The Citadel Rehab and Nursing Center at Kingsbridge
August 1, 2016 Certification Survey

Standard Health Citations

FF09 483.15(a):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's foley catheter bag and tubing were not covered. This was evident for 1 of 36 residents reviewed for Dignity (Resident # 400). The findings are: Resident #400 is a [AGE] year-old male with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 ( MDS) assessment dated [DATE] documented the resident had intact cognition. On 7/26/16 at 12:38 PM and 1:43PM, the resident was observed sitting up in bed. The resident's foley catheter drainage bag and catheter tubing, with yellow urine draining into the bag, was exposed and visible from the hallway. On 7/26/16 at 2:39PM, the Registered Nurse (RN) Supervisor was interview and stated when the resident is in bed, the foley bag should be covered with urine catheter privacy bag or placed on the side of the bed that does not face the door, which would be the left side for this resident. On 7/27/16 at 4:10PM, the Assistant Director of Nursing (ADN) was interviewed and stated the facility policy, revised today 7/27/16, documents that when a resident is in bed, the drainage bag should be positioned/placed on the opposite side of the bed, away from the doorway so as not to be visible. On 7/28/16 at 12:42PM, the 7-3 shift Certified Nursing Assistant (CNA) was interviewed and stated the catheter and bag is supposed to be placed on the other side away from the doorway so as not to be visible, but she forgot to place it on the other side. The facility Policy & Procedure on Catheter Care Effective date 7/10, rev 7/27/16, documented when a resident is in bed, the drainage bag should be positioned on the opposite side of the bed, away from the doorway so as not to be visible 415.5(a)

Plan of Correction: ApprovedAugust 25, 2016

F 241
Immediate Correction Action Taken:
Resident # 400?s urinary drainage bag was covered with a Foley bag cover on 7/29/16.
Identification of other areas:
All residents with Foley drainage bags received covers.
Measures/ Systematic Changes Taken
to assure the Practice does not recur
1.The Policy and Procedure on all urinary drainage tubes was reviewed. Revisions were made to include the following:
14. All urinary drainage bags will be covered whether in or out of bed for dignity purposes.
2. All nursing staff were re-in serviced on the changes to the policy and procedure.
3. The CNA Plan of care was updated to include covering the foley with a privacy bag.
How Corrective Measures will be
Monitored
1. The DNS created an audit tool to monitor for compliance with the policy and procedure.

2. All residents with urinary drainage bags will be audited weekly x 1 month, bi weekly x 1 month and then monthly and results of the audits will be reported to the Quality Assurance Committee monthly x 6 months and then quarterly thereafter until such time an acceptable level of compliance is achieves at which time the frequency of the audits may change.

Title of Person Responsible for
Correction of Deficiency and Date
Director of Nursing

FF09 483.60(b), (d), (e):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

Based on observation and interview, the facility did not ensure medications and biologicals were stored under proper temperature controls and in accordance with manufacturers' specifications. This was evident for 1 of 10 units reviewed for Medication Storage (Unit 7E). The findings are: On 7/26/16 at 12:20 pm, the medication refrigerator on 7E was observed. The temperature registered 50 degrees Fahrenheit (F). The refrigerator contained several vials of insulin- 5 vials of Lantus, 1 vial of 70/30 Novolin, 1 vial of Humulin 70/30, 1 vial of Levemir, and 1 vial of Novolog. Several vials of insulin. The Registered Nurse (RN) was immediately interviewed and stated she verbally notified the RN Supervisor of the temperature this morning, and the RN supervisor would let maintenance know. RN Supervisor was interviewed and stated the refrigerator should be between 35 F and 40 F. She further stated Maintenance checked the refrigerator temperature, which was 44F, so they removed it and obtained a new refrigerator. 415.18(d)

Plan of Correction: ApprovedAugust 25, 2016

F 431
Immediate Correction Action Taken:
The refrigerator on 7 East was replaced, and a new thermometer was installed on 7/26/16. The temperature was monitored to ensure that the temperature was within the acceptable limits.
Identification of other areas:
All medication refrigerators on each Unit were checked for temperature. Two other refrigerators were replaced.
Measures/ Systematic Changes Taken
to assure the Practice does not recur
The policy and procedure on medication refrigerators was reviewed. No changes were needed.
Licensed Nursing staff were re-in serviced on the P/P for medication refrigerator temps.
How Corrective Measures will be
Monitored
Licensed staff will continue to check the temperature of the medication refrigerator every shift, and enter the temperature into the task section of the 24 hour report, in the EMR. Any refrigerator found to be outside of the acceptable temperature will be reported to the maintenance department immediately.
The DNS will create an audit tool to monitor for the compliance with the P/P on refrigerator temperatures.
The Audit will be conducted by the Nurse Managers on a weekly basis x 3 months, monthly x 3 months then Quarterly x 3 months.
Results of the audits will be presented to the Quality Assurance Committee monthly x 6 months and then quarterly at which time the frequency of the audits may change.

Title of Person Responsible for
Correction of Deficiency and Date
Director of Nursing

Title not available

REGULATION: N/A

Scope: N/A
Severity: N/A
Citation date: N/A
Corrected date: N/A

Citation Details

Details not available

Plan of Correction: Approved

Plan of correction not approved or not required

FF09 483.75:EFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING

REGULATION: A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

Based on observation, record review and staff interviews , the Administrator failed to use the facility's resources in a manner designed to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident . Specifically, the administrator failed to ensure that there were systems in place to provide a safe environment and effectively supervise and monitor residents on the use of the siderails. This was evident for 5 of 5 residents reviewed for Accidents (Resident #s 27, 354, 363, 336, 283 and 347). The facility has 385 certified beds located in two buildings designated as East and West buildings. The observations of deficient practice were noted in the East building. However 50 resident beds in one of two facility buildings were observed to have siderails with bar gaps measuring of 7 and 1/2 inch. This was found in the East building. The findings are: Refer to F 323 This deficient practice resulted in immediate jeopardy with the potential for more than minimal harm and substandard quality of care. The Administrator was interviewed on 7/29/16 at 4:12PM and stated that siderails are used for transfer and as an enabler. The Administrator further stated that an audit was done in (MONTH) (YEAR). This audit only looked at the gap between the mattress and the siderails as potential accident and entrapment hazards. The Administrator stated that he was was aware of the DAL NH 15-05 letter. He stated that he reviewed the recommendations made about sidreail measurements overall. He did not look at the recommended measurements regarding the space in between bars, specifically in the area identified as Zone 1. On 8/1/16 at 1:00PM, the facility Administrator was interviewed and stated he came on board as Administrator in (MONTH) (YEAR). The DAL (Dear Administrator Letter) came in (MONTH) (YEAR) . He stated that to his knowledge the previous Administrator conducted an audit on the siderails. As a result of the audit all siderails were changed in the West building. Howeve, in the East side only 10-15 siderails were changed. The residents on the East side are more ambulatory, high functioning, and alert. The Administrator said most of them use the siderails as enablers for positioning and transfering, and were applied as per physician orders. Everyone of them are with MD ( medical doctor ) orders. The facility has no accidents or incidents involving siderails . On the use of the siderails , to my knowledge , the nurses do the assessment for three (3) days for positioning upon admission and then the rehabilitation department staff will evaluate the residents . I believe there is a good coordination between nursing and rehabilitation in the use of the Siderail as transfers and enablers to assist and help the residents to maintain mobility. On 08/01/2016 the Immediate Jeopardy was removed after monitoring confirmed the facility had implemented a plan to remove the immediacy. The determination to remove the Immediate Jeopardy was based on the facility's Policy and Procedure revision to include an interdisipinary team approach for side rail assessment, education of staff regarding the revised Policy and Procedure, and removal of the siderails which exceeded the FDA recommended 4 3/4 inch space within the rail space. On 08/01/2016 the survey team conducted a visual assessment of all resident beds to validate that all siderails that did not meet the FDA recommendation had been removed. 415.26

Plan of Correction: ApprovedAugust 25, 2016

F- 490
I. The following actions were accomplished for the residents identified in the sample:
Please refer to corrective actions at F-323 for individual residents.

Please refer to corrective actions at F-520 related to the Administrator?s responsibility to provide guidance to the QA Committee regarding the identification and correction of deficient practices in the facility.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents who reside in the facility have been identified as potentially being affected by the same practices.
On 8/23/16, the Administrator met with the Outside Consultant to discuss responsibility for the overall management of the facility and need for effective management to maintain compliance with all regulations including the need to have effective systems in place specifically for the issues identified in the Statement of Deficiencies specifically related to (1) housekeeping and maintenance of a sanitary, orderly and comfortable environment, (2) maintaining an environment free of accident hazards prevent accidents and each resident receives supervision and assistive devices to prevent accidents; and (3) maintenance of an effective Pest Control Program. Emphasis was given to a thorough review of accident prevention and accident hazards related to side rail use.

The Administrator is facilitating and participating corrective actions being implemented and is enforcing and monitoring the overall implementation of the Plan of Correction.
Effective 08/22/16, the Administrator is participating in daily discussions on a Monday through Friday basis to review and assess the progress of the facility in implementation of the P(NAME) related to all deficiency citations and to discuss identified issues related to the status of compliance with the facility?s policies related to housekeeping; pest control; and side rail use. All identified issues will be addressed and monitored through the QA process. These discussions will be incorporated into Morning Report for timely follow-up.
The Administrator has directed that education related to the Directed Inservice F-tags (F-253, F-323, F-371, F-469 and F-520) as well as all other cited deficiencies be mandatory for all identified staff and is monitoring the attendance records for compliance.

III. The following system changes will be implemented to assure continuing compliance with regulations:

As of 8/23/16, the facility has a newly appointed Administrator.
The Administrator, or designee, will continue to assist Department Heads in reviewing and revising or developing policies and procedures to ensure that the facility?s protocols comply with current standards of practice and address findings in the Statement of Deficiencies related to the Directed Plan for F- 253, F-323, F-469 and F-520. Further revision to policies and procedures will be implemented as indicated.
The Administrator and Director of Housekeeping will review and revise, as needed the facility?s policies and procedures and QA reporting and auditing for issues identifies under F-253 and F-469.
The Administrator, Director of Nursing and Medical Director will review and revise, as needed, the facility?s policies and procedures and QA auditing and reporting schedule as outlined in F-323, and F-520. They will continue to review and revise, as needed, all facility policies and procedures related to these regulations to ensure ongoing compliance.
The Outside Consultant will assist will policy and procedure reviews and revisions and will assist in monitoring attendance for mandatory educational sessions.
The Administrator will hold AD Hoc QA meetings as needed.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
As per the Directed Plan of Correction, a QA Committee meeting was held on 8/18/16 co-chaired by the Outside Consultant to examine the deficiencies cited.
The Administrator will monitor that any identified deficient practices related to compliance with F-253, F-323, F-469 and F-520 are promptly addressed by the QA Committee. If needed, an ad hoc QA Committee meeting will be convened to reassess any reported non-compliance with the Plan of Correction for F-253, F- 323, F-469 and F- 520 or additional concerns related to all other cited deficiencies.
The Administrator will monitor compliance with the Plan of Correction for F-253, F-323 and F-469 per the audit schedule outlined at that citation.
The Administrator will monitor and assess the QA Committee?s follow-up as outlined at F-520. Corrective actions, such as policy revision, additional auditing, or additional education, will be implemented, as indicated.
The Administrator will ensure that the QA Committee is provided with any information distributed by the DOH/CMS or any other regulatory entity so that this shared information can be discussed and applicable policy review and revision takes place. The Administrator will monitor that staff education related to new/revised protocols is provided and that appropriate staff members are involved in the development, implementation and monitoring of facility policies and procedures. The Administrator will monitor that follow-up evaluation is conducted by the QA Committee.

