Norwich Rehabilitation & Nursing Center
September 8, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.25(a)(3):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, it was determined for 2 of 11 residents (Residents #5 and 15) reviewed for activities of daily living (ADLs), the facility did not provide the necessary services to maintain good nutrition and continence care. Specifically, Resident #5 was not toileted as planned. Resident #15 was not provided with assistance timely during a meal. Findings include: 1) Resident #5 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 5/24/2016 documented the resident was at risk for skin breakdown. She was incontinent of bladder and required extensive assistance for toileting. She had actual alteration in bladder elimination related to unknown origin and history of urinary tract infections. Staff were to provide toileting every 1 hour and as needed (prn). The certified nurse aide (CNA) care card (care instructions) dated 7/19/2016 documented the resident was to be toileted with the assistance of 2 staff every hour and prn. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She was frequently incontinent of bladder and required extensive assistance for toileting. The (MONTH) (YEAR) toileting schedule form was in with the resident's care card, with no evidence of the (MONTH) (YEAR) toileting schedule form. The resident was not toileted from 11:45 AM through 1:20 PM on 9/6/2016, and was observed as follows: - at 11:45 AM, in her room in the wheelchair, tray table in front of her; - at 12:00 PM, in her room in the wheelchair, tray table in front of her; - at 12:40 PM, in her room in the wheelchair, tray table in front of her, waiting for lunch; - at 1:00 PM, in her room in the wheelchair, tray table in front of her, waiting for lunch; - at 1:20 PM, in her room, attempting to wheel herself to bathroom in her wheelchair. The resident was not toileted at 2:00 PM on 9/8/2016, and was observed as follows: - at 1:45 PM, in her room in wheelchair, tray table in front of her; - at 2:05 PM, in her room in wheelchair, asleep; a licensed practical nurse walked into the room and immediately walked out; - at 2:30 PM, in her room in the wheelchair; and - at 2:34 PM in her room and she was observed turning on her call light. During an interview with Nurse Manager #9 at 11:50 AM on 9/7/2016, she stated the toileting schedule form was in the CNA care card book and was a monthly form. She stated most of the toileting schedules were every two hours. On 9/8/2016 at 10:00 AM, the (MONTH) (YEAR) toileting schedule form was in the CNA care card book and was missing CNA initials for all of the scheduled toileting times for 9/1/2016 - 9/7/2016. During an interview with Nurse Manager #9 at 11:15 AM on 9/8/2016, she stated it was the night CNA's responsibility to change out the monthly forms. She stated she was not aware that the (MONTH) forms had not been placed in the CNA care card book. She stated the resident was placed on an hourly toileting program because she had moisture-related skin issues on her bottom. 2) Resident #15 had [DIAGNOSES REDACTED]. A speech evaluation dated 2/17/2016 documented a recommendation for the resident to be on pureed consistency with honey thick liquids as a result of moderate to severe oropharyngeal dysphagia (difficulty swallowing). Staff were to encourage the resident to alternate solids and liquids and should check the resident's oral cavity after meals for remaining residue. The resident was considered at high risk for aspiration. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive loss with inattention and disorganized thinking. She required extensive to total assistance with ADLs, including eating. The comprehensive care plan (CCP) dated 6/30/2016 documented the resident required extensive assistance for all ADLs. The resident was on a pureed diet with honey thick liquids, and left 25% of her meals uneaten. The resident was to be encouraged to eat at and between meals to meet her estimated needs. The current physician orders [REDACTED]. The resident was observed on 9/7/2016 at 9:20 AM with her breakfast in front of her at the table (overbed table at the end of a regular dining room table) . The resident sat with her eyes closed and was not eating. The meal consisted of scrambled eggs, a donut, milk, juice and coffee. At 9:25 AM, a staff member approached the table, gave her a clothing protector, and walked away. On 9/7/2016 at 5:50 PM, the resident was observed at the table in the dining room with her meal in front of her. The resident was not eating and no staff were present at the table. During an interview with certified nurse aide (CNA) #14 on 9/8/2016 at 2:10 PM, she stated the resident needed a varying amount of help, depending on the day. She said she often would fall asleep and the CNA would have to feed her. 10NYCRR 415.12(a)(1)(iii)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.20(d), 483.20(k)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe 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 §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification and abbreviated surveys (NY 943), the facility did not ensure comprehensive care plans (CCPs) were developed for 3 of 16 residents (Residents #7, 9, and 15) reviewed for CCPs. Specifically, Residents #7 and 9 had histories of [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clots) and there was no CCP to identify signs and symptoms of a [MEDICAL CONDITION] or interventions to aid in prevention of further [MEDICAL CONDITION]. Resident #15's CCP did not reflect the resident's individualized needs for completion of activities of daily living (ADLs). Findings include: 1) Resident #9 had [DIAGNOSES REDACTED]. A hospital discharge summary dated 5/9/2016 documented the resident had an intertrochanteric [MEDICAL CONDITION] femur with closed reduction with nail fixation (surgical repair) on 5/3/2016. The resident was on [MEDICAL CONDITION] with [MEDICATION NAME] (used to inhibit blood clots) 40 milligrams (mg) subcutaneously (SC) for 21 days. The discharge instructions included documentation of risk for development of blood clots in the legs after a femur fracture. Physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required extensive assistance with most ADLs. The resident received daily anticoagulant medications (blood thinners). A physician progress notes [REDACTED]. The resident stated it improved with leg elevation. A nurse practitioner (NP) progress note dated 6/9/2016 documented the resident reported swelling in her left leg despite wearing TED stockings. There was non-[MEDICAL CONDITION], no calf tenderness, pulses were present, and TED (anti-embolism) stockings were in place. Continuation of TED stockings was recommended in addition to elevation of the leg. There was no documentation a CCP was developed to address the risk for development of a [MEDICAL CONDITION], including signs and symptoms and preventative measures in place such as TED stockings or elevation of the leg as recommended by the NP. Undated resident care instructions did not document the resident was to wear TED stockings or to elevate her left leg. An orthopedic physician progress notes [REDACTED]. An ultrasound was performed and showed a possible non-occlusive mild and distal femoral [MEDICAL CONDITION]. It appears the [MEDICAL CONDITION]ly developed about a week into her stay at the nursing facility. The registered nurse (RN) Manager was interviewed on 9/8/2016 at 10:45 AM. She stated she was responsible for nursing care plans, and the other disciplines would write their own. She stated she had been working as the Unit Manager for 2 months and was not familiar with the resident as the resident had been discharged prior to her starting on the unit. She stated if a resident was admitted after a surgery and was on blood thinning medications, there should be a care plan addressing both the preventative measures in place to avoid a [MEDICAL CONDITION] and possible symptoms of development of a [MEDICAL CONDITION], as well as a care plan addressing the side effects of blood thinners. 2) Resident #7 had [DIAGNOSES REDACTED]. A physician progress notes [REDACTED]. Staff noted a decline in the resident's appetite and in her overall status. A physician progress notes [REDACTED]. The resident had been on anticoagulant therapy, and the physician was to determine the course of action as the resident was recently placed on comfort measures. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. She did not ambulate, and required extensive assistance with bed mobility, transferring, dressing, eating, and toileting. The CCP updated 8/18/2016 documented the resident required supervision for eating, with tray set up only. The care plan addressing ADLs documented the resident ambulated with the assistance of 1 and a rolling walker. The CCP addressing falls documented the resident was non ambulatory. Additional ADLs documented the resident used a wheelchair for mobility and documented the resident wheeled herself under supervision of staff and was provided assistance as needed around the facility and the grounds. The CCP further documented the resident was in a geri chair (cushioned positioning chair), propelled by staff. There were no dates to determine the current interventions related to the conflicting information. The CCP did not document the resident's history or current concern related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident was observed in a geri chair: - On 9/6/2016 from 7:50 AM through 9:35 AM in the dining room; - On 9/7/2016 at 9:15 AM in the dining room being fed by staff; and - On 9/7/2016 at 10:30 AM reclined seated in the hallway and asking to be taken outside. During an interview with the registered nurse (RN) Manager on 9/8/2016 at 2:05 PM, she stated she had not been working in the facility very long and was still learning procedures, including care planning. She stated the therapy department was responsible for updating information on the CCP related to ADLs, and it was nursing responsibility to include clinical concerns. 3) Resident #15 had [DIAGNOSES REDACTED]. The most recent speech-language pathology (SLP) evaluation dated 2/17/2016 documented the resident had dysphagia and was at high risk for aspiration and pneumonia. The SLP recommended a pureed diet with honey thick liquids. Staff were to encourage the resident to alternate solids and liquids, and the resident's mouth was to be checked after meals for any remaining residue. The resident's MOLST (Medical Orders for Life Sustaining Treatment) dated 3/28/2016 documented treatment guidelines including comfort measures only and included no weights, no vitals, no labs. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. She was non ambulatory and required extensive to total assistance with ADLs, including eating. The resident was on a mechanically altered diet. The CCP updated 6/30/2016 documented: - The resident had high blood sugar levels related to diabetes and the plan included monitoring the resident's weight. - The resident required assistance of one person for eating and was on a pureed diet with honey thick liquids. There were no further approaches/interventions documented related to the resident's need for assistance with eating or monitoring for her risk for aspiration. - The resident had the potential for alteration in cardiovascular functions as evidenced by [MEDICAL CONDITION] and elevated blood pressure. The interventions included weighing the resident monthly and monitoring the results. - The resident's meal intake was documented as a concern, as she left 25% of her meals uneaten and her [MEDICATION NAME] was low (measurement of protein in the blood). The interventions included labs as ordered, and monitoring the resident's weight as available. - The resident was on comfort care related to her advanced directives. No specific interventions were documented. The physician and nurse practitioner progress notes dated 5/31/2016, 6/21/2016, 7/21/2016, 8/8/2016, and 8/22/2016 documented the resident was on comfort measures/palliative care that included no weights, no vitals, and no labs. The orders conflicted with the interventions documented in the CCP. The physician orders [REDACTED]. The resident was on aspiration precautions that included removing any oral residue after all meals and to feel/watch for every swallow. These directives were not included in the CCP. The resident was observed not being assisted at meals on 9/7/2016 at 9:20 AM during the breakfast meal, and at 5:50 PM during the supper meal. During an interview with the registered nurse (RN) Manager on 9/8/2016 at 2:05 PM, she stated she had not been working in the facility very long and was still learning procedures, including care planning. She stated the therapy department was responsible for updating information on the CCP related to ADLs, and it was nursing responsibility to include clinical concerns. 10NYCRR 415.11(c)(1)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure the residents' drug regimens were free from unnecessary medications for 1 of 3 residents reviewed for antipsychotic medication (Resident #1). Specifically, Resident #1's antipsychotic medication was increased when she experienced an acute illness. In addition, she was medicated with an anti-anxiety medication without documented evidence non-pharmacological interventions where attempted prior to administering the medication. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The certified nurse aide (CNA) Kardex (care instructions) dated 1/25/2016 did not include any behavioral problems or interventions. The physician progress notes [REDACTED]. The staff reported she was occasionally anxious but tolerable and redirectable. The physician progress notes [REDACTED]. A physician order [REDACTED]. The nurse practitioner (NP) note progress note dated 8/1/2016 documented the resident was seen for an acute visit as staff reported she was having occasional anxiety and agitation and was difficult to redirect. Staff were requesting an as needed (PRN) dose of [MEDICATION NAME] (anti-anxiety medication). The NP documented if the [MEDICATION NAME] did not help with the resident's behavior we will consider continuing her on the [MEDICATION NAME] at 0.5 mg twice daily as previously ordered. A physician order [REDACTED]. The physician progress notes [REDACTED]. The plan was to do a urine dip at the facility and if [MEDICATION NAME] (used to indicate an infectious process in the urine) were positive, a urinalysis was to be sent to the lab. There were no nursing progress notes documented from 7/13/2016 - 8/2/2016. A nursing progress note dated 8/3/2016 documented the resident was alert and had increased agitation and confusion. The resident had no complaints of pain. An NP progress note dated 8/3/2016 documented the resident was seen for a monthly review. The staff reported the resident was more fatigued and had a change in mental status. A urinalysis and culture and sensitivity would be ordered and she would increase the [MEDICATION NAME] back up to 0.5 mg twice daily. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired and she required extensive assistance with all activities of daily living (ADLs). She did not have any hallucinations, delusions, or rejections of care, and she exhibited wandering behaviors daily. The physician progress notes [REDACTED]. The physician documented the resident had an altered mental status which may be an acute issue due to the patient's infection. The comprehensive care plan (CCP) dated 8/8/2016 documented the resident had the potential to be abused by others as she bumped into other individuals related to her visual deficit. The resident had behavioral symptoms as evidenced by verbally abusive behaviors toward staff and when frightened she may pinch staff when they attempt to stand her. Interventions included she may eat her meals in the hallway to decrease stimulation. The CCP did not document the resident was receiving an antipsychotic medication or an anti-anxiety medication. A nursing progress note dated 8/9/2016 documented the resident was self propelling her wheelchair up and down the hallway all day. The Medication Administration Record (MAR) documented the resident received [MEDICATION NAME] 0.5 mg on 8/28/2016, 8/30/2016, and 9/4/2016. The MAR and the nursing progress notes did not contain any documentation why the resident received the [MEDICATION NAME]. The controlled substance/narcotic count sheet documented the resident received [MEDICATION NAME] 0.5 mg on 8/14/ at 8:00 AM, 8/23/2016 at 8:00 AM, 8/28/2016 at 2:00 PM, 8/30/2016 at 7:20 AM, 9/4/2016 at 7:00 AM, and 9/7/2016 at 8:00 AM. There was no documented evidence in the medical record, including nursing progress notes, why the resident received [MEDICATION NAME] on those days and if non-pharmological interventions were attempted prior to the administration of the medication. The resident was observed on 9/7/2016 at 9:16 AM seated at the table in the dining room with her head down and her eyes closed. Certified nurse aide (CNA) #2 was asking her to open her eyes and was attempting to feed her. At 9:25 AM, the CNA said to the resident you're not hungry today and the resident, with her eyes closed, shook her head no. The CNA was heard informing the licensed practical nurse (LPN) the resident was not even drinking her fluids and the LPN suggested the CNA leave the resident and assist a resident at another table. At 9:40 AM, CNA #3 was observed attempting to assist the resident and, when unsuccessful, she left the resident to assist another resident at the same table. On 9/7/2016 at 10:45 AM, the resident was observed seated in the alcove near the water cooler. She was in her wheelchair, with her head down and her eyes closed. During an interview with the resident's CNA #5 on 9/8/2016 at 10:40 AM, she stated the resident's behaviors at times consisted of self-propelling her wheelchair up and down the hallway, and she would occasionally bump into people as she cannot see very well and can only see shadows. She stated the resident had a specific spot on the unit where she liked to sit and was territorial at times if someone else was in that spot. She did not know why the resident received [MEDICATION NAME]. During an interview with the NP on 9/8/2016 at 11:20 AM, she stated antipsychotic medications were used for residents who have clinical [DIAGNOSES REDACTED]. She stated she addressed any underlying medical issues the resident may have had as a cause of the behaviors prior to prescribing antipsychotic medications. She stated [MEDICATION NAME] was also used for agitation and anxiety. She stated she did not review the medical record for information about the resident's behaviors and was given verbal reports from the nursing staff. She stated the resident was prescribed [MEDICATION NAME] and she increased her [MEDICATION NAME] as she was agitated and going up and down the hallway fast in her wheelchair and running into other residents although she did not think it purposeful. She stated prior to giving [MEDICATION NAME] she would expect the nursing staff to redirect or give an activity to the resident, and if that did not work then they could give the PRN [MEDICATION NAME]. During an interview with the resident's physician on 9/8/2016 at 11:25 PM, he stated resident's were prescribed antipsychotic medications when they experienced delusions, hallucinations, or were a threat to the themselves or others. He stated he looked at underlying medical causes before prescribing an antipsychotic or he would refer the resident for psychiatric services. He stated he did not like PRN [MEDICATION NAME] use as resident behaviors were very subjective and he expected non-pharmacological measures to be attempted, such as redirection or activities, prior to administering [MEDICATION NAME]. He stated the resident had dementia and at times refused care. During an interview with licensed practical nurse (LPN) #4 on 9/8/2016 at 12:10 PM, she stated the resident's behaviors were going fast up and down the hallway in her wheelchair and running into other people. At times, the resident needed the [MEDICATION NAME] to calm her down. She stated the resident also became very upset when she was not responded to right away. LPN #4 stated the resident had a decline in her mental status recently, and the resident says she cannot see, but she can. During an interview with the registered nurse (RN) Unit Manager #4 on 9/8/2016 at 12:30 PM, she stated she was new to the facility and had only been there a few weeks. She was not aware the resident had any behavioral issues other than she occasionally got in the way of others with her wheelchair. During an interview with the Director of Social Services on 9/8/2016 at 12:40 PM, she stated the resident's behavior was often related to urinary tract infections. At those times, the resident was not easily redirected and usually was more anxious and became obsessive wheeling in the hallways. 10NYCRR 415.12(l)(1)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure food was stored under sanitary conditions for 1 of 2 unit resident refrigerators (third floor dining room). Specifically, the third floor resident refrigerator had undated and spoiled food in it. Findings include: On 9/6/2016 at 8:50 AM in the third floor resident refrigerator, a surveyor observed the following foods to be undated: - tray of 4 turnovers; - a peanut butter and jelly sandwich; and - a plastic container of ravioli in sauce. On 9/6/2016 at 8:50 AM, on the bottom shelf of the third floor resident refrigerator, a surveyor observed two opened 8 ounce blocks of spoiled/moldy cheese that were dated 7/10/2016. On 9/7/2016 at 3:51 PM, a surveyor re-checked the third floor resident refrigerator and all items in the refrigerator were properly labeled and dated. The surveyor could not find any of the food identified on 9/6/2016. When interviewed on 9/7/2016 at 3:51 PM, the Food Service Director stated food brought in by a resident's family is labeled and dated by nursing staff. She stated she was not aware of the spoiled/moldy cheese located in the third floor resident refrigerator. When interviewed on 9/9/2016 at 12:45 PM, dietary aide #7, who checked the refrigerators on 9/7/2016, stated when tasked to check the facility's refrigerators, he would toss out undated and outdated food items. He did not recall tossing out cheese that was dated 7/10/2016 that day. 10NYCRR 415.14(h), 14-1

