Pontiac Nursing Home
April 1, 2019 Certification/complaint Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey the facility did not ensure residents were provided the necessary care and services to ensure a resident's abilities in activities of daily living (ADLs) did not diminish for 3 of 8 residents (Residents #1, 10 and 15) reviewed for ADLs. Specifically, Residents #1 and 15 had a decline in their feeding abilities and were not provided appropriate assistance at meals. Resident #10 was not assisted with oral hygiene and haircuts. Findings include: There was no documented evidence of a facility policy addressing ADLs. 1) Resident #1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. A physician order [REDACTED]. The 2/23/19 comprehensive care plan (CCP) documented the resident was at nutritional risk. The CCP documented conflicting information for eating/feeding assistance. One portion of the plan of care documented assistance of one staff another documented assist with meals as needed. The 3/7/19 registered dietitian (RD) nutrition assessment documented the resident's intake had decreased and her weight had remained in goal range. The resident's feeding ability required assistance and total feeding. A physician order [REDACTED]. The resident was observed seated at the dining table with 3 other residents on 3/27/19 at 12:32 PM. There was one staff at the table assisting a male resident. Staff started serving trays at 12:39 PM and were completed 10 minutes later. The resident was seated at the table not eating at 1:00 PM. At 1:02 PM, licensed practical nurse (LPN) #2 came to the table and handed the resident a cup. The resident took a sip of her drink, placed it back and did not attempt to try her solids. The LPN left the table. The resident remained at the table not eating or drinking. At 1:09 PM, certified nurse aide (CNA) #3 offered the resident potatoes, the resident accepted, and the CNA fed them to her. The CNA then offered juice and the resident accepted. At 1:11 PM, the CNA got up from the table and went to assist another resident. The resident remained seated not eating or drinking with her head down. At 1:13 PM, the resident still had untouched pureed turkey and orange juice on her meal tray. The intake record for 3/27/19 documented the resident had consumed 25% during the lunch meal. During an interview with CNA #20 on 4/1/19 at 4:13 PM, she stated the resident needed to be fed by staff as she was blind. She stated if staff placed a drink in her hand, she would then drink it on her own and set it down. She stated it was not common for the resident to pick up her own utensils and feed herself. During an interview with certified occupational therapy assistant (COTA) #28 on 4/2/19 at 9:48 AM, she stated the resident was last screened on 5/2018 for self-feeding and equipment. The resident was able to feed herself at that time and she was not placed on treatment. She stated she had not received a new referral on the resident. During an interview with licensed practical nurse (LPN) #14 on 4/2/19 at 10:05 AM, she stated the resident did not use to need help at meals, she had a decline in her vision and now needed assistance. She stated she had not notified anybody about a decline. During an interview with LPN Unit Manager #4 on 4/2/19 at 12:30 PM, she stated the staff had to describe where items were on the table and hand them to the resident. She stated the resident tables were arranged so that staff were available for residents requiring assistance. She had not been notified of any change in the resident's feeding ability. 2) Resident #10 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The 1/2/19 comprehensive care plan (CCP) documented the resident needed assistance of one staff for grooming. The resident required assistance with dental care as he had a lack of hygiene awareness. Staff were to monitor the resident's mouth and assess his ability to brush and floss. The 3/21/19 certified nurse aide (CNA) Instructions documented the resident required supervision with upper body hygiene. The resident had upper dentures and his own bottom teeth. The instructions did not include directions on performance of oral hygiene. During an interview with the resident on 3/27/19 at 11:50 AM, the resident had hair long that was extending over his ears, and he had significant buildup of debris and film along his lips, the corner of his mouth and on his teeth. He stated his hair was getting long and he needed a haircut. The resident was observed intermittently until 3:48 PM with debris and film along his lips, the corner of his mouth and on his teeth. The resident's hair remained long through 4/2/19 at 6:45 PM. During an interview with CNA #20 on 4/1/19 at 4:13 PM, she stated staff previously had to help the resident with his PM (evening) care as he was not doing it for himself. He only recently started doing care for himself. She stated the resident was able to do his own oral care and he had never asked for a haircut. During an interview with CNA #24 on 4/2/19 at 8:48 AM, she stated the resident had not been his normal self for a time and he was not able to do anything. She stated the resident now could do his own care but needed to be instructed by staff and needed prompting and reminders. During an interview with certified occupational therapy assistant (COTA) #28 on 4/2/19 at 9:48 AM, she stated if the resident had a change in his ability to do his own care, therapy should have been notified, and they were not. She stated the last time she had seen the resident in therapy he needed a lot of cueing and encouragement to perform care. During an interview with CNA #3 on 4/2/19 at 1:42 PM, she stated the resident's level of assistance varied. He was able to do his own oral care, but if he was having a bad day the staff had to assist him more. She stated the resident had not had a hair trim recently. 3) Resident #15 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The 7/20/18 certified nurse aide (CNA) instructions documented the resident required extensive assistance with eating. The comprehensive care plan (CCP) active in 3/2019 documented the resident required limited assistance with eating and was at nutritional risk. During a meal observation on 3/27/19 at 12:39 PM staff were serving the residents their meal trays. At 12:55 PM, Resident #15 was feeding herself half of a turkey sandwich. LPN #2 and CNA #3 would stop at the table and assist with feeding the resident and get up and leave the resident to assist other residents in the dining room. The resident remained at the table in the dining room through 1:24 PM and she had not finished her sandwich. During an interview with CNA #20 on 4/1/19 at 4:13 PM, she stated staff had to help the resident with feeding related to her vision. During an interview with CNA #24 on 4/2/19 at 8:48 AM, she stated the resident could feed herself finger foods, but without finger foods she did not do well. The resident was not able to see as well as she used to and could no longer reach for items and she now required staff handing her items. The resident required a staff member at the table to help. During an interview with certified occupational therapy assistant (COTA) #28 on 4/2/19 at 9:48 AM, she stated the resident had been screened in the past and had not been picked up for treatment by occupational therapy. She stated she thought she saw the resident in the past for eating/feeding assistance. If the resident had a change in ability to feed herself the resident should be referred to therapy. During an interview with RD #23 on 4/2/19 at 10:36 AM, she stated the last few times she had seen the resident she had a hard time eating. The resident had been messy when feeding herself or was sleepy at meals. She stated she would recommend verbal cues or physical assistance during meals. During an interview with LPN Unit Manager #4 on 4/2/19 at 12:30 PM, she stated she was not aware of a decline or increased need for assistance for the resident. She said the resident did have a decline and she had participated in therapy. She stated she was behind on updating care plans. During an interview with CNA #3 on 4/2/19 at 1:42 PM, she stated the resident required staff to hand her items and she could not eat on her own. 10NYCRR 415.12(a)(2)

Plan of Correction: ApprovedApril 30, 2019

I. The following actions will be accomplished for the residents identified in the sample:
Resident # 1
OT screened resident during meals. Resident utilized utensils, requires minimal assistance on scooping the food and guiding the utensils to feed self (completed on 04/26/19). Her care plan and care card will be reviewed and updated. The Unit Manager will review the care plan and care card with staff responsible for the care of this resident. SW to notify resident representative.
Resident # 10
The resident is scheduled for a haircut/trim appointment within the week of 04/28/19. SW to notify resident's representative. OT to screen resident. Care plan to review and update to include frequent hair cut as per the resident's preference consistent with his needs for grooming and hygiene assistance. The unit manager will review the care plan with the staff responsible for the care of this resident.
Resident # 15
OT will screen resident for updated ADL status (completed on 04/29/19). Her care plan will be reviewed and updated consistently with her needs for assistance for meals, grooming/hygiene, bathing, dressing, and toileting in conjunction with OT report. The Unit Manager will review the care plan and care card with staff responsible for the care of this resident.

Unit Manager will complete a chart review to identify residents who have a decline in their feeding abilities.
II. All residents who are dependent on staff for ADL care have the potential to be affected by this practice.
III. The following systemic changes will be put in place to ensure that deficient practice does not recur:
The Administrator and Director of Nursing implemented a Policy and Procedures for ADL care guidelines provided for all residents. All RNs, LPNs, and CNA will receive in-service education regarding the ADL Care Policy and Procedures and the importance of ensuring residents who are not able to carry out ADL will receive necessary services to maintain or improve his or her ability to carry out the activities of daily living.
IV. The facility's compliance will be monitored utilizing the following Quality Assurance system:
A. ADL audit tool and clinical competency were implemented to monitor compliance with providing ADL care guidelines for dependent residents with the focus on dining/feeding assistance, grooming, oral care, and hygiene. The audit will include clinical record reviews as well as direct observation of the residents being audited.
B. Rounds will be conducted by all Department heads and rotating basis for a three (3) month period with the focus on dining room during meals. The ADL audit tool will also be used by the auditors. Any immediate issues or concern during rounds will be brought to morning report and the DON for analysis and action if needed.
C. The Unit Manager will audit 25% of dependent residents on their respective unit monthly for three (3) months. Immediate corrective action will be taken for identified concerns. The Unit Manager will present the findings to the Quality Assurance Committee monthly for review. At the end of three months, the QA committee will evaluate the need for additional monitoring or other corrective action.
D. Corrective action such as discipline up to including termination will be implemented as necessary.
V. The Director of Nursing Services is responsible for the correction of this deficiency.

FF11 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: §483.24(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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey the facility did not ensure a resident was who unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 6 of 8 residents (Residents #1, 15, 24, 33, 35 and 151). Specifically, Residents #24 and 33 did not receive their showers as care planned. Resident #1 did not have hair hygiene provided. Resident #15 was not assisted with nail care. Resident #35 was not assisted with oral hygiene or clothing changes. Resident #151 was not assisted at meals to ensure adequate nutrition. Findings include: There was no documented evidence the facility had policies addressing ADLs, including feeding assistance, oral hygiene, hair care, or nail care. 1) Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/27/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, had behaviors of wandering, and required extensive assistance for dressing, toileting, personal hygiene and bathing. The 2/13/19 comprehensive care plan (CCP) documented the resident had a self-care deficit related to cognitive issues. Interventions included encourage the resident to participate in bathing, dressing, grooming, toileting and praise accomplishments; and monitor for any changes, declines or improvements with activities of daily living (ADL) performance. The dental care area documented the resident goal was for oral hygiene to be performed every day with interventions to supervise and cue for mouth care and hygiene; monitor mouth, tongue and gums for odor, redness, swelling, coating, sores, cracking, or loose or missing teeth; and dental consult as needed. The 8/28/18 certified nurse aide (CNA) care card (care instructions) documented the resident required supervision for toileting, extensive assistance for upper body hygiene, and limited assistance for lower body hygiene. Care areas for oral care, nail care and showering were not filled in. On 3/27/19 at 11:23 AM, the resident was observed wandering in the hall, the front of her shirt had dried food on it, her breath smelled strong and sour, her teeth were grey colored and had food in them, and her hair was uncombed. On 3/28/19 at 8:47 AM, the resident was observed with foul smelling breath and her hair was greasy and uncombed. On 3/29/19 at 8:22 AM, the resident was observed wandering in the halls wearing a sweater with food dried on the front. Her hair was greasy and uncombed. On 4/1/19 at 1:11 PM, the resident was observed wandering in the hall with unkept hair. During an interview on 4/1/19 at 2:11 PM, CNA #10 stated Resident #35 had very bad breath. The CNA would set up the resident's toothbrush and mouth wash but sometimes the resident just walked away. During an interview on 4/2/19 at 9:31 AM, licensed practical nurse (LPN) Unit Manager #4 stated hair was washed during the shower or when residents went to the beauty shop. Nail care and dental care should be listed on the CNA care card and if the areas were blank staff should ask her. She stated residents were supposed to have their clothes changed daily or as needed. She stated Resident # 35's family came in to help her because she was difficult. If the family did not come in, it was the staff's responsibility to change her. 2) Resident #33 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The undated certified nurse aide (CNA) care card (care instructions) documented the resident was to receive a shower and required total dependence during bathing. The day of the week for showers was not listed on the instructions. The 3/21/19 comprehensive care plan (CCP) documented the resident required the assistance of 2 staff for bathing and staff were to encourage the resident to participate in bathing. The undated CNA activities of daily living (ADL) documentation book listed residents requiring showers and their scheduled days. Resident #33 was not listed. The 3/2019 CNA ADL record had no documentation the resident was offered or received a shower in 3/2019. During an interview with the resident on 3/27/19 at 11:00 AM, she stated she had not received a shower while at the facility and she wanted to. During an interview with CNA #24 on 4/2/19 at 8:48 AM, she stated if a shower was not documented on the ADL documentation it meant it was not done. She stated there were not enough staff to complete resident showers. During an interview with licensed practical nurse (LPN) Unit Manager #4 on 4/2/19 at 12:30 PM, she stated the staff should report if a resident refused or a declined a shower. If someone's shower was not completed, a nurse should be notified, and they should try to get a shower on another shift. During an interview with CNA #8 on 4/2/19 at 1:42 PM, she stated if a resident received a shower it would be documented on the ADL record. If it was not recorded the resident did not receive a shower. She did not know when Resident # 33 received her showers. 3) Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 7/20/18 certified nurse aide (CNA) care card (care instructions) documented the resident required total dependence on staff for hygiene and bathing. The resident was to receive a shower on Tuesdays and Thursdays. The 2/23/19 comprehensive care plan (CCP) documented the resident required assistance of one staff for bathing. The 3/2019 physician orders [REDACTED]. The 3/2019 CNA ADL record had no documentation the resident was offered or received a shower in 3/2019. The ADL record documentation between 3/27-4/2/19 the resident had received hygiene care. The resident was observed with significant build up on her scalp on 3/27/19 at 10:11 AM and 12:48 PM, on 3/28/19 at 8:50 AM, 2:45 PM and 4:10 PM, and on 3/29/19 at 9:31 AM. During an interview with CNA #20 on 4/1/19 at 4:13 PM, she stated she saw the buildup in the resident's hair last week and it looked like cradle cap. She did not do anything about it as the resident received showers on another shift. During an interview with CNA #24 on 4/2/19 at 8:48 AM, she stated she had not noticed the resident's hair being unclean or with buildup. She stated if the ADL record had no documentation a shower was completed, then it was not. There was not enough staff to complete all the showers. During an interview with licensed practical nurse (LPN) Unit Manager #4 on 4/2/19 at 12:30 PM, she stated the resident would get her showers on evenings or nights. She stated staff had not reported concerns about the resident's hair. She stated she had seen the resident in the last week and she had not noticed her hair. During an interview with CNA #8 on 4/2/19 at 1:42 PM, she stated the resident had build-up in her hair for a couple of months. She stated the resident had medicated shampoo at one point, but she was not sure if the resident still had that in place. 10NYCRR 415.12(a)(3)

Plan of Correction: ApprovedApril 29, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions will be accomplished for the residents identified in the sample:
Resident # 1, 15, 24, 33, 35, and 151)OT will screen for updated ADL status in order for the Facility to give appropriate treatment and services to maintain good nutrition, grooming, and personal and oral hygiene. Care plans and care card will be reviewed and revised to include provisions for their need for assistance with ADLs. Shower schedule was reviewed and revised in accordance with resident's preference consistent with their needs for grooming and hygiene assistance. The unit Manager will review the care card and care plan with staff responsible for the care of these residents. SW to notify their respective representative accordingly.
Resident # 1
Previous order for [MEDICATION NAME] shampoo was discontinued. New order for prn [MEDICATION NAME] shampoo in place to be applied to wet hair and rinse thoroughly every Tuesday and Thursday. Unit manager updated resident's care card to include new order of medicated shampoo.

