Teresian House Nursing Home Co Inc
April 16, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews during a recertification survey, the facility did not ensure assessments accurately reflected residents status in two (Resident #s 65 and #183) of thirty residents reviewed. Specifically, the Minimum Data Set (MDS) Section I, did not identify that Resident #s 65 and 183 were receiving antipsychotic medications without the documentation of [MEDICAL CONDITION]. This is evidenced by: Resident #65: The resident was admitted to facility on 6/1/17 with the [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that the resident has severe cognitive impairments, rarely/never makes self understood and rarely/never understands others. Section I of the MDSs dated 6/9/17, 9/7/17, and 1/16/18, did not include the [DIAGNOSES REDACTED]. Section N documented that antipsychotic medications were received in the last seven days. Psychiatrist consult notes dated 6/16/17 and 12/22/2017 documented: [MEDICAL CONDITION] with delusions ([MEDICAL CONDITION] are severe mental disorders that cause abnormal thinking and perceptions). During an interview on 4/12/18 at 8:50 am, the MDS Coordinator stated that if the medical doctor (MD) had not documented a [DIAGNOSES REDACTED]. Resident #183: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severe cognitive impairments, rarely/never make self understood and rarely/never understands others. Section I for the MDSs dated 9/7/17 and 2/16/18 did not include a [MEDICAL CONDITION] on the [DIAGNOSES REDACTED]. Psychiatrist consult note dated 3/30/2018 documented the resident had a [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] are severe mental disorders that cause abnormal thinking and perceptions) During an interview on 4/12/18 at 8:50 am, the MDS Coordinator stated that if the medical doctor (MD) had not documented a [DIAGNOSES REDACTED].

Plan of Correction: ApprovedMay 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Accuracy of Assessments Resident #65 & #183
Element I
Corrective Action for Affected Resident
Residents #65 & #183 MDS were reviewed and corrected to accurately reflect [DIAGNOSES REDACTED].
Date of completion: 5/09/18
Element II
Identify Other Residents
EMR report of all residents receiving antipsychotic medications will be obtained, to ensure that appropriate [DIAGNOSES REDACTED].
An audit will be completed on section I of the most recent MDS for all reported residents, to assure residents receiving antipsychotic medication have appropriate [DIAGNOSES REDACTED].
Date of completion: 5/09/18
Element III
Systemic Changes
Nurse Manager will review resident consult by Psychiatrist after each visit to ensure that any new medication order has the correct [DIAGNOSES REDACTED].
Any/all [DIAGNOSES REDACTED].

Element IV
Quality Assurance
An audit will be completed on all residents seen by Psychiatrist after each visit by nurse manager, to ensure that any new medication order have the correct diagnosis. Reports will be reported to the QA committee monthly x 2 months and thereafter at the frequency determined by the Quality Assurance committee.
Responsible Individual:
Director of Nursing

FF11 483.20(e)(1)(2):COORDINATION OF PASARR AND ASSESSMENTS

REGULATION: §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not refer residents with newly evident or possible serious mental illness for level I to determine if level II review was needed for two (Resident #'s 61 and 157) of four residents reviewed for PASRR (Preadmission Screening and Resident Review). Specifically, the facility did not ensure that Resident #61 was referred for the completion of a new SCREEN when the resident experienced a significant change in condition and newly evident possible serious mental illness and that Resident 157 was referred for the completion of a new SCREEN for a new [DIAGNOSES REDACTED]. Resident #61: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 1/20/18, assessed the resident with severe cognitive impairment. It did not document any Psychiatric/Mood disorders The Screen form dated 10/11/13 documented under Level 1 Review for possible Mental Illness-Question #23: Does this person have a serious mental illness-NO. A Psychiatric Evaluation done on 11/18/16, documented the resident had a [DIAGNOSES REDACTED]. A new screen was not done for the new [DIAGNOSES REDACTED]. A Psychiatric Evaluation on 11/17/17, documented the resident was unstable and episodically displaying mood lability. The resident was displaying suspicious demeanor and other signs of paranoid process. The resident was started on low doses of [MEDICATION NAME] with positive effect. The [DIAGNOSES REDACTED]. A new screen was not completed for the newly evident symptoms. A significant change MDS of 1/2/18 documented under Section I- depression-other than [MEDICAL CONDITION] and [MEDICAL CONDITION], other than [MEDICAL CONDITION]; adjustment disorder checked as present. A new SCREEN was not completed for a significant change in status of a resident with mental illness. During interview on 4/10/18 at 9:53 am, the floor social worker stated the resident does not have a psychiatric [DIAGNOSES REDACTED]. After a fall she had delusional disorder, had delusions, but was not sure when that was. During interview on 04/10/18 at 10:57 am, Registered Nurse Manager (RNM) # 7 stated the resdient has a mental illness diagnosis. The resident had a period when she had delusions and paranoia. The MD (medical doctor) put her on [MEDICATION NAME] 12.5 daily. We did a significant change MDS for a [MEDICAL CONDITION]. She stated she was not aware a new SCREEN needed to be done for a significant change in a person with mental illness or new onset of mental illness. She did not know who would be responsible for doing the screen. During interview on 4/10/18 at 11:15 am, the MDS Coordinator stated she was not aware that persons with the [DIAGNOSES REDACTED]. During interview on 4/10/18 at 11:22 am, the Social Director stated she would have to base doing a screen on the type of mental illness. For this resident she did not know if the resident had a new mental illness or came in with the [DIAGNOSES REDACTED]. She stated she was not aware of a delusional disorder [DIAGNOSES REDACTED]. She stated she would take the cue from the Psychiatrist in looking at newly diagnosed mental illness. She stated it looked like first time was noted last November. Resident #157: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS of 2/9/18 assessed that the resident sometimes understands, was understood and was severely cognitively impaired. It documented under Section I- anxiety, depression and [MEDICAL CONDITION]. The Screen form dated 7/21/16 documented under Level 1 Review for Possible Mental Illness-Question #23: Does this person have a serious mental illness- NO. The Admission MDS on 8/9/16 under Section A 1500 documented no serious mental illness. Section I did not document any Psychiatric/Mood disorders. A Psychiatric Evaluation on 9/8/16, documented thinking is tangential, mood lability has been observed and behavior suggests hallucinations are being experienced and borderline paranoid process. The Evaluation documented [DIAGNOSES REDACTED]. During interview on 4/12/18 at 2:23 pm, the Director of Social Work stated a screen was not done for the resident's new [DIAGNOSES REDACTED]. 10NYCRR415.11(e)

Plan of Correction: ApprovedMay 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Coordination of PASARR & Assessment
Residents 61 & # 157
Element I :
Corrective Action for Affected Resident

SCREENs were completed on residents # 61 and #157, showing that Level II resident referrals were not indicated in either case.

Element II :
Identify other Residents

All other facility residents will be reviewed to determine if they have a [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED].

Element III :
Systemic Change

A policy and procedure for completing SCREENs in the event a resident is newly diagnosed with [REDACTED].
All Admissions staff, Licensed Nurses and Social Workers will be inserviced on the policy and procedure for completing SCREENs for residents with a new [DIAGNOSES REDACTED].
All psychiatric consults written by the facility psychiatrist will be reviewed. [DIAGNOSES REDACTED]. If a newly found serious mental illness is diagnosed , a certified screener will complete a new SCREEN to determine if the resident requires a Level II resident referral.

Element IV
Quality Assurance

Weekly, 100% of all new psychiatric consults will be audited to identify residents with new [DIAGNOSES REDACTED].

