Luxor Nursing and Rehabilitation at Mills Pond
June 21, 2016 Certification Survey

Standard Health Citations

FF09 483.15(h)(3):CLEAN BED/BATH LINENS IN GOOD CONDITION

REGULATION: The facility must provide clean bed and bath linens that are in good condition.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2016
Corrected date: August 19, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on residents, Ombudsperson and staff interviews during a Recertification survey, the facility did not ensure provision of clean bed and bath linens that are in good condition. Specifically, facility did not address long standing frequent shortage of linen supplies including towels, sheets, pillow cases and night gowns. This was noted from interviews with one Resident (#113) out of a total of 12 census resident interviews conducted, the Resident Council President (#48), the Ombudsperson and review of the monthly Resident Council minutes from February, (MONTH) and (MONTH) (YEAR). The finding is: A) Resident #48 is the Resident Council President. The Resident Council President's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The Resident Council President was interviewed on 6/16/16 at 11:10 AM and stated that residents have been complaining about shortage of sheets, towels, pillow cases and night gowns in the Resident Council meetings on and off through the year. She stated that many times when there is shortage of night gowns, people have had to sleep in the same clothes that they wore all day. She stated that bed linens are supposed to be changed every Monday, and some times pillows are without cases for 2-3 days and beds might be without a sheet for a whole day until supplies are available. She stated that the Administrator has informed the Resident Council that he is trying his best. B) The Facility Ombudsperson was interviewed on 6/16/16 at 10:15 AM. She stated that the residents have been complaining in the Resident Council for the past year about shortage of towels, sheets and gowns to wear. She stated that some residents do not get showers because towels are not available. C) Resident #113's MDS dated [DATE] documented a BIMS score of 15 indicating intact cognition. Resident #113 was interviewed on 6/15/16 at 11:00 AM and stated that she is unhappy because the staff often run out of sheets, blankets, towels and night gowns. Monthly Resident Council meeting minutes were reviewed from (MONTH) to (MONTH) (YEAR). The following was documented regarding linen supplies shortage including, sheets, pillow cases, night gowns and towels: - (MONTH) (YEAR) meeting, documented,Administrator has placed an order for [REDACTED]. - (MONTH) (YEAR) meeting documented, Administrator informed the residents that if they need additional towels, sheets or night gowns ask a staff member for assistance because they are available. - (MONTH) (YEAR) meeting documented, Administrator has ordered additional pillow cases, towels and sheets. The Administrator was interviewed on 06/16/2016 at 1:25 PM and stated that the facility always has 3 days emergency supplies of linen (sheets, pillow cases, night gowns and towels). He stated that the outside vendor for Laundry service has its ups and downs in terms of short delivery. The Administrator stated sometimes 1000 items may have been sent out and only 800 might be returned and the difference has to be made up from back up supplies. The Administrator also stated that he knew there was a linen shortage problem so he had placed a large purchase order 2 months ago. The Administrator added that corrections have been made to Laundry service issues and there are very few complaints in the Resident Council for the last couple of months. The Environmental Director was interviewed on 6/16/16 at 2:00 PM. He stated that he over sees the Laundry Service. He stated that, we do have issues here and there regarding inadequate linen numbers. I have never heard of any major issues. He stated that the porters deliver linen to the units. He stated that the Laundry delivers linen daily, sometimes it more and at other times it is less. He delivers what is available and then if he gets paged for more, he goes to the back up storage and delivers. He stated he was not aware of any par levels to be delivered to the specific units. He stated he thought that the Certified Nurses Assistants (CNA's) hoarded the linen away in their assigned Resident rooms and other CNA's were unable to find them. A 7:00 AM -3:00 PM Porter 1 was interviewed on 06/16/2016 at 1:47 PM and stated he delivers supplies to the unit twice a day and is not aware of any shortage. A 7:00 AM - 3 PM Porter 2 was interviewed on 06/16/2016 at 1:48 PM and stated that they distribute the supplies that they have received from Laundry and if the units call in a shortage they retrieve from storage and supply. He was not sure if Par levels of supplies were required to be delivered for every shift. A 7:00 AM to 3:00 PM shift CNA was interviewed on 06/17/2016 at 11:22 AM and stated that at times the linen has not been delivered to the units at the start of her shift and the wait is sometimes 10 minutes to 30 minutes. She stated that if there are additional shortages, she tell the Nurses, who call for supplies. 415.5(h)(3)

