Ellis Residential & Rehabilitation Center
January 11, 2019 Certification/complaint Survey

Standard Health Citations

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 28, 2019

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not ensure that 1 of 3 employees with negative findings were removed from providing direct care to residents. Specifically, the facility did not remove an employee from direct care, after the facility received a notification from the Criminal History Record Check (CHRC) on 7/9/18. This is evidenced by: During an interview on 1/9/19 at 12:11 PM, the Human Resources Coordinator stated the CNA was removed from service on 9/28/18. She stated the negative determination letter was dated 7/9/18. She stated that she would have notified the administrator of the negative determination via email. She stated she would have to refer to her emails to find documentation. During an interview on 1/09/19 at 2:31 PM, the Administrator stated she did not receive an email from the Human Resources Coordinator.

Plan of Correction: ApprovedFebruary 13, 2019

Corrective action for those residents found to have been affected by the deficient practice:
There were no specific residents identified.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken:
An audit of CHRC roster to identify potential deficient practices will occur by 2/8/19.

Any CHRC designation that requires removal from patient care or supervision will be immediately addressed as required and the employee either removed or supervised.
Measures to be put in place/systemic changes to ensure the deficient practice does not recur:
The policy ?Employment Background Screening Process? was reviewed and revised on 2/1/19 to include the following:
The(NAME)Authorized User of CHRC in Human Resources will continue to log into the Document Viewer on a daily basis to look for notifications. In the event there is a negative finding, the CHRC Human Resources User will call the Staff Scheduler so the employee may be removed from the schedule. An internal communication (email) will then be sent directly the ERRC Nursing Home Administrator, Director of Nursing, Administrative Secretary and Staff Scheduler for review and dispensation.
Additionally, a weekly audit will be performed by an approved CHRC Authorized Person from(NAME)Residential and Rehabilitation Center.
Monitoring to ensure the practice will not recur:
An audit of the CHRC roster report will be conducted to ensure compliance. To be completed weekly x 4 weeks, then biweekly x 2 months.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Date of Correction and title of person responsible for the correction:
2/14/19 by Administrator

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey and an abbreviated survey (Case #NY 587), the facility did not ensure comprehensive person-centered care plans were developed and implemented for each resident that included measurable observations and time frames to meet a resident's medical, nursing, mental and psychosocial needs for two (2) (Resident #'s 51 and 219) of eighteen (18) residents reviewed. Specifically for Resident #219, the facility did not ensure a comprehensive care plan (CCP) was developed for a Stage 2 pressure ulcer to the resident's coccyx and an unsteagable pressure ulcer to his left heel; for Resident #51, the resident's immobility on admission was not addressed in the initial CCP for at risk for pressure injury. When breakdown occurred the care plan was not updated with all the new interventions initiated. This is evidenced by: A Policy for Comprehensive Careplans with an effective date of (MONTH) (YEAR) documented the comprehensive care plan is based on a thorough and on-going assessment of the resident that is designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; reflect treatment goals, timetables and objectives in measurable outcomes; identify the professional services that are responsible for each element of care; aid in preventing or reducing declines in the resident's funcitonal status and/or functional levels; enchance the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standards of practice for problem areas and conditions. Resident #219: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Per nursing admission assessment, the resident had no cognitive impairment and was able to understand others and was able to be understood. Admission Wound and Skin Record dated 6/28/18, documented the resident had an unstageable pressure ulcer to his left heel measuring 6 cm x 4 cm x 0 cm and a stage 2 pressure ulcer to the resident's coccyx measuring 1 cm x 0.5 cm x 0 cm. Risk factors were documented as [MEDICAL CONDITIONS]. Potential for Pressure Injury Care Plan dated 6/28/18, documented a goal that the resident will not sustain an avoidable pressure injury x 30 days. Nursing Progress Note dated 7/2/18, documented resident response to interventions: Non weight bearing right leg. Surgical incision to right leg, Stage 2 pressure ulcer to coccyx, right plantar wound, and left heel unstageable pressure ulcer. No bleeding or signs/symptoms of infection, all dressings clean, dry and intact. During an interview on 1/11/19 at 11:43 AM, Nurse Manager (NM) #1 stated the Certified Nursing Assistants (CNAs) should be applying barrier cream and should be positioning the residents off their bony prominence. She stated documentation in the careplan should indicate how to care for the heel and coccyx pressure ulcers. This information should also be on the Kardex but was not. If a resident has a wound on their heel, the foot would float on a pillow and a turning schedule would be put into place. The NM reviewed the potential for pressure ulcer care plan and stated she did not see care to be provided to the pressure ulcers. She stated there is no actual pressure ulcer careplan. There should be, but there is not. Resident #51: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) of 11/27/18, assessed the resident understands, was understood, had no cognitive impairment, had one or more pressure ulcers, at Stage II, required extensive assist of two staff for bed mobility and transfer and did not walk. The Admission Braden Scale (assessment tool used to identify pressure ulcer risk) dated 11/20/18, had a score of 17 or mild risk for skin breakdown. It identified the resident was chairfast; had slightly limited mobility; probably had inadequate nutrition; and potential shear and friction problems. The CNA Documentation History Detail report for 11/20/18 to 11/26/18, documented the resident needed two plus person extensive physical assist for bed mobility. The Comprehensive Care Plan (CCP) for pressure injury risk dated 11/20/18, documented a goal that the resident would not sustain a pressure injury in 30 days. The interventions included: Braden Score on admission and quarterly; barrier cream per protocol; pressure reducing mattress (standard); monitor meal intake; skin check by nurse weekly; and CNAs (Certified Nurse Aide) to report any redness or open areas every shift. A nursing note dated 11/21/18, documented the resident had immobilizers in place to bilateral lower extremities. The resident was a two plus person assist for bed mobility, dressing, transfers and toilet use. He was non ambulatory. A nursing note dated 11/26/18, documented the CNA reported the resident had an open area to the coccyx. On inspection there was a stage II which measured 2.7 cm long by 1.4 cm wide. A blue overlay mattress was to be placed on the resident's bed to reduce pressure. Care card and care plan were to be updated. The CCP Pressure injury Actual effective date of 11/20/18 documented: Braden score = 17; 11/26/18 stage II to coccyx measuring 2.7 length and 1.4 cm width; and 12/6/18 full bilateral leg casts. Interventions included: alternative air mattress - check inflation every shift (initiated 12/6/18); encourage T&P (turn and positioning) every 2 hours (initiated 12/2/18); place pillows between legs for comfort (initiated 12/2018); see Treatment Administration Record for pressure injury treatment (initiated 12/2/18). The interventions from the pressure injury risk CCP also continued. The blue overlay mattress was not included on this CCP. During interview on 1/10/19 at 8:52 AM, Resident #51 stated he had immobilizers on his legs when he first came in. He was not able to move himself around in bed. He could not roll over or move his legs at that time so staff needed to help him. He needed help getting out of bed, had no ability to walk and was a 2 person assist. He stated at first there was no schedule of T&P. They did not talk with him about it until after he broke down. He was feeling a pinch and brought it to their attention. They put an air mattress on the bed with first breakdown then upgraded to this new one (alternating air). He stated after the skin breakdown he got wedges to help him move in bed and they told me to turn every 2 hours (the wedges were observed in the resident's room in a corner). He did not have any skin breakdown that he knew of when he came in. During interview on 1/10/19 at 10:27 AM, CNA #7 stated she took care of the resident when he first came in and could not walk. He needed help turning in bed, and we needed to move his legs for him. He would turn himself a little, he could use the urinal, and do some of his own care. She did not remember when his skin broke down. After the skin breakdown he was getting up more and had therapy. He did have a pressure relief cushion in his chair. He got a Barco (large comfortable reclining chair) for some change in position but he did not like it. He had an air mattress. He did not have any pressure areas when he first came in. If his skin was at all red she would have reported it to the nurse. She did not remember needing to put any cream on red spots on his skin when he first came in. The pressure relief cushion and Barco were not added to the care plan. During interview on 1/10/19 at 10:50 AM, the Registered Nurse Manager (RNM) stated the resident did not have a pressure ulcer when he first came in. He developed it here due to laying immobile. The initial CCP was at risk for pressure ulcer. When one developed she just continued the same CCP and changed it to actual breakdown. She was asked what they were doing to prevent skin breakdown since he was immobile. She stated they were doing weekly checks of skin, if any redness staff would report it. He had a standard pressure relieving mattress and an overlay air mattress when the skin broke down. That was not put on the CCP. 10 NYCRR 415.11(c)(1)