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.15(h)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not ensure the environment was maintained in a sanitary and orderly manner for 2 of 2 resident units (second floor unit and third floor unit). Specifically, both units had multiple areas that had torn/disrepaired fall mats, damaged/delaminated walls and floors, nightstands missing knobs, resident room curtains not on ceiling track hooks, ventilation not working in resident bathrooms, and doors with gouges in them. Findings include: On 9/6/2016 from 11:00 AM to 11:58 AM, the following was observed on the second floor: - in room 2013, there were three fall mats in disrepair/torn; - in room 2013, the wall behind a bed had a plastic wall protector sheet that was delaminated; - in room 2010, a nightstand was missing two knobs; - in room 2045, a wall corner had exposed corner bead; - in room 2041, a wall corner had exposed corner bead; - in room 2041, the room curtain divider was not attached to three ceiling track hooks; - in room 2041, the wall under the windowsill was scraped; - in room 2041, the bathroom negative ventilation fan was not working; - in room 2035, the door side resident nightstand was missing a knob; and - in room 2035, the room's curtain divider was not attached to four ceiling track hooks. On 9/6/2016 from 12:12 PM to 12:40 PM, the following was observed on the third floor: - in room 3042, the door to the bathroom had a four inch gouge in it; - in room 3040, the door to the bathroom had a four inch gouge in it; - in room 3010, the bathroom negative ventilation fan was not working; and - in room 3013, the window side dresser had a drawer that was loose, not in alignment, and touching the floor. On 9/6/2016 at 3:00 PM, a surveyor observed near the second floor nursing station, directly across from the unit's dining room, several deep gouges in the floor. When interviewed on 9/8/2016 at 11:24 AM, the Director of Plant Operations stated he was not aware of the above mentioned findings found during tour. He also stated there was a work order book on each resident floor that the housekeepers/aides/nurses/etc. could fill out if they found an environmental issue. 10NYCRR 415.5(h)(2)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.65:INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) 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. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection for 1 of 2 residents (Resident #2), reviewed for indwelling Foley catheters (urinary drainage tube) and one additional resident (Resident #18). Specifically, Resident #2's Foley catheter equipment was not stored in a sanitary manner. Resident #18's Foley catheter was not maintained in a santitary manner. Findings include: 1) Resident #2 had [DIAGNOSES REDACTED]. A physician order [REDACTED]. A nurse practitioner (NP) progress note dated 12/17/2015 documented the resident had a urine dipstick positive for white blood cells and blood. The urine was to be sent for analysis and culture and sensitivity. Because the patient uses a Foley catheter routinely, bacteria may be present often. The comprehensive care plan originally dated 1/17/2016 documented the resident had alterations in urinary elimination related to the use of an indwelling catheter. A goal included the resident would be free from UTIs for 90 days and free of recurrent UTIs for 90 days. Interventions included catheter care as ordered. Nursing progress notes documented the resident was treated with antibiotics for UTIs on 12/27/2015, 1/2/2016, 1/17/2016, 3/9/2016, and 3/17/2016. An NP progress note dated 3/26/2016 documented the resident had recently completed a course of antibiotics for a UTI and would be starting [MEDICATION NAME] (an antibiotic) 250 milligrams (mg) every 6 hours for 7 days for continued [MEDICATION NAME] (inflammation of the bladder). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and had a urinary catheter for obstructive uropathy (blockage of urine flow). The resident's urinary drainage bag was observed hanging in the bathroom with the end of the tubing that connects to the Foley catheter uncapped and open to air: - on 9/6/2016 at 8:00 AM and 11:25 AM; - on 9/7/2016 at 9:05 AM and 4:18 PM; and - on 9/8/2016 at 9:18 AM and 11:17 AM. Certified nurse aide (CNA) #8 was interviewed on 9/8/2016 at 9:45 AM. She stated the resident usually got up with the 11:00 PM - 7:00 AM staff and they would change his drainage bag over to the leg bag (collection bag worn on the leg). She stated when she changed over bags, she would take an alcohol wipe to clean the outside of the tubing, clean the bag with vinegar and water, clean the end of the tube again with an alcohol wipe and place a blue cap on the end of the tubing before hanging the bag in the bathroom. Registered nurse (RN) Unit Manager #9 was interviewed on 9/8/2016 at 10:45 AM. She stated when a resident was changed over to a leg bag in the morning, the staff member should wipe the end of the drainage bag tubing with an alcohol wipe and place a blue plastic cap on the end. If the blue cap was missing, they should seek a replacement. 2) Resident #18 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, was non ambulatory and required extensive assistance in activities of daily living. The resident had an indwelling catheter. The comprehensive care plan (CCP) updated 8/15/2016 documented the resident had urinary retention, BPH, and an indwelling catheter. The resident was to receive catheter care and was to be monitored for signs and symptoms of a urinary tract infection. The resident did not utilize a leg bag. The physician orders [REDACTED]. The resident was observed on 9/8/2016 seated in his wheelchair from 10:20 AM through 11:25 AM. The resident's catheter bag was in a privacy bag and the bag and catheter tubing were on the floor under the chair. At 10:25 AM, 2 certified nurse aides (CNAs) were observed walking past the resident as he was wheeling the chair backward and forward into the tubing. During an interview with the registered nurse (RN) Manager on 9/8/2016 at 2:05 PM, she stated the catheter bag and tubing should always be off the floor, and any staff observing it on the floor should have corrected the problem. 10NYCRR 415.19(a)(1-3)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.10(b)(5) - (10), 483.10(b)(1):NOTICE OF RIGHTS, RULES, SERVICES, CHARGES

