Hornell Gardens, LLC
January 13, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: (a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for two (Residents #48 and #45) of four residents reviewed for Activities of Daily Living (ADL), the facility did not provide the necessary care to maintain personal hygiene. The issues involved lack of fingernail care and lack of toileting. This is evidenced by the following: 1. Resident #48 has [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP), dated 12/20/16, included that the resident dis-impacts her bowels and the team approach is to ensure her hands and fingernails are clean. The Certified Nursing Assistant (CNA) Resident Care Plan, updated on 12/20/16, included that the resident requires total assistance with grooming, has a history of dis-impacting herself especially first thing in the morning and to check her before breakfast and as needed. It also included that the resident is at risk for skin breakdown due to a history of self-inflicting scratches and self-digging to the extent of opening her skin. Review of the progress notes for the last 30 days revealed only one refusal of care when the resident refused to be shaved on 1/11/17. Review of the Wound Care Flow Sheets, dated 12/13/16, revealed the resident had an area on the buttocks with increased redness and scratches noted. On 12/27/16, the resident had a small scratched open area remaining on her buttock. Review of the CNA ADL tracking form from 12/1/16 through 1/11/17 revealed documentation of nail care on 12/8/16 only. When observed on 1/10/17 at 8:46 a.m., 1/11/17 at 9:02 a.m., and 1/12/17 at 7:52 a.m. and 11:13 a.m., the resident's fingernails were long, jagged, and caked with brown debris. Interviews conducted on 1/12/17 included the following: a. At 1:22 p.m., CNA #1 stated she provided the resident's care but did not offer to clean or trim her fingernails. In a joint observation with the surveyor and CNA #1 at that time, CNA #1 said the resident's nails are long and dirty. She said she did not notice the resident's nails and did not offer to clean them. CNA #1 said the resident's nails should have been cleaned and trimmed. b. At 1:28 pm, the Licensed Practical Nurse (LPN) Charge Nurse #1 said she expects the CNAs to cut nails on the day shift because the resident sometimes will dig at herself. She said the resident will sometimes refuse care but she expects this to be reported to the nurse and the resident should be re-approached. In a joint observation with the surveyor and the LPN Charge Nurse #1 at that time, LPN Charge Nurse #1 said the resident's nails are long and dirty and need to be cleaned and trimmed. She said the resident is unable to do her own ADLs. When interviewed on 1/13/17 at 10:51 a.m., the Registered Nurse Manager (RNM) stated that the resident needs assistance with her grooming. She said if the resident refuses care, she expects staff to report that to the nurse. She said the nurse should document the refusal. The RNM said she expects the resident's nails to be cleaned and trimmed at least weekly and as needed. The undated facility policy, Care of Fingernails/Toenails Guideline, included that the facility will keep resident's nails trimmed and cleaned. Nail care will be provided on the resident's shower days and as necessary. The nurse will check resident nails on their shower days to assure all resident nails are trimmed and clean. 2. Resident #45 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/3/17, revealed that the resident's cognition is severely impaired, is always incontinent of bowel and bladder, and is totally dependent on staff for toileting. Review of the current CCP and CNA Resident Care Plan revealed that the resident is incontinent of bladder and bowel due to dementia and being non-ambulatory. Goals included that the resident have all incontinence needs met and dignity maintained. Interventions included that the resident should receive prompt incontinence care and for staff to check and change. The CCP also includes that the resident is at risk for skin breakdown due to incontinence. During continuous observations on 1/11/17 from 8:00 a.m. through 12:50 p.m., the resident was sitting in a wheelchair with a Hoyer sling underneath her. She was not toileted or given incontinence care throughout the time period. During an observation of incontinence care at 12:50 p.m. with CNAs #2 & #3, the resident's incontinence brief was completely saturated with urine. The buttocks and perineal area were bright red and there were multiple indentations over the entire buttocks area. When interviewed at that time, both CNA #2 and #3 stated that the resident is a heavy wetter. They both said they did not provide care that morning or toileted or changed her that day because CNA #4 was her assigned CNA. They both said that the indentations on the resident buttocks were from sitting on the Hoyer sling. Interviews conducted on 1/11/17 include the following: a. At 1:23 p.m., CNA #4 stated that the resident got out of bed during the night shift. She said she toileted the resident at approximately 7:00 a.m., but not since then. She said that the resident should be changed every few hours but that was not done because they were short staffed that day. b. At 2:57 p.m., the LPN stated that the resident should be toileted after breakfast or before lunch, and at least three times a shift. The LPN said that five hours was too long to wait to be toileted/changed. When interviewed on 1/12/17 at 12:49 p.m., LPN Charge Nurse #2 stated that the resident should be toileted every few hours. (10 NYCRR 415.12(a)(3))

