Cayuga Nursing and Rehabilitation Center
December 5, 2017 Certification Survey

Standard Health Citations

FF11 483.24(c)(1):ACTIVITIES MEET INTEREST/NEEDS EACH RESIDENT

REGULATION: §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey for 2 of 9 residents (Residents #72 and 124) reviewed for activities, the facility did not ensure all residents were provided an ongoing program to support resident choice in their activities and designed to meet their individual needs. Specifically, Resident #72 was not assisted out of bed for afternoon activities. Resident #124 was not provided meaningful activities as care planned. Findings include: 1) Resident #72 was admitted [DATE], re-admitted [DATE], and had [DIAGNOSES REDACTED]. The 07/28/17 Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired and required extensive to total assistance with most activities of daily living (ADLs). The resident considered choice of newspaper, music, animals, news, groups, outdoors, and her favorite activities important to her. Activity progress notes documented on 05/24/17 activity progress note documented the resident enjoyed programs of choice. On 08/04/17 the resident had been on bed rest and rarely assisted out of bed. The note documented staff provided in room visits, music programs, and the resident had her TV on in her room. On 10/30/17 the resident was usually in bed during programs, was offered music in her room, and volunteers visited her. She yelled out and was disruptive during programs, needed to sit next to the program leader, and enjoyed intelligent conversation. The 10/20/17 comprehensive care plan (CCP) documented the resident was dependent on staff, could be verbally disruptive and attempted to get out chair for activities. Interventions included to provide activities of interest, invite to scheduled activities, provide calendar, provide classical music, news, public TV channel, old movies, and groups. The Recreation Program participation report documented the resident was unavailable for morning activities 14 times and afternoon activities 24 times between 10/02-12/04/17. Between 11/17-11/28/17 there was no documentation the resident participated in music therapy, TV, or movies. The undated certified nurse aide (CNA) Kardex (care instructions) documented the resident preferred activities that did not involve overly demanding cognitive tasks. The Kardex documented the resident was to be engaged in simple structured activities such as music, movie, cooking, baking, special events, discussion groups and trivia. On 11/29/17 at 11:18 AM, the resident stated it depended on the activity if she would go. During the visit, a scheduled resident unit program was taking place in the unit dining room on the resident's unit. She stated she was not offered to go this date and and may have attended if staff would have asked her. The resident was observed in her room in bed without a TV, music or movies on 11/29/17 at 10:01 AM, 11/30/17 at 04:35 PM, 12/01/17 at 09:50 AM, 12/04/17 at 11:36 AM and at 11:53 AM. During an interview on 12/05/17 at 09:43 AM, CNA #6 stated staff had to assist with all care for the resident. The resident required a mechanical lift for transferring and would be seated in a geri chair when out of bed. The resident liked music and balloon toss. She thought the resident liked to go to bed after lunch and she did not assist her up for programs in the afternoon. During an interview on 12/05/17 at 10:04 AM, recreation leader #3 stated the resident loved music, trivia, discussion groups, cooking, and sometimes movies or related programs. She was not interested in sport-like activities. The resident would be provided with head phones when she was not out of bed. The resident missed a lot of activities as staff were not assisting the resident out of bed to be able to attend activities. Unit staff were usually too busy to assist in transporting to programs. The resident was often documented as unavailable on the attendance sheet as she would be in bed. If the resident was in bed, even in the afternoon, the resident still should have been offered to attend an activity. There were independent activities staff could offer the resident when recreation staff were not available on the unit. During an interview on 12/05/17 at 10:49 AM, CNA #13 stated the resident would like to go to every activity, she did not always participate, and would be in the room listening to music. The resident would talk and socialize when she was around others. The recreation staff were responsible for asking the residents if they wished to attend an activity out of their room. 2) Resident #124 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired; he required extensive assistance with activities of daily living (ADLs), utilized a wheelchair for locomotion and it was very important to be around animals. The comprehensive care plan (CCP) dated 11/2017 documented the resident had little or no activity involvement, enjoyed pet visits and attended activities of his choice. The goal was to have the resident participate in activities 2 times weekly. The certified nurse aide (CNA) Kardex (care instructions) dated 11/30/2017 documented the resident needed to be reminded and escorted to activities, and enjoyed pet visits. The Recreation Program participation record: - Documented the resident had family, friend or staff visits or was unavailable to participate in activities between 11/05-11/13/17. There was no documentation the resident was invited or participated in scheduled programming offered at the facility during those dates. - Between 11/15-11/24/17, there was limited documentation the resident was offered or attended additional programming of interest. - Had no documentation the resident was offered or attended the facility's scheduled pet visits on 11/16 or 11/30/17. When interviewed on 11/30/17 at 09:24 AM, the resident stated he had not attended any activity with pets since his admission. When interviewed on 12/04/17 at 09:08 AM, CNA #19 stated the resident required total assistance with all care including being transported to and from recreation programs. The resident liked to watch the news and loved pet visits. The resident had not participated in pet visits scheduled by the facility. When interviewed on 12/4/2017 at 10:30 AM, registered nurse (RN) #18 stated the resident's wife assisted the resident in his wheelchair throughout the facility, and no unit or in room activities were provided to the resident during the day shift. When interviewed on 12/5/2017 at 10:30 AM, the Director of Therapeutic Recreation stated residents would be assisted off the unit for group programs, the recreation staff completed room to room programs which lasted 5-10 minutes. The resident was not provided pet visits in 11/2017. The resident's attendance included 5 structured programs and 2 refusals. There was no documentation what the resident was doing, participating in, or how long the visit was when it was documented family/friend/staff visits. He stated there was no further documentation in the resident's medical record regarding recreation programs and what was provided if the resident declined to participate in a group program. 10NYCRR 415.5(f)(1)

Plan of Correction: ApprovedJanuary 10, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
Resident #72 has been interviewed to gauge current activity interests and appropriate changes made to the care plan. Activity attendance was also reviewed on 11/05 to 11/13/17 and has noted documentation of resident participation of 7 days on various in house scheduled activities.
Unit nursing staff will be notified of activities of resident interest where #72 should be out of bed and available for attendance, per resident activity preferences. Resident attendance will be documented daily with additional weekly summary progress note.
Resident #124 was recently admitted on (MONTH) 4, (YEAR) from home with primary [DIAGNOSES REDACTED]. Comprehensive assessment indicated that resident considered not only pet therapy but also keeping up to date with news and group activities as important to him. Resident # 124 was re- interviewed on (MONTH) 5, (YEAR) to gauge current activity interests and appropriate changes such as the addition of 1:1 activity was added to the care plan. Staff will also keep residents wife abreast of activities of interest as she will often encourage participation. Resident progress will be documented daily with additional weekly summary progress note.
Recreation staff were all educated on (MONTH) 5, (YEAR) by the Administrator on the importance of person centered care plan that includes resident expressed preferences for activities and ensuring that activities are designed to those preferences the resident consider it to be the most important to them. Importance of documentation is also reviewed with them.
2.
**Unit nursing staff will be notified of activities that resident must attend because it meets their needs or choice via point of care alerts at least a day before the event. Director of Recreation/ designee will report to Director of Nursing/ Administrator residents who missed their elected activities of choice because staff failed to get them ready.
The Director of Recreation / designee will conduct an audit of all residents that were care planned past 30 days and new admissions to be completed by (MONTH) 12, (YEAR). The audit will include review of resident responses on the MDS section F or structured questionnaires for preferences for routine and activity specifically what resident consider to be the most important activity, participation records, and person centered care plans designed to reflect resident preferences. Any resident audited that did not meet audit criteria will be corrected immediately by the Director of Recreation or recreation leader.
Audit threshold is 90%
Recreation staff were all educated on (MONTH) 5, (YEAR) by the Administrator on the importance of person centered care plan that includes resident expressed preferences for activities and ensuring that activities are designed to those preferences the resident consider it to be the most important to them. Importance of documentation is also reviewed with them.
**Director of Recreation and Recreation leaders will review weekly resident participation, any deviance noted will require a written activity progress note addressing changes in participation. Changes may include more specific interventions such as 1:1/in-room program to residents who frequently decline.
**Attendance records are also reviewed during scheduled care plan reviews to ensure that the activity department is meeting resident preferences for activities.
3.
**Director of Recreation and Recreation leaders will review weekly resident participation, any deviance noted will require a written activity progress note addressing changes in participation. Changes may include more specific interventions such as 1:1/in-room program to residents who frequently decline.
**Attendance records are also reviewed during scheduled care plan reviews to ensure that the activity department is meeting resident preferences for activities.
Policy and procedure on documentation of Activity attendance is reviewed and updated.
Recreation Department staff was in-serviced on the updated Activities Attendance policy and procedure that specifies the importance of reviewing attendance records frequently and addressing any deviances immediately on (MONTH) 5, (YEAR) by the Administrator.
** All nursing staff will be educated by facility educator/ designee by (MONTH) 26, (YEAR) on ensuring that residents attends their activity of choice or assisting with in room activities as needed.
4.
Director of Recreation will conduct audits on activity participation and appropriateness of activity offered to each resident monthly with the following schedule; 30% for the first two (2) months then 40% on the third month. Audit results will be reported to the monthly QAPI meeting for further review.
Audit Threshold is 90%
5.
Person Responsible for correction is the Director of Recreation.

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: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey the facility did not ensure all residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, person and oral hygiene for 4 of 8 residents (Residents #72, 101, 116 and 124). Specifically, Resident #72 was not provide facial grooming or her call bell for assistance. Residents #101 was not provided with regular oral care. Resident #116 was not provided with regular grooming and was dressed in a hospital gown throughout survey. Resident #124 was not provided with his wheelchair pedals per physician's orders [REDACTED]. Findings include: 1) Resident #72 was admitted [DATE], re-admitted [DATE], and had [DIAGNOSES REDACTED]. The 10/16/17 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, and required extensive assistance with most activities of daily living (ADLs) to include shaving, dressing, bed mobility and eating. The MDS documented the resident did not have impairment to her upper or lower extremities, was at risk for pressure injury, and had pressure reducing devices to the bed and chair. The updated 10/20/17 comprehensive care plan (CCP) documented the resident had ADL self-care deficits and [MEDICAL CONDITION]. Interventions included shower every Wednesday, total dependence on staff for bed mobility, dressing, eating, bathing/showering, toileting, and personal hygiene. Interventions included to ensure call bell was in reach, respond promptly to all requests for assistance, and encourage use of call bell for assistance. The 11/17 and 12/17 certified nurse aide (CNA) ADL documentation documented the resident was assisted with personal hygiene daily, and given a bath/shower every Wednesday. The undated CNA Kardex (care instructions) documented to encourage use of call bell for assistance, ensure call bell was within reach, and respond promptly to all requests for assistance. The Kardex documented the resident was totally dependent for personal hygiene, bathing/showering, toileting, transferring, dressing, and bed mobility. On 11/29/17 at 11:21 AM, long hair was visible on the upper lip and below the resident's chin. The resident stated to the surveyor at that time she knew she had hair on her chin and she wished she could shave it. The resident stated she did not have a razor herself, staff had not offered to shave it and it bothered her. The resident was observed in bed in her room with her call bell at the end of her beds, by her feet, and out of reach on 11/30/17 at 04:35 PM and on 12/01/17 at 09:50 AM. On 12/04/17 at 08:34 AM, the resident was in bed in her room with the head of bed elevated. A CNA was in the room standing to the right of her bed feeding the resident her breakfast meal. When interviewed on 12/05/17 at 09:43 AM, CNA #6 stated staff had to do everything for the resident related to care, and the resident could call for assistance using a touch call bell. She used the touch bell by tilting her head and leaning on it. She got whiskers on her chin at times. She stated she shaved the resident's whiskers about a week ago using a disposable razor, and had not since. When interviewed on 12/05/17 at 10:35 AM, registered nurse (RN) Unit Manager #7 stated the resident could yell out or use call bell when it was in reach. The resident had a call bell that was sensitive to touch and she was able to use it. She did not know if the resident had a plan for shaving, she noticed the resident had some chin hair on 12/1/2017, and would now have a plan for shaving as it was not being done. She stated staff should have offered to shave her. 2) Resident #101 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 11/01/17 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required extensive assistance with personal hygiene. The certified nurse aide (CNA) Kardex (care instructions) documented the resident was totally dependent on staff for oral care every 2 hours and as necessary. The 04/25/17 comprehensive care plan (CCP) documented the resident was totally dependent on 2 staff for personal hygiene and oral care. During observation by a surveyor: - On 11/28/17 at 11:43 AM, the resident had a thick tan coating on her mouth, tongue and teeth. When asked if anyone helped her brush her teeth she stated no, the resident was unable to do so independently related to contracture. - On 11/30/17 at 9:42 AM, the resident had a coating on her mouth and poor oral hygiene. - On 12/04/17 at 10:20 AM, the resident had a coating in her mouth and on her teeth and tongue. - On 12/04/17 at 12:04 PM, the resident was lying in bed, her mouth was coated and she had poor oral hygiene. During an interview on 12/05/17 at 9:46 AM, CNA #3 stated the resident received mouth care 2 or 3 times a day. The CNA was not aware that the resident was care planned for mouth care every 2 hours and it was not on the CNA care instructions. During an interview on 12/05/17 at 11:06 AM, registered nurse (RN) Unit Manager #2 stated oral care was completed at least once a shift. The care plan documented the resident was to have her mouth swabbed and rinsed with mouth wash every 2 hours. This was not being done. The care plan was old and needed to be updated. 3) Resident #116 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 11/04/17 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required extensive assist for personal hygiene and dressing. The undated certified nurse aide (CNA) Kardex (care instructions) documented the resident required assistance by 1 staff with hygiene and dressing. The 11/21/17 comprehensive care plan (CCP) documented the resident required assistance with dressing and personal hygiene. The resident was observed in a hospital gown on 11/28/17 at 10:54 AM and on 11/30/17 at 10:02 AM with her hair unkempt; On 11/30/17 at 02:38 PM; On 12/01/2017 at 08:25 AM; On 12/01/17 at 10:00 AM; On 12/01/17 at 12:04 PM; and on 12/01/17 at 02:24 PM. During interview on 12/05/17 at 09:46 AM with CNA #8, the resident refused to get changed, get dressed or get washed up. She had clothes, and would somtimes get dressed. The CNA was unsure why she had not been getting dressed and was left in a hospital gown all week. When interviewed on 12/05/17 at 11:06 AM, registered nurse (RN) Unit Manager #2 stated the resident does not have enough clothes and that was the reason she was in a hospital gown. When interviewed on 12/05/17 at 11:35 AM, social worker #3 she stated the facility would help obtain clothing for any resident who did not have anything to wear. The facility had a clothing closet in the basement for CNAs to obtain clothing for residents in need. The resident had a sister who visited often and would bring her clothes. The laundry may not have been back. The CNAs should go to the clothing closet in the basement and obtain clothes as needed. 10NYCRR 415.12(a)(3)

Plan of Correction: ApprovedJanuary 16, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
Resident #72 is a [AGE] year-old woman with [DIAGNOSES REDACTED]. BIMS score has fluctuated on 4 assessments ranging from as low as 4 to as high as 15. Resident behaviors include being verbally and physically aggressive, chronically rolling onto the floor mat. In her room. This resident yells out for help over the choice of using her call bell. Behaviors reviewed over the last 30 days include the resident yelling and screaming and combative with care. Such behaviors may have contributed to resident being observed with facial hair on upper lip and chin.
Resident kardex /task have been updated to include facial hair removal during scheduled weekly shower and call bell in reach.
Therapy completed evaluation and recommended a bariatric recliner with lateral support. Care plan and kardex updated by manager.
**Resident # 72 behavior care plan such as resistive to ADLs, personal care and getting out of bed was care planned by the Unit Manager with the following specific interventions: allowing resident to make decisions about her care to provide resident with sense of control, staff will try to negotiate a time for her ADLS when she resist and then return at the agreed time; staff is to encourage as much participation/ interaction as possible during care, the resident will be provided with choice during care provision such as washing her hands first before her face and resident shower is to be offered and given after 10 am in the morning to give time for the routine anti-anxiety medications that is scheduled at 8 am in the morning.
***Resident # 72, facility policy states that when a resident refuse care, CNA documents how many times re-approach was attempted and alternative care offer. For instance, a resident may refuse her scheduled shower day, but was bed bath offered or done. All refusals including failed attempts must be reported to nurse.
** For refusals or non-compliant with care, plan also includes re-approaching of resident at a later time apart from reporting and offering an alternative as already mentioned.
All nursing staff will be educated by the manager on ensuring that call bells are within reach when residents are in bed or in the room. Education is ongoing and will be completed by (MONTH) 12, (YEAR).
Resident #101 is an [AGE] year old woman admitted after a [MEDICAL CONDITION], non verbal, unable to make needs known, NPO requiring tube feeds for all nutritional needs and was unable to follow the simplest of commands. Resident received extensive SLP therapy and went from being non verbal, never understood or understands to having clear speech usually understood and understands. In addition the resident was able improve from NPO status to being able to eat with assist from staff. With such clinical improvement staff reported some refusals such as mouth care. Unit Manager updated the care plan to reflect her behaviors of refusal of mouth care and changing the mouth care from every two hours to have oral care completed every shift and PRN. Tasks/ kardex added for CNA documentation.
Resident #116 is a [AGE] year old woman [DIAGNOSES REDACTED]. On admission this resident was alert with confusion. Prior to the resident?s acute illness and surgery the resident was frequently up in her wheelchair visiting with staff and peers on her unit. After receiving surgery resident returned to facility had a general decline, treated for [REDACTED]. This resident health continued to decline and health care proxy decided it was in the best interest of resident to receive Hospice services for end of life care.
* Resident # 116 sister had brought in some of her clothes from home. Care plan was updated since she elected to be on office as it relates to her preference for comfort level ie. staying in bed and to stay in bed in her gown. Resident expired on (MONTH) 4, (YEAR).
Unit Manager, assistant manager and unit CNAs were educated by the Director of Nursing to report to social services if resident does not have sufficient clothes to wear. Staff were also informed the availability of clothes donated in the facility closet that can be used/ borrowed for use so long as the resident agrees/ consents to wearing them. Education will be completed by (MONTH) 12, (YEAR).
Resident # 124 was recently admitted on (MONTH) 4, (YEAR) from home with primary [DIAGNOSES REDACTED]. His primary care giver at home was his wife who can no longer take care of him because of her own health care issues.
It was reported by staff through documentation on behavior care progress note that resident have been having behavioral disturbance that are difficult to redirect such as calling out and yelling out frequently and does not use his call bell. Resident was issued a wheelchair with elevating leg rest to assist during transport specifically when the wife wheels him off the unit. Call bell was care planned that staff must ensure that it is within reach during there routine checks.
All staff on the unit was educated by the RN unit manager that any resident with an elevating leg rest must have them all the time and *call bells must be within reach when they are in their rooms.
2.
Audit is currently being completed on all residents requiring assistance of 1 and above on all areas of ADL. Audit will be completed by unit managers/ designee by (MONTH) 12, (YEAR). Focus of audit is mouth care for residents on enteral feed, grooming/ dressing, facial hair, adaptive devices for chair and call bell accessibility. Any non ? compliance will be reviewed by the Director of Nursing and immediately corrected.
Facility policy and procedure on bathing/ shower of resident was reviewed. Policy updated to include shaving resident during scheduled weekly shower days. Nursing staff will be educated on update on procedure by facility educator and completed by (MONTH) 26, (YEAR).
*Audit threshold is 95%.
Mandatory education to all nursing staff will be conducted by facility educator on Provision of ADL care for dependent residents specifically grooming/ dressing, facial hair, mouth care, adaptive devices for positioning and call bell accessibility. Education will be completed by (MONTH) 26, (YEAR).
3.
* Daily rounds observation by Managers and Assistant managers, they will observe residents grooming/ dressing, oral care, facial hair, call bell accessibility and use of recommended adaptive devices for maintaining positioning in chair.