Plan of Correction: ApprovedJuly 20, 2016

I.Immediate Corrective Action
The Maintenance Director and Administrator immediately inspected the facility and developed an action plan to address the clean bed and bath linen issue. Additional linen supply was ordered and delivered to Mills Pond Nursing and Rehabilitation Center.
II.Identification of Other Residents
The facility respectfully acknowledged that all residents could be potentially affected by the deficiency. The facility promotes environment in which bed/bath lines are in good condition and always available and accessible for all residents at all times.
III.Systematic Changes
1)Facility policy was reviewed and found to be in compliance.
2)Additional linen supply was ordered.
3)All linen deliveries will be monitored for sufficient supply.
4)Linen deliveries will be inspected to ensure linens are in good condition.
5)Facility will replace and purchase additional linens as needed.
6)Weekly reconciliation of linen supply levels will be audited to ensure PAR levels are maintained throughout facility.
7)Adequate linen will be maintained and supplied to all residents in a sanitary condition.
IV.QA Monitoring
1)The Director of Maintenance developed an audit tool to conduct routine linen cart monitoring to ensure adequate supply is on all units. This audit will be conducted weekly.
2)The audit findings will be filed for reference and validation.
3)Audits with negative findings will have on site corrective actions implemented by the auditor immediately.
4)Audit findings will be presented to the Quality Assurance Committee quarterly for evaluation and follow-up as indicated.
Responsible Party: Director of Maintenance

FF09 483.20(b)(2)(iii):COMPREHENSIVE ASSESS AT LEAST EVERY 12 MONTHS

REGULATION: A facility must conduct a comprehensive assessment of a resident not less than once every 12 months.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2016
Corrected date: August 19, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that comprehensive assessments of a resident were completed not less than once every 12 months. This was evident for 1 of 2 Stage 2 residents reviewed for Participation in Care Planning in a total sample of 28. Specifically, the Annual Minimum Data Sets (MDS) Assessment for Resident #204 was not completed timely. The finding is: Resident #204 has [DIAGNOSES REDACTED]. An Annual MDS was completed on 6/2/15. Quarterly MDSs were completed on 7/29/15, 10/29/15, 1/29/16 and 4/29/16. There was no documented evidence that an Annual MDS was completed within 12 months, as required. The Registered Nurse (RN) MDS Coordinator was interviewed on 6/20/16 at 11:44 AM and stated there was an error. Four quarterly MDSs were completed, without the completion of an annual MDS assessment. 415.11(a)(3)(iii)

Plan of Correction: ApprovedJuly 20, 2016

I.Immediate Corrective Action
The resident #204?s chart was reviewed and an Annual MDS assessment was created and completed with the ARD of 6/20/16.
The Director of Nursing provided re-education counseling to the MDS Coordinator regarding the importance of accurate and timely scheduling of Comprehensive MDS Assessments.
II.Identification of Other Residents
The Director of Nursing and MDS Coordinator reviewed all residents? MDS to verify if any other Annual MDS assessments were missed within a 12 month span. Missing Entries MDS assessment reports were evaluated and all other residents found in compliance.
III.Systematic Changes
a.The MDS Coordinator will ensure that all MDS Assessments that are scheduled are consistent with the type of assessment recorded on the MDS tracker.
b.The MDS scheduling process will be reviewed with the MDS staff and the use of the MDS tracker.
c.The Missing Entries MDS Assessment will be generated weekly to ensure a comprehensive MDS was completed on all residents within a 12 month time frame.
IV.QA Monitoring
a.The MDS Coordinator will run the Missing Entries assessments reports weekly to verify that all if there were any Comprehensive MDS assessments that were missed. Tracking of weekly reports will be kept in a binder for reference.
b.MDS audits with negative findings will have immediate corrections implemented by the MDS Coordinator.
c.MDS Audits will be presented to the Quality Assurance Committee quarterly for evaluation and follow up as needed.
Responsible Discipline: MDS Coordinator

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2016
Corrected date: August 19, 2016