II. All residents who are dependent on staff for ADL care and/or unable to carry out activities of daily living have the potential to be affected by this practice.
III. The following systemic changes will be put in place to ensure that deficient practice does not recur:
The Administrator and Director of Nursing implemented a Policy and Procedures for ADL care guidelines provided for all residents. All RNs, LPNs, and CNA will receive in-service education regarding the ADL Care Policy and Procedures and the importance of ensuring residents who are not able to carry out ADL will receive necessary services to maintain proper grooming and personal hygiene.
IV.the facility's compliance will be monitored utilizing the following Quality Assurance system:
A. ADL audit tool and clinical competency was implemented to monitor compliance with providing ADL care guidelines for residents who are unable to carry out activities of daily living (ADLs)with the focus on shower assistance, grooming, personal and oral care and hygiene. The audit will include clinical record reviews as well as direct observation of the residents being audited. The threshold is for 100% compliance.
B. Rounds will be conducted by all Department heads and rotating basis for a three (3) month period. The ADL audit tool will also be used by the auditors. Any immediate issues or concern during rounds will be brought to morning report and the DON for analysis and action if needed.
C. Full house shower audit will be conducted by Unit managers weekly for three (3) months and monthly thereafter. Immediate corrective action to be taken as necessary.
D. The licensed nurses will audit 25% of residents who are unable to carry out activities of daily living (ADLs) monthly for three (3) months. Immediate corrective action will be taken for identified concerns. The Unit Manager will present the finding to the Quality Assurance Committee monthly for review. At the end of three months, the QA committee will evaluate the need for additional monitoring or other corrective action.
E. Corrective action such as discipline up to including termination will be implemented as necessary.
V. The Director of Nursing Services is responsible for the correction of this deficiency.


FF11 483.25(e)(1)-(3):BOWEL/BLADDER INCONTINENCE, CATHETER, UTI

REGULATION: §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure all residents were provided the appropriate treatment and services to achieve or maintain as much as possible normal bladder/bowel function for 5 of 8 residents (Residents #14, 17, 33, 47 and 151) reviewed for bladder/bowel function and indwelling catheters (Foley- a tube inserted into the bladder to drain urine). Specifically, Residents #14 and 17's medical records did not contain documentation pertaining to the care and treatment of [REDACTED].#33 and 151 did not have urine output consistently monitored. Resident #47 had a urinalysis that was not obtained and sent to the laboratory timely and the resident experienced a delay in treatment of [REDACTED]. Findings include: The 8/2009 facility Urinary Tract Infection [MEDICAL CONDITION] Management policy documented the acute care plan for UTI was initiated by staff who received the order for treatment. The care plan was maintained in the Acute Care Plan binder until UTI signs or symptoms resolved. The 9/25/09 revised facility catheterization policy documented all residents were assessed for risk related to urinary catheters and medical records contained medical justification for the continued use of the catheter. The resident assessment was to include individualized care planning for use of the catheter based on the assessment and the clinician's decision to support the use of the catheter. 1) Resident #47 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 1/17/19 nurse progress note documented the nurse practitioner (NP) was contacted for an increase in the resident's behaviors and yelling out, and the NP ordered a urinalysis with culture and sensitivity (to determine which antibiotic was best to order). The 1/10/19 physician order [REDACTED]. The 2/4/19 licensed practical nurse (LPN) #21 progress note documented the resident had dark foul smelling urine. There was no further documentation what was done to address the urine. The comprehensive care plan (CCP), updated 2/6/19, documented the resident had decreased fluid intake and dark urine. Interventions included 240 milliliters (ml) of fluid twice daily and antibiotics per physician discretion. The 2/6/19 registered dietitian (RD) progress note documented the resident had dark foul smelling urine, the resident needed assistance at meals due to visual impairments, and the resident received 240 ml of fluids three times a day. The 2/6/19 LPN Unit Manager #4 progress note documented the resident's family member was concerned with the resident's change in condition and increased frequency of asking to use the bathroom. The physician assistant (PA) was notified and ordered a urinalysis. The 2/6/19 physician order [REDACTED]. Nursing progress notes documented: - On 2/7/19, to straight catheterize for a urinalysis; - On 2/8/19, a repeat urinalysis was done and the resident was yelling out; and - On 2/9/19, the NP was in and ordered a urinalysis. The 2/9/19 physician progress notes [REDACTED]. The 2/11/19 urinalysis report documented the sample was obtained on 2/9/19 and was processed on 2/11/19. There was no documentation that a urinalysis was completed when it was initially ordered on [DATE]. Nursing progress notes documented: - On 2/11/19, the resident had a urine infection. - On 2/12/19, the facility was waiting for the culture and sensitivity results. - On 2/14/19, LPN Unit Manager #4 contacted the laboratory to find out the urinalysis results, which were abnormal and orders were obtained after calling the PA. - On 2/14/19, antibiotics were started on the 3:00 PM-11:00 PM shift. The 2/16/19 NP progress note documented the resident was on an antibiotic and a repeat urinalysis was planned 48 hours after the last antibiotic was given. The 2/2019 treatment administration record (TAR) did not document the repeat urinalysis was completed. The 2/18/19 physician order [REDACTED]. During an interview on 4/2/19 at 10:39 AM, LPN Unit Manager #4 stated the resident's behavior was abnormal for her, and expected staff to contact the physician with the noted 2/4/19 change in condition. She stated the urinalysis was not obtained timely and normally should not take that long. She was not sure why the NP was not called earlier and was not sure why the repeat urinalysis was not done. During an interview on 4/2/19 at 11:11 AM, PA #27 stated he expected the results to be provided to him within one to two days, and called if there were issues. He stated the resident should have been started on an antibiotic on 2/11/19 and was not treated timely. 2) Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 3/8/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, required extensive assistance for her activities of daily living (ADLs), and had a Foley catheter. The updated 7/20/18 certified nurse aide (CNA) care instructions documented the resident required extensive assistance of two for toileting every 2-3 hours. The Foley catheter box was not checked. The 3/1/19 hospital discharge summary documented the resident was hospitalized from [DATE] to 3/1/19 with UTI [MEDICAL CONDITION] (life-threatening response to infection). Her urine grew E. coli bacteria and she was treated with [MEDICATION NAME] (antibiotic). She had mild bilateral hydro-[DIAGNOSES REDACTED] (excess fluid in the kidney due to back up of urine) and was seen by the urologist who recommended life-long Foley catheter use. The 3/5/19 physician re-admission progress note documented the resident had a fever of 103 degrees Fahrenheit, and a white count of 16,000 (indication of infection). She had been sent to the hospital, where she was treated for [REDACTED]. The physician orders [REDACTED]. The 3/11/19 and 3/21/19 physician assistant (PA) progress notes did not mention or address the Foley catheter. A repeat urine culture was sent on 3/19/19 and documented abnormal bacteria in the resident's urine. The 3/21/19 physician order [REDACTED]. The 3/2019 treatment administration record (TAR) had no interventions listed or documented regarding the resident's Foley catheter. On 4/2/19, the Director of Nursing (DON) #17 documented the Foley catheter/urinary tract infection section of the comprehensive care plan was unable to be located. On 3/27/19 at 12:37 PM, the resident was in her wheelchair/in the dining room with the Foley catheter tubing resting on the floor. During observation on 3/29/19 at 7:55 AM, certified nurse aides (CNAs) #10 and 24 cleaned the resident's peri-area from front to back, washed the catheter tubing, and the resident was transferred to a shower chair. The plastic hook on the Foley urine collection bag was broken off so the collection bag was placed in the resident's lap during the shower. CNA #10 stated the hook was present the day prior and the hooks came off frequently. On 4/1/19 at 9:39 AM, the resident was observed in her wheelchair/ in her room with the catheter bag hanging covered on the lower frame of the wheelchair. The tubing was touching the floor. During an interview on 4/1/19 at 1:59 PM, CNA #10 stated she had not received catheter training at the facility. She stated she positioned residents so the catheter was not yanked on, and covered the catheter and as much of the tubing as she could in a dignity bag when the resident was in their chair. She stated if the tubing or the bag were on the floor, they were contaminated. She stated she thought the bags were supposed to be changed weekly, as it was not written down anywhere. During an interview on 4/2/19 at 9:12 AM, licensed practical nurse (LPN) Unit Manager #4 stated catheter bags were changed weekly and as needed, and it was documented in the TAR. She stated there needed to be physician orders [REDACTED]. The physician ordered the size of the catheter, the frequency of change for the catheter, and what to do if the catheter became plugged. The care was also documented on the Foley catheter care plan. She stated the registered nurses (RNs) were responsible to initiate the care plans. The care plans were updated in the care plan meetings. She stated whoever admitted the resident was responsible to get orders. She stated she was not aware there were no orders or a care plan for the resident's catheter. She did not look at the care plans. She stated everybody was responsible to update the CNA care guide and expected the CNAs to ask if information was not there. During an interview on 4/2/19 at 12:37 PM, PA #19 stated staff called him that the resident had pulled out her Foley that morning and was not told there were no catheter orders. During an interview on 4/2/19 at 02:18 PM, the DON stated the RN who admitted the resident assessed for the catheter and was responsible for initiating a care plan. She stated either the RN or the LPN called and obtained orders for the catheters. She stated the CNAs needed the information on the care guide so they knew how to manage the resident's catheter and provide care. 3) Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/21/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required limited or extensive assistance with activities of daily living, was frequently incontinent, and did not have an indwelling catheter or require intermittent catheterization. The 1/14/19 comprehensive care plan (CCP) documented the resident had urinary incontinence due to impaired mobility. There were no resident specific interventions listed and there were no documented updates to the care plan. On 3/27/19 at 11:40 AM, the resident was observed to have a urinary catheter. The 1/14/19 to 3/29/19 physician orders [REDACTED]. The treatment administration records (TAR) from 1/2019 to 4/2019 did not include documentation regarding care of the Foley. The physician progress notes [REDACTED]. The 2/28/19 nursing progress note documented the resident was straight catheterized for an urinalysis. Progress notes through 4/1/19 were reviewed and there was no documentation the resident had an indwelling catheter. The 3/28/19 baseline care plan documented the resident was incontinent of bladder and used briefs. It did not include documentation regarding the resident's Foley. During an interview on 4/2/19 at 1:02 PM, the licensed practical nurse (LPN) Unit Manager #18 stated the resident had a urinary catheter, there should be a documented justification for the catheter, and it should be documented in the care plan. If the catheter were to fall out, they should know the size and type of the catheter to be able to replace it. The LPN reviewed the chart and could not find any documentation of the resident having a catheter. The Nursing Admission Assessment on 3/2/19 when the resident was readmitted was incomplete and did not document the resident had a catheter. During an interview on 4/1/19 at 5:20 PM, the Director of Nursing (DON) stated the RN was to initiate the parts of a CCP. The RN would be made aware by the 24 hour report, team meetings, or the unit manager. The Foley and its care should have been on the CCP. The LPN could update the CCP and the CNA care guide. The CNAs would go to the care guide for resident specific care. 10NYCRR 415.12(d)(2)


Plan of Correction: ApprovedMay 1, 2019

For Resident #14 the following corrective action will occur:
Foley care plan initiated by RN. Foley catheter discontinued on 4/24/19. Foley care plan resolved on 4/25/19.
For resident #17 the following corrective action will occur:
Foley Catheter discontinued on 4/5/19.
All residents have the potential to be affected by the same deficient practice:
The following systemic changes will be made to ensure the deficient practice does not recur:
All residents that are admitted with an indwelling catheter or receives one will be assessed for risk, have medical justification and will have individualized care planning that provides the appropriate treatment to achieve or maintain as much as possible normal bladder function.
The facility catheterization was revised; all nurses will be educated on the policy and procedure.
CNAs will be educated on Foley Catheter Care and complete a catheter care competency.
Audits will be conducted on all residents who currently have catheters as well as when admitted with a catheter, or when they receive one to ensure they are properly care planned, orders are obtained for the catheter and its care.
For Resident #33 and #151 the following corrective action will occur:
A policy for documenting output will be implemented.
All CNA's will be educated on the policy and procedure for observing and recording output.
All CNA's will complete a competency on observing and recording output.
The Intake and Output records will be audited,5 per per week per unit for total of 10 a week x 8 weeks.
For resident #47 the following corrective action will occur:
Resident #47 is asymptomatic.
All residents have the potential to be affected by the same deficient practice:
The following systemic changes will be implemented to ensure the deficient practice does not recur:
The facility UTI Management policy was reviewed and updated to include recognizing change in condition, UAs-obtaining sample guidelines, testing and follow up for results as necessary.
Infection report form must be filled out as soon as criteria/s for presence of infection is/are met by charge nurse to be attached to 24 hour report to be brought to morning meeting for review and follow up as necessary. If interventions were ordered, nurse carrying out the order must complete acute care plan and note in the 24 hour report for monitoring. Completed infection report form must be submitted to the DON within 5 days of initiation for final review and QA reporting.
All nursing staff will be re-educated on the revised policy and procedure including utilizing the standing order documentation for for UTI and infection surveillance report.
The facility will conduct audits of 5 charts per week, x 8 weeks on laboratory orders for urinalysis and culture to verify specimens were obtained timely and that the resident was treated timely, and that an order from the medical provider exists to do so.
Responsible Party: Director of Nursing