Facility policy and procedure on bathing/ shower of resident was reviewed. Policy updated to include shaving resident during scheduled weekly shower days. Nursing staff will be educated on update on procedure by facility educator and completed by (MONTH) 26, (YEAR).
Mandatory education to all nursing staff will be conducted by facility educator on Provision of ADL care for dependent residents specifically grooming/ dressing, facial hair, mouth care, adaptive devices for positioning and call bell accessibility. ** Education includes timely reporting of any changes in ADls through point of care ( P(NAME)) alerts by the CNAs. Such alerts are being monitored and reviewed frequently by Managers, assistant managers, DNS and MDS coordinator for prompt referral or follow-up. Education will be completed by (MONTH) 26, (YEAR).
4.
Unit Managers will audit ADL Care provided for dependent residents for the next three months with the following schedule: weekly audits x 4 for the first month, bi-monthly x2 for the following two months. Non- compliance will be reported immediately to the Director of Nursing for review and correction. Director of Nursing will report result of Audits to monthly QAPI for further review.
Audit Threshold is 95%
5.
Director of Nursing is responsible for 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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey for 1 of 6 residents (Resident #124) reviewed for incontinence the facility did not ensure all residents were provided the appropriate treatment and services to achieve or maintain as much normal bladder function as possible. Specifically, Resident #124 was not toileted as care planned. Findings include: Resident #124 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 11/10/17 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired; the resident was totally dependent on staff to meet his toileting needs, required extensive assistance with most other activities of daily living (ADLs), utilized a wheelchair for locomotion; was incontinent of bowel and bladder; and a toileting program was not attempted. The 11/04/17 comprehensive care plan (CCP) documented the resident had ADL deficits and bladder incontinence. Interventions included total dependence using a mechanical lift with 2 assist for toilet use, use of disposable incontinence briefs, change briefs routinely and as needed, offer the urinal throughout the day, and check as required for incontinence. The 11/04/17 certified nurse aide (CNA) Kardex (care instructions) documented to encourage call bell use, change disposable incontinence briefs routinely and as needed (prn), check as required for incontinence, clean peri area after each incontinence, transfer using a mechanical lift and 2 assist, offer urinal throughout the day to assist in urine incontinence, and total dependence on 2 staff for toileting. On 11/29/17 at 10:20 AM, the resident's call bell was observed on the bed and out of reach, no foot pedals were on his wheelchair, a large puddle of liquid was observed on the resident's floor, and there was a urine odor in the area. The resident stated he had to urinate, staff was not around, and he urinated on the floor. On 11/29/17 at 10:23 AM, housekeeper #23 entered the resident's room and asked what happened. The resident stated he urinated on the floor. The housekeeper left the resident's room to report the issue to staff. On 11/29/17 at 10:59 AM, CNA #14 entered the resident's room, stated the puddle was water, left the room, and proceeded down the hall with a mechanical lift to assist with another resident's care. She did not approach the resident or check him for incontinence. The housekeeper cleaned up the puddle and told the resident someone would be helping him soon. On 11/29/17 at 11:05 AM, the call bell remained out of reach and the resident had received no further assistance from staff. When interviewed on 12/04/17 at 09:08 AM, CNA #19 stated the resident required total assistance with care including bowel/bladder, he was slightly confused, needed to be toileted every 2 hours per his plan of care, and did not always go. The CNA stated a behavior of the resident was that he would not use his call bell but would yell for assist and would urinate in his attends or on the floor if staff did not intervene in time. The CNA stated the resident was transferred for toileting using a mechanical lift, 2 staff members were needed to use it, and other staff were not always available. He stated he toileted the resident twice daily if he had someone to help. When interviewed on 12/04/17 at 09:30 AM, CNA #14 stated the resident was toileted every 2 hours or prn using the mechanical lift, he knew how to use the call bell and urinal, and she was assigned to another part of the hallway. She was unsure why there was a puddle of urine under the resident and thought he might have missed the urinal. She entered the room, cleaned the puddle of urine with towels, left the room with the soiled towels, and went to assist with another resident's care. She did not ask the resident if he needed to be toileted and could not remember if she informed other staff of his incontinence. When interviewed on 12/04/17 at 12:13 PM, registered nurse (RN) Unit Manager #7 stated she expected staff to follow the care instructions and care plan, and to check and toilet residents every 2 hours. 10 NYCRR 415.12(d)(2)

Plan of Correction: ApprovedJanuary 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #124 is a [AGE] year old male recently admitted on [DATE] from home with primary [DIAGNOSES REDACTED]. Wife was unable to meet his needs any longer in the community and was admitted here for LTC. Upon admission bowel and bladder assessment were competed. Wife states that the resident was incontinent of bladder within the last year prior to being admitted .
Care plan initiated 11/4/17 and interventions are that Resident to be offered urinal in the morning, throughout the day, at bed time and check and change at night. This resident requires mechanical lift for all transfers. He is on a modified toileting because toileting resident to the bathroom on a mechanical lift is unreasonable and may even agitate more the resident. The resident has a reasonable and attainable plan for bladder incontinence.
The Director of Nursing educated CNAs assigned to the unit regarding appropriate response behaviors when called for help and following care plan. Education was completed on (MONTH) 12, (YEAR).
2.
All residents requiring assistance with urinary continence will be audited by Unit Managers and will be completed on (MONTH) 12, (YEAR). Any deviation from the audit will be immediately reviewed and corrected before (MONTH) 26, (YEAR).
Audit Threshold is 95%
Additionally, continence evaluation template has been made available on the electronic health record system. All Unit managers/ assistant managers, MDS coordinator, MDS nurse were educated on (MONTH) 20, (YEAR) regarding its purpose and frequency of evaluation.
3.
**Unit Managers and assistant managers will frequently spot audit resident Kardex to ensure that communication to CNAs regarding continent care is appropriate and reasonable. Any issues will be reviewed and corrected.
CNAs and floor nurses (LPN) will be educated on reporting incontinence changes or non-compliance to plan though use of the electronic health system alerts.
**Unit Managers and assistant managers are re-educated on their daily task of monitoring the clinical dashboard for any alerts related to incontinence or issues with the bowel and bladder plan of care. Education will be conducted by the facility educator/ designee by (MONTH) 26, (YEAR).
**All nursing staff will be educated on strategies of preserving dignity through bowel and bladder interventions specifically for residents that require mechanical lift for transfers by the facility educator/ designee by (MONTH) 26, (YEAR).
4.
MDS coordinator/ designee will conduct bowel and bladder audit monthly for 3 months and report issues to the Director of Nursing for review and correction.
Audit Threshold is 95%
Audit results will be report by the Director of Nursing to monthly QAPI for further review.
5.
Director of Nursing will be the person responsible for the correction of this deficiency.

FF11 483.10(e)(4)-(6):CHOOSE/BE NOTIFIED OF ROOM/ROOMMATE CHANGE

REGULATION: §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. §483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement. §483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey the facility did not ensure 1 of 7 (Resident #338), reviewed for participation in care planning, received written notice, including the reason for the change, before the resident's room in the facility was changed. Specifically, Resident #338 was not involved in decisions regarding her right to transfer rooms. Findings include: Resident #338 was admitted on [DATE] with diagnose including Cerebral Infarct and [MEDICAL CONDITION]. The 10/27/17 Minimum Data Set (MDS) assessment documented the resident's cognition was intact and she made her own decisions. The undated certified nurse aide (CNA) Kardex (care instructions) documented staff were to allow the resident to make her own decisions regarding her treatment regime and to help provide a sense of control and provide the resident with opportunities for choice. The psychosocial note dated 09/02/17 at 11:32 AM documented the resident was admitted to the sub acute unit, the social worker met with the resident and the discharge plan was to return home. The psychosocial note dated 11/07/17 documented the resident was ready for discharge, she required occasional therapy and the resident stated she was ready to go home. There was no documentation from 11/07-11/27/17 regarding the resident's change in placement status or room transfer from a specialized rehabilitation unit to a long term care unit. The social services progress note dated 11/27/17 at 10:45 AM documented the resident was notified by social work that an appropriate room had opened on the third floor and it was time for her to move off the rehab unit. There was no documented evidence the resident was given a choice of a room or had been introduced to her potential new roommate to ensure compatibility was not a concern. When interviewed on 11/28/17 at 11:00 AM, the resident stated she was discharged off the rehabilitation unit, moved to a different unit, was not given a choice of which room she would move to, and was not introduced to her roommate to ensure compatibility prior to the move. She had clarified with the social worker prior to being moved that she needed to be in a room where she was able to have lighting during the night. When she arrived on the unit she and her roommate were not compatible as she needed her lights on at night and her roommate insisted they be turned off. When she expressed her concerns, nothing was being done about it. When interviewed on 12/04/17 at 10:00 AM, CNA #16 stated the resident was alert, made her own decisions, was made long term care and moved to the unit about 2 weeks prior. The resident and her roommate had a lot of concerns with one another, including concerns related to the lighting. When the resident arrived on the unit on 12/03/17, she was moved to the window bed and her roommate was assigned to another room. Prior to arriving on the unit, she had not been shown the room she was to move into prior to being moved. When interviewed on 12/05/17 at 10:06 AM, social worker #3 stated the resident was admitted for rehabilitation, she was to be short term and then return home. The resident was moved to a long-term bed as staff knew she was not going home. When a resident became long term and an appropriate room became available, the staff discussed the move with the resident. The social worker stated she had discussed the room change with the resident and the resident agreed. The social worker was unable to provide documentation to support the discussion. The social worker stated the resident was not shown the room and did not meet the new roommate prior to moving. The social worker stated she was aware the resident stayed up all night watching movies but she was unsure if it had been discussed with the pending roommate. 10 NYCRR 415.5(e)(2)

Plan of Correction: ApprovedJanuary 8, 2018

1.
Resident #338 initially was admitted to the facility for short term therapy. During her brief stay in the facility her anticipated support group in community have changed their minds in providing care for her. Her current medical conditions do not support being discharged without help/ assistance. She was approached by social services at least twice on the room transfer to the long term care unit and afforded her the chance to see it but resident have refused to get out of bed to check the unit/ room prior to transfer. Unfortunately those encounters were not documented by the social worker. Resident is currently happy and contented in her room and placement.
All 3 social workers were educated by the Administrator on (MONTH) 18, (YEAR) on the facility policy and procedure on Room to room transfer and resident Self Determination and participation. Both policies ensure promotion of the right of each resident to exercise autonomy regarding what they consider important facets of their life.
2.
An audit was completed on (MONTH) 22, (YEAR) to all residents who moved within the past 30 days to assure these room changes were documented correctly in the facility electronic health record. From this audit 25% did not meet facility threshold; social services immediately corrected their oversight.
All 3 social workers were educated by the Administrator on (MONTH) 18, (YEAR) on the facility policy and procedure on Room to room transfer and resident Self Determination and participation. Both policies ensure promotion of the right of each resident to exercise autonomy regarding what they consider important facets of their life.
Room Change Progress note template was also created on the electronic health record or point click care on (MONTH) 18, (YEAR) with the objective of ensuring appropriate documentation, resident and / family representative will be afforded the opportunity to check room/ roommate and ask pertinent questions about the move or room/ unit. Availability of room change progress note template was in serviced to all social services staff and licensed nursing staff on (MONTH) 18 and completed on (MONTH) 23, (YEAR).
3.
The Social Services Department has a new protocol for room changes. THIS ACTIONS WILL ENSURE THAT SOLUTIONS WILL BE SUSTAINED:
There is now a specific ?room change? progress note template in the electronic health record which needs to be completed EVERY time there is a room change. This progress note REQUIRES Social Services to #1. explain why the move is required. #2. It requires staff to make sure the person in the room will be informed of the possibility of a new roommate prior to him/her moving in (NEW Admission). The prospective resident will#3. view the possible room, and meet with the resident already residing in that room. They will both visit with each other for a period of time, and the prospective roommate will have the opportunity to #4 ask Social Services questions about the room. Should a resident not be able to be interviewed or make independent decisions Social Work staff will be required to notify the resident?s representative and will go through the same process.
ADDITIONALLY, starting (MONTH) 15, (YEAR) all residents / their representatives will receive notification in writing prior to room change except for emergency reasons.
4.
The Director of Social Services will audit room changes once a month for three months, results will be reported to monthly QAPI meetings for further review. THRESHOLD FOR AUDIT is 85%.
5.
Person Responsible for the correction is the Director of Social Services

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 4 of 32 reviewed (Residents #44, 72, 89, and 125). Specifically, comprehensive care plans (CCP) were not developed for Resident #44 to improve or maintain bed mobility and positioning, for Resident #72 to maintain range of motion, positioning, or pressure injury reduction; for Resident #89 to maintain positioning; and for Resident #125 for a plan for vision and needed devices including glasses. Findings include: 1) Resident #44 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 09/20/17 Minimum Data Set (MDS) assessment documented the resident was cognitively intact; required extensive assistance for bed mobility; did not have functional limitation to the range of motion to his upper extremities; and had impairment to both of his lower extremities. The 07/27/17 rehabilitation communication form documented the resident was referred as he needed bilateral grab bars and a trapeze for bed mobility. The physical therapy (PT) response to the referral documented this plan was ok with therapy as both would help with bed mobility. A side rail assessment was to be completed by a registered nurse (RN). It would be entered in the maintenance log that a trapeze was needed. The 08/02/17 rehabilitation communication form documented the resident was referred to therapy by nursing to have bilateral grab bars installed per care plan for bed mobility. Physical therapy responded to the referral documenting the resident would benefit from a trapeze over his bed to assist with raising himself in bed and grab bars would not be needed. The 08/03/17 comprehensive care plan (CCP) documented the resident had an activities of daily living (ADL) self-care performance deficit or limited physical ability related to weakness. It continued to document the need for extensive assistance of 1 staff to turn and reposition in bed as necessary. There was no documentation a plan was implemented to include interventions that would aid in the resident's bed mobility. The 08/06/17 rehabilitation communication form documented the resident was referred to them as he did not want grab bars and he wanted a trapeze. PT response to the referral documented that a trapeze would be helpful as the resident lifted his pelvis for toileting and hygiene. The 09/21/17 nursing progress note documented the resident returned from a hospitalization to a new nursing unit at the facility. The 10/30/17 RN event follow up note documented a trapeze was given to assist with bed mobility. Neither the CCP or CNA instructions were updated to reflect the recommendation. The 12/05/17 certified nurse aide (CNA) care instructions documented the resident required extensive assistance of 1 to turn and reposition in bed as necessary. Bilateral grab bars were in place to promote assistance with bed mobility and the resident transferred with assistance of 2 staff. There was no documentation that a trapeze was added to the resident's plan of care to aid with bed mobility and positioning. The resident was observed in his room in bed without side rails or a trapeze on 11/28/17 at 01:24 PM and 1:44 PM, 11/29/17 at 10:35 AM, on 12/03/17 07:24 PM, and on 12/04/17 07:54 AM. On 12/05/17 at 09:39 AM, the resident was observed laying in bed, his toes and feet were were hanging off the bottom of the bed, and there were no side rails or a trapeze on the bed. The resident stated he had trouble rolling from side to side and he needed assistance from the CNAs for bed mobility. When interviewed on 12/05/17 at 09:57 AM, CNA #13 stated the resident did not have a trapeze or side rails, and he pushed himself up in bed by pushing up with his feet. When interviewed on 12/05/17 at 10:30 AM, registered nurse (RN) Unit Manager #7 stated the resident was evaluated by PT after re-admission following a hospital stay and then he refused to participate in strengthening provided by PT. There was no plan regarding his refusals as he refused everything. The resident had an area on his great toe, they felt it was from the podiatrist, and they removed his footboard as a precaution. He was initiated a trapeze for mobility, and pulled himself up in bed by using the trapeze. She was not aware the resident did not have a trapeze currently on his bed. 2) Resident #72 was re-admitted on [DATE] and had [DIAGNOSES REDACTED]. The 10/16/17 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; required extensive assistance with bed mobility and eating. The MDS documented the resident did not have impairment to her upper or lower extremities, was at risk for pressure injury, and had pressure reducing devices to the bed and chair. The 11/14/17 comprehensive care plan (CCP) documented the resident required total dependence on staff for personal hygiene and bed mobility and repositioning in bed. The resident had an alteration in musculoskeletal status related to [MEDICAL CONDITION] and left hand and shoulder contracture. There was no documentation a plan was implemented to maintain the resident's comfort with positioning related to her contracture(s). The CCP documented the resident had an air mattress in place. There was no further documentation specific to preventing pressure injuries. The 11/17 and 12/17 activities of daily living (ADL) record had no documentation staff provided or had a plan specific to positioning for the resident. The resident required total dependence for care including bed mobility and transferring. The 12/4/17 certified nurse aide (CNA) care instructions did not document a plan for positioning to the resident's neck, shoulder or skin prevention to the resident's lower body. The resident was observed: - On 11/28/17 at 01:03 PM, seated across from the nursing station in a geri chair. Her feet were off the edge of the leg rest, her toes both pointed left and were not touching the floor. Her head was tilted significantly to the left towards her shoulder, she had a standard bed pillow to the left side that was not offering support to her neck. The resident had her right hand on the right arm rest to hold herself upright. The left hand was contracted and laying across her lap without any devices. - With her head tilted to the left without support in her bed and/or in her geri chair on 11/29/17 at 10:01 AM, 11/30/17 at 04:35 PM, 12/01/17 at 09:50 AM, 12/04/17 at 11:36 AM, and on 12/04/17 at 11:53 AM with her head further towards her left shoulder than it was at 11:36 AM. - With her head tilted to the left without support while being fed and assisted by staff during meals on 11/28/17 at 11:57 AM, 11/29/17 at 12:00 PM, and on 12/04/17 at 08:34 AM. On 11/29/17 at 11:22 AM, the resident stated to the surveyor, her foot was sliding and the surveyor could look at her foot. The resident's feet were under her bed sheet, bare, and her right foot's heel was directly on the top of her left foot, without a barrier preventing skin to skin contact. She wanted her feet re-positioned and was unable to do so herself. At 11:23 AM, the resident notified the surveyor, her head had started to tilt after she had a stroke. It often leaned to the left and was uncomfortable. She would prefer if she had something to support her neck in a more upright position. During the visit with the surveyor, the resident's head was observed tilted to the left, a regular bed pillow was under the back of her head and her head was sliding off the left of the pillow with no support to her neck. During an interview with CNA #6 on 12/05/17 at 09:43 AM, she stated the staff had to provide all care to the resident. The resident had a lateral support to both sides of her body while in her geri chair. One of the support cushions had been missing and staff would use a pillow to put on her left side. The lateral support had been missing a couple weeks and she was not sure if it was reported. The resident had to be positioned in bed and she normally stayed in one place for awhile. The resident's head tilted and leaned to the left. She did not have a plan for support to her neck. A pillow was in place for behind her head, not to the left of her head, shoulder, or neck. The resident was able to move her own legs, she had impairment to one arm that she was unable to move on her own, and there was no plan for range of motion (ROM) for the resident. During an interview with licensed practical nurse (LPN) #17 on 12/05/17 at 10:16 AM, she stated the resident maneuvered herself into a pretzel-like position and staff repositioned her. Her head tilted to the left and they assisted in placing her head upright, and it would tilt back to the left afterward they had adjusted it. She had a wedge cushion to the left side while in her geri-chair that extended from her hip to mid-chest and not to her upper body. There was nothing else in place to position her head or body. During an interview with registered nurse (RN) Unit Manager #7 on 12/05/17 at 10:35 AM, she stated the resident had a turn in her neck that made feeding difficult. Her head would not position upright. She was not sure if the resident's neck would continue to worsen without support. Staff could have placed a rolled towel for support between her head and neck; and there should have been a plan in place to do this, and there was not. There should have been something in place in the resident's plan of care between her feet for skin prevention, so there would not be skin to skin contact. During an interview with CNA #13 on 12/05/17 at 10:49 AM, she stated the resident's left arm was paralyzed from a past stroke. She was always leaning to the left, did not have use of her arm at all, and her leg often twisted in. The resident's head always leaned to the left and they would place a pillow to the neck. Any staff could offer repositioning to the resident when they saw her. The resident had a positioning wedge on the left side by her back and thigh, and a pillow behind her head. There were no further measures in place to the rest of her body. The resident leaned and was positioned to the left when in bed, as staff wanted to off-load her right side for skin prevention. 3) Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/23/17 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired; she required extensive assistance for bed mobility; and total dependence for transfers and eating. The resident had an unhealed pressure ulcer upon admission to the facility, she had a pressure reducing device for the wheelchair only, there was not a pressure reducing device for the bed, and she was not on a turning and repositioning program. The 10/16/17 comprehensive care plan (CCP) documented the resident had a self-care deficit limited to physical immobility. Interventions included a physical and occupation therapy (PT/OT) evaluation and treatment per physician orders. A Care Guide Update Form documented by physical therapy on 10/17/17 documented the resident was non- ambulatory and please use Hoyer lift for all transfers. There was no further physical therapy or occupation therapy documentation in the resident's medical record. The 10/16/17 social services progress note documented the resident would stay in the facility long term after her rehab has finished. The 10/18/17 physician progress notes [REDACTED]. The 10/26/17 registered nurse (RN) skin assessment documented the resident was seen by the skin team for the first time related to a pressure ulcer on the right outer ankle. There was no description of the wound bed and the assessment included measurements of 0.3 (centimeters) cm x 0.5 cm x 0.1 cm. Treatment included a foam dressing. The 10/26/17 wound nurse practitioner (NP) note documented the resident had a Stage III pressure injury on the right outer ankle. Interventions included to turn and reposition the resident every 2 hours and hourly while in wheelchair and float heels off bed with pillow or offloading boots. Observations by a surveyor of the resident's positioning included: - On 11/28/17 at 10:50 AM, the resident was in her wheelchair sleeping with her head leaning forward toward her lap. - On 11/28/17 at 02:21 PM and 02:26 PM, she was leaning toward the right, with her head leaning forward almost in her lap and she was using her left hand holding up her forehead. - On 11/29/17 at 10:12 AM, the resident was observed sleeping in her wheelchair with her head tilted forward and to the side. - On 11/30/17 at 09:28 AM, the resident was observed in a wheelchair in the unit lounge, in a high back wheelchair tilted slightly back with head in a more upright position. The resident continued to cover her face in a blanket. - On 12/01/17 at 01:28 PM, the resident was observed in her room in her wheelchair with her head leaning forward and resting on right side arm rest. - On 12/03/17 at 07:00 PM, the resident was sitting in her room in her wheelchair facing the door with the lights out. Her head was down with her face tucked in to the front of her shirt. She did not have pants on, and her blanket was falling off to right exposing her upper legs. There was a maroon plate cover on the floor to the left of her. - On 12/04/17 at 11:23 AM, a certified nurse aide (CNA) was observed wheeling the resident down the hallway in the wheelchair and she was leaning forward to her left side with her head resting on the wheelchair arm rest. The 11/2017 certified nurse aide (CNA) Kardex (care instructions) did not contain instructions on the resident's positioning nor did it identify the resident should be repositioned in her wheelchair hourly per the recommendation of the wound specialist. During an interview with CNA #1 on 11/30/2017 at 01:16 PM, she stated at times the resident leaned toward one side of her wheelchair and there was a wedge cushion or pillow that they could use if she was doing that. The resident was not resistive to care and would follow directions. During an interview with the Director of Rehabilitation on 12/04/17 at 10:29 AM, she stated all residents admitted to the facility received an initial PT/OT evaluation. The evaluation consisted of determining bed mobility, range of motion, transfer status and positioning. When the resident was eyeballed when she was admitted , that was considered her evaluation. She was lethargic and they had determined she was a mechanical lift for transfers. There was no further assessment of the resident other than eyeballing her and there had been no re-assessment. During an interview with social worker #3 on 12/04/17 at 10:35 AM, she stated the hospital had reported to her the resident was coming to the facility for long term care and would benefit from some short-term rehabilitation so she could get a little stronger. That was the request of the hospital as well as the family. The resident did not receive PT as it was obvious when she got here she not going to be cooperative with PT. During an interview with the registered nurse (RN) Unit Manager #2 on 12/04/17 at 11:25 AM, she stated a physical therapy evaluation included assessing the resident's positioning, ability to transfer, bed mobility and positioning while in wheelchair. The resident was always positioned well in her wheelchair, she had not observed any issues with her position in the wheelchair as leaning forward and to the side was the resident's baseline position in the wheelchair. 10NYCRR 415.11(c)(1)