Responsibility: Administrator

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

Based on observations, interviews and record reviews, the facility did not ensure that the sanitary conditions were maintained in the kitchen and pantries to prevent food borne illness and cross contamination. Specifically, (1) the freezer temperature did not meet the standard, (2) hot and cold foods were not held at the proper temperature during tray line, (3) the sanitizing solution did not have adequate concentration to sanitize pots and pans, and (4) food was not properly labeled. This was evident for the Kitchen and 1 of 10 unit pantries (Unit 2W). This resulted in no actual harm with the potential for more than minimal harm. The findings are: 1) On 7/26/16 at 9:45 AM, a tour of the kitchen was conducted and the following was observed: The Freezer temperature registered +11 degrees Fahrenheit (F). It was being used for lunch preparation. On 7/27/16 at 12:00 noon, a second observation was made of the freezer and the temperature registered at 28 F. On 7/27/16 at 12:05 PM, the Director of Food Service (FSD) was interviewed and stated that the staff are using the freezer for lunch preparations, so the door is opened frequently. He further stated around 3 PM the temperature will come down when the door stays shut. The facility food service policy for Storage of food in Refrigerator / Freezer, revised 2013, documented: Foods will be stored in the Refrigerator at 41 F or below and in the Freezer at 0 F or below. 2) On 7/27/16 at 11:30 AM, the tray line was observed and food temperatures were taken. The following hot foods did not meet the temperature guidelines: Chopped chicken 120 F - (kept in a shallow pan in the steam table well. The pan was not touching the well's hot water to heat the pan and maintain the temperature). The Food Service Supervisor (FSS) asked the staff to heat up the chicken again. A second pan of Chopped Chicken registered at 130 F. The following cold foods did not meet the temperature guidelines: Chilled apple slices 75 F Puree fruit 58 F Fruit Cocktail 62 F Apple juice 60 F All these items were placed on prepped trays and placed in a truck by tray line. There was no mechanism in place to keep them cold. A cup of chilled apple slices from the refrigerator registered at 65 F, and pudding was 50 F. The refrigerator interior temperature registered at 40 F. On 7/27/16 at 12:30 PM, the FSD was interviewed and stated that normally the cold items are placed in the freezer for a short time to bring the temperature down. He further stated staff did not do it today. There is no excuse, we will fix it tomorrow. The facility policy for Hot Foods, revised 2013, documented: All hot foods cooked to minimum of 165 F and held in steam table at a minimum of 140 F. All cold foods requiring refrigeration are held at 41 F or below. 3) On 7/29/16 at 11:20 AM, the pot washing procedure was observed as follows: The Food Service Worker (FSW) was washing dishes and sanitizing a few pans in sink. FSW explained the pot washing procedure and checked the sanitizer concentration. He took a test strip and immersed it in the sanitizer solution for 10 seconds and compared it against the color code. The concentration registered at zero Parts per Million (PPM), with a bright orange color. The Surveyor observed that the Sanitizer bottle on the floor was almost empty and contained very little sanitizer at the bottom, not enough to reach the tubing to flow. Then the FSW placed the tubing to a full bottle of Sanitizer, drained the sink and refilled it. He then checked the concentration of the Sanitizer which registered 200 PPM. On 7/29/16 at 11:30 AM, the FSW was interviewed and stated that he did not notice that the sanitizer bottle was empty. He checked this morning, and found it ok. The FSW further stated that he cannot clearly see the color or the numbers on the test strip code container, since he does not have his eye glasses with him.
4) On 7/26/16 at 9:50:41 AM, the 2W pantry was observed. The refrigerator contained one container of food labeled with a name but no date and one unlabeled container of food. The Registered Nurse (RN) was immediately interviewed and stated staff are responsible for labeling food with the resident's name and date. She further stated that the food in the plastic container was brought in by a resident's family yesterday, but she was not sure who the other container of food belonged to. She stated that the unknown food will be discarded. 415.14 (h)

Plan of Correction: ApprovedAugust 25, 2016

F- 371
I. The following actions were accomplished for the residents identified in the sample:
No residents were identified in the Statement of Deficiencies.
The following actions were accomplished for the observations identified in the Statement of Deficiencies:
Kitchen
o Freezer ? all Food Service Workers were reeducated by the Director of Food Service , on (MONTH) 9, (YEAR) regarding appropriate freezer temperature and maintaining the designated temperature during meal preparation times
o Hot foods ? all Food Service Workers were reeducated by the Director of Food Services on (MONTH) 9, (YEAR) regarding the need to ensure the pans reach the steam table well and touch the water in order to maintain the appropriate hot food temperatures.
o Cold foods ? all Food Service Workers were reeducated by the Director of Food Services on (MONTH) 9, (YEAR) regarding ensuring all cold foods requiring refrigeration are placed in the freezer to bring the temperature down prior to placement on prepped trays.
o Sanitizer ? the Food Service Worker identified to not having the appropriate sanitizer concentration for pot sanitizing was reeducated by the Director of Food Services on (MONTH) 5, (YEAR) relative to checking the amount remaining in the sanitizer bottle is sufficient to complete the task and to appropriately test the solution. The staff member was counseled regarding ensuring he has his eyeglasses while working to ensure his ability to correctly read the sanitizer test strip.
Unit 2W Pantry
o The pantry was cleared of all undated / unlabeled food items. The Unit Manager provided education to the unit staff relative to the proper dating and labeling of all food items stored in the unit pantries. This education also addressed the removal of undated / unlabeled items in a timely manner.

II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have been identified as potentially being affected by the same practice.
On (MONTH) 24, (YEAR) the Outside Consultant provided education to all Food Service Workers relative to maintaining sanitary conditions to prevent food borne illness and cross contamination. This education included maintaining appropriate standards for freezer temperatures; ensuring hot and cold foods are held at proper temperatures during meal and tray line preparation and ensuring the sanitizing solution is of adequate concentration to sanitize pots and pans.
On (MONTH) 24, (YEAR) the Outside Consultant provided education to all facility staff regarding the proper labeling and storage of food items in the unit pantries. This education also addressed the responsibility for removal of undated / unlabeled items in a timely manner.
All unit refrigerators were inspected for the dating and labeling of foods, the timely discard of expired foods.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Director of Food Service and the Administrator reviewed and revised, as necessary, the Food Service policies and procedures related to the Proper Storage and Preparation of foods under sanitary conditions inclusive of maintaining freezer / refrigerator temperatures and hot and cold food temperatures during meal and tray preparation.
Beginning (MONTH) 9, (YEAR) the Director of Food Service / designee will monitor freezer and refrigerator temperatures as well as the temperatures of hot and cold food items during meal / tray preparations daily for all meals for two weeks; then each meal three times per week for two weeks followed by each meal weekly for two weeks and then each meal monthly. Corrective action will be implemented as necessary.
Beginning (MONTH) 5, (YEAR) The Director of Food Service / designee will ensure the Food Service Workers responsible for testing the sanitizer solution for the appropriate concentration are appropriately testing / reading and ensuring the appropriate concentration is in use during pot / pan washing. The Director of Food Services / designee will complete direct observation and validation of the sanitizing solution concentration testing by the assigned Food Service Worker daily following all meals for two weeks. Following this random weekly observation after each meal will continue to ensure the proper concentration continues to be employed. Corrective action will be implemented as necessary.
The Administrator and the Food Service Director have reviewed and revised, as needed, the policies and procedures addressing the labeling and dating of food items stored in the unit pantries.
The Outside Consultant provided additional education to all staff regarding the appropriate storage of food items in the pantry refrigerators inclusive of labeling and dating of all items. This education also included who is responsible for removal of items that are not appropriately labeled or beyond the acceptable date.
Residents will be advised of the time limited storage of their food items in the pantry refrigerators and the facility?s discard policy through the Resident Council meeting scheduled on 9/14/16.
The Director of Food Service will develop and maintain a log of the freezer / refrigerator temperatures; hot / cold food temperatures logged during observations and observations of the sanitizing concentration testing. The findings will be reviewed with the Administrator on a weekly basis for a month, followed by monthly for three months and then quarterly.
The Food Service Director / designee will monitor the unit refrigerators on a daily basis to ensure compliance via an audit tool to ensure facility compliance with policy for labeling / dating and timely discard of stored food items. Corrective action will be implemented as necessary. The Food Service Director will report findings to the Administrator on a weekly basis for a month, followed by monthly for three months and then quarterly.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
The facility will develop an audit tool to monitor compliance with the above protocols. The Administrator and Food Service Director / designee will conduct monitoring of freezer / refrigerator temperatures and hit and cold food temperatures during tray preparation daily for all meals for two weeks; then each meal three times per week for two weeks followed by each meal weekly for two weeks and then each meal monthly.
The Director of Food Service will conduct competency evaluations of all food service staff to ensure they are following the established protocols and have a clear understanding of the protocols. On site education will be provided as necessary to ensure staff compliance. Competency evaluations will be conducted on all new foods service staff upon completion of orientation and twice yearly thereafter.
The Food Service Director/ designee will conduct audits of the unit pantries every Monday / Wednesday and Friday for compliance with labeling and dating and timely discard of expired items.
The Food Service Director will report all findings to the Administrator on a weekly basis for the next three months and monthly thereafter. Additional corrective action will be implemented as necessary.
The Food Service Director will report findings to the QA Committee on a monthly basis for the next six months. The Committee will determine the continued need for monthly review following the completion of this time. Additional corrective action will be implemented as deemed necessary by the committee.


