Edna Tina Wilson Living Center
September 22, 2017 Certification Survey

Standard Health Citations

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: September 22, 2017
Corrected date: November 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #44) of four residents reviewed for dignity, the facility staff did not promote care for the resident in a manner that maintains or enhances the resident's dignity. Specifically, staff continued to provide care while the resident was moaning and crying. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/2/17, revealed that the resident's cognitive skills for daily decision making were moderately impaired. The Comprehensive Care Plan, dated 6/8/17, revealed that the resident had cognitive loss, and signs of depression as evidenced by paranoia and anxiety. Approaches included to speak to the resident in a calm manner, and to speak clearly and slowly to enhance her understanding. During an observation on 9/21/17 at 2:00 p.m., the Certified Nursing Assistant (CNA), without talking to or explaining the process, hooked the resident's sling to a mechanical lift. When the resident was lifted, she yelled, Help, and the CNA responded, Cross your hands. After the resident was placed in bed, the CNA, in an abrupt manner and without speaking, turned the resident away from her and the resident said, Don't hurt me. Then again, without talking to the resident, the CNA positioned the resident on her back and removed her brief. At that time, the resident said, Oh, oh. The CNA took the wet washcloth and, without engaging in conversation, the CNA washed the resident. Again, the resident started to moan and said, Oh my God, I can't take it. The CNA said to the resident, Open your legs. She then turned the resident to the left and the resident said, Oh. The surveyor asked the CNA why the resident was moaning, and she responded the resident always does that. When interviewed on 9/21/17 at 2:26 p.m., the CNA said that she knows that she should have explained to the resident what she was going to do prior to providing care. (10 NYCRR 415.5(a))

Plan of Correction: ApprovedOctober 13, 2017

F241 483.10(a)(1) Dignity and Respect of Individuality
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice?
1. CNA involved for resident #44 has been counseled in regards to dignity issues
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. Facility nursing direct care staff will be observed to ensure staff are explaining procedures and providing reassurance during care.
What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
1. Nursing staff will be in-serviced in regards to explaining and procedures and providing reassurance while performing care to residents
2. An audit tool will be developed to monitor ten percent of facility direct care staff and will report results to the quality assurance committee.
3. Staff observed not meeting expectations will have counseling provided.
4. Direct care staff will receive education upon orientation.
5. Social work staff will interview ten percent of residents to ensure staff are explaining procedures and providing reassurance
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
1. The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to the DON/Designee who will review results at the monthly Quality Assurance meeting. The Quality Improvement Committee will determine the length of audits.
Overall Responsibility: DON/Designee

FF10 483.80(d)(1)(2):INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS

REGULATION: (d) Influenza and pneumococcal immunizations (1) Influenza. The facility must develop policies and procedures to ensure that- (i) Before offering the influenza immunization, each resident or the resident?s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident?s representative has the opportunity to refuse immunization; and (iv) The resident?s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident?s representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. (2) Pneumococcal disease. The facility must develop policies and procedures to ensure that- (i) Before offering the pneumococcal immunization, each resident or the resident?s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident?s representative has the opportunity to refuse immunization; and (iv) The resident?s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident?s representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: November 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined for one (Resident #145) of five residents reviewed for influenza and pneumococcal immunizations, the facility did not ensure that each resident is offered immunizations unless the immunization is medically contraindicated or the resident has already been immunized. The issues involved the lack of a documented pneumococcal vaccination. This is evidenced by the following: Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician admission orders [REDACTED]. The Minimum Data Set (MDS) Assessments, dated 4/27/17 (Admission) and 7/27/17 (Quarterly), both revealed that the resident's pneumococcal vaccination is not up to date and had not been offered. Review of the Electronic Medical Record, (EMR), under Immunizations revealed no documentation regarding the pneumococcal vaccination. Interviews conducted on 9/22/17 included the following: a. At 10:25 a.m., the Unit Secretary said, upon admission, she enters the resident's immunization history into the EMR. She said if the immunization history is not available, then she notifies the Registered Nurse Manager (RNM). b. At 11:08 a.m., the RN/Clinical Leader said he would review the hard copy chart for the resident's immunization record. He said that he was unable to locate any data. c. At 11:18 a.m., a Physician's Assistant (PA) said, upon admission, the immunization history is entered directly into the EMR. She reviewed the EMR and another computer application and said there was no documented history that the resident received a pneumococcal vaccination. The PA said the facility protocol directs that if a resident has no documented history of the pneumococcal vaccination then it should be offered to the resident. She reviewed medical orders, from 4/20/17 through 9/18/17, and said the vaccination had not been ordered. d. At 1:20 p.m., the MDS/RN said when completing the MDS Assessment (Section O), if a vaccination is not up to date and had not been offered, the nurse completing the MDS Assessment is to notify the RNM for follow up. She said that had not been done. Review of a facility policy, Pneumococcal/Influenza Immunization, dated 11/1/12, directs that upon admission, each resident is evaluated to determine their pneumococcal immunization status. If the resident has not been previously vaccinated, education regarding the benefits and potential side effects of the pneumococcal immunization will be provided to the resident or their legal representative. The resident or representative will have the opportunity to refuse immunization and refusal will be documented in the EMR. If consent is given, the immunization will be ordered. (10 NYCRR 415.12)