Plan of Correction: ApprovedJanuary 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #44 is a [AGE] year-old male with primary [DIAGNOSES REDACTED]. Resident is non-compliant with all aspects of his care including participation with restorative therapy refuses to get out of bed, weights, some medications and diagnostic tests. Resident prefers having care provided for him rather than completing ADLs that he can do independently or with limited assistance. Nursing referred resident to therapy to promote more independence with bed mobility. Therapy approved grab bars. On [DATE] grab bars were attempted to be placed in bed and resident refused. After the refusal of grab bars therapy recommended trapeze, again resident refused. Resident has a long history of manipulative behavior. Resident will continue to be re-approached by therapy, nursing and social services to ascertain and assist him with his mobility goals.
**Careplan for resident #44 non- compliance and continued refusals to therapy recommendations such as use of grab bars or participation in restorative therapy are updated by the Unit manager on [DATE] and reflected in therapy/ restorative notes.**
RN Unit manager was counseled by Director of Nursing in ensuring that adaptive devices are in place as recommended and documenting refusals and future plan of care on (MONTH) 29, (YEAR).
Resident #72 is a [AGE] year old woman with [DIAGNOSES REDACTED]. Resident behaviors include being verbally and physically aggressive, chronically rolling onto the floor mat. This resident will frequently yell out for help over the choice of using her call bell even if call bell is within reach. Resident has a pressure redistributing mattress and wheelchair cushion when in chair.
** All of these interventions are in the preventative care plan for this resident.
Resident does not have pressure ulcer. PT/OT evaluation ordered for neck positioning when in bed and in chair. Therapy recommended and in place on (MONTH) 4, (YEAR) use of bariatric geri chair with lateral support for positioning. Care plan updated by unit manager for positioning. No changes with her current type of call bell.
RN unit manager will conduct education to all unit staff to ensure that all residents call bell are within reach at all times when in room. Education will be completed by (MONTH) 12, (YEAR).
Resident # 89 is an [AGE] year-old woman [DIAGNOSES REDACTED]. Resident was admitted to facility from the hospital [MEDICAL CONDITION] treatment for [REDACTED].
All bed mattresses on Unit 1 where resident # 89 resides are graded as pressure redistributing.
Wound healing Solutions NP consultant recommended use of blue booties and turning and positioning while in bed and wheelchair.
Resident # 89 plan of care was reviewed by the Director of Nursing and Unit manager and updated care plan and kardex/ task as appropriate on ,[DATE]/ (YEAR).
Unit manager was educated by the Director of Nursing on [DATE] on the following: all new wounds must be referred to wound healing solutions (WHS) for follow-up and weekly pressure ulcer assessment follow-up. WHS recommendations must be followed and if not must be documented as to why.
Resident #89 was admitted at a hoyer level for transfer, total assistance for ADLs, and the plan to attempt short-term rehabilitation in order to return home.
Physical and occupational therapy was attempted unsuccessfully in the hospital prior to admission to the facility.
On [DATE], speech therapy assessed the resident and placed her on a restorative therapy program. Physical and occupational therapy were unable to fully assess resident due to lethargy and the resident?s inability to actively participate in the evaluation process. Upon screening the resident on [DATE], resident was determined that a hoyer level for transfers was appropriate. Skilled physical and occupational therapy were not indicated at that time. Per nursing reports and therapist informal clinical observations, throughout (MONTH) and November, there was no change in resident abilities indicating a need for skilled physical or occupational therapy service.
On [DATE], physical therapy completed a comprehensive evaluation. Resident repeatedly put the blanket over her head and would not participate in a full evaluation. It was again determined that skilled therapy services were not indicated at that time.
On [DATE], physical therapy attempted an evaluation and there were no changes noted. Resident again would not participate. Nursing will monitor resident for changes and notify therapy if resident begins to attempt active participation in ADLs/transfers.
Resident expired on [DATE].
The Administrator reviewed the facility policy and procedure on Functional Impairment- Clinical protocol with the Director of Rehabilitation and all therapists on staff which states that all new admissions must be evaluated by either PT or OT on (MONTH) 5, (YEAR).
Resident # 125 is a [AGE] year old woman with [DIAGNOSES REDACTED]. Daughter stated to the Unit Manager on [DATE] she (the daughter) noticed that resident was not wearing her glasses for several days but never reported this to staff. Daughter states knowingly the resident wanders the entire unit, in and out of peer?s rooms thinking that the resident probably misplaced them during her wandering behaviors. Documentation states the resident often thinks that her peer?s belongings are her own. Resident can become combative and agitated with re-direction.
Resident # 125 did not have a event such as fall or run over stuff the time that she did not have her eyeglasses.
Resident was seen and examined on [DATE] by Optometrist. Eyeglasses are not recommended at this time.
Unit Manager and nursing staff were educated by the Director of Nursing on timely reporting of missing assistive devices such as eyeglasses on (MONTH) 5, (YEAR).
Social services reiterated to resident daughter and family about timely reporting of missing assistive devices to nursing staff or to social services so that facility can intervene quickly. This was completed by Director of Social services on [DATE].
All managers were educated by the Director of Nursing that any resident with visual adaptive devices must be care planned. This was completed on (MONTH) 12, (YEAR).
2.
Resident Centered Care plan Audit will be conducted by managers and assistant managers on all residents whose care plans were scheduled in past 30 days, residents with pressure ulcers and visual adaptive devices. Audit will be completed by (MONTH) 12, (YEAR). Any deviations will be reported to the Director of Nursing for review and necessary correction.
Audit threshold is 95%.
Nursing will work alongside therapy to ensure that mobility devices recommended for residents are in place, documented in the care plan and kardex. This will be completed by (MONTH) 26, (YEAR)
Facility educator/ designee will conduct mandatory education to all RN and unit managers on facility policy and procedure as it relates to weekly follow up of pressure ulcer, following recommended intervention for prevention and updating care plan and CNA kardex. Education will be completed by (MONTH) 26, (YEAR).
All residents without a visual care plan that are indicated to have eyeglasses will have a visual care plan completed by (MONTH) 26, (YEAR).
All managers were educated by the Director of Nursing that any resident with visual adaptive devices must be care planned. This was completed on (MONTH) 12, (YEAR).

3.
Unit Manager will immediately update all care plans and kardex with appropriate intervention as recommended by PT/OT or providers.
After each wound rounds any recommendation will be reviewed, ordered, care planned and or added to CNA kardex as appropriate.
All residents will receive a PT or OT evaluation within ,[DATE] hours of admission to ensure comprehensive plan of care is attained.
If resident is unable or unwilling to participate in the evaluation process it will be documented on the medical record and reported to Social services and provider for follow - up.
All other residents will be continually be screened by all staff for decline in their ADLs, transfer/ mobility status and positioning during their stay and will be referred to the provider for an order of specialized services such as PT, OT or Speech.
All managers are educated that any resident admitted with eyeglasses or visual deficit must be care planned and added to task/ kardex within 21 days after admission. All other residents that may require visual adaptive devices after admission will be care planned as necessary. Education will be done by facility educator/ designee and will be completed by (MONTH) 26, (YEAR).
Unit manager will educate all nurses, CNAs that all residents are to be encouraged to wear vision device and report refusals or misplacement. Education will be completed by (MONTH) 12, (YEAR).
4.
Comprehensive Care Plan audit- Audit Threshold is 95%; will be conducted by the MDS coordinator on all scheduled care plans every month for 3 months. Any deviations will be reported to the Director of Nursing, Unit managers and rehabilitation Director for review and necessary correction. MDS coordinator will report result of audit to monthly QAPI for further review and recommendation.
5.
The Director of Nursing is the person responsible for the correction.

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

Based on observation, record review, and interview conducted during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, kitchen areas contained unclean surfaces, and the dish wash sink was not maintained at acceptable temperatures. Findings included: During observation of the main kitchen on 11/28/17 at 10:53 AM, the following was observed by a surveyor: - The preparation station drawer with sticky substance with 3 serving items in the drawer. - The vegetable freezer contained food particle/debris on the floor of the freezer. - There was rusty build up on the backside of the meal service tray line table. - There was condiment debris on the floor near the meal service tray line. - The meal plate cover rack contained a build up of white film. The metal ring on the hot plate covers contained a build up of a film. During a second observation of the main kitchen on 12/01/17 at 11:38 AM, a surveyor observed the following: - The interior of the foam used for adaptive silverware contained a build up of white film. - The meal plate cover rack contained a build up of white film. The metal ring on the hot plate covers contained a build up of a film. During a meal tray line observation on 12/01/17 at 12:06 PM, the meal plate covers located on a warming rack were wet and being used during tray line service to cover the hot meal plates. On 12/01/17 at 02:27 PM a surveyor observed a kitchen employee wiping a meal delivery cart that contained a build up of white film. The employee used a rag and quickly wiped off debris from the cart. The cart was not thoroughly cleaned or wiped. On 12/1/2017 at 02:29 PM, the dish wash station was observed in use by a surveyor and the Food Service Director. The dish wash machine reached a high of 152 degrees Fahrenheit (F.) when in use. The dish machine, under the thermometer, documented manufacturer guidance for the machine to be used at 160 degrees F. At that time a surveyor requested the dish machine temperatures. On 12/01/17 at 02:33 PM, the Food Service Director provided the surveyor a 11/17 Dish Machine Temperature Log. The log documented the dish machine ran between 140-149 degrees F. 7 times, between 150-152 degrees F. 17 times and 155 degrees F. 4 times, during the 30 days of the month. The surveyor requested the Food Service Director to provide documentation for the manufacturer recommendations for the dish machine guidance documenting 160 degrees F. The Food Service Director stated he would look for additional information. During an interview with the Nutritionist on 12/01/17 at 03:06 PM, she stated the facility had a problem recently with the dish machine, it occasionally happened and it was supposed to be fixed. The facility staff should have called to have it fixed if it was not reaching acceptable temperatures. The surveyor did not receive manufacturer recommendations for the dish machine prior to the exit of the recertification survey. 10NYCRR 415.14(h)

Plan of Correction: ApprovedJanuary 11, 2018

1. No resident were affected by this practice.
*Prep station drawer with sticky substance with 3 serving items in the drawer - Correction: Daily cleaning and organizing of utensil drawers by cooks/production staff.
*Vegetable Freezer contained particle/debris on the floor of the freezer - ** Initial correction:Weekly cleaning of freezer floors by staff member putting away stock.
-Rusty build-up on backside of the meal service tray line table-Correction:Line staff will scrub and clean tray line prior to leaving after tray service
-Condiment debris the floor near meal service tray line - Correction:Line staff will continue to monitor that items are picked up off the floor immediately.
- Meal plate cover rack contained build-up of white film- Correction:Meal plate cover will by cleaned by line staff 2x per month to remove white build-up
- Metal ring on the hot plate covers contain build-up of white film - Correction: Metal plates will be scoured 2x per month by line staff to ensure that white build-up is removed.
- Interior of the foam used for adaptive silverware contained a build-up of white film- Correction: Wash in Dish machine as directed, allow to air dry prior to use, replace after signs of deterioration.
-Meal plate covers located on a warming rack were wet and being used during tray line to cover hot meal plates- Correction:When completed wash through dish machine, allow to air dry by putting in drying rack before use.
- Kitchen employee wiping meal delivery cart that contained a build-up of white film - Correction: will use Quat 146 sanitizer to completely wipe down meal delivery cart prior to delivering food trays
On (MONTH) 6, (YEAR) the dish machine manual was located. Manufacturers? recommended temperature does not match the temperature log. Immediately, temperature log was changed to match the parameters set by the manufacturer including an instruction on what will the staff so when temperature does not meet requirement. Staff were educated on the use of the log and reporting by the Kitchen supervisor and completed on (MONTH) 7, (YEAR).
**Facility maintenance checked and tested dish machine on (MONTH) 6, (YEAR). After cleaning and re-arrangement of the dish machine curtain', there are no issues with the dish machine meeting the wash and rinse temperatures. Kitchen supervisor was educated by facility maintenance on proper arrangement of the curtain and for staff to thoroughly clean/ empty daily.
2.
Prep station drawer with sticky substance. ? item has been added to cooks daily cleaning list.
Vegetable Freezer contained debris on floor of freezer. -- ** after further review with Account Manager, cleaning of the vegetable freezer changed to daily by the cook.
List will be checked by supervisor prior to leaving for the day to ensure that station has been cleaned and sanitized
Rusty build-up on backside of the meal service tray line table. ? Maintenance will clean and repaint areas that have rust. This will be added to daily cleaning list to be completed by Line staff.
Condiment debris on floor near meal service tray line. ? sweeping the floor will be added to each station daily cleaning list.
Meal Plate cover rack contained build-up of white film. ? This will be added to monthly cleaning list for line staff to complete 2x per month.
Metal ring on the hot plate covers contain build-up of white film. ? Cleaning of Wax pellets are added to monthly cleaning list for line staff
Interior of white build-up on foam used for adaptive equipment. ? Line staff to monitor red foam and wash in dish machine as directed.
Meal plate covers located on on warming rack were wet and being used to cover plates. ? Line staff to wash through dish machine as directed, and place on drying rack to dry before use.
Kitchen employee wiping meal delivery cart that contained a white film build-up ? All staff receive in service on proper cleaning and sanitizing of meal delivery carts.
Dish Machine not reaching Manufacture recommended wash temperature. ? All staff in serviced on proper dish machine temperatures, instructed that temperatures must be logged on a Temperature log during all meals. If all temperatures are not up to proper temperatures, notify supervisor immediately.

3.

Prep station drawer with sticky substance-- List will be checked by supervisor prior to leaving for the day to ensure that station has been cleaned and sanitized
Vegetable Freezer contained debris on floor of freezer --. List will be checked by supervisor prior to leaving for the day to ensure that station has been cleaned and sanitized, Supervisor will inservice all staff on labeling , dating and storage of food.
Rusty build-up on backside of the meal service tray line table ? Supervisor will check to ensure stations are clean and sanitized.
Condiment debris on floor near meal service tray line. ? Supervisor will check to ensure that all stations are clean.
Meal Plate cover rack contained build-up of white film ? Supervisor will audit to ensure that rack was cleaned.
Metal ring on the hot plate covers contain build-up of white film? Supervisor will check to ensure that the pellets are clean and free of white build-up.
Interior of white build-up on foam used for adaptive equipment ? Supervisor to audit condition on red foam for adaptive equipment, and replace as needed
Meal plate covers located on warming rack were wet and being used to cover plates ? Supervisor to monitor procedure of drying dishes
Kitchen employee wiping meal delivery cart that contained a white film build-up ? Supervisor to instruct all staff on proper cleaning and sanitizing on meal delivery carts.
Dish Machine not reaching Manufacture recommended wash temperature ? Supervisor to monitor daily to ensure all temperatures are in proper range, if they are not turn machine off notify maintenance and continue washing with a 3-bay sink procedure (wash, rinse and sanitize)
** The Facility Nutritionist/ designee will conduct unscheduled kitchen audits at least 3x/ week for 3 months
Audit threshold is 85%.

4.
Vegetable Freezer contained debris on floor of freezer ? Account manager to audit all tasks are completed, and in services are complete.
Rusty build-up on backside of the meal service tray line table ? Account manager to audit all stations are cleaned
Prep station drawer with sticky substance ? Account manager to audit all drawers have been cleaned and organized.
Condiment debris on floor near meal service tray line ?- Account Manager to do audits during tray line to ensure no condiments are off floor.
Meal Plate cover rack contained build-up of white film ? Account manager to audit cleaning lists that rack has been cleaned and free of white film build-up.
Metal ring on the hot plate covers contain build-up of white film ? Account manager to audit pellet plates to ensure that white film build-up is gone 2x per month
Interior of white build-up on foam used for adaptive equipment ? Account manager to audit condition of red foam used for adaptive equipment.
Meal plate covers located on warming rack were wet and being used to cover plates ? Account manager will audit procedure on drying plate covers.
Kitchen employee wiping meal delivery cart that contained a white film build-up ? Account manager to ensure that all staff are in serviced on proper cleaning and sanitizing of meal delivery carts.
Dish Machine not reaching Manufacture recommended wash temperature ? Account manager to monitor dish machine temperatures 1x per week
The account manager will conduct scheduled audits as scheduled monthly for 3 months. Any deviations will be corrected immediately. Account manager/ designee will report results of audit to monthly QAPI for further review and recommendation. Audit threshold 85%
Nutritionist will report result of on the spot kitchen audits monthly for the next 3 months to monthly QAPI for further review and recommendation.
5. Account manager will be responsible for correction of this practice.