Plan of Correction: ApprovedFebruary 13, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action to be accomplished for those residents found to have been affected by the deficient practice:
Both residents identified as affected by the deficient practice have been discharged from the facility:
Resident #51 ? discharged [DATE]
Resident #219 ? (closed chart review) ? discharged [DATE]
Identification of other residents having the potential to be affected by the same deficient practice and corrective actions to be taken
Review Braden scores and care plans for all current residents who are currently listed as an ?extensive assist x 2? for ADLs
Review care plans of all current resident with lower extremity casts or immobilizers to ensure that adequate preventative measures are in place for pressure injury prevention.
Ensure that appropriate care plans are in place for pressure injury prevention
Measures to be put in place/systemic changes to ensure the deficient practice does not recur
Policy reviewed, no changes made at this time
Re-educate RNs on risk assessment and appropriate care planning, including preventive measures to be put in place and equipment/strategies for prevention. This will also include a review of all pertinent policies related to time frames for reporting and direction towards appropriate interventions. To be completed by 2/28/19.

Monitoring:
An audit will be performed for all new admissions and residents with a significant change in condition as applicable.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations at the conclusion of the prescribed audit schedule.
Date of correction and title of person responsible:
2/1/19 by Director of Nursing

FF11 483.60(i)(4):DISPOSE GARBAGE AND REFUSE PROPERLY

REGULATION: §483.60(i)(4)- Dispose of garbage and refuse properly.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, there was garbage and debris on the ground and greenish-brown colored ice build-up in the area of the dumpsters. This is evidenced as follows: The dumpster area was observed on 1/10/19 at 10:51 AM. The first dumpster had an ice-build-up of greenish-brown liquid in the lower left-hand back area which was frozen along the blacktop. Food debris and garbage were on the ground in the dumpster area, near the second dumpster. During an interview on 1/10/19 at 11:00 AM, the Environmental Service Manager stated that he had not noticed any garbage juice at the first dumpster. He was not sure if it was usually there. This is something they should look at. His team puts the garbage in the dumpsters, and they call the refuse company for service if there are any problems. He stated it is not typical to have debris or garbage on the ground in the dumpster area. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedFebruary 4, 2019

Corrective action to be accomplished for those residents found to have been affected by the deficient practice:
No specific residents were found to be affected.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken:
All residents have the potential to be affected.
Measures to be put in place/systemic changes to ensure the deficient practice does not recur:

Republic, our regulated waste vendor completed inspection and identified the area on the container that is in need of repair. Republic is to repair by 2/4/19.
Monitoring to ensure the practice will not recur:
EVS will conduct a visual inspections of the compactor daily for 30 days, then monthly x2 months.
Date of correction and title of person responsible:
2/8/2019 by EVS Manager.

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 14, 2019

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure there were time frames established for the steps in the MRR process and that there were steps the pharmacist needed to take when he/she identified an irregularity that required urgent action to protect the resident. This is evidenced by: A document titled (facility named) Medicine organizational policy for Drug Regimen Reviews (DRR) dated 8/2018 documented: 1. Each month the pharmacist will conduct a drug regimen review (DRR) for clinically significant drug irregularities associated with adverse consequences, or medication interactions. If present the pharmacist will generate a note to the medical provider. These DRRs must be addressed by the medical provider in a timely manner, but no later than 30 - day time frame. If there is a pressing problem that requires immediate attention the consultant will contact the provider. 2. For those recommendations that do not require a physician intervention, such as one to monitor vital signs or weights, the Director of nursing (DON)/designated licensed nurse addresses and documents actions taken. 3. The pharmacist's findings are considered part of each resident's clinical record. The interdisciplinary care team is encouraged to review the reports and to get the pharmacist's input on the residents' problem and issues. 4. The pharmacist compiles and analyzes data collected during DRR and presents findings to the Quality Assurance Performance Improvement (QAPI) committee or administrator. 5. The patients admitted to a rehabilitation center or long-term care (LTC) unit or residents that have a significant change of condition will have a pharmacist review their medications at that point and generate a document addressing any medication irregularities, and any note should be reviewed within 30 days. In case of an urgent medication issue the prescriber will be contacted immediately, with documentation by the pharmacist within 72 hours. 6. The pharmacist will notify the DON of recommendations after initial notification of the provider and Registered nurse (RN). The DON will ensure the RN Manager/Supervisor, Minimum Data Set (MDS) coordinator and any other pertinent team members are made aware of the recommendations. The RN Manager/Supervisor and pharmacist will be responsible to update the physician of recommendations. During interview on 1/10/19 at 8:50 AM, the Administrator and DON stated they did not realize time frames were required in the MMR review policy and procedure for each step in the process. 10NYCRR415.18 (c)(2)