Citation Details

Based on observation and staff interviews during the recertification survey, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior were provided. Specifically, during the initial tour of the general environment on 2 of 7 Nursing Units (3 North and 3 South), individual room observations and Environmental Facility Rounds, there were multiple housekeeping and maintenance issues observed, including uneven cracked floor tiles, and walls and furniture in disrepair. The findings are: During the Initial tour of the facility on 6/15/16 during the hours of 8:30 AM and 10:00 AM, and throughout the survey process from 6/15/16 through 6/21/16 the following observations were made: 3 South Unit: Room 302- wall in disrepair, cove molding in disrepair adjacent to bathroom and behind bathroom door. Room 311- chipped 3 drawer nightstand, wall and cove molding near closet in disrepair and floor tiles cracked adjacent to bathroom door. Room 317- floor tiles cracked adjacent to bathroom door. Room 321- floor tiles cracked at entrance to bathroom and encrusted with glue-like gray substance and tiles are uneven. Room 387- frame of overbed table is rusted and 6 drawer dresser is chipped. 3 North Unit: Room 336- wooden frame of padded chair has scuffed varnish, chair seat padding is ripped, bedside table is chipped and overbed table has dirty rusted frame. Room 338- scuffed, detached wallpaper on walls near window, and wall is bubbled. Cove molding on wall under window is in disrepair. The Director of Environmental Services was interviewed on 6/21/16 at 12:40 PM and stated that he was aware of the needed repairs on the 3rd Floor Nursing Units, as rounds are made every week. The Director further stated that the areas brought to his attention will be repaired and a complete renovation of the 3rd Floor is planned to include removal of all wallpaper, spackle and painting of walls and replacement of all floor tiles. The Administrator was interviewed on 6/21/16 at 12:45 PM and stated that some furniture has already been ordered and a proposal was received for the work to be done on the 3rd Floor, but was unable to provide a date for the work to begin. 415.5(h)(2)

Plan of Correction: ApprovedJuly 20, 2016

I.Immediate Corrective Action
The Maintenance Director and Administrator immediately inspected the facility and addressed the following items:
a.Room 302- Wall repaired and cove molding adjacent to bathroom and behind bathroom door replaced.
b.Room 311 - Chipped 3 drawer nightstand replaced, wall and cove molding near closet replaced and floor tiles adjacent to bathroom door replaced.
c.Room 317 - Floor tiles adjacent to bathroom door replaced.
d.Room 321 - Floor tiles at entrance replaced.
e.Room 387 ? Overbed table and 6 drawer dresser replaced.
f.Room 336 - padded chair and bedside table removed and replaced.
g.Room 338 ? Wall was repaired and wallpaper was reattached. Cove molding on wall under window was replaced.
II.Identification of Other Residents
The facility respectfully acknowledged that all residents could be potentially affected by the deficiency. The facility promotes a clean and well maintained environment for all residents at all times.
III.Systematic Changes
1)The Director of Maintenance developed an audit tool to inspect the facility for repairs, all identified repairs or soiled areas will be addressed immediately. Facility will replace and purchase new furniture as needed.

IV.QA Monitoring
1)The Director of Maintenance developed an audit tool to inspect the facility for repairs, all identified repairs or soiled areas will be addressed immediately. The Audit will be conducted weekly for the first month then monthly thereafter.
2)The audit findings will be filed for reference and validation.
3)Audits with negative findings will have on site corrective actions implemented by the auditor.
4)Audit findings will be presented to the Quality Assurance Committee quarterly for evaluation and follow-up as indicated.
Responsible Party: Director of Maintenance