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey for 1 of 7 residents (Resident #15) reviewed for falls, the facility did not ensure all residents were free of accident hazards, supervision and devices. Specifically, Resident #15 had a personal alarm in place to prevent falls and the alarm was not consistently implemented as planned. Findings include: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 08/28/17 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and he required extensive assistance for all activities of daily living. The comprehensive care plan (CCP) dated 08/28/17 documented the resident had multiple falls related to poor safety awareness, lack of impulse control, noncompliant with transfers and frequently removed personal alarm. Interventions included to use the personal alarm in the bed and wheelchair and ensure device was in place. The undated certified nurse aide (CNA) Kardex (care instructions) documented to keep the resident in high visibility areas and assist to stand every 2 hours while in chair. Use personal alarm while in bed and wheelchair. The alarm was to be attached while in bed, and staff were to be sure the safety devices were in place and functioning. The 11/11/17 event report documented the resident had a fall at 05:30 PM, he was last seen in his room at 03:43 PM by a CNA. The statement from the resident's primary CNA was included with the report. The box asking if the resident had safety devices in place and functioning was checked off as no. The report's investigative summary documented the resident had poor impulse control, frequent behaviors and the resident's plan of care was reviewed and updated accordingly. The summary documented there was no reasonable cause to believe that abuse or neglect had occurred. There was no documented evidence of any updates to the resident's CCP and the report did not identify why the resident did not have his personal alarm in place at the time of the fall. The 11/12/17 event report documented the resident had a fall at 04:45 PM. The statement from the resident's primary CNA was included with the report. The box asking if the resident had safety devices in place and functioning was checked off as n/a. The report's investigative summary documented the resident had poor impulse control, frequent behaviors and the resident's plan of care was reviewed and updated accordingly. The summary documented there was no reasonable cause to believe that abuse or neglect had occurred. There was no documented evidence of any updates to the resident's CCP and the report did not identify why the resident did not have his personal alarm in place at the time of the fall. The 11/14/17 event report documented the resident had a fall prior to the 11-7 shift. The statement from the resident's primary CNA was included with the report. The box asking if the resident had safety devices in place and functioning was left blank. The report's investigative summary documented the resident had poor impulse control, behavioral disturbances and the resident's plan of care was reviewed and updated accordingly. The summary documented there was no reasonable cause to believe that abuse or neglect had occurred. There was no documented evidence of any updates to the resident's CCP and the report did not identify why the resident did not have his personal alarm in place at the time of the fall. The 11/30/17 event report documented the resident had a fall at 04:45 PM. The statement from the resident's primary CNA was included with the report. The box asking if the resident had safety devices in place and functioning was left blank. The report's investigative summary documented the resident had poor impulse control, behavioral disturbances and the resident's plan of care was reviewed and updated accordingly. The summary documented there was no reasonable cause to believe that abuse or neglect had occurred. There was no documented evidence of any updates to the resident's CCP and the report did not identify why the resident did not have his personal alarm in place at the time of the fall. On 11/28/17 at 11:57 AM, the resident was observed in the unit dining room. The resident stood from his chair and no alarm sounded. On 11/30/17 at 02:22 PM the resident was observed lying in bed. He had a fading bruise to beneath left eye and stated he fell about a week ago. At that time he had a clip alarm attached to his shirt and the alarm was set at the top of the bed without being attached to anything. On 12/03/17 at 07:07 PM the resident was observed sitting in lounge area of the unit sleeping in chair, leaning to the right and there was no personal alarm observed attached to the resident. At 07:08 PM the personal alarm box was observed on his dresser in his room. The box did not have the clip and string that would attach to resident and alarm when loosened. At 07:15 PM he was leaning forward in the wheelchair and there was no personal alarm observed and there was no staff near the resident. During an interview with CNA #10 on 12/03/17 at 07:19 PM, he stated he would know a resident needed an alarm by reviewing their care instructions. I know exactly who you are talking about and he does not have his alarm on right now. He destroyed the alarm last evening and we were having trouble finding the string for it. The nursing supervisor was notified and whether they did anything about it I don't know. The resident frequently pulled at his alarm and staff were using a paper clip to keep in it on him. It was working but like I said last night he pulled if off. We have been keeping a close eye on him because he does not have his alarm on. On 12/03/17 at 07:49 PM, the resident was observed scooting himself to the edge of the wheelchair and then stood up. There was not staff in the lounge area at the time. Licensed practical nurse (LPN) #11 walked around the corner, saw the resident standing and told the resident to sit down. The LPN stated the resident had a personal alarm and it was probably in his pants somewhere and she proceeded to look for the alarm and stated she could not find it. LPN #11 was interviewed 12/03/17 at 07:53 PM and stated she would be notified in shift report and any issues with a resident or if they needed monitoring. She was not notified or aware the resident had destroyed his alarm last night and thought he had it on earlier. During an interview with registered nurse (RN) Unit Manager #7 on 12/04/17 at 09:40 AM, she stated when a fall occurs residents care plans were reviewed and new interventions were initiated. She reviews incident reports including staff statements and would do any follow up if she had any questions. The report then goes to the Director of Nursing (DON) for review who makes the final determination if abuse/neglect did or did not occur. The RN reviewed the resident 11/17 incident reports and stated she did not question why it was not identified if the resident had on his personal alarm during those incidents as he was always taking the alarm off. The alarm was used to alert staff that he was standing up. The purpose of investigating falls was to determine why the fall occurred and to prevent further falls as well as determine if the resident's care plan followed. According to these incident reports she was unable to determine if the resident's CCP was followed as she did not know if he had his personal alarm on or not. During an interview with the Director of Nursing (DON) on 12/04/17 at 13:55 PM, she stated she reviewed incident reports and would give the report back to the Unit Manager if it was incomplete or if she had questions. She stated the resident frequently took the personal alarm off and it was being used as an intervention to prevent falls. She reviewed the resident's incident reports and did not know why she had not questioned whether or not the resident had his personal alarm in place during those falls and she could not determine if the resident's plan of care had been followed. 10 NYCRR 415.12(h)(1)

Plan of Correction: ApprovedJanuary 16, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 is a [AGE] year-old male with [DIAGNOSES REDACTED]. Resident ADL status has progressively declined in the past few months related to multiple co ?morbidity. Personal alarm in bed and wheelchair is an intervention that was added to his plan of care sometime in (MONTH) (YEAR) for safety. There are numerous documentation of this resident having behaviors including aggression, restlessness and removing, hiding or breaking the personal alarm. Such behavior has been care planned in (MONTH) (YEAR).
* Review of records showed that during a fall meeting done on 10/25/17 attended by provider, Nurse manager, therapy the use of personal alarm should have been removed and d/c because it continue to resident continue to remove alarm .This resident had events of fall 9 times since the alarm was put into place in (MONTH) to end of July. Resident had 5 falls from (MONTH) to (MONTH) which maybe related to changes such as pain medication and addition/ maintaining of other positioning devices such as drop seat, reclining back chair and eventually broda pedal chair. Resident # 72 last documented un-witnessed fall was (MONTH) 2, (YEAR).
**Resident # 15 has been updated to reflect removal of the personal alarm system as an intervention for falls, room was also checked to ensure that staff do not put it back.
*The Administrator counselled Unit manager on ensuring that fall meeting interventions are followed and documented on 1/5/2018.
*Facility have initiated removal/ minimize use of fall alarm systems as a choice of intervention for post falls sometime in (MONTH) of (YEAR).The plan for this initiative was spearheaded by MDS during scheduled care plan to review falls/events and check use of alarms as an intervention. The plan was to use other alternatives that encourages mobility and function instead of restriction.

The Director of Nursing and Unit Manager were both re-educated by the Administrator on ensuring that CNA statements are reviewed thoroughly after an event and care plans reviewed to reflect facility wide initiative or changes such as removal of fall alarm systems on 12/12/2017.
The Director of Nursing educated unit staff on 1/12/2018 related to the importance of reporting of any adaptive device that is misplaced or malfunctioning.
2.
Audit was conducted and completed on 1/4/2018 by Unit Managers. Result showed minimal compliance issues or 6%, mostly related to care plan update and accuracy of questions on CNA assigned statement form. Those with compliance issues with the audit conducted were corrected by Unit Managers on 1/5/2018.
*Audit threshold is 95%. *Audit consists of Record review - care plan and kardex for devices in use post fall and Observation- that includes use of device, appropriateness,working condition (not broken) and staff awareness of devices being used.
The CNA assigned statement will be revised to reflect current initiative related to alarms this was a result of the clinical meeting with nursing management and the Administrator on (MONTH) 3, (YEAR). Revised forms will be in serviced to all clinical staff by the facility educator/ designee by (MONTH) 26, (YEAR).
Mandatory education of all Managers, Assistant Managers and Supervisors on thorough event investigation will be conducted by the Administrator by (MONTH) 26, (YEAR).
3. Nursing leadership that includes the Director of Nursing, Unit managers, assistant managers, and supervisors must thoroughly review every event that occurs including statements, care plan and kardex as soon as possible. All events/ incident must be investigated immediately to quantify presence of care plan violation as it relates to devices/ accident preventive intervention. All nursing staff will be in- serviced by the facility educator/ designee by (MONTH) 26, (YEAR)
*The CNA assigned statement will be revised to reflect current initiative related to alarms which was a result of the clinical meeting with nursing management and the Administrator on (MONTH) 3, (YEAR). Revised forms will be in serviced to all clinical staff by the facility educator/ designee by (MONTH) 26, (YEAR).
Mandatory education of all Managers, Assistant Managers and Supervisors on thorough event investigation will be conducted by the Administrator by (MONTH) 26, (YEAR).
**ALL staff will be educated on alternative to post fall interventions by Administrator/ Rehab. Director/therapist to be completed by (MONTH) 31, (YEAR)
4. ** The Director of Nursing will review all events for thoroughness of investigation which include CNA statements, interviews, care plan, kardex before submission to the Administrator.
The MDS coordinator/ designee will conduct monthly audit of events for 3 months and report to the Director of Nursing any untoward findings for immediate review and correction. Audit threshold 95%
The Director of Nursing will report to monthly QAPI result of ** Preventive Devices audit for further review.
5. The Director of Nursing is the person 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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey for 5 of 6 residents (Residents #8, 10, 55, 104 and 137) observed during a medication administration observation, 2 of 3 residents (Residents #99 and 132) reviewed for catheters, and 1 of 9 residents (Resident #99) observed during a treatment observation, the facility did not ensure the facility established and maintained 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. Specifically, hand hygiene and basic infection control measures were not practiced during medication administration for Residents #8, 10, 55, 104, and 137. Resident #99 was observed with his wound dressing coming in contact with the floor. Residents #99 and 132 had Foley catheter (urinary drainage tube) drainage bags (bag for collecting urine from the urinary drainage tube) that were uncovered and on the floor of their room. Findings include: 1) On 11/30/17 at 04:20 PM, licensed practical nurse (LPN) #12 was observed during medication administration for Resident #10. She removed a [MEDICATION NAME] 10.0 milligram (mg) tablet from the blister pack, dropped the pill directly into her bare hand and then placed the tablet into a medicine cup. She then removed a [MEDICATION NAME] 20.0 mg tablet into her hand, the tablet fell on the medication cart, she picked it up and placed the pill in the medicine cup. During this administration, the nurse was observed touching the iPad (electronic device) while reviewing which medications were due. Prior to administering medications to Resident #10, she administered medication to Resident #8 and did not perform hand hygiene between Resident #8 and Resident #10. After she completed medication administration for Resident #10, she administered medications to Resident #55, Resident #104 and Resident #137 and was not observed performing hand hygiene. During an telephone interview with LPN #12 on 12/05/17 at 09:25 AM, she stated the purpose of placing a pill into a medication cup was to keep the medication as clean as possible and free from germs. If a pill was placed into your bare hand it became contaminated. If the medication fell on to the cart the process was to discard the pill and administer a new one. Nurses were required to sanitize their hands after passing medications to each resident. She did not recall placing Resident #10's pill into her hand or the resident's other medication falling onto the cart. She recalled using hand sanitizer between residents. She received annual training on medication administration. During an interview with registered nurse (RN) Unit Manager #7 on 12/05/17 at 10:00 AM, she stated she expected nurses to remove pills from the blister pack into the medicine cup and not into their hand as the medication could be contaminated in a hand. When a pill accidentally fell on to a surface she expected it to be discarded and a new pill taken from the blister pack. She did not expect they would pick it up with a bare hand and place it in the cup for administration to the resident. Hand sanitization was to occur before medications were administered and whenever they were unclean. She was not sure if there was an annual medication refresher in place for nurses and recalled talking about it at one time. 2) Resident #99 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The 11/02/17 Minimum Data Set (MDS) assessment documented the resident's cognition was intact and he required extensive assistance for bathing, limited assistance for personal hygiene and dressing. A comprehensive care plan (CCP) dated 11/17/17 documented the resident had an infection of the left foot. Interventions listed on the CCP did not address how the facility would maintain infection control measures to the foot. On 11/29/17 at 09:55 AM the resident was observed with a gauze dressing on his left foot, he was not wearing a sock over the dressing and the dressing was in direct contact with the floor. During a skin observation with the wound specialist nurse practitioner (NP) on 11/30/2017 at 11:05 AM, she stated she would not want the resident's dressing on the left foot to come in contact with the floor as that would contaminate the dressing exposing him to bacteria. The resident's foot should be covered with a sock at all times as there was visible bone in the resident's left foot wound. On 12/01/17 at 08:53 AM the resident was observed sitting on the side of the bed with his left foot uncovered and his dressing in direct contact with the floor. During an interview with registered nurse (RN) Unit Manager #2 on 12/04/17 at 11:37 AM, she stated she was covering her unit for infection control as the facility currently did not have an infection control nurse. She monitored hand washing and provided education on antibiotic tracking and hand washing. The resident's left foot dressing should not be in contact with the floor as it could contaminate the dressing and foot should be covered at all times with a sock. 3) Resident #132 was admitted [DATE], re-admitted [DATE], and had [DIAGNOSES REDACTED]. The 06/05/17 comprehensive care plan (CCP) documented the resident had an indwelling catheter (Foley) for a [MEDICAL CONDITION] bladder. Interventions included check tubing for kinks twice a shift, monitor intake and output per policy, monitor for discomfort, and monitor for UTI. The 06/29/17 physician order [REDACTED]. The 09/06/17 physician order [REDACTED]. The undated certified nurse aide (CNA) Kardex care instructions documented to monitor for UTIs, check tubing for kinks twice a shift, and monitor/document for pain/discomfort caused by catheter. On 11/28/17 at 01:39 PM, the Foley catheter drainage bag was out of the privacy bag that was hanging on the window side bed. The drainage bag was laying uncovered and folded in half on the floor on the window side of bed. On 12/01/17 at 11:44 AM, certified nurse aide (CNA) #4 stated she cared for the resident on 11/28/17. The drainage bag should be in a privacy bag on the left side of his bed, and she checked the bag for issues every 2-3 hours. The bag should be positioned below bladder level and off the floor. The resident could pull the bag off the bed himself if it was not in a privacy bag. He would not be able to do this if it was in a privacy bag. When she went in his room [ROOM NUMBER]/28/17 around 10:00 AM, the bag was hanging from the bottom of the bed. She checked the bag sometime between 1:00 PM and 2:00 PM, and did not notice anything wrong with the bag at that time. She stated the drainage bag was not supposed to touch the floor for infection control purposes. On 12/01/17 at 12:01 PM, licensed practical nurse (LPN) Assistant Unit Manager #5 stated catheter drainage bags were supposed to be in a privacy bag, below bladder level, checked and emptied every shift minimally, and not supposed to be on floor due to infection control. The bags should be checked during care and at various times. The resident could roll to his left side and could dislodge the drainage bag from the bed frame if the bag was on the right side of the bed. She did not think he could pull it using his left arm as he could not use his left arm. On 12/05/17 at 11:25 AM, the Director of Nursing (DON) stated drainage bags were to be in a privacy bag at all times for dignity, hung below bladder level, and off the floor for infection control purposes. Staff were to check the drainage bags when providing care, when doing treatments or medication passes, or passing by the resident. She expected the drainage bags to be off the floor and in a privacy bag. 10 NYCRR 415.19(b)(2)

Plan of Correction: ApprovedJanuary 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
For residents #8, #10, #55, #104 and # 137 were assessed by the Unit managers on (MONTH) 29, (YEAR) and no untoward injury was sustained from LPN observed during medication pass.
All LPNs who worked on the evening shift during day of observation were educated on infection control during medication pass by the Director of Nursing on (MONTH) 19, (YEAR).
Resident # 99 admitted with [MEDICAL CONDITION] and [MEDICAL CONDITION]. This resident values his independence and is able to transfer and ambulate with minimal assistance. Resident encouraged to wearing socks when up and about and or asking for assistance so that staff can assist him put on socks or shoes before ambulating or transferring. Added Kling wrap as secondary dressing to minimize contamination of the primary dressing
Residents # 99 and # 132 both have urinary catheters secondary to their medical diagnosis. Facility is currently in search of other options for urinary drainage bag covers that cannot be easily removed or slide off the drainage bag.
All staff will be educated by each unit manager to ensure that urinary drainage bags are covered with a dignity bag at all times. Education completed (MONTH) 12, (YEAR).
2.
Infection Control Audits including medication pass observation are currently underway. Audit and observation will be completed by (MONTH) 19, (YEAR) by facility educator/ Infection preventionist. Any deviation from the audit will be immediately corrected.
Audit Threshold is 100%
Infection Control during medication pass and treatment education will be conducted by the facility educator/ Infection Preventionist to all licensed nursing staff by (MONTH) 26, (YEAR).
All staff will be educated by the facility educator/ Infection preventionist to observe and ensure that all residents who have urinary drainage bag are covered with a dignity bag. Education will be completed by (MONTH) 26, (YEAR).
All Licensed staff will be educated by the Administrator on wound treatment / dressing protocol that includes minimizing of exposure to infection through use of appropriate primary or secondary dressing. Education will be completed by (MONTH) 31, (YEAR).
3.
**Unit managers, assistant managers and supervisors will monitor licensed staff (medication nurses) compliance to infection control during medication administration that includes hand hygiene and handling of medications. Any deviations will be reported to the Director of Nursing and Infection Preventionist for immediate correction.
**Unit managers, assistant managers and supervisors will daily monitor presence/ use of drainage bags on all residents with urinary catheters. Immediately correct any issues.
Central supply will continue to contact vendors for other urinary drainage bag options and inform administrator.
** Currently the facility has 2 types of of catheter drainage bag covers. Staff and managers are monitoring usage of these covers at all times.
Infection preventionist/ designee will conduct medication administration competency to all licensed staff whose primary function is medication administration. Competencies will be completed by (MONTH) 3, (YEAR).
Infection Control during medication pass and treatment education will be conducted by the facility educator/ Infection Preventionist to all licensed nursing staff by (MONTH) 26, (YEAR).
All staff will be educated by the facility educator/ Infection preventionist to observe and ensure that all residents who have urinary drainage bag are covered with a dignity bag. Education will be completed by (MONTH) 26, (YEAR).
All Licensed staff will be educated by the Administrator on wound treatment / dressing protocol that includes minimizing of exposure to infection through use of appropriate primary or secondary dressing. Education will be completed by (MONTH) 31, (YEAR).
** Hand hygiene observation/ competencies will be conducted with all staff by Infection preventionist/ designee monthly.
** Education was conducted on (MONTH) 27-28 on hand hygiene by the Administrator. The Infection preventionist will continue to educate on hand hygiene until (MONTH) 3, (YEAR).
4.
Infection Preventionist/ designee will conduct audit monthly for 3 months.
** Infection Control Audit included random sampling of medication pass, wound dressing and all resident with indwelling foley catheter. Director of Nursing will report results to monthly QAPI for further review and guidance.
Audit Threshold is 100%
5.
Person responsible for the correction of this deficiency is the Director of Nursing.

FF11 483.10(g)(14)(i)-(iv)(15):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.)