Individual Responsible:
Director of Social Services

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not ensure development of comprehensive person-centered care plans, that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Resident #'s 61,174, 229, and #269) of 35 residents reviewed. Specifically: For Resident #174 there was no Comprehensive Care Plan (CCP) to address the resident's anxiety and [MEDICAL CONDITION] [DIAGNOSES REDACTED]. For resident #61 there was a lack of a person centered CCP to address needs related to [MEDICAL CONDITION]. For resident 269 there was a lack of person centered CCP to address needs related to discharge planning. For Resident #229, the facility did not ensure the CCP for [MEDICAL CONDITION] drug use was revised to include non-pharmacological interventions by staff prior to administering PRN [MEDICATION NAME]. This is evidenced by: A Policy and Procedure for a Care Plan Procedure with a revision date of 11/07/16, documented care plans are to be individualized, all approaches/interventions should be specific to the resident, the RN updates care plans quarterly and as needed after the initiation of the development of the careplan. Resident #174: Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessed the resident to be understood, able to understand, and having severe cognitive impairment. A physician's orders [REDACTED]. A CCP created on 8/17/17, last updated on 3/28/18, documented; The resident uses antidepressant medication. The interventions documented were; 1. Administer antidepressant medications as ordered and monitor/document side effects and effectiveness every shift. 2. Followed by psychiatry, review for gradual dose reduction. During an Interview with Registered Nurse Manager (RNM) #3 on 04/12/18 at 11:01 AM, she reported that when she went to print the CCP she realized it was not complete and did not address the resident's needs, so she corrected it to include antianxiety and antipsychotic medications and appropriate interventions. The RNM also reported that the Social Worker is responsible for writing the care plans that address psychoactive medications and behaviors. During an interview on 04/12/18 at 11:21 AM, Social Worker (SW) #4 reported she did not realize there was no CCP addressing the resident's antianxiety and antipsychotic medications. I was told by the SW that trained me to select appropriate items from the drop down list when doing a CCP. I did not know I could or should add interventions specific to the resident's behaviors and needs. Resident #61 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 1/20/18 assessed the resident was severely cognitively impaired. A Comprehensive Care Plan dated 3/19/18 for Impaired Circulation related to cholesterol had a goal of: no complications of poor circulation. Interventions included: assess fingers and toes for warmth and color every ( the word specify in parentheses) but nothing after it. A Physician order [REDACTED]. During interview on 4/09/18 at 2:38 pm the Registered Nurse Manager (RNM) said the resident's problem with [MEDICAL CONDITION] is a long standing one. The RNM was asked if there was a Comprehensive Care Plan for [MEDICAL CONDITION] since it was a chronic problem. She said there was nothing specific for the [MEDICAL CONDITION], she should definitely have one. Resident #229 This resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact and was usually understood by others and understands. The Resident's [MEDICAL CONDITION] Careplan revised 4/05/18-upon return from the hospital. Interventions documented to administer [MEDICAL CONDITION] medications as ordered by physician. Monitor for side effects and effectiveness every shift and to consult with psychiatrist to consider dosage reduction when clinically appropriate. Review of the resident's [MEDICAL CONDITION] Careplan did not reveal non-pharmacological interventions provided by staff prior to administering PRN [MEDICATION NAME] and as needed throughout the day. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Psychiatrist Progress Note dated 4/6/18, documented the resident is not doing well and seems worse. She is declining and is in the process of dying. Her [MEDICAL CONDITION] medication was discontinued at the hospital which worsened her anxiety. The resident's motor restlessness worsened and is associated with anxiety and probable withdrawal of antipsychotic medications. Progress notes dated 4/10/18 at 10:39 am, the Medical Director was called by the nurse due to the resident's thrashing, constant moving and moaning. The physician ordered [MEDICATION NAME] 5 mg to be given now. Observation on multiple occasions revealed the resident seated in a reclined geri chair in the resident lounge. The resident was observed to be restless, moving her extremities and moaning. The eMAR dated 4/01/18 to 4/10/18, documented the resident received [MEDICATION NAME] 0.5 mg every 2 hours PRN on 4/01/18 at 5:06 am, 9:58 am and 2:14 pm; 4/02/18 at 4:06 am 9:20 am, 11:39 am, 7:07 pm and 11:42 pm; 4/03/18 at 8:38 am 4/04/18 at 12:39 pm, 4/05/18 at 6:19 am, 8:20 am and 10:31 am; 4//06/18 at 6:55 am, 10:49 am and 1:46 pm; 4/07/18 at 12:35 am, 2:51 am, 10:01 pm and 11:36 pm; 4/08/18 2:43 am and 11:40 pm; 4/09/18 1:47 am, 5:36 am, 12:30 pm and 10:31 pm; and 4/10/18 at `1:20 am, 5:12 am, 9:43 am and 11:53 am. During an interview on 04/10/18 at 10:42 am, RN NM #5 reviewed the Care Plan and stated there were no non-pharmacological approaches listed. She stated non-pharmacological measures performed by staff were to reassure the resident that she is safe, spend time with her, apply [MEDICATION NAME]es, encourage the resident to talk, listening to music and listening to mass on the TV. RN NM #5 stated they should be getting credit for doing these interventions by listing them on the care plan since they are already doing them. During an interview on 04/10/18 at 10:45 am, SW #7 stated non-pharmacological interventions should be on the care plan as they are already being done. She stated the staff take turns sitting with the resident. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedJune 1, 2018

Develop/Implement Comprehensive Care Plan
Residents #61, #174, #229 & #269
Element I:
Corrective Actions for Residents Affected
A comprehensive review of residents #s 61,174, 229 plan of care and medical record was completed by Nurse manager. A resident-centered care plan for each resident, consistent with the resident rights,that includes measurable objectives and timeframes to meet the medical, nursing, mental and psychosocial needs identified in the comprehensive assessment.
Resident #269 no action taken resident has been discharged to home
Element II:
Identify Others
Every resident has the potential to be affected by the lack of a fully developed resident-centered care plan.
A comprehensive review of resident care plans will be completed to assure that individualized approaches and interventions are in place and specific to resident needs.
Element III
Systemic Changes
Review and revise facility Care Plan Procedure policy. The interdisciplinary team will be re-educated to assure that care plans are individualized and appropriate to each resident and their diagnosis.
Interdisciplinary meetings are held quarterly, annually and with significant changes and as needed to capture new diagnosis, medications etc. Resident care plan reviews and revisions will be conducted at this scheduled time assuring that all are comprehensive and resident centered.

Element IV
Quality Assurance
Interdisciplinary meetings are held quarterly, annually and with significant changes. Resident care plan reviews and revisions will be conducted at this scheduled time assuring that all are comprehensive and resident centered.
Audits will be conducted weekly on all residents who have completed their quarterly review and with significant change to assure compliance with facility policy.
Results will be reported to the Quality Assurance Committee monthly x2 months and thereafter at the frequency determined by the Quality Assurance committee.
Responsible Individual:
Director of Nursing