REGULATION: The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under §1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing. The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and inform each resident when changes are made to the items and services specified in paragraphs (5)(i)(A) and (B) of this section. The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate. The facility must furnish a written description of legal rights which includes: A description of the manner of protecting personal funds, under paragraph (c) of this section; A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels. A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care. The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, it was determined for 11 of 16 residents (Residents #2, 3, 4, 5, 6, 7, 8, 11, 12, 13, and 14) plus one additional resident (#17) reviewed for resident rights, the facility did not ensure each resident was informed of the name of the physician responsible for his or her care. Specifically, the residents' medical records and wrist bands did not identify their primary physician as the physician responsible for their routine care. Resident #17 stated he was unfamiliar with the physician documented on his wrist band. Findings include: 1) Resident #13 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required extensive assistance for most activities of daily living (ADLs). The resident's chart documented different medical providers: - The spine of the chart had the name of the Medical Director; - The face sheet had the name of physician #11; - The medical progress notes and physicians' orders were written by the Nurse Practitioner (NP) and physician #12. During an interview 9/7/2016 at 4:00 PM, Resident #13 stated she had seen physician #12 once and the NP often. She stated the Medical Director was supposed to be the head of medical services, but she had never seen him. 2) Resident #8 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADLs). The resident's medical record documented the Medical Director as the resident's primary/attending physician: - On the spine of the medical record; - On the admission facesheet; - On the physician orders [REDACTED]. - On the Medication Administration Record [REDACTED] - On the treatment administration record dated through 9/2016. The physician admission visit, physician progress notes [REDACTED].#12. There were no physician notes completed by the medical director. During an interview with the Director of Nursing on 9/7/2016 at 3:45 PM, she stated the Medical Director was not the attending physician for the residents and physician #12 did the routine visits. The resident was observed on 9/8/2016 at 9:00 AM in the dining room. The resident had a name band on his wrist that documented the medical director as his physician. 3) Resident #7 was admitted to the facility in 2014 and had a primary [DIAGNOSES REDACTED]. The admission facesheet documented physician #11 was the resident's primary physician. Physician telephone orders signed and dated 7/29/2016, 7/30/2016, 8/1/2016, 8/3/2016, 8/4/2016, 8/9/2016, 8/22/2016, 8/29/2016, and 9/2/2016 documented the Medical Director as the resident's attending physician. physician progress notes [REDACTED].#12 and the Nurse Practitioner (NP) completed all the interval, acute care visits and progress notes. There were no notes completed by the Medical Director. During an interview with the Director of Nursing on 9/7/2016 at 3:45 PM, she stated the Medical Director was not the attending physician for the residents and physician #12 did the routine visits. 10NYCRR 415.3(e)(2)(i)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.13(c):PROHIBIT MISTREATMENT/NEGLECT/MISAPPROPRIATN