Plan of Correction: ApprovedFebruary 6, 2017

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
1
The Nurse Manager has counseled CNA #1 and ensured that the nails of resident #48 have been cleaned and manicured.
The Nurse Managers have observed the nails of all residents to ensure that they all were clean and well-manicured.
The Acting Director of Nursing has reviewed and revised, where necessary, the facility guideline Care of Fingernails/Toenails.
The Staff Development Coordinator will in-service all nursing staff on the fingernail and toenail guidelines with the expectation that they will be adhered to.
The nurse Managers, or their designee, will conduct random weekly audits for four weeks then monthly and then intermittently as determined by the Quality Assurance Committee of resident?s nails for proper care. The results of these audits will be provided to the Quality Assurance Committee for their review and action as necessary.
The Nurse Managers will be responsible for the correction of this deficiency.
2
The Nurse Manager has counseled CAN #4 and has been ensuring that resident #45 is being toileted and, when necessary, receives prompt and appropriate incontinence care.
The Nurse Managers have been monitoring resident cares to ensure that all residents are toileted and, when necessary, receive prompt and appropriate incontinence care.
The Staff Development Coordinator will in service all CNAs on the Facility?s policy and procedure for the toileting and incontinence care of the residents.
Nurse Managers, or their designee, will conduct random weekly audits for four weeks and then monthly and then intermittently as determined by the Quality Assurance Committee to ensure that residents are being toileted and when necessary receive prompt incontinence care. The results of these audits will be provide to the Quality Assurance Committee for their review and action as necessary.
The Nurse Managers will be responsible for the correction of this deficiency.

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2017
Corrected date: March 10, 2017

Citation Details

Based on observations, interviews, and record reviews, it was determined that for one of two residential units reviewed for medication storage, the facility did not provide for the safe and secure storage of medications. Issues involved medications left on top of an unsupervised, unattended medication cart on Unit 2. This is evidenced by the following: In an observation on 1/12/17 at 1:14 pm, the Unit 2 medication cart was located outside of a resident's room. There was no nurse within sight of the cart. On top of the cart was a medicine cup containing three unpackaged and unlabeled medications. All drawers were able to be opened by the surveyor and contained multiple stock medications and blister packs of prescription medications. The narcotic drawer was locked. A resident, who has dementia and a history of wandering throughout the unit independently, was in the hallway at the time. After several minutes the surveyor went to the doorway of a resident's room and observed the Licensed Practical Nurse (LPN) administering medications. When interviewed at that time, the LPN stated that she should not have left the medication cart unlocked and unattended. She added that the resident that was currently ambulating in the hallway does wander a lot and the pills should not have been left on top of the cart. The narcotic drawer held numerous narcotic pain and anti-anxiety medications that were not double locked per the regulations. When interviewed on 1/12/17 at 1:31 p.m., the LPN Charge Nurse stated that the medication cart should not be left unlocked and unattended. She said the pills should never be left on top of the medication cart unattended. She said that the resident in the hallway at that time touches everything. When interviewed on 1/13/17 at 8:30 a.m., the Administrator said that the facility constantly monitors the medication carts to ensure that they are locked and the medications are stored properly. Review of current facility policy, Medication Administration Guideline, includes that the medication cart is not to be left unlocked when out of sight and to never leave any medications or equipment on top of the cart. Review of current facility policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, includes that controlled substances are locked in all cases in accordance with applicable law. (10 NYCRR 415.18(e))