FF09 483.75(j)(2)(ii):PROMPTLY NOTIFY PHYSICIAN OF LAB RESULTS

REGULATION: The facility must promptly notify the attending physician of the findings.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2016
Corrected date: August 19, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, the facility did not provide timely notification of abnormal laboratory results to the Physician. The was evident for one of three residents reviewed for Nutrition in a total Stage 2 sample of 28 residents. Specifically, Resident # 35 had laboratory results with abnormal findings for Red Blood Cells (RBC), Hemoglobin (HGB) and Hematocrit (HCT) which were not called into the Physician for immediate review. The finding is: Resident # 35 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident has a Brief Interview for Mental Status (BIMS) Score of 14, indicating that the resident is cognitively intact. The MDS documented that the resident requires staff assistance in all activities of daily living. Laboratory results for a Complete Blood Count (CBC) dated 6/11/16 documented that the resident's RBC was 3.53 (Normal (N) 4.20-5.40) indicated as a low critical value, HGB 8.6 (N 12.0-16.0) indicated as a very low critical value and HCT of 28.7 (N 35.0-49.0) indicated as a low critical value. There was no documentation in the Electronic Medical Record (EMR) that the Physician (MD) was notified of the laboratory critical values. The Physician's Assistant (PA) was interviewed on 6/20/2016 at 1:18 PM. The PA stated that the laboratory results should have been called to the covering PA or Physician (MD) for that weekend. The PA stated that the resident has history of fluctuating laboratory results. The PA also stated that the results were not an issue which would have required any intervention at that time. In addition, the PA stated that the resident has weekly CBCs and is monitored closely. The MD was interviewed on 6/21/16 at 11:00 AM. The MD stated that there would have been no interventions for this resident's abnormal laboratory results related to the resident's medical history, however, the covering MD or PA would normally have been notified. An interview with a laboratory staff member was completed on 6/21/16 at 10:00 AM. The staff member stated that the critical values were called into the Nursing Supervision on 6/11/16 at 7:07 PM and faxed to the facility at the same time. There was no documentation in the medical record that the critical laboratory values were received by the facility. 415.20

Plan of Correction: ApprovedJuly 20, 2016

I. Immediate Corrective Action
The Director of Nursing conducted an investigation relative to this deficiency. Based on the investigation findings, the following corrective actions were implemented
1.The Director of Nursing reviewed the lab results for resident #35 on 6/21 with the attending physician and there were no changes in the resident?s care plan.
2.The RN Supervisor who received the critical lab results was immediately in serviced and received an educational counseling for not following the facility?s policy on Physician Notification of Lab results.
II.Identification of Other Residents
The facility completed a full house audit of all residents who received orders for blood work over the past three months to ensure all results were reviewed with the attending physician. No other residents were affected by this deficiency.

III.Systematic Changes
1.The Director of Nursing reviewed the facility?s policy on Physician Notification of Lab Results and noted it to be compliant.
2.All licensed nurses will be re-inserviced on physician notification of all lab results.
3.A copy of the lesson plan and attendance will be filed for reference and validation.
IV.QA Monitoring
1.The Director of Nursing developed an audit tool to track compliance and validate physician notification of all lab results.
2.This audit will be completed on 10% of the residents having blood work weekly for the first month, monthly for the first quarter and then quarterly thereafter.
3.Audits with negative findings will have on site corrective actions implemented by the auditor.
Person Responsible: Director of Nursing

FF09 483.20(d)(3), 483.10(k)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: June 21, 2016
Corrected date: August 19, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and family and staff interviews during the recertification survey, the facility did not ensure that comprehensive care plans (CCP) were developed with the participation of the resident's family and reviewed and revised. This was evident for 1 of 2 Stage 2 residents reviewed for Participation in Care Planning in a total sample of 28. Specifically, there was no documented evidence that the family of Resident #204 was contacted to participate in the resident's annual care planning meeting. This is a repeat deficiency. The finding is: Resident #204 has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident has long and short term memory problems and is moderately impaired in cognitive skills for daily decision making. A CCP dated 10/25/12 and updated on 6/20/16 documented that the resident had impaired cognitive function/dementia or impaired thought processes related to Dementia. During a Family interview on 6/16/16 at 1:35 PM, a family member stated that he could not recall being invited to a CCP meeting in a few years. An Annual MDS was completed on 6/2/15. Under the section Q, Participation in Assessment and Goal Setting, the MDS documented that the family did not participate in the assessment. Quarterly MDSs were completed on 7/29/15, 10/29/15, 1/29/16 and 4/29/16. There was no documented evidence that an Annual MDS was completed for (YEAR). The Director of Social Services was interviewed on 6/20/16 at 11:07 AM and stated that letters are sent out to invite family members to the Annual and Significant Change care plan meetings, copies are kept in the medical record and a note is written in the Social Services Progress Notes. The Director stated that the family of Resident #204 was invited to the Annual care plan meeting, but a note was not written and a copy of the letter could not be located. The Director further stated that an Annual care plan meeting was not scheduled as of yet for (YEAR). 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedJuly 20, 2016