Plan of Correction: ApprovedFebruary 13, 2019

Corrective actions to be accomplished for those residents found to have been affected by the deficient practice:
There were no specific residents found to have been affected by the deficient practice.
Identification of other residents having the potential to be affected by the same deficient practice and corrective actions to be taken
An audit of consultant pharmacist recommendations for the previous 30 days will be completed by 2/8/2019 to ensure timely notification and response by the provider/pharmacy has occurred.
Measures to be put in place/systemic changes to ensure the deficient practice does not recur
The Drug Regimen Review (DRR) policy was reviewed and revised on 1/31/19 to include specific time frames as noted below:
J. Immediately ? ?immediately? means as soon as possible, but not to exceed 24 hours after discovery.
PR(NAME)EDURES
Each month the pharmacist will conduct a drug regimen review for clinically significant drug irregularities associated with adverse consequences, or medication interactions. If present the pharmacist will generate a note to the medical provider within 24 hours. These DRRs must be addressed by the medical provider in a timely manner, but no later than a 30 day time frame. If there is a pressing problem that requires immediate attention the consultant will contact the provider immediately. In performing drug regimen reviews, the pharmacist incorporates federally mandated standards of care in addition to other applicable professional standards such as the American Society of Consultant Pharmacists (ASCP) Practice Standards, and clinical standards such as the Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guidelines and American Medical Directors Association (AMDA) Clinical Practice Guidelines.
For those recommendations that do not require a physician intervention, such as one to monitor vital signs or weights, the DON / designated licensed nurse addresses and documents actions taken within 72 hours.
The pharmacist?s findings are considered part of each resident?s clinical record. If documentation of the findings is not in the active records, it is maintained within the facility and is readily available for review. The interdisciplinary care team is encouraged to review the reports and to get the pharmacist?s input on the residents? problems and issues.
The pharmacist compiles and analyzes data collected during DRR and presents findings to the QAPI committee or administrator as part of the facility continuous quality improvement program.

The patients admitted to the rehabilitation center admitted to a LTC unit or residents that have a significant change of condition will have a pharmacist review their medications at the point and generate a document addressing any medication irregularities any note should be reviewed within 30 days. In the case of an urgent medication issue the prescriber will be contacted immediately, with documentation by the pharmacist within 72 hours.
The pharmacist will notify the DON of recommendations after initial notifications of the provider and RN immediately. The DON will ensure the RN Manager/Supervisor, MDS Coordinator and any other pertinent team members are made aware of the recommendations. The RN Manager/Supervisor and pharmacist will be responsible to update the physician of recommendations immediately following notification.

Education related to the revisions of the policy conducted with the Nurse Managers and MDS Coordinator.
Monitoring:
An audit of all monthly recommendations from pharmacy will be conducted x 3 months to ensure compliance with timelines set forth in the Drug Regimen Review policy.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Date of Correction and title of person responsible for the correction:
By 2/14/19 by Administrator

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 4, 2019

Citation Details

Based staff interview and the Legionella Water Management Plan (WMP) review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Part 4, Protection Against Legionella, Section 4-2.3 requires that environmental assessment be updated annually. Specifically, the facility did not complete the water system risk assessment form as required by New York State regulation. This is evidenced by the following. The facility's WMP was reviewed on 01/08/2019. The facility did not complete the water system risk assessment form as required by New York State regulation. The Director of Maintenance stated in an interview on 01/08/2019 at 2:15 PM, that he was not aware that a water system risk assessment needed to be completed. 415.19(a)

Plan of Correction: ApprovedFebruary 4, 2019

Corrective action for those residents found to have been affected by the deficient practice:
No specific residents were identified.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken:
All other residents have potential to be affected.
Measures to be put in place/systemic changes you will make to ensure the deficient practice does not recur:
The Water Management Plan was reviewed and updated on 2/4/19 (completed primarily on 8/25/18).
Monitoring to ensure the practice will not recur:
The WMP will be audited annually in (MONTH) of each year for risk assessment completion.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Date of Correction and title of person responsible for the correction:
2/4/19 by Director of Engineering