FF11 483.45(d)(1)-(6):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- §483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertfication survey, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. Each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being; Medications are only used when the medication is necessary for (1) (Resident #173) of ten (10) residents reviewed. Specifically, [MEDICATION NAME] (a cognition enhancing medication to treat dementia) was not discontinued per physician's orders [REDACTED]. Policy and Procedure for Transcription of physician's orders [REDACTED]. physician or Nurse Practitioner and obtain order to follow the recommendation. Resident #173: This resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was moderately impaired for cognition and was able to understand others and was able to understand. physician's orders [REDACTED]. Psychiatrist Consult Note dated 2/19/18, documented a recommendation to stop [MEDICATION NAME] XR 28 mg daily for gradual dose reduction (GDR). There is documentation the Medical Director signed and dated the Psychiatrist Consult Note which included recommendation for the medication changes on 2/20/18. Psychiatrist Consult Note dated 3/02/18, documented a recommendation to discontinue [MEDICATION NAME] as it was not effective due to the resident's advanced dementia. Documentation revealed the Medical Director signed and dated the Psychiatrist Consult Note and medication recommendation on 3/06/18. The Electronic Medication Administration Record [REDACTED]. During an interview on 4/11/18 at 9:05 am, NM RN #5 stated the Optim Nurse Practitioner saw the psychiatrist's recommendations and deferred the orders to NP #8. NM RN #5 stated when the Medical Director signed a consult it meant he is just acknowledging the recommendation. She stated it is not yet an order. During an interview on 4/11/18 12:00 pm, the Medical Director stated when he signs a psychiatric recommendation it means he is agreeing with it and the recommendations are to be followed. He stated this order should have been carried over in February. You are telling me it was not carried over? It should have been. He acknowledged he signed medication renewals on 2/20/18 and 3/20/18 which included the cognition-enhancing medication which had not been discontinued per psychiatry recommendations. During an interview on 4/11/18 at 12:15 pm, NM RN #5 stated that is not what happened. [MEDICATION NAME] NP # 11 was aware of the recommendations and was to give this information to NP #8. During an interview on 04/12/18 at 8:50 am, the psychiatrist stated he meets with the Nurse Managers and the Nurse Practitioners prior to going to the nursing units. He stated he writes his recommendations directly into the computer program (PCC). The psychiatrist stated he will always tell either a Nurse Manager or Licensed Practical Nurse of his recommendations. He stated he may tell the Social Worker. He will communicate with [MEDICATION NAME] if it is a complicated case. He stated he always tells a nurse of his recommendations. During an interview on 04/12/18 at 9:00 am, RN NM #2 stated when the Medical Director signs psychiatric recommendations, the order has already been followed, it is a done deal. She stated she accompanies the psychiatrist when he sees a resident. He will tell RN NM #2 of his recommendations and she will then write a Telephone Order for the Medical Director. She will change the orders per recommendations. RN NM #2 stated, When the Medical Director signs a consult, the order has already been changed. During an interview on 04/12/18 at 9:12, RN NM #6 stated she accompanies the psychiatrist while he sees the resident and will write a telephone order for the Medical Director to change the order per recommendations. RN NM #6 stated when the Medical Director signs a consult order, it has already been changed. Progress note dated 2/16/18 at 09:50 am, documented recommendations reviewed from the psychiatrist with [MEDICATION NAME] Nurse Practitioner #11. Recommendations to be deferred to primary NP #8 to be addressed on Monday. During an interview on 04/12/18 at 12:03 pm, NP #6 stated if the psychiatrist is on the units after 5:00 pm on Fridays communication is ambiguous. An evening nurse would be told of new orders by the psychiatrist. The on-call NP #11 assumed, in this case, the recommendations would be brought to the primary NP #6 on Monday. The medications had been renewed when the resident came back from the hospital. NP #6 had read the orders, talked to the resident's family, and requested the psychiatrist to come back in to reconsider medications. The Medical Director had been due in that week and he would have input from the psychiatrist. NP #6 stated generally if the order is urgent it will be called on phone after hours and the recommendation will be read. Sometimes she will call the psychiatrist to discuss the recommendation. NP #6 stated she did not see this consult stating if it did not contain her signature, she did not see it. I sign everything . The Medical Director signed the consult. Progress Note dated 2/16/18 at 9:44 pm, documented LPN #10 reviewed recommendations from the psychiatrist with Optum NP #11. There were no new orders as she was deferring recommendations to primary NP #6. During an interview on 04/12/18 at 12:33, the Assistant Director of Nursing (ADON) stated the psychiatrist brought his recommendations to the attention of the nurse on duty at that time. That nurse is responsible to notify the primary care or [MEDICATION NAME] NP to receive an order if desired. If follow up was on Monday, [MEDICATION NAME] NP #11's documentation was to include her checking the box that she was deferring to [MEDICATION NAME] NP #6. The consult was presumed to have been followed. Follow up should be done immediately. She stated the Medical Director has the last say on whether to follow a consultant recommendation. During an interview on 04/12/18 at 2:04 pm, RN NM #5 stated there was a problem in communication. She stated the Social Worker put the psychiatric consult in the Medical Director's book instead of in the [MEDICATION NAME] book. Optum NP #6 never saw the consult. She stated policy is to put consults in the [MEDICATION NAME] book if the resident is a patient with [MEDICATION NAME]. 10NYCRR4154.12(l)(1)

Plan of Correction: ApprovedMay 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Drug Regimen is free from unnecessary drugs
Residents #173
Element I
Resident Affected
Medication changes suggested by psychiatry were reviewed with Attending and resident representative with changes as indicated by Nurse Manager.
Element II
Identify Other Residents
A full house audit of consulting physicians from the past 30 days will be completed to identify any residents with an unaddressed recommendation and review with Attending Physician or Nurse Practitioner for response and action as appropriate. All changes will be entered into EMR as indicated.

Element III
Systemic Changes
Policy Transcription of physician's orders [REDACTED]. Nursing and Social Worker department will be re-educated on facility policy to assure understanding of process.
Audits of all consults note will be completed on a weekly basis to assure that no recommendations are overlooked.
Element IV
These corrective actions will be monitored through:
Further reporting at the monthly Quality Assurance committee x 2 months and thereafter for the frequency determined by the Quality Assurance Committee for continuous quality improvement with change in processes as indicated.
Responsible Individual:
Director of Nursong

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertfication survey, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. Each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being; PRN orders for [MEDICAL CONDITION] medications are only used when the medication is necessary and PRN use is limited for one (1) (Resident #173) of ten (10) residents reviewed. Specifically, [MEDICATION NAME] (an antipsychotic medication) as needed (PRN) were not discontinued per physician's orders [REDACTED]. Policy and Procedure for Transcription of physician's orders [REDACTED]. physician or Nurse Practitioner and obtain order to follow the recommendation. Resident #173: This resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was moderately impaired for cognition and was able to understand others and was able to understand. physician's orders [REDACTED]. Psychiatrist Consult Note dated 2/19/18, documented a recommendation to stop [MEDICATION NAME] 25 mg every 12 hours PRN (gradual dose reduction-GDR). There is documentation the Medical Director signed and dated the Psychiatrist Consult Note which included recommendation for the medication changes on 2/20/18. Psychiatrist Consult Note was dated 3/02/18. Documentation revealed the Medical Director signed and dated the Psychiatrist Consult Note and medication recommendation on 3/06/18. The Electronic Medication Administration Record [REDACTED]. [MEDICATION NAME] PRN is documented on the eMAR through 4/11/18 as the order had not been discontinued. There is no documentation the resident received additional doses of the medication. During an interview on 4/11/18 at 9:05 am, NM RN #5 stated the Optim Nurse Practitioner saw the psychiatrist's recommendations and deferred the orders to NP #8. NM RN #5 stated when the Medical Director signed a consult it meant he is just acknowledging the recommendation. She stated it is not yet an order. During an interview on 4/11/18 12:00 pm, the Medical Director stated when he signs a psychiatric recommendation it means he is agreeing with it and the recommendations are to be followed. He stated this order should have been carried over in February. You are telling me it was not carried over? It should have been. The Medical Director stated he was not aware PRN antipsychotics could only be ordered for 2 week intervals. He acknowledged he signed medication renewals on 2/20/18 and 3/20/18 which included the psychiatric medications which had not been discontinued per psychiatry recommendations. During an interview on 4/11/18 at 12:15 pm, NM RN #5 stated that is not what happened. [MEDICATION NAME] NP # 11 was aware of the recommendations and was to give this information to NP #8. During an interview on 04/12/18 at 8:50 am, the psychiatrist stated he meets with the Nurse Managers and the Nurse Practitioners prior to going to the nursing units. He stated he writes his recommendations directly into the computer program (PCC). The psychiatrist stated he will always tell either a Nurse Manager or Licensed Practical Nurse of his recommendations. He stated he may tell the Social Worker. He will communicate with [MEDICATION NAME] if it is a complicated case. He stated he always tells a nurse of his recommendations. During an interview on 04/12/18 at 9:00 am, RN NM #2 stated when the Medical Director signs psychiatric recommendations, the order has already been followed, it is a done deal. She stated she accompanies the psychiatrist when he sees a resident. He will tell RN NM #2 of his recommendations and she will then write a Telephone Order for the Medical Director. She will change the orders per recommendations. RN NM #2 stated, When the Medical Director signs a consult, the order has already been changed. During an interview on 04/12/18 at 9:12, RN NM #6 stated she accompanies the psychiatrist while he sees the resident and will write a telephone order for the Medical Director to change the order per recommendations. RN NM #6 stated when the Medical Director signs a consult order, it has already been changed. Progress note dated 2/16/18 at 09:50 am, documented recommendations reviewed from the psychiatrist with [MEDICATION NAME] Nurse Practitioner #11. Recommendations to be deferred to primary NP #8 to be addressed on Monday. During an interview on 04/12/18 12:03 PM NP #6 stated if the psychiatrist is on the units after 5:00 pm on Fridays communication is ambiguous. An evening nurse would be told of new orders by the psychiatrist. The on-call NP #11 assumed, in this case, the recommendations would be brought to the primary NP #6 on Monday. The medications had been renewed when the resident came back from the hospital. NP#6 had read the orders, talked to the resident's family, and requested the psychiatrist to come back in to reconsider medications. The Medical Director had been due in that week and he would have input from the psychiatrist. NP #6 stated generally if the order is urgent it will be called on phone after hours and the recommendation will be read. Sometimes she will call the psychiatrist to discuss the recommendation. NP #6 stated she did not see this consult stating if it did not contain her signature, she did not see it. I sign everything . The Medical Director signed the consult. Progress Note dated 2/16/18 at 9:44 pm, documented LPN #10 reviewed recommendations from the psychiatrist with Optum NP #11. There were no new orders as she was deferring recommendations to primary NP #6. During an interview on 04/12/18 at 12:33, the Assistant Director of Nursing (ADON) stated the psychiatrist brought his recommendations to the attention of the nurse on duty at that time. That nurse is responsible to notify the primary care or [MEDICATION NAME] NP to receive an order if desired. If follow up was on Monday, [MEDICATION NAME] NP #11's documentation was to include her checking the box that she was deferring to [MEDICATION NAME] NP #6. The consult was presumed to have been followed. Follow up should be done immediately. The ADON stated she cannot speak to why the nurse did not pick up on the PRN dose of [MEDICATION NAME] and why she did not follow through. She stated the Medical Director has the last say on whether to follow a consultant recommendation. During an interview on 04/12/18 at 2:04 pm, RN NM #5 stated there was a problem in communication. She stated the Social Worker put the psychiatric consult in the Medical Director's book instead of in the [MEDICATION NAME] book. Optum NP #6 never saw the consult. She stated policy is to put consults in the [MEDICATION NAME] book if the resident is a patient with [MEDICATION NAME]. 10NYCRR415.12(l)(2)(ii)