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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey the facility did not ensure that each resident and/or resident representative, was involved in developing the plan of care and making decisions about his or her care for 1 of 3 residents (Resident #22) reviewed for care planning. Specifically, Resident #22's representative was not invited to the resident's comprehensive care plan meetings. Findings include: The 11/21/17 Comprehensive Care Planning policy documented all residents and their representatives were to be invited to the comprehensive care plan meeting. Resident #22 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 7/29/18 annual Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired and required extensive to total assistance for most activities of daily living (ADLs). The 10/13/16 Medical Orders for Life-Sustaining Treatment (MOLST) Chart Documentation form documented the resident lacked medical decision-making capacity and the resident's family member served as his surrogate decision maker. The 8/7/18 comprehensive care plan (CCP) documented the family was to be invited to meetings, facility events, and was to be kept apprised of overall well-being. The 8/7/18 social work progress notes documented the resident's care plan was ongoing and appropriate. The resident's family member was unable to visit due to an illness and she called and inquired about the resident's well-being and medical needs. The interdisciplinary team care conference attendance record documented the resident had an annual care planning conference (comprehensive) on 8/15/18. The attendance record did not include the resident or the family member. During an interview on 3/28/19 at 10:54 AM, the resident's family member stated she was not invited to the resident's care plan meetings and did not receive correspondence regarding when the meetings occurred. She had been ill and unable to visit the resident during the winter months. During an interview on 4/1/19 at 4:04 PM, the social worker stated she was responsible for coordinating the care plan meetings and the residents' families were invited to annual care plan meetings. She did not send out written notices, she called the residents' families and she did not always document when she called family members. She stated the resident had his annual care plan meeting in 8/2018. She stated she did not document that the resident's family member was invited but did document the family member was unable to visit due to illness. She stated it was an oversight and the family member could participate in care planning by phone. 10NYCRR 415.11(c)(2)(ii)

Plan of Correction: ApprovedApril 29, 2019

I. For Resident #22 the following corrective action will occur:
A call will be made by the Social Worker to resident #22 family representative to review the facility process for invites to comprehensive care plan (ccp) meetings and advise where the process broke down, and to advise what the process is going forward. The call will be documented in the social worker notes.
II. All residents have the potential to be affected by the same deficient practice.
III. To ensure the deficient practice does not recur, the following systemic changes will occur:
A. The Administrator reviewed the Comprehensive Care Planning policy and educated the Social Worker regarding the said policy to ensure the participation of the resident and the resident's representative for the development of the resident's care plan.
B. The social worker will continue to coordinate the care plan meeting by sending out written notices with CCP invitations to residents and residents' representative prior to the meeting date. The SW will keep a copy of all written invitations sent to the resident family representative in a binder in the social worker's office.
C. The social worker will monitor the scheduled CCP meeting from the time of admission and any assessments thereafter that warrants comprehensive care plan meeting such as annual and/or any significant change assessment to ensure that each resident and/or the resident representative is invited and involved in developing a plan of care and making decisions about the resident's care.
D. The social worker will provide a report in morning meeting regarding any residents and family/representative who is unable to attend to the upcoming CCP meeting and other approaches she utilized (i.e., phone call, fax, re-scheduling, etc.) in an attempt to reach out to the resident and resident's family. The SW will document and include an explanation if the participation of the resident and/or their representative is determined not practicable.
IV. The facility compliance will be monitored utilizing the following quality assurance system to ensure the deficient practice will not recur:
A. The Admission Director/designee will perform a monthly audit on residents consistent with the scheduled CCP meeting to ensure that resident was invited and proper invitation has been sent to family member to assure that P(NAME) has adhered as well and that no other resident were affected by this practice.
B. The results of the audits will be brought to the monthly QA meeting for review and if further audit is necessary.

C. Audits will continue for a period of one year or until the next recertification survey.
V. Responsible Party: Social Worker







FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals, and addressed the resident's medical, physical, mental and psychosocial needs for 2 of 4 residents (Residents #13 and 49) reviewed for unnecessary medications, 1 of 8 residents (Resident #16) reviewed for catheters, and 1 of 6 residents (Resident #22) reviewed for pressure ulcers. Specifically, Resident #22's care plan was not updated to include new interventions to heal pressure ulcers and prevent new ones when the resident developed a new skin impairment. Resident #16 did not have a person-centered care plan to include all areas of care including catheter use and care. Residents #13 and 49 did not have individualized care plans to address their behavioral symptoms and/or use of anti-psychotic medications. Findings include: The 11/21/17 facility Comprehensive Care Planning policy documented the comprehensive care plan (CCP) will include measurable objectives and timetables in order to meet the resident's medical, nursing and psycho-social needs that are identified from admission assessments, the Minimum Data Set (MDS) assessment, and application of the care area assessment (CAA). Additional problems, strengths or needs identified by the interdisciplinary team will be included in the CCP as appropriate. Acute changes including but not limited to colds, uncomplicated infections, short term therapeutic treatments and actual skin breakdown will be care planned by the appropriate discipline in a timely manner. 1) Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/26/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, required extensive assistance for most activities of daily living (ADLs), was always incontinent of bowel and bladder, was at risk for pressure ulcers, and had moisture associated skin damage. The 1/29/19 revised comprehensive care plan (CCP) documented the resident was incontinent of bowel and bladder with interventions including: check resident every two hours and assist with toileting as needed, apply barrier cream/ointment after each incontinence, and to provide peri-care after each incontinent episode. The resident had a self-care deficit that required assistance of two staff for toileting. Interventions included skin check weekly, observe for any concerns due to occasional incontinence of urine, update the physician, nurse practitioner (NP), or nurse manager with any changes as indicated. The CCP did not include s problem area for alterations in skin integrity or interventions to prevent development and promote healing of skin impairment. The Braden Scale for Predicting Pressure Sore Risk Assessment forms completed on 11/13/18 and 2/12/19 were unsigned. The resident was assigned a score of 19, which indicated no risk for pressure ulcers. The 2/15/19 licensed practical nurse (LPN) progress note documented staff reported a red area on the left buttock, measuring 0.4 x 0.4 with no open area. The resident complained of irritation and the physician assistant (PA) was called, and orders were obtained. The 2/16/19 Unit 2 24-Hour Report Sheet documented the resident had a red area on the left buttocks and Allevyn (protective dressing) applied. The 2/16/19 PA order documented to cleanse left buttock, pat dry, apply skin prep, apply Allevyn every 5 days and as needed, and to check placement every shift. The 3/1/19 PA order taken by LPN #4 documented the area was resolved and to discontinue left buttock treatment. On 3/29/19 at 9:45 AM, Resident #22 was observed in bed with an incontinence brief on. The resident was positioned onto his side by certified nurse aides (CNAs) #10 and 24. The resident's brief was removed and the skin on his buttocks area was observed to be intact with white skin protective ointment visible. During an interview on 4/2/19 at 9:54 AM, LPN #4 stated there were weekly skin checks done by the medication nurse that was documented on the treatment administration record (TAR). If the nurse found something new, they should put it on the 24-hour report sheet. She stated if the CNA found a skin issue, they filled out a Skin Monitoring form and gave it to the charge nurse, who stapled it to the 24-hour report sheet. She stated the registered nurses (RNs) were responsible to update the care plan. If the RNs were not aware of a new skin issue, there would be nothing in the care plan. She was made aware of the red area on the resident by the CNAs. She did not remember if there was an RN working on 2/15/19, but stated she wrote a note about it. She did not remember if she told any RN about the red area on the resident's buttocks. During an interview on 4/2/19 at 2:07 PM, the Director of Nursing (DON) stated the RN on duty was responsible to assess new wounds and initiate a care plan based on the resident and their needs. 2) Resident #16 was readmitted from the hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/17/19 Minimum Data Set (MDS) assessment documented the resident had full cognition; required limited assistance with toileting, transfers and hygiene; used a walker and wheelchair; and had an indwelling catheter (tube inserted for bladder emptying). The 1/5/19 comprehensive care plan (CCP) documented the resident had a self-care deficit with toileting. Interventions included update the nurse manager with any changes, and toilet with assist of 2 per schedule and resident request. There was no updated CCP or one that included a catheter or catheter care provided. The 1/8/19 physician order [REDACTED]. The 2/14/19 physician order [REDACTED]. The resident was observed on 3/27/19 at 2:00 PM, 3/28/19 at 10:06 AM, and 4/1/19 at 1:48 PM in his room with a Foley drainage bag hanging under his wheelchair in a cloth privacy bag and the bottom of the bag touching the floor. When interviewed on 3/29/19 at 2:18 PM, certified nurse aide (CNA) #1 stated the resident had the cloth bag since he arrived. He stated resident specific care was found on the CNA care guide. The undated CNA care guide documented the resident had a Foley catheter; there was no documentation of care guidance for the catheter. When interviewed on 4/1/19 at 4:50 PM, licensed practical nurse (LPN) Unit Manager #18 stated only a registered nurse (RN) initiated an area on a CCP and the LPN could update it. The CNA care guide was updated by an RN or LPN. She stated the CCP and care guide should have been updated when the resident had the Foley inserted. She stated it was her responsibility to make sure an RN initiated the CCP area and was not sure why it was not done. When interviewed on 4/1/19 at 5:20 PM, the Director of Nursing (DON) stated an RN initiated the CCP. The RN would be made aware by the 24-hour report, team meetings, or the unit manager. The Foley and its care should have been on the CCP. The LPN could update the CCP and the CNA care guide. The CNAs would go to the care guide for resident specific care. All CCPs were to be resident specific, and she was not sure why the CCP or care guide were not updated. 3) Resident #49 was admitted [DATE] with [DIAGNOSES REDACTED]. The 3/11/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, disorganized thinking, wandered daily, required supervision with most activities of daily living (ADLs), received an anti-psychotic medication daily, and no gradual dose reduction (GDR) of the anti-psychotic was attempted. The undated baseline care plan documented the resident had dementia with behaviors. Interventions included 1:1, redirect and reapproach. The 11/27/18 physician order [REDACTED]. The 12/17/18 physician order [REDACTED]. The 11/27/18 Victim and Abuser assessments documented the resident was a low risk to abuse others and a moderate risk to be a victim. The 11/27/18 social services progress note documented the resident was confused, was on [MEDICATION NAME], family was consulted, and interventions were redirection and reassurance. The 1/28/19 nurse practitioner (NP) progress note documented the resident was admitted due to altered mental status, had been living alone, was brought to the hospital by adult protective services, and was not suicidal. He was seen by his attending physician 12/4/18 and a gradual dose reduction (GDR) was performed for [MEDICATION NAME]. He had been stable with no aggression or agitation. The 2/14/10 and 2/15/19 nursing progress notes documented the resident was using a butter knife to try to remove Wanderguard bracelet. The 2/19/19 Victim and Abuser assessments documented the resident was a moderate risk to abuse others and a high risk to be a victim. The updated 2/19/19 comprehensive care plan (CCP) documented the resident had impaired decision making due to dementia, wandered and had potential to abuse or be abused. Interventions included psychiatric evaluations as indicated, non-pharmacological interventions, offer 2 simple choices, avoid change, calm environment, reorient, 1:1, social services consult as needed PRN, GDR of medication if appropriate, redirect, reapproach, Wanderguard, behavior flow sheets, medicate, and provide needs (toilet, fluids, food, pain, reposition). There were no resident specific interventions documented. The 3/24/19 nursing progress note documented the resident was wandering into others' rooms and attempting to take belongings; the resident was redirected. He was near the west side window attempting to open windows and maintenance found his sneakers on ground outside of the window. The window and screen were open, and the resident closed them. The resident had increased behaviors. He was taking utility keys from behind the nursing station and refused care at times. The 3/26/19 physician assistant (PA) progress note documented it was reported the resident had been yelling at other residents and generally been meddling in other people's business. The note documented the plan was to increase the [MEDICATION NAME] 0.5 mg to twice daily and monitor. The 3/27/19 PA order documented increase [MEDICATION NAME] to 0.5 mg twice a day. When interviewed on 3/29/19 at 2:25 PM, PA #19 stated the resident liked to tinker with objects, wandered into other residents' rooms and took things that may put him in danger of retaliation from another resident. He stated he was told the resident got in other residents' faces and yelled at them. He had started providing care for the resident within the past month or so. He stated he relied on staff to let him know if the resident had an increase in behaviors as he only saw him for a brief time during each monthly visit. When interviewed on 4/1/19 at 2:19 PM, certified nurse aide (CNA) #10 stated staff knew how to provide resident specific care via the CCP or the care guide. Behaviors were included in the CCP or on the care guide. The nurse was to document any behaviors on the 24-hour report and write a progress note. There were no behavior logs and CNAs had nowhere to document. She stated the resident sundowned, took his roommate's walker and would not let go, and made physical threats to staff only. She had never seen him hit anyone. He had thrown his clothes out the window one day this past weekend on an evening or night shift. She stated there were no specific interventions to use with him. She had never seen him get agitated to the point where someone was hurt. When interviewed on 4/1/19 at 3:53 PM, CNA #20 stated she worked on the behavioral unit and had learned dementia care at another facility. She stated the resident was calm and could become overwhelmed at times. She stated he was easily redirected as he was one of the calmer residents. The CCP documented resident specific care, and she talked to him about maintenance things as he was a mechanic. She did not think that was on his CCP or care guide. When interviewed on 4/1/19 at 4:25 PM, licensed practical nurse (LPN) Unit Manager #4 stated a registered nurse (RN) was responsible for CCPs on her unit. The CNA care guides and CCPs were pre-printed and updated as needed for each specific resident. LPNs could not initiate a CCP area but could add information. She stated Resident #49's specific interventions were to redirect and that was usually effective. There were no specific resident interventions in his CCP or care guide. He liked Western movies, reading magazines for short periods, and talking about working on cars. She stated those were specific interventions and should be on his care guide and CCP, and she did not know why they were not. When interviewed on 4/1/19 at 5:20 PM, the Director of Nursing (DON) stated an RN initiated the CCP. The RN would be made aware by the 24-hour report, team meetings, or the unit manager. The LPN could update the CCP and the CNA care guide. The CNAs would go to the care guide for resident specific care. All CCPs were to be resident specific, and she was not sure why the CCP or care guide were not updated. 10NYCRR 415.11(c)(1)

Plan of Correction: ApprovedApril 28, 2019

For Resident #22 the following corrective action will occur:
CCP reviewed, updated to include risk for alteration in skin integrity, including resident specific goals, treatments and interventions in place at time of left buttock wound development on 2/15/19 up to and including the 3/1/19 when wound resolved. Braden Scale and Skin Assessment completed, there is no alteration in skin integrity at this time, CCP updated and is ongoing at this time and skin continues to be monitored.
All residents have the potential to be affected by the same deficient practice.
A RN will assess all new wounds as soon as it is reported to him/her. The wound assessment will be noted on a CCP which will be developed by the RN and initiated at that time which will be tailored to meet the residents preferences and goals. The CCP will also include person centered individualized measurable objectives, interventions and time frames.
The facility has assigned the development and initiation of all new care plans as well as the initiation of care plans for acute issues to the MDS Coordinator. RNs and LPNs will update care plans as needed.
Care plans will also be reviewed in each residents care planning meeting with any necessary changes to the care plan made at that time.
The facility Comprehensive Care Planning (CCP) Policy was revised. All nursing staff will be educated on the revised CCP policy and procedure.
In an effort to identify residents with care planning needs, who may be affected by the same deficient practice, The facility will audit all new admission assessments, all MDS admission assessments, the CAA, the 24 hour shift report, as well as significant changes and/or changes from a persons baseline that may warrant implementation and/or additional resident centered care plan review and to implement any individualized resident centered care plan needs at that time.
The audits will occur daily on both units for 8 weeks with the results brought to the QA Team for review and who will determine need for further auditing.