Plan of Correction: ApprovedFebruary 6, 2017

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The LPN who left the medication cart unlocked and unsupervised outside of a resident?s room has been counseled and re-educated as to the policy and procedures for medication administration with emphasis on medication cart procedures.
The Nurse Managers have reinforced, to all medication nurses, their responsibility for keeping the medication cart locked when now within their sight. In addition, the Nurse Managers have been monitoring their compliance. The Nurse Managers conducted and inspection and found no other unsupervised and unlocked medication carts.
The Staff Development Coordinator will in service all medication nurses on the facility?s Medication Administration policies and procedures which will include the reason and necessity for keeping the medication carts locked when out of sight and unsupervised.
The Nurse Managers, or their designee, will complete weekly and random audits then monthly and then intermittently as designated by the Quality Assurance Committee to ensure that all medication carts are locked if they are left unsupervised and out of sight of the medication nurse. The results of these audits will be provided to the Quality Assurance Committee for their review and action as necessary.
The Nurse Managers will be responsible for the correction of this deficiency.

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: January 13, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 677) completed on 1/13/17, it was determined that for one (Resident #85) of three residents reviewed for grievances, the facility did not ensure that each resident's grievance was resolved in a prompt manner. Specifically, the facility did not consistently honor the plan implemented in response to a grievance. This is evidenced by the following: Resident #85 has [DIAGNOSES REDACTED]. The Integrated Progress Note, dated 5/24/16, revealed that the resident's daughter called the Licensed Practical Nurse (LPN) Charge Nurse and requested that Certified Nursing Assistant (CNA) #1 no longer provide care for the resident. The LPN indicated in the progress note that it could be done. The Nurse Manager (NM) investigation, dated 5/25/16, revealed that the NM informed CNA #1 that she will no longer be assisting with care for the resident, per the family's request as of 5/24/16. The Nurse/Nursing Assistant Accountability sheets revealed that CNA #1 provided care for the resident on 14 occasions (8/16, 8/17, 8/18, 9/3, 9/4, 10/24, 10/25, 10/27, 10/29, 10/30, 10/31, 11/1, 11/3 and 11/4/16). The Minimum Data Set Assessment, dated 12/1/16, revealed the resident's cognition is severely impaired. The Activities of Daily Living (ADL) Care Restrictions List, updated 12/15/16, documented that CNA #1 is not allowed in the resident's room. When interviewed on 12/23/16 at 9:00 a.m., the NM stated that on 5/25/16, she was notified that the LPN Charge Nurse had spoken with the resident's family member. The family member requested that CNA #1 not be allowed in the resident's room. The NM stated that on 12/12/16, she spoke with the family member for the resident and the family member was upset because CNA #1 was still taking care of the resident. The NM stated that she did not realize that CNA #1 was going into the resident's room. The NM stated that the LPN Charge Nurse completes the CNA assignments, and she is not sure why CNA #1 was assigned to the resident. The NM added that she is unable to provide the care restrictions list prior to 12/15/16, because she does not keep the old list. She said CNA #1 was placed on the list in (MONTH) (YEAR), as she was not to provide care or go into the resident's room. Interviews conducted on 12/29/16 included the following: a. At 9:30 a.m., CNA #1stated that in (MONTH) (YEAR), she was told by the NM that she was no longer allowed to provide care for the resident per family wishes. CNA #1 stated that the LPN Charge Nurse does the assignments and, in (MONTH) (YEAR), she was assigned to the resident and provided care. CNA #1 stated she has been assigned to the resident every five weeks for a two-week period. CNA #1 stated the Charge Nurse makes the assignments. CNA #1 said she knew her name was placed on the restricted list and she was not allowed to go into the resident's room. CNA #1 stated that the list is only changed if the family and/or resident agrees. She said as far as she knows, that did not happen. b. At 10:40 a.m., CNA #2 stated that in (MONTH) (YEAR), CNA #1 was told she could not go in the resident's room anymore. CNA #2 stated that the CNA is responsible for switching with another CNA if she was assigned that resident, or the LPN Charge Nurse could change the assignment to ensure that the resident was not cared for by CNA #1. c. At 11:20 a.m., the resident stated that she does not recall the situation, but would agree with her family members, because they would not say something if it was not so. d. At 12:00 p.m., the LPN Charge Nurse stated that effective (MONTH) (YEAR), CNA #1 was not supposed to be in the resident's room. The LPN Charge Nurse stated she told CNA #1 that she could no longer provide care for the resident. The LPN Charge Nurse added that this was never lifted and was not supposed to end. She said that CNA #1 should have never gone back into the resident's room unless the family or the resident changed the plan. The LPN Charge Nurse stated that she is not aware of any changes and does not know why CNA #1 was going back into the resident's room. The LPN Charge Nurse stated that it is up to the CNAs to make a switch if they are assigned to a resident for which they are not supposed to be providing care. She said LPNs are supposed to check the CNA Accountability Sheets and should have realized that CNA #1 was assigned to the resident. e. At 12:20 p.m., the Interim Director of Nursing (DON) stated that a CNAs name is not removed from the restriction list unless the resident and/or family agrees. The DON said that the list should be given to the LPN Charge Nurse and assignments should be made accordingly. The DON stated that the LPN Charge Nurse should be sure that CNA #1 is not assigned to the resident. The DON added that CNA #1 could also tell the LPN Charge Nurse that she cannot go into the resident's room and that her assignment needed to be changed. The undated facility policy, The Rights and Responsibilities of Residents, included the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of deprivations or infringements of right to adequate and proper treatment and care established by any applicable statute, rule, regulation or contract. (10 NYCRR 415.3(c)(1)(ii))