Responsibility: Food Service Director

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of records, and interviews, the facility failed to ensure that the resident environment remained free from accident hazards. Specifically, siderails with a space measuring 7.5 inches in width between the bars and a vertical space measuring 17 inches and 9 inches were observed on 50 resident beds. This space exceeded the FDA recommendation that spaces between the bed siderail bars should be no larger than 4 3/4 inches. This was evident for 6 of 6 residents reviewed for Accidents (Resident #s 27, 354, 363, 336, 283 and 347). The facility has 385 certified beds located in two buildings designated as East and West buildings. The observations of deficient practice were noted in the East building. This resulted in no actual harm with the potential for more than minimal harm that was immediate jeopardy and substandard quality of care. The findings are: 1) Resident #27 is a [AGE] year-old, readmitted on [DATE], with [DIAGNOSES REDACTED]. On 7/26/16 at 4:05 PM, the resident was observed in bed with 1/2 siderails up on both left and right side of bed. The siderail to the left of the resident was observed with large spaces between the horizontal and vertical bars. On 7/28/16 at 12:40 PM, the resident's bed was observed, the resident was not in bed at the time of the observation. The siderail were down, the surveyor accompanied by facility staff pulled the side rail up. There were bilateral (B/L) upper half siderail, mismatched in design. The siderails on the right side had close bars with a 3 1/2 inch gap of between the bars. The facility staff member measured the gaps between bars on both left and right siderail. The siderail on the left side had bars with a 7 1/2 inch gap between the bars on both ends located in Zone 1 (head and foot). The Registered nurse (RN) stated that the resident uses B/L upper half siderails when in bed for bed mobility. The FDA recommends that the space between siderail bars should not exceed 4 3/4 inches. On 7/28/16 at 12:45 PM, the resident was observed in the dining room during lunch. The resident was sitting in a high back wheelchair (wheelchair) with a wheelchair alarm, left hand with hand splint, left cushioned arm rest, and a cushioned foot rest. The resident seemed confused and had unclear speech, making noise without any clear words. On 7/29/16 at 10:45 AM, a second observation was made of the resident's bed. The facility changed the left siderail to a different siderail that did not have large gaps between bars, and the new siderails matched the right siderails. The RN stated that they changed the siderails on 7/28/16 in the afternoon. The Minimum Data Set 3.0 (MDS) annual assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident required extensive assist of two people for bed mobility and transfers, and the resident was non-ambulatory. The MDS documented the resident had no restraints. The Comprehensive Care Plan (CCP), revised 12/13/15, for bed mobility documented the resident required extensive assist, and it included the intervention of optimum use of devices such as B/L (bilateral) half siderails for bed mobility. The CCP dated 5/20/16. Identified falls as a risk, it documented that the resident has had no falls since 6/15/15. On that date the CCP noted an intercepted fall with no injury. The CCP for Behavior had a review date of 7/26/16. It documented that the resident is anxious, easily redirected; verbally disruptive, makes noise, attempts to get out of bed and wheelchair unassisted. The EMR (Electronic Medical Record) included a physician's (MD) Order dated 7/13/16 which documented: bilatateral 1/2 siderail for bed mobility. According to the EMR this order was originally initiated on 7/14/15; Resident on Palliative care (4/1/16), with directives (DNR, DNI, DNH), Bed and wheelchair alarm for safety, Left wrist brace for proper positioning to be worn at all times, except care times; out of bed to wheelchair with 2 person assist; on Keflex 500 mg (milligrams) BID (twice a day) x 7 days starting 7/26/16 for Cellulitis of left toe; on Leviteracetam 250 mg BID for Convulsions, Mirtazapine 15 mg QD (daily) HS (at hour of sleep) for major depression; and on PRN (as needed) oxygen. There was no documented evidence that an assessment was done for the use of siderail for this resident. On 7/28/16 at 1:42 PM and 8/1/16 at 12:05 PM the Registered Nurse (RN) (MDS coordinator), who helped measure the siderails, was interviewed and stated that these are old siderails, and many have been changed. She stated the resident is non-ambulatory, requiring 2 assist for transfer; the resident is on Palliative care and too weak to transfer without assist. The RN further stated that nursing does risk assessments for skin break down, pain, fall, elopement and smoking but not on siderail use. She stated that she did not receive in-service on siderail use in the past year, but she was in-serviced on ADLs, including bed mobility. The RN further stated that prior to the in-service the weekend of 7/29/16, she was not aware of the specifications for siderails. When she worked in another facility, she heard about the dangers of siderails, but not the specifications for the space between bars. On 7/28/16 at 12:50 PM, the regular day shift Certified Nursing Assistant (CNA) was interviewed and stated that she knew the resident well, and the resident can occasionally say a few words (ie, bread, drink) and understand simple directions (ie lift your hands). She stated the resident requires total care and assistance of 2 people for transfer. She further stated that the resident is too weak to get up and do anything for herself, and she is fed by staff. The CNA stated that when the resident is in bed, she does not move much and is unable to position herself due to weakness. On 7/29/16 at 11:02 AM, rounds were conducted of the East building. Fifty beds were observed having one or both half siderail with large openings measuring 7.5 inches. The beds were located on 3E, 4E, 5E, 6E, and 7E. On 7/29/16 at 2:10 PM and 8/1/16 at 1:50 PM, the Director of Maintenance was interviewed and stated that the siderails with large gaps were the old ones, which were ordered by the rehabilitation department in the past. He further stated he ordered siderails from the same company one time in the past 6 months, but the new siderails are black in color with closer bars. He stated that the new siderails ordered in the past 6 months meet the FDA guidelines, and the siderails in question have been in the facility prior to the 3 years he has been working here. The Director stated that last year he became aware of the entrapment zones with regard to gaps between the bed and siderails, but not about gaps between the bars. He saw the zone requirement for siderails from the Health Care Association or the Administrator, he does not recall. He also stated that he received a copy to read, but maybe he missed it. He stated he was not aware of the measurements for siderails gaps between vertical /horizontal bars prior to this week when it was discussed during survey. On 7/29/16 at 2:20 PM, the Regional Director of rehabilitation (RD) department was interviewed and stated that the current rehabilitation director has been here for 2 months. The RDR further stated the rehabilitation services have been outsourced to an outside vendor since 2009. The RDR stated that a year ago there were guidelines for measurements between the bars and bed not to exceed 4 and 3/4 inches in diameter to avoid potential entrapment. The (RD) further stated that the rehabilitation staff do not check the siderails on the beds to see if they meet the guidelines. She further stated that rehabilitation staff assess bed mobility but not the siderail requirement and the potential for entrapment. She stated when she joined the facility in May, (YEAR), the practice was to assess bed mobility of the resident, not the siderail itself. The RD was not aware of the siderail guidelines and space specifications. On 7/29/16 at 2:24 PM, the rehabilitation technician was interviewed and stated that the rehabilitation staff member who used to order siderails in the past is no longer working at the facility. He stated there was only one type of siderails used for beds, and it was ordered. The technician stated he was not aware of any specific guidelines. On 7/29/16 from 3:13 PM to 5:00 PM staff interviews in the East building were conducted. Interviews of staff consisted of 4CNAs (Certified Nursing Assistant, 3LPNs (Licensed Practical Nurse), and 3 RNs (Registered Nurse), and 1 RN Supervisor. Only 2 of 4 CNAs were aware of the safety concerns regarding spacing between the mattress and the siderails and large spaces between the bars. Only one of the two CNAs ever reported a concern with siderail spacing (one time) and the siderail was switched. The 3 LPNs were not aware of what the spacing should be between the siderail bars. Ther 3 RNs were not aware of the guidelines for gaps between the the bars of the siderails and other entrapment zones. They had never received training on the FDA guidelines from the facility. The RN Supervisor was not aware of the FDA guidelines for siderail and bed safety and entrapment zones. She was not aware of the required measurments for spacing between the siderail bars, and she never received an inservice on the FDA guidelines. On 8/1/16 at 11:20 AM, the Licensed Practical Nurse (LPN-Charge nurse) was interviewed and stated the RN does the assessment and identifies the need for siderails, and the Physician writes the order for siderails. She stated that LPNs do determine if siderails are used for a resident. The LPN further stated that the residents who are able to follow commands for bed mobility and hold on to the siderails for movements or who have one sided weakness, like CVA, benefit from the use of siderails. She stated siderails used for safety are considered a restraint. Triangular wedges, bed bolsters or pillows should be used for safety and to prevent accidents. The LPN stated the resident is confused and unable to verbalize needs, and she is unsteady when standing and requires 2 persons for transfer. She stated the resident has bilateral upper half siderails for bed mobility, and this resident needs siderails while giving care. She stated the resident is able to hold on to siderails and take directives sometimes, not always. If you place her hand on the siderails, she will hold on to it. The LPN further stated the resident is able to move side to side in bed but not up and down. She stated she has not observed any of the resident's body parts inside the siderails bars when she sees her in bed, and she is not aware of any incidents of entrapment in the siderails for this resident or any other resident. She stated she became aware of guidelines for siderails bar spacing not to exceed 4 3/4 inches just this weekend, during survey, and prior to that she was under the impression it should be 3 inch gap. The LPN stated she did not receive any in-service on siderail use in the past year, but all staff were in-serviced this past weekend on the siderails bar space, gaps, and zones of body that can be trapped within siderails. The siderails are a restraint if it is for safety, but not if used for bed mobility. On 8/1/16 at 11:50 am, CNA#2, a floater who covers 7-3 pm or 3-11 pm shifts, was interviewed and reported that she cares for the resident sometimes. She stated the resident is confused and follows simple command like lift hand. She is not able to turn and position or move in bed by herself, and requires extensive assist of two people to transfer out of bed. Resident stands up unsteadily; she uses the siderails for bed mobility. If you tell her to hold the siderails, by guiding her hand, she will do it. The siderails for this resident is not a restraint, because, she cannot get up by herself. CNA#2 stated she was not in-serviced in the past year, but just this weekend she was in-serviced on siderails for bed mobility and proper fit, including siderails bar spacing not to exceed 4 and 3/4 inch between bars. She was not aware of any incident of entrapment to this resident or to any other resident in this facility, during her employment in the last 6 years. On 8/1/16 at 12:30 PM, the RN Supervisor (RNS) was interviewed and stated that the RN Supervisor or RN charge nurse, makes the decision for siderails. Staff follow behavior monitoring in bed, and if the resident is identified as fall risk, the RN decides and tells the Physician (MD) to order siderails. She stated for this resident, the siderails are for bed mobility. The resident used to try to get up before, but since the resident was placed on Palliative care (4/1/16), the siderails are for bed mobility only. The RNS further stated the need for siderails is evaluated based on the Bed behavior /mobility Monitoring Form. She stated if the siderails are for bed mobility or safety awareness, they are not considered a restraint and a Restraint evaluation is not done. She recommended the siderails for the resident to the MD, and the MD wrote the order. The RNS stated she did not know any specifications for siderails prior to last weekend, when they were in-serviced. She stated she was not aware of the siderails guidelines memo from DOH or FDA prior to last weekend. She stated all siderails identified as not meeting the guidelines were removed, and changed to the current standard over the weekend, throughout the facility. The Director of Nursing (DNS) in-serviced all the supervisors; In turn, the RNs in-serviced the floor staff, including nurses and CNAs. 2) Resident #354 is an [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition, and was sometimes understood and sometimes understands. The MDS further documented the resident had fluctuating inattention and disorganized thinking. The MDS documented the resident required extensive assistance of two people for bed mobility, and the resident had no physical restraints. On 7/29/16 at 11:02 AM, rounds were conducted of the East building. The resident's bed was one of 50 beds observed having one or both half siderail with large openings measuring 7.5 inches. The FDA recommends that the space between siderail bars should not exceed 4 3/4 inches. On 8/01/16 at 12:33 PM, the resident was observed in lunch. The resident was verbal but confused, and she was able to pick up and move items on her tray independently. The Bed Behavior/Mobility Monitoring Form dated 1/13/15 documented a 3-day observation for the resident's behavior in bed. The form documented the resident displayed the ability to turn in bed (staying centered) and maintained supine position. The Comprehensive Care Plan (CCP) for ADL's (Activities of Daily Living): All tasks dated 4/26/16 included the intervention: (Bilateral) 1/2 siderails for bed mobility. The CCP for Falls dated 4/26/16 documented the intervention: bilateral 1/2 siderails for bed mobility for safety. The Physical Therapy (PT) Discharge Summary dated 3/10/16 documented the resident required maximum assist with use of siderails and 75% verbal and tactile cues for bed mobility tasks. The Physician's (MD) Orders dated 7/25/16 (initiated 1/13/15) documented an order for [REDACTED]. The Certified Nursing Assistant Accountability Record (CNAAR) dated (MONTH) (YEAR) documented the resident required supervision and half siderails for bed mobility. On 8/1/16 at 12:40 PM, the Certified Nursing Assistant (CNA) assigned to the resident was interviewed and stated the resident is able to participate in her care to varying degrees depending on her level of confusion at the time. She further stated the resident does not require turning and positioning because she is able to move in bed. The CNA stated the resident is able to use the siderails to assist with her movement. She stated that the resident would be able to physically press the call bell, but she may not be able to remember what it is for. She stated that the facility provided inservices in the past regarding how to use the siderails and prevent falls, but the inservices did not cover risks of entrapment and getting caught in the siderails. The CNA stated that she would report loose siderails to the nurse. On 7/29/16 at 3:46 PM and 8/1/16 at 12:08 PM, the Registered Nurse Unit Manager (RNUM) of 3E was interviewed and stated the residents are assessed for bed mobility upon admission, readmission, and as needed to see if a bed alarm is needed. She further stated there is no written documentation for the assessment for half siderails, but the rehabilitation nurse assesses the siderail need and fit of the siderail. She stated the nurse on duty assesses whether the resident is able to hold onto the siderail and use it for moving in bed. She stated the order is entered by nursing and the rehabilitation nurse does the siderail assessment to ensure they are appropriate. The RNM stated that she cannot recall receiving an inservice regarding siderail safety or entrapment prior to now. She was not aware of the spacing requirements between the siderail bars, but she was aware of the risk for entrapment between the mattress and the siderails. She stated that she was also aware that if a resident's whole limb can fit between the bars, it would be considered a hazard. She stated that if a resident has fragile skin or presses themselves against the siderails, padding can be added. 3) Resident #363 is a [AGE] year-old, admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition and displayed the mood symptom of trouble sleeping. The MDS further documented the resident required limited assist of 1 person for bed mobility and transfers and extensive assist of one person for ambulation in the room. The resident was not on psychotropic medication. On 7/27/16 at 10:32 AM, the resident's room was observed. The bed had half siderails with large openings between the horizontal and vertical bars. Meausurements had not been taken at this time. On 7/29/16 at 10:40 am, the resident was observed in his wheelchair in the day room reading a newspaper with his eyeglasses on. The resident was wearing a left hand splint. He was interviewed and stated that he is on a Floor Ambulation Program (FAP), and he is able to transfer himself from bed to wheelchair. The resident further stated he prefers to have the bilateral (B/L) 1/2 siderails as a safety device since he gets seizures. They do not interfere in any way with transfers or sleeping. On 8/1/16 at 12:55 pm, the resident was observed in bed, awake and lying down. The resident stated that both half siderails have been changed to newer ones this past Saturday. He stated that he uses the siderails to get up from bed, transfer himself to the wheelchair, and go to the bathroom. He stated he is not able to walk in the room independently. The Comprehensive Care Plan (CCP) for falls was revised on 7/19/16, documented the resident was high risk for falls due to seizures, and noncompliant behavior. The resident was on fall precautions. The interventions included low bed and B/L upper 1/2 siderails for bed mobility. The CCP notes documented the resident had one incident, on 2/20/16, when he was observed sitting on the bathroom floor after independently transferring without calling for help. There were no further incidents or accidents documented. The CCP for Seizure, revised 7/19/16, documented the resident had no seizuers in the past year, and the resident was on Keppra 500 milligrams (mg) BID (twice per day). The CCP for ADLs dated 9/29/15 documented the intervention of both 1/2 upper siderails for bed mobility. The Certified Nursing Assistant Accountability Record (CNAAR) dated (MONTH) (YEAR) documented the resident required 2 half siderails for bed mobility. The rehabilitation Physical Therapy (PT) assessment dated [DATE] documented siderails use for the resident. The Nursing admission assessment dated [DATE] had no documentation of assessment done for siderails; Bed behavior /mobility evaluation done but no recommendations made. No current annual nursing assessment done, that includes siderails evaluation or need for use. The MD order dated 7/19/16 documents orders for B/L 1/2 siderails for bed mobility, Fall precautions, FAP for 200 ft with Rolling Walker (RW) with 1 assist, and seizure precautions. On 8/1/16 at 1:00 PM, the Registered Nurse Supervisor (RNS) was interviewed and stated that if resident has the ability to use siderails for bed mobility, transfers, or turning and positioning, then siderails can be used. For residents lacking safety awareness, i.e. restlessness, bed alarms, and bed bolsters for bed boundaries can be used. Upon admission, the rehabilitation nurse assesses ADLs and the need for siderails, the RN makes a recommendation for siderails, then MD orders the siderails. She further stated this resident has left sided weakness, and he uses right side siderail to turn. She stated now, the resident is mobile in bed and able to transfer himself to the wheelchair with the siderails. She received no in-service in the past year on siderails and the guidelines, but over the weekend she was in-serviced on siderail use. She stated there were no incidents of entrapment for the resident. On 7/29/16 at 10:30 AM, the Administrator was interviewed and stated that he was informed that the gap in siderails could be an accident hazard from a different facility a year back. He further stated he had done rounds and had not noticed any issues with siderails. On 7/29/16 at 10:33 AM , the Director of Nursing (DNS) was interviewed and stated that she did an entire audit of siderails in all the units for any gaps between the bed and siderails as part of Quality Assurance (QA). She further stated that any findings were reported to maintenance and fixed it by either changing the siderails or the mattress. She stated she was not aware the space between bars was a potential problem, so that concern was never looked into, but it will be looked into right away and any siderails are a potential accident hazard will be replaced.
4) Resident #336 is a [AGE] year-old with [DIAGNOSES REDACTED]. On 7/29/16 at 11:02 AM, rounds were conducted of the East building. The resident's bed was one of 50 beds observed having one or both half side rails with large openings measuring 7.5 inches. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident required extensive assist of one person for bed mobility and transfer, and the resident only ambulated once or twice with assist of one person. The MDS documented the resident had no physical restraints. On 8/1/16 at 12:48 PM, the resident was interviewed and stated that he is able to use the half siderails, and they help him with positioning. The resident further stated that staff also assist him as needed. The resident was observed with a splint on his right arm and hand, and he used his left hand to move his right arm. The Bed Behavior/Mobility Monitoring Form dated 2/6/14 documented the resident displayed the following at least once: turns but slide to edge of bed, agitated/restless, tries to get up to sit, tries to get out of bed, climb over side rails. The Comprehensive Care Plan (CCP) for ADL's (Activities for Daily Living): All tasks dated 5/11/16 documented the intervention bilateral 1/2 siderails for bed mobility. The CCP for Falls dated 5/11/16 documented the interventions: bilateral 1/2 sideails for Bed mobility, B Floor Mats, Bed at lowest level possible. The Physical Therapy Discharge Summary dated 6/9/16 documented the resident performs bed mobility tasks with Contact Guard Assist (CGA) and use of siderails. The Physician's (MD) Orders dated 7/13/16 documented an order for [REDACTED]. The Certified Nursing Assistant Accountability Record (CNAAR) dated (MONTH) (YEAR) documented the resident required bilateral 1/2 side rails for bed mobility. On 8/1/16 at 3:06 PM, the 7-3 Certified Nursing Assistant (CNA) assigned to the resident was interviewed and stated the resident is able to move in bed on his own and transfer using the siderails to assist him. The CNA stated that she had just received education about siderail safety and entrapment, but she did receive an inservice previously. She stated that the staff are instructed to look at the space between the head and sides of the bed and between the siderail bars. She further stated that she is supposed to inform the nurse of any concerns so that maintenance will be contacted. The CNA stated that she never noticed any problems with the siderails for any of the beds. On 7/29/16 at 11:22 AM and 8/1/16 at 1:20 PM, the Registered Nurse Manager (RNM) covering 4E and 5E was interviewed and stated the Bed Behavior/Mobility Monitoring Form is used to determine whether a resident needs siderails. If a resident requires siderails, rehab is called for an evaluation. She stated that there had never been an inservice regarding siderail fit, gaps, or dimensions to reduce the risk for entrapment. She stated that she was not aware of guidelines for spacing between the bars. The RNUM further stated that they would make sure the siderails were ordered, and maintenance or rehab is responsible for checking the siderails. She stated the RN is responsible for determining the need for padding and ensuring it is ordered by the physician and put into place. On 8/1/16 at 11:26 AM, the Medical Director was interviewed and stated that half side rails are usually a nursing issue, and it is mostly used as an enabler. The Director stated that the nurses assess the residents for use of 1/2 siderails and enter the orders into the Electronic Medical Record (EMR). He stated that if a siderail is used as a restraint, it has to be assessed and ordered by the physician. He stated that a siderail is only used for a limited time and as a last resort to prevent a resident from harming themselves. The Director stated that a 1/2 siderail could be seen as a restraint if the resident is totally dependent on staff and unable to move on his or her own. He stated that he was aware of the FDA guidelines recommending the spaces in between the siderail bars and mattress and bed not be more than 4 3/4 inches. He stated that he was not involved in the bed audit conducted by Administration and Nursing, and he was no aware that any of the siderails in the facility did not meet the guidelines. On 8/1/16 at 11:48 AM, the Assistant Medical Director (AMD) was interviewed and stated that nursing determines if 1/2 siderail is needed and enters the order into the EMR. He further stated that the siderails are used as enablers, and they are never used as a restraint. The AMD stated that a 1/2 siderails are not a restraint, and if the resident is totally dependent on staff and unable to move, there is no need for a 1/2 siderail. He stated that the FDA guidelines for bed siderails should be followed, and another administrator informed him of the guidlelines. He stated that it was his understanding that the measurments were required for full siderails and not half siderails. The AMD also stated he was not involved in the bed audits conducted by the Director of Nursing (DON).
5) Resident # 283 is [AGE] yeara old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required limited assistance with bed mobility. On 7/28/18 at 1:10 PM, the resident was observed sitting on the front of the bed. The resident was awake, alert and oriented, and able to make his needs known, The resident was tall with a right below knee amputation. The bed had bilateral upper 1/2 siderails on it. The left 1/2 siderail was up and the right siderail was down. The resident was sitting on the right side of the bed. The bilateral upper 1/2 siderails had spaces between the bars measuring 7.5 inches. The resident stated that he is able to ambulate using a walker, and he is on floor ambulation with staff assistance. The resident also demonstrated that he was able to pull the siderails up and down himself. The FDA recommends that spaces between siderail bars should not exceed 4 3/4 inches. The Comprehensive Care Plan (CCP) for ADL Functional/Rehabilitation Potential dated 6/24/16 documented the resident required supervision for bed mobility and one person assist for transfers. The CCP included the intervention rignt siderail for bed mobility. The Physician's (MD) Orders dated 7/24/14, revised 7/29/16, documented Bilateral (B) 1/2 SR(Siderails) for bed mobility. The Bed Behavior Mobility Monitoring Form dated 7/24/16 through 7