Plan of Correction: ApprovedOctober 13, 2017

F334 483.80(d)(1)(2) Influenza and Pneumococcal Immunizations
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice.
1. Resident #145 was offered pneumovaccine and administered on 9-25-2017
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. All residents were reviewed. Any residents not up to date with their pneumococcal vaccination will be given education and offered the vaccination. Vaccination given or declined will be documented in the Electronic Health Record.
2. A root cause analysis was conducted to identify potential issues.

What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
1. 24 hour report sheet has been updated to reflect the need for pneumococcal vaccines
2. An inservice has been provided to license nursing personnel and unit secretaries.
3. A report will be produced weekly to ensure compliance. Results will be review at the quality assurance meeting.
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
1. The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to the DON/Designee who will review results at the monthly QAPI meeting. The Quality Improvement Committee will determine the length of audits.
Overall Responsibility: DON/Designee

FF10 483.55(b)(1)(2)(5):ROUTINE/EMERGENCY DENTAL SERVICES IN NFS

REGULATION: (b) Nursing Facilities The facility- (b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; (b)(2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; (b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: November 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #75) of two residents reviewed for dental services covered by Medicaid, the facility did not provide or obtain routine dental services to meet the needs of each resident. The issues involved the lack of follow up for dental concerns. This is evidenced by the following: Resident #75 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Dental Consult Note, dated 4/19/17, included that the resident had root remnants to teeth #26 and #27, possible caries to tooth #3, and soft tissue that was generally inflamed. It was recommended that an office appointment be scheduled for x-rays and development of a treatment plan if desired. This was initialed as being reviewed on 5/1/17. No other documentation was provided for communication with the family or dentist regarding follow up. When interviewed on 9/21/17 at 1:45 p.m., a Unit Secretary said the dental forms go to the Minimum Data Set Assessment Nurse, then the Nurse Manager, then the Physician Assistant Board, and then to the Unit Secretary to file/scan in the medical record. When interviewed on 9/22/17 at 1:10 p.m., the Assistant Director of Nursing said that there was no documented evidence that the family was notified of the dental concerns or follow up was provided by the dentist. She said she will contact the family. (10 NYCRR 415.17(a-d))

Plan of Correction: ApprovedOctober 13, 2017

F412 483.55(b)(1)(2)(5) Routine/Emergency Dental Services
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice.
1. A dental appointment was made for resident #75 on 9-21-2017.
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. Facility has conducted a root cause analysis to review follow up recommendations for dental consults
2. All residents who received a dental consult will be reviewed to assure that recommendations were implemented
What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
2. All dental consults will be given the DON/Designee for review
3. Licensed staff and unit secretaries will be educated on the new process
4. DON/Designee will audit all dental consults to assure recommendations are implemented
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to the DON/Designee who will review results at the monthly QAPI meeting. The Quality Improvement Committee will determine the length of audits.
Overall Responsibility: DON/Designee