Plan of Correction: ApprovedFebruary 6, 2017

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The LPN Charge Nurse and CNA # 1 were counseled by the Nurse Manager regarding consistently honoring the family/resident request that CNA #1 not care for the resident cited here.
Both Nurse Managers have reviewed the list of which staff members, if any, are prohibited from caring for certain residents to ensure that it is up to date and located so that it is accessible to all nursing staff members.
The Staff Development Coordinator will in service all nursing staff on their obligation to respect resident wishes as well as the grievance policy and procedure itself.
Audits will be conducted by the Nurse Managers, or their designee, weekly for four weeks then monthly and then intermittently as determined by the Quality Assurance Committee to ensure that staff members who are not to care for certain residents are not doing so. The results of these audits will be presented to the Quality Assurance Committee for their review and action as necessary.
The Nurse Managers are responsible for the correction of this deficiency.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Resident #45) of three residents reviewed for Range of Motion (ROM), the facility did not provide services in accordance with the resident's written plan of care. Specifically, the resident did not have rolled washcloths in both hands. This is evidenced by the following: Resident #45 has [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 1/3/17, included that the resident has severely impaired cognitive skills, impairment in ROM of upper extremities that interferes with daily functioning, and is totally dependent on staff for activities of daily living and eating. The Occupational Therapy (OT) Screen, dated 9/29/16, documented that the resident has contractures (fixed high resistance to passive stretch of muscle) of both hands. The OT Screen, dated 9/29/16, and the Certified Nursing Assistant (CNA) Resident Care Plan, dated as last reviewed on 1/11/17, revealed that the resident is to have rolled washcloths in both hands after care. Observations made on 1/9/17 at approximately 11:00 a.m., 1:00 p.m. and multiple times on 1/11/17 from 8:00 a.m. to 1:00 p.m., revealed the resident did not have rolled washcloths in her hands. Interviews conducted on 1/11/17 included the following: a. At 1:00 p.m. following observation of incontinence care and after surveyor intervention, CNA #1 stated that the resident is supposed to have rolled washcloths in both her hands. b. At 1:23 p.m., assigned CNA #2 stated that the resident should have rolled washcloths in both hands but she forgot them that day. c. At 2:57 p.m., the Licensed Practical Nurse (LPN) stated that the resident is supposed to have rolled washcloths in both hands for her contractures. The LPN said she did not notice that the resident did not have rolled washcloths in her hands all day. (10 NYCRR 415.11(c)(3)(ii))