REGULATION: §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview conducted during the recertification survey for 1 of 5 residents (Resident #115) reviewed for pain, the facility did not ensure the physician was notified timely. Specifically, the physician was not notified when Resident #115 had increased pain and decreased mobility. This resulted in untreated pain as the physician was not notified timely to determine if a change was needed in the resident's treatment plan. Findings include: Resident #115 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 02/21/17 physician orders [REDACTED]. A 06/15/17 nurse practitioner (NP) progress note documented the resident was on Tylenol three times daily and [MEDICATION NAME] 5.0 mg one tablet twice a day prn. Her pain was well controlled, stable, with no changes. A 06/16/17 physician progress notes [REDACTED]. The resident had a pain medication added in the past and she was adequately comfortable at this time with no changes. The resident's pain medication would continue and the resident would be watched carefully. A 06/27/17 pain assessment documented a pain assessment was not needed, the resident did not have symptoms of pain and received APAP and [MEDICATION NAME] (medications used to treat pain symptoms). A 07/13/17 NP progress note documented the resident had not exhibited any further signs or symptoms of pain or discomfort. The 07/2017 Medication Administration Record [REDACTED]. The pain levels documented in 07/2017 were on a scale of 2-5 on a scale of 1-10 (10 being highest pain). The 08/2017 MAR indicated [REDACTED]. The resident received prn [MEDICATION NAME] on 08/12, 08/13, 08/14, 08/18, 08/20, 08/23, 08/24, and 08/26/2017, for pain levels between 5 and 8. 2017 Nursing progress notes documented: - Between 07/12 and 08/11, the resident had no documentation of pain. - On 08/12, received prn pain medication for difficulty ambulating - On 08/13 and 08/14, [MEDICATION NAME] provided, no location of pain was noted. A licensed practical nurse (LPN) noted on 08/13/2017 the resident was assessed and alert. On 08/14, the resident was on the floor and assisted up by staff. There was no documentation a physician or registered nurse was notified or assessed the resident prior to assisting her off the floor. - On 08/18 at 11:41 PM, a LPN noted the resident was administered [MEDICATION NAME] for hip pain. - On 08/19 at 02:56 PM, a registered nurse (RN) noted the resident had a slower gate than normal and was barely shuffling her feet. The note documented conflicting information as it noted the resident denied pain, did not display signs or symptoms of pain, and was provided ben gay to hips and pain medications as ordered. There was no documentation a physician was notified when the resident had a change in her mobility. - On 08/19 at 11:13 PM, a licensed practical nurse (LPN) noted the resident had difficulty ambulating with slower gate. There was no documentation a registered nurse or physician was notified to assess the resident's change in gate. - On 08/20 at 09:16 AM, a LPN noted the resident had hip pain every 4 hours and received a prn medication. - On 08/20 at 11:42 PM, a LPN noted the resident continued with difficulty walking. There was no documentation a registered nurse or physician was notified to assess the resident's change in ambulation. - On 08/23 and on 08/24, a LPN noted the resident had pain when her depends were changed and was administered prn pain medication. - On 08/26 at 12:07 AM, physician #29 ordered a bowel medication. There was no documentation the physician was notified of changes in ambulation and pain with care. - On 08/26 at 01:36 AM, the resident had hip pain. - On 08/26 at 01:58 AM, a LPN noted the resident's family member was updated regarding a fall and orders for x-rays. There was no additional documentation in the nursing notes regarding a fall or when x-rays would be completed. - On 08/26 at 12:13 PM, the resident displayed signs of pain during ADLs and says oh yeah when asked if in pain. There was no documentation the physician was updated on the pain symptoms or if an x-ray had been completed. - On 08/26 at 04:07 PM, a RN noted the resident had an X-ray that showed right fracture of femoral head and right pubic. The physician and family were notified and the resident was sent to the hospital. During an interview on 12/05/17 at 09:51 AM, certified nurse aide (CNA) #6 stated the resident used to walk with a walker throughout the unit. She would state she had pain more in her back and feet, not in her hip. Staff would notify the nurse if she stated she was in pain as the resident was cognitively not able to report to staff on her own if she had pain. She did not recall if she had reported any pain symptoms to nursing, the CNAs used to report verbally and did not have documentation to support their reporting, since the fracture they were now able to enter in an electronic system if they notified the nurse of changes in a resident's condition. During an interview on 12/05/17 at 10:19 AM, LPN #17 stated when the resident first moved to the unit she would state she only had foot pain and prn [MEDICATION NAME] was administered at 5.0 mg ever so often. Even when the resident had foot pain, she would still walk. The staff had provided her with a wheelchair prior to 08/26/17 related to a decline in her ambulation. During an interview with CNA #13 on 12/05/17 at 10:57 AM, she stated the resident had a decline in her status. Prior to 08/26/17 staff would assist the resident last to the dining room for meals as the resident was not able to be left in a chair alone, as she would get hurt if she was left by herself. Registered nurse (RN) #26, who was documented as working between 08/11-08/26/17, was contacted by phone on 12/05/17 at 12:56 PM and did not return the surveyors call prior to the exit of the recertification survey. Nurse practitioner (NP) #21 was contacted by phone twice on 12/5/2017 and surveyors were unable to leave a message to return their call. During an interview with CNA #27 on 12/05/17 at 01:12 PM, she stated she remembered a time just prior to 08/26/17 the resident had a recliner brought to her room related to a change in her ambulation status. The resident was not able to transfer herself out of a chair or the bed and they would change her in bed. She was no longer mobile, at that time. She remembered the resident having the recliner as she had become unsteady on her feet a few days prior to the determination of a fracture. She was no longer able to walk and they were using a wheelchair. She could not recall if the resident had pain, if she had she would have notified the nurse. A telephone message was left on 12/05/17 at 01:33 PM for physician #29. The physician did not return the surveyors calls prior to the exit of the recertification survey. CNA #30, who worked with the resident between 08/11-08/26/17, was no longer employed by the facility at the time of the recertification survey. CNAs #31 and 32, who worked with the resident between 08/11-08/26/17 were left messages on 12/05/17 and did not return the surveyor's call prior to the exit of the recertification survey. During an interview with LPN Assistant Unit Manager #5 on 12/05/17 at 01:45 PM, she stated the resident's pain was difficult to assess as she always kind of presents with pain. She had dementia and it was difficult to receive an accurate answer from her. The resident had been using a walker and she started having hip pain and was going between walking independently and using a wheelchair prior to 08/26/17. During an interview with registered nurse (RN) Unit Manager # on 12/05/17 at #7 she stated if the resident's frequency of pain increased the physician should be notified or a significant change note should be completed. She stated it was difficult to determine the pain for this resident as some of the nursing notes documented potential symptoms she had presented with in the past. During a phone interview with physician #28 on 12/05/17 at 03:50 PM, he reviewed his notes via the electronic medical system. He prescribed [MEDICATION NAME] a long time prior related to back pain. If there was an increase in use of a prn medication staff would and should point it out to the physician. If someone was complaining of severe pain with care, like her displaying signs of pain during changes of her briefs, a medical provider should be notified. A resident should not be experiencing pain in that way and without an evaluation and treatment by the medical provider. It would be abnormal for this resident if there was a change in ambulation and pain with care. She should have had an evaluation and X-ray done when this pain began occurring to determine the potential location of pain. 10 NYCRR 415.3(2)(ii)(a)

Plan of Correction: ApprovedJanuary 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
Resident #115 is a [AGE] year old female with [DIAGNOSES REDACTED]. Because of her dementia and behavior accurately assessing and quantifying her pain has been a challenge to staff.
Providers have standing pain MEDICATION ORDERS FOR [REDACTED]. The decline in ADLs matches the timing of increased pain trend.
Director of Nurses educated all nurses on (MONTH) 5, (YEAR) regarding timely recognition and reporting of changes to providers and documenting any new interventions.
Resident was transferred to the hospital on (MONTH) 6, (YEAR) per family request; resident expired under hospice care in the hospital.
2.
Audit is being conducted by all unit managers/ designee focusing on all residents on narcotic pain medications and any resident who have had a decline in ambulation in the last 30 days. Such audit is scheduled to be completed by (MONTH) 12, (YEAR).
Any resident that will be found affected will be immediately corrected by re-assessment or further referral as necessary.
Facility educator/ designee will conduct mandatory education to all licensed staff on facility policy on timely documenting and reporting of changes which includes ADL changes and pain recognition. Education will be completed by (MONTH) 26, (YEAR).
**Facility currently check all residents every shift for signs and symptoms of pain; either via pain scale or other indicators of pain such as physical signs ie. grimacing, increased behavior etc. Unit managers will review all indicators of pain for each resident and update pain APL ( Acceptable Pain Level). Any pain level (verbalized) or observed beyond the resident APL will be addressed/ reported.
**The audits aims to address 2 areas: decline/ issues with mobility and ambulation and any resident currently of narcotic medication.
**At least quarterly during care planning pain assessment/ evaluation is completed to check for increased usage of pain medication or symptoms of pain.
Facility educator/designee will conduct mandatory education to all CNAs, activity staff and therapy staff on facility policy on timely reporting and documentation of changes that includes ADL changes and signs of pain via point of care STOP and WATCH or custom alert. Education will be completed by (MONTH) 26, (YEAR).
Facility educator/ designee will conduct mandatory education to licensed staff on procedure for documenting any new orders or interventions. Education will be completed by (MONTH) 26, (YEAR).
3.
Managers, assistant managers and supervisors will frequently review the electronic health documentation system. These include the dashboard specifically high risk progress notes and point of care alerts.
Managers, assistant managers and supervisors will review or follow up any significant change note, communication to provider and new medication/ intervention orders to ensure that clinical issues are addressed timely and appropriately by the right discipline such as the doctor, therapy or social services.
To avoid confusion the current new medication order progress note template will be revised to New Intervention template. This will avoid confusion from licensed staff where to document any new orders or interventions such as radiography orders or referrals such as therapy. New template will be available for use and mandatory education will be conducted by the facility educator/ designee before (MONTH) 26, (YEAR).
4.
Unit Managers will audit timely notification and documentation of weekly audits x 4 for the first month, bi-monthly x2 for the second and third month.
Audit threshold is 90%. Noncompliance will be submitted to the Director of Nursing/ designee for review and correction as necessary. Director of Nursing will submit results of audits to monthly QAPI for further review.
5.
The Director of Nursing will be responsible for the correction of this deficiency

FF11 483.65(a)(1)(2):PROVIDE/OBTAIN SPECIALIZED REHAB SERVICES

REGULATION: §483.65 Specialized rehabilitative services. §483.65(a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident's comprehensive plan of care, the facility must- §483.65(a)(1) Provide the required services; or §483.65(a)(2) In accordance with §483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey for 1 of 5 residents (Resident #89) reviewed for position and mobility, the facility did not ensure specialized rehabilitative services required in the resident's comprehensive plan of care were provided. Specifically, Resident #89 was not provided with a thorough physical therapy (PT) and occupational therapy (OT) evaluation as planned when admitted to the facility. In addition, she was poorly positioned in her wheelchair throughout the survey. Findings include: Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/23/17 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired; she required extensive assistance for bed mobility; and total dependence for transfers and eating. The 10/16/17 comprehensive care plan (CCP) documented the resident had a self-care deficit limited to physical immobility. Interventions included a PT/OT evaluation and treatment per physician orders. The 10/16/17 social services progress note documented the resident would stay in the facility long term after her rehab has finished. A Care Guide Update Form completed by PT on 10/17/17 documented the resident was non-ambulatory and please use Hoyer lift for all transfers. There was no further PT or OT documentation in the resident's medical record. The 10/18/17 physician progress notes [REDACTED]. The 10/26/17 wound nurse practitioner (NP) note documented pressure injury interventions including to turn and reposition the resident every 2 hours and hourly while in wheelchair. The 11/2017 certified nurse aide (CNA) Kardex (care instructions) did not contain instructions on the resident's positioning nor did it identify the resident should be repositioned in her wheelchair hourly per the recommendation of the wound specialist. Observations by a surveyor of the resident's positioning included: - On 11/28/17 at 10:50 AM, the resident was in her wheelchair sleeping with her head leaning forward toward her lap. - On 11/28/17 at 02:21 PM and 02:26 PM, she was leaning toward the right, with her head leaning forward almost in her lap and she was using her left hand holding up her forehead. - On 11/29/17 at 10:12 AM, the resident was observed sleeping in her wheelchair with her head tilted forward and to the side. - On 11/30/17 at 09:28 AM, the resident was observed in a wheelchair in the unit lounge, in a high back wheelchair tilted slightly back with head in a more upright position. The resident continued to cover her face in a blanket. - On 12/01/17 at 01:28 PM, the resident was observed in her room in her wheelchair with her head leaning forward and resting on right side arm rest. - On 12/03/17 at 07:00 PM, the resident was sitting in her room in her wheelchair facing the door with the lights out. Her head was down with her face tucked in to the front of her shirt. She did not have pants on, and her blanket was falling off to right exposing her upper legs. - On 12/04/17 at 11:23 AM, a CNA was observed wheeling the resident down the hallway in the wheelchair and she was leaning forward to her left side with her head resting on the wheelchair arm rest. During an interview with CNA #1 on 11/30/2017 at 01:16 PM, she stated at times the resident leaned toward one side of her wheelchair and there was a wedge cushion or pillow that they could use if she was doing that. During an interview with the Director of Rehabilitation on 12/04/17 at 10:29 AM, she stated all residents admitted to the facility received an initial PT/OT evaluation. The evaluation consisted of determining bed mobility, range of motion, transfer status and positioning. When the resident was eyeballed when she was admitted , that was considered her evaluation. She was lethargic and they had determined she was a mechanical lift for transfers. There was no further assessment of the resident other than eyeballing her and there had been no re-assessment. During an interview with social worker #3 on 12/04/17 at 10:35 AM, she stated the hospital had reported to her the resident was coming to the facility for long term care and would benefit from some short-term rehabilitation so she could get a little stronger. That was the request of the hospital as well as the family. The resident did not receive PT as it was obvious when she got here she not going to be cooperative with PT. During an interview with the registered nurse (RN) Unit Manager #2 on 12/04/17 at 11:25 AM, she stated a PT evaluation included assessing the resident's positioning, ability to transfer, bed mobility and positioning while in wheelchair. The resident was always positioned well in her wheelchair, she had not observed or been notified of any issues with the resident's positioning in the wheelchair. Leaning forward and to the side was the resident's baseline position in the wheelchair. 10NYCRR 415.16(a)

Plan of Correction: ApprovedJanuary 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
Upon admission to the facility on [DATE], Resident #89 was admitted at a hoyer level for transfer, total assistance for ADLs, and the plan to attempt short-term rehabilitation in order to return home.
Physical and occupational therapy was attempted unsuccessfully in the hospital prior to admission to the facility.
On [DATE], speech therapy assessed the resident and placed her on a restorative therapy program. Physical and occupational therapy were unable to fully assess resident due to lethargy and the resident?s inability to actively participate in the evaluation process. Upon screening the resident on [DATE], resident was determined that a hoyer level for transfers was appropriate. Skilled physical and occupational therapy were not indicated at that time. Per nursing reports and therapist informal clinical observations, throughout (MONTH) and November, there was no change in resident abilities indicating a need for skilled physical or occupational therapy service.
On [DATE], physical therapy completed a comprehensive evaluation. Resident repeatedly put the blanket over her head and would not participate in a full evaluation. It was again determined that skilled therapy services were not indicated at that time.
** Resident positioning was also addressed by therapy by lengthening the wheelchair leg rest and for nursing to encourage her to uncross her legs when in the wheelchair. This is in addition to a recliner wheelchair with lateral supports and regular leg rest on admission.
On [DATE], physical therapy attempted an evaluation and there were no changes noted. Resident again would not participate. Nursing will monitor resident for changes and notify therapy if resident begins to attempt active participation in ADLs/transfers.
**Providers / physicians are made aware of non-compliance to therapy through the Unit Managers. Unit Managers will in turn inform providers through MD communication prior to next scheduled visits. Resident physician is aware of non compliance with therapy and other recommendations and noted on MD visit on [DATE]. Plan of care at that time was to contact resident HCP and plan for a realistic plan of care.
**Therapy are made aware of positioning concern through therapy referral from nursing daily or during scheduled care planning.
** Functional Impairment Policy and procedure includes directive on any incidence of non-compliance and resident is still in the facility will be re-evaluated within the 72 hour time frame and documented.
Resident expired on [DATE].
The Administrator reviewed the facility policy and procedure on Functional Impairment- Clinical protocol with the Director of Rehabilitation and all therapist on staff which states that all new admissions must be evaluated by either PT or OT on (MONTH) 5, (YEAR).
2.
The Director of Rehabilitation/ designee will audit all admissions within the past 45 days for evidence of PT or OT evaluation within 48- 72 hours of admission. Any incidence of non-compliance and resident is still in the facility will be re-evaluated. Any changes different from the current plan of care will be updated. Audit will be completed by (MONTH) 12, (YEAR)
** The therapy audit includes concerns with optimum positioning.
3.
** Weekly during Utilization meeting, MDS coordinator will check and ensure that all new admissions or re-admission with qualifying hospital stay are evaluated within ,[DATE] hours by therapy.Any non-compliance will be reported to the Rehab. Director and Administrator.
All residents will receive a PT or OT evaluation within 48- 72 hours of admission to ensure comprehensive plan of care is attained.
If resident is unable or unwilling to participate in the evaluation process it will be documented on the medical record and reported to Social services and provider for follow - up.
All other residents will be continually be screened by all staff for decline in their ADLs, transfer/ mobility status and positioning during their stay and will be referred to the provider for an order of specialized services such as PT, OT or Speech.
4. Director of Rehabilitation will conduct monthly audits for all new admissions for 3 months and quarterly thereafter; results will be reported to monthly QAPI meetings for further review.
Audit Threshold: 95%
5.
Person Responsible for the correction of this deficiency is the Director of Rehabilitation


FF11 483.25(a)(1)(2):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- §483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey the facility did not provide proper treatment and assistive devices to maintain vision for 1 of 1 residents (Resident #125) reviewed for devices to maintain vision. Specifically, Resident #125 was not assisted in locating her glasses and her plan of care did not include a plan for vision and devices. Findings include: Resident #125 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Record face sheet dated 11/06/17 included a picture of the resident wearing eyeglasses. There was no documentation of the resident's requirement for eyeglasses in the 11/2017 comprehensive care plan (CCP) or the 11/2017 certified nurse aide (CNA) Kardex (care instructions). The resident's family member was interviewed on 11/29/17 at 12:12 PM. She stated the resident had lost her glasses (trifocals) and it had been about a week. She had not reported to staff yet, and staff had not approached her regarding the glasses. The resident was observed without eyeglasses on 12/03/17 at 07:12 PM in the hall near entrance to the unit, and on 12/04/17 at 07:51 AM in the dining room. On 12/05/17 at 09:35 AM, certified nurse aide (CNA) #6 was interviewed She stated the resident had glasses the first few days or the first week she was at the facility and they had disappeared somewhere. Somebody had asked the resident one morning, where are your glasses? and the CNA then noticed she did not have them. They would eventually be found. Other residents picked up items and she would check those residents that picked things up first as that was usually where missing items could be found. She did not find the resident's glasses. It was difficult to check the resident's room as she would become upset. She was not sure if the glasses were reported missing, and she had not reported them missing. On 12/05/17 at 10:22 AM licensed practical nurse (LPN) #17 stated she did not think she had seen the resident with glasses on. Other residents had missing glasses. There was a paper that was filled in if something was missing and she would inform the supervisor and she would handle it. The family would also be called and she would check around the floor. She had not completed any of these forms. On 12/05/17 at 10:29 AM registered nurse (RN) Unit Manager #7 was interviewed. She stated the resident's family member reported on 12/4/2017 the resident's glasses were missing, and the Unit Manager was not aware they were missing prior to that date. The glasses were likely in the resident's room or someone else's room and she did not know where the resident could have put them. The resident's admission picture showed the resident had her glasses on admission. Staff should have noticed the glasses were missing and reported it to her, and staff should not rely on the family to recognize they were missing. 10NYCRR 415.12(3)(b)

Plan of Correction: ApprovedJanuary 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
Resident # 125 is a [AGE] year old woman with [DIAGNOSES REDACTED]. Resident was admitted with eye glasses on 11/6/17. Daughter stated to the Unit Manager on 12/5/17 she (the daughter) noticed that resident was not wearing her glasses for several days but never reported this to staff. Daughter states knowingly the resident wanders the entire unit, in and out of peer?s rooms thinking that the resident probably misplaced them during her wandering behaviors. Documentation states the resident often thinks that her peer?s belongings are her own. Resident can become combative and agitated with re-direction.
Resident # 125 did not have an event such as fall or run over stuff the time that she did not have her eyeglasses.
*Resident missing eyeglasses can't be found. Daughter brought in another pair ** on /around week of 12/10/17 , resident is wearing/using them sporadically. ** Optometrist is aware of the eyeglasses brought in by daughter that she uses sporadically and is care planned.
Resident was seen and examined on 1/3/18 by Optometrist. Eyeglasses are not recommended at this time.
*Care plan updated per new recommendation from Optometry.
Unit Manager and nursing staff were educated by the Director of Nursing on timely reporting of missing assistive devices such as eyeglasses on (MONTH) 5, (YEAR).
Social services reiterated to resident daughter and family about timely reporting of missing assistive devices to nursing staff or to social services so that facility can intervene quickly. This was completed by Director of Social services on 1/12/18.
All managers were educated by the Director of Nursing that any resident with visual adaptive devices must be care planned. This was completed on (MONTH) 12, (YEAR).
2.
Audit was conducted on residents who were indicated to require eyeglasses. Audit was completed on 1/ 4/ (YEAR). Result of audit showed 47% of those audited with eyeglasses do not have a current visual care plan. 13% of residents of those audited refused to wear eyeglasses. All residents recommended to have eyeglasses have their eyeglasses.
Audit Threshold is 95%
All residents without a visual care plan that are indicated to have eyeglasses will have a visual care plan completed by (MONTH) 26, (YEAR).
All managers were educated by the Director of Nursing that any resident with visual adaptive devices must be care planned. This was completed on (MONTH) 12, (YEAR).
3.
**All staff are required to report any incidence of missing property such as eyeglasses etc, immediately to Unit manager/ supervisor or charge nurse up to the Grievance officer.
All managers are educated that any resident admitted with eyeglasses or visual deficit must be care planned and added to task/ kardex within 21 days after admission. All other residents that may require visual adaptive devices after admission will be care planned as necessary. Education will be done by facility educator/ designee and will be completed by (MONTH) 26, (YEAR).
Unit manager will educate all nurses, CNAs that all residents are to be encouraged to wear vision device and report refusals or misplacement. Education will be completed by (MONTH) 12, (YEAR). Unit Managers to complete weekly audits x 4, monthly x2 then bi-monthly x2.
4. Audits will be conducted by the MDS coordinator/ designee monthly for 3 months.
*Audit threshold is 95%.
Result of non compliance will be reported to the Director of Nursing for review and correction. MDS coordinator will report to monthly QAPI result of Audits for further review.
5. Director of Nursing will be responsible for correction of this deficiency.