REGULATION: The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 10 sampled residents (Resident #5) remained free from neglect. Specifically, Resident #5 was not provided a meal during the lunchtime hour. Findings include: Resident #5 had [DIAGNOSES REDACTED]. The 7/19/2016 certified nurse aide (CNA) care card (care instructions) and 7/19/2016 comprehensive care plan (CCP) documented the resident required set-up assist for eating. The 8/19/2016 Minimum Data Set (MDS) assessment documented the resident was cognitively intact. She required extensive assistance with most activities of daily living (ADLs) and supervision with set-up for eating. On 9/6/2016, the resident was observed in her room at 12:40 PM and 1:15 PM, sitting in her wheelchair. She said she was waiting for her lunch. On 9/6/2016 at 1:20 PM, the resident was observed wheeling herself to the bathroom. The resident had not yet received her lunch tray. On 9/6/2016 at 1:23 PM, the kitchen staff was observed cleaning and putting away the food that was served for lunch. When Food Service Worker #10 was asked if Resident #5 had received her lunch tray, he looked through the meal tickets and could not find one for the resident. Two CNAs and a licensed practical nurse (LPN) verified there was not a meal ticket for Resident #5. A CNA looked in Resident #5's chart for a diet order, and a tray for the resident was prepared at that time. On 9/6/2016 at 1:30 PM, the resident received a meal tray in her room. During an interview on 9/8/2016 at 11:15 AM, Nurse Manager #9 stated the meal tickets are printed in the kitchen and come up with the meal cart. She stated Resident #5's meal ticket must have gotten stuck to something or misplaced. She stated more than one CNA is responsible for passing out and picking up meal trays, and it would be possible for one CNA to think that another CNA had already taken care of the meal tray. During an interview on 9/8/2016 at 11:30 AM, Food Service Worker #10 stated he gets all of the meal tickets and knows the residents by memory that get a meal tray in their room. He could not explain why Resident #5 did not receive a meal tray on 9/6/2016. 10NYCRR 415.4(b)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.25:PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure the necessary care and services were provided to residents to attain or maintain the highest practicable physical well-being for 2 of 16 sampled residents (Residents #7 and 8). Resident #7 was identified at high risk for skin breakdown and was not provided with a wheelchair cushion. Resident #8 had skin breakdown treated with an antifungal cream and when there was worsening or delay in healing, the treatment was not re-evaluated for effectiveness and the physician was not notified or consulted to evaluate the area of breakdown to ensure correct treatment was in place. In addition, Residents #7 and 8 did not have documented rationale for not obtaining routine weights to ensure the residents received an accurate nutritional assessment. Findings include: 1) Resident #8 had [DIAGNOSES REDACTED]. An admission assessment dated [DATE] documented the resident had a fungal rash to his groin and buttocks, and he had [MEDICAL CONDITION] to both the right and left buttocks. The measurements of the [MEDICAL CONDITION] were: - the right buttock included 3 areas that measured 1.8 centimeters (cm) x 1.8 cm, 0.4 cm x 0.4 cm, and 1.8 cm x 1.0 cm. - the left buttock had an area that was pinpoint and an area that measured 1.1 cm x 1.5 cm. The admission assessment documented the areas were not pressure related; it did not contain a wound assessment of the areas other than the measurements. A nursing admission progress note dated 5/12/2016 documented the resident had a fungal rash and open areas to his buttocks. A certified nurse aide (CNA) care guide (care instructions) documented the resident was not be placed on his back while in bed. He required 2 assist for bed mobility and he was checked and changed every 2-4 hours and he was not to wear a brief while in bed. Physician orders [REDACTED]. The resident's wound assessments documented the area to the left lower buttock was treated with antifungal cream from 5/12/2016 until the area closed on 5/20/2016. The wound assessment did not document the type of wound. The resident's wound assessments documented the area to the left upper buttock was treated with antifungal cream from 5/12/2016 until the area closed on 7/6/2016 and the area was classified as fungal. On 7/13/2016, the assessment sheet documented the resident had a fungal area on the left buttock. The area had reopened and the wound bed was red and measured 0.5 cm x 0.5 x 0.1 cm and the antifungal cream was to continue. On 7/20/2016, the area measured 1 cm x 1 cm with a red wound bed and to continue same treatment. On 7/26/2016, the assessment identified the resident had 2 open area on his buttock: #1 measured 0.9 cm x 0.9 cm and #2 measured 0.2 x 0.5 cm, both areas had scant drainage and the wound beds were red and to continue the same treatment. On 8/9/2016, the areas measured 0.9 cm x 1.0 x 0.1 cm, had greenish drainage and the wound bed was red and white and to continue the same treatment. On 8/23/2016, the areas measured 0.5 cm x 0.6 cm and the wound bed contained pink and yellow tissue, the antifungal cream was discontinued and DermaMed (protective cream) was started. On 8/31/2016, the area measured 0.9 cm 0.9 cm, and the treatment was changed to wound gel and [MEDICATION NAME] (protective dressing) to be changed every 3 days as needed. The resident's wound assessments documented the area to the middle of the right buttock was treated with antifungal cream from 5/12/2016 until the area closed on 6/3/2016. The area reopened on 6/7/2016 and improved and continue to the antifungal cream. The area was documented as closed again on 6/14/2016. The resident's wound assessments documented the area to the right lower buttock was treated with antifungal cream from 5/12/2016 until the area closed on 6/21/2016. The resident's wound assessments documented the area to the top of the right buttock was treated with antifungal cream from 5/12/2016 until the area closed on 8/2/2016. A second open area was identified to the top of the right buttock on 7/6/2016 and was classified as fungal and measured 1.5 cm x 0.5 cm with a red wound bed; the area was treated with antifungal cream. On 7/20/2016, the area measured 1.5 cm x 1 cm and the wound bed contained slough (moist dead tissue), had bloody drainage and to continue the same treatment. On 7/26/2016, the right buttock had two open areas #1 measuring 1.5 cm x 0.6 cm, #2 was 2 cm in diameter, continue the same treatment. On 8/2/2016, the second open area closed and the remaining open area measured 1.8 cm x 1.7 cm x 0.1 cm, continue the same treatment. On 8/23/2016 the open area measured 2.1 cm x 1.5 cm x 0.1 cm and the wound bed was yellow, the treatment was changed to DermaMed. On 8/31/2016 the open area measured 2.5 cm x 1.5 cm and the treatment was changed to wound gel and [MEDICATION NAME] change every 3 days and as needed. The comprehensive care plan (CCP) initiated on 8/16/2016 documented the resident had altered skin integrity related to a fungal rash and there were no individual interventions marked off on the CCP. A physician order [REDACTED]. An update documented on the CNA care guide dated 8/24/2016 documented the CNAs were to apply absorbent pads to the areas on the resident's buttocks and to change with incontinence care. A physician order [REDACTED]. A physician order [REDACTED]. There was no documented evidence in the medical record the areas on the resident's buttocks were evaluated by a physician or a nurse practitioner to ensure the areas were being treated with the most appropriate and effective treatment. During a skin observation on 9/8/2016 at 10:02 AM, the resident was assisted to his side by registered nurse (RN) Unit Manager #4 and a certified nurse aide (CNA). The resident had an [MEDICATION NAME] dressing in place on the right buttock and on the left buttock. The dressing on the left buttock had a moderate amount of dark reddish/brownish drainage on it. RN #4 removed the dressings. The resident had an open wound on the left buttock that measured 1 cm x 0.5 cm in diameter. The wound was surrounded by pink intact scar tissue and the wound bed was moist and light red in color. On the right buttock in the same spot as on the left buttock, the resident had an open wound measuring 1.3 cm x 1.7 cm; the wound bed was moist and light red in color and the surrounding skin was macerated (softened by moisture). During an interview with the Nurse Practitioner (NP) on 9/8/2016 at 11:20 AM, she stated she did not attend the weekly skin rounds. If the resident needed a treatment, the nursing staff would ask her to order something. During an interview with the resident's physician on 9/8/2016 at 11:25 AM, he stated he was not aware the resident had fungal areas on his buttocks. He stated the NP did skin rounds with the skin team weekly. 2) Resident #7 had [DIAGNOSES REDACTED]. The Braden scale for predicting pressure sore risk documented the resident was to have a pressure reduction support surface if the resident was bed or chair bound. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. She was non ambulatory, and required extensive assistance with all activities of daily living. She was always incontinent of urine and frequently incontinent of stool. The MDS documented the resident was at risk for pressure ulcers and did not have a pressure relieving device in her chair or in her bed. A physician order [REDACTED]. The physical therapy evaluation dated 8/18/2016 documented the resident required substantial to maximal assistance with basic mobility. She was dependent for wheeling, and benefited from the use of a geri chair (positioning chair), as she needed increased support when out of bed. Due to the documented physical impairments, the resident was at risk for increased dependency on caregivers and required extensive assistance of 2 for transfers. The comprehensive care plan (CCP) dated 8/18/2016 documented the resident was non ambulatory and was in a geri chair for safety and positioning. The CCP documented the resident required extensive assistance of 2 people for bed mobility and transfers. The certified nurse aide (CNA) care guide (care instructions) updated 8/18/2016 documented the resident required assistance of 2 for transfers and used a gerichair for mobility. The resident was observed throughout survey in the geri chair with no pressure relieving cushion in place: - On 9/6/2016 from 8:10 AM to 9:35 AM in the dining room; - On 9/6/2016 at 1:30 PM in the dining room; - On 9/7/2016 from 9:15 AM through 9:40 AM in the dining room; - On 9/7/2016 from 10:27 AM through 10:50 AM reclined in the hallway; - On 9/7/2016 at 12:15 PM and 5:50 PM in the dining room; and - On 9/8/2016 at 9:50 AM reclined in the hallway. During an interview with the Director of Rehabilitation Therapy on 9/8/2016 at 11:30 AM, she stated therapy assessed the resident for the geri chair and stated it did not need a pressure relieving cushion as the chair was for comfort. She stated if a resident had a pressure ulcer, they would assess the resident for the most appropriate pressure relieving cushion at that time. She provided the manufacturer's information on the geri chair and it documented the chair increased comfort and encouraged natural relaxation and improved blood circulation. The information did not document the chair was pressure reducing or pressure relieving. The Director of Rehabilitation Therapy did not address pressure ulcer prevention techniques. When the registered nurse (RN) Manager was interviewed on 9/8/2016 at 2:05 PM, she stated if a resident was in a wheelchair or geri chair, she expected the resident would have a pressure relieving cushion in the chair, to assist in prevention of pressure ulcers. 3) Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. She required extensive assistance with transfers, ambulating in her room, dressing, personal hygiene, and toileting. The resident was able to eat with supervision and set up. The resident was 59 inches tall and weighed 121 pounds. She was continent of bowel and frequently incontinent of urine. She used a walker and a wheelchair for mobility. A physician progress notes [REDACTED]. The resident's appetite was poor and there was a noted decline in her overall status. The plan was to obtain an x-ray and a Doppler study (ultrasound test to estimate blood flow through blood vessels) of the resident's left leg. The physician orders [REDACTED]. The comprehensive care plan (CCP) documented comfort measures were addressed on 7/25/2016 as the resident had experienced a progressive decline. Interventions included educating the resident/responsible party about the dying process and expected physiological changes. There was no documented evidence this education occurred at the time changes were made to the advanced directives. A nursing progress note dated 7/29/2016 documented physician #13 requested input from the family because the resident had a MOLST (Medical Orders for Life-Sustaining Treatment) regarding the results of the Doppler study. The MOLST signed by the surrogate on 7/26/2016 and the physician on 7/30/2016 documented the resident's comfort measures included no weights. There was no documented evidence the surrogate was counseled/educated regarding the outcome and effect of initiating specific comfort measures. A physician progress notes [REDACTED]. The physician documented the resident was now comfort measures only as of 7/27/2016. physician progress notes [REDACTED]. The physician documented the resident's bilateral lower extremity [MEDICAL CONDITION] appeared to have evened out and appeared to be somewhat better now. The MDS assessment dated [DATE] documented the resident required extensive assistance with eating, and no weights were obtained. The CCP updated 8/9/2016 documented the resident left 25% of meals uneaten. The resident was on a therapeutic diet due to hypertension, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The resident was on a no added salt diet, and supplements included ice cream at lunch and supper, milk at breakfast and supper, and the 2 Cal to be given 4 times a day. The CCP documented there were some improvements noted in the resident's status. The resident remained on no weights, as documented on 7/29/2016. The resident was observed seated at the table in the dining room on 9/6/2016 at 9:00 AM giving her glass of milk to her tablemate. Her meal was served at 9:33 AM, and the resident was observed not eating and offered her meal items to the surveyor and staff who occasionally encouraged her to eat. Physician #12 stated during an interview on 9/8/2016 at 12:05 PM, he was the resident's attending physician and his understanding was the social worker discussed comfort measures with the resident's surrogate. He said he sometimes questioned a resident's orders for comfort measures if they were not truly end of life. He said with Resident #7's unstable [MEDICAL CONDITION], obtaining a weight was probably a more objective indicator than observation of the resident. The physician stated he was not sure why the resident's surrogate requested the resident not be weighed. During an interview with the Director of Social Services on 9/8/2016 at 12:40 PM, she stated comfort measures were usually discussed with resident/surrogate and the social worker and either the Unit Manager or the Director of Nursing (DON). If the resident/surrogate wanted to discuss it with the physician, a meeting was set up for them to do so. The Director of Social Services stated Resident #7 was thought to be end of life at the time comfort measures were discussed and she had since improved. Comfort measures were discussed verbally with the family. The discussion should have been documented by someone and she stated she was unable to find the documentation upon reviewing the chart with the surveyor. She stated when a resident was end of life and losing weight, it was the recommendation of the Medical Director to discuss no weights with the resident/family. 10NYCRR 415.12