FF10 483.55(a)(1)(2)(4):ROUTINE/EMERGENCY DENTAL SERVICES IN SNFS

REGULATION: (a) Skilled Nursing Facilities A facility- (a)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident; (a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services; (a)(4) Must if necessary or if requested, assist the resident; (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: November 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #46) of one private pay resident reviewed for dental services, the facility did not provide or obtain routine dental services to meet the needs of each resident. The issues involved the lack of follow up dental work. This is evidenced by the following: Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 6/30/17, revealed that the resident had severely impaired cognition, and obvious or likely cavity or broken natural teeth. During an observation and interview conducted on 9/19/17 at 1:31 p.m., the resident had several missing teeth on both the top and bottom. The resident said that she had some missing teeth that she would like fixed. She asked if she could see a dentist to replace some teeth. The resident said that she might have told someone about wanting some dental work done but she could not remember who. A Dental Hygienist Note, dated 8/3/17, revealed that the resident was seen for dental hygiene services. The resident had cavities throughout her mouth and requested that her broken teeth be fixed. Interviews conducted on 9/20/17 included the following: a. At 3:04 p.m., a Registered Nurse/Clinical Leader (RN/CL) said dental consults are faxed to the facility, and he thought someone from nursing reviewed them and followed up on recommendations. b. At 3:05 p.m., a Licensed Practical Nurse said a Nurse Practitioner or physician reviews the dental consult and evaluates the need for follow up. c. At 3:21 p.m., the RN/CL said he had verified the process. He said after the dental forms and recommendations are returned back to the facility, a RN reviews and signs the forms. He said the dental forms are then left on the medical provider's board for review. He said the provider will review the consult and recommendations, and write an order for [REDACTED]. Interviews conducted on 9/21/17 included the following: a. At 11:01 a.m., the Assistant Director of Nursing (ADON) said that a Nurse Manager is supposed to review the dental consults/recommendations and follow up for treatment. The ADON said she is not sure how or why it was missed. b. At 1:09 p.m., a Social Worker (SW) said a care planning meeting was held with the resident's family via teleconference on 8/22/17. She said the resident did not attend the meeting as she wanted to participate in an activity scheduled at the same time. The SW said the family members said that they would think about a dental follow up. When asked if she had discussed the desire for dental treatment with the resident, the SW said she thought she had but could not find any supporting documentation. The SW said this resident is certainly able to make decisions regarding dental care. (10 NYCRR 415.17(a-d))

Plan of Correction: ApprovedOctober 13, 2017

F411 483.55(a)(1)(2)(4) Routine/Emergency Dental Services
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice.
1. A dental appointment was made for resident #46 on 10-9-2017. At the dental office, resident refused any treatment.
2. Social worker will discuss with family to determine next steps.
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. Facility has conducted a root cause analysis to review follow up recommendations for dental consults
2. All residents who received a dental consult will be reviewed to assure that recommendations were implemented
What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
1. All dental consults will be given the DON/Designee for review
2. Licensed staff and unit secretaries will be educated on the new process
3. DON/Designee will audit all dental consults to assure recommendations are implemented
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to the DON/Designee who will review results at the monthly QAPI meeting. The Quality Improvement Committee will determine the length of audits.
Overall Responsibility: DON/Designee

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: September 22, 2017
Corrected date: November 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #18) of three residents reviewed for pressure ulcers, the facility did not ensure that care was provided in accordance with the resident's written plan of care. Specifically, the resident did not have a cushion in the wheelchair. This is evidenced by the following: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/28/17, revealed that the resident was cognitively intact and at risk for pressure ulcers. The current Comprehensive Care Plan revealed that the resident had a diabetic right heel ulcer and a left buttock Stage II (partial thickness skin loss) pressure ulcer. The current Resident Profile directed to put a dycem (non-slip product) mat on top of the wheelchair cushion to prevent sliding. Observation and interviews conducted on 9/22/17 included the following: a. At 9:00 a.m., the resident's wheelchair cushion was observed in the resident's recliner chair and was covered with a white pad. b. From 9:05 a.m. until 12:00 p.m., the resident was sitting in the small living room in her wheelchair. There was no pressure cushion in the wheelchair and the resident was sitting on a dycem mat. At 12:00 p.m., the resident's family member asked if someone would assist the resident to the bathroom. c. At 12:10 p.m., the Nurse Manager stated that she expects staff to read residents' care plans every day because something could have changed from the day before. d. At 12:45 p.m., the Certified Nursing Assistant (CNA) stated that she saw the cushion in the resident's recliner. She said that she did not know what that was about. She said she put the dycem mat underneath the resident while she was sitting in her wheelchair. The CNA said that the resident should have had a cushion in her wheelchair. (10 NYCRR 415.11(c)(3)(ii))