FF11 483.40(b)(1):TREATMENT/SRVCS MENTAL/PSYCHOSCIAL CONCERNS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey for 1 of 3 residents (Resident #124) reviewed for mood and behaviors the facility did not ensure a resident who displayed or was diagnosed with [REDACTED]. Specifically, Resident #124 exhibited behaviors, expressed thoughts of suicide and received an antipsychotic medication without a documented plan of care. Findings include: Resident #124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimal Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment; required extensive assistance with activities of daily living (ADLs); and did not have behavioral symptoms. The comprehensive care plan (CCP) dated 11/2017 did not document a plan of care or interventions to address his behavioral symptoms. Nursing progress notes documented the resident exhibited behavioral symptoms on the following days: - On 11/05/17, the resident was agitated, yelling out at times for assistance,and angry the family left him here. - On 11/16/17, the resident yelled, knocked on the wall to get staff attention, and was not using the call bell. - On 11/24/17 and 11/25/17, the resident yelled and screamed. - On 11/26/17, the resident yelled and screamed, was hard to redirect, easily angered, and the MD would be called for evaluation of medication. The nurse practitioner (NP) note dated 11/27/17 documented the resident was seen for an acute visit regarding his behaviors, staff reported the resident had been frequently shouting out especially at night, it was difficult to calm him down and he did not show violence towards others. The note documented the resident's behaviors were a result of dementia and possible sun-downing and the resident was started on [MEDICATION NAME] 25.0 milligrams (mg) 1/2 tab at bedtime. The physician orders [REDACTED]. Nursing progress notes documented on 11/29/17 the resident was hollering loudly, and on 11/30/17 he was yelling for help. The surveyor observed the resident on 11/30/17 at 09:47 AM, yelling in his room I want to be dead. He then exited his room when no staff responded, entered the hallway and with his hands around his mouth yelled I want to die! Registered nurse (RN) #18 responded, asked what was wrong, then left the resident alone in his room. The NP note dated 11/30/17 documented the resident was seen on that day after he stated he wanted to die. He was previously seen by another NP, and was started on a antipsychotic medication [MEDICATION NAME] 12.5 mg at night time. The note documented he continued to yell out at night. During her visit he was easily redirected, calm, and pleasant during examination, he did have some cognitive decline, he reported he felt anxious, had apprehension about living at the facility and was frustrated. The NP suspected his dementia with behavioral disturbances was partly due to his new environment, and he did not appear to have [MEDICAL CONDITION]. The plan was to increase the resident's [MEDICATION NAME] to 25.0 mg at bed time and continue to redirect with supportive treatment and encourage the resident to attend activities. The physician's medication orders dated 11/30/17 documented the resident was to receive [MEDICATION NAME] 25.0 mg one tab at bedtime for dementia with behavioral disturbance. The social services progress note dated 11/30/17 documented the resident was yelling in the hallway stating he was going to kill himself, she took the resident to a quiet area to discuss his suicidal thoughts, and asked why he had those thoughts. The note documented the resident settled down and requested to return to his room and at that time he did alone. The recommendation was the resident would be asked to eat in the dining room that day. There was no documented plan or interventions put in place to monitor the resident for suicidal precautions except at meals if he chose to go to the dining room for meals. The Psychological Service note dated 12/03/17 documented the resident was being seen for voicing suicidal thoughts, his new [DIAGNOSES REDACTED]. The note did not include planned dates or what the trial basis time frame would be. On 12/04/17 at 9:30 AM the CCP was reviewed and there was no documented evidence the resident's CCP was updated to included suicidal thoughts and behavioral interventions to address his mood. When interviewed on 12/04/17 at 09:08 AM, CNA #19 stated the resident was slightly confused, he would yell help, help and staff would direct him to use the call bell. They would explain his yelling was disruptive. The resident had been yelling out since his admission, and other residents have reported he yelled out at night as well. The CNA did not hear the resident state he wanted to harm himself, he was informed by the Unit Manager. The intervention included to assist the resident up for meals, except breakfast where he can eat alone in his room. The CNA was unsure if the CNA Kardex reflected this information. When interviewed on 12/05/17 at 09:34 AM, social worker #20 stated she received a phone call from the nurse on the resident's unit, reporting the resident was in the hallway stating he wanted to kill himself. She arrived on the unit, approached the resident to talk, asked him if he was suicidal, and he stated he wanted to kill himself. He did not have a plan; he did state he would not eat anymore. He was angry, felt abandoned by his wife, and they discussed his ability to leave the facility and go home. She stated to the resident if he was suicidal or had a plan she would have to send him to the hospital. At that time the resident calmed down, she gave him water, asked if he felt safe to go to his room or if he wanted to attend an activity, and he chose to go back to his room. The social worker informed nursing that the resident needed to go to the dining room, and staff were to observe if he ate and he did. She informed the family member of the situation, and the family member came to the facility and had a long conversation with the social worker. The social worker observed him later that day, he still seemed a little sad and she put in a psychological consult to be seen and the psychological services saw him on 12/03/17. A behavioral care plan was initiated 12/04/17 and she was responsible to ensure the resident's care plan reflected all his psychosocial needs prior to 12/04/17. There was no documentation addressing the resident's behavior symptoms or suicidal thoughts. The resident's plan of care going forward was nursing would monitor him she would see him every 3-4 days for suicidal ideation and he would be referred for psychological services on a trial basis. There was no documentation of when the resident was to be seen. The social worker saw the resident on 12/04/17 just to say hello and possibly involve him in more activities. She did not document goals or interventions other than to administer medications and coping. NP #21 was contacted by telephone on 12/04/17 and 12/05/17 and surveyors were unable to leave a voicemail and did not receive a call prior to the exit of the recertification survey. When interviewed on 12/04/17 at 10:30 AM, RN#18 stated the resident had behaviors since he arrived on the unit, she attempted to talk to him, asked him what was wrong, and changed the subject. Sometimes it worked and sometimes it did not. The resident received [MEDICATION NAME] for his behaviors starting 11/27/17 at bedtime for one week. On 11/30/17 the ordered medication was increased to [MEDICATION NAME] 25.0 mg at bedtime after he stated he wanted to die and threatened to kill himself. She did not know what monitoring was in place prior to or after the resident made the suicidal ideation. The care plan was updated by the Unit Manager and when reviewing the care plan with this surveyor, she stated there was no documentation of the resident's behaviors or his outburst of suicidal ideation. On the day the resident expressed he wanted to die the social worker was notified, she came to the unit, talked to the resident for a short time and she did not observe any further interaction between the resident and the social worker. When interviewed by telephone on 12/05/17 at 11:03 AM, NP #22 stated she saw the resident on 11/30/17 as he was having behaviors of yelling out, sundowning and was not able to be redirected. She reviewed the medical record, saw the resident received [MEDICATION NAME] 1/2 tablet at bedtime and changed the dose to 25.0 mg per recommendations for effectiveness. She talked to the staff regarding his behaviors, when staff were unable to redirect the resident she increased the medication dose. Redirection would mean non-pharmacological interventions that supported the use of the antipsychotic. She was unable to state interventions that were attempted prior to ordering the antipsychotic. The resident's [DIAGNOSES REDACTED]. There was no documentation in the resident's medical record outside of the NP note, the resident had a [DIAGNOSES REDACTED]. During an interview on 12/05/17 at 11:19 AM, with the resident's family member, she stated she was not made aware the resident was started on an antipsychotic and no one from the facility discussed that with her prior to the surveyor. When interviewed on 12/04/17 at 12:13 PM, RN Unit Manager #7 stated the resident did not exhibit many behaviors in her presence and she only heard him yell out once or twice since admitted to the unit. There was not a behavioral care plan in place at that time to address behavioral symptoms. She thought social services would have initiated a behavioral care plan especially after the resident stated he wanted to die. After review of the resident's plan of care prior to and after he expressed suicidal thoughts she was unable to find a documented behavioral care plan for the resident. When the resident stated he wanted to kill himself social worker #20 spoke with the resident, alerted the family and the physician. The verbal directive after the interview was to have the resident go to meals in the dining room. She was unable to provide any documentation to support this directive during the interview. She stated the order for [MEDICATION NAME] was initiated about 1 month prior due to his adaptability and the change from home to the facility. She was unable to find documentation to support the resident had a [DIAGNOSES REDACTED]. She stated it was not until 11/30/17 when he had a reference documented in the NP note that the resident had dementia with behaviors. Staff attempted no- pharmacological interventions using activities which he refused to attend and she was not sure if he liked any particular activity. She was responsible to ensure the resident's plan of care was implemented and updated to reflect the resident needs/status. 10NYCRR 415.12(f)(1)

Plan of Correction: ApprovedJanuary 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
Resident # 124 was recently admitted on (MONTH) 4, (YEAR) from home with primary [DIAGNOSES REDACTED]. His primary care giver at home was his wife who can no longer take care of him because of her own health care issues.
It was reported by staff through documentation on behavior care progress note that resident have been having behavioral disturbance that are difficult to redirect such as calling out and yelling out frequently. Such un redirectable behavior with non-pharmacological intervention such as redirection and verbal comfort lead to nursing staff referring him to facility provider on (MONTH) 27, (YEAR). Night dose of [MEDICATION NAME] was started to assist him to sleep and with his behavioral disturbance. Wife was informed of drug initiation as documented on the medical records on 11/27/2017.
On (MONTH) 30, (YEAR) resident expressed suicidal thoughts but did not really have a plan aside from not eating. He was seen and followed up by facility social worker who is a LCSW. He was also referred to consultant psychologist who has seen him on 12/3/2017. Psychologist impression was adjustment disorder. He will be seen again by psychologist before (MONTH) 10, (YEAR).
*Resident # 124 [MEDICAL CONDITION] will be scheduled for gradual dose reduction as per policy and awaiting psychologist recommendation.
Resident has now acclimated to the facility and has since been started on antidepressant.
Resident care plan has been updated by both nursing and social services on management of his behavior.
Social services were educated by Administrator on timely review and follow up of high risk progress notes specifically behavior notes and behavior alerts.
Social services and unit manager were both educated on ensuring that care plan is up to date as it relates to definitive goals and interventions/ management on 1/5/2017 by the Administrator.
2.
Social services will conduct an audit on all residents currently on antipsychotic medications and on any other residents reported to have exhibited behavioral issues in the last 30 days. Audit will be completed by (MONTH) 12, (YEAR).
*Audit threshold is 95%
Any item not meeting established criteria in the audit will be reviewed and corrected immediately.
Mandatory education will be conducted to all licensed staff on timely completion of behavior notes, significant changes notes and new medication/ intervention order by facility educator/ designee and will be completed on (MONTH) 26, (YEAR)
Mandatory education will be conducted on all CNAs on timely completion and reporting of behavioral issues residents by facility educator/ designee and will be completed on (MONTH) 26, (YEAR).

3.
**Social services will be re educated on frequent review of the electronic health documentation system' dashboard. This includes the high risk progress; behavior, significant change and the point of care alert for behavior alerts.
Social services will follow up any psychosocial concerns noted or reported. Social services will document findings, care plan definitive goals and interventions and make further referrals as necessary.
**Social Services will be the facilitator in the quarterly Gradual Dose Reduction meeting for all residents on [MEDICAL CONDITION] medications. This will ensure that all residents on [MEDICAL CONDITION] medications are appropriately documented.
Mandatory education will be conducted to all licensed staff on timely completion of behavior notes, significant changes notes and new medication/ intervention order by facility educator/ designee and will be completed on (MONTH) 26, (YEAR)
Mandatory education will be conducted on all CNAs on timely completion and reporting of behavioral issues residents by facility educator/ designee and will be completed on (MONTH) 26, (YEAR).
4.
Additional to frequent checks of the electronic health record documentation system, the Director of Social Services will audit all residents on [MEDICAL CONDITION] and any resident with [MEDICAL CONDITION] concerns monthly for 3 months;
Threshold is 95%, results will be reported to monthly QAPI meetings for further review.
5. Person responsible for the correction of this deficiency is the Director of Social services.

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: December 5, 2017
Corrected date: February 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducting during the recertification survey for 1 of 8 residents reviewed for pressure ulcers (Resident #89), the facility did not ensure all residents received treatment and services to prevent and/or heal pressure ulcers. Specifically, Resident #89 was identified to have a Stage II pressure ulcer on admission that was not re-assessed timely and she was not provided with pressure relief interventions as planned to promote healing. Findings include: Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/23/17 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, she required extensive assistance for bed mobility, and was totally dependent on staff for transfers and eating. The MDS documented the resident had an unhealed pressure ulcer upon admission to the facility, she had a pressure reducing device for the wheelchair only, there was not a pressure reducing device for the bed and she was not on a turning and repositioning program. The 10/16/17 comprehensive care plan (CCP) documented the resident had the potential for impaired skin integrity and had a Stage II pressure ulcer on the right outer ankle. A revision to the CCP on 11/09/17 documented the resident was admitted to the facility with a pressure ulcer on the ankle related to immobility. Interventions included to avoid pressure to both ankles, encourage non-skid socks, and monitor the dressing every shift to ensure it remained intact. The 10/16/17 admission skin assessment documented the resident had a Stage II pressure ulcer on the right outer ankle that measured 1.5 centimeters (cm) x 1.1 cm 0.1 cm. The admission assessment did not document a description of the wound bed. There was no documented evidence the pressure ulcer identified on 10/16/17 was re-assessed until 10/26/17. The 10/26/17 weekly wound nurse practitioner (NP) note documented the resident had a Stage III pressure injury on the right outer ankle. The wound bed contained 10% slough and 90% granulation tissue and measured 0.3 cm x 0.5 cm x 0.1 cm. Interventions included to turn and reposition the resident every 2 hours and hourly while in wheelchair and float heels off bed with pillow or offloading boots. The 11/02/17 weekly wound NP note documented the resident had a newly resolved stage 3 pressure injury at right lateral ankle and the interventions were turning and repositioning, pressure redistribution support surface for bed, heel protection and wheelchair cushion. The plan of care and treatment recommendations were discussed with the nursing staff and verbalized understanding. The 11/16/17 RN skin assessment documented the Stage II pressure ulcer on the right outer ankle was healed, contained 100% granulation tissue and measured 0.5 cm x 0.9 cm x 0.1 cm. The treatment was to apply calcium alginate to wound bed and cover with foam dressing 3 times per week and as needed (prn). The 11/16/17 weekly wound NP note documented the resident had a recurring stage 3 pressure injury at right lateral ankle that measured 0.5 cm x 0.9 cm x 0.1 cm. The hypergranulation tissue on the wound bed was debrided with silver [MEDICATION NAME] and the patient tolerated well. The NP documented the interventions were turning and repositioning, pressure redistribution support surface for the bed and heel protection, please obtain foam boots rather than offload with pillow. The plan of care and treatment recommendations were discussed with the nursing staff and verbalized understanding. The 11/21/17 weekly wound NP note documented the resident had a recurring stage 3 pressure injury at right lateral ankle that measured 0.5 cm x 0.7 cm x 0.1 cm. The wound contained 100% granulation tissue and interventions included turning and repositioning, pressure redistribution support surface for the bed and heel protection, please obtain foam boots rather than offload with pillow. The plan of care and treatment recommendations were discussed with the nursing staff and verbalized understanding. The undated certified nurse aide (CNA) Kardex (care instructions) active on 11/30/17 at 10:33 AM documented to avoid pressure to both heels, encourage the use of non-skid socks in bed, and turn and reposition in bed every 2 hours and as necessary. The Kardex did not document to offload the resident's feet or use foam boots, nor did the Kardex document to reposition the resident hourly while in wheelchair per the recommendations of the wound NP. The observations of the resident included: - On 11/30/17 at 09:28 AM, she was in a wheelchair in the unit lounge, she had on slippers, there was a bolster pillow/cushion on the left side of the wheelchair, and there was not a pillow to her right side. A CNA came in at that time and said to the resident she was going to put her to bed. She wheeled the resident out of the room, asked another CNA to help her put the resident in bed. - On 11/30/17 at 10:25 AM, the resident was observed in bed lying on her right side. The resident did not have foam booties, and her feet were not elevated. The right outer ankle was lying directly on the mattress. There were no foam booties observed in the room at that time. - On 11/30/17 at 10:46 AM, the surveyor entered the room with the wound NP. The NP stated the resident was on wound rounds for a pressure ulcer on her right outer ankle, and was supposed to have booties on her feet to keep pressure off the ankle. The NP looked at the resident's feet and stated she did not know why the resident did not have booties on and her ankle should not be resting directly on the mattress. It was important to relieve the pressure on the wound to allow it to heal. The NP assessed the resident's right outer ankle pressure ulcer and stated the pressure ulcer was bigger and more red. The surveyor observed a pressure ulcer directly over the right outer ankle and the surrounding skin was red. There was a small area of maceration to the top aspect of the wound with a small amount of darkish purplish tissue to the lower aspect and directly in the center of the wound is a small area that is darkish purplish in color. The NP stated the pressure ulcer measured 0.8 cm x 1.1 cm and the skin surrounding the pressure ulcer was reddened from the pressure that was applied while the ankle was lying directly on the mattress. The NP told the licensed practical nurse (LPN) and the Director of Nursing (DON), also present in the room, to ensure the resident was given booties for her feet and to ensure offloading from the mattress at all times. She stated pressure ulcers could potentially worsen if pressure relief was not provided. The NP stated she saw the resident's pressure ulcer when she was admitted to the facility, the pressure ulcer healed as she was spending more time up in her wheelchair, and then it had re-opened when the resident was spending more time in her bed. - On 11/30/17 at 11:11 AM, the resident was in bed on her back, there were no booties or offloading devices to her feet, and both heels were lying directly on the mattress. - On 12/04/17 at 11:03 AM, the resident was lying in bed on her left side with a pillow between her knees and and both feet were lying directly on the mattress. The blue booties where observed in a chair in the corner of the room. During an interview on 11/30/17 at 01:16 PM, CNA #1 she stated she would know if a resident needed any special devices or pressure preventative measures by reviewing the resident's Kardex. The resident did not have any pressure relief interventions in place until today after the wound NP came in to see her and now they were going to start putting booties on her feet. The resident was re-positioned every couple of hours when in bed and always rolled on to her right side. A copy of the CNA Kardex was obtained by the surveyor on 12/01/17 and did not identify to offload the resident's feet or use foam boots, nor did the Kardex document to re-position the resident hourly while in wheelchair per the recommendations of the wound NP. During an interview on 11/04/2017 at 11:25 AM, RN Unit Manager #2 stated she was notified of residents admitted with pressure ulcers immediately and the resident would be re-assessed on the next scheduled wound round. Pressure ulcer monitoring was done weekly with the wound NP and either herself or the Assistant Nurse Manager would be present. When the wound NP made recommendations for pressure relief they were initiated immediately, inputted into their plan of care and the Kardex so the CNAs knew to put the interventions in place. She would receive and review the wound NP documentation via email the day after the visit. She thought the resident did not have the booties in place as it was an oversight. Had they been in place the pressure ulcer may have healed or it may not have, she could not be sure. 10NYCRR 415.12(c)(1)

