2017

Citation Details

Based on interview conducted during the recertification survey, it was determined the facility did not ensure a formal and documented risk assessment procedure for the building system catagories was performed. Specifically, the buildings system categories assessment was not completed. Finding include: During an interview on 3/29/2017 at 1:40 PM, the Environmental Service Director stated he was aware the facility must comply with 2012 Edition of NFPA (National Fire Protection Association) 99, and was not aware the facility was required to have a formal and documented risk assessment procedure for the building system categories. 2012 NFPA 99 - Chapter 4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 20, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of this facility to ensure that its building systems are designed to meet the specific category 1-4 requirements as detailed in NFPA 99. The facility will seek out and complete a formal and documented risk assessment procedure to be completed by qualified personnel for the building systems categories.
The risk assessment obtained will be made readily available and will be maintained as necessary to remain compliant with 2012 NFPA 99 chapter 4
The risk assessment obtained will be reviewed by the QA committee monthly for 3 months and then periodically thereafter as determined by the committee.
Completion date: 5/19/2017
Responsible party: Environmental Service Director or Designee

K307 NFPA 101:MULTIPLE OCCUPANCIES - CONSTRUCTION TYPE

REGULATION: Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: June 22, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the 2-hour fire rating of 2 of 2 common walls with a nonconforming building was maintained (the residential building/dining room building wall, and the dining room building/Administration building wall). Specifically, the fire rated double doors between the residential building and the dining room building were damaged and had unapproved pieces of metal installed on one of the doors. Additionally, the fire rated double doors between the dining room building and the Administration building had a gap greater than 1/8 inch between them and there were two unsealed holes in one of the doors. Findings include: On 3/29/2016 at 7:18 AM, a surveyor at the residential building/dining room building wall separation observed the following: - The 1-1/2-hour fire rated double door closest to the Director of Nursing's office was cracked near the top door hinge and both sides of the door near the crack had unapproved metal pieces fastened to the door. Also, the top door hinge was attached to the door with three different types of fasteners (1 bolt, 2 regular screws, and 1(NAME)head screw). - The other 1-1/2-hour fire rated double door was cracked by the middle and lower door hinges. Also, these hinges were loose/not fully attached to the door. On 3/29/2016 at 7:42 AM, a surveyor at the dining room/Administration building wall separation observed the following: - A gap between the 1-1/2-hour fire rated double doors was 1/4 inch in size. - One of 1-1/2-hour fire rated double doors had two unsealed 1/8 inch holes in it. When interviewed on 3/29/2017 at 2:40 PM, the Environmental Services Director stated part of the door holder was removed from the door about three weeks ago during the dining room painting project. He was aware of the holes and overlooked not sealing the holes when the project was completed. He also stated the gap was from the constant use of the door and a work order to be repaired was just filled out. He stated he was not aware of the cracks in the residential building/dining room building fire rated double doors. 2012 NFPA 101: 19.1.3.5 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedApril 20, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of this facility to maintain the fire rating of the fire walls and doors in the facility in compliance with 2012 edition NFPA 8.2.1.3. The materials to properly fix or replace the cited doors as necessary will be ordered and the doors will be fixed or replaced and made to be compliant with NFPA 8.2.1.3.
A visual inspection of the fire doors will be conducted quarterly to ensure doors remain in compliance with NFPA regulations. These checks will be incorporated into the fire drill program and added to the checklist to ensure proper preparedness.
The fire drill checklist will be reviewed by the QA committee monthly for 3 months and then periodically thereafter as determined by the committee.
Completion date: 5 /19/2017
Responsible party: Environmental Service Director or Designee