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on 2 on 3 units and for 1 (Resident #63) of two residents reviewed needing contact precautions and did not annually review its IPCP (Infection Prevention and Control Program) and update as necessary. Specifically; the facility did not ensure that facility staff who did not receive the influenza vaccine wore surgical masks that covered both their mouth and nose in areas where residents are typically present leaving residents at higher risk for transmission of the flu; and for Resident #63, who was on contact precautions, the facility did not ensure that staff donned a gown and gloves prior to entering the resident's room. Additionally, the facility did not ensure that their Infection Control policies were reviewed annually. This is evidenced by: On (MONTH) 20, (YEAR), New York State Department of Health Commissioner declared Influenza prevalent in New York State. This announcement put into effect the regulation requiring healthcare workers who are not vaccinated against influenza (flu) to wear surgical or procedure masks in areas where patients (residents) are typically present. The facility policy titled Influenza Immunization Requirements of Health Care Personnel, dated (MONTH) (YEAR) documented: Those health care personnel who for religious, medical, or personal choice are not immunized against influenza shall be required to wear a hospital provided mask in areas where patients are typically present during influenza season. Finding #1 During observation on 1/7/19 at 5:05 PM, Certified Nursing Assistant (CNA) #7 was transporting residents to the dining room on the Stockade Unit wearing a surgical mask below her nose. During observation CNA #7 came in and out of the residents dining room wearing a mask below the nose. CNA #7 was not advised by facility staff that mask placement should cover both mouth and nose. During observation on 1/7/19 at 5:20 PM, Registered Nurse Unot Manager (RNUM) #10 advised CNA #7 to pinch the top of the mask. CNA #7 was unable to do this. The mask was worn upside down. RNUM #10 assisted CNA #7 on proper placement of the surgical mask. She turned the mask around, demonstrated the way to put the surgical mask on so the nose clip could be pinched securing the mask in place above the mouth and nose. During interview on 1/7/19 at 5:25 PM, CNA #7 stated I didn't get the flu shot, so I have to wear the mask. It always falls below my nose, it won't stay up. The CNA was not aware how to pinch the nose piece on the mask to keep the surgical mask up. She stated she was not sure how to do that until the RNUM showed me. During an interview on 1/7/19 at 5:35, RN #10 stated CNA #7 needed re-education on how to wear the face mask. She should not have been doing resident care if the mask wasn't covering her nose and mouth. She stated she hadn't noticed CNA #7's mask was down because she was busy. Flu season had been called and the staff needs to wear masks if they have not been vaccinated. Finding #2 During observation on 1/9/19 at 8:16 AM, Licensed Practical Nurse (LPN) #4, was sitting at the open nurses' station desk on the Mohawk Unit. She was wearing a surgical mask that was positioned down below her chin while on the phone. Residents were sitting and ambulating freely in the hall by the desk where the LPN was sitting. The LPN put down the phone, walked to a back room and then returned to the phone at the nurses' station. The surgical mask was still not covering her nose and mouth. During interview on 1/9/19 at 8:35 AM, LPN #4 stated I did not have a flu shot so that's why I have a mask on. I lowered the mask from my face because I was on the phone and they couldn't hear what I was saying. I did have another area to go to, but I didn't. I am supposed to have the mask covering my nose and mouth when in a patient area. During interview on 1/10/19 at 2:55 PM, the Infection Control Registered Nurse stated wearing masks under the nose is not appropriate, they need to be over the nose. She said in the nursing station staff needing masks need to wear them appropriately with mask over nose. During an interview on 1/11/19 at 2:20 PM, the Director of Nursing (DON) stated anyone who hasn't had a flu shot needs to wear a mask when in resident care areas once the flu season has been declared. Any area a resident has direct access to is considered a resident care area. Staff that have not had the flu vaccine are required to wear the masks to minimize the spread of the flu upon entering the unit. We audit to make sure staff are wearing their masks properly. Masks need to cover the nose and mouth. Education is given to staff on how and why to wear the masks. Finding 3 On 1/10/19, the policies provided by the facility for Infection Control were reviewed. Approximately half of the policies had been reviewed annually. The rest had not been reviewed annually. During interview on 1/10/19 at 2:55 PM, the Infection Control Registered Nurse stated her policies for the Nursing Home are reviewed annually, but those from the Hospital are not. The Hospital policies provided are also used in the Nursing Home. Resident #63 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 12/29/18, assessed the resident understands, was understood, had no cognitive impairment and had an infection of the foot. The Wound Comprehensive Care Plan initiated 11/28/18 for osteo[DIAGNOSES REDACTED] of the left foot [MEDICAL CONDITION] had interventions that documented to maintain precautions as ordered. MD orders documented: 1/7/18 maintain on contact precautions every shift. On 1/09/19 at 10:25 AM, an Medical Doctor walked into Resident # 63's room without gowning or putting gloves on. This surveyor walked to room door and observed the MD taking a sock off the resident's infected foot. The RNM went into the room and the MD came out and a put gown and gloves on and went back into the room. During interview on 1/07/19 at 11:27 AM, the resident said she has a bone infection and wound on her foot. There was a contact precautions sign on her door frame with supplies in a cart next to her door. During interview on 1/09/19 at 10:35 AM, the Medical Doctor (MD) stated he did not don gloves or a gown prior to entering the resident's room. The MD stated he was in a hurry and entering the resident's room without gloves or a gown was a mistake. During interview on 1/09/19 at 3:57 PM, the Director of Nurses said the expectation is that anyone going into a room with precautions should don a gown and gloves, including the MD. During interview on 1/10/19 at 2:55 PM, the Infection Control Registered Nurse stated the MD should have worn gown and gloves prior to entering a resident's who was on contact precautions room. 10NYCRR415.19(a)(1-3), (b)(1)

Plan of Correction: ApprovedFebruary 13, 2019

Corrective action to be accomplished for those residents found to have been affected by the deficient practice:
Resident #63 ? staff corrected and re-educated regarding appropriate use of face masks for staff found to be in non-compliance with proper mask placement
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken?
Observation audit of all staff required to wear masks for proper use and fit to be conducted by 2/8/19. Education of staff as to deficient practice to occur by 2/28/19.
Staff will be audited for compliance with appropriate PPE usage upon entering resident rooms noted with orders for precautions. To be completed by 2/8/19. Counseling and ongoing discipline for staff found to be out of compliance.
An audit of the Infection Control Policies will be conducted by 2/8/19 to ensure all policies are reviewed/updated annually. Any policies requiring review and updating will be completed at the time of the audit.
Measures to be put in place/systemic changes to ensure the deficient practice does not recur:
Infection control policy & procedures reviewed and updated, organizational policies in use at the ERRC reviewed by 2/8/19 and documented appropriately.
Re-education of all employees regarding appropriate mask usage during to be completed by 2/28/19.
Follow up education provided to MD found to be out of compliance completed by supervisor on 1/10/2019.
Monitoring to ensure the practice will not recur
All staff required to wear masks will be audited to ensure compliance with proper face mask usage. Any non-compliance will be noted in the audits and corrective action will occur in real time. To be completed weekly x2 weeks, then biweekly x2 months.
Staff will be audited for compliance with appropriate PPE usage upon entering resident rooms noted with orders for precautions. Any non-compliance will be noted in the audits and corrective action will occur in real time. To be completed 1x per shift x 1 week, weekly x 2 months.
Audits of Infection Control Policies will be conducted monthly x 12 months to ensure annual reviews are completed.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations at the conclusion of the prescribed audit schedule.
Date of correction and title of person responsible:
2/4/2019 by Director of Nursing