Plan of Correction: ApprovedMay 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Free from unnecessary [MEDICAL CONDITION] medications/PRN use.
Residents #173
Element I
Resident Affected
Medication changes suggested by psychiatry were reviewed with Attending and resident representative with discontinuation carried out by Nurse Manager.
Element II
Identify Other Residents
A full house audit of consulting psychiatry recommendations from 3/01/18 will be completed to identify any residents with an unaddressed recommendation and review with Attending Physician or Nurse Practitioner for response and action as appropriate. All changes will be entered into EMR as indicated.

Element III
Systemic Changes
Policy Transcription of physician's orders [REDACTED]. Nursing and Social Service department will be re-educated on facility policy to assure understanding of process.
Audits of psychiatry consult note will be completed following visit and on a weekly bases to assure that no recommendations are overlooked.
EMR review of as needed medications not used in a 30day period will be reviewed by Nurse Manager and Attending/ordering physician for discontinuation.
EMR review of as needed psychiatric medications not used in a 14 day period will be reviewed by Nurse Manager and Attending/ordering physician for discontinuation. All initial orders of these medications will be for a 14 day period requiring re-evaluation for appropriateness of continuation.
Element IV
These corrective actions will be monitored through:
Audits of psychiatry consult note will be completed following visit and on a weekly bases to assure that no recommendation are overlooked.
Further reporting at the monthly Quality Assurance committee x 2 months and thereafter for the frequency determined by the Quality Assurance Committee for continuous quality improvement with change in processes as indicated.
Responsible Individual:
Director of Nursing

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did not ensure it maintained an infection control program to prevent the spread of infection in one (1) of fourteen (14) service kitchens. Specifically, in unit 5A hands were not washed and gloves not changed when touching food while making a sandwich and food was not covered as it was being transported across the hall to resident lounge area. Specifically for Resident # 243 did not receive a Mantoux test at the time of admission. This is evidenced by: Finding #1 During Dining Observation at Unit 5A, on 04/05/18 at 12:22 PM, Resident Assistant (RA) #9 was wearing gloves while making a sandwich for a resident. She was observed while wearing the same gloves to get the bread by opening and closing the cabinet. She then touched the sandwich meat, wearing the same gloves, and made the sandwich, opened and closed the cabinet to get bag of chips, opened the bag and never removes gloves or washed her hands. When the sandwich had been prepared and given to the resident, the RA removed her gloves and washed her hands. Policy and Procedure- Sanitation and Infection Control-Food Safety with a revision date of 3/2010, documented ready-to-eat food must not be touched with bare hands. Disposable gloves, tongs, or other dispensing devices must be used properly to handle food. During an interview on 4/05/18 at 12:30 pm, RA #9 stated she realized she should not have opened the cabinet and touched the food without washing her hands and wearing the same gloves. During an interview on 04/12/18 at 10:42 am, the Kitchen Director stated he had talked to RA #9 about not washing her hands and changing gloves while making a sandwich and after touching the cabinet. Kitchen Director stated staff are inserviced yearly on infection control practices. Finding #2 During a dining observation on 04/05/18 at 12:40 pm, neighborhood assistant #10 was waiting for a resident's food to be served on the tray. He suggested covering the resident's food and beverages since he would be bringing the food across the hall to the TV area. The serving staff ruled against it telling him the food did not have to be covered. NA #10 was then observed bringing the uncovered food on the tray across the hall to the resident. During an interview on 4/12/18 at 12:45 pm, NA #10 stated he knew the food should have been covered and tried to tell the kitchen staff but they over ruled him. During an interview on 04/12/18 at 10:42 am, the Kitchen Director stated the food should be covered when taken out of kitchen area. He stated the staff are Inserviced all the time and yearly. Finding #3 A Mantoux (testing for [MEDICAL CONDITION]/PPD) policy and procedure last revised on 1/9/108 documented: 1. A Mantoux will be given to all residents upon admission. 2. The registered Nurse (RN) will measure test results in 48 to 72 hours after the test is given. 3. Repeat 2nd step if 1st step is 0-9 mm unless step 2 is required. Resident #243 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 3/10/2018, documented the resident was understood and could understand others, with a Brief Interview for Mental Status (BIMS) score of 99. It further documented the resident had moderately impaired cognition for decision making. A physician's orders [REDACTED]. The e MAR (electronic administration record) dated (MONTH) (YEAR) documented [MEDICATION NAME] PPD solution 5 unit/0.1 ML inject 5 unit intradermally one time only for new admission until 2/12/18 to forearm start date 2/12/18. Review of the eMAR for 2/12/18 the Licensed practical Nurse (LPN) #10 documented see progress note in the administration box for the medication administration. Review of the orders administration progress note dated 2/12/18 at 1:00 pm, the Licensed Practical Nurse (LPN) #10 documented [MEDICATION NAME] PPD solution 5 unit/0.1 ML, inject 5 unit intradermally one time only for new admission until 2/12/18 to forearm on order. Review of the eMAR, eTAR (electronic treatment record), progress notes, or immunization record did not provide any evidence that the test was done or that the supervisor or physician had been notified that the test was not completed. During an interview on 4/12/18 at 1:39 PM, the Assistant Director of Nursing (ADON) stated no evidence could be found that the PPD was done on admission. The PPD step 1 should have been done no later than 2/10/2018. Also it was not done as order on 2/12/18. Neither the supervisor or the physician had not been notified it was not done. A PPD was done on 2/19/18 and not repeated as required until 4/10/18 when the ADON noted the error after being questioned by the surveyor. 10NYCRR415.19(b)(3)

Plan of Correction: ApprovedJune 1, 2018

Infection Prevention & Control
Resident #243 Finding#1, #2, #3
Finding #1
Element I
Resident Affected
The employee on 5A was In-Serviced on proper procedures for Hand Washing and proper glove use when handling Ready to Eat Foods.
Element II
Other Residents Affected
Neighborhood Assistant Meal and Training Manual was reviewed, one update was drafted and placed in NAMTM instructing staff to remove all necessary product from refrigerator, freezer, drawers to include serving utensils before properly washing hands, putting on gloves and handling ready to eat foods.
Element III
Systemic Changes
All staff members trained to serve will be re-inserviced on proper glove use during team meeting.