Plan of Correction: ApprovedAugust 25, 2016

F-323 ? Free of Accident Hazards/Supervision/Devices
I. The following actions were accomplished for the resident identified in the sample:
Resident #27
On 7/31/16, the resident?s side rails were replaced with bilateral ½ side rails consistent with the FDA guidelines. On 8/18/16, the side rail assessment was completed and on 8/19/16, the IDCPT reviewed the side rail assessment and rehab bed mobility screen and determined that no side rail is indicated since the resident is immobile and makes no attempt or shift in bed. Side rails were discontinued and removed.
Resident #354
On 7/31/16, the resident?s side rails were replaced with bilateral ½ side rails consistent with the FDA guidelines. On 8/18/16, the side rail assessment was completed and on 8/19/16 the IDCPT reviewed the side rail assessment and rehab bed mobility screen and determined resident does not need side rails. Side rails were discontinued and removed.
Resident #363
On 7/29/16, the resident?s side rails were replaced with bilateral ½ side rails consistent with the FDA guidelines. On 8/18/16 the side rail assessment was completed and on 8/19/16, the IDCPT reviewed the completed side rail assessment and rehab bed mobility screen and determined resident would benefit a right ½ side rail to assist in bed mobility/transfer. MD order was obtained and care plan and CNA plan of care were updated.
Resident #336
On 7/29/16, the resident?s side rails were replaced with bilateral ½ side rails consistent with the FDA guidelines. On 8/18/16 the side rail assessment was completed and on 8//19/16, the IDCPT reviewed the assessment and rehab bed mobility screen and determined resident would benefit two ½ side rails for turning and positioning, pulling self to sitting position and transfer. MD order was obtained and care plan and CNA plan of care were updated.
Resident #283
On 7/29/16, the resident?s side rails were replaced with bilateral ½ side rails consistent with the FDA guidelines. On 8/16/16 the side rail assessment was completed and on 8/19/16, the IDCPT determined no side rail is indicated since the resident is able to safely enter and exit bed without side rail use. Side rails were discontinued and removed.
Resident # 347
On 7/29/16, the resident?s side rails were replaced with bilateral ½ side rails consistent with the FDA guidelines. On 8/18/16 the side rail assessment was completed and on 8/19/16, the IDCPT reviewed the assessment and rehab bed mobility screen and determined resident would benefit R
1234

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: August 1, 2016
Corrected date: September 20, 2016