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 19, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the building was protected throughout by an approved automatic sprinkler system, in accordance with National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, for 3 isolated areas (2 in the kitchen and 1 in the basement). Specifically, the kitchen and basement had sprinkler heads installed too close to other objects, and both kitchen walk-in coolers had unsealed annular spaces around the dry pendant heads. Findings include: 1) Sprinkler Heads Installed Too Close On 3/29/2017 at 11:30 AM, a surveyor in the kitchen bathroom observed a sprinkler head installed less than 2 inches from a light cover. The light cover was lower than the sprinkler head and water from this sprinkler head would be deflected. A 3 foot x 12 foot section of the room was lacking sprinkler coverage. During an interview on 3/29/2017, at 11:30 AM, the Environmental Service Director stated after the third-party sprinkler system vendor came and updated the facility to be fully sprinklered in 2013, they told him the facility was in compliance. On 3/29/2017 at 11:43 AM, a surveyor in the kitchen observed a sprinkler head near the Director's desk was installed approximately 2 inches from a ceiling light. On 3/29/2017 at 11:55 AM, a surveyor in the basement laundry area observed a sprinkler head installed approximately 2 inches from a drain pipe. This drain pipe was in front of the sprinkler head and would block the water flow from the sprinkler head. A 4 foot x 6 foot section of the area was lacking sprinkler coverage. 2) Annular Space Around Sprinkler Heads On 3/29/2017 at 11:40 AM, a surveyor in the kitchen observed both walk-in coolers had a single dry pendant sprinkler head. The annular space around both sprinkler heads was not smoke-tight. During an interview on 3/29/2017, at 11:40 AM, the Environmental Service Director stated after the third-party sprinkler system vendor came and updated the facility to be fully sprinklered in 2013, they told him the facility was in compliance. 2012 NFPA 101 19.3.5.1, 9.7.1 2010 NFPA 13 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 20, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of this facility to ensure that it is protected throughout with a complete automatic sprinkler system in accordance with NFPA 13. A sprinkler system professional will fix all sprinkler placement issues so that the facility will be in accordance with NFPA 13 8.1.1 and the annular space around the citied sprinkler heads in walk in coolers will be filled in properly to be smoke tight.
An inspection of the facilities sprinkler system will be conducted quarterly to ensure proper coverage. This inspection will be completed by our sprinkler inspection company which will ensure proper function of the sprinkler system.
The inspection reports will be reviewed by the QA committee monthly for 3 months and then periodically thereafter as determined by the committee.
Completion date: 5/19/2017
Responsible party: Environmental Service Director or Designee

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2017
Corrected date: May 19, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the building's automatic sprinkler system was maintained in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-Based Fire Protection Systems, for 2 isolated locations (main shower room and basement activities storage room). Specifically, there was a section of the main shower area that was not protected by a sprinkler when the curtain was fully drawn, and objects were stored less than 18 inches from a sprinkler. Findings include: 1) Area Not Protected By A Sprinkler Head On 3/29/2017 at 7:05 AM, a surveyor observed an unopened dividing curtain in the main shower room. This curtain was a solid curtain with no mesh and would not allow water from the sprinkler head to access the other side of the curtain. A 3 foot x 4 foot section of the shower room was not protected by a sprinkler when the curtain was fully drawn open. On 3/29/2017 at 10:35 AM, a surveyor observed the main shower room dividing curtain fully drawn open. During an interview on 3/29/2017 at 10:35 AM, the Environmental Service Director stated the shower curtain was installed about 6 months ago. He was not aware that a section of the room was not sprinkler protected when the curtain was fully drawn open. 2) Items Stored Less Than 18 Inches From Sprinkler Head On 3/29/2017 at 12:15 PM, a surveyor in the basement activity storage room observed multiple bins, totes, boxes of decorations, and other items stored 12 inches or less from the only sprinkler head in the room. Also, in this room was a plastic bin that was touching the ceiling. During an interview on 3/29/2017 at 3:00 PM, the Environmental Service Director stated the basement activity storage room was reorganized about a week ago by the housekeeping and activities departments. He stated he had not inspected that room after it was reorganized. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 20, 2017

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
It is the policy of this facility to ensure that it is protected throughout with a complete automatic sprinkler system in accordance with NFPA 101 9.7.5, 9.7.7, 9.7.8, and NFPA 25. The issues cited were corrected during survey on 3/29/2017
An inspection of the facilities sprinkler system will be conducted monthly to maintain proper clearance. These checks will be incorporated into the fire drill program and added to the checklist to ensure proper preparedness.
The inspection reports will be reviewed by the QA committee monthly for 3 months and then periodically thereafter as determined by the committee.
Completion date: 5/19/2017
Responsible party: Environmental Service Director or Designee