Element IV
Quality Assurance
These corrective actions will be monitored through:
Detailed Meal Observation Audit revised by Food Service Department to include questionnaire.
Audits will be conducted daily. Two units per day one meal period until 100% compliance has been achieved.
Audits will continue to be conducted daily as part of Food Service Quality Assurance Standard compliance program
Finding #2
Element I
Resident Affected
Employee on 5A was in-serviced on proper procedure when transporting food from Unit Dining Room to other areas including Resident Room?s and unit lounge area.
Element II
Other Residents Affected
All food serving staff will be re inserviced on proper procedure when transporting Foods from Unit Dining Room to other areas of the Unit during team meeting.
Element III
Systemic Change
Neighborhood Assistant Meal and Training Manual was reviewed & revised. Amendment will be made to section two.

Element IV
Quality Assurance
Detailed Meal Observation Audit revised by Food Service Department to include audit question.
Audits will be conducted daily, two units per day until 100% compliance has been achieved.
Audits will continue to be conducted daily as part of Food Service Quality Assurance Standard compliance program
Finding #3
Element I
Resident Affected
Upon review of records resident was noted not to have received step 2 of ppd administration. Resident received ppd on 4/10/18. Results read and documented on 4/12/18.
Element II
Other Residents Effect
A full house report on all residents ppd records will be completed to ensure compliance per facility policy.
Element III
Systemic Change
Policy review and revision of Mantoux Administering, Recording & Reading completed and re-education of licensed staff will be conducted to assure compliant practice per CMS guidelines.
EMR revised to include step 1 & 2 to prepopulate orders for all new admissions.
Infection prevention and Control program will be established to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection.
Element IV
Quality Assurance
An audit will be completed on all new admissions to insure that Mantoux testing is completed per policy weekly x4 weeks, then monthly x3, then thereafter as determined by Quality Assurance Committee.
Responsible Individuals:
Director of Nursing.
Director of Food Service.

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey and an abbreviated survey (Case #NY ) the facility did not ensure that alleged violations of abuse mistreatment and neglect, including an injury of unknown source were thoroughly investigated for 1 (Resident #'s 96) of 5 resident's reviewed. Specifically, for Resident #96, the facility was not able to provide an investigation to rule out abuse, mistreatment or neglect for an injury of unknown origin. This is evidenced by: Resident #96: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 1/26/18 assessed that the resident had severely impaired cognitive ability. A nurses note dated 2/15/17 at 4:40 pm, documented the nurse was called to assess the resident for a 10 by 3 cm (centimeter) irregular purplish red colored area and five linear dry scabbed areas each about 1 to 2 cm in length on top of the ecchymotic area. The area was cleaned with normal saline, triple antibiotic ointment applied, ROM (range of motion) was baseline and no discomfort exhibited. A nurses note on 2/15/17 at 5:00 pm documented the 10 cm by 3 cm ecchymotic area as previously mentioned was located on the left posterior forearm. 4/9/18 at 9:00 am the investigation of the bruise of unknown origin on 2/15/17 was requested from the facility. On 04/10/18 at 12:03 pm the Assistant Director of Nurses (ADON) said they could not find the investigation, it was logged as done but not available. She said they would keep looking. During interview on 4/11/18 at 10:31 am Certified Nurse Aide # 7 said the resident does not bruise easily. She remembered seeing the bruise and scratches about a year ago. She said that was the only bruise she has seen on the res. On 4/12/18 at 2:17 pm the facility had not provided an investigation of the bruise that occurred Feb. 15, (YEAR) 10 NYCRR 415.4(b)(2)

Plan of Correction: ApprovedJune 1, 2018

Investigate/Prevent/Correct Alleged Violation Resident #96
Element I
Corrective Action for Affected Resident
Incident/accident investigation for injury of unknown origin found for resident #96 on 2/15/2017 would not reveal accurate information for reporting and therefore no corrective action is indicated.
Elememt II
Identify Other Residents
All incident/accident investigatons for injury of unknown origin over the past 30 days will be reviewed by Assistant Director of Nursing and Risk Management Director to assure full completion to rule out abuse, mistreatment or neglect.
Element III
Systemic Changes
Incident/ Accident Reporting, Identification and Investigation policy will be reviewed and revised.

All licensed staff will be re-educated on facility policy Incident/ Accident Reporting, Identification and Investigation to identify any incidents requiring further investigation to rule out abuse, mistreatment or neglect. Policy will be updated to reflect that a Root Cause Analysis will be completed for all incidents and accidents and saved to Teresian House hard drive for retreval in the event that paper documented become misfiled.
House wide review of progress notes of change in condition and incidents will be conducted by each floor Nurse Manager daily and on the first working day following weekends and holidays. The results will be reported at Interdisciplinary morning meeting to assure that all incidents have a corresponding investigation report completed.

Element IV
Quality Assurance
All incident reports will be reviewed by the Interdisciplinary team at morning meeting to establish the possible cause to determine if there is reason to suspect abuse, mistreatment or neglect.
Each incident report will be audited by Director of Nursing/Designee weekly to ensure that a through investigation was completed for any injury of unknown origin.
Results of the audits will be reported to the Quality Assurance Committee monthly x2 and thereafter at the frequency determined by the Quality Assurance Committee.

Responsible Individual:
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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure written notice which specifies the duration of the bed-hold policy, was provided to the resident and the resident representative at the time of transfer for hospitalization . This was evident for 5 (residents #2, 54, 229, 271, and 423) of 5 residents reviewed for hospitalization . Specifically, for Residents # 2, 54, 229, 271, and 423, There was no documented evidence the resident and the resident's representative were notified in writing of the bed hold policy when the resident was admitted to the hospital. This is evidenced by the following: Resident #271 Resident # 271 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set had not been completed prior to the resident's discharge. Nursing Progress Notes documented the resident was sent to the hospital and admitted on [DATE]. There was no documentation of written notification of the bed hold policy being sent to the resident or resident's representative. During an interview on 4/12/18 at 11:00 AM Registered Nurse Manager (RNM) #3 reported the Social Worker would be responsible for sending written notification to families. During an interview on 04/11/18 at 1:33 PM Social Worker #4 reported she believed a telephone call regarding a bed hold was sufficient, she was not aware that they needed to send written notification of the bed hold policy when a resident is sent to the hospital. Resident #54 Resident # 54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident could understand, be understood, and had intact cognitive skills. Nursing Progress Notes documented the resident was sent to the hospital and admitted on [DATE]. There was no documentation of written notification of the bed hold policy being sent to the resident or resident's representative. During an interview on 4/12/18 at 11:00 AM Registered Nurse Manager (RNM) #3 reported the Social Worker would be responsible for sending written notification to families. During an interview on 04/11/18 at 1:33 PM Social Worker #4 reported she believed a telephone call regarding a bed hold was sufficient, she was not aware that they needed to send written notification of bed hold when a resident is sent to the hospital. Resident #423 This resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per MDS dated [DATE], the resident had long and short term memory impairment, was able to understand others and was able to be understood. Nurse practitioner note dated 4/3/17, documented the resident was admitted to hospital on [DATE] and returned to the nursing home on 3/27/18. The resident was diagnosed with [REDACTED]. There was no documentation of written notification of the bed hold policy being sent to the resident or resident's representative. During an interview on 04/10/18 at 3:12 pm, Social Worker #12 stated she would find out about bed hold notification to the resident's family. She stated it was not done for this resident but would find out who is responsible to notify resident families. 10NYCRR415.3(h)(4(i)(a)

Plan of Correction: ApprovedMay 11, 2018

Notice of bed hold policy before and upon transfer
Element I
Affected Resident
Letters were sent to survey sample and their representatives explaining the oversight of not sending bed hold letters at the time of resident hospitalization .
Date of Completion: 5/11/18
Element II
Other Residents Affected
When a resident is being transferred to the hospital, even if facility census is below that which Medicaid will pay to hold the bed, a bed-hold notification letter will be given to the resident. A copy of the letter will be mailed to the residents representative and the forwarding of the bed-hold notification to resident and resident representative will be documented in the resident's EMR.
Element III
Systemic Changes
The policy and procedure for Hospital Bed-hold was reviewed and revised to include bed-hold letters being sent to residents and resident representatives when facility census is below that for which Medicaid will hold the bed.
The Director of Admission, Admissions Assistant and Social Work will be in-serviced on revised policy and procedure for Hospital Bed-hold.
Upon hospitalization , the Admission Assistant will call the resident representative to inform him/her of the bed-hold policy and will send the bed-hold letter to the resident representative. The Admissions Assistant will give a bed-hold letter and a copy of the letter to the resident's Social Worker who will give the original to the resident and file the copy in the resident's chart in social services section. The social worker will document in the medical record when the bed-hold letters were forwarded to the resident and resident representative.