I. Immediate Corrective Action:
The resident (#204) chart was reviewed and the Director of Social Services contacted the Guardian/son and invited him to come in for an ad hoc care plan meeting to review his mother?s plan of care. This meeting was held on 6/21/2016. There were no outstanding concerns identified. As this resident?s son is also the Guardian he visits regularly and a Guardianship report was completed on 5/14/2015 congruent with the resident?s Annual Assessment in (YEAR).
II.Identification of Other Residents:
The Director of Social Work reviewed all residents in house for compliance with invitations to Care Plan meetings and documentation of same via letter or documented communication. All other residents were found in compliance.
III.Systemic Changes:
1.The Director of Social Work/Designee and MDS Coordinator reviewed the existing facility policy regarding Care Plan invitations and documentation and found it to be in compliance.
2.The Director of Staff Education will provide re-education regarding the care plan meeting policy and procedure and review responsibilities identified therein. A copy of the education and attendance record shall be maintained by the Staff Education Coordinator.
IV.Quality Assurance Monitoring:
1.The Director of Social Services will review invitation, attendance and documentation of all care plans meetings weekly for the first month, then monthly for the first quarter and then a 20% random sample quarterly thereafter.
2.Audits with negative findings will have on site corrective actions implemented by the auditor.
3.Audits will be presented to the Quality Assurance Committee quarterly for evaluation and follow up as indicated.
Person Responsible - Director of Social Services

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2016
Corrected date: August 19, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the recertification survey, it was determined the facility did not provide or arrange services that met professional standards of quality for 1 of 3 residents (#248) reviewed for Pressure Ulcers. Specifically, the facility did not ensure that a Braden Scale Skin Assessment (BSSA) was completed by qualified professional staff (Registered Nurse). The BSSA was completed by a Licensed Practical Nurse (LPN) and was an inaccurate assessment. The finding is: Resident #248 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had long and short term memory loss and that the resident had moderately impaired decision making. The MDS documented that the resident was always incontinent of bladder and was extensive assistance with two staff members for bed mobility. A BSSA dated 1/5/16 was incorrectly assessed under the category of moisture, mobility and sensory perception. The BSSA documented under the category moisture that the resident's skin was only occasionally moist. The BSSA also documented under the category mobility that the resident's mobility was slightly limited and under the category for sensory perception that the resident was slightly limited in the ability to respond to verbal commands. Review of the MDS in the medical record revealed that the BSSA was incorrect under the category for moisture. For mobility, the MDS revealed that the resident required extensive assistance of two staff members for bed mobility. The Certified Nursing Assistant Accountability Record (CNAAR) documented that the resident was always incontinent of urine so the resident's skin was very moist. An observation on 6/21/16 at 11:45 AM revealed that the resident was not responsive to questions and was totally dependant on the staff for mobility. An interview was held with the resident's Certified Nursing Assistant (CNA) on 6/21/16 at 10:15 AM. The CNA stated that the resident is totally incontinent of urine and dependent with all care and that the resident rarely responds to questions. An interview was held with the LPN on 6/21/16 at 11:45 AM. The LPN stated that she completed the BSSA dated 1/5/16 and could not explain how she assessed the resident to determined the answers she documented under the category for sensory perception, moisture and mobility. An interview was held with the MDS Nurse on 6/21/16 at 11:55 AM. The MDS Nurse stated that she initiates the BSSA but does not complete the form, the LPN on the unit completes it. The MDS Nurse also stated that it should be co-signed by an RN but could not explain why this assessment was not co-signed. 415.11(c)(3)(i)

Plan of Correction: ApprovedJuly 20, 2016

I.Immediate Corrective Action
The Director of Nursing conducted an investigation relative to this deficiency. The Licensed Practical Nurse completed the Braden Scale incorrectly. Based on the investigation findings, the following corrective actions were implemented:
1.A new Braden Assessment was completed by a Registered Nurse for resident #248
2.The Licensed Practical Nurse received re-education regarding the accurate completion of the Braden Scale.
3.The Interdisciplinary team met and reviewed the residents care plan. All interventions continue to be appropriate.