Plan of Correction: ApprovedOctober 13, 2017

F282 483.21(b)(3)(ii) Services by qualified persons/per care plan
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice.
1. Resident #18 care plan and care card were reviewed and updated
2. Staff member has been counseled on following the resident?s care card
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. All residents requiring a cushion in their chairs will be reviewed to ensure compliance.
2. Residents requiring a cushion will be audited to ensure cushions are in place per care plan.
What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
1. An inservice to all nursing staff will be completed in regards to resident?s cushions on chair per care plan.
2. An audit tool has been developed and ten percent of residents will be audited monthly
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
1. The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to the DON/Designee who will review results at the monthly QAPI meeting. The Quality Improvement Committee will determine the length of audits.
Overall Responsibility: DON/Designee

FF10 483.24(a)(1):TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS

REGULATION: (a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: November 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #86) of three residents reviewed for Activities of Daily Living (ADL), the facility did not provide the necessary care and services to maintain or improve ADL function. Specifically, the resident was not provided assistance with oral care as care planned. This is evidenced by the following: Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Dental Consult exam, dated 1/5/17, included that the resident had very heavy calculus (tartar) throughout her mouth. The annual Minimum Data Set Assessment, dated 7/18/17, included that the resident was moderately cognitively impaired and required extensive assistance with personal hygiene. The Comprehensive Care Plan for Dental Care, last updated 5/20/14, included that the resident had moderate plaque and calculus accumulation with gingival (gum) inflammation with a goal to have no evidence of debris in her mouth. The resident was to be provided with mouth care twice a day and as needed, required cueing to brush her teeth, and if she resisted mouth care, she was supposed to be reapproached later. The current Certified Nursing Assistant (CNA) Care Card included that the resident required set up and cueing with morning and evening care. When observed on 9/19/17 at 10:22 a.m., 9/20/17 at 1:45 p.m., and 9/21/17 at 9:32 a.m., the resident's upper and lower teeth had thick white buildup. During an observation and interview on 9/21/17 at 11:35 a.m., the CNA said she tried to brush the resident's teeth that morning but the resident was agitated and would not allow her teeth to be brushed. When the resident was asked to smile, her teeth had thick white buildup. The CNA said that the resident needed to have her teeth cleaned. When observed on 9/21/17 at 11:55 a.m., the resident said that the CNA helped her to brush her teeth. The resident smiled, revealing clean teeth. When interviewed on 9/21/17 at 12:11 p.m., the Assistant Director of Nursing (ADON) said that everyone is supposed to receive mouth care. She looked in care tracker (computerized documentation of care provided) and said the resident is scheduled to have oral care set up and cueing in the morning and evening. The ADON said the resident can have some behaviors but when she looked in care tracker there was no documentation of behaviors or rejection of care for the past week. (10 NYCRR 415.12(a)(2))

Plan of Correction: ApprovedOctober 13, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F311 483.24(a)(1) Treatment/Services to improve/maintain ADL?s
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice.
1. Resident #86 oral care was completed per the care plan on 9-21-2017.
2. Staff members were counseled and educated on proper dental care.
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. All residents will be reviewed for oral care needs and care planned appropriately
2. Residents identified for oral care needs will have their [MEDICATION NAME] cavity inspected for completion
of oral care.
What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
1. An audit tool will be developed to ensure compliance.
2. Ten percent of residents weekly will be audited for three months and results will be reported to the quality assurance committee.
3. Standards of care has been reviewed and revised to reflect oral hygiene
4. Nursing Staff will inserviced on the Standards of care for oral hygiene
5. Caretracker dental compliance will be monitored on days and evenings. Any staff identified with a deficient practice will be educated on the spot.
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
1. The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to DON/designee who will review results at the Quality Improvement Committee meeting. The Quality Improvement Committee will determine length of audits
Overall Responsibility: DON/Designee