Element IV
Quality Assurance
Weekly audits of all hospital transfers will be completed to confirm that this procedure has been completed.
Results of audits will be reported to the Quality Assurance Committee for a period of two quarters and thereafter at the frequency to be determined by the Quality Assurance Committee.
Responsible Individuals:
Director of Admissions
Director of Social Services

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure that written notification was sent to the resident, the resident's representative, and a representative of the Office of the State Long-Term Care Ombudsman of the resident's transfer or discharge and the reasons for the move for 5 (residents #2, 54, 229, 271, and 423) of 5 residents reviewed for hospitalization . Specifically, for Residents # 2, 54, 229, 271, and #423, there was no documented evidence the resident, the resident's representative, or the Ombudsman were notified in writing by the facility when the residents were admitted to a hospital from the facility. This is evidenced by: Resident #271: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set had not been completed prior to the resident's discharge on 2/18/18. A Nursing Progress Note dated 2/18/18, documented the resident was sent to the emergency room for evaluation and admitted to the hospital. There was no documentation that written notification was sent to the resident, resident's representative, or Ombudsman regarding the hospital admission. During an interview on 4/12/18 at 11:00 am, Registered Nurse Manager (RNM) #3 reported she was not aware that written notification had to be sent. She stated the social worker would be responsible for sending letters. During an interview on 04/11/18 at 1:33 pm, Social Worker #4 reported the resident's family is always called, however she was not aware that they had to send written notification to them and the Ombudsman when a resident is sent to the hospital. During an interview on 04/11/18 at 1:45 pm, the facility Administrator reported she was not aware that the resident's family had to be notified in writing. Resident #54 Resident # 54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident could understand, be understood, and had intact cognitive skills. Nursing Progress Notes documented the resident was sent to the hospital and admitted on [DATE]. There was no documentation that written notification was sent to the resident, resident's representative, or Ombudsman regarding the hospital admission. During an interview on 4/12/18 at 11:00 am, Registered Nurse Manager (RNM) #3 reported she was not aware that written notification had to be sent. She stated the social worker would be responsible for sending letters. During an interview on 04/11/18 at 1:33 pm, Social Worker #4 reported the resident's family is always called, however she was not aware that they had to send written notification to them and the Ombudsman when a resident is sent to the hospital. During an interview on 04/11/18 at 1:45 pm, the facility Administrator reported she was not aware that the resident's family had to be notified in writing. Resident #423 This resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per MDS dated [DATE], the resident had long and short term memory impairment, was able to understand others and was able to be understood. Nurse practitioner note dated 4/3/17, documented the resident was admitted to hospital on [DATE] and returned to the nursing home on 3/27/18. The resident was diagnosed with [REDACTED]. During an interview on 04/10/18 at 3:12 pm, Social Worker #12 stated the letter of discharge to the resident's family was not done for this resident but would find out who is responsible to notify resident families. 10NYCRR415.3 (h)(1)(iii)(a-c)

Plan of Correction: ApprovedMay 11, 2018

Notice Requirement Before Transfer/Discharge.
Element I
Corrective action for affected resident.
Letters were sent to survey sample residents and their representatives explaining the oversight of not sending transfers letters at the time of the resident's hospitalization .

A list of hospital transfers for the month of (MONTH) was e-mailed to the NYS Long Term Care Ombudsman servicing the facility.
Date of Completion: 5/10/18
Element II
Identify other residents.
When a resident is being transferred to the hospital, in addition to the resident and his/her representative being notified of the transfer verbally by licensed nursing staff, a transfer notification letter will be mailed to the resident's representative and the forwarding of the hospital notification to the resident and resident representative will be documented in resident's medical record.
Element III
Systemic Change.
A policy and procedure for Resident Notice of Transfer to Hospital was developed. All licensed, Admission staff and Social Workers will be in-serviced on this policy.
A log of hospital transfers will be maintained documenting the dates that a notification of transfer letter was given the resident and mailed to the resident representative and a date that a monthly list of hospital transfers was sent to the Ombudsman.
Element IV
Quality Assurance.
Weekly, 100% of all hospital transfers will be audited to confirm that a notification of hospital transfer letter was given to the resident and sent to the resident's representative. The audit completed the last week of each month will confirm list of hospital transfers was sent to the Ombudsman.
The results of the audit will be reported to the Quality Assurance Committee for a period of two quarters and thereafter at a frequency to be determined by the members of the committee.
Responsible Individual:
Director of Social Services
Director of Admissions


FF11 483.12(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during a recertification and abbreviated survey (Case # NY 716) the facility did not ensure that injuries of unknown source was immediately reported to the State Agency, for one resident (Resident #180) of five residents reviewed for abuse, neglect, and mistreatment. Specifically, for Resident #180, the facility did not report alleged violations (injuries of unknown source) discovered on 11/12/17 and 11/15/17, to the Department of Health. The resident complained of right sided pain and swelling noted in the right [MEDICATION NAME] region on 11/12/17 and on 11/15/17 the facility's Accident Report Form documented the resident had fractures of the right 8th and 9th ribs. This is evidenced by: Definitions Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Injuries of unknown source - An injury should be classified as an injury of unknown source when both of the following criteria are met: o The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and o The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Resident #180: The resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 2/28/2018, documented the resident was understood, could sometimes understand and had severely impaired cognition for decision making. A facility Nurse's Progress Note dated 11/12/17 at 8:40 pm, written by the Registered Nurse (RN) supervisor, documented that the writer was called to the resident's room, as the resident's family reported that the resident was screaming in pain when his right side was pressed. The right [MEDICATION NAME] area was swollen and the resident was grimacing in pain. STAT x-ray showed a right sided pneumothorax and the resident was sent to the hospital. A facility Nurse's Progress Note dated 11/12/17 at 9:39 pm,written by the Licenced Practical Nurse (LPN) documented the resident's daughter stated he wasn't feeling well and complaining of right sided pain. The physician ordered STAT (immediately) chest x-ray. The Hospital Emergency Department (ED) records dated 11/12/17, documented that staff at the nursing home reported the resident complained of right-sided chest and rib pain. A chest X-ray done at nursing facility demonstrated a right-sided pneumothorax. According to staff it is unknown whether or not the patient fell . Of concern the patient is on Eliquis for stroke due to [MEDICAL CONDITION]. Result of a Cat Scan on 11/12/17 documented a large right pneumothorax and [MEDICAL CONDITION] 8th and 9th rib. The Accident Report Form dated 11/15/17, documented Resident #180 was observed scooting on the floor of his room on 11/11/17 at 10:24 am. The suspected fall was unwitnessed. The resident complained of right sided discomfort on 11/12/17, and swelling on the right [MEDICATION NAME] area with an oxygen saturation of 86% on room air. The physician was notified and a chest X-ray was ordered. The x-ray results noted a right-side pneumothorax. This form also documented that per the hospital the resident had right 8th and 9th rib fractures. Review of the facility's submissions to the Stat Department of Health, did not include submission for the injuries of unknown origin. During an interview on at 4/11/18 at 1:45 pm, the Administrator stated that the LPN who found the resident on the floor, should have reported it immediately. During an interview on 4/11/18 at 3:43 pm, LPN #7 stated she saw the resident on the floor in his room on 11/11/2017 at approximately 10:37 am. LPN #7 stated she should have called the supervisor and waited until someone was with the resident. She did not because it was not her side of the unit. During an interview on 04/12/18 at 10:15 am, LPN #8 stated that on 4/11/18, she was walking down the hall when a Certified Nursing Assistant (CNA) told her the resident was on the floor. LPN #8 went to the resident's room, and saw that the resident was up, walking around and seemed fine. LPN #8 stated she did not notify anyone or follow up with CNA #5 or LPN #7, and did not report it to the next shift because she did not think the resident actually fell . LPN #8 stated that the protocol was to call the supervisor and that she should have called. During an interview on 4/12/18 at 11:15 am, the RNUM (Registered Nurse Unit Manager) stated she was not on duty on 11/11/17 but the LPN should have called the supervisor when the resident was found on the floor on 11/11/17. The RNUM gave the investigation to the DON and thought the DON would follow up with the NYSDOH. During a phone interview on 4/12/18 at 12:35 pm, CNA #5, stated LPN #7 found the resident on the floor in his room and called her. She stated the bottom half of the door to the resident's room was closed, and the resident was on the floor. She stated she called to LPN # 8 to alert her the resident was on the floor and left the area. She didn't know if anyone had reported the incident to the supervisor. 10 NYCRR 415.4(b)(2)