Plan of Correction: ApprovedJanuary 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
Resident # 89 is a [AGE] year old woman with [DIAGNOSES REDACTED]. Co- morbidity factors that contributes to poor healing or chronicity are poor intake, severe right sided contractures, bilateral lower [MEDICAL CONDITION], brittle diabetic with poor controlled blood sugar and malnutrition as evidenced by a low weight. Resident admission weight was 89.0 LBS. Resident was admitted to facility from the hospital [MEDICAL CONDITION] treatment for [REDACTED]. Treatment was ordered upon admission for the affected area. Wound Health Solutions NP consultant saw resident on [DATE]. Daughter has verbally expressed to nursing staff that her mother resident # 89 has this chronic would for ?a few years? and was unable to heal the wound.
All bed mattresses on Unit 1 where resident # 89 reside are graded as pressure redistributing.
Wound healing Solutions NP consultant recommended use of blue booties and turning and positioning while in bed and wheelchair.
Resident # 89 plan of care was reviewed by the Director of Nursing and Unit manager and updated care plan and kardex/ task as appropriate on ,[DATE]/ (YEAR).
Unit manager was educated by the Director of Nursing on [DATE] on the following: all new wounds must be referred to wound healing solutions (WHS) for follow-up. Weekly pressure ulcer assessment follow-up and *accuracy of information- must match WHS NP assessment . WHS recommendations must be followed and if not must be documented as to why.
* Resident #89 actual pressure ulcer was revised to reflect current preventative recommendations such: offloading boots to affected ankle, minimize to one hour when up in chair, turning and re-positioning when in bed.
* Resident transferred and expired in the hospital on [DATE]
2.
Audit was conducted and completed on [DATE] on all residents in house with pressure areas. No other resident was found to have been affected by the same practice.Audit Threshold is 85%.
Facility educator/ designee will conduct mandatory education to all RN and unit managers on facility policy and procedure as it relates to accurate weekly follow up of pressure ulcer, following recommended intervention for prevention and updating care plan and CNA/ kardex. Education will be completed by (MONTH) 26, (YEAR).
**ALL RNs are aware of facility requirement of completing an initial wound assessment either in the Admission skin assessment or Weekly wound assessment for newly found skin issue. ALL RNs have been educated on this procedure numerous times in the past but will be re-educated again by Facility educator on assessment, treatments and interventions by (MONTH) 26, (YEAR).
*CNAs wil be educated on importance of following preventative intervention as stated on kardex for wound healing and reporting any non-compliance, refusals or issues to nurse and point of care alert. Education will be conducted by facility educator/ designee and completed on [DATE].
3.
**Unit Managers/ designee will review all new admissions for presence of pressure ulcer within 24 hours of admission.
**Managers/designee will ensure pressure follow up within a week either by an RN or WHS consultant.
**After each wound rounds any recommendation will be reviewed, ordered, care planned and or added to CNA kardex as appropriate.
**Unit managers/ designee and Director of Nursing will check weekly that pressure ulcer documentation and follow-up is completed by ensuring that a completed RN weekly wound follow up is in the active clinical chart of the resident.

4.
*Monthly audit will be conducted by the assistant managers/ designee for treatment and services provided to residents with actual pressure ulcers for 3 months. Audit includes accuracy nursing documentation, care plan, care plan interventions, weekly wound assessment. Any issues will be immediately reported to the Director of Nursing for follow-up and correction.
Audit threshold is 90%
Results of audit will be reported to monthly QAPI by the Director of nursing for further review.
5. The Director of Nursing will be responsible for the correction of this deficiency.

Standard Life Safety Code Citations

ARRANGEMENT WITH OTHER FACILITIES

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview during an Emergency Preparedness (EP) survey, the operator did not ensure arrangements were made to transport and receive residents. Specifically, there were no agreements with emergency shelter or emergency transportation providers to receive residents and maintain the continuity of services for the residents. Findings include: Review of the facility's Disaster and Emergency Plan for evacuation on 12/12/2017 revealed: - There were no current commitment agreements available for review and no emergency shelter providers identified in the plan. - There was not a current commitment agreement available for review and there was not an emergency transportation provider identified in the plan. When interviewed on 12/12/2017 at 10:00 AM, the Administrator stated there were no agreements made with other facilities or transportation providers. The only agreement the facility had was for emergency water to be provided. 42 CFR 483.73(b)(7)

Plan of Correction: ApprovedJanuary 7, 2018

1.
The facility is now a member of the Southern Tier Mutual Aid Plan (STMAP). The mutual plan includes consideration of care needs of evacuees, staff responsibilities, transportation and primary, alternate external needs of communication and identification of evacuation locations.
The facility maintains its long-term agreement with Oakhill Manor and the Seventh Day Adventist Church.
Facility is working with a memorandum of agreement with the local hospital, Cayuga Medical Center of Ithaca for transfers and participation with emergency plan exercises.
The facility will continue to work with local emergency response groups, hospital and other SNF facilities to ensure an integrated response during a disaster or emergency.
2.
The facility emergency plan team leader will ensure that facility will maintain its membership to the mutual aid plan by complying with its requirements.
The facility will continue to work with local emergency response groups, hospital and other SNF facilities to ensure an integrated response during a disaster or emergency.
3.
The facility emergency plan team leader will ensure that facility will maintain its membership to the mutual aid plan by complying with its requirements such as continued training, participation with exercises or drills, annual reviews and maintenance of equipment or resources.
4.
The emergency team leader will report pertinent information that affects the emergency plan, such as changes in current agreements or any new commitments forged with other entities to assist with emergency planning to QAPI for further review.
5.
The Administrator will be responsible for the correction of this deficiency

DEVELOP EP PLAN, REVIEW AND UPDATE ANNUALLY

REGULATION: The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview conducted during an Emergency Preparedness (EP) survey, the operator did not maintain a current Emergency Preparedness Plan. Specifically, the plan was not updated at least annually. Findings include: During review of the EP plan there was no documented evidence that the plan was being reviewed and updated on an at least annual basis, as required. When interviewed on 12/12/2017 at 10:00 AM, the Administrator stated the plan had not been updated annually. 42 CFR 483.73(a)

Plan of Correction: ApprovedJanuary 7, 2018

1.
The facility formed an Emergency program team and appointed a team leader whose primary function is to ensure that the facility Emergency Plan meets current life safety requirements.

The facility is currently in the process of working with a consultant; Russell(NAME)& Associates (RPA) to review and update the Emergency Plan to meet all Federal and State and local emergency preparedness requirements. Review will be completed before (MONTH) 10, (YEAR).
2.
After the review of RPA, the emergency program leader will work with the Administrator on the full implementation of the plan including training etc. This will be completed before (MONTH) 10, (YEAR).
3.
After the review of RPA, the emergency program leader will work with the Administrator on the full implementation of the plan including adding the emergency plan on the schedule of policy and procedures to reviewed annually.
4.

The emergency program leader will ensure that the emergency plan is reviewed as scheduled. Scheduled review and completion of its review will be reported to QAPI for further review or recommendation.
5. The Administrator will be responsible for the correction of this deficiency

DEVELOPMENT OF COMMUNICATION PLAN

REGULATION: (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview during an Emergency Preparedness (EP) survey, the operator did not ensure there was a communication plan. Specifically, there was no communication plan and the facility did not comply with state requirements. Findings include: During review of the EP Plan on 12/12/2017, there was not a communication policy included within the plan. When the Minimum Data Set (MDS) Coordinator was observed by a surveyor on 12/11/2017 at 1:30 PM accessing the facility's New York State Health Commerce System (NYSHCS), current and complete updates of the NYSHCS directory were not maintained accurate and/or complete for Emergency Office Roles, including 24/7 facility contact, Director of Nursing, Emergency Medical Supplies Receiving Office and Office of the Administrator. In addition, Contact Person Roles, including e-FINDS (Evacuation of Facilities in Disasters System - a New York State patient/resident tracking application) Data Reporter, were not completed. When interviewed on 12/12/2017 at 11:00 AM, the Administrator stated there was not a communication policy in the Emergency Preparedness Plan. 42 CFR 483.73(c)

Plan of Correction: ApprovedJanuary 7, 2018

1.
The facility formed an Emergency program team and appointed a team leader whose primary function is to ensure that the facility Emergency Plan meets current life safety requirements.
The facility is currently in the process of working with a consultant; Russell Phillips & Associates (RPA) to review and update the Emergency Plan to meet all Federal and State and local emergency preparedness requirements. Review will be completed before (MONTH) 10, (YEAR).
The Communication plan in the emergency plan currently being reviewed by consultants will reference the e-Finds policy and procedure that has been developed.
Emergency office Roles were all up dated by the facility HPN Coordinator on (MONTH) 12, (YEAR).
Facility have relocated its e-FINDS bar scanner and completed initialization on (MONTH) 20, (YEAR).
Facility is currently awaiting e-FINDS wristbands ordered from NYSDOH, ITS/DOH Service management group. When e-FINDS wristbands become available key staff from the newly developed Emergency Preparedness Program Team will be trained before (MONTH) 10, (YEAR).
2.
After the review of RPA, the emergency program team leader will work with the Administrator on the full implementation of the plan including training etc. This will be completed before (MONTH) 10, (YEAR).
The Communication plan in the emergency plan currently being reviewed by consultants will reference the e-Finds policy and procedure that has been developed.
3.
After the review of RPA, the emergency program leader will work with the Administrator on the full implementation of the plan including the communication plan.
The Emergency preparedness program Team leader will ensure compliance to the facility e-Finds policy and procedure and communication plan.
4.
The emergency preparedness program team leader will compliance or changes to communication plan or emergency roles to QAPI for further review and guidance.
5.
The Administrator will be responsible for the correction of this deficiency

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: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure all emergency exit exterior discharges provided a level hard-packed all weather travel surface for 6 of 15 emergency exits (basement southeast corner emergency exit, first floor north emergency exit, first floor main dining room emergency exit, ramp/lounge emergency exit, 3C stairwell emergency exit, and second floor wing 1 emergency exit). Specifically, all the aforementioned emergency exit exterior discharge pathways were not made with a hard-packed all weather travel surface. Findings include: On 12/12/2017, between 12:11 PM and 12:21 PM, a surveyor observed the following emergency exit exterior pathways to means of way were grass/not hard packed: - The basement southeast corner emergency exit pathway was approximately 52 feet long. - The first floor north emergency exit pathway was approximately 110 feet long. - The first floor main dining room emergency exit pathway was approximately 200 feet long. - The ramp/lounge emergency exit pathway was approximately 176 feet long. - The 3C stairwell emergency exit pathway was approximately 60 feet long. - The second floor wing 1 emergency exit pathway was approximately 11 feet long. During an interview on 12/12/2017 at 2:31 PM, the Director of Maintenance stated he was aware the facility had external pathways that were grass/not hard packed surfaces, and new pathways were to be installed during an upcoming construction project. 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: ApprovedJanuary 7, 2018

1.
Cayuga respectfully requests for a time limited waiver for this tag due to current weather conditions.
2.
On 12-13-2017 all building discharges were reviewed by a building architect and a contractor has been retained to install a hard packed all-weather travel surface to the basement southeast corner, first floor north, first floor main dining, ramp/lounge, 3c stairwell and 2nd floor wing 1 emergency exits. Construction will begin in the spring of (YEAR).
3.
On 12-13-17 all other building discharges were reviewed by the building architect and will be updated as necessary to meet the requirements of K271 during the construction of discharges listed above.
4.
Maintenance of all exit discharges will be done by maintenance staff as needed. Special attention during seasonal weather that will cause them to become unusable.
The results of the Environmental checks will be reported by the Facilities Director to monthly QAPI monthly x3 and quarterly thereafter or until completion of work.
5. The Facilities Director will be responsible for the correction of this deficiency.

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: December 12, 2017
Corrected date: February 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not properly maintain electrical installations for 1 of 3 nursing stations (third floor nursing station), and 2 isolated resident rooms (rooms [ROOM NUMBERS]). Specifically, the third floor nursing station had daisy-chained electrical cords (device plugged into a relocatable power tap that was plugged into another relocatable power tap); and resident rooms [ROOM NUMBERS] had unapproved extension cords/adaptors. Findings include: 1) Daisy-Chained Electrical Cords On 12/11/2017 at 2:39 PM, a surveyor near the third floor nursing station observed a string of holiday lights that was plugged into a 6 prong relocatable power tap that was plugged into a 6 prong relocatable power tap that was plugged into a 6 prong relocatable power tap. During an interview on 12/11/2017, between 2:39 PM and 3:02 PM, the Director of Maintenance stated he was not aware of the daisy-chained power taps near the third floor nursing station. He knew that the facility did not allow this. 2) Unapproved Extension Cords/Adaptors On 12/11/2017, between 2:39 PM and 3:02 PM, a surveyor observed the following resident rooms had unapproved extension cords/adaptors: - room [ROOM NUMBER] had a light that was plugged into an unapproved extension cord. - room [ROOM NUMBER] had holiday lights located in two different areas of the room that were plugged into unapproved 3 prong adaptors. During an interview on 12/11/2017 at 3:02 PM, the Director of Maintenance stated that he was not aware of the unapproved extension cords/adaptors, and that resident rooms were inspected monthly. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 7, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
On 12-11-17 the director of maintenance removed all the 6 prong relocatable power taps from the nursing station on 3b.
On 12-11-17 the Director of maintenance removed the unapproved extension cord from room [ROOM NUMBER]
On 12-11-17 the unapproved 3 prong adaptor was removed by maintenance staff in room [ROOM NUMBER]
In-service will be conducted by the Director of Facilities to all staff on policy and procedure on extension cords / adaptors. In-service to be completed on (MONTH) 26, (YEAR).
2.
Maintenance staff will conduct room/ area inspection to check, remove and if necessary replace unapproved extensions to meet UL 1363 by (MONTH) 3, (YEAR).
3.
All future multi prong relocatable power taps purchased will meet UL 1363
Th facility will develop a phasing plan to replace all necessary extension cords to meet UL 1363 dependent on full house room/area inspection audit.
In-service will be conducted by the Director of Facilities to all staff on policy and procedure on extension cords / adaptors. In-service to be completed on (MONTH) 26, (YEAR).
Additionally, Admissions Director will inform all new admissions regarding facility policy and procedure on extension cords via the admission packet.
Addition of extension cord/ adapters to daily maintenance rounds/audit

4.
Audit results will be reported to monthly QAPI by the Director of Facilities for 3 months, then quarterly thereafter for further review and guidance.
5.
The Facilities Director will be responsible for the correction of this deficiency

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on interview conducted during the recertification survey, the facility did not ensure the emergency generator remote annunciator was properly installed for the generator. Specifically, the emergency generator did not have an alarm annunciator remotely installed in an area that had 24-hour staff coverage. Findings include: During an interview on 12/11/2017 at 4:46 PM, the Director of Maintenance stated the facility did not have a remote annunciator panel for the emergency generator. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 7, 2018

1.
Cayuga respectfully requests a time limited waiver for the remote annunciator requirement for emergency power source/ generator.
The existing generator is scheduled to be replaced as part of an existing CON. The replacement generator will have remote annunciator hard wired to indicate alarm conditions.
2.
The facility has no other generators
3.
The new generator that will be installed will meet this requirement.
4.
Maintenance will continue monitor and schedule loading test for the generator. Any issues must be dealt with immediately. Facility retains a contract with a generator company as a back up.
5.
The Facilities Director will be responsible for the correction of this deficiency

EP PROGRAM PATIENT POPULATION

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a)(3):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview conducted during an Emergency Preparedness survey, the operator did not ensure the emergency preparedness requirements were met. Specifically, the emergency plan did not address resident population. Findings include: Record review of the EP Plan on 12/12/2017 revealed information on the resident population, including persons at-risk, delegations of authority and succession plans were not addressed. When interviewed on 12/12/2017 at 10:00 AM, the Administrator stated the information on the resident population, including persons at-risk, was included in the Facility Assessment Plan, and the Facility Assessment Plan was not referenced in the emergency plans. 42 CFR: 483.73(a)(3)

Plan of Correction: ApprovedJanuary 7, 2018

1.
The facility is currently in the process of working with a consultant; Russell Phillips & Associates (RPA) to review and update the Emergency Plan to meet all Federal and State and local emergency preparedness requirements. Review will be completed before (MONTH) 10, (YEAR).
Russell Phillips & Associates (RPA) will include or reference the facility assessment in developing the emergency plan.
2.
After the review of RPA, the emergency program team leader will work with the Administrator on the full implementation of the plan including ensuring that the plan addressed persons at risk, services, continuity of operations and delegations of authority. This will be completed before (MONTH) 10, (YEAR).
3.
After the review of RPA, the emergency program team leader will work with the Administrator on the full implementation of the plan.
4.

The emergency program team leader will ensure that the emergency plan is updated with any changes to persons at risk and changes in services or key personnel assigned to the emergency plan. Any updates will be reported to reported to QAPI for further review or recommendation.
5.
The Administrator will be responsible for correction of this deficiency


EP TESTING REQUIREMENTS

REGULATION: *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview during an Emergency Preparedness (EP) survey, the operator did not ensure there was EP testing performed at least annually. Specifically, the facility did not conduct EP exercises that were community-based at least annually. Findings include: During review of the EP plan on 12/12/2017, there was no documentation the facility participated in a full-scale exercise that was community-based. When interviewed on 12/12/2017 at 11:00 AM, the Administrator stated the facility did not work with other facilities in the community currently and they were not participating in community-based exercises on an at least annual basis. 42 CFR 483.73(d)(2)

Plan of Correction: ApprovedJanuary 7, 2018

1.
The facility is now a member of the Southern Tier Mutual Aid Plan (STMAP). Being a member, the facility will be given the opportunity to test our emergency plan with other members of the mutual plan at least annually.
Facility is working with a memorandum of agreement with the local hospital, Cayuga Medical Center of Ithaca for transfers and participation with emergency plan exercises, this will be another opportunity for the facility to test our emergency plan and participate with our local hospital at least annually.
The facility will continue to work with local emergency response groups, hospital and other SNF facilities to ensure an integrated response during a disaster or emergency.
2.
As a member of the STMAP, the facility will comply to the responsibilities set forth to all its members including participation with disaster drills and exercises.
3.
The emergency plan program team leader is also the designated Regional response committee responder.
The emergency plan program leader with the administrator will ensure that the facility meets the STMAP requirements for continued membership such as training, meetings and participation in the region and joint region mutual aid plan exercises.
4.
The emergency plan program team leader will ensure facility training and attendance to the joint meetings and exercises. The emergency program leader will report any changes to the plan or updates to the QAPI meeting for further review.