FF11 483.15(d)(1)(2):NOTICE OF BED HOLD POLICY BEFORE/UPON TRNSFR

REGULATION: §483.15(d) Notice of bed-hold policy and return- §483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e)(1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 12, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey, the facility did not ensure written notice was provided to the resident's representative of the bed hold and return policy for two (2) (Resident #'s 219 and 220) of two (2) residents reviewed for hospitalization . Specifically, there was no documented evidence the resident and the resident's representative received written notice of the bed hold policy when the resident was admitted to the hospital. This evidenced by: Resident #219: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Per nursing admission assessment the resident had no cognitive impairment and was able to understand others and was able to be understood. A Nursing Progress Note dated 7/10/18, documented the resident had an appointment at the wound center for evaluation and treatment of [REDACTED]. Call received that the physician's assistant from the wound center wanted the resident sent to the hospital for treatment of [REDACTED]. At 3:00 pm the resident was directly admitted to the hospital. During an interview on 1/11/19 at 12:13 PM, Social Worker #10 stated she was not aware of the new regulation requiring the submission of the the bed hold policy in writing to the resident's representative when the resident is discharged to a hospital. She stated the family is notified of the bed hold policy at the time of admission. Resident #220 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS of 3/12/18 assessed the resident understands, was understood and had moderately impaired cognition. A nursing progress note dated 6/8/18 at 7:19 pm documented the resident was admitted to the hospital with [REDACTED]. During an interview on 1/11/19 at 12:13 PM, Social Worker #10 stated she was not aware of the new regulation requiring the submission of the the bed hold policy in writing to the resident's representative when the resident is discharged to a hospital. She stated the family is notified of the bed hold policy at the time of admission. 10NYCRR415.3(h)(4)(i)(a)

Plan of Correction: ApprovedFebruary 12, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action to be accomplished for those residents found to have been affected by the deficient practice:
Resident #219 was discharged on [DATE] and resident #220 was discharged on [DATE]. No further action is needed at this time.
Identification of other residents having the potential to be affected by the same deficient practice and corrective actions
Audit all transfers/discharges from the last 30 days to ensure that a copy of the bed hold policy has been provided and documented in the EHR ,to be performed by 2/8/19.
A copy of the bed hold policy will be provided to all residents or designated caregiver(s) identified as not having these readily available in their charts and documented in the electronic health record
Measures to be put in place/systemic changes to ensure the deficient practice does not recur
Reviewed the Bed Hold Notice policy.
Initiated a new process for nursing and social work related to the requirements.
Educated staff on the policy and the new process.
Monitoring:
An audit will be completed by the Nurse Manager, Nursing Supervisor, Charge Nurse, or designee within 24 - 48 hours following any discharge or transfer from LTC or SAR. Audits will commence immediately (1/28/19) and continue for a 3 month period through 5/1/19.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.

Date of correction and title of person responsible for correction:
Completed by Director of Nursing by 2/1/19

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 12, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey, the facility did not ensure three (2) (Resident #'s 219 and #220) of three (3) residents reviewed for hospitalization , received written notice of discharge. Specifically, the residents and their representatives did not receive written notice of the discharge to a hospital. This evidenced by: Resident #219: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The nursing admission assessment documented the resident had no cognitive impairment, was able to understand others and was able to be understood. A Nursing Progress Note dated 7/10/18, documented the resident had an appointment at the wound center for evaluation and treatment of [REDACTED]. Call received that the physician's assistant from the wound center wanted the resident sent to the hospital for treatment of [REDACTED]. At 3:00 pm, the resident was directly admitted to the hospital. During an interview on 1/11/19 at 12:13 PM, Social Worker #10 stated she was not aware of the regulation requiring the facility to notify the resident or resident representative in writing of a resident's discharge from the nursing home. She stated she would usually call the family and nursing would document the discharge in the chart. Resident #220 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS of 3/12/18 assessed the resident understands, was understood and had moderately impaired cognition. A nursing progress note dated 6/8/18 at 7:19 pm documented the resident was admitted to the hospital with [REDACTED]. During interview on 1/11/19 at 12:53 PM the Director Of Nurses said he could not find a transfer/discharge notice for the resident's hospitalization [DATE]. He said it is their policy to provide written notice. He did not know why it was not being done. 10NYCRR415.3(h)(1)(iii)(a-c)

Plan of Correction: ApprovedFebruary 12, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective actions for those residents found to have been affected by the deficient practice:
Resident #219 was discharged on [DATE] and resident #220 was discharged on [DATE]. No further actions are required at this time.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken
Audit all transfers/discharges from the last 30 days to ensure that the transfer/discharge notice has been appropriately provided , completed by 2/8/19.
Information from transfer/discharge notice will be provided to the residents or designated caregiver(s) identified as not having these readily available in their charts and documented in the electronic health record
Measures to be put in place/systemic changes to ensure the deficient practice does not recur
Reviewed the Transfer/Discharge Notices policy.
Initiated a new process for nursing and social work related to the requirements.
Educated staff on the policy and the new process.
Monitoring to ensure the practice will not recur
Audits will be completed by the Nurse Manager, Nursing Supervisor, Charge Nurse, or designee within 24 - 48 hours following any discharge or transfer from LTC or SAR. Audits will commence immediately (1/28/19) and continue for a 3 month period through 5/1/19.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Date of correction and title of person responsible for correction:
Completed by Director of Nursing by 2/1/19

FF11 483.60(i)(3):PERSONAL FOOD POLICY

REGULATION: §483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 28, 2019

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure they had a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not provide comprehensive information for family and visitors on safe food preparation and handling practices or on the facility procedure for reheating foods brought in for residents. This is evidenced as follows: Record review on 1/9/19 of the facility policy on foods brought in by family and visitors showed the policy did not include a process to ensure family and other visitors were given comprehensive information on proper food handling practices. The instruction sheet given to families and visitors did not provide information on the safe handling and preparation at home of foods to be brought into the facility. The sheet did not include how long home-made dishes, take-out foods, fruits, and vegetables could be kept refrigerated at the facility. There was no explanation regarding the discard date. The sheet did not include that family/visitors must ask staff to reheat the foods. In an interview on 1/11/19 at 8:13 AM, the Dietetic Technician stated that the sheet provided to family and visitors did not address the home preparation or cooling of foods to be brought into the facility. Visitors learned by word of mouth that they should ask staff to reheat foods. In an interview on 1/11/19 at 8:14 AM, the Kitchen Manager said the facility's unwritten policy was that food can only be kept in the facility for up to 3 days, including the day it was brought in. He stated that the food instruction sheet should state that staff must be asked to reheat food. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedFebruary 14, 2019