Plan of Correction: ApprovedJune 1, 2018

Reporting of Alleged Violation Resident #180
Element I
Corrective Action for Affected Resident

The x-ray results for resident # 180 noted a right-side pneumothorax. This form also documented that per the hospital the resident had right 8th and 9th rib fractures. The Incident/Accident report dated 11/15/2017 will be submitted to the State Department of Health due to Injuries of unknown source.
Element II
Identify Other Residents
All incident/accident reports completed over the past 30 days will be reviewed for any injury of unknown source to assure that other residents were not potentially affected by this deficient practice.
Any/all reportable incidents as defined by CMS guidelines will be reported immediately to the State Department of Health.
Element III
Systemic Changes
Incident/Accident, Reporting, Identification and Investigation policy reviewed and revised.House wide re-education of all employees to assure individuals roles.
House wide review of progress notes of change in condition and incidents will be conducted by each floor Nurse Manager daily and on the first working day following weekends and holidays. The results will be reported at Interdisciplinary morning meeting to assure that all reportable incidents are submitted to the State Department of Health.
If it is determined that an incident is of a suspicious nature or a resulted in serious injury the Administrator/DON or the designee will be contacted immediately so that all appropriate agencies are contacted in a timely manner.
Element IV
Quality Assurance
These corrective actions will be monitored through:
Each incident will be audited by the Director of Nursing
weekly to ensure compliance.
Results of the audits will be reported to the Quality Assurance Committee monthly x2 and thereafter at the frequency determined by the Quality Assurance Committee.
Responsible Individual:
Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not protect cooking facilities in in accordance with the adopted regulations. NFPA 17A Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2009 Edition section 7.2 requires that a monthly Owner's Inspection of the fire suppression system (system) be conducted which includes, but is not limited to, an inspection of the suppressant pressure gauge (gauge) to ensure it is in the operable range. Specifically, 13 of 13 kitchen fire suppression monthly Owner's Inspections did not include an inspection of the gauges and 5 systems were not in the operable range. This is evidenced as follows. The kitchen fire suppression systems' gauges were inspected on 04/12/2018 at 9:30 am. The indicating needles in the gauges servicing the systems on the Carmel Gardens East unit, Carmel Gardens West unit, Mount Carmel West unit, Fifth Floor A unit, and Sixth Floor B unit pointed right of green-operable range into the red area indicating a pressure more than slightly and greater than the operable range. Maintenance Technician #1 stated in an interview conducted on 04/12/2018 at 9:30 am that he is responsible for conducting monthly inspections of all kitchen fire suppression systems and that this inspection did not include checking the pressure gauges. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.2.5.5, 9.2.3; 2011 NFPA 96 10.2.6; 2009 NFPA 17A 7.2; 10 NYCRR 415.29, 711.2(a)(1) and (25); 2000 NFPA 101 19.3.2.6, 9.2.3; 1998 NFPA 96 1-3.1

Plan of Correction: ApprovedMay 11, 2018

Element I
Corrective Action for Affected Residents
The five cylinders found out of range were replaced with new cylinders on 4/30/18. The gauges showed pressure in the green zone.
Element II
Identify Other Residents
Maintenance will inspect the fire suppression hoods on a monthly basis as per NFPA 17A Section 7.2 and an inspection tag will be kept on each unit.
Element III
Systemic Changes
The policy will be amended to include monthly inspections.
Element IV
Quality Assurance
The Director of Environmental Services or designee will do monthly audits after each inspection to assure inspections are carried out as written. The results of the audits will also be reported to Quality Assurance.
Responsible Individual:

Director of Environmental Services

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

Based on observation and employee interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 70 National Electrical Code 2011 Edition Articles 400.8, 400.7, and 368.56(B) require that relocatable power taps (power strips) be secured to the wall when used to energize appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, such as for communications equipment. Specifically, power strips were dangling and not secured. This is evidenced as follows. Observations on 04/11/2018 at 9:15 am revealed power strips being used to power electronics were dangling loosely mid-air in the Physical Therapy room, Tea Lounge resident area,(NAME)Parlor resident area, and the Office room on the fifth floor. The Director of Environmental Services stated in an interview conducted on 04/11/2018 at 11:40 am that he did not know dangling power strips were not to code. 42 CFR 483.70 (a) (1); 2011 NFPA 70 400.8, 400.7, 368.56(B); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 70

Plan of Correction: ApprovedMay 14, 2018

Element I
Corrective Action for Affected Residents
All dangling power cords were attached to the wall.
Element II
Identify Other Residents
Maintenance performed a facility wide check to make sure no other deficient power cord issues were noted.
Element III
Systemic Changes
All power strips will be attached to the wall. Facility wide staff training will be done on electrical safety. The policy on power cords will be revised to include dangling power cord hazards.
Element IV
Quality Assurance
Daily audits will be performed on ten random rooms until we reach full compliance and then audits will be performed monthly.
Responsible Individual:

Director of Environmental Services

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee interview and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that facilities maintain PCREE with consideration of the owner's manual. Specifically, one of 3 PCREE observed was not maintained as prescribed in the owner's manual. This is evidenced as follows. Observation on 04/12/2018 at 1:50 of the electric inhalation-treatment nebulizer # assigned to the resident in room [ROOM NUMBER] revealed that the unit was not in use and was plugged into an electrical outlet. The resident was in their room. Registered Nurse #4 stated in an interview conducted on 04/12/2018 at 1:50 pm that the nebulizers are not unplugged after use. Review of the owner's manual for nebulizer # on 04/11/2018 revealed that on page 3 of the manual, to reduce the risk for electrocution, the unit is to be unplugged immediately after use. The facility maintenance policies for PCREE were reviewed on 04/11/2018. This policy states that the preventative maintenance for PCREE will be consistent with the manufacturer recommendations. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedMay 15, 2018

Element I
Corrective Action for Affected Residents
The nebulizers were unplugged. The unit staff was educated regarding unplugging nebulizers when not in use.
Element II
Identify Other Residents
All nursing staff will be educated on following the owner's manual recommendations for all patient care electrical equipment.
Element III
Systemic Changes
All patient care electrical equipment policies will be reviewed and revised to correspond with the owner's manual recommendations of proper usage and preventive maintenance.
All nursing staff will be educated on following the owner's manual recommendations for all patient care electrical equipment.
Element IV
Quality Assurance
The Nurse Manager or designee will perform audits on all patient care electrical equipment to ensure safe use as per the owner's service and maintenance manuals. Audits will be done weekly until there is 100% compliance for four consecutive weeks then audits will be done monthly.
Responsible Individual:
Director of Nursing
Director of Environmental Services

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

Based on observation, interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the communication plan of the Emergency Plan did not include sharing emergency preparedness policies and procedures with residents and their families or representatives. This is evidenced as follows. A review of the Emergency Plan on 04/06/2018 revealed the communication plan did not include sharing relevant portions of the emergency preparedness plans and policies with family members and resident representatives. The Administrator, Director of Environmental Services, and Director of Risk Management stated in an interview conducted on 04/06/2018 at 1:00 pm that the Emergency Plan has not been communicated to all residents, their families, or their representatives. 42 CFR: 483.73(c)(8)

Plan of Correction: ApprovedMay 11, 2018

Element I
Corrective Action for Affected Residents
A brochure has been created to inform residents and resident representatives about our emergency preparedness plan.
Element II
Identify Other Residents
All residents have the potential to be affected therefore there will be a systemic change.
Element III
Systemic Changes
Brochures will be given to all residents that are able to receive and understand them. Brochures will be handed to or mailed to all current resident representatives. We will also be handing out brochures as part of the admission packet when residents are admitted to the facility. We will also post the information on our facility website.
The Admission Packet policy will be revised to include the emergency preparedness brochure.
Element IV
Quality Assurance
An audit will be created to assure that all newly admitted residents or their representatives receive the emergency preparedness brochure. The audit will be done by the Director of Admissions or designee on a weekly basis until there is 100% compliance for four consecutive weeks and then on a monthly basis.
Responsible Individual:
Director of Admissions
Director of Risk Management