II.Identification of Other Residents
The facility completed a full house audit of all Braden Scales completed to ensure accurate completion and that based on the score appropriate interventions were initiated. No other residents were affected by this deficiency.
III.Systematic Changes
a.The Director of Nursing reviewed and revised the Braden Scale Assessment to include an RN co-signature.
b.The Director of Nursing/Designee will re-educate all licensed nurses regarding the revision and accurate completion of a Braden Scale.
c.A copy of the lesson plan and attendance will be filed for reference and validation.
IV.QA Monitoring
a.The Director of Nursing developed an audit tool to track compliance and validate accurate completion of the Braden Scale.
b.This audit will be completed on 10% of the residents weekly for the first month, monthly for the first quarter and then quarterly thereafter.
c.Audits with negative findings will have on site corrective actions implemented by the auditor.
Person Responsible: Director of Nursing

FF09 483.25(c):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2016
Corrected date: August 19, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey the facility did not ensure that an individualized plan of care for a resident at risk for the development of Pressure Ulcers was effective to prevent the development of two nosocomial Pressure Ulcers (P/U). This was evident for 1 of 3 residents reviewed for Pressure Ulcers out of a total Stage 2 sample of 28 residents. Specifically, Resident #248 developed 2 nosocomial unstageable Pressure Ulcers (P/U) to the right hip and right gluteal fold. The medical record lacked individualized care specific to the resident who was at risk for developing P/Us and that interventions that were in place were not provided. The finding is: Resident #248 has [DIAGNOSES REDACTED]. A Braden Scale Score Assessment (BSSA) dated 1/5/16 was not correctly assessed under the category of moisture, mobility and sensory perception. The BSSA documented under the category moisture that the resident's skin was only occasionally moist. The BSSA also documented under the category mobility that the resident's mobility was slightly limited and under the category for sensory perception that the resident was slightly limited in the ability to respond to verbal commands. This resulted in a score of 11 which was low risk pressure ulcer development. The correct assessment would have assessed the resident as high risk. A Comprehensive Care Plan (CCP) dated 2/19/16 titled potential/actual impairment to skin integrity due to impaired mobility documented interventions as follows: Bilateral heel booties at all times, encourage good nutrition, keep skin clean and dry. A Treatment Administration Record (TAR) dated (MONTH) (YEAR) and (MONTH) 1 to 23, (YEAR) had no documented evidence that a Nurse completed the skin checks on the resident's shower days. A Wound Care Note dated 2/23/16 documented that the Registered Nurse (RN)/Wound Care Nurse was asked to assess Resident #248. The RN documented that the resident was assessed to have two nosocomial unstagable P/Us. The RN documented that there was one unstagable P/U to the right hip that measured 6.5 centimeters (cm) by 6 cm and that it was 100 percent darkened tissue. The RN documented that the right gluteal fold measured 3.5 cm by 3 cm and was 100 percent brown/black tissue. A Minimum Data Set (MDS) assessment dated [DATE] documented that the resident has long and short term memory loss and that the resident had moderately impaired decision making. The MDS also documented that the resident was high risk for pressure ulcers and that the resident had 2 unstagable P/Us. A Certified Nursing Assistant (CNA) Documentation Report (CNADR) dated (MONTH) 7, (YEAR),had no documented evidence that the resident was turned and positioned on the 7:00 AM to 3:00 PM shift. The CNADR dated (MONTH) 13, 14,15 and 17, (YEAR) on the 11:00 PM to 7:00 AM shift had no documented evidence that the resident was turned and positioned every 2 hours. An interview was held with the RN on 6/20/16 at 10:15 AM. The RN stated that the right hip P/U was now a Stage 4 and measured 0.5 cm by 0.5 cm by 0.5 depth. The right gluteal fold was a Stage 4 and measured 2.5 cm by 2.3 cm by 2 cm with undermining. An observation of Resident #248 was held on 6/20/16 at 12:25 PM. The observation revealed that the resident had a right hip stage 4 P/U and a right gluteal fold P/U. The right hip P/U was clean and dry, no visible drainage or signs of infection and was approximately the size of a quarter with minimal depth. The right gluteal fold P/U had minimal brown drainage, no signs of infection and was approximately the size of a nickel and had depth. An interview was held with the resident's Certified Nursing Assistant (CNA) on 6/21/16 at 10:15 AM. The CNA stated that the resident is totally dependent with all care and that the resident rarely responds to questions. The CNA also stated that the policy is that the CNAs check the residents skin every shift and that on shower days the unit nurse does the skin checks. The CNA stated she did not see any skin impairment the day before she was informed the resident had the P/Us. An interview was held with the LPN on 6/21/16 at 11:15 AM. The LPN stated that the policy of the facility is that the unit nurse checks the resident's skin on shower days. The LPN also stated that she could not explain why there was no documented evidence in the medical record that skin checks were completed by a nurse in (MONTH) (YEAR) up until (MONTH) 24, (YEAR). The LPN also stated that she could explain why the CNADR had missing documentation for the resident's turn and position schedule. An interview was held (via phone) with the Wound Care Physician on 6/21/16 at 11:33 PM. The Physician stated that she could not recall the resident and was not able to answer questions without reviewing the resident's record. The Physician stated that she was unable at this time to be available to review the records. 415.12(c)(1)