FF10 483.25(b)(1):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: (b) Skin Integrity - (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: November 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #44) of three residents reviewed for pressure sores, the facility did not provide the necessary services to prevent the development of, or promote healing of, pressure sores. The issues involved the lack of timely repositioning and a skin assessment. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/2/17, documented that the resident's cognitive skills for decision making were moderately impaired, was always incontinent of bowel and bladder, no toileting program and at risk for pressure ulcers. The Comprehensive Care Plan (CCP), dated 6/8/17, revealed that the resident was at risk for pressure ulcers related to incontinence and the goal was for the resident's skin to remain clear. Approaches included to check the resident's skin each day, to assist with mobility needs, and to provide incontinence care. The CCP was updated on 9/18/17 to reflect that the resident currently had a pressure ulcer on the heel, to monitor the area weekly and document changes. The current Resident Profile directs to check and change the resident's position every two to three hours while in the chair. The Skin Observation Sheets, dated 9/7/17 and 9/13/17, revealed no skin issues on the resident's buttocks. An Interdisciplinary Note, dated 9/19/17, documented that the resident did not have any skin issues observed. The Medical Communication Note, dated 9/20/17, revealed that the resident's buttocks were red. The physician order, written on 9/21/17 at 8:00 a.m., directs to apply barrier cream (helps protect the skin) twice daily to bilateral buttocks for contact [MEDICAL CONDITION]. During a continuous observation on 9/21/17 from 8:55 a.m. until 2:00 p.m., the resident was sitting in her wheelchair. When taken to her room at 2:00 p.m. and placed in bed, the staff turned the resident onto her right hip. The resident had a circular Stage II (partial thickness skin loss) pressure ulcer measuring approximately 1 inch in diameter near the left gluteal fold. The buttocks had what appeared to be denuded (loss of some or all of the epidermis) skin near the anal area with a small blister on the left buttock. There were two reddened areas that appeared to be Stage II pressure ulcers both measuring approximately 1 inch in diameter on the right buttock. The resident had diffuse areas of redness down her thighs. Interviews conducted on 9/21/17 included the following: a. At 2:00 p.m. and 2:26 p.m., the assigned CNA said that she did not know how often the resident should be repositioned. She said maybe every two to three hours. The CNA said that she knows what to do for the resident because it is on her assignment. The CNA and the surveyor together reviewed the assignment sheet. The CNA was carrying a list of residents' names on her assignment, not the actual resident care information. The CNA said the resident was put in her wheelchair around 9:00 a.m., and then to bed at 2:00 p.m. She said she does not know why the resident was not repositioned sooner. The CNA said that she reported the areas on the resident's buttocks to the Licensed Practical Nurse (LPN) the previous week and was told to put some cream on it. b. At 2:50 p.m., the Registered Nurse (RN) Clinical Leader said that she was not aware of any skin issues with the resident. She said no one reported anything to her. She said the resident could be toileted every two to four hours, but that specific information would be on the resident's care card. Interviews conducted on 9/22/17 included the following: a. At 10:53 a.m., the Nurse Practitioner (NP) said she was told that the resident had a contact [MEDICAL CONDITION], but was unable to recall who reported that to her. The NP said that she ordered the barrier cream that morning based on the note in the Medical Communication Book written on 9/20/17. She said she did not assess the resident's skin at that time. The NP said when she assessed the resident's buttock on 9/21/17, it was not a contact [MEDICAL CONDITION]. She said she documented it in the medical record. The NP Note, dated 9/21/17, revealed that the resident had an unstageable pressure ulcer on the sacrum and a Stage II pressure ulcer on the right buttock. b. At 2:01 p.m., the Medical Director and the Director of Nursing said that the LPN reported to them that the CNA reported the areas on the buttocks, but it was the end of the shift and she did not have time to look at the areas so she added an entry into the Medical Communication Book. They both said that a lack of repositioning the resident for a prolonged period could have made the areas worse. The LPN, who was not available for interview, reported to Administration that the CNA came to her at the end of the shift and reported that the resident's buttocks were red, but she did not look at the area. c. At 2:34 p.m., the Registered Nurse Manager (RNM) said when there is a problem with a resident's skin, the CNA reports the concern to a nurse, and then it should be documented in the Medical Communication Book, and the medical record. She said the LPN that received the report should have looked at the area, documented it, and notified the RNM. (10 NYCRR 415.12(c)(1-2))