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.25(m)(2):RESIDENTS FREE OF SIGNIFICANT MED ERRORS

REGULATION: The facility must ensure that residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (#NY 045 and NY 943), it was determined the facility did not ensure residents were free of significant medication errors for 2 of 16 sampled residents (Residents #9 and 10). Specifically, Resident #9 had a physician order [REDACTED]. Resident #10 was administered the wrong dose of antibiotic. Findings include: 1) Resident #9 had [DIAGNOSES REDACTED]. A hospital discharge summary dated 5/9/2016 documented to continue [MEDICAL CONDITION] with [MEDICATION NAME] 40 milligrams (mg) subcutaneous (sc) for 15 more days and to start on 5/10/2016. Discharge instructions included risks and complications including risk for blood clots in the legs caused by swelling and immobility after the fracture. Physician admission orders [REDACTED]. The orders were noted by registered nurse (RN) #1 on 5/9/2016, signed by the physician on 5/10/2016, and checked by an undeterminable (due to illegibility) nurse on 5/10/2016. The (MONTH) (YEAR) Medication Administration Record (MAR) documented [MEDICATION NAME] 40 mg sub q every day, was dated 5/9/2016, and was initialed by RN #1. The [MEDICATION NAME] was handwritten on the MAR and marked as scheduled to be given at 4:00 PM from 5/10/2016 - 5/19/2016 (a total of 10 days). [MEDICATION NAME] was documented as administered at 4:00 PM from 5/10/2016 - 5/19/2016 (10 days). There were x's written in the right lower box of the medication names of all the handwritten medications. Nursing progress notes dated 5/9/2016 - 5/23/2016 documented the resident had frequent complaints of left leg pain. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required extensive assistance with most activities of daily living (ADLs). The resident received an anticoagulant daily. Nursing progress notes dated 5/24/2016 - 6/12/2016 documented the resident had frequent complaints of left leg pain. A physician progress notes [REDACTED]. The note documented there appears to be some dependent [MEDICAL CONDITION]ly secondary to the fact that the patient had a surgery to her leg. It appears to be consistent with an [MEDICAL CONDITION] from inflammation. A nurse practitioner (NP) progress note dated 6/9/2016 documented the resident reported swelling in her left leg despite wearing TED (anti-embolism) stockings. There was no calf tenderness and pulses were present. Swelling on the surgical leg was expected. An NP progress note dated 6/13/2016 documented the resident reported marked pain in her legs because of [MEDICAL CONDITION]. Both legs had 1-2+ [MEDICAL CONDITION] (indentation of skin remaining after being pressed) and generalized tenderness. The plan was to continue with TED stockings and to monitor. A nursing progress note dated 6/16/2016 documented the resident was transferred to the hospital from the doctor's office. The resident was seen for orthopedic post-op follow up on 6/16/2016. Orthopedic progress notes documented the resident had a large amount of swelling from her thigh to her foot. A Doppler ultrasound was obtained which showed evidence of a femoral vein [MEDICAL CONDITION] of her left thigh. The resident was referred to the emergency department (ED) for further evaluation. An ED progress note dated 6/16/2016 documented the resident stated she had been experiencing more left leg [MEDICAL CONDITION]. An ultrasound was performed during her follow up at the orthopedic doctor earlier in the day, which showed a possible non-occlusive mid and distal femoral [MEDICAL CONDITION], age indeterminate. The resident was sent to the ED for further management. The resident stated her left calf began swelling about one week ago after arrival to the facility. She stated the swelling did not change much with elevation and antiembolism stockings. The ED documented the resident received [MEDICATION NAME] 40 mg sc daily for 15 days after surgery and discharge from the hospital. The RN who transcribed the admission orders [REDACTED]. A voicemail message was left with the RN. The RN did not return the telephone call. The RN Unit Manager was interviewed on 9/8/2016 at 10:45 AM. She stated when a resident was admitted from the hospital, the physician would be notified of the medications recommended at the time of discharge and would determine if the medications would be continued upon admission to the facility. The nurse would then write the medications on the physician order [REDACTED]. The transcription would include the name of the medication, the dosage, the route of administration, the time of administration, and the duration of the medication administration. The nurse would date and initial the order on the MAR. A second nurse would then check the physician orders [REDACTED]. Another nurse would then do the third accuracy check. The Unit Manager was unable to determine who had completed the second check by the initials on the physician order [REDACTED]. The attending physician was interviewed on 9/8/2016 at 11:25 AM. He stated [MEDICATION NAME] was used to keep someone from developing a [MEDICAL CONDITION]. He stated if he ordered the [MEDICATION NAME] to be administered for 15 days he would expect it be administered for the full 15 days unless he made revisions to the order, which he had not. He stated the resident may have already had a [MEDICAL CONDITION] and could not unequivocally say the 5 days of not receiving [MEDICATION NAME] contributed to the formation of a [MEDICAL CONDITION]. The Director of Nursing was interviewed on 9/8/2016 at 12:15 PM. She stated there were checks and balances when transcribing physician orders [REDACTED]. The first nurse transcribed the orders directly onto the MAR. The second nurse checked the physician orders [REDACTED]. She stated when the medication nurses administered the [MEDICATION NAME], they should have noticed the order was for 15 days and only 10 days were blocked off on the MAR. 2) Resident #10 [DIAGNOSES REDACTED]. A physician order [REDACTED]. A nursing progress note dated 9/4/2016 documented a verbal order was obtained from the physician to give the resident [MEDICATION NAME] 500 mg x 1 dose and the medication was administered by staff nurse. The medication administration record (MAR) documented to give the resident [MEDICATION NAME] 250 mg STAT (now). The MAR documented the [MEDICATION NAME] 250 mg was given on 9/4/2015 at 8:00 AM. The comprehensive care plan (CCP) dated 9/16/2016 documented the resident had a UTI. Interventions included to administer antibiotics as ordered. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. He required extensive assistance with all activities of daily living (ADLs) and he had an indwelling catheter in place. During an interview with the Director of Nursing on 9/8/2016 at 2:45 PM she stated the wrong dose of [MEDICATION NAME] was put in the MAR. She stated the physician orders [REDACTED]. A second check was to take place on the next shift and that nurse was to check the order and the MAR to ensure accuracy. She stated the physician order [REDACTED]. There was no evidence on the MAR the order was compared to the physician order. 10NYCRR 415.12(m)(2)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.10(b)(4):RIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES

REGULATION: The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section. The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure 3 of 11 residents (Residents #7, 8, and 12), reviewed for advanced directives, had the right to formulate advanced directives in accordance with New York State law. Specifically, Resident #7 and 12's Medical Orders for Life Sustaining Treatment (MOLST) were completed by a health care proxy (HCP)/surrogate (person designated to consent or refuse to consent to health care when someone is determined to lack capacity for decision making), and there was no documentation a physician determined the residents lacked capacity, nor was there documentation from a concurring physician/health care professional as required. For Resident #8, the medical record had conflicting orders regarding the resident's advance directives. Findings include: 1) Resident #8 had [DIAGNOSES REDACTED]. A MOLST was completed on 5/12/2016 requesting a Do Not Resuscitate order (allow natural death). The MOLST was signed by the physician on 5/12/2016. The admission progress note completed by the attending physician on 5/19/2016 did not include the resident's wishes for advance directives. On 6/15/2016, a nurse practitioner (NP) progress note documented the resident was a DNR with limited medical interventions. A physician's progress note dated 7/21/2016 documented the resident had a DNR with limited medical interventions as per notes. The NP and attending physician progress notes [REDACTED]. The physician renewal orders dated 5/12/2016, 6/15/2016, and 7/21/2016 documented the resident was a full code (cardiopulmonary resuscitation was to be performed). On the orders signed 8/18/2016, full code was crossed off and dated 5/12/2016 Per MOLST, resident is a DNR/DNI. During an interview with the attending physician on 9/8/2016 at 1:55 PM, he stated the DNR order should have been written either as a new order or in the renewal orders immediately following the request for the DNR. He did not know why it was not carried over timely and contradicted the orders on the MOLST for a DNR. 2) Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive loss, and did not exhibit behaviors. The resident usually was able to make herself understood, and was sometimes able to understand others. The MOLST signed by the physician on 7/30/2016, documented resuscitation was not to be attempted (DNR, Do Not Resuscitate) and treatment guidelines documented comfort measures only. The resident's family member signed requesting/consenting to both the DNR and the comfort measures. Review of the medical record, including the advance directive section of the chart and the physician documentation, revealed no documented evidence the attending physician had determined the resident lacked capacity. During an interview with the Director of Social Services on 9/8/2016 at 10:00 AM, she stated the physician was not involved in determining capacity; the social worker determined if the resident had the capacity to make the decision regarding advanced directives. If it was unclear, the social worker discussed it with nursing, or the interdisciplinary team. At 11:00 AM on 9/8/2016, the Director of Social Services stated there had never been a medical determination (for determining a resident's capacity) in the facility and she was unaware of the requirement. During an interview with the resident's physician on 9/8/2016 at 12:05 PM, he stated he did not determine if a resident had capacity, and thought the social worker screened the resident for that purpose. 3) Resident #12 had [DIAGNOSES REDACTED]. The resident had a living will and HCP signed by the resident and dated 8/3/2016. A nursing admission assessment dated [DATE] documented the resident was oriented to person with questionable orientation to place and time. Physician orders [REDACTED]. The comprehensive care plan (CCP) dated 8/25/2016 documented the resident had cognitive impairment as evidenced by deficits in short term memory and/or recall and severely impaired daily decision making. The MOLST form signed by the HCP on 8/25/2016 and by the physician on 8/26/2016 documented the resident had DNR instructions and treatment guidelines to include comfort measures only, DNI, do not send to the hospital unless symptoms cannot otherwise be controlled, no feeding tubes, no IV (intravenous) fluids and determine use or limitation of antibiotics when infection occurs. Other instructions included no weights, no vitals, and no labs. There was no documented evidence the resident's decision making capacity was determined according to New York State law, prior to writing the order requested by a HCP. Physician orders [REDACTED]. During an interview with the Director of Social Services on 9/8/2016 at 10 AM, she stated she determined if a resident had capacity to make decisions. She stated the determination was often based on the Brief Interview for Mental Status (BIMS). If it was unclear, the Director of Social Services discussed it with nursing and sometimes with the interdisciplinary team. At 11:00 AM on 9/8/2015, the Director of Social Services informed the surveyor that she was not aware of the requirement to determine capacity, and said there had never been a medical determination for resident capacity in this facility. 10NYCRR 415.(e)(1)(ii)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.10(g)(1):RIGHT TO SURVEY RESULTS - READILY ACCESSIBLE

REGULATION: A resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination and must post in a place readily accessible to residents and must post a notice of their availability.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not ensure the results of the most recent survey (statement of deficiencies and the plan of correction) were posted in the facility and 2 of 2 resident units did not have signage informing residents of the availability of the most recent survey. Findings include: During the resident group meeting held on 9/6/2016 at 3:00 PM with 15 anonymous residents present, the residents indicated they were not aware of the location of the most recent survey inspection results. On 9/7/2016 at 5:15 PM, a surveyor observed a plastic holder on the wall in the main lobby. The plastic holder was labeled survey results and was empty. Further observation revealed that the survey book was located behind the reception desk. When reviewed, the survey book did not contain the statement of deficiencies (SOD) and the plan of correction (P(NAME)) from the (YEAR) federal survey. During an interview with the Administrator on 9/8/2016 at 9:36 AM, he stated he had pulled the (YEAR) SOD out of the survey book prior to the 9/7/2016 surveyor observation, in order to complete the FSR (Facility Survey Report). He also stated the P(NAME) was not present in the survey book at the beginning of the survey and was reprinted the night of 9/7/2016. During an interview with the Social Services Director on 9/8/2016 at 9:42 AM, she stated: - residents were reminded through resident council where the SOD and P(NAME) was located; - signage to where the last SOD and P(NAME) were located was posted on each resident floor prior to building renovations; - the third floor was renovated several years ago, about 3 years; - the second floor was renovated in (MONTH) (YEAR); and - she did not think there were any current locational signs on either resident floor. On 9/8/2016 at 9:54 AM, a surveyor, with the Administrator, toured the second and third resident floors and could not find any signage indicating the location of the SOD and the P(NAME). 10NYCRR 415.3(c)(1)(v)