For Resident #13 and #49 the following corrective action will occur:
Behavior CCP for resident #13 and #49 reviewed. The CCP and CNA care card was updated to include Individualized approaches to be utilized when the resident exhibits increased behaviors:
Resident #13: Residents individualized interventions include: offer pet therapy, bingo, cards, music programs, 1:1 visitation, game shows, calls to family.

Resident #49 :Residents individualized interventions include: patio time, folding/matching socks/laundry a job as resident thinks he is working, 1:1 visits, magazines, allow ambulation on unit to socialize w peers and staff.
All residents have the potential to be affected by the same deficient practice.
In an effort to identify residents with care planning needs, who may be affected by the same deficient practice, the facility will audit all residents with Behavior Care Plans which will be reviewed and updated for person centered individualized intervention to meet the residents physical, mental and psychosocial needs. Any necessary changes will be noted and included on the CNA care card.
The facility Comprehensive Care Planning (CCP) Policy was revised. All nursing staff and social worker will be educated on the revised CCP policy and procedure.
The audits will occur on both units, 5 care plans per week for 8 weeks by the social worker or her designee or until all resident care plans have been reviewed and revised if necessary, with the results brought to the QA Team for review who will determine need for further auditing.

For Resident #16 the following corrective action will occur:
Foley Catheter CCP and CNA Care Card reviewed and updated to include Individualized approaches to be utilized:Foley size,frequency of change, drainage/leg bag care, irrigation instructions, privacy bag/foley bag off floor.

All residents have the potential to be affected by the same deficient practice.
The facility Comprehensive Care Planning (CCP) Policy was revised. All nursing staff will be educated on the CCP policy and procedure.
In an effort to identify residents with care planning needs, who may be affected by the same deficient practice, the facility will audit all residents with Foley Catheters which will be reviewed and updated for person centered individualized measurable objectives, interventions and time frames to meet the residents physical, mental and psychosocial needs. Any necessary changes will be noted and included on the CNA care card.
Audits will be conducted on the CCP and the CNA Care Card for all residents with Foley Catheters. This will ensure the care guidance is on the CNA Care Card and the residents individualized interventions are present.
Responsible Party: Director of Nursing










FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure 1 of 3 residents reviewed for positioning and range of motion had the necessary treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, Resident #1 was observed as being poorly positioned during survey in her reclining wheelchair with her head down and chin almost to neck with no head or chin supports, and her plan of care did not include interventions to address neck positioning. Findings include: The 11/2018 facility policy Positioning Residents documented proper positioning should always be done after moving and lifting residents. After positioning, nursing should always check that the resident is in good body alignment with spine straight with head, arms, hands, legs, feet, and lower back supported. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/16/19 Minimum Data Set ( MDS) assessment documented the resident was cognitively impaired, totally dependent on staff for most activities of daily living (ADLs), and did not have impairment to her upper extremities. There was no documentation in the resident's record that she had been referred to or screened by physical or occupational therapy since (YEAR). The 7/2018 certified nurse aide (CNA) care instructions had no documented interventions for the resident's positioning of head and neck. The 2/23/19 comprehensive care plan (CCP) had no documented interventions to ensure proper head and neck positioning. The resident was observed with her head down, chin almost to chest, without any neck or head support on 3/27/19 at 10:11 AM and 1:00 PM, on 3/28/19 at 2:45 PM and 4:08 PM, and on 3/29/19 at 10:27 AM. During an interview on 4/1/19 at 4:13 PM, CNA #20 stated the resident's head would be tilted down when she was tired. Staff did not have anything in place to offer the resident support or positioning when her head was like this. During an interview on 4/2/19 at 8:48 AM, CNA #24 stated sometimes the resident's head would be tilted down, and there was nothing in place to offer support to her head and neck. During an interview with certified occupational therapy assistant (COTA) #28 on 4/2/19 at 9:48 AM, she stated the last time the resident was screened was 5/2018 and it was unrelated to her positioning. She stated she had not received any referrals since that time. If there were concerns with positioning of the resident's neck, she should be referred, as that was something therapy could address. During an interview with licensed practical nurse (LPN) Unit Manager #4 on 4/2/19 at 12:30 PM, she stated the resident would sit with her head tilted down. The resident did not have anything in place to offer head or neck support and that would be beneficial for her. During an interview with CNA #3 on 4/2/19 at 1:42 PM, she stated it was common for the resident's head to be down. She stated the resident used to have a high back chair to try and assist with that, but that did not work for her and she had not had it since. She stated there was no plan for support to the resident's neck for direct care staff to follow. 10NYCRR 415.12(e)(1,2)

Plan of Correction: ApprovedApril 29, 2019

I. The following corrective actions were accomplished for the resident affected:
Resident # 1
On 04/03/19, PT screened resident for proper positioning in bed and wheelchair. Recommendation of high back reclining wheelchair with seat cushion and leg rest for proper positioning and comfort. Annual assessment completed by PT on 04/23/19 indicating resident is baseline status. PT recommendation of soft cervical collar trial for neck positioning and comfort (proprioceptive feedback) to address head down. Order for lateral support for wheelchair to prevent lateral leaning (04/24/19). Resident was started on a scheduled turning and positioning every two (2) hours while in bed.
OT screened on 04/26/19 for assistance required with ADLs and during meals.
PT provided in-service to all nursing staff of all shifts in regards to turning and positioning resident every 2 hours while resident is in bed. T&P schedule was posted in the resident's room.
Careplan will be reviewed and updated. Unit manager will review the care plan and care card with staff responsible for the care of the resident. SW to notity resident's representative.

II. All residents with limited range of motion or limited mobility have the potential to be affected by this deficient practice.
III. The following measures will be put in place to ensure that the deficient practice does not recur:
A. The Administrator and Director of Nursing reviewed the Facility policy and procedures on Positioning Residents. Range of Motion policy implemented consistent with the positioning policy. All staff to be in-serviced on the updated policy and its importance to provide necessary treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
B. Therapy Director educated all CNAs on the importance of positioning and range of motion and of being consistent with documenting range of motion performed on residents.
IV. The Facility's compliance will be monitored utilizing the following Quality Assurance system:
A. Therapy department staff will conduct weekly audits on each floor and dining room on a sample of 25% residents for three (3) months, and monthly thereafter looking specifically to make sure that a resident is in good body alignment with spine straight with head, arms, hands, legs, feet, and lower back supported. Any immediate issues or concern during rounds will be brought to morning report and the DON for analysis and action if needed.

B. Audit reports will be brought to monthly Quality Assurance meeting for review and to determine if any additional audit is needed.
V. The Director of nursing is responsible for the correction of this deficiency.

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 8 residents (Residents #14, 16, 17, 30, and 33) reviewed for urinary catheters and 1 of 1 laundry room. Specifically, Residents #14, 16, 17, and 30's catheter bags and/or tubing were in direct contact with the floor and Resident #33's catheter bag was seated in her chair with her. Additionally, washers and dryers were not maintained per manufacturer's instructions. Findings include: Urinary Catheters: 1) Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/8/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, required extensive assistance for her activities of daily living (ADLs), and had a urinary catheter. The 9/25/09 facility Catheterization policy did not address resident dignity or proper placement (cover the collection bag, keep below the level of the bladder, off the floor, without kinks or dependent loops in the tubing) of Foley catheters. The 3/1/19 hospital discharge summary documented the resident was hospitalized from [DATE] to 3/1/19 with a urinary tract infection [MEDICAL CONDITIONS]. She had a urinary catheter inserted for bilateral mild hydro-[DIAGNOSES REDACTED] (excess fluid in the kidneys due to a back-up of urine) and urology recommended a life-long urinary catheter. The repeat urine culture collected on 3/19/19 grew greater than 100,000 colony forming units of the bacteria [MEDICATION NAME] faecalis, and escherichia coli (signifies bacterial infection). The 3/21/19 MD order documented [MEDICATION NAME] (anti-biotic) 100 mg twice daily for 10 days. On 3/27/19 at 12:37 PM, 3/28/19 at 8:35 AM, and 4/1/19 at 9:39 AM, the resident was observed seated in her wheelchair in the dining room and her room. Her catheter bag was covered with a dignity bag. The tubing hung outside of the dignity bag and was dragging on the floor. On 4/2/19, a copy of the resident's current care plan section related to urinary catheter/UTI care was requested. The DON documented one was unable to be located. 2) Resident #16 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/17/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact; required limited assistance with toileting, transfers and hygiene; used a walker and wheelchair; and had an indwelling catheter (tube inserted for bladder emptying). The 9/25/09 facility Catheterization policy did not address resident dignity or proper placement (cover the collection bag, keep below the level of the bladder, off the floor, without kinks or dependent loops in the tubing) of Foley catheters. The 1/5/19 hospital discharge summary documented the resident was admitted for a urinary tract infection [MEDICAL CONDITION]. The 1/5/19 physician order [REDACTED]. The 1/5/19 baseline care plan documented the resident was followed by urology. There was no documentation for bowel or bladder care. The 1/5/19 comprehensive care plan (CCP) documented the resident had a self-care deficit with toileting. Interventions included to update the nurse manager with any changes, and toilet with assistance of 2 per schedule and resident request. There was no updated CCP to include catheter or catheter care. The 1/7/19 urinalysis documented the resident had many gram-positive cocci (signifies bacterial infection) of [MEDICATION NAME] faecalis. The 1/8/19 urology consult documented the resident had a 16 French Foley catheter inserted and it was to be changed every 6 weeks. The 1/8/19 physician order [REDACTED]. The 1/11/19 history and physical documented the resident was readmitted from the hospital due to UTI and was treated with antibiotics The 2/14/19 physician order [REDACTED]. The 2/15/19 urinalysis documented the resident had many gram-negative rods (signifies bacterial infection) of Proteus mirabilis. The 2/16/19 NP progress note documented the resident had abnormal urine and was started on antibiotic. The 3/2019 treatment administration record documented the resident had his Foley catheter changed on 3/13/19 and 3/25/19, the catheter bags were changed on 3/14/19, 3/21/19, and 3/28/19. There was no documentation that the catheter bags were changed the first week of the month The undated fall risk assessment documented the resident had a Foley catheter. The resident was observed on 3/27/19 at 2:00 PM, 3/28/19 at 10:06 AM, and 4/01/19 1:48 PM in his room with a Foley drainage bag hanging under his wheelchair in a privacy bag and the bottom of bag touching the floor. When interviewed on 3/29/19 at 2:18 PM, certified nurse aide (CNA) #1 stated the resident had the cloth bag since he arrived and was not sure if the bag was permeable or non-permeable. He stated the Foley drainage bag should be hanging from under the wheelchair and the bottom of bag off the floor. He stated staff tried to keep them off the floor and readjusted when they saw it touching the floor. When interviewed on 4/01/19 at 1:56 PM, CNA #8 stated all privacy bags were made from plastic and the bottom of the drainage or privacy bag was not to touch floor as it was an infection control issue. She was not aware of anyone rounding to check to ensure the bags were off the ground. 3) Resident #30 was admitted on to the facility on [DATE], re-admitted [DATE], and had [DIAGNOSES REDACTED]. The 2/13/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance with most activities of daily living (ADLs), had impairment of a leg, and had a Foley catheter. The 9/25/2009 facility Catheterization policy did not address resident dignity or proper placement (cover the collection bag, keep below the level of the bladder, off the floor, without kinks or dependent loops in the tubing) of Foley catheters. The 2/6/19 physician orders [REDACTED]. The 2/13/19 comprehensive care plan (CCP) documented the resident was at risk for bladder infection due to indwelling Foley catheter, [MEDICAL CONDITION], and a history of UTIs. Interventions included follow physician orders, change catheter as needed, monitor urine, catheter care per policy, and check for leakage. The resident was observed on the 3/27/19 at 1:08 PM and 4:14 PM, 3/28/19 at 9:59 AM and 11:28 AM, and 4/1/19 at 10:05 AM lying in bed with the Foley catheter drainage bag uncovered and lying flat on the floor on the window side of his bed. When interviewed on 3/27/19 at 1:08 PM, the resident stated his catheter had been in for a couple of weeks, and he was able to pivot from bed to chair and vice versa by himself. During an interview 4/1/19 1:59 PM, certified nurse aide (CNA) #10 stated it was not ok for catheter tubing or the bag to be on the floor. She stated the resident was at risk for an infection if it got dirty. When interviewed on 4/1/19 at 3:05 PM, licensed practical nurse (LPN) #11 stated Foley drainage bags were to be hung off the base of the bed or under the wheelchair in a privacy bag. The facility's privacy bags were made from a tough plastic and non-permeable, and the resident had a cloth bag that she was not sure if it was non-permeable. The drainage and privacy bags were supposed to be off the floor for infection control purposes. If it was touching the ground, it was susceptible for germs to get into the drainage bag when emptied or opened. There was no one assigned to check if the bags were on the ground. When interviewed on 4/1/19 at 5:20 PM, the Director of Nursing stated (DON) stated the plastic Foley drainage privacy bags were non-permeable to germs from the environment including the floor, and the cloth ones were not. The Foley drainage bags and the privacy bags were supposed to be off the floor due to infection control issues and may contract organisms. She expected the unit LPN to round the unit throughout the shift the ensure the bags were off the floor. During an interview on 4/2/19 at 9:12 AM, licensed practical nurse (LPN) Unit Manager #4 stated the CNAs were expected to keep the catheter in a dignity bag, and the bag and tubing could not be kept on the floor. She stated if they were on the floor, they would be contaminated and dirty. She stated she was unsure who was trained regarding catheters because the staff person who did the education no longer worked there. Washers and Dryers Not Maintained Per User Manual: 4) During record review on 3/29/19 of the manufacturer's instructions for washing machines #1 and 2, the facility was required to check belt tension monthly. During record review on 3/29/19 of the manufacturer's instructions for tumbler dryers #1 and 2, the following tasks were required monthly: - to lubricate the drive chain; and - remove the exhaust duct from exhaust thimble and remove lint. During record review on 3/29/19 of the manufacturer's instructions for tumbler dryers #1 and 2, the following tasks were required quarterly: - clean the lint and any other foreign materials from the air vents located on the front and back of the drive motor; - check belt tension and adjust if needed; and - check chain tension and adjust if needed. Additional tasks included checking the tumbler over for loose nuts, bolts, and screws, and for loose gas and electrical connections. During an interview on 3/29/19 at 1:15 PM, the Environmental Services Director stated that there was no maintenance documentation for the washers and dryers, however, it was being completed. 10 NYCRR 415.19(a)(1)(c)