EP TRAINING PROGRAM

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview during an Emergency Preparedness (EP) survey, the operator did not ensure there was EP training and testing for staff. Specifically, staff were not trained at orientation or thereafter at least annually on the EP plan that included all hazards. Findings include: During review of the EP on 12/12/2017, there was no documentation staff received training and testing on the entire EP plan that included all hazards. Review of a fire safety quiz, dated 11/14/2017, revealed the facility only trained staff on fire hazards, not on additional hazards. When interviewed on 12/12/2017 at 11:00 AM, the Administrator stated staff only received training and testing on fire procedures and not the whole EP plan. There were no initial trainings and no trainings there after on an at least annual basis. 42 CFR 483.73(d)(1)

Plan of Correction: ApprovedJanuary 7, 2018

1.
The facility formed an Emergency program team and appointed a team leader whose primary function is to ensure that the facility Emergency Plan meets current life safety requirements.
The facility is currently in the process of working with a consultant; Russell(NAME)& Associates (RPA) to review and update the Emergency Plan to meet all Federal and State and local emergency preparedness requirements. Review will be completed before (MONTH) 10, (YEAR).
After completion of review and update of the emergency plan by RPA and reviewed by the emergency program team. All staff including agency /contractual staff will be trained and tested on all hazards by (MONTH) 10, (YEAR) and annually thereafter.
All new staffs or contractual staff will be trained and tested on the emergency plan upon scheduled orientation and annually thereafter.
2.
The emergency program team leader and Human Resources Director will ensure compliance including maintenance of documentation of the training.
3.
Human Resources Director will conduct staff including agency staff record review at least quarterly for compliance with mandatory training. Any issues will be reported to the emergency plan team leader for review and necessary correction.
Emergency team plan leader/ designee will conduct random emergency plan knowledge audit of staff after the initial training at least monthly. 20% of staff each month for the next 5 months
4.
Emergency team plan leader/ designee will conduct random emergency plan knowledge audit of staff after the initial training at least monthly. 20% of staff each month for the next 5 months. Result of audit will be reported to QAPI for further review or recommendation.
Human Resources Director will report to QAPI result of record review monthly for further review or recommendation.
5.
The Administrator will be responsible for the correction of this deficiency

4FGA 400.10 (d):HEALTH PROVIDER NETWORK ACCESS AND REPORTING

REGULATION: The operator of a facility shall obtain from the department ' s health provider network (HPN), HPN accounts for each facility he or she operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, 24-hour, seven-day-a-week contacts for emergency communication and alerts must be designated by each facility in the HPN communications directory. A policy defining the facility's HPN coverage consistent with the facility ' s hours of operation, shall be created and reviewed by the facility no less than annually. Maintenance of each facility ' s HPN accounts shall consist of, at a minimum, the following: (d) current and complete updates of the communications directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview during an Emergency Preparedness survey, the operator did not maintain a current Health Commerce System (HCS) account and did not ensure that current staff were assigned to various HCS roles, to receive information and ensure rapid response to requests for information by the State and/or local Department of Health at the facility. Specifically, complete updates of the current HCS directory were not maintained accurate and/or complete for facility personnel defined roles. Findings include: During review of the current updated HCS on 12/11/2017, a surveyor observed multiple directory roles were unassigned. These included, but were not limited to: - Emergency Office Roles: 1. 24/7 Facility Contact; 2. Director of Nursing; 3. Emergency Medical Supplies Receiving Office; and 4. Office of the Administrator. - Contact Person Roles: 1. e-FINDS (Evacuation of Facilities in Disasters System - a New York State patient/resident tracking application) Data Reporter The facility did not have e-FINDS equipment available for review, did not have an e-FINDS policy or conduct any training for staff on the implementation and use of e-FINDS, prior to the survey. When interviewed on 12/11/2017 at 1:50 PM, the Minimum Data Set (MDS) Coordinator stated she was unaware the roles were unassigned. When interviewed on 12/12/2017 at 10:00 AM, the Administrator stated the facility did have a scanner or bracelets and needed to get the equipment. She further stated they did not have an e-FINDS policy and did not train on e-FINDS. 10NYCRR 400.10(d)

Plan of Correction: ApprovedJanuary 7, 2018

1.
Emergency office Roles were all updated by the facility HPN Coordinator on (MONTH) 12, (YEAR).
Facility have relocated its e-FINDS bar scanner and completed initialization on (MONTH) 20, (YEAR).
Facility is currently awaiting e-FINDS wristbands ordered from NYSDOH, ITS/DOH Service management group. When e-FINDS wristbands become available key staff from the newly developed Emergency Preparedness Program Team will be trained before (MONTH) 10, (YEAR).
e-FINDS policy is developed that included future updates on the emergency office role assignment on HCS, equipment management, storage and staff training. Such e-finds policy is developed in consideration with Southern Tier Mutual Aid Plan in which the facility is now a member.
2.
e-FINDS policy is developed that included future updates on the emergency office role assignment on HCS, equipment management, storage and staff training. Such e- finds policy is developed in consideration with Southern Tier Mutual Aid Plan in which the facility is now a member.
3.
e-FINDS policy and procedure will be included in the annual review of facility policy and procedure.
The Emergency preparedness program Team leader will ensure compliance to the facility e-Finds policy and procedure.
4.
The emergency preparedness program team leader will report any deviations to monthly QAPI for further review and guidance.
5.
The Administrator will be responsible for the correction of this deficiency


LOCAL, STATE, TRIBAL COLLABORATION PROCESS

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years (annually for LTC facilities). The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview conducted during the Emergency Preparedness (EP) survey, the operator did not ensure the emergency preparedness requirements were met. Specifically, the emergency plan did not include a process for cooperation and collaboration or maintain an integrated response during a disaster or emergency situation. Findings include: During record review of the EP Plan on 12/12/2017, the following were not addressed: 1) A process for the cooperation and collaboration with local, tribal, regional, State, and Federal Emergency Preparedness officials to maintain an integrated response during a disaster or emergency situation. 2) The facility's efforts to contact officials and what if any collaborative and cooperative planning efforts those officials were involved in. Specifically, contact information for the Central New York Regional Office (CNYRO) and under what circumstances to contact were not contained within the plan. When interviewed on 12/12/2017 at 10:30 AM, the Administrator stated the facility was not currently part of a mutual aid plan and did not work with other facilities for Emergency Preparedness. 42 CFR 483.73(a)(4)

Plan of Correction: ApprovedJanuary 22, 2018

1.
The facility is now a member of the Southern Tier Mutual Aid Plan (STMAP).
Facility is working with a memorandum of agreement with the local hospital, Cayuga Medical Center of Ithaca for transfers and participation with emergency plan exercises.
The facility will continue to work with local emergency response groups, hospital and other SNF facilities to ensure an integrated response during a disaster or emergency.
2.
As a member of the STMAP, the facility will comply to the responsibilities set forth to all its members.
**The internal emergency plan and the Southern Tier Mutual Aid Plan both addresses flow chart/ hierarchy of communication for when there is a disaster. These includes numbers to call for the DOH central syracuse office, DOH Rochester office, DOH 24 hour Duty officer and DOH Hotline number.
3.
The emergency plan program leader is also the designated Regional response committee responder.
The emergency plan program leader with the administrator will ensure that the facility meets the STMAP requirements for continued membership such as training, meetings and participation in the region and joint region mutual aid plan exercises.
4.
The emergency plan program leader will ensure facility training and attendance to the joint meetings and exercises. The emergency program leader will report any changes to the plan or updates to the QAPI meeting for further review.
5.
The Administrator will be responsible for the correction of this deficiency.

POLICIES FOR EVAC. AND PRIMARY/ALT. COMM.

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCs at §403.748(b)(3) and ASCs at §416.54(b)(2):] Safe evacuation from the [RNHCI or ASC] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview during an Emergency Preparedness (EP) survey, the operator did not ensure there was a complete evacuation policy and procedure. Specifically, there was no documented evacuation plan which included consideration of care and treatment needs of evacuees, staff responsibilities, transportation, and identification of evacuation locations. Findings include: During review on 12/12/2017, there was not a complete evacuation policy located within the EP Plan to include the residents' specific needs for care and treatment and for transportation and assistance needs during an emergency evacuation. When interviewed on 12/12/2017 at 10:00 AM, the Administrator stated there was no evacuation policy that listed residents' needs or relocation shelters when evacuating the facility. 42 CFR 483.73(b)(3)

Plan of Correction: ApprovedJanuary 7, 2018

1.
The facility formed an Emergency program team and appointed a team leader whose primary function is to ensure that the facility Emergency Plan meets current life safety requirements.
The facility is currently in the process of working with a consultant; Russell(NAME)& Associates (RPA) to review and update the Emergency Plan to meet all Federal and State and local emergency preparedness requirements. Review will be completed before (MONTH) 10, (YEAR).
The facility is now a member of the Southern Tier Mutual Aid Plan (STMAP). The mutual plan includes consideration of care needs of evacuees, staff responsibilities, transportation and primary, alternate external needs of communication and identification of evacuation locations.

2.
The facility is currently in the process of working with a consultant; Russell(NAME)& Associates to review and update the Emergency Plan to meet all Federal and State and local emergency preparedness requirements. Review will be completed before (MONTH) 10, (YEAR).
After the review of RPA, the emergency program team leader will work with the Administrator on the full implementation of the emergency plan alongside the mutual aid plan including training etc. This will be completed before (MONTH) 10, (YEAR).
3.
After the review of RPA, the emergency program team leader will work with the Administrator on the full implementation of the emergency and mutual aid plans including training and if necessary simulations to ensure staff can identify location of receiving facilities for relocated staff and residents.
4.
The emergency program team leader will ensure that the emergency and mutual aid plans are implemented. Any issues or schedules for further training, simulations or changes will be reported to QAPI meeting for further review and recommendation.
5.
The Administrator will be responsible for the correction of this deficiency

PROCEDURES FOR TRACKING OF STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on record review and interview during an Emergency Preparedness (EP) survey, the operator did not ensure there was a tracking system and policy in place during an emergency. Specifically, there was no documented evidence of a system to track the location of on-duty staff and sheltered residents in the facility during an emergency. Findings include: During review on 12/12/2017, there was not a policy and procedure located within the EP Plan to include the name and location of receiving facilities for relocated staff and residents. When interviewed on 12/12/2017 at 10:00 AM, the Administrator stated there was no policy for tracking residents. 42 CFR 483.73(b)(2)

Plan of Correction: ApprovedJanuary 7, 2018

1.
The facility is currently in the process of working with a consultant; Russell(NAME)& Associates (RPA) to review and update the Emergency Plan to meet all Federal and State and local emergency preparedness requirements. Review will be completed before (MONTH) 10, (YEAR).
The facility emergency plan will include tracking of on-duty staff and sheltered residents during emergency.
The facility is now a member of the Southern Tier Mutual Aid Plan (STMAP). The mutual plan includes tracking of resident and staff during relocation.
Facility have relocated its e-FINDS bar scanner and completed initialization on (MONTH) 20, (YEAR).
Facility is currently awaiting e-FINDS wristbands ordered from NYSDOH, ITS/DOH Service management group. When e-FINDS wristbands become available key staff from the newly developed Emergency Preparedness Program Team will be trained before (MONTH) 10, (YEAR).
e-FINDS policy is developed that included future updates on the emergency office role assignment on HCS, equipment management, storage and staff training. Such e-finds policy is developed in consideration with Southern Tier Mutual Aid Plan in which the facility is now a member.
2.
The facility is currently in the process of working with a consultant; Russell(NAME)& Associates (RPA) to review and update the Emergency Plan to meet all Federal and State and local emergency preparedness requirements. Review will be completed before (MONTH) 10, (YEAR).
After the review of RPA, the emergency program team leader will work with the Administrator on the full implementation of the plan including training etc. This will be completed before (MONTH) 10, (YEAR).
3.
After the review of RPA, the emergency program leader will work with the Administrator on the full implementation of the plan including training on e-finds and tracking of residents, staff during emergency and relocation.
4.
The emergency program leader will ensure that the emergency plan and the mutual aid plan are implemented. These will all be reported to QAPI for further review or recommendation.
5.
The Administrator will be responsible for correction of this deficiency.

K307 NFPA 101:SPRINKLER SYSTEM - SUPERVISORY SIGNALS

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined that the facility did not ensure the automatic sprinkler system was monitored in accordance to NFPA 72. Specifically, the facility has a outside sprinkler valve (post indicator valve) that was not electronically supervised as required. Findings include: On 12/12/2017 at 8:30 AM, a surveyor observed an outside sprinkler valve (post indicator valve) that was locked with a padlock. The post indicator valve indicated the valve was open. No electronic supervision was observed on the valve. During an interview on 12/12/2017 at 2:28 PM, the Director of Maintenance stated the facility currently had a waiver for the secured/not supervised post indicator valve and would be re-applying for a waiver. 2012 NFPA 101 19.3.5.1, 9.7.2.1 2010 NFPA 72 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 7, 2018

1.
Cayuga has an existing waiver in place approved by BAER in (MONTH) 12, (YEAR).
Cayuga is respectfully requesting for the existing waiver to continue to be honored contingent to a CON that includes the relocation of the aforementioned post indicator valve from its current location.
The facility continued to comply with the other conditions of the waiver which is the provision of fenced enclosure with gate and lock to prevent unauthorized access.
The distance from the alarm control panel and the location of the other utility servicing the facility prevents proper wiring to be run, particularly in this current weather condition.
2.
Maintenance continues to add daily check and log of the post indicator valve and ensure that the fence gate lock is not breached.
3.
Director of maintenance will audit completion of daily checks and perform routine spot check on the site being monitored.
4.
Maintenance and monitoring of the post indicator valve will continue to be reported to QAPI until it is relocated.
5.
The Facilities Director will be responsible for the correction of this deficiency

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure all smoke barrier doors were smoke resistant for 2 isolated smoke doors observed (third floor A Unit/C Unit smoke barrier door, and second floor smoke barrier door near the nursing station). Specifically, these smoke barrier doors had holes in them. Findings include: On 12/11/2017, between 1:05 PM and 1:13 PM, a surveyor observed one of two smoke barrier doors for the third floor A Unit/C Unit smoke barrier had an unsealed 0.25 inch hole in it. On 12/11/2017, between 1:28 PM, a surveyor observed one of two smoke barrier doors for the second floor smoke barrier near the nursing station had an unsealed 0.25 inch hole in it. During an interview on 12/12/2017 at 12:24 PM, the Director of Maintenance stated that he was not aware of the unsealed holes found in the above-mentioned smoke barriers, and that smoke barrier doors were checked monthly. This monthly check was not documented. 2012 NFPA 101: 19.3.7.6 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 7, 2018

1.
On 1-6-18 the maintenance sealed 0.25 inch hole in smoke barrier door on 3rd floor A unit/ C unit.
On 1-6-18 the maintenance staff sealed the 0.25 inch hole in the smoke barrier door near the nursing station on 2nd floor.
2.
By 1-30-18 the maintenance staff will have conducted an audit of all smoke doors and repaired and with open penetration in the surface.
3.
A smoke door audit will be done by the DES/designee monthly
4.
Audits results will be reported by the DES to the QAPI Committee monthly x3 and quarterly thereafter until released by the QAPI.
5.
The Facilities Director will be responsible for the correction of this deficiency

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure that 4 of 5 floors (first floor, second floor, third floor, and fourth floor) had smoke barriers constructed to a 1/2 hour fire rating. Specifically, these floors/units contained smoke barriers with unsealed penetrations. Findings include: On 12/11/2017, between 12:45 PM and 2:15 PM, a surveyor observed the following floors had 1/2 hour fire rated smoke barriers with unsealed penetrations: a) First Floor - The smoke barrier near the lobby had two 1 inch holes with data wires passing through it. b) Second Floor - The smoke barrier near the nursing station had unsealed data wires, an unsealed 0.5 inch conduit, and the head of the wall was not sealed. - The smoke barrier near elevator #1 had a 4.0 inch x 10.0 inch hole with multiple communication wires passing through it. c) Third Floor - The smoke barrier near room 381 had multiple unsealed data wires and pipes. - The A Unit/C Unit smoke barrier had a 0.5 inch hole with a fire alarm wire passing through it. - The 3A dining room smoke barrier had a 2.0 inch x 3.0 inch hole with multiple cables passing through it. - The smoke barrier near room 334 had a 2.0 inch x 6.0 inch hole with multiple data wires and cables passing through it. - The smoke barrier near room 313 had a 0.5 inch hole with three data wires passing through it. d) Fourth Floor - The smoke barrier near room 481 had a 3.0 inch hole with two metal conduits and data wires passing through it; and - The smoke barrier near room 484 had a 3.0 inch hole with two metal conduits and data wires passing through it, and the head of wall was not sealed. During an interview with the Director of Maintenance on 12/11/2017 at 2:15 PM, he stated he was not aware of unsealed penetrations observed in the smoke barrier walls. He stated usually smoke barriers would be checked after wires were pulled and the last wires were pulled in 1/2017. He stated smoke walls had not been checked since 1/2017. 2012 NFPA 101: 19.3.7.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 7, 2018

1.
Unsealed penetrations to smoke barriers on first floor near the lobby were sealed by maintenance staff on (MONTH) 6, (YEAR)
Identified unsealed penetrations on second, third and fourth floors will be sealed and completed by (MONTH) 26, (YEAR) by maintenance staff.
2.
Maintenance staff will audit and repair any other smoke barriers penetrations by (MONTH) 10, (YEAR).
3.
Smoke barrier penetrations will be audited by DES/ designee biannually.
Facility maintains a current contract with(NAME)Philips and Associates (RPA) which include annual life safety inspections.
4.
Result of audits and RPA annual life safety inspection will be reported to monthly QAPI for further review.
5.
The Facilities Director will be responsible for the correction of this deficiency

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2017
Corrected date: February 10, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for 4 of 7 emergency stairwells (stairwell 5, stairwell 6, stairwell 7, and stairwell 4). Specifically, access doors to stairwell 5, stairwell 6, and stairwell 7 had unsealed holes in them, and stairwell 4 had an unsealed penetration. Findings include: 1) Stairwell Doors with Unsealed Holes On 12/11/2017, between 12:30 PM and 12:40 PM, a surveyor observed the following stairwell doors had an unsealed 1/4 inch hole in them: - fourth floor stairwell 5; - fourth floor stairwell 6; and - fourth floor stairwell 7. During an interview on 12/12/2017 at 12:24 PM, the Director of Maintenance stated he was not aware of the unsealed holes in the stairwell fire rated doors for stairwell 5, stairwell 6, and stairwell 7, and that they were checked monthly. This monthly check was not documented. 2) Stairwell with Unsealed Penetration On 12/11/2017 at 3:06 PM, a surveyor observed an unsealed 1 inch sprinkler line penetration on the third floor of stairwell 4. During an interview on 12/12/2017 at 12:24 PM, the Director of Maintenance stated he was not aware of the unsealed penetration in stairwell 4 and that all the stairwells were checked monthly. This monthly check was not documented. 2012 NFPA 101: 19.3.1, 8.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 7, 2018

1.
Identified unsealed holes on the fourth floor stairwell doors specifically stairwell 5, 6 and 7 will all be sealed by maintenance staff with UL 1 hour fire rated products before (MONTH) 26, (YEAR)

The unsealed 1 inch sprinkler line penetration on the third floor of stairwell 4 were sealed by
maintenance staff on (MONTH) 6, (YEAR).
2.
Identified unsealed holes on the fourth floor stairwell doors specifically stairwell 5, 6 and 7 will all be sealed by maintenance staff with UL 1 hour fire rated products before (MONTH) 26, (YEAR)

The unsealed 1 inch sprinkler line penetration on the third floor of stairwell 4 were sealed by
maintenance staff on (MONTH) 6, (YEAR).
3.
On 1-6-18 the Director of maintenance developed and implemented a monthly fire barrier inspection checklist.
4.
The results of the Environmental audits will be reported by the Facilities Director to monthly QAPI monthly x3 and quarterly thereafter until released by QAPI Committee.
5.
The Facilities Director will be responsible for the correction of this deficiency.