Plan of Correction: ApprovedFebruary 6, 2017

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The Nurse Manager has ensured that resident #45 has and continues to have rolled washcloths in both hands in accordance with the resident? s Care Plan.
The Director of Rehabilitation has provided the Nurse Managers with a list of all residents who have been recommended to have assistive devices. The Nurse Managers have reviewed the Care Plans of these to ensure that the recommendation has been included in their Care Plan and on the CNA assignment sheet.
The Staff Development Coordinator will in service all Certified Nurse Aids on the importance, reason and need to be sure all assistive devices are appropriately applied in accordance with therapy recommendations and the resident?s Care Plan.
All residents who have been Care Planned to have an assistive devise(s) will be audited by the Nurse Managers, or their designee weekly for four weeks then monthly and then intermittently as determined by the Quality Assurance Committee to ensure that they are being appropriately applied. The results of these audits will be provided to the Quality Assurance Committee for their review and action as necessary
The Nurse Managers will be responsible for the completion of this deficiency.

FF10 483.25(g)(2):SUFFICIENT FLUID TO MAINTAIN HYDRATION

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (2) Is offered sufficient fluid intake to maintain proper hydration and health.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Resident #120) of one resident reviewed for hydration, the facility did not ensure that each resident received sufficient fluid intake to maintain proper hydration and health. Specifically, fluid intake was not consistently monitored for a resident with a fluid restriction. This is evidenced by the following: Resident #120 was admitted to the facility on [DATE] from the hospital with recent [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 12/27/16, revealed that the resident is cognitively intact and requires supervision and set up for eating. In an observation on 1/9/17 at 1:41 p.m., the resident's lips were dry and slightly cracked with dry mucous membranes, making it difficult to speak. The resident stated at that time that he prefers apple juice to drink but he is often told they do not have any. There were no fluids in the resident's room at that time. In an observation on 1/10/17 at 1:08 p.m., the resident was sitting in bed with his lunch tray in front of him, uneaten. There were no beverages on the tray or in his room at that time. The resident stated he did not get any beverages on his tray, adding that he does not get a lot to drink. He said that he has to ask for a drink and then sometimes he gets it and sometimes he does not. The resident asked the surveyor at that time if he could get some apple juice. The surveyor passed the resident's request on to the Licensed Practical Nurse (LPN). The hospital Discharge Summary and Instructions, dated 12/20/16, included a low sodium diet with a fluid restriction of 1,500 milliliters (ml) per day. Physician orders, dated 12/21/16, included to weigh the resident daily before breakfast and to call the physician if the resident gains two pounds or more. In a dietary progress note, dated 12/22/16, the Dietary Technician (DT) documents that dietary was notified of the resident's admission to the facility and that his diet includes a 1,500 ml fluid restriction per 24 hours. Dietary is to provide 540 ml of fluids per 24 hours and nursing is to provide the remaining fluids. A nutritional assessment will be completed. A Nutritional Assessment, dated and signed by the Registered Dietician (RD) on 12/26/16, includes that the resident is on a fluid restriction of 1500 ml per day and actual fluid intake was 1,200 ml. Under notes, the RD documents that fluids reported are from meals only and additional fluids are offered with medication and fluid passes. The assessment includes that the resident has no symptoms of dehydration and to monitor and evaluate weight, intakes, and symptoms of dehydration. Review of the Intake/Output Flow Sheets, dated 12/20/16 through 1/10/17, revealed intakes are documented every shift. The shift intakes were only totaled up to reveal the 24-hour amounts the resident consumed on 1 of 21 days. Review of the daily weight log, dated 12/20/16 through 1/11/17, revealed that the resident weighed 199 pounds (lbs.) on 12/20/16 and 184 lbs. on 1/11/17. Interviews conducted on 1/11/17 included the following: a. At 11:51 a.m., the LPN stated a record of all the fluids given during medication pass and meal intakes are documented and totaled on the flow sheets each shift. She said dietary then totals and reviews the 24-hour intake. b. At 2:19 p.m., and again on 1/12/17 at 3:05 p.m., the DT stated that the resident should get a total of 840 ml of fluid per day with meals and then whatever nursing gives him. She said that nursing should total the daily intakes and complete a form (Oral Intake Monitor Sheet) every three days for her review. The DT said she does not remember if she has done a review on this resident or not. When asked to review the resident's fluid intakes since admission, at that time the DT stated that the resident was averaging 1042 ml a day or 69 percent of his estimated fluid needs. She stated that they would prefer a resident gets 80-100 percent of the estimated needs. c. At 11:35 a.m. and again at 2:45 p.m., the Registered Nurse Manager stated that they do not complete an Oral Intake Monitor Sheet for residents on fluid restrictions. She said dietary should have seen the resident's weight loss. When interviewed on 1/12/17 at 10:24 a.m. and again on 1/13/17 at 9:04 a.m., the LPN Charge Nurse stated that the evening staff are to total the resident's fluid intakes and let her know if a resident is not getting enough. She added that she thought dietary was reviewing the totals. She said that the Certified Nursing Assistants report the resident's weights to her daily and that she should have seen the weight loss. (10 NYCRR 415.12(2)(j))