Plan of Correction: ApprovedApril 29, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following corrective action will occur:

#14 Foley Catheter was discontinued on 4/24/19.
#30 resident discharged on [DATE].
Resident #16, #17, and #33 will have their Foley CCP and Care Card updated to include resident specific Foley Catheter Care to include: plastic privacy cover over bedside drainage bag at all times, secure tubing to prevent kinks and promote urine flow, keep drainage bag below level of bladder at all time, keep tubing and drainage bag w/privacy cover off the floor to prevent contamination.
All residents have the potential to be affected by the same deficient practice.
The following systemic changes will be made to ensure the deficient practice does not recur:
All residents that are admitted with an indwelling catheter or receive one will have resident specific interventions to assist in preventing contamination and maintaining infection control and will be placed on their CCP Foley Care Plan and the CNA Care Card.
The facility Foley Catheter policy and procedure was reviewed and revised to include measures to assist with infection control and prevention of contamination. All nursing staff will be educated on the said policy and procedure.
All nursing staff will be educated on the revised Foley Catheter policy and procedure.
All nursing staff will complete a Foley Catheter Care competency.
Audits will be conducted on all residents who currently have catheters as well as when admitted with a catheter, or when they receive one to ensure they are properly care planned, and that the orders obtained for catheter care are on the CCP and the care card in an effort to maintain infection prevention in all residents with Foley Catheters.
Responsible Party: Director of Nursing

The following corrective action for tumbler dryers #1 and #2will occur:
The Manufacturers Instructions including monthly and quarterly tasks, for tumbler dryers #1 and #2 were reviewed with Environmental Services Director.
All residents of the facility have the potential to be affected by the same deficient infection control practice.
Dryers #1 and #2 had the proper maintenance but the Environmental Services Director failed to document it.
A preventative maintenance log for all tumbler dryers will be implemented and maintained by The Environmental Services Director. It will include the following tasks:
Monthly:
a. Lubricate drive chain
b. remove exhaust duct from exhaust thimble and remove lint.
Quarterly:
a. cleaning of lint/foreign materials from air vents on front and back of drive motor
b. checking belt tension and adjustments needed
c. checking chain tension and adjustments if needed
d. checking tumbler for loose nuts, bolts, screws
e. checking for loose gas and or electrical connections.
All maintenance staff, in addition to the director that may assist with this maintenance will also be in serviced on the said requirements.
The facility administrator will conduct audits monthly and quarterly on the dryer equipment preventive maintenance log to ensure the proper manufacturers maintenance recommendations have been completed timely.
Responsible Party: Environmental Services Director


FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(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. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(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. §483.45(h)(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: April 2, 2019
Corrected date: May 26, 2019

Citation Details

Based on observation, interview and record review conducted during the recertification survey, the facility did not maintain stored drugs and biologicals in accordance with currently accepted standards and expiration dates for 1 of 2 medication room refrigerators (Unit 2) inspected. Specifically, there were two multi dose vials of influenza vaccine on Unit 2 that were not dated or initialed when opened. Findings include: During an inspection of the medication room refrigerator on Unit 2 on 03/27/19 at 1:45 PM with licensed practical nurse (LPN) #2, a box of influenza vaccine was observed opened. The box contained two multi-dose vials of influenza vaccine lot # 9 with a manufacturer expiration date of 5/2019. The plastic caps of the vials were removed, and the rubber access ports had been accessed. The vials were not dated or initialed with an opened date. During the observation, LPN #2 stated the nurse who opened the vial was responsible for writing the opened date on the vial along with their initials. He stated once a vial was opened, it was good for 30 days. On 3/28/19, the Director of Nursing (DON) stated there was no facility policy regarding storage of medications. During an interview on 4/2/19 at 09:08 AM, LPN Unit Manager #4 stated multi-dose vials were good for 28 days after opened and whoever opened one was responsible to date and initial the vial. 10NYCRR 415.18(d)

Plan of Correction: ApprovedApril 30, 2019

The following corrective will occur:
All residents have the potential to be affected by the same deficient practice.
The cited deficient practice of vaccine storage on unit 2 was reviewed with the facility pharmacist as well as the fact the facility did not have policy in effect at the time of the survey.
The particular flu vaccine in question and the package insert for Flucelvax states vaccine can be utilized until the printed expiration date 5/2019, additionally the flu vaccines that were cited on survey were still ok to use so long as they were stored under refrigeration.
Due to the fact LPN #4 stated it was only good for 28 days after opened the facility recognizes there remains some confusion.
The facility adopted a policy of Storage of Medications In The Facility. It will be updated yearly to include the vaccine information for the particular vaccine the facility uses each flu season. All nurses will be educated on the said policy.
The facility medication storage procedure will be monitored monthly and as needed by the pharmacy staff on units 1 and 2, which will include verification that drugs are stored properly and dated in accordance with manufacturers instructions. The pharmacy will report any discrepancy in the procedure to nursing for immediate action. Reports will be provided by the pharmacy and retained by the Director of Nursing.
The nursing staff will be inserviced by pharmacy personnel on the storage of medications that includes reinforcement of the newly adopted policy and procedure.
In addition, Medication refrigerators and medication carts units 1 and 2 will be audited by the unit manager 3 times per week x 4 weeks with the results brought forth to the QA Team who will determine the need for further auditing .
Responsible Party : Director of Nursing


FF11 483.10(g)(17)(18)(i)-(v):MEDICAID/MEDICARE COVERAGE/LIABILITY NOTICE

REGULATION: §483.10(g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure 2 of 3 residents (Residents #401 and #5) and/or their designated representative were fully informed of potential financial liability for rehabilitative services during a non-covered stay. Specifically, Residents #401 and #5 did not receive Notice of Medicare Non-Coverage (NOMNC) at least two calendar days before Medicare A covered services ended. Findings include: The facility did not have a policy regarding Beneficiary Notices. 1) Resident #401 was readmitted to the facility on [DATE]. The 12/21/18 Minimum Data Set (MDS) assessment documented it was a Medicare-covered stay starting 12/14/18 and did not document an end date. The MDS documented the resident had severely impaired cognition. The Beneficiary Protection Notification Review documented the resident started Medicare Part A Skilled Services on 12/14/18 and the last covered day was 12/22/18. The facility noted they initiated the discharge from Medicare Part A services when benefit days were not exhausted. Forms CMS- and CMS- were dated on 12/21/18, one day prior to discharge from Medicare Part A. During an interview on 4/2/19 at 9:40 AM, the social worker stated she was responsible for providing the notices of non-coverage. She stated rehabilitation utilization review identified the Medicare Part A discharge date and the letter should be given 2 to 3 days before the cut date. She stated she was told the resident's therapy discharge date was 12/24/18 and the progress notes documented 12/22/18 as the discharge date . She had not read the progress notes until a couple of days prior to the discharge date , and that was why the letter was given later than the 2 to 3 day timeframe. 2) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/23/18 Minimum Data Set (MDS) assessment documented it was a Medicare-covered stay starting 9/11/18 and did not document an end date. The resident was cognitively intact. The Beneficiary Protection Notification Review documented the resident started Medicare Part A Skilled Services on 9/11/18 and the last covered day was 10/19/18. The facility noted they initiated the discharge from Medicare Part A services when benefit days were not exhausted. Forms CMS- and CMS- were dated on 10/18/18, one day prior to discharge from Medicare Part A. During an interview on 4/2/19 at 9:40 AM, the social worker stated she was responsible for providing the notices of non-coverage and the letter should be given 2 to 3 days before the cut date. She stated the resident got the letter on 10/18/18 and it was not timely. 10NYCRR 415.3(g)(2)(iii)

Plan of Correction: ApprovedApril 28, 2019

I. The following corrective actions were accomplished for the residents affected:
Residents #5 and #401
Notice of Medicare Non-Coverage (NOMN(NAME))/Liability notice were reviewed by Social Worker with the Beneficiaries and their designated representatives so they are aware of the correct procedure and notice requirements should the beneficiary become eligible in the future and so they are fully informed of potential financial liability for rehabilitative services during a non-covered stay.
II. All residents receiving Medicare-covered services are potentially at risk by the said deficient practice.
III. The following systemic changes will be put in place to ensure the deficient practice does not recur:
A. Beneficiary Notices Policy and Procedure implemented.

B. The Administrator educated the Social Worker on Beneficiary Notices Policy and Procedure and 42 CFR 405.1200(b) 1 and 2 and 42 CFR 422.624 (b)1 and 2.
C. The social worker will conduct a review of all residents that are currently receiving Medicare services within the facility to reveal that no other residents were affected by this same deficient practice.
IV. The facility compliance will be monitored utilizing the following quality assurance system to ensure the deficient practice will not recur:
A. A weekly audit will be conducted by the Admission Director/designee for any Medicare covered residents for a period of six (6) months to ensure notices are given timely or at least two calendar days before Medicare Part A covered services ended. This report will be brought to the existing facility RUG/Medicare weekly meeting.
B. The MDS coordinator/designee will perform an audit on a sample of 50% of residents receiving Medicare services, and will audit the Notice of Medicare Non-Coverage (NOMNC) to assure the validity of the notice and that it was issued in a timely manner. This audit will be performed monthly for three (3) months, and quarterly thereafter to ensure that no other residents are affected by this said practice and that the P(NAME) in place is followed. Immediate corrective action will be taken for identified concerns. The threshold is for 100% compliance. All audit findings will be presented at the Quality Assurance committee monthly for review.

V. Responsible Party: Social Worker

FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE

REGULATION: §483.25(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- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not ensure residents maintained acceptable parameters of nutritional status or were offered sufficient fluid intake to maintain proper hydration and health for 2 of 9 residents (Residents #45 and 251) reviewed for nutrition. Specifically, Residents #45 and 251 did not have their weights taken at the facility to ensure accurate nutritional assessments. Findings include: The 8/17/15 Weight Monitoring Program policy documented weight monitoring is used to assure that residents maintain acceptable parameters of nutritional status. Each residents weight will be monitored consistently and closely by the interdisciplinary team. The procedure for obtaining weights was as follows: - On admission, nursing staff will weigh each resident within 24-hours or readmission to the facility to establish an accurate weight. A list is kept on the unit's weight book. - Weights are to be taken by nursing staff for four weeks after admission and subsequent weights will be obtained weekly or monthly as ordered by the physician or recommended by the registered dietitian (RD). - Weekly weights will be obtained by Wednesday of the week and monthly weights will be obtained by the 7th of the month. - Unit Nurse Managers are responsible for ensuring residents are weighed as planned. 1) Resident #45 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 2/24/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required extensive assistance for most activities of daily living, except eating, for which she required supervision. The resident did not have a weight loss or gain and was on a therapuetic diet. The 3/1/19 nutrition comprehensive care plan (CCP) documented the resident was at nutrition risk due to self-feeding difficulty and elevated body mass index (BMI). Goals included to maintain weight range 235-240 pounds and meet nutritional needs for wound healing. Interventions included to monitor weights. The 3/1/19 Nutrition Assessment documented the resident's admission weight was used to determine estimated nutrition needs. There were no documented weekly weights for the four weeks after the resident's admission. During an interview on 3/27/19 at 10:59 AM, the resident stated she had not been weighed since she was admitted , she wanted to be weighed at least once, and felt that she had lost weight since admission. On 3/27/19 from 12:49 PM to 1:26 PM, the resident was observed in the dining room. She utilized a long straw to drink her beverages and needed to be fed by a certified nurse aid. On 3/29/19 from 8:29 AM to 8:56 AM, the resident was observed in the dining room. She was fed by a certified nurse aid. During an interview on 3/29/19 at 11:30 AM, certified nurse aide (CNA) #3 stated it was the CNA's responsibility to weigh residents. Some residents were weighed weekly on Wednesday and everyone else was weighed monthly. Dietary could request additional weights and they would tell the licensed practical nurse (LPN). The LPN was responsible for telling the CNAs which residents had to be weighed on that day. Residents could request to be weighed and the LPN could not recall if the resident had requested to be weighed. During an interview on 4/2/19 at 8:57 AM, LPN #11 stated residents were to be weighed on admission, weekly for 5 weeks, and then monthly after that. The weights were documented in the weight book' on the unit, which included weekly and monthly weights. CNAs were responsible for completing the weights and they knew everyone was weighed on the first of the month. For the weekly weights, the LPN made a list and provided it to the CNAs. The LPN checked the computer system and did not see weights for the resident, past or present. She thought the resident refused one day, but the resident should have been apprached another day. Weights were needed to make sure resident's were maintaining their nutritional status and some medications were weight based. During an interview on 4/2/19 at 9:19 AM, LPN Unit Manager #18 stated residents were to be weighed on admission, then weekly for 4 weeks for a total of 5 weeks. The LPN stated the Resident #45 should still be weighed weekly as she was a new admission. During an interview on 4/2/19 at 10:42 AM, registered dietitian (RD) #23 stated there was a weight policy in place where residents were to be weighed within 24-hours of admission and weekly for 4 weeks. She said it was possible the Resident #45 had not been weighed. Weights were needed to complete nutrition assessments and to monitor residents who were not eating. She stated weights were not being completed consistently. 2) Resident #251 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/13/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance with activities of daily living, her most recent weight was 112 pounds, and she had no or unknown weight loss in the last 6 months. The 3/14/19 comprehensive care plan (CCP) documented the resident required total assistance for activities of daily living. The 3/27/19 updated nutrition CCP documented the resident was to receive Ensure (oral nutritional supplement) three times a day at medication passes. The 3/14/19 physician orders [REDACTED]. The 3/27/19 Nutrition Assessment documented the resident was last weighed while she was in the hospital sometime between 2/19/19 and 3/6/19, and she was underweight. The 3/2019 Weight Worksheet did not include the resident's name on the list and there were no documented weights for the resident. During an interview on 3/27/19 at 2:14 PM, the resident stated she had been eating poorly and losing weight since admission. She had an Ensure on her bedside table which she stated she was attempting to drink. On 3/28/19 at 9:33 AM, the resident was observed in bed with her breakfast tray on her bedside table. Her breakfast was untouched and she was making to attempts to eat it. During an interview on 4/2/19 at 8:57 AM, LPN #11 stated Resident #251 was not listed on the Weight Worksheet and did not have any weights documented. During an interview on 4/2/19 at 9:19 AM, LPN Unit Manager #18 stated the 3/2019 Weighing Worksheet did not list the resident and she should have been weighed. During an interview on 4/2/19 at 10:42 AM, registered dietitian (RD) #23 stated I don't know off the top of my head in terms of her weights referring to Resident #251. She said with all the changes in staffing there had not been a consistent system and weights were not being completed consistently. 10NYCRR 415.12(i)(1)