Plan of Correction: ApprovedJuly 20, 2016

I.Immediate Corrective Action
The Director of Nursing conducted an investigation relative to this deficiency. Based on the investigation findings, the following corrective actions were implemented:
1.A complete skin assessment was completed on Resident #248 revealing no new skin concerns.
2.Turning and Positioning and twice weekly skin checks were implemented for Resident #248.
3.The licensed nurse assigned to resident #248 received re-education regarding individualized care plans.
II.Identification of Other Residents
a.100% facility audit conducted on skin shower checks. All residents were found to have skin shower checks documentation in place.
b.The facility completed a full house audit of all residents at High Risk for developing pressure ulcers to ensure an individualized plan of care to prevent the development is in place. No other residents were affected by this deficiency.

III.Systematic Changes
1.The Director of Nursing reviewed the facility?s policy on Identification and Prevention of Pressure Ulcers and noted it to be compliant.
2.The Director of Nursing/Designee will re-educate all licensed nurses regarding the development of an individualized plan of care for residents at high risk for developing pressure ulcers.
3.A copy of the lesson plan and attendance will be filed for reference and validation.
IV.QA Monitoring
1.The Director of Nursing developed an audit tool to track compliance and validate the completion of individualized care plans for all high risk residents.
2.This audit will be completed on 10% of the residents weekly for the first month, monthly for the first quarter and then quarterly thereafter.
3.Audits with negative findings will have on site corrective actions implemented by the auditor.
Person Responsible: Director of Nursing

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2016
Corrected date: July 6, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1998 NFPA 25:2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded or in the improper orientation. 1999 NFPA 13:5-6.3.4 Minimum distance between sprinklers. Sprinklers shall be spaced not less than 6ft (1.8m) on center. Based on observation and staff interview, the facility failed to ensure that sprinklers were (1) maintained free of corrosion and (2) were not spaced less than 6 feet on center. This was observed on 2 of 2 floors of the facility including the basement. The findings are: On 6/15/2016 and 6/16/2016 between the hours of 9am and 2pm during the recertification survey, the following was observed: (1) The roof access level in exit stair 4 contained a corroded sprinkler (2) Sprinklers spaced not less than 6 feet on center. Locations include but are not limited to: 2 South Nursing Station, the MDS Office and Housekeeping Storage in the basement. In an interview with the Director of Maintenance at approximately 9:45am on 6/15/2016, he stated the facility is coming up on the [AGE] year maintenance and would have the sprinkler head replaced. In an interview with the Director of Maintenance at approximately 11:10am on 6/15/2016, he stated he would have the sprinklers either moved or removed depending on the area. 10NYCRR 711.2(a)(1) 1998 NFPA 25:2-2.1.1 1999 NFPA 13:5-6.3.4

Plan of Correction: ApprovedJuly 6, 2016

I.Immediate Corrective Action
a.Mills Pond Nursing and Rehabilitation Center immediately removed the corroded sprinkler head located at the roof access level in exit stair 4 and installed a new sprinkler head. All sprinkler heads located within(NAME)Pond Nursing and Rehabilitation Center have been checked for corrosion.
b.Mills Pond Nursing and Rehabilitation Center relocated sprinkler heads located in the MDS Office and Housekeeper storage in the basement to be greater than 6 feet on center. Sprinkler head located in the 2 South Nursing Station was removed.
II.Identification of Other Residents
As this deficiency impacted the sprinkler system within(NAME)Pond Nursing and Rehabilitation Center, all residents are potentially affected.
III.Systematic Changes
Mills Pond Nursing and Rehabilitation Center replaced the corroded sprinkler head, relocated two sprinkler heads located within 6 feet of