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan policies and procedures (P&Ps) did not include the role of non-medical volunteers and the use of medical volunteers, such as State and Federal health care professional to address surge needs, in an emergency. This is evidenced as follows. A review of the Emergency Plan on 04/06/2018 revealed the P&Ps did not include the use of medical volunteers, such as for an influx of patients or residents, and the roll of non-medical volunteers in an emergency. The Administrator, Director of Environmental Services, and Director of Risk Management stated in an interview conducted on 04/06/2018 at 1:00 pm that the Emergency Plan will be revised to include the use of medical volunteers and specify the roll of non-medical volunteers. 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedMay 11, 2018

Element I
Corrective Action for Affected Residents
The emergency preparedness manual has been revised to state that the Labor Pool Coordinator will check the credentials of arriving volunteers and assign clinical roles to medical volunteers and non-clinical roles to non-medical volunteers.
Element II
Identify Other Residents
All residents have the potential to be affected so therefore there will be a systemic change.
Element III
Systemic Changes
The Labor Pool Coordinator will check credentials of volunteers and assign roles as medical and non-medical. The policy on the use of volunteers in an emergency or other emergency staffing will be revised to state that the Labor Pool Coordinator will check the credentials of the arriving volunteers and assign clinical roles to medical volunteers and non-clinical roles to non-medical volunteers.
Element IV
Quality Assurance
The emergency preparedness manual will be reviewed and updated at least annually by the Director of Risk Management and the Director of Environmental Services.
Responsible Individual:
Director of Risk Management
Director of Enviromental Services

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

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 for the care and treatment of [REDACTED]. This is evidenced as follows. A review of the Emergency Plan on 04/06/2018 revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Administrator, Director of Environmental Services, and Director of Risk Management stated in an interview conducted on 04/06/2018 at 1:00 pm that the Emergency Plan does not currently have but will be revised to include provisions for care at alternate site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedMay 11, 2018

Element I
Corrective Action for Affected Residents
A policy will be implemented to describe the facility's role in providing care at alternate care sites during emergencies. The policy will include collaboration with local emergency officials for proactive planning to allow an organized and systemic response to assure continuity of care.
Element II
Identify Other Residents

All residents have the potential to be affected therefore there will be a systemic change.
Element III
Systemic Changes
The emergency preparedness manual will be reviewed and updated at least annually by the Director of Risk Management and the Director of Environmental Services to ensure compliance with E026. Key personnel will also be educated on the requirements of E026.
Element IV
Quality Assurance
The emergency preparedness manual will be reviewed and updated at least annually by the Director of Risk Management and the Director of Environmental Services to ensure compliance with E026.
Responsible Individual:
Director of Risk Management
Director of Enviromental Services

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed and maintained in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.6.4.1.1.1 states that the distance between the deflector of a pendent sprinkler head and the ceiling shall be a minimum of 1 inch (25.4 mm) and a maximum of 12 inches (305 mm) throughout the area of coverage of the sprinkler. Section 8.6.5.1.2 permits certain limitations on obstructions to the sprinkler system discharge pattern. Specifically, the deflectors of several pendent sprinkler heads were less than 1 inch from the ceiling and the parts of the system were encumbered unacceptable obstructions. This is evidenced as follows. Observations of the sprinkler system 04/11/2018 at 9:15 am revealed the deflectors of nine (9) sprinkler heads on the second floor of the high-rise building were closer than 1-inch from the ceiling, and light fixtures obstructed the spray area in(NAME)Lounge closet; Ladies Locker Room (3 sprinkler heads); resident room [ROOM NUMBER]; trash room (2 sprinkler heads), and the medical waste room. The Director of Environmental Services stated in an interview on 04/11/2018 at 11:40 am that he was not aware of the 1-inch requirement. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 9.7.5; 2010 NFPA 13: 8.6.4.1.1.1, 8.6.5.1.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101: 9.7.5; 1999 NFPA 13: 5-5.6

Plan of Correction: ApprovedMay 11, 2018

Element I
Corrective Action for Affected Residents
The sprinkler heads found to be closer than one inch from the ceiling and the ceiling lights obstructing the sprinkler heads were repaired on 4/13/18.
Element II
Identify Other Residents
A facility wide audit was carried out to assure that thee were no obstruction issues in other areas. A quarterly audit will be performed to make sure we have no other sprinkler obstructions.
Element III
Systemic Changes
A policy will be written to include NFPA 13 standard Section 8.6.5.1.2 to check that measurements from the ceiling to the sprinkler head are a minimum of one inch and any obstruction, if closer than twelve inches, must be even or above the sprinkler head height. All other obstruction measurements will be referenced to NFPA 13 chapter for calculations for obstructions.
Element IV
Quality Assurance
The Director of Environmental Services or designee will do quarterly audits to assure compliance. The results of the audits will be reported on a Quality Assurance report.
Responsible Individual:

Director of Environmental Services

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: April 16, 2018
Corrected date: June 8, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust. Specifically, sprinkler heads were found with a coating of dust. This is evidenced as follows. Observations of the sprinkler system on 04/11/2018 at 9:15 am revealed three sprinkler heads in the main kitchen, 4 sprinkler heads in the ladies' locker room, and 2 sprinkler heads in the Carmel Gardens elevator foyer were found with a coating of dust. The Director of Environmental Services stated in an interview conducted on 04/11/2018 at 11:40 am that he is about 3 months behind on cleaning sprinkler heads. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.5; 1998 NFPA 25 2-2.1.1, 2-4.1.8

Plan of Correction: ApprovedMay 14, 2018

Element I
Identify Affected Residents
The dusty sprinkler heads were cleaned on 4/12/18.
Element II
Identify Other Residents
Maintenance carried out a facility wide inspection to make sure that we had no other dusty sprinkler heads.
Element III
Systemic Changes
A policy will be written to include cleaning of sprinkler heads. Maintenance will clean all sprinkler heads monthly for the first six months and it will be recorded in a maintenance log. After the first six months, frequency of cleaning will be determined by the audit results.
Element IV
Quality Assurance
The Director of Environmental Services or designee will do monthly audits to assure compliance.
Responsible Individual:

Director of Environmental Services

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

REGULATION: Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 16, 2018
Corrected date: June 8, 2018

Citation Details

Based on observation and staff interview during the recertification, the facility did not maintain electrical wiring and equipment in accordance with the adopted regulations. NFPA 70 National Electrical Code 2011 edition Article 210.8 requires that Ground Fault Circuit Interrupter protection (GFCI) be provided on electrical outlets within six-feet of a sink rim or water source. Specifically, electrical outlet GFCI protection was not provided near water fountains and aquariums. This is evidenced as follows. Observations of the water fountains and aquariums on 04/11/2018 at 9:15 am revealed that the electrical outlets directly below the fountains on the Second Floor units, Third Floor unit, Fourth Floor unit, Fifth Floor unit, and Sixth Floor unit and the aquariums in the Saratoga Room and Tea Room did not have GFCI protection. The Director of Environmental Services stated in an interview conducted on 04/11/2018 at 11:40 am that he will install GFCI outlets in the areas found. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.2; 2011 NFPA 70 Article 210.8; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 70 Article 210.8

Plan of Correction: ApprovedMay 11, 2018

Element I
Corrective Action for Affected Residents
GFCI were installed by each water source outlined in the deficiency on 4/16/18 and 4/17/18
Element II
Identify Other Residents
A facility wide inspection was carried out and no other areas of concern were identified.
Element III
Systemic Changes
We will add to our monthly compliance inspection and our daily preventive room maintenance inspection to include that GFCI are present near all water sources if there is an outlet within six feet.
Element IV
Quality Assurance
The Director of Environmental Services or designee will do monthly audits to monitor for compliance and will report on a quarterly basis to Quality Assurance.
Responsible Individual:

Director of Environmental Services