Plan of Correction: ApprovedApril 29, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following corrective actions were accomplished for the residents identified in the sample:
Resident # 45
MDS assessment admission weight dated 03/04/19 was noted at 240 lbs. Resident is no longer at the facility, was discharged on [DATE] to the community.
Resident # 151
MDS assessment admission weight dated 03/26/19 was noted at 112 lbs. Resident is no longer at the facility, was discharged on [DATE].
All residents have the potential to be affected by the deficient practice.
In an effort to ensure the deficient practice does not recur, the following systemic changes will occur:
The Weight Monitoring Program Policy was reviewed to ensure that residents maintain acceptable parameters of nutritional status and proper hydration and health.
All nursing staff will be re educated in regards to the weight monitoring policy. Nurse managers will be educated of their responsibility of ensuring that residents are weighed as planned and for monitoring resident weight records and meal consumption on a daily and on going basis.
CNA will notify a nurse immediately if there is a weight change of 3# or more between weights utilizing the stop and watch audit tool. The re weigh will be taken immediately. Food Service Director will follow up and ensure that re weigh was in order.
Nursing staff will notify the FSD of any changes in orders related to weights.
Food service director will conduct audit of all residents that needs weight monitoring and will follow up with the interdisciplinary team during morning meeting to ensure that all residents on a monitoring weight are being followed up accordingly.

The facility compliance will be monitored utilizing the following quality assurance system to ensure the deficient practice will not recur:
The Director of Nursing/designee will monitor weight on a weekly basis utilizing an audit tool that was developed specifically for this purpose.
The tool will include information on residents in need of weight monitoring to ensure accurate nutritional assessments. The audit will include a focus on weights upon admission and necessary re weighs.
Unit managers will conduct random audit to validate 10% of weights that are taken on their respective unit each week and will report the validation to the DON for a minimum of three months.
Food service director will conduct weekly audit for three months and quarterly thereafter validating that anybody on a weekly weights are being followed up accordingly.
All audit reports will be brought to Quality Assurance committee monthly for a minimum of three (3) months for review. The QA team will determine the need to continue weight audits at
The Food Service Director is responsible for the correction of this deficiency.



FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §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- §483.10(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. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure a safe, clean, comfortable and homelike environment for 2 of 2 floors (first floor and second floor) observed. Specifically, the ceiling in the first floor shower/tub room shower stall #2 had a damaged ceiling; a wall in resident room [ROOM NUMBER] was damaged; the second floor shower/tub room shower stall #1 was unfinished/not complete; the light cover in the visitor elevator and hall lights contained bugs; Residents #15 and 22 had unclean wheelchairs; and the water temperatures in Resident #33's room and room [ROOM NUMBER] were below the acceptable range of 90 degrees Fahrenheit (F) to 120 F. Findings include: 1) Damaged Walls/Ceilings During an observation on 3/27/19 at 11:25 AM, the first-floor shower/tub room shower stall #2 had a loose/cracked/damaged ceiling. During an observation on 3/27/19 at 11:31 AM, resident room [ROOM NUMBER] had a damaged/cracked wall near the bathroom. During an interview on 3/27/19 at 11:31 AM, the Maintenance Director stated he was not aware of the damaged wall in resident room [ROOM NUMBER] or the damaged ceiling in the shower/tub room. During an observation on 3/27/19 at 1:13 PM, the second-floor shower/tub room shower stall #1 had an unfinished wall section with exposed rock board/uncleanable surface. During an interview on 3/27/19 at 1:13 PM, the Maintenance Director stated he was not aware of the damaged/unfinished wall in the second-floor shower/tub room. 2) Unclean Environment The facility Wheelchair Cleaning Policy, reviewed 10/2018, documented there will be a shared accountability between clinical night shift and housekeeping staff to ensure that wheelchairs are appropriately and consistently cleaned. Resident #15 was observed with an unclean wheelchair seat and back on 3/27/19 at 12:46 PM, 2:14 PM and 3:53 PM. Resident #22's wheelchair was observed unclean with dried food debris on the foot rests, arms and wheels on 3/28/19 at 1:30 PM and 3/29/19 at 9:13 AM. During an observation on 3/27/19 at 3:27 PM and 4/2/19 at 2:00 PM there was a significant amount of debris and bugs in the overheat light/ceiling in the visitor/resident elevator. During an observation on 3/28/19 at 2:44 PM, there was a buildup of bugs in the light fixture in the hallway outside of room [ROOM NUMBER]. During an interview with Resident #24 on 3/27/19 at 10:25 AM, she stated there were spiders in her room. A spider was observed crawling on the wall by the closet. On 3/28/19 at 9:44 AM, there were cobwebs in the corner of the wall near the window and bed of Resident #24's room. During an observation on 3/27/19 at 2:36 PM room [ROOM NUMBER] had yellowing flooring along the baseboards and along the wall at the entrance to the room. During an interview on 4/1/19 at 3:22 PM, the Maintenance Director stated the elevator vendor was responsible for cleaning the light cover for the visitor elevator. During an interview on 4/1/19 at 3:24 PM, the Environmental Services Director stated the light covers in the hallways were cleaned out by housekeeping and maintenance staff but were not documented. She was not aware of any light covers on the second floor that had bugs in them. During an interview on 4/1/19 at 3:54 PM, the Housekeeping Director stated the cleaning of wheelchairs was split between 3rd shift certified nurse aides (CNA) and housekeeping. All resident wheelchairs and Gerichairs were cleaned monthly and cleaning was documented. She stated the housekeeping department did not clean Resident #15's wheelchair in 3/2019 and the department was short staffed. During an interview with CNA #24 on 4/2/19 at 8:48 AM, she stated Resident #22's wheelchair was unclean because of meals. She stated it was the CNAs responsibility to clean the chairs. She stated she noticed Resident #15's chair was unclean, and she wiped it off today. She stated the staff did not have a lot of extra time to clean wheelchairs. During an interview with LPN Unit Manager #4 on 12:30 PM, she stated that in the summer housekeeping and maintenance would assist with clean/power washing of wheelchairs. Currently it was the responsibility of the overnight nursing staff to clean and if there were spills on a wheelchair someone should clean them at that time. She stated when she assisted Resident #22 at meals she tried to use two clothing protectors across the lap and body to help prevent spills on the chair but not all staff do that. 3) Resident Room Water Temperatures There was no documented facility policy for Resident Room Water Temperatures. During an interview with Resident #33 and her representative on 3/27/19 at 11:10 AM, the resident stated that the water in her bathroom was cold and it did not get warm. Staff provided her with cold wash clothes to perform personal hygiene. During an observation on 3/28/19 at 4:06 PM, the water temperature in Resident #33's room was measured at 86 Fahrenheit (F). During a review on 3/29/19 of the facility's Monthly Hot Water Distribution Sheet for 3/2019, the following temperatures were recorded under the acceptable range of 90 F: - on 3/21/19 at 7:54 AM, the water temperature for resident room [ROOM NUMBER] was 86 F; and - on 3/21/19 at 8:04 AM, the water temperature for resident room [ROOM NUMBER] was 86 F. During an interview on 3/29/19 at 1:38 PM, the Maintenance Director stated he was aware of the low water temperatures documented on the 3/2019 Monthly Hot Water Distribution Sheet. When he checked resident rooms [ROOM NUMBERS] later that day the temperatures were over 90 F. he did not document the rechecking of the resident rooms. During observation on 4/1/19 at 12:00 PM, the water temperature in Resident #33's room was 87 F. During observation on 4/1/19 at 12:05 PM, the water temperature in resident room [ROOM NUMBER] was 85 F. During an interview on 4/1/19 at 3:00 PM, the Maintenance Director stated: - the facility had a weak circulating pump and it was is hard for hot water to circulate to the end rooms of the resident floors; - the water must run for a while to allow the water to adjust and get over 90 F; and - there were two factors to the fluctuation of water temps - lack of rooms being used/occupied, and lack of roof insulation. During an interview with CNA #20 on 4/1/19 at 4:13 PM, she stated Resident #33's room water temperature did not get warm. She stated staff would have to get warm water from another location to bring back to the resident. During an interview with CNA #24 on 4/2/19 at 8:48 AM, she stated Resident #33's bathroom water was always cold, and staff did not have time to try and let it run. She stated she notified management and they told her to let it run, and she stated staff had even tried to let it run a half hour and it did not get warm. 10NYCRR 415.5(h)(2)

Plan of Correction: ApprovedApril 29, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following corrective actions were accomplished for the rooms and residents identified in the sample:
A. First floor shower/tub room stall damaged ceiling was removed and replaced with a new sheet rock. Repaired and painted completed on 04/08/19 by Maintenance Department.
B. room [ROOM NUMBER] damaged/cracked wall near the bathroom was repaired by Maintenance staff on 04/25/19.
C. Visitor/resident elevator light cover/ceiling debris and bugs removed and cleaned, completed on 04/04/19
D. Hall lights/fixtures cover cleaned on 04/04/19
E. Residents # 15 and 22 wheelchair were completely cleaned on 04/05/19, and re visited by the Housekeeping Supervisor on 04/08/19.

F. Housekeeping provided terminal cleaning on Resident 24 room on 04/02/19.

G. Resident 33 - water temperature in room has been addressed and shall meet acceptable standards.
II. The following corrective actions will be implemented for the rooms and residents identified in the sample:
A. Second floor shower/tub stall #1 will have a recap end and new molding installed(completed on 04/27/19)
B. room [ROOM NUMBER] floor is scheduled for a strip and wax by Maintenance Department.
C. Resident # 24 room - exterminator is scheduled to come in to check for spiders.
II. All residents have the potential to be affected by the deficient practice.
III. The following measures will be put in place to ensure that the deficient practice does not recur:
A. The Administrator, DON, and Housekeeping supervisor reviewed the Policy and Procedures for Wheelchair Cleaning Policy to ensure that wheelchairs are being cleaned appropriately and consistently. Housekeeping department maintains monthly wheelchair cleaning audit. Nursing staff will be educated in regards to wheelchair cleaning policy and procedures.
B. Water temperature regulatory requirement reviewed with Maintenance Dept. Water temperature policy implemented and reviewed with Maintenance staff and what steps to be taken when temps fall out of acceptable range. Education to be provided by the Facility Administrator.
C. All staff will be in-serviced to reiterate the need to utilize the maintenance log on each unit to communicate the need to clean and/or maintain a particular area of the facility as needed.
D. Environmental service director will in-service housekeeping and maintenance staff to check the maintenance log each shift, every day and sign off on the completion of any request work that was written in the said maintenance log book.
IV. The facility compliance will be monitored utilizing the following quality assurance system to ensure the deficient practice will not recur:
A. The Environmental Services Director will conduct weekly random audits on each floor on a sample of 10% different rooms for three (3) months, then monthly looking specifically to make sure that water temperature does not fall out of range. Immediate corrective action will be taken for identified concerns.
B. Housekeeping Supervisor in conjunction with Maintenance staff will conduct weekly rounds of the facility for three three (3) months and monthly there after to ensure facility is maintained in a sanitary, orderly fashion. Written rounds report to be brought to QA monthly meetings.
C. The Environmental director and housekeeping supervisor will conduct audits and/or environmental rounds on a sample of 20 different rooms, including shower/tub rooms, and elevator areas weekly for three (3) months, then monthly, looking specifically for any unclean wheelchair, damaged ceilings and/or walls, debris and bugs in overheat light/ceiling, cobwebs and/or spiders, and yellowing flooring to ensure compliance with this P(NAME) as well as to ensure that no other residents were affected by this practice.