Corrective action for those residents found to have been affected by the deficient practice:
No specific residents were noted.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken:

All other residents have the potential to be affected.
Measures to be put in place/systemic changes to ensure the deficient practice does not recur:
Policy ?Food brought by Families/Visitors? reviewed and revised on 2/1/19 to include specific instructions for preparation and transportation of food using safe food handling practices, safe cooling and reheating processes, temperature specifications, prevention of cross-contamination, preventing food-borne illnesses, and hand hygiene. Safe storage education is also included.
Staff educated on policy by 2/28/19.
Information for families outlined and delivered via mail to all current resident representatives. Information provided in admission packets for all new admissions.
Instructions/information regarding food brought in from families/visitors and safe food handling practices posted in the unit kitchens for easy reference.
Monitoring to ensure the practice will not recur:
An audit of the receipt of information sent to resident/representatives to be completed 30 days after mailing/delivery to residents.
An audit of signed acknowledgement upon admission to be completed monthly for all new admissions x 3 months.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Date of correction and title of person responsible:
2/6/2019 by Food Service Manager

FF11 483.60(a)(1)(2):QUALIFIED DIETARY STAFF

REGULATION: §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who- (i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. §483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who- (i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 6, 2019

Citation Details

Based on record review and interviews during the re-certification survey, the facility did not ensure food and nutrition staff had appropriate qualifications. Specifically, the facility did not ensure that the food service director designated to serve as the director of food and nutrition services received frequent scheduled consultations from the dietitian. This is evidenced by: A staffing grid dated 12/30/18 - 1/12/19, documented Diet technician #11 worked at the facility from 7:00 AM - 3:30 PM Monday through Friday on a full time basis, Dietitian #12 worked at the facility from 7:00AM - 5:30 PM on Wednesdays, and Dietitian #9 had a varied schedule. The facility did not provide documentation of frequently scheduled consultations from the qualified dietitian to the Manager of Dining and Food Service. During an interview on 1/11/19 at 8:31AM, Diet technician #11 stated she is full time in the facility, and Dietitian #9 and #12 are part time. During an interview on 01/11/19 at 9:35 AM, Dietitian #9 stated Diet technician #11 works full-time. During an interview on 01/11/19 at 10:15 AM, Manager of Food and Dining Services #8 stated he has does not have a food service degree or a national certification for food service management. 10NYCRR415.14(a)(1)(2)

Plan of Correction: ApprovedFebruary 13, 2019

Corrective action for those residents found to have been affected by the deficient practice:
There were no identified residents.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken
All other residents are at risk.
Measures to be put in place/systemic changes to ensure the deficient practice does not recur:

?Registered Dietitian/Food Service Manager Consultation? Policy developed for supervision of Food Service Manager by Registered Dietitian by 2/4/19. Policy includes the following steps:
1. The Food Service Manager will attend weekly scheduled consultations with the Clinical Nutrition Manager and the Registered Dietitian to review diet concerns, menu review, resident concerns, food safety and project items.
2. The Registered Dietitian will provide supervisory direction to the Food Service Manager to include diet concerns, menu review, food safety, and project items.
3. Weekly scheduled consultations with agenda and attendance documentation will be kept on file.

Monitoring:
A monthly audit of regularly scheduled will be completed x 3 months to ensure the consultations are held on schedule and all required members are in attendance.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Date of correction and title of person responsible:
2/6/2019 by Food Service Manager

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey and abbreviated survey (Case #NY 770), the facility did not provide care to the highest practicable physical, mental, and psychosocial well-being and did not provide treatment and care in accordance with professional standards of practice for one (1) (Resident #70) of eighteen (18) residents reviewed. Specifically, for Resident #70, the facility did not provide instructions to elevate the resident's right foot due to amputation of the right great toe. This is evidenced by: Resident #70: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had no cognitive deficits, was able to understand and was able to be understood by others. Hospital consultation report dated 9/26/18, documented right leg revascularization/bypass with evidence of some non-healing incision; dry non-adherent dressing to areas of non healing; follow up with vascular weekly; compression-change daily from end of toes to groin; and elevation when not ambulating. Physical Therapy recommended. Hospital Discharge notes dated 8/10/18, documented [DIAGNOSES REDACTED]. Admission Wound and Skin Record dated 8/10/18, documented the resident had a right great toe amputation, 3 cm x 0.1 cm x 0 cm. Kardexes dated 9/1/18 and 10/1/18, documented under transfer and walk in room the resident was to have an off load shoe donned on the right foot. Under Locomotion off Unit, it documented to have a manual wheelchair with leg rests - only for transportation. During an interview on 1/11/19 at 2:21 PM, Registered Nurse Manager (RNM) #1 stated there was no documentation to show the left leg was being elevated. She stated the leg was being elevated, but it was not documented in the Certified Nursing Assistant Record or the Kardex. 10 NYCRR 415.12

Plan of Correction: ApprovedFebruary 13, 2019

Corrective actions to be accomplished for those residents found to have been affected by the deficient practice:
The resident identified as affected by the deficient practice (Resident #70 ? closed chart review) was discharged from the facility on 10/9/2018
Identification of other residents and corrective action to be taken:
Review of all external consults for current SAR residents by RN, ensure that appropriate interventions are in place and care planned for.
Implement corrective actions for any areas identified as currently deficient
Measures to be put in place/systemic changes to ensure the deficient practice does not recur:
Policy created to address staff responsibilities regarding review of recommendations made from external resident consultants
Education performed with all RNs to include policy update outlining process for receipt, review and communication of provider recommendations from external consultants to the attending physician.
Monitoring:
An audit of consults and recommended interventions will be performed weekly x 4 weeks, then biweekly x 2 months.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations at the conclusion of the prescribed audit schedule.
Date of correction and the title of the person responsible:
2/4/2019 by Director of Nursing