Citation Details

Based on observation and interview, the facility did not ensure that necessary housekeeping services were provided to maintain a sanitary, orderly, and comfortable interior. This was evident for 1 of 10 units reviewed for Environmental Observations (Units 3E, 4E, and 5E). The findings are: 1) On 7/29/16 at 11:50 am, an environmental tour was conducted on 5 east unit. The hallways on both sides of the unit had a strong urine odor. Room 509 was observed with a dirty privacy curtain between the beds. The curtain had brown stains in four places, and it did not appear clean. On 7/29/16 at 12:00 PM, the Registered Nurse (RN) on 5E was interviewed and stated that a resident urinated on the hallway floor in the morning, but it was cleaned up. The RN further stated that she will have the privacy curtain replaced.
2) On 7/26/16 at 1:15:22 PM, Resident #283 was interviewed and stated that the facility was not really clean. He stated that the staff clean every morning, but the building does not seem clean. He further stated there are floor stains they don't take care of. On 7/26/16 at 3:40 PM, the designated representative of Resident #369 was interviewed and stated the floors are often dirty. She further stated that the resident's former boss came to visit the facility and contacted her to tell her how disappointed he was in how the facility looks. The representative further stated that she spoke to staff about cleaning the floors, but the floors are still not clean. On 7/26/16 at 11:35 AM and 3:54 PM, Room 3E/308P was observed. The floor had brown ground in dirt around the perimeter. There were light brown dried liquid stains on the floor around the resident's tube feeding pole and on the base of the tube feeding pole. The sink in the room had yellow stains in it. On 7/27/16 at 10:20AM, the resident's room was observed again with the same. On 7/27/16 at 10:53 AM, Room 4E/401 was observed with the following: The base of overbed table for the D bed was covered with dust and dirt, and there were crumbs on table top. The window sills were dusty and the wallpaper on the back wall had brown and gray stains. The air conditioner cover was dusty with chipping paint on the frame around it. The privacy curtain of C bed was heavily stained with brownish and grayish dirt stains. The bathroom floor had grayish brown ground in dirt along the perimeter, and the sink had brownish/yellowish stains in it. On 7/26/16 at 1:35 PM, Room 3E/316 was observed. The window curtains had fraying edges and loose seams. There was dust on top of the air conditioner (a/c), and the floor was stained with brown stains and ground in dirt around the perimeter of the room. The base of the A bed overbed table was covered with dust and dirt. On 7/27/16 at 10:24 AM, Room 3E/313 was observed. The window curtains were worn and tattered with loose seams and strings hanging down from the worn fabric. The wall to the left of the window had numerous brown drip and splatter stains. The privacy curtain for the D bed was heavily stained with gray and light brown stains and drip marks. On 7/27/16 at 10:48 AM, Room 4E/403A was observed. Some areas of the wallpaper had light brown stains. The floor had light brown stains and black scuff marks. On 7/26/16 at 11:56 AM and 7/27/16 at 10:22AM, Room 3E/306C was observed. The floor to the left of resident's bed was heavily stained with a light brown substance, and the floor throughout the room was dirty with light brown mark. There were black scuff marks on the floor by the door. The perimeter of the floor had ground in brown dirt. The privacy curtain for the C bed was stained light gray on the bottom edge with dirt. The window curtains had fraying edges where the seams were undone. The bottom of the curtain was repaired with staples, which were holding the fabric together. There were light and dark brown stains on the curtain. The wallpaper throughout the room was yellowing, and there were large sections peeling off the wall in two places approximately 4 ft in length. On 7/26/16 at 1:05 PM, Room 3E/314A was observed. The window curtain hems were loose revealing frayed edges, hanging strings, and fabric pulls along the bottom. The toilet room had a urine smell. On 7/28/16 at 11:07 AM, the Certified Nursing Assistant (CNA#1) was interviewed and stated that she is a regular CNA on the unit and was covering rooms 303, 304. 307, 311, 310, and 316. She stated that any environmental concerns such as dirty privacy curtains, spills, dirty walls, bugs, and broken items are reported to the nurse. CNA#1 stated that either the CNA or nurse can document things in the maintenance book. She further stated she has not noticed any flies or housekeeping concerns requiring deep cleaning lately, but she did report a dirty privacy curtain an it was replaced. CNA #1 stated that she is responsible for wiping the top of the overbed tables and nightstands if they are dirty. She also stated that housekeeping is called for larger spills so they can be mopped. On 7/28/16 at 11:18 AM, CNA#2 was interviewed and stated she is a regular CNA and usually covers rooms 303A, 305, 306D, 308, 309A, 313A /D, 316B, 317A, and 318B. She stated if there is anything dirty or in disrepair, she informs the nurse and it is put in the maintenance book. She stated Housekeeping and Maintenance do rounds on the floor daily. CNA#2 stated any bugs have to be reported so that they can send someone to take care of it. She stated dirty privacy curtains are changed, but Maintenance said the window curtains will eventually be changed when the units are renovated (renovations have started in the West building). She stated Housekeeping cleans the tube feeding poles. CNA#2 also stated that she has not noticed any flies or ants in the rooms recently, but she has seen fruit flies if a resident has fruit. She stated that she has only noticed the window curtains are in need of repair. On 7/28/16 at 12:21 PM, CNA#3 (covering rooms 306, 302, 313, 312, 309, and 318) was interviewed and stated if she notices any problems with things that need cleaning or broken items, she reports it to the nurse. She further stated the nurse or CNA documents concerns in the maintenance book. CNA#3 sated she should report dirty privacy curtains so that they can be changed. She stated she has never noticed any problems with bugs, but she would report them if she did. On 7/28/16 at 12:41:51 PM, the Housekeeper was interviewed and stated that her duties include sweeping, garbage removal, cleaning tables, dusting surfaces and window sills, and mopping in all resident rooms, bathrooms, the day room, and hallways. She stated one room is assigned for a complete room cleaning daily. The Housekeeper stated that she also tries to clean bathroom walls and bedroom walls for rooms with an odor, and she reports any dirty privacy curtains to the supervisor so they can be changed. She stated that any bugs are killed and reported to the head nurse on the floor. The Housekeeper stated she has noticed small gnats in room 307 because sometimes there is urine on the floor. She stated that she cleans with a disinfectant and a deodorizer, and she will use the deodorizer in the hallway and rooms for bad smells. She also stated there is another deodorizer for urine smell that is held by the supervisor. She stated that she asked for some of that to use because there was none of it on the floor, but she has to wait until the supervisor is back from his lunch break. She stated that she tries to remove the sink stains with a scrubber but it does not work all the time. On 7/28/16 at 12:56 PM, the Director of Housekeeping (DH) was interviewed and stated that he has been working in the facility for 2 months. He stated that all the resident rooms are being stripped, and 3E was done 2 weeks ago. He further stated that there are a lot of stains and dirt that cannot be removed. He stated that stripping is done for hallways and rooms once per year and as needed. The DH stated that the staff try to clean the window sills and dust, but he admitted that he does not believe the weekly dusting was done prior to his arrival. He stated that since the start of the survey, the department has been working hard to get the rooms and hallway floors cleaned. The DH said he conducts daily rounds in both buildings. The rounds consist of looking at the walls, windows, floors, an privacy curtains for cleanliness, and he also looks for any maintenance concerns. He also stated that housekeeping is responsible for the window curtains as well, and he is working on improving many things. 415.5(h)(2)

Plan of Correction: ApprovedAugust 25, 2016

F- 253
I. The following actions were accomplished for the residents identified in the sample:
Residents #283 & #369
On (MONTH) 25, (YEAR), the Housekeeping staff completed a thorough cleaning of the floors on these units.
The Maintenance/Housekeeping staff has scheduled repairs/cleaning for all concerns identified on Units 3E, 4E and 5E and cited in the SOD related to the following rooms:
? Rm 509
? Rm 308P
? Rm 401
? Rm 316
? Rm 313
? Rm 403
? Rm 306
? RM 314
On 8/19/16, the facility?s Exterminator addressed the issue identified with gnats in Room 307. This room has been scheduled to be addressed by Housekeeping three (3) times daily for odor control and more frequently as deemed necessary.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have been identified as potentially being affected by the same practice.

Terminal cleaning was initiated and implemented for 2 resident rooms daily since 8/8/16. The terminal cleaning schedule was reviewed and updated.
On 8/19/16, the Directors of Maintenance and Housekeeping toured all resident areas of the building and develop a punch list of all repairs/cleaning or painting that is required. The Maintenance and Housekeeping Directors will schedule repair work and cleaning for all identified issues.
As per the Directed Inservice, the Outside Consultant provided education on 8/22/16 through 8/25/16 to all staff regarding their responsibilities for maintaining a sanitary, orderly and comfortable interior. This education included a review of the survey findings as well as the need for routine and special cleaning of rooms, equipment, bathrooms, privacy/window curtains, walls and floor. Emphasis was also given to responsible Maintenance and Housekeeping staff conducting routine rounds to identify areas that require cleaning or repairs, such as torn/peeling wallpaper, scuff marks on floors; build up of wax / dirt on floor perimeters, dust on overbed tables / bases and window sills, spills on feeding poles, curtains that are in poor repair or observation of pests, as well as responsibility for scheduling needed cleaning, repairs or pest control.
The facility is in the process of renovations for the East Building and these renovations are expected to be completed by Fall (YEAR) which will resolve the identified environmental concerns.
Effective 8/23/16, the Director of Housekeeping will initiate use of a room checklist and audit tool to ensure satisfactory compliance with standards utilizing the developed cleaning schedule to identify those rooms requiring an inspection after cleaning. Nursing unit hallways were stripped and buffed on 8/19/16.
A room audit will be completed by Director of Housekeeping/designee for all resident rooms to identify unsanitary resident care equipment and medical devices and cluttered physical environment. Deficiencies identified will be corrected immediately such as schedule for cleaning, repairs, etc.
III. The following system changes will be implemented to assure continuing compliance with regulations:
As of 8/26/16, the facility appointed a new Director of Housekeeping.
An ad hoc QA meeting was held on 08/18/16 to discuss the cited deficiency related to housekeeping and maintenance services. An analysis was conducted, which determined the need to implement weekly multidisciplinary environmental rounds to ensure a sanitary, orderly, and comfortable homelike environment.
Effective (MONTH) 23, (YEAR), weekly environmental rounds by the multidisciplinary team will be implemented. Department Heads will be appointed as ambassadors and team leader. A unit and resident room observation checklist will be utilized and completed for all rounds made. Deficiencies will be reported immediately to the Director of Housekeeping and Administrator.
The Administrator and Maintenance and Housekeeping Directors will review and revise, as needed, the facility?s Environmental Rounds protocol and associated Inspection Tool and the Preventative Maintenance schedule and plan. This review will include a review of Housekeeping and Maintenance staff assignments to ensure that all issues identified during the survey are included in routine cleaning and maintenance assignments.
Effective 8/23/16, the Maintenance Directors/designee will inspect the building and furnishings on a daily basis and address needed replacement of items and/or schedule cleaning/repairs for identified building/furnishing issues.
Effective 8/23/16, the Director of Housekeeping/designee will conduct daily environmental rounds focused on assessing the cleanliness of the environment and will schedule additional cleaning of specific areas when indicated.
Housekeeping staff will be provided with additional education or counseling when issues with job performance are identified.
Effective 8/23/16, the Directors of Maintenance and Housekeeping will conduct joint weekly environmental rounds to identify issues that require corrective actions. These rounds will continue on a weekly basis until renovations are completed.
New Housekeeping and Maintenance staff will receive education on their job responsibilities during orientation and on an as needed basis.
The Director of Staff Education / designee will provide additional education to facility staff regarding the identification and reporting of maintenance / housekeeping and pest control issues in order for the issues to be addressed in a timely manner. This education will continue to be provided until all facility staff receive this required education.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
As per the Directed Plan of Correction, a QA Committee meeting co-chaired by Outside Consultant was convened on 08/18/16 to examine this deficiency
The facility will develop an audit tools to monitor compliance with the maintenance of a sanitary, orderly and comfortable interior.
The facility will utilize the findings from Environmental Rounds Inspection list and adherence to the Preventative Maintenance Schedule to monitor compliance with maintaining a sanitary, orderly and comfortable interior.
The Directors of Housekeeping and Maintenance will conduct comprehensive Environmental Rounds, minimally, on a monthly basis and report all environmental findings to the Administrator monthly. Corrective actions, including scheduling of repair work, painting, cleaning or replacement of an item in disrepair, will be implemented, as needed.
The Directors of Housekeeping and Maintenance will report environmental findings to the QA Committee on a monthly basis for the next six months for evaluation and follow-up. At the end of the six months, the Committee will determine if the frequency of reporting needs to be changed.

Responsibility: Maintenance and Housekeeping Directors


FF09 483.70(h)(4):MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

REGULATION: The facility must maintain an effective pest control program so that the facility is free of pests and rodents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

Based on observation, record review, and interview the facility did not ensure that an effective pest control program was maintained so the facility remains free of pests. Specifically, ants and gnats were observed in resident rooms and the hallway. This was evident for 1 of 10 resident units. (Unit 3E) The findings are: On 7/26/16 at 1:35 PM, Room 3E/316A was observed with fruit flies flying around the A bed. There were 2 flies on the privacy curtain. During the resident's interview, he kept swatting at the fruit flies flying around his head. A fly was also flying around the surveyor. On 7/28/16 at 10:41 AM, Room 3E/306C was observed during a resident interview. The resident opened her nightstand drawer and 5 ants were observed crawling on the items inside and in the drawer. The resident stated there are ants all over the place, and the staff are aware of the issue. She stated that she told them. On 7/28/16 at 11:55 AM, the 3E hallway in between Rooms 316 and 317 was observed. There were 6 gnats were on the wall, 2 gnats observed on the wall across the hallway. Rm 316A was observed with 3 gnats on the wall, 1 on the urinal, and 1 flying in the air. On 7/28/16 at 12:17 PM, Room 3E/306C was observed again. There were small ants on top of air conditioner, radiator, wall, and in the nightstand drawer, numbering at least 10 total. The Pest Management Log for the unit was reviewed. There were no reports for the flies or ants on the log. On 7/28/16 at 11:07 AM, the Certified Nursing Assistant (CNA#1) was interviewed and stated that she is a regular CNA on the unit and was covering rooms 303, 304. 307, 311, 310, and 316. She stated that any bugs should be reported to the nurse. She further stated she has not noticed any flies or housekeeping concerns requiring deep cleaning lately. On 7/28/16 at 11:18 AM, CNA#2 was interviewed and stated she is a regular CNA and usually covers rooms 303A, 305, 306D, 308, 309A, 313A /D, 316B, 317A, and 318B. She stated any bugs have to be reported so that they can send someone to take care of it. CNA#2 also stated that she has not noticed any flies or ants in the rooms recently, but she has seen fruit flies if a resident has fruit. On 7/28/16 at 12:21 PM, CNA#3 (covering rooms 306, 302, 313, 312, 309, and 318) was interviewed and stated she has never noticed any problems with bugs, but she would report them if she did. On 7/28/16 at 12:41:51 PM, the Housekeeper was interviewed and stated that if she noticed any bugs, she would kill them and report it to the head nurse on the floor. The Housekeeper stated she has noticed small gnats in room 307 because sometimes there is urine on the floor. On 7/28/16 at 12:56 PM, the Director of Housekeeping (DH) was interviewed and stated that he has been working in the facility for 2 months. He further stated that he did not know who was responsible for the pest control program, but the exterminator reports to him every Friday, during the weekly visit. He stated that any sitings of bugs should be entered into the Pest Control log on the unit, so that they can be addressed. He stated that he rounds on the units daily, and he was not aware of any ants or gnats. The DH stated that no one reported any pest concerns to him, but he will have these issues addressed. 415.29(j)(5)

Plan of Correction: ApprovedAugust 25, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 469
I. The following actions were accomplished for the residents identified in the sample:
On 8/19/16, the Outside Consultant and Administrator met with the facility?s exterminator to review issues identified on survey with pest control. Unit 3E was addressed on this day with particular attention to - Rooms 316A, 306C and the hallway.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have been identified as potentially being affected by the same practice.
An ad hoc QA meeting was held on 08/18/16 to discuss the cited deficiency and the current post control program. An analysis of the deficiency was conducted, which determined the hoarding behavior of residents contributing to the pest infestation in the facility.
IDCPT will convene an ad hoc meeting to discuss residents with hoarding behavior and establish routine scheduled room visits and cleaning as well as interventions to eliminate unsanitary practices.
On 08/19/16, a room audit was completed by ADNS and Outside Consultant of all resident rooms to identify pest infestations and food storage issues and concerns. All resident rooms identified with deficiencies will be reported to the pest control technician.
Administrator and Outside Consultant met with the pest control technician on 8/19/16 to discuss resident room extermination plan during the twice weekly visit. Discussion include a schedule of extermination of all resident rooms in the facility.
As of 8/24/16, all resident rooms were visited and checked by the pest control technician. Pest control visits will continue to all nursing unit and checking of identified resident rooms twice weekly.
Insect light traps will be installed to all nursing unit?s hallways and dining rooms by (MONTH) 1, (YEAR).
The Director of Housekeeping / designee will accompany the exterminator during weekly visits in order to ensure all areas are addressed inclusive of resident unit?s offices, common areas, storage areas, day rooms and utility areas in order to ensure a continuing and effective pest control program is maintained. All areas of complaint / concern relative to pest control will be addressed. The need for more frequent visits will continue to be addressed on an as needed basis.
The Director of Housekeeping will ensure the Exterminator is accompanied during all visits to the facility and addresses all identified issues and areas of concern in addition to provision of routine treatment for [REDACTED].

As per the Directed Inservice, the Outside Consultant provided education on 8/22/16 through 8/25/16 to the Director of Housekeeping and Department staff regarding their responsibilities for maintaining an effective pest control program. This education will also be provided to all other facility staff in order to reinforce their responsibilities in maintaining an effective pest control program by maintaining a clean environment, observation and timely reporting.
This education included a review of survey findings and maintaining a clean environment to prevent pests in all areas of the facility as well as reinforcement of the need for observation and reporting of pests and ensuring issues are addressed in a timely manner. This education will continue until all identified staff members have received the education.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Administrator and Director of Housekeeping will review and revise, as needed, the facility?s Pest Control protocol, Preventive Exterminator Treatment schedule and process for identification and management of issues / complaints received relative to pest control.
A Pest Control complaint log will continue to be maintained in each nursing unit indicative of concerns identified and reported relative to pest control and when and how the issue was addressed. The Nursing staff and other staff members will continue to report pest control issues that require corrective actions via the Pest Control Complaint Logs. The Director of Housekeeping/designee will check and review the complaint log during daily rounds follow-up on reported concerns on a daily basis and implement a corrective action plan as needed
The Director of Housekeeping / designee will ensure the Exterminator is accompanied during all visits to the facility and addresses all identified issues and areas of concern in addition to provision of routine treatment for [REDACTED].
Effective 8/23/16, the Director of Housekeeping/designee will conduct daily environmental rounds focused on assessing the cleanliness of the environment and will schedule additional cleaning of specific areas when indicated to assist in pest control. The unit reporting logs will be reviewed during these rounds for pest sightings and other housekeeping issues that may contribute to pest control issues. Housekeeping staff will be provided with additional education or counseling when issues with job performance are identified as contributing to issues with pest control. In addition, the Director will schedule an additional visit by the facility?s Pest Control company as needed.
New housekeeping and facility staff will receive education on their job responsibilities related to pest control during orientation and on an as needed basis. This education will be provided by the Inservice Director/designee/

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
As per the Directed Plan of Correction, a QA Committee was held on 8/18/16 co-chaired by the Outside Consultant to examine this deficiency.
The facility has developed an audit tool to monitor compliance with the pest control program.
The Director of Housekeeping/designee will audit all rooms of residents with hoarding behavior for pests on a monthly basis for the next six months and then quarterly for an additional two quarters. Findings will be reported to the Administrator on a monthly basis. Corrective action, including resident education on food storage and/or staff re-education for reporting responsibilities, will be implemented as indicated.
The Director of Housekeeping will review the pest control complaint log daily and report to the Administrator any pest control trends and commonly reported issues. Corrective actions, such as scheduling an additional exterminator visit, will be implemented as indicates.
The facility will utilize the findings from Environmental Rounds / Pest Control logs and adherence to the Preventative Pest Control Schedule to monitor compliance with maintaining an effective pest control program.
The Director of Housekeeping will report issues with pest control reports and / or sightings minimally on a monthly basis and any identified contributing issues to the Administrator monthly. Additional corrective actions, including increased frequency of scheduled preventive pest control treatments will be implemented, as needed.
The Director of Housekeeping will report pest control issues to the QA Committee on a monthly basis for the next six months for evaluation and follow-up. At the end of the six months, the Committee will determine if the frequency of reporting needs to be changed.

Responsibility: Housekeeping Director


FF09 483.40(b):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: The physician must review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; write, sign, and date progress notes at each visit; and sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews it was determined that the facility did not ensure that the Attending Physician reviewed the resident's total plan of care. Specifically, one resident received Halperidol an antipsychotic medication for a [DIAGNOSES REDACTED]. In addition the Attending Physician did not implement an order for [REDACTED]. (Resident #313) The findings are: Resident #313 is a [AGE] year old Spanish speaking female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/26/2016 12:08 PM the resident was observed lying down in her bed alert and awake. The resident was neatly groomed. The resident is neatly dressed wearing a beige and brown sweatshirt and. beige pants. On 7/27/2016 at 3:37PM the resident was observed lying down in her bed with a sheet covering her body. She was awake, calm and relaxed. The most recent Comprehensive Annual Assessment as documented on the Minimum Data Set (MDS) 3.0 dated 11/19/2015 documents the following: Hearing adequate, Clear speech, usually understood, usually understands. Cognitive patterns -Brief Interview for Mental Status (BIMS) score = 10. Cognitive patterns - NO- Resident was able to complete interview. [MEDICAL CONDITION] - the following behaviors are not present, Inattention, Disorganized thinking, altered level of consciousness and Psychomotor [MEDICAL CONDITION]. Total Mood severity score = 00. Behavior- Behavior not exhibited- Physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others, Rejection of Care - Presence and Frequency- 0 - behavior not exhibited. Wandering- presence and frequency- behavior not exhibited, How does residents current behavior status, care rejection or wandering compare to prior assessment?- same. Functional Status- Supervision- Set up help only -- bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, and eating, Extensive assistance - Two plus persons physical assist - dressing, toilet use, and personal hygiene. Mobility devices - None. Always continent of bowel and bladder. Medications received during last 7 days- Antipsychotic. The MDS Quarterly assessment dated ,[DATE] documents- Cognitive patterns- Yes- BIMS score = 8, Cognitve Patterns - resident was able to complete the interview, [MEDICAL CONDITION]- Behavior not present, No evidence of change in acute mental status, Mood - severity score = 0 Behavior- not exhibited, Rejection of care not exhibited, Wandering not exhibited, Functional status- Extensive assistance- dressing, toilet use and personal hygiene, Supervision- bed mobility, transfer, walk in room, walk in corridor, and eating and locomotion on unit. No Functional Limitation in Range of Motion. Always continent of bowel and bladder. Medications received during last 7 days- antipsychotic and antidepressant. Care Plans - 1) Behavior Symptoms - Wandering updated 4/2016 documents- Resident exhibits wandering behavior as evidenced by; entering other residents rooms. 2) Behavior Symptoms- Physical Abuse updated 4/2016 documents - Resident exhibits physically aggressive behavior towards staff/others. Becomes agitated and physically aggressive when chairs, pillows and old food she keeps in her room are being taken away. Physically aggressive when being stopped by staff from taking things from other resident ' s rooms and when attempting to pull chairs to her room. 3) Behavior Symptoms - Resists Care updated 4/2016 documents - Resident is resistive to care as evidenced by: Refusing blood work, CXR, EKG, and other procedures. Refusing ADL care, showers. Refusing eye drops. 4) Behavior Symptoms - Socially Inappropriate Behavior updated 4/2016 documents - As evidenced by Keeping food, tray, cups in her drawer. Placing dirty clothes, diapers under her mattress. Taking other residents ' chair, pillows, blanket and taking it to her room. Placing furniture, chairs behind her room door. 5) Behavior Symptoms - Verbal Abuse updated 4/2016 documents - Resident exhibits verbally abusive behavior towards staff as evidenced by -cursing, shouting at staff. The Medication Administration Record [REDACTED] Halperidol 0.5 mg- One tablet 2 times a day [MEDICATION NAME] 7.5 mg - one tablet daily at bedtime [MEDICATION NAME] 50 mg- one half tablet 2 times a day Vitamin D3 - 1,000 unit tablet - one tablet daily [MEDICATION NAME] 5 - one tablet daily Physicians monthly orders dated 7/2015 - 7/2016 documents Halperidol 0.5 mg - one tablet 2 times a day. - dx - unspecified [MEDICAL CONDITION]. Medication Administration Records dated 7/2015 - 7/2016 - documents the resident received Halperidol 0.5 mg - 2 times a day. physician progress notes [REDACTED]. 7/16/2015- Dementia with behavioral disturbances - [MEDICAL CONDITION]. Stable. Manageable. Followed by Psyche on 6/2015. If agitated increase Halperidol to 0.5 mg 2 times a day. 8/11/2015 - Dementia with behavioral disturbances - [MEDICAL CONDITION]. Stable. Manageable. Followed by Psyche on 6/2015. If agitated increase Halperidol to 0.5mg 2 times a day. Refused blood w/u. Non compliant with diagnostic tests. 9/9/2015 - Dementia with behavioral disturbances - [MEDICAL CONDITION]. Stable. Manageable. Followed by Psyche on 6/2015. If agitated increase Halperidol to 0.5 mg 2 times a day. Refusing medication. 10/9/2015 - Dementia with behavioral disturbances - [MEDICAL CONDITION]. Stable. Manageable. Halperidol 0.5 mg 2 times a day, may consider decreasing the dose. Psychiatry f/u. 10/10/2015 - Unable to exam in throat as uncooperative. Dementia with behavioral disturbance: Stable, no decline in function, No behavioral/psychotic issues per report. C/w Halperidol 0.5 mg 2 times a day. Supportive care. Plan of care discussed with nursing staff. 11/3/2015 - Current [DIAGNOSES REDACTED]. Psyche f/u. Medications and treatments reviewed and renewed, continue plan of care. 12/2/2015 - Current [DIAGNOSES REDACTED]. Medications and treatments reviewed and renewed. 12/29/15 - Current [DIAGNOSES REDACTED]. Medications and treatments reviewed and renewed. Continue current plan of care. 2/22/16 - Current [DIAGNOSES REDACTED]. Medications and treatments reviewed and renewed. Continue current plan of care. 3/22/16 - Current [DIAGNOSES REDACTED]. Continue Halperidol, continue [MEDICATION NAME]; appreciate psychiatry consult. If behavior disturbances escalate will consider [MEDICATION NAME]. 4/19/16 - Current [DIAGNOSES REDACTED]. Continue Halperidol, continue [MEDICATION NAME], start [MEDICATION NAME] and observe behavior. 5/17/16 - Current [DIAGNOSES REDACTED]. Medications and treatments reviewed and renewed, continue current plan of care. 6/14/16 - Current [DIAGNOSES REDACTED]. Medications and treatments reviewed and renewed, continue current plan of care. 7/12/16 - Current [DIAGNOSES REDACTED]. Medications and treatments reviewed and renewed continue current plan of care. Psychiatric Consult dated 7/13/2016 documents - Psychotic D/O (disorder), NOS /Dementia. Patient with episodic behavioral disturbances. Seen in room, lying in bed. Resident stated, Everything is fine. ' Medications- [MEDICATION NAME] 0.5 mg 2 times a day, [MEDICATION NAME] 7.5 mg at bedtime. Diagnosis -Psychotic D/O NOS, Dementia NOS. Psychiatric Consult dated 5/17/2016 documents - Psychotic D/O NOS. Dementia. With history of depression. Patient stated, OK. Staff states she ' s more manageable. Medications- [MEDICATION NAME] 0.5 mg - 2 times a day. [MEDICATION NAME] 7.5 mg at bedtime. Diagnosis - Psychotic D/O NOS, Dementia NOS Psychiatric Consult dated 3/16/2016 documents - Psychotic D/O, Dementia. Seen in room. Is calm, disorganized. Staff report patient is often unmanageable. As documented in chart often agitated/combative. Medications- [MEDICATION NAME] 0.5 mg 2 times a day. [MEDICATION NAME] 7.5 mg at bedtime. Diagnosis - Psychotic D/O, Dementia. Add [MEDICATION NAME] 25 mg 2 times a day. Psychiatric Consult dated 3/12/2016 documents - Dementia. Resident with behaviors of taking residents chairs in rooms and when redirected tends to be aggressive and guards chairs. Patient seen sitting calmly in bed. Denies delusions, agitation depression. Medications- [MEDICATION NAME] 0.5 mg 2 times a day, [MEDICATION NAME] 7.5 mg at bedtime. Diagnosis- Psychotic D/O NOS, Dementia. Plan - if above disruptive behaviors continue consider adding [MEDICATION NAME] 25 mg daily. Psychiatric Consult dated 2/4/2016 documents - Dementia. Chart notes patient hoarding and sometimes refusal behaviors. Seen in room. She had a chair bracing her door. Is guarded, speaks in a low tone and rate. Denies depression. Medications- [MEDICATION NAME] 0.5 mg 2 times a day. Diagnosis - Psychotic D/O NOS. Dementia with Behavioral disturbances. Pharmacist Monthly Drug Regimen Review - Note to Attending Physician/Prescriber dated 12/7/2015 documents - Medication- The resident has an order for [REDACTED]. Recommendation - Please consider a taper of discontinuation of the order, or document below the medical justification for the use of [MEDICATION NAME] for a [DIAGNOSES REDACTED]. Reason - [MEDICATION NAME] does not have an FDA approved indication for [MEDICAL CONDITION]. The Attending Physician answered as follows: checked the following statement. No, continue the [MEDICATION NAME] order with the current indication. [MEDICATION NAME] has proven to be effective at alleviating the behavioral symptoms that can present a risk of harm to either the resident or others. The behavioral symptoms targeted for the use of [MEDICATION NAME] for this resident include: (Please check all that apply) The Physician checked - other symptoms. A United States Food and Drug Administration Alert dated 6/16/2008 documents the following: FDA is notifying healthcare professionals that both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for [REDACTED]. Since issuing that notification, FDA has reviewed additional information that indicates the risk is also associated with conventional antipsychotics. Antipsychotics are not indicated for the treatment of [REDACTED]. The following Black Box warning is included in the prescribing information product labeling in the package insert of the drug Halperidol. Warning: Increased Mortality in Elderly Patients with Dementia-Related [MEDICAL CONDITION]. Elderly patients with dementia related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. Halperidol is not approved for the treatment of [REDACTED]. The FDA approved product labeling documents only two approved indications for the use of Halperidol. Halperidol is indicated for use in the treatment of [REDACTED]. On 7/27/2016 at 3:37 PM the Certified Nursing Assistant (CAN) working 7AM to 3 PM was interviewed and stated She resists care. But she knows me for a long time. I talk to her and I let her know in Spanish what I will be doing. I tell her I want to wash you and dress you and put you in the day room for breakfast. With me she is okay. With almost all the other CNAs and Nurses she says she can dress herself. She tells everyone I can take a shower. She says she can do everything herself. But she really can't. She does not fight with other residents. If nobody bothers her she does not fight. She will fight if somebody wants to change her clothes. She likes to stay in her room almost all the time. She goes sometimes to activities. If somebody bothers her she can curse and she can fight. She is a wanderer and likes to bring a chair from another room to her room. She likes to collect chairs. On 7/27/2016 3:45PM the Licensed Practical Nurse (LPN) who works 3PM to 11PM was interviewed and stated, She is aggressive to the staff. She does not let staff wash her. She refuses to change her clothing. She hoards food. She does not want to leave her room. She is depressed. I have been working on this unit for 6 months. On 07/28/2016 at 12:36PM the Attending Physician who wrote the monthly order for Halperidol was interviewed and stated, I write the orders for the medications every month. I prescribe the Halperidol for [MEDICAL CONDITION]. She also has dementia with behavioral disturbances and depression. She seems to be following internal stimuli, I think she is following some internal stimuli. I can ' t speculate if she has hallucinations or delusions. Maybe when she barricades herself there is some delusional thing going on. She is not a threat to herself. She would be aggressive, She punched a Podiatrist who tried to give her care. I started working here in the building in November. (YEAR). I was prescribing this Halperidol for her monthly since (YEAR). I don ' t know off the top of my head for what indications the drug is approved by the FDA. I believe it is for [MEDICAL CONDITION]. This resident does not have [MEDICAL CONDITION]. She does not have Schizo affective disorder. She has dementia, (MONTH) opinion is that she has dementia and [MEDICAL CONDITION]. I prescribe this drug due to aggressive behavior, She does wandering, I believe she is following an internal stimuli. I have probably read the PDR or the package insert on this drug quite some time ago. I am not familiar with any warning that the FDA put out at this point in time. I would have to look it up. The Surveyor showed the MD the FDA Black Box warning which he read and then stated, Just by looking and reading the warning it would behoove me to change her medication. I am not familiar with the federal regulations on antipsychotic drugs. I have heard of Gradual Dose Reduction. Sometime after a patient has stabilized I would consider a gradual dose reduction over a period of time. I don't know off the top of my head what the regulations are and how often you are supposed to do a drug reduction. The FDA says the drug is to be used for patients with [MEDICAL CONDITION] or indications of [MEDICAL CONDITION] ' s. It looks like I should be putting her on something else. I believe the drug was controlling some of her symptoms. Now that you brought this to my attention I would change the medication. The black box warning and the specific indications point out that I should not have had this patient on this medication. The Pharmacist in 12/2015 advised me to d/c the [MEDICATION NAME]. I did not do because at the time she was benefiting from the drug behavior wise. At this point forward I do not think she needs it anymore. I will taper it off starting this week. I will taper the drug to see if there are increased behaviors or not. On 07/28/2016 1:13PM the Registered Nurse in Charge was interviewed and stated, When it is her shower day she does not want to get into the shower. Every mealtime especially at breakfast, it takes an hour to get her to the day room. Immediately when she is done she wants to go back to her room to lay down on her bed. When she is on her way to her room she would go into another resident ' s room and take their chair and carry it back to her room. She would go into other rooms until she has 4 chairs. She would use the chairs to block herself inside the room. The resident believes she will have visitors, That ' s why she takes the chairs. She says she brought the chairs from Santo Domingo. The Podiatrist was here in (MONTH) to examine her foot and she punched him on the head. With the regular CNA she is more comfortable. If there is another CNA from another floor she will try to hit you. I have been working here since (MONTH) (YEAR). She refuses to have blood drawn, unless her regular nurse or CNA is present. We redirect her. In general if nobody bothers her she minds her own business. She is incontinent she needs to take a bath, this is when we have 2 CNA's to assist her and talk in Spanish and explain to her. If she knows the CNA or Nurse she will let you do care. If there are new people she does not recognize she will resist care. She thinks that whoever goes to her wants something from her. Like when the Dr. sees her she says I don ' t have any money to pay you. She will find a way to refuse care by also saying I am healthy. If you need to change her brief, she will say I am dry, I just changed it. I think her overall problems are from dementia including her behaviors from the time I have been here. The past 2 months she has been quite and behaving. On 07/28/2016 at 1:26PM the resident was observed in her room lying down on her bed. Resident speaks only Spanish. When asked how she is in Spanish she responded Bien - okay. Resident is quiet and relaxed. On 07/28/2016 1:57PM the facility Psychiatrist was interviewed and stated, Halperidol is indicated for [MEDICAL CONDITION] such as [MEDICAL CONDITION], for [MEDICAL CONDITION] disorders, for delusions for hallucinations for depression with [MEDICAL CONDITION], any kind of abnormal thinking and thoughts. The FDA says it is only indicated for [MEDICAL CONDITION], We also use it for [MEDICAL CONDITION] such as delusions. We use it for a number of other situations. We use it for many things. We use it outside the FDA recommendations for a number of situations. The drug does have a Black box warning that says certain patients with dementia have a higher risk for stroke and other vascular problems. At some point she might have had psychotic symptoms. It is possible the therapy was continued as maintenance. I do a gradual dose reduction as needed. I try to do this within 3 to 4 months. In general I do recommend a gradual dose reduction. What you are saying now it does make sense to have a gradual dose reduction based on what you are saying about the patients age, and that the staff said she is stable. There was no documented evidence that the nursing staff attempted the use of non-pharmacological interventions prior to administering Halperidol to the resident. There is no documented evidence of the effectiveness of Halperidol after administration. There was no documented evidence a Gradual Dose Reduction was attempted as required by Federal regulations. Halperidol was being prescribed for a non FDA approved indication and contrary to the FDA warning that it should not be prescribed for patients with Dementia related [MEDICAL CONDITION]. 415.15(b)(2)(iii)

Plan of Correction: ApprovedAugust 25, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F386 (Physician Visits)
Immediate Correction Action Taken:
Resident #313 was seen and examined by the attending physician. A gradual dose reduction was initiated. [MEDICATION NAME] o.5 mg was decreased to once daily x 7 days and discontinued on (MONTH) 3, (YEAR). Psychiatry evaluation ordered for GDR.
Identification of other areas:
All residents on [MEDICAL CONDITION] medication were reviewed by the attending physicians and the pharmacy consultant to ensure that the patient has a proper [DIAGNOSES REDACTED]. Also, ensure that a GDR is attempted as required by Federal regulations.
All residents on [MEDICAL CONDITION] medications were referred to the Psychiatrist for follow-up and recommendations for GDR as required by Federal regulations.
The pharmacy consultant will review the drug regimen of all residents on [MEDICAL CONDITION] medications and make recommendations to the attending physicians
Measures/ Systematic Changes Taken
to assure the Practice does not recur
The pharmacy consultant will review the drug regimen on a monthly basis and make recommendations to the attending physician.
The Attending Physician will acknowledge the pharmacy consultant?s recommendation(s) by signing the drug regimen review and following the recommendation and in the case of not accepting the recommendation, document the reason.
The Medical Director will re- inservice all attending physicians and nurse practioners on unnecessary drugs, GDR?s and documentation of same.

How Corrective Measures will be
Monitored
The Medical Director/designee will conduct random audits of at least 33% of the drug regimen reviews and the physicians? response on a monthly basis.
The Medical Director will report the findings of these audits to the Quality Assurance Committee on a monthly basis x 6 months and then quarterly until an acceptable level of compliance has been achieved at which time the frequency of the audits may change.

Title of Person Responsible for
Correction of Deficiency and Date
Medical Director

FF09 483.75(o)(1):QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS

REGULATION: A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility quality assessment and assurance committee failed to identify issues that required quality assessment and assurance activities, and the facility did not ensure that appropriate action plans were developed and implemented to correct identified quality deficiencies. Specifically, the committee failed to identify siderails that did not meet the FDA recommendations as accident hazards. In addition, the facility did not ensure that deficiencies cited in the previous recertification survey were addressed, resulting in repeat citations for housekeeping services and pests. The findings are: Please refer to citation text at F323, F253, and F469. During the survey process a number of staff were interviewed including the DNS ( director of nursing ) , Medical Director ,Director of Rehabilitation, Director of maintenance ,nine (9) Registered Nurses (RN) several of which were Unit managers (RNUM), five (5) Licensed Practical Nurses (LPN ) and eleven (11) Certified Nursing Assistants (CNA). The DNS was interviewed on 08/01/2016 at 12:45 PM and stated the SR policy and procedure is that the RNUM would complete the bed behavior/mobility monitoring form when they are admitted and readmitted and this is use for three (3 ) days . Once completed submitted to the rehab department and they do there own assessment and collaborate as a team whether a side rail would enhance residents bed mobility. They use this for the purpose for the RN to assess the resident for use of side rails for bed mobility. Only use the bed side rails for bed mobility not for safety. If a resident is cognitively impaired and unable to move the side rails should not be used. Once they collaborate as a team and if it deemed necessary a physician order [REDACTED]. DNS stated she was not aware of specific measurements of the side rails space between bars prior to survey . The RNs /LPNs and CNAs who were interviewed indicated that the siderails were mostly used as enablers and for safety. The general consensus of the nursing staff who were interviewed was that they were not aware of the FDA recommendations regarding the spacing between bars of siderails. Particularly the recommendations identified in Zone 1 of the siderails. The staff were aware that they had to ensure the stability of the siderails, and the spacing between the mattress and the siderail. Also, to check if the siderails were loose. If they identified any concerns they were to report the issues to maintenance. 415.27 (a-c)

Plan of Correction: ApprovedAugust 25, 2016

F-520 - QAA COMMITTEE ? MEMBERS/MEET QUARTERLY/PLANS
I. The following actions were accomplished for the residents identified in the sample:
Please refer to F-253 for corrective actions related housekeeping and maintenance services.
Please refer to F-323 for corrective actions to side rail entrapment risk and accident prevention.
Please refer to F-469 for corrective action related to pest control.
Please refer to F-490 for corrective action related to Administration.
As per the Directed Plan of Correction, an ad hoc QA meeting was held on 8/18/16 to discuss environmental issues cited in the statement of deficiencies, pest control and the appropriate use of side rails. The Outside Consultant led the discussion of survey findings, review of current procedures; analysis of contributing factors to negative outcomes; corrective measures implemented or to be implemented and monitoring to be implemented to prevent reoccurrence.

II. The following corrective actions will be implemented to identify other resident who may be affected by the same practice:
All residents have been identified as potentially being affected by the same practice.
Effective 08/22/16, the Committee will meet monthly (more frequently as needed) to review the corrective action implemented and to ensure there are no indicators of any additional issues / trends related to findings at F-253, F-323 and F-469.
The Committee will ensure that the Administrator participate in the QA process and assists in the development or revision of resident care policies, procedures and protocols.
Effective 8/22/16, the Administrator initiated daily discussions/meetings on a Monday through Friday basis to review and assess the progress of the facility in implementation of the P(NAME). All identified issues will be addressed and monitored through the QI process.
As per the Directed Inservice, the Outside Consultant provided education to the QA Committee members on 8/23/16. This education addressed the function of the QA Committee as well as the Committee?s responsibility to identify and follow-up on potentially problematic issues as well as known issues/concerns. Education addressed the specifics of the IJ citation related to side rails. This education included a review of the findings in the Statement of Deficiencies and the facility?s responsibilities to identify and address environmental issues, pest control issues, and food storage / temperature maintenance concerns.

III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility policy related to the QA Committee will be reviewed and revised to include an increase in the frequency of committee meetings. Reporting scheduling was revised for additional accountability. Additional department will be required to attend the meeting on an ongoing basis.
The Administrator and Director of Nursing will continue to review and revise, as needed, the facility?s policy related to the Quality Assurance Program. The Administrator and Director of Nursing will review and revise, as needed, the facility?s QA Reporting Calendar to include areas cited during the survey of 8/1/16 inclusive of F-253, F-323, F- 371, F-469 and F-520.
Additional education on the Quality Assurance Program will be provided, as needed, by the Director of Inservice Education. Education on the Quality Assurance Program will be included in staff orientation and be reviewed on an as needed basis.
The Administrator and Director of Nursing will monitor for compliance through review and assessment of submitted audit summaries and the Quality Assurance Committee?s follow-up on identified issues. Immediate corrective action will be implemented, as indicated.

IV. The facility?s compliance will be monitored utilizing the following Quality Assurance system:
As per the Directed Plan, a Quality Assurance Committee meeting chaired by Outside Consultant was held 8/18/16.
The facility will develop audit tools to monitor the issues identified during the 8/1/16 survey. Findings will be reported to the Administrator as the audits are completed. Findings will be reported to the Quality Assurance Committee as outlined at each cited F-tag for evaluation and follow-up. Additional corrective actions will be implemented, as indicated.
The facility?s QA Committee meeting schedule is being revised to convening monthly versus quarterly meetings.

The QA Committee?s reporting schedule will be reviewed by the Administrator and Director of Nursing, minimally, on a quarterly basis to ensure that the Committee is monitoring problematic areas identified by internal audit or any newly identified problematic area that is brought to the attention of the Committee, to ensure that the issue is assessed by the Committee and a corrective action plan is developed to correct the deficient practice. Corrective action will be implemented, as indicated.
The Administrator, or designee, will report recommended reporting schedule changes to the Quality Assurance Committee on a quarterly basis. The Quality Assurance Committee will re-evaluate and follow-up on recommended changes to the reporting schedule.
The Administrator will be responsible for ensuring that all audits are completed as per the outlined schedule and that results of each audit are reported to the QA Committee for evaluation and follow-up.
The Administrator will attend monthly QA Committee meetings and ensure that the Medical Director and Director of Nursing participate in these meetings. The Administrator, will ensure necessary evaluation and development of a follow-up action plan is completed during these meetings for any newly identified concern as well as for any issue identified during routine compliance monitoring that indicates a system failure. The Administrator will monitor that the status of all corrective action plans are discussed at the next QA meeting and additional corrective actions are implemented, when indicated. QA Committee agendas will include all subject matter to be discussed and the Administrator will review the agenda prior to the meeting to determine if additional topics for discussion need to be added to the agenda.
Ad hoc committee meetings will be scheduled when indicated.

Responsibility: Administrator

FF09 483.10(f)(2):RIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES

REGULATION: A resident has the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that a resident's grievance was responded to promptly. This was evident for 1 of 1 residents reviewed for Social Services (Resident #283). The finding is: Resident #283 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented it is very important to the resident to listen to music, keep up with news, do favorite activities, and go outside when the weather is good. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. On 7/26/16 at 1:17 PM, the resident was interviewed and stated that a maintenance staff member broke his television (TV) last month while removing items from the room. He further stated that the Nurse Supervisor and the nurse were aware. He also stated that a staff member informed the Social Worker (SW) that he wanted to speak to her about it, but she never came to speak to him. The Maintenance Communication Book was reviewed. A note dated 6/28/16 documented a request to fix the resident's TV because it was broken after a room cleaning. The note was crossed out and the response written documented TV Broke Need new one. A second note dated 7/6/16 documented the resident needed a television set. On 7/28/16 at 11:34 AM, the Licensed Practical Nurse (LPN) was interviewed and stated that she was not aware that the resident's TV was broken. She remembered that he had a new TV recently. On 7/28/16 at 11:32 AM, the Registered Nurse Manager (RNM) was interviewed and stated that she recalled speaking to a SW about the TV about a month ago, but she cannot remember what happened. She further stated that she recalls being told that since the television was recently purchased, it should be under warranty and the manufacturer had to be contacted. On 7/28/16 at 1:21 PM, the SW assigned to the resident was interviewed and stated that last month, a rehab employee came to the SW Office and informed me that the resident's TV had a crack in the middle but still worked. She stated that the Director of Social Work (DSW) was present. The SW further stated that she was investigating the issue and found out the television was broken, and she spoke with the DSW and was told to find out the price of the TV so that it could be replaced. The SW stated that she spoke to the resident about it in June, but she could not remember if she asked him if he had a receipt for the TV or discussed whether maintenance will replace it. The SW stated she also spoke to the resident's brother and he had no receipt or warranty for the TV. The SW stated that she did not write up the grievance or investigation. She also stated that she asked maintenance for a temporary TV for the resident, but she did not follow up. The SW stated that she was not sure what the timeframe is for following up on grievances, but is should be right away. The SW stated that she would not say a month is right away. On 7/28/16 at 12:14 PM, the DSW was interviewed and stated she was not aware the resident's new TV was broken, and no one reported it to her. She stated the TV was ordered by SW online, so she has the receipt. At 12:36 PM, the DSW approached the surveyor to report that maintenance has been called to replace the resident's TV temporarily until his personal TV can be replaced. She also stated that she has the receipt and will be taking care of getting another TV. The facility policy and procedure for Grievance Reporting and Response dated (MONTH) 2010 documented: The resident's Social Worker will meet with the resident and/or complainant to review the complaint and assist them in completing the Customer Dis-satisfaction Reporting and Resolution Form. Forms will be available from the Social Service office .Completed forms will be submitted to the respective Department Head(s) who will sign upon the receipt. A copy will be maintained in the Social Service office .The Social Worker and respective Department Head(s) will initiate a prompt investigation of the complaint. The investigation will conclude as soon as possible, and the resident/complainant will be apprised of the progress toward resolution .Findings and recommendations for corrective action will be submitted to the Director of Social Services who will sign upon receipt . The resident's Social Worker will notify the resident and /or complainant of the final disposition of the complaint. 415.3(c)(1)(ii)

Plan of Correction: ApprovedAugust 25, 2016

F166
Immediate Correction Action Taken:
Resident # 283 received a temporary TV on 7/26/16 and a new TV on 8/15/16.
Identification of other areas:
All current grievances were audited to ensure that responses were prompt in an effort to resolve grievances. No other issues were identified.
All Maintenance Communication Books were audited to ensure no other TV sets were in need of repair or replacement. No others were found.
Measures/ Systematic Changes Taken
to assure the Practice does not recur
The Policy and Procedure on grievances was reviewed, no changes were necessary.
The Policy and Procedure on Maintenance reporting was reviewed, no changes were necessary.
All SWs, Nursing and Maintenance workers were re-inserviced on the policy and procedures.

How Corrective Measures will be
Monitored
The Director of Social Services develop an audit tool to monitor for the compliance with the Policy and Procedure on Grievances
The director of Social Services will monitor the grievances on a monthly basis to ensure compliance with the policy and procedure.
The Director of Maintenance Developed an audit tool to monitor for compliance with the Policy and Procedure and will audit the Maintenance Communication Books on a monthly basis to ensure
compliance with the policy and procedure.
Results of the audits will be presented to the Quality Assurance Committee on a monthly basis x 6 months at which time the frequency of the audits may change.

Title of Person Responsible for
Correction of Deficiency and Date
Director of Social Services
Director of Maintenance

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2016
Corrected date: September 20, 2016

Citation Details

Based on observation and interview it was determined that the facility did not post the most recent copy of the New York State Department of Health Survey Report in a place that is readily accessible and in a manner that allows review without the need to ask nursing staff for these documents. The finding is: On 7/26/16 at 9:15AM upon entry to the facility during the Annual Recertification Survey it was observed that the most recent copy of the New York State Department of Health Survey Report was not seen displayed anywhere on the first floor. In addition there were no signs observed on the nursing units advising residents, visitors or staff with the location of the survey report. During the day at various times observations were made on nursing units West 2-3-4-5-6 and East 3-4-5-6-7. A copy of the survey report was not observed, nor was a sign posted indicating the location of the survey report. On 7/27/16 at 9:02AM the most recent copy of the New York State Department of Health Survey Report was not seen displayed in the first floor reception area or anywhere else on the first floor. On 7/27/2016 10:36 the President of the Resident Council was interviewed and stated, I don't remember seeing a copy of the survey report displayed anyplace in the building. On 7/27/16 at 11:47AM the facility Administrator was interviewed in the hallway adjacent to the reception desk on the first floor. When asked where a copy of the most recent New York State Department of Health Survey Report is located he responded, I am not sure. The Receptionist overheard the conversation and asked do you want to see the book? She then proceeded to pick up a black loose leaf binder labeled Survey Result on the front cover. This loose leaf binder was removed from behind the Receptionist desk and placed on the countertop of the receptionist desk. The loose leaf had a chain attached to the loose leaf binder at one end and the chain was hanging freely at the opposite end not attached to anything. On 7/27/16 at 11:54AM the Receptionist was interviewed and stated, The loose leaf containing last years survey results are always kept behind the reception desk If someone wants to see the survey book, they would have to ask me or someone else and we would give them the loose leaf binder to look at. On 7/27/16 at 12:05PM the facility Administrator was interviewed and stated, I know the survey results are kept at the front desk. I wanted to check with the Receptionist as to the exact placement at the front desk. The receptionist removed the survey results from behind the desk and then placed it on the counter on top of the desk for you to see. The regulations are to my knowledge that they should be available upon request at the front desk. There is a sign posted at the front desk advising all visitors and residents of the location of the survey results. On 7/27/16 at 12:12PM the surveyor accompanied the Administrator to the front receptionist desk. The Administrator attempted to find a sign advising people that the survey results are available for review. The Administrator could not find any sign. On 7/27/16 at 12:15PM the Administrator stated, As far as I know that is the only place we had a sign posted. I don't see it. It is not here know. 415.3(1)(c)(1)(v)

Plan of Correction: ApprovedAugust 25, 2016

F 167
Immediate Correction Action Taken:
A file holder was installed at the front desk at wheelchair height in which to store the binder that contains the survey results on 8/1/16.
A prominent laminated sign was attached to the lobby wall that reads: ?Please be advised that the Citadel Rehab and Nursing Center at Kingsbridge most recent New York State Survey results are available at the front desk.?
Laminated signs were posted on all Resident Units that read: ?Please be advised that the Citadel Rehab and Nursing Center at Kingsbridge most recent New York State Survey results are available at the front desk.?
Identification of other areas:
No other areas were affected.
The Resident Council president was educated to the location of the most recent survey results.
Measures/ Systematic Changes Taken
to assure the Practice does not recur
The receptionist will check each shift to ensure that the Survey results are accessible.
All residents will be educated to the placement of survey results at the next Resident Council meeting on 9/14/16.
How Corrective Measures will be
Monitored
The Administrator will audit to ensure compliance and will report to the QA committee on a monthly basis x 6 months and then Quarterly thereafter.

Title of Person Responsible for
Correction of Deficiency and Date
Administrator