Plan of Correction: ApprovedOctober 13, 2017

F314 483.25(b)(1) Treatment/SVCS to Prevent/Heal Pressure Ulcers
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice.
1. Resident #44 skin was evaluated on 9-21-17 and updated the care cared and care plan to reflect current skin needs.
2. The Nurse Practionner, License Practical nurse and Certified Nursing assistant were re-educated and counseled.
3. Medical Director assessed resident and reviewed and revised plan of care
4. LPN was re-educated on importance of verbally communicating changes in skin condition to a registered nurse or provider at time of occurrence.
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. Any new skin conditions will be assessed by a Registered Nurse and medical provider will be notified if appropriate.
2. Skin checks on all residents have been performed and care plans will be updated to reflect any needed changes.
3. All residents will be reviewed for turning and positioning as outlined by the care plan
What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
1. Nursing Staff will be educated to include turning and positioning to prevent skin breakdown, and steps for communicating and reporting skin changes.
2. An audit will be developed to monitor compliance in turning and positioning of residents according to the care plan.
3. An audit tool will be developed to ensure that changes identified on the written communication tool resulted in assessment and careplan follow up as needed.
4. Ten percent of residents weekly will be audited for three months and results will be reported to the quality assurance committee.
5. Based on results of audits, nursing staff not in compliance will be re-educated and progressive discipline as indicated
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
1. The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to DON/designee who will review results at the Quality Improvement Committee meeting. The Quality Improvement Committee will determine length of audits.
Overall Responsibility: DON/Designee

Standard Life Safety Code Citations

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: November 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Life Safety Code Survey, it was determined that for three of three residential units, the facility did not properly maintain the sprinkler system. Specifically, sprinkler heads lacked proper clearance from the ceiling. This is evidenced by the following: Observations on 9/19/17 between 9:06 a.m. and 12:00 p.m. revealed pendant heads that protruded less than 1 inch below the ceiling in Resident room [ROOM NUMBER]D, Bathing Suite #319, the bathroom inside Bathing Suite #319, in the corridor in front of exit door M-2, in bathroom [ROOM NUMBER]A, in the closet of the(NAME)suite and in the closet in Resident room [ROOM NUMBER]. When interviewed during observations, the Facilities Engineering Manager stated that after last year's survey, they came through and adjusted a whole bunch of sprinkler heads for the same issue. The 2010 edition of NFPA 13, Standard for the Installation of Sprinkler Systems, states: under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.3.5.1, 9.7.1.1, 2010 NFPA 13:8.6.4.1.1.1)

Plan of Correction: ApprovedDecember 8, 2017

ETW Director of Facilities and(NAME)Fire Protection will complete an inspection of all sprinkler heads that were cited.
ETW Director of Facilities and(NAME)Fire protection will complete an inspection of 100% of the sprinkler heads in the facility.
A time limited waiver has been submitted on 11/14/2017 to the NYSDOH Dept of Health Care Facility Planning. The requested date in the time limited waiver is (MONTH) 12, (YEAR). Sprinkler heads that are identified as incorrectly installed will be replaced.
An audit will be developed by the Director of Facilities and completed by Rochester Regional Health Corporate safety staff and(NAME)Fire protection on a quarterly basis.
Results of the audit will be reported to the ETW Safety and Quality Assurance committee by the Facilities Director.
The Director of Facilities is responsible for this plan of correction.