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

REGULATION: §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers and that care was provided to promote healing of an existing pressure ulcer for 2 (#219) of two residents reviewed for pressure ulcers reviewed during the recertification and abbreviated (Case #NY 587) surveys. Specifically: For Resident #51 the facility did not initiate interventions to address identified pressure ulcer risk factors to prevent pressure ulcer development with the subsequent development of a pressure ulcer; for Resident #219, the facility did not ensure there was documentation on the Kardex to reflect care to be provided to the resident's stage II sacral decubitus ulcer and a unstageable decubitus ulcer to the resident. Additionally, there was no documentation on the CNA's daily documentation history to indicate care was provided to the resident's pressure ulcers. This is evidenced by: The facility's Policy and Procedure for Pressure Injuries: Prevention and Treatment documented effective pressure injury treatment is best achieved through a team approach. The recommended treatment program should focus on; Assessment of the resident and the pressure injury, managing tissue loads, pressure injury care. If a resident is admitted with a pressure injury, the policy provides prompt, consistent and effective treatment guidelines to address the needs of the resident thereby minimizing potential complications and speeding resident recovery. It is the responsibility of the Registered Nurses to initiate and evaluate effectiveness of preventative interventions. Resident #51: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) of 11/27/18, assessed the resident understands, was understood, had no cognitive impairment, had one or more pressure ulcers at Stage II, required extensive assist of two staff for bed mobility and transfer and did not walk. During interview on 1/07/19 at 9:31 AM, the resident stated he developed a pressure ulcer shortly after coming to the facility. He did not know why he got the ulcer in the first place, and did not know what stage it was. He said one day he felt a pinch on his buttock and that was the start of it. The Admission Braden Scale (assessment tool used to identify pressure ulcer risk) dated 11/20/18, had a score of 17 or mild risk for skin breakdown. It identified the resident was chairfast; had slightly limited mobility; probably had inadequate nutrition and potential shear and friction problems. The Certified Nursing Assistant Documentation History Detail Report for 11/20/18 to 11/26/18, documented the resident needed two plus person extensive physical assist for bed mobility. The Comprehensive Care Plan (CCP) for pressure injury risk dated 11/20/18, documented a goal that the resident would not sustain a pressure injury in 30 days. The interventions included: Braden Score on admission and quarterly; barrier cream per protocol; pressure reducing mattress (standard); monitor meal intake; skin check by nurse weekly; and CNAs (Certified Nurse Aides) to report any redness or open areas every shift. The Admission Wound and Skin Record dated 11/20/18, identified a risk factor of bilateral quadriceps injury/tear secondary to a fall. It identified the right knee was bruised and swollen, the left knee was swollen, there was a purple bruise on the left chest and the right hand had an injection site. There were no other skin issues. A Nursing Note dated 11/21/18, documented the resident had immobilizers in place to bilateral lower extremities. The resident required a two plus person assist for bed mobility, dressing, transfers and toilet use and was non ambulatory. A Nursing Note dated 11/26/18, documented the CNA reported the resident had an open area to the coccyx. On inspection there was a stage II which measured 2.7 cm long by 1.4 cm wide. A blue overlay mattress was to be placed on the resident's bed to reduce pressure. Care card and care plan were to be updated. The Wound and Skin Record dated 11/26/18, identified the resident had a right coccyx stage II that was 2.7 cm (centimeter) by 1.4 cm by 0 cm. On 11/28/18, the treatment to this pressure area included turn and position (T&P) every two hours. A new left coccyx area stage II on 12/5/18 measured 3.2 cm by 1.95 cm by 0.1 cm The CCP for Pressure injury Actual effective 11/20/18 documented: Braden score = 17; 11/26/18 stage II to coccyx measuring 2.7 length and 1.4 cm width;12/6/18 full bilateral leg casts. Interventions included: Alternative air mattress - check inflation every shift (initiated 12/6/18); encourage T&P every 2 hours (initiated 12/2/18); place pillows between legs for comfort (initiated 12/2018); and see Treatment Administration Record for pressure injury treatment (initiated 12/2/18). The interventions from the pressure injury risk CCP also continued. The Resident Nursing Instructions (care card which told caregivers how to provide care to the resident) documented: on 11/26/18 a B-mattress started on 11/26/18 for pressure relief. On 12/5/18 an alternating airflow mattress and T and P every two hours while in bed started on 12/5/18. During interview on 1/10/19 at 8:52 AM, Resident #51 stated he had immobilizers on his legs when he first came in. He was not able to move himself around in bed. He could not roll over or move his legs at that time so staff needed to help him. He needed help getting out of bed, had no ability to walk and was a 2 person assist. He stated at first there was no schedule for T&P. They did not talk with him about it until after he broke down. He was feeling a pinch and brought it to their attention. They put an air mattress on the bed when the first breakdown appeared then upgraded to this new one (alternating air). He stated after the skin breakdown he got wedges to help him move in bed and they told me to turn every 2 hours. He did not have any skin breakdown that he knew of when he came in. During interview on 1/10/19 at 10:27 AM, CNA #7 stated she took care of the resident when he first came in and he could not walk. He needed help turning in bed, and we needed to move his legs for him. He would turn himself a little, he could use the urinal, and do some of his own care. She did not remember when his skin broke down. After the skin breakdown he was getting up more and had therapy. He did have a pressure relief cushion in his chair. He got a Barco (large comfortable reclining chair) for some change in position but he did not like it. He had an air mattress. He did not have any pressure areas when he first came in. If his skin was at all red she would have reported it to the nurse. She did not remember needing to put any cream on red spots on his skin when he first came in. During interview on 1/10/19 at 10:50 AM, the Registered Nurse Manager (RNM) stated the resident did not have a pressure ulcer when he first came in. He developed it here due to laying immobile. The initial CCP was at risk for pressure ulcer. When one developed she just continued the same CCP and changed it to actual breakdown. She was asked what they were doing to prevent skin breakdown since he was immobile. She said they were doing weekly checks of skin, and if any redness staff would report it. He had a standard pressure relieving mattress and an overlay air mattress when the skin broke down. That was not put on the CCP. She said the breakdown was unavoidable as he couldn't move. Resident #219: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Per nursing admission assessment, the resident had no cognitive impairment and was able to understand others and was able to be understood. Admission Wound and Skin Record dated 6/28/18, documented the resident had an unstageable pressure ulcer to his left heel measuring 6 cm x 4 cm x 0 cm and a stage 2 pressure ulcer to the resident's coccyx measuring 1 cm x 0.5 cm x 0 cm. Risk factors were documented as [MEDICAL CONDITIONS]. Potential for Pressure Injury Care Plan dated 6/28/18, documented a goal that the resident will not sustain an avoidable pressure injury x 30 days. Nursing Progress Note dated 7/2/18, documented the resident's response to interventions; Non weight bearing right leg, Surgical incision to right leg, Stage 2 pressure ulcer to coccyx, right plantar wound, and left heel unstageable pressure ulcer. No bleeding or signs/symptoms of infection, all dressings clean, dry and intact. During an interview on 1/11/19 at 11:40 AM, CNA #5 stated she does not remember the resident. General care for a resident with a pressure sore on a heel would include elevating the feet on a pillow. During an interview on 1/11/19 at 11:43 AM, NM (Nurse Manager #1 stated the CNAs should be applying barrier cream and should be positioning the residents off their bony prominences. She stated documentation in the careplan should indicate how to care for the heel and coccyx pressure ulcers. This information should also be on the Kardex, but was not. If a resident has a wound on their heel, the foot would float on a pillow and a turning schedule would be put into place. The NM reviewed the potential for pressure ulcer care plan and stated she did not see a care to be provided to the pressure ulcers. She stated there is no actual pressure ulcer careplan. There should be, but there is not. She stated information indicating how the CNAs are to provide care for a resident with pressure ulcers should have been added to the Kardex and CNA documentation, but had not been. Any nurse can enter information onto the Kardex upon admission. If resident condition changes, they will add new information to the Kardex. 10 NYCRR 415.12(c)(1)(2)