Plan of Correction: ApprovedFebruary 6, 2017

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The Nurse Manager has ensured that resident #120 has and continues to receive and consume an adequate amount of fluids within the parameters of his restriction.
The Nurse Managers have reviewed each resident on fluid restrictions and have ensured that adequate fluids were provided and consumed. The Nurse Mangers and Consultant Dietician will meet weekly to review any and all residents on fluid restrictions to ensure appropriate interventions are occurring.
The Acting Director of Nursing and Consultant Dietician will review and revise, where necessary, the facility policy and procedure on fluid restriction.
The Staff Development Coordinator will in service all nursing staff on the facility?s policy and procedure for fluid restrictions and the procedure for ensuring an adequate fluid intake within the fluid restriction.
The Nurse Managers, or their designee, will conduct weekly audits for four weeks then monthly and then intermittently as determined by the Quality Assurance Committee on all residents who may be on intake/output as well as a fluid restriction in order to ensure that they are consuming an adequate fluid intake and within the parameters of the restriction. The results of these audits will be provided to the Quality Assurance Committee for their review and action as necessary.
The Nurse Managers shall be responsible for the correction of this deficiency.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2017
Corrected date: March 24, 2017

Citation Details

Based on interviews and record reviews conducted during the Life Safety Code Survey, it was determined that for four of four pieces of electric medical reviewed and all non-medical patient equipment, the facility did not implement policies and procedures for routine and preventive maintenance. This is evidenced by the following: A review of facility records revealed that the manufacturers specifications for the Schuro Medical Aspirators required inspection of suction tubing and collection bottle for leaks and cracks before every use. The manufactures specifications also stated that the bacterial filter should have been replaced every two months. When interviewed on 1/12/17 at approximately 9:07 a.m., the Director of Maintenance stated that they do not have a policy for maintenance of electrical patient care equipment or electrical no patient care equipment. The Director of Maintenance also stated that they do not perform any preventative maintenance on the Medical Aspirators, they just fix items when they are broken. (2012 NFPA 99:10.5.2.1.1, 10.4.2.1)

Plan of Correction: ApprovedFebruary 6, 2017

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The Administrator and maintenance Supervisor have begun to develop policies and procedures for the testing, inspection, maintenance and repair of these four pieces of patient-care related electrical equipment. As well as collecting service and operator?s manuals for the four pieces of electrical medical equipment cited in this deficiency. They will be inspected in accordance with these manuals and documented on forms specific to that piece of equipment.
At the same time, an inventory of all other patient-care related electrical equipment (facility owned as well as resident owned) is being completed and will be subject to the same procedure as above.
Once completed, the Maintenance Supervisor will oversee the periodic (the frequency will be in accordance with the manufacturer?s recommendation) inspection and/or repair of each piece of equipment and documented according to Facility procedure.
On a quarterly basis, the Quality Assurance Committee will request, from the Maintenance Supervisor, the testing and maintenance logs of four (4) different patient-care related electrical equipment. The Quality Assurance Committee will review these records to ensure compliance with pertinent code requirements.
The Maintenance Supervisor will be responsible for the correction of this deficiency.