Plan of Correction: N/A

Plan of correction not approved or not required

FF09 483.20(k)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: The services provided or arranged by the facility must meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (#NY 045 and NY 943), it was determined for 2 of 16 residents reviewed for physician orders [REDACTED]. Specifically, Resident #9 and 10's physician orders [REDACTED]. Findings include: 1) Resident #9 had [DIAGNOSES REDACTED]. A hospital discharge summary dated 5/9/2016 for the resident documented to continue [MEDICAL CONDITION] ([MEDICAL CONDITION] [MEDICATION NAME] with [MEDICATION NAME] 40 milligrams (mg) subcutaneous (sc) for 15 more days starting on 5/10/2016. Discharge instructions included risks and complications including risk for blood clots in the legs caused by swelling and immobility after the fracture. Physician admission orders [REDACTED]. The orders were noted by registered nurse (RN) #1 on 5/9/2016, signed by the physician on 5/10/2016, and checked by an undeterminable (due to illegibility) nurse on 5/10/2016. The (MONTH) (YEAR) medication administration record (MAR) documented [MEDICATION NAME] 40 mg sub q every day, dated 5/9/2016 and initialed by RN #1. The [MEDICATION NAME] was handwritten on the MAR and marked as scheduled to be given at 4:00 PM from 5/10/2016 - 5/19/2016 (a total of 10 days). [MEDICATION NAME] was documented as administered at 4:00 PM from 5/10/2016 - 5/19/2016 (10 days). There were x's written in the right lower box of the medication names of all the handwritten medications. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and received an anticoagulant daily. The resident was seen for orthopedic post-op follow up on 6/16/2016. Orthopedic progress notes documented the resident had a large amount of swelling from her thigh to her foot. A Doppler ultrasound (to measure blood flow) was obtained, which showed evidence of a femoral vein [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot) of her left thigh. The resident was referred to the ED (emergency department) for further evaluation. An ED progress note dated 6/16/2016 documented an ultrasound was performed during her follow up at the orthopedic doctor earlier in the day, which showed a possible non-occlusive mid and distal femoral [MEDICAL CONDITION], age indeterminate. The resident was sent to the ED for further management. The ED documented the resident received [MEDICATION NAME] 40 mg sc daily for 15 days after surgery and discharge from the hospital. RN #1, who had transcribed the admission orders [REDACTED]. A voicemail message was left with the RN. The RN did not return the telephone call. The RN Unit Manager was interviewed on 9/8/2016 at 10:45 AM. She stated when a resident was admitted from the hospital, the physician would be notified of the medications recommended at the time of discharge and would determine if the medications would be continued upon admission to the facility. The nurse would then write the medications on the physician order [REDACTED]. The transcription would include the name of the medication, the dosage, the route of administration, the time of administration, and the duration of the medication administration. The nurse would date and initial the order on the MAR. A second nurse would then check the physician orders [REDACTED]. Another nurse would then do the third accuracy check. The RN Manager was unable to determine who had completed the second check by the initials on the physician order [REDACTED]. The attending physician was interviewed on 9/8/2016 at 11:25 AM. He stated [MEDICATION NAME] was used to keep someone from developing a [MEDICAL CONDITION]. He stated if he ordered the [MEDICATION NAME] to be administered for 15 days he would expect it be administered for the full 15 days unless he made revisions to the order, which he had not. The Director of Nursing was interviewed on 9/8/2016 at 12:15 PM. She stated there were checks and balances when transcribing physician orders [REDACTED]. The first nurse would transcribe the orders directly onto the MAR, the second nurse would check the physician orders [REDACTED]. She stated when the medication nurses administered the [MEDICATION NAME], they should have noticed the order was for 15 days and only 10 days were blocked off on the MAR. 2) Resident #10 had [DIAGNOSES REDACTED]. A physician order [REDACTED]. A nursing progress note dated 9/4/2016 documented a verbal order was obtained from the physician to give the resident [MEDICATION NAME] 500 mg x 1 dose and the medication was administered by staff nurse. The medication administration record (MAR) for (MONTH) (YEAR) documented to give the resident [MEDICATION NAME] 250 mg STAT (now). The MAR documented the [MEDICATION NAME] 250 mg was given on 9/4/2015 at 8:00 AM. The comprehensive care plan (CCP) dated 9/16/2016 documented the resident had a UTI. Interventions included to administer antibiotics as ordered. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. He required extensive assistance with all activities of living (ADLs) and had an indwelling catheter in place. During an interview with the Director of Nursing on 9/8/2016 at 2:45 PM, she stated the wrong dose of [MEDICATION NAME] was written in the MAR. She stated the physician orders [REDACTED]. She stated the physician order [REDACTED]. There was no evidence on the MAR the order was compared to the physician order. 10NYCRR 415.11(c)(3)(i)

Plan of Correction: N/A

Plan of correction not approved or not required

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: One hour fire rated construction (with o hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the one hour fire rated walls were not maintained for 2 of 8 hazardous areas observed (elevator machine room within physical therapy room, and elevator machine room by north elevator). Specifically, the elevator machine room within the physical therapy room contained a hole on one side of the fire rated wall and there was an unsealed data wire penetration. In the elevator machine room by the north elevator, there was an unsealed data wire penetration. Findings include: On 9/7/2016 at 10:20 AM, a surveyor in the elevator machine room within the physical therapy room observed two bundles of data wires passing through an unsealed 1 inch hole, and a 6 inch x 10 inch rectangular cut-out on one of two pieces of sheetrock that create the one hour fire rated wall shared by the unrated physical therapy room. On 9/7/2016 at 10:40 AM, a surveyor in the elevator machine room by the north elevator observed three data wires passing through an unsealed 1/2 inch hole, and 2 data wires passing through an unsealed hole that was partially sealed. When interviewed on 9/8/2016 at 11:24 AM, the Director of Plant Operations stated he was not aware of the unsealed penetrations found in the two elevator machine rooms. 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: N/A

Plan of correction not approved or not required

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the electrical wiring and equipment was in accordance with National Electrical Code. 9-1.2 (NFPA 99) for one isolated area (first floor central supply room). Specifically, the required clearance of electrical panels was not maintained for the first floor central supply room. Findings include: On 9/7/2016 at 9:30 AM, a surveyor in the first floor central supply room observed the main electrical panel for the computer back-up energy supply was blocked by 76 E-size oxygen tanks. The clearance from the electrical panels to the cabinets was less than three feet as required by code. When interviewed on 9/8/2016 at 11:24 AM, the Director of Plant Operations stated he was aware there were clearance requirements and that he was able to reach the panel. When asked if a shorter person could reach this panel, he stated that a shorter person may not have been able to reach the panel. 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: N/A

Plan of correction not approved or not required

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms. 18.7.1.2, 19.7.1.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 8, 2016
Corrected date: November 7, 2016

Citation Details

Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure that fire drills were completed on 1 of 3 shifts (night shift) in (YEAR) and (YEAR), as required. Specifically, night shift fire drills were not completed during the fourth quarter of (YEAR) and the second quarter of (YEAR). Findings include: During review on 9/6/2016 at 1:35 PM of the facility's fire drill reports, there was no documented evidence found that night shift fire drills were completed for the fourth quarter of (YEAR) and the second quarter of (YEAR). When interviewed on 9/8/2016 at 10:03 AM, the Director of Plant Operations stated he could not locate documentation for night shift fire drills for the fourth quarter of (YEAR) and the second quarter of (YEAR). 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: N/A

Plan of correction not approved or not required