D. All audits and round reports will be brought to monthly Quality Assurance meeting for review. The QA team will continue to perform monthly environmental rounds as a team and bring any concerns to the appropriate Dept Head for immediate attention.
V.The Director of Environmental Services is responsible for the correction of this deficiency.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure the services provided met professional standards of quality for 1 of 3 residents (Resident #22) reviewed for pressure ulcers. Specifically, Resident #22 developed a skin condition that was not assessed by a qualified professional. Findings include: The 1/2019 facility Pressure Ulcer and Non-Pressure Skin Breakdown policy documented a pressure ulcer skin condition care plan and a Skin Condition monitor sheet was to be initiated for each pressure ulcer. The person filling out the Skin Condition sheet was to inform the physician/nurse practitioner and write what, if any, pressure relieving/positioning device was initiated. The nurse manager was to review the Skin Condition monitor and care plan. A Skin Condition monitor sheet was to be initiated for all residents with non-pressure related skin conditions. The wound team was to be notified for all pressure/non-pressure ulcers to be placed on weekly skin rounds. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/26/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, required extensive assistance for most ADLs, was always incontinent of bowel and bladder, was at risk for pressures ulcers, and had moisture associated skin damage. The 10/30/18 comprehensive care plan (CCP) documented the resident was incontinent of bowel and bladder and had a self-care deficit. Interventions included included skin checks weekly, observe for any concerns due to occasional incontinence of urine, update the physician/nurse practitioner/nurse manager with any changes as indicated. The unsigned Braden Scale for Predicting Pressure Score Risk Assessment form entries 11/13/18 and 2/12/19 documented the resident was assigned a score of 19 indicating he was not at risk for developing pressure ulcers. The 2/15/19 licensed practical nurse (LPN) #4 progress note documented staff reported a red area on the resident's left buttock measuring 0.4 x 0.4 centimeters (cm), no open areas, the resident complained of irritation, the physician assistant (PA) was called and orders were obtained. The 2/16/19 unsigned Unit 2 24-Hour Report sheet documented the resident had a red area on the left buttocks and Allevyn (protective dressing) was applied. The 2/16/19 PA order documented to cleanse left buttock, pat dry, apply skin prep, apply Allevyn every 5 days and as needed, and check placement every shift. The 3/1/19 PA order taken by LPN #4 documented to discontinue left buttocks treatment as the area had resolved. The 3/19/19 physician progress notes [REDACTED]. There was no documented evidence of completed Skin Condition monitor sheets, Skin Monitoring: Comprehensive CNA Shower Review, or if the resident's skin impairment had been assessed by a qualified professional. On 3/29/19 at 9:45 AM, the resident's skin was observed to be intact. During an interview on 4/2/19 at 09:54 AM, LPN #4 stated if a CNA found a skin issue, they filled out a Skin Monitoring: Comprehensive CNA Shower Review form and gave it to the charge nurse, who stapled it to the 24-hour report sheet. The charge nurse would look at the skin and call the doctor for orders. She stated if there was an RN in the building she called them to assess the wound. If not, she described what she saw to the provider and they gave her orders. She stated she measured the new area on the Resident #22's buttocks and called the doctor. She stated the RN assessment should have been in the nurse's notes after her entry. She did not know if the physician saw the resident for his new skin condition and she did not remember if she told an RN. During an interview on 4/2/19 at 1:02 PM, the Director of Nursing (DON) stated RNs were responsible for assessing wounds and initiating the care plans. During an interview on 4/2/19 at 2:46 PM, CNA #24 stated she provided care for the resident on 2/15/19 and she told LPN #4 about Resident #22's area on the buttocks. She stated she never filled out the Skin Monitoring: Comprehensive CNA Shower Review form. She stated the CNAs were supposed to, but she had only seen the form filled out once. 10NYCRR 415.11(c)(3)(i)

Plan of Correction: ApprovedApril 30, 2019

For Resident #22 the following corrective action will occur:
Braden Scale and Skin Assessment completed by RN on 4/23/19, there is no alteration in skin integrity at this time, the Braden scored moderate risk and the CCP was updated by RN and is ongoing at this time and skin continues to be monitored.
All residents have the potential to be affected by the same deficient practice.
The Pressure Ulcer and Wound Care policy and procedure was reviewed and revised. All nurses will be educated on the said policy.
A RN is required to assess all wounds as soon as it is reported to him/her. The wound assessment will be noted in the nurses notes and wound tracking sheet if indicated, all resident pressure ulcers will be tracked and re-assessed weekly during skin rounds, with status recorded on the a CCP which will be developed and initiated by a RN and will be tailored to meet the residents preferences and goals based on the RN assessment of the wound. The presence of a wound requires notification to the IDT via the 24 hr shift report.The physician must be notified, order obtained to treat the wound and a physicians assessment and progress note must be in the chart regarding the status of wound.
The RN assessing the wound is required to develop and initiate the presence of skin breakdown care plan care with resident specific goals, objectives, interventions and timeframes. The RN will notify the MDS Coordinator of the presence of a wound.
All residents that develop wounds and/or pressure ulcers will have chart audits done to ensure wounds have been assessed by a RN and seen by the physician, that it is documented appropriately and communicated via the 24 hr shift report.
Audits of said charts will be conducted 5 charts per week x 8 weeks with results brought to the QA team who will determine the need for further auditing.

Responsible Party: Director of Nursing

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(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: April 2, 2019
Corrected date: May 26, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey the facility did not ensure all residents received treatment and services to prevent and/or heal pressure ulcers for 1 of 6 residents (Resident #151) reviewed for pressure ulcers. Specifically, Resident #151 had skin break down that was not addressed or assessed by a qualified person and when she was admitted to the hospital she had multiple pressure ulcers on her buttocks. Additionally, when the resident was readmitted to the facility her skin was not thoroughly assessed and interventions to promote healing were not implemented. Findings include: The facility Pressure Ulcer and Wound Care policy revised on 11/17/17 documented the resident's skin would be assessed during care routinely and weekly by a nurse and changes in skin integrity would be reported to the charge nurse. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 10/29/18 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and she required extensive assistance for bed mobility, transfers, toileting and personal hygiene. She did not have any pressure ulcers and was at risk for developing pressure ulcers. The 11/7/18 comprehensive care plan (CCP) documented the resident had a self-care deficit and she was always incontinent of both bowel and bladder. Interventions included to check for incontinence every 2 hours, weekly skin checks, observe for any concerns due to incontinence and update provider with any changes as indicated. The CCP documented the resident had skin breakdown, an ulcer to her left foot related to immobility and [MEDICAL CONDITION]. Interventions included to inspect skin and report any changes in skin integrity. A physician order dated 11/30/18 documented to apply Zinc Oxide ointment to the resident's buttocks every shift. Physician wound care assessment documented: - On 12/19/18, the resident had moisture associated [MEDICAL CONDITION] on her groin and buttock. The areas had greatly decreased in size and irritation. - On 12/26/18, the moisture associated [MEDICAL CONDITION] on her groin and buttocks had resolved. The resident was seen on wound rounds by the Wound Nurse (licensed practical nurse, LPN #4) and the wound physician for a wound on the resident's left leg on 1/4/19, 1/11/19 and 1/21/19. The documented assessments did not contain any documentation regarding the resident's buttocks. Nursing progress notes dated 1/2/19 and 1/3/19 documented the resident's buttocks were very excoriated (raw and irritated). The 1/2019 treatment administration record (TAR) documented the resident's weekly skin checks were done on 1/1/19, 1/8/19, 1/15/19 and on 1/22/19. The results of the resident's skin checks were not documented. The 1/28/18 hospital record documented the resident presented to the emergency room with fever and an unresponsive episode. The resident was admitted with multiple Stage II (partial-thickness skin loss) pressure ulcers on her buttocks. During an interview with certified nurse aide (CNA) #8 on 2/1/19 at 10:10 AM, she stated the resident was antsy and spent most of her time in her wheelchair. The resident was frequently incontinent, and the CNA would have to change her frequently. The resident had sores on both of her buttocks and the CNA stated she had been reporting that to the nursing staff and they were applying some cream. The areas on the bottom kept getting worse and they were continuing to use the same cream. During an interview with LPN #13 on 2/14/19 at 7:35 AM, she stated the resident was very restless and did not like to stay in bed and would spend most of her time in her wheelchair. The resident was getting [MEDICATION NAME] (skin protectant) to her bottom. She did have 3 small open areas on her bottom prior to being sent out to the hospital. A CNA had told her about them and asked her to come look at them as she thought they were getting worse. She believed she notified LPN #4 who said she was aware of the areas. During an interview with the attending physician on 2/14/19 at 10:45 AM, he stated he would want to be notified if a resident had developed pressure ulcers and he would expect that a registered nurse (RN) would assess the areas and then notify him or an on-call provider for treatment orders. He could not recall being notified of the resident having pressure ulcers on her bottom. During an interview with Wound Nurse/Unit Manager LPN #4 on 2/14/19 at 11:40 AM, she stated she was the facility wound nurse and areas of skin concern were reported to her. She did weekly rounds with the wound physician. If a staff member reported a change in the resident's skin or open areas were noted than she would go look at them and then call the on-call provider and would document on 24-hour report for monitoring, as well as add them to the weekly skin rounds. The resident was on weekly skin rounds for an area on her leg. She used to be on the rounds for some areas on her bottom and they resolved. The resident would have moisture associated areas on her bottom that would resolve and then reappear. She was heavily incontinent of urine and required frequent changing and had [MEDICATION NAME] applied to her bottom. When the resident was sent to the hospital she was not aware the resident had any pressure ulcers. READMISSION A nursing progress note dated 3/14/2019 documented the resident was readmitted to the facility from another nursing home. The 3/14/2019 signed admission physician orders did not include any skin/wound treatments and there was no documented evidence the resident's skin was assessed by a qualified person until 3/15/2019. A 3/15/19 skin sheet completed by RN #31 documented the resident had a 1.5 x 0.5 ulcer on the left buttocks, a scabbed ulcer on the bottom of the right heel and a calloused area and a dry slit that measured 1.5 x 0.2 on the left heel. The RN also documented the resident had a wound on the back of the left calf that measured 1.5 x 0.8. There was no further description of the areas identified on the skin sheet. There was no documented evidence the physician was notified of the resident's skin status and there were no physician orders for treatments to the areas identified by the RN on 3/15/2019. Review of the 3/2019 treatment administration record (TAR) documented Zinc Oxide ointment to the resident's sacrum (lower back) every shift. There was no corresponding physician order. The 3/16/19 CNA care instructions documented the resident was non-ambulatory and required total assistance of 2 staff for transfers and bed mobility. She was to have wall pad foams (protective) when sleeping and had altered skin integrity to the left calf. The instructions documented the resident was at risk for skin breakdown. There were no documented pressure relief interventions. A physician order dated 3/19/2019 documented to apply Santyl (chemical debridement ointment used for removal of dead tissue) to the wound bed and cover with a dressing daily and as needed. There was no location of the wound documented or a description of the wound that required chemical debridement. There was no documented evidence this treatment was initiated for the resident. A Baseline Care Plan dated 3/19/2019 documented the resident had a pressure ulcer (no stage or description documented) on her buttocks and a pressure ulcer on the back of her left leg. Other skin concerns documented included the heels. Interventions included to turn and reposition every 2 hours and skin/wound treatment to the buttocks. There was no documented evidence the interventions were added to the CNA care instructions. The wound physician evaluation dated 3/22/2019 documented the resident had a wound on the left calf that measured 1 cm x 0.5 cm x 0.2 cm and the wound bed contained 100% necrotic (dead) tissue. The wound physician debrided the wound and a clean dressing was applied. There was no evidence the resident's pressure ulcer on her heels or buttock were evaluated by the wound physician. A physician order dated 3/22/2019 documented to discontinue the current treatment to the left calf and apply Santyl and cover with an island dressing (waterproof barrier) daily and as needed. The wound physician's evaluation dated 3/27/2019 included an assessment of the left calf wound and did not include the left buttock or the resident's heels. The resident was observed in her bed that was directly against the wall, lying on her back with bare feet and no pressure relief devices on 3/27/19 at 10:11 AM, 11:12 AM, 2:01 PM, 2:29 PM, and 3:48 PM. The resident was again observed in bed, with no pressure relief devices on her feet on 3/28 at 2:45 and 4:08 PM. On 3/29/19 at 11:25 AM, the resident's skin was observed by a surveyor during care provided by certified nurse aides (CNAs) #10 and 24. - The resident was positioned on her right side in bed. The resident had areas of scarring visible across her buttocks. The left lower buttock was red and there was also a small open wound. CNA #10 stated there was no dressing being applied to that area as the CNAs applied protective ointment to her bottom. - The resident was wearing non-skid socks. When removed, the resident's left foot was observed to have [MEDICAL CONDITION] (swelling). The inner aspect of the left heel had a large scabbed area. The center of the scab was brown colored that faded to a yellow/white color toward the edges. The tissue surrounding the scab was red and spongy. CNA #10 and 24 both stated there were no pressure relieving boots used and there were no treatments for the left heel. - The resident's right upper outer knee was observed to have two fresh red scabs, one above the other. Below the scabs were two abrasions. CNA #10 stated the scabs appeared on the resident the day she returned to the facility. She stated the resident's bed used to be positioned against the wall and when she went in to do the resident's care, there was a bloody smear on the wall from the resident rubbing her knee on it. She stated if she saw new skin issues on residents she reported it to the Wound Nurse/Nurse Manager LPN #4 tirelessly until something was done for the resident. On 3/29/19 at 3:45 PM Wound Nurse/Unit Manager LPN #4 referred the surveyors to RN #31 to assess the resident's skin. During a skin observation on 3/29/2019 at 3:58 PM with RN #31 she stated she had not seen the resident's skin and had not been asked to. LPN #4 was responsible for assessing resident's skin on this unit. The RN noted the scabs on Resident #151's knee and stated that was caused from rubbing her knee on the wall. She did not see the area prior to this and LPN #4 would have assessed and documented it. The resident was rolled onto her side and when she looked at the resident's buttocks she stated she did not see anything. When asked what the open area on the resident's left buttock was, the RN stated she did not know what to call it, maybe incontinence. She then proceeded to measure the open area. The measurement was 0.3 cm x 0.7 cm. The RN asked for LPN #4 to come and assess the resident's skin and RN #31 was not able to offer any further description of the wound on the left buttock. The RN then looked at the resident's heels and said they were blanchable and when asked if the heels were boggy she did not know what that meant. She did not know if there were pressure relief interventions for the heels and they would usually put some sort of Allevyn on the heels. During an interview with RN #31 on 4/1/19 at 3:56 PM, she stated when she saw the resident on 3/29/19 the resident had a stage 2 pressure ulcer of the left buttocks. She stated that just ointment had been in place as far as she knew. She stated the resident had been getting Allevyn to her heel. She rubs the heel and the knee when in her chair and bed. She stated she thought the resident had protective heel booties in the past. They had a department meeting at the end of the day 3/29/19 and then LPN #4 contacted the physician to get treatment orders. LPN #4 was responsible for going on wound rounds with the physician on her assigned unit as well as making any care plan changes. During an interview with CNA #20 on 4/1/19 at 4:13 PM, she stated the CNAs would apply ointment if they saw any redness on a resident's bottom. The resident had a history of [REDACTED]. During an interview with CNA #24 on 4/2/19 at 8:48 AM, she stated the resident had a history of [REDACTED]. She stated the resident had a current mark on her right knee that was from scraping against the wall. She stated the resident had not had foot booties in place and she was supposed to be repositioned but was up in her chair most of the day. During an interview with LPN Unit Manager #4 on 4/2/19 at 12:30 PM, she stated she had not looked at the resident's skin and was not aware of any skin breakdown after she was readmitted . She had not put any pressure relief interventions in place. On 3/29/2019 after RN #31 assessed her skin the physician was called to get treatment orders. During an interview with Director of Nursing (DON) #17 on 4/2/19 at 1:02 PM, she stated when RN #31 viewed the resident's skin and noted skin breakdown she should have immediately put treatments and pressure relief interventions in place. She stated on 3/29/19 the team met at the end of the day and they were not updated there were skin concerns to the resident's buttocks or heels. She stated if the resident was rubbing her knee against the wall causing skin breakdown then interventions to protect the resident's skin should have been implemented. During an interview with CNA #3 on 4/2/19 at 1:42 PM, she stated the resident fidgets and shifts her feet and body a lot. She did not have any booties or interventions in place for her feet prior to survey. She stated the resident would bend her knees and her legs would be against the metal pieces of the pedals of the Gerichair. She stated the resident's buttocks were red and she was not sure if a positioning plan was in place. She knew there were marks on her knee, but she did not know where the marks came from. 10NYCRR 415.12(c)(1)