K307 NFPA 101:EMERGENCY LIGHTING

REGULATION: Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2017
Corrected date: February 10, 2017

Citation Details

Based on interviews and record reviews conducted during the Life Safety Code Survey, it was determined that for one of one battery powered emergency light located in the generator room, the facility did not perform proper maintenance. Specifically, no documentation of a currently performed or regularly scheduled 90-minute test could be provided. This is evidenced by the following: A review of facility records revealed that there was no documentation of a 90-minute test on the battery powered emergency lighting located in the generator room. When interviewed on 1/10/17 at approximately 11:38 a.m., the Director of Maintenance stated that there is no specific preventive maintenance system in place to do the 90-minute test. He said they just look at the log that is kept in the generator room and check when the last 90-minute test was done. (2012 NFPA 101: 19.2.9.1, 7.9)

Plan of Correction: ApprovedFebruary 6, 2017

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The Maintenance Supervisor has performed a 90 minute test of the battery powered emergency light located in the generator room and documented that it functioned properly.
The maintenance staff has tested all of the other battery powered emergency lights located throughout the facility to ensure that they perform properly and documented the results of the test.
The Maintenance Supervisor has revised the preventative maintenance log for all battery powered lights including the one in the generator room to ensure that none of the lights are overlooked.
The Maintenance Supervisor will present a copy of the maintenance log quarterly to the Quality Assurance Committee for their review and action as necessary.
The Maintenance Supervisor will be responsible for the correction of this deficiency.

K307 NFPA 101:SPRINKLER SYSTEM - SUPERVISORY SIGNALS

REGULATION: Sprinkler System - Supervisory Signals Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 13, 2017
Corrected date: February 13, 2017

Citation Details

Based on observation and interviews conducted during the Life Safety Code Survey, it was determined that for one of one sprinkler system, the facility did not provide continuous monitoring of sprinkler components for integrity. Specifically, a valve controlling water flow to the sprinkler system was not electronically supervised. This is evidenced by the following: Observations conducted on 1/10/17 at approximately 10:20 a.m. revealed that there was a sprinkler control valve on the incoming side of the backflow prevention device (RPZ) but on the system side of the Main sprinkler control valve, which was chained and locked, but did have an electronically supervised tamper switch. Both the Main sprinkler control valve before this valve and the sprinkler control valve on the outgoing side of the RPZ where supervised electronically with a tamper switch. In an interview at that time, the Director of Maintenance stated that the sprinkler system was installed in 2011. When interviewed on 1/12/17, the Director of Maintenance stated that he had reached out to his sprinkler vendor who told him that NFPA 13 states that valves do not need electronic supervision if they are locked in place. The 2010 Edition of NFPA 72: National Fire Alarm and Signaling Code states that two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position (off-normal), and the other indicating restoration of the valve to its normal position. (2012 NFPA 101:19.3.5.1, 9.7.2.1; 2010 NFPA 72: 17.16.1.1)

Plan of Correction: ApprovedFebruary 13, 2017

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The Facility has contracted with Solution One, Inc. for the installation of an electronic supervising system on the cited sprinkler valve. Work will be performed as soon as the part arrives and the wok can be scheduled.
There are no other unsupervised sprinkler valves within the facility.
The Facility will continue to contract with Solution One for the testing, inspection and repair of the Facility?s sprinkler system. In addition, the Administrator and Maintenance Supervisor will monitor the Life Safety Code for changes in the regulations as they apply to sprinkler systems.
The Maintenance Supervisor will submit quarterly, a copy of the sprinkler test results to the Quality Assurance Committee for their review and action as necessary.
The Maintenance Supervisor will be responsible for the correction of this deficiency.