Plan of Correction: ApprovedFebruary 13, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action to be accomplished for those residents found to have been affected by the deficient practice:
Both residents identified as affected by the deficient practice have been discharged from the facility:
? Resident #51 ? discharged [DATE]
? Resident #219 ? (closed chart review) ? discharged [DATE]
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken:
Audit all current residents to ensure that Braden scores are current and appropriate interventions are in place:
Any identified deficiencies will be corrected and care planned for as needed
Measures to be put in place/ systemic changes to ensure the deficient practice does not recur
?Pressure Injuries: Prevention, treatment and specialty mattresses? policy reviewed and revised on 2/1/19.
RN staff education will be performed and completed by 2/28/19. This will includde common risk factors for perssure injuries and care planning for appropriate interventions. Pressure injury policy revised to include maintenance of an at risk care plan for pressure injuries in the presence of an actual pressure injury to ensure continuous monitoring of other potentially vulnerable body surfaces. Turning and positioning to be added to care card in all cases to ensure aide documentation will reflect performance.
Monitoring:
An audit of care plans will be performed on all new admissions and resident?s triggering a significant change to ensure that any residents with a pressure injury have the appropriate care plans in place. To be completed weekly x 30 days, then biweekly x 2 months.
Care Card audits will be completed within 24 hours of admission and significant changes by nurse manager/supervisor/charge RN to ensure turning and positioning schedules are present on care card. To be completed weekly x 30 days, then biweekly x 2 months.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations at the conclusion of the prescribed audit schedule.
Date of correction and title of person responsible:
2/4/2019 by Director of Nursing

Standard Life Safety Code Citations

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 5, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan did not include provisions detailing their role for the care and treatment of [REDACTED]. This is evidenced as follows. A review of the Emergency Plan on 01/10/2018, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Administrator stated in an interview on 01/10/2018 at 10:45 AM, that County emergency preparedness officials will be contacted and the Emergency Plan will be revised to include provisions outlining their role for care at alternate site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedFebruary 5, 2019

Corrective action for those residents found to have been affected by the deficient practice:
No residents were identified.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken:
No other residents were affected.
All policies and procedures for Emergency Preparedness were reviewed for compliance with regulations by 2/1/19.
Measures to be put in place/systemic changes to ensure the deficient practice does not recur:
Emergency Preparedness Policy reviewed 2/1/19. Letter of agreement received 1/28/19 from Schenectady County Office of Emergency Management outlining facility requirements for an evacuation to an emergency shelter.
Monitoring to ensure the practice will not recur:
An audit of the Emergency Preparedness Policy and Procedure will be done annually to ensure compliance.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee quarterly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Date of correction and title of person responsible:
2/1/19 by Administrator

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2019
Corrected date: February 19, 2019

Citation Details

Based on staff interview and review of inspection records during the recertification survey, the automatic sprinkler system was not tested and maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 14.2.1 requires that an internal inspection of piping and branch line conditions shall be conducted every 5 years. Specifically, an internal inspection of sprinkler piping was not conducted within the past 5 years. This is evidenced as follows. The sprinkler system inspection records were reviewed on 01/13/2019. The facility could not provide documentation that an internal obstruction inspection was completed in the last 5 years. The Maintenance Manager stated in an interview on 01/13/2018 at 11:55 AM, that the last internal obstruction of the sprinkler system was performed in 2012 and he will contact the vendor to conduct the obstruction inspection. 2012 NFPA 101 9.7.5; 2011 NFPA 25 14.2; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.6; 1998 NFPA 25 10-2.2

Plan of Correction: ApprovedFebruary 5, 2019

Corrective action for those residents found to have been affected by the deficient practice:
No specific residents were identified.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action to be taken:
All residents are at risk.
Measures to be put in place/systemic changes to ensure the deficient practice does not recur:
The internal inspection of the sprinkler system piping is scheduled with SRI Fire Sprinkler (our contracted vendor) for 2/11/19 through 2/28/19.
Monitoring to ensure the practice will not recur:
An audit of the inspection results will occur annually to ensure the inspections remain within required time frames.
Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Date of Correction and title of person responsible for the correction:
By 2/14/19 by Director of Engineering