Plan of Correction: ApprovedApril 30, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** For Resident #151 the following corrective action will occur:
On 3/29/19 Medical provider notified and orders obtained for left buttocks, apply [MEDICATION NAME] ung every shift and prn with each incontinence care.
On 4/25/19 Left buttock assessed by RN and remains healed. Resident is not being followed at this time by Wound Care physician for left buttocks. RN is following the Left Buttocks weekly x 4 weeks, with an assessment to ensure Left Buttock wound remains resolved.
On 3/29/19 Medical provider notified and orders obtained for bilateral heels, apply skin prep every shift, allevyn heels apply and check every shift, change weekly, heel floats to heels while in bed.
4/25/19 Heels assessed by RN and skin remains intact. Continues same treatment from 3/29/19.
4/30/19 Heels assessed by DON and RN and skin remains intact. Resident is not being followed at this time by Wound Care physician. Left heel assessment shows epithelized tissue. Discussed with medical provider (PA), change skin prep to daily and continue to offload heels while in bed. RN is following left heel weekly x 4 weeks, with an assessment to ensure wound remains resolved.
All residents have the potential to be affected by the same deficient practice.
All residents who present with a wound will be assessed by a RN , the medical provider will be notified and a treatment will be put in place to prevent further breakdown per the medical provider. The wound will be noted in the medical record and will include the location and description of the wound.
All admissions and readmissions will be receive a thorough skin check by RN at the time of the admission. If there is skin breakdown the medical provider will be notified and a treatment will be put in place to prevent further breakdown per the medical provider. The wound will be noted in the medical record and will include the location and description of the wound.
The facility Skin Condition Monitor Pressure Ulcer and Non Pressure Skin Breakdown Policy reviewed. All RNs will be re-educated on the policy and procedure.
All RNs will complete a Skin Check Competency, that will include proper assessment of wounds that also includes pressure ulcers.
RN# 31 will start education on pressure ulcer wound assessment online: NDNQI Pressure Ulcer Training.
RN# 31 educated 4/30/19 by DON that assessments are not within the LPN scope of practice.
RN#31 re-educated by DON on Skin Condition Monitor Pressure Ulcer and Non Pressure Skin Breakdown Policy which includes wound assessment.
All residents with wounds are being reviewed to ensure they are appropriately assessed by RN and medical provider if needed.
The facility will audit all new admissions and readmissions to ensure a thorough skin assessment was performed. The results of all skin assessment s will be brought to the QA Team who will determine the need for further auditing.
Responsible Party: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2019
Corrected date: May 26, 2019

Citation Details

Based on observation and interview during the recertification survey, the facility did not ensure all emergency exit exterior discharges provided a level, hard-packed, all-weather travel surface for 1 isolated emergency exit (second floor ramp emergency exit). Specifically, the emergency exit exterior discharge ramp was not made with a hard-packed all weather travel surface. Findings include: During observation on 3/28/19, between 9:35 AM and 11:29 AM, the second-floor ramp emergency exit exterior ramp to means of way was not hard-packed. When walked on by the surveyor, the ramp was made with loose crushed gravel, and was soft and uneven. During an interview on 3/28/19, between 9:35 AM and 11:29 AM, the owner of the facility stated: - the facility never tried to take a wheelchair down the ramp after it was constructed in (YEAR); - the material for the ramp was packed down mechanically with a tamper; - the second-floor emergency exit ramp was a walking ramp and could not be used for wheelchairs; and - if the local city code officials had allowed him to do it, the path would have been harder packed by putting in crushed stone and tampering them down. During observation on 3/29/19 at 4:30 PM, the second-floor ramp emergency exit exterior ramp to means of way was not hard-packed. When walked on by the surveyor, the path was soft and not easy to walk on. During an interview on 4/1/19, at 3:09 PM, the Maintenance Director stated he was not aware the second-floor emergency exit exterior ramp surface was not in compliance. 2012 NFPA 101 19.2.7, 7.1.7 CMS Survey and Certification Letter 05-38 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 15, 2019

I. There were no specific residents identified for this deficiency.
II. Those residents on the second floor have the potential to be affected by this deficient practice.
III. To ensure that the deficient practice does not recur, the following systemic changes will be put in place:
A. Ramp area identified in the survey report will be surveyed by a licensed architect(NAME)Maxim in coordination with J. D. Taber Masonry (vendor).
B. A proposal for work will be provided in conjunction with information provided in the SOD related to the deficiency.
C. In addition, Oswego County Code Enforcement was notified and has visited the facility to review the SOD findings. Code enforcement is okay with the plan to utilize the architect and vendor to bring the Facility up to city code and health department concerns.
D. Facility to request limited time waiver to get work completed as work cannot get completed by completion date due to the nature of what needs to be done and due to inclement weather as well as the need for a permit.

IV. To ensure deficient practice does not recur, deficiency to be rectified by the facility in conjunction with a licensed architect. When repairs are made, the final report is to be brought to the monthly Quality assurance meeting for review by the team.
V. Responsible Party: The Administrator

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2019
Corrected date: May 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Life Safety Code survey, the facility did not ensure electrical installations were maintained for 3 isolated area (resident room [ROOM NUMBER], second floor dining room, and physical therapy room). Specifically, resident room [ROOM NUMBER] had a patient care related electrical equipment (PCREE) plugged into an unapproved 6 prong adapter and there were also non-PCREE equipment plugged into this adapter, the second-floor dining room had a PCREE plugged into an unapproved 6 prong adaptor, and the physical therapy room had a wall air conditioning unit plugged into an extension cord. Findings include: The facility Resident Care Related Electrical Items policy, dated 12/6/2017 documented, No extension cord is allowed within the resident living area or anywhere in the facility premise. During observation on 3/27/19 at 11:31 AM, resident room [ROOM NUMBER] had an electric bed (PCREE), a CD player (non-PCREE), and a phone (non-PCREE) plugged into a 6 prong UL 1363 adapter. PCREE can only be plugged into 1363A adapters, and PCREE cannot be plugged into the same adapter as non-PCREE. During observation on 3/27/19 at 1:48 PM, the second-floor dining room had an oxygen concentrator (PCREE) plugged into a 6 prong UL 1363 adapter. PCREE can only be plugged into 1363A adapters. During an interview on 3/27/19 at 1:48 PM, the Maintenance Director stated he was told that the oxygen concentrator was going to be removed from the second-floor dining room approximately two hours prior to observation. During observation on 3/27/19 at 1:55 PM, the physical therapy room had a wall air conditioner unit plugged into an extension cord. During an interview on 4/1/19 at 1:48 PM, the Maintenance Director stated he was aware of the PCREE and non-PCREE being plugged into unapproved adapters and/or extension cords. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 11, 2019

I. No specific residents were affected by this deficiency.
II. All residents have the potential to be affected by this deficiency.

III. To ensure that deficient practice does not recur;
A. Policies and procedures for the Resident Care Related Electrical Items have been reviewed and updated.
B. The Administrator educated all Department heads regarding the policy update. Department heads will in service their staff. Consistent with the updated policy, surge protectors may be permitted for office use only with written permission from the Administrator or her designee.
C. All newly admitted residents and/or families will be advised that no extension cord is allowed within the resident living area or anywhere in the facility premise. Should electrical items be permitted, each must be in good working order, free of frayed cords, and must be UL approved.
IV. The Maintenance Staff will conduct weekly inspections and rounds and look specifically for any power cord usage in all residents rooms, and all other areas in the facility premise that residents utilize to ensure electrical installation are maintained. Inspections will be recorded by Maintenance staff in the pertinent inspection log sheet. Any equipment (PCREE and non-PCREE) discovered that is plugged into unapproved adapters and/or extension cords will be corrected immediately.
The status and results of the power cord usage inspections will be presented to the monthly facility Quality Assurance Committee for review and for any necessary corrections for maintaining electrical installations or the inspection process. This audit process will be ongoing.
V. Responsible Party: Director of the Environmental Services

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2019
Corrected date: May 20, 2019

Citation Details

Based on record review and interview during the Life Safety Code survey, the facility did not ensure 1 of 1 fire alarm system was tested in accordance with the requirements of National Fire Protection Association (NFPA) 72. Specifically, the semi-annual visual maintenance requirements for all initiating devices of the fire alarm system were not completed. Findings include: Review on 3/27/19 of the semi-annual fire alarm system inspection reports, dated 5/20/18 and 11/14/18, indicated there was no documented evidence of semi-annual visual inspections for all fire alarm initiating devices. During an interview on 4/1/19 at 1:37 PM, the Maintenance Director stated the required NFPA 72 semi-annual visual maintenance requirements for the facility's initiating devices was not completed. He stated the third-party vendor for the fire alarm system maintenance had not told him about the semi-annual visual maintenance requirements. 2012 NFPA 101: 19.3.4.1, 9.6.1.3 2010 NFPA 72: 14.3 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedApril 12, 2019

I. No specific residents were identified by this deficiency.
II. All residents have the potential to be affected by this deficiency.

III. We will institute semi-annual visual inspection to be put in place which is systemic changes to make sure that this deficiency does not recur.

1. Third party vendor Syracuse Time and alarm Co, Inc. sent us a revised quote for monitoring with provisions to include semi-annual visual maintenance requirements including the following:
A. 100 % Function test listed devices -Annually
B. 100 % Power clean system smoke detector - Annually
C. 100 % Evance reporting - Semi-Annual
D. 100 % Visual Inspection - Semi-Annual
2. Field rep will be onsite to in-service maintenance staff regarding the semi-annual visual maintenance requirements for all initiating devices of the fire alarm system.
IV. Maintenance staff will conduct an audit to make sure that the required NFPA 72 semi-annual visual maintenance is completed as a preventative maintenance every six months. Findings will be reported to the Quality Assurance Committee meetings for review with the team. This audit process will be ongoing.
V. Responsible Party: Director of the Environmental Services

K307 NFPA 101:RAMPS AND OTHER EXITS

REGULATION: Ramps and Other Exits Ramps, exit passageways, fire and slide escapes, alternating tread devices, and areas of refuge are in accordance with the provisions 7.2.5 through 7.2.12. 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2019
Corrected date: May 26, 2019

Citation Details

Based on observation and interview during the recertification survey, the facility did not ensure all emergency exit exterior discharge ramps for 1 isolated emergency exit (second floor ramp emergency exit ramp) in accordance with National Fire Protection Association (NFPA) 101 - Life Safety Code section 7.2.5 which states approved existing ramps with slopes not steeper than 1 in 6 shall be permitted to remain in use, and refers to table 7.2.5 (b) which indicates existing ramps can have a maximum slope of 1 in 8. A 1 in 6 ratio is equal to 17% slope, and a 1 in 8 ratio is equal to a 13% slope. Specifically, the second-floor ramp emergency exit ramp slope was too steep, lacked handrails, and lacked landings. Findings include: The rise refers to the change in height, and the run refers to the length of the ramp. The 1 in 6 ramp slope ratio or 17% was the steepest allowed for existing ramps. During observation on 3/28/19, between 9:35 AM and 11:29 AM, the following was observed: - the second-floor ramp emergency exit ramp to means of way was steep; - there were no handrails; and - there were no landings. During an interview on 3/28/19, between 9:35 AM and 11:29 AM, the owner stated the ramp railing was removed. During observation and measuring the ramp on 3/29/19 with the Maintenance Director present, between 4:10 PM and 5:08 PM, the second-floor ramp emergency exit ramp to means of way had a slope of approximately 1 (rise) in 6 (run). Specifically, the height from the top of the ramp to the bottom of the ramp (rise) was approximately 8 ft 8 inches, the ramp length (run) was approximately 51 feet. When these numbers were converted into slope, the slope was 18% or a 1 in 5 ratio. During an interview on 4/1/19, at 3:09 PM, the Maintenance Director stated he was not aware that the second-floor emergency exit exterior pathway surface was not in compliance. 2012 NFPA 101 19.2.2.6, 7.2.5, 7.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 15, 2019

I. There were no specific residents identified for this deficiency.
II. Those residents on the second floor have the potential to be affected by this deficient practice.
III. To ensure that the deficient practice does not recur, the following systemic changes will be put in place:
A. Ramp area identified in the survey report will be surveyed by a licensed architect(NAME)Maxim in coordination with J. D. Taber Masonry (vendor).
B. A proposal for work will be provided in conjunction with information provided in the SOD related to the deficiency.
C. In addition, Oswego County Code Enforcement was notified and has visited the facility to review the SOD findings. Code enforcement is okay with the plan to utilize the architect and vendor to bring the Facility up to city code and health department concerns.
D. Facility to request limited time waiver to get work completed as work cannot get completed by completion date due to the nature of what needs to be done and due to inclement weather as well as the need for a permit.
IV. To ensure deficient practice does not recur, deficiency to be rectified by the facility in conjunction with a licensed architect. When repairs are made, the final report is to be brought to the monthly Quality assurance meeting for review by the team.
V. Responsible Party: The Administrator

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: April 1, 2019
Corrected date: May 20, 2019

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility's building was not protected throughout by an approved automatic sprinkler system for 1 isolated area (second floor shower/tub room) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems. Specifically, the two shower stalls within the second-floor shower/tub room contained pendant sprinkler heads that were installed less than 4 inches from a wall. Findings include: During observation on 3/27/19 at 10:28 AM, the two shower stalls within the second-floor shower/tub room contained sprinkler heads that were installed approximately 2 inches from a wall. During an interview on 4/1/19 at 1:39 PM, the Maintenance Director stated he was not aware the sprinkler heads in the second-floor shower/tub room were installed too close to a wall. He stated he thought the sprinkler alarm system third party vendor would have identified this during one of their inspections. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.6.3.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 13, 2019

I. No specific residents were found to have been affected by this deficiency
II. All residents have the potential to be affected by this deficiency
III. The measures to be put in place to make sure that deficiency will not recur:

A. Third party vendor M. Walker Sprinkler Co, will perform a field survey on or before (MONTH) 19. Third party vendor will survey similar areas in the facility.

B. The company that installed the fire sprinkler system improvements, Dwyer Fire Protection was notified of the citation noted in the survey report and was requested to come provide the necessary work.
V. To ensure that corrective action does not re-occur; the corrections/repairs completed will be verified by the Administrator and the Director of Environmental Services when completed and report will be brought to monthly Quality Assurance Committee for review by the team. Same repair will also be reviewed in the next sprinkler system inspection, and will be part of the periodic system inspections.

IV. Responsible party: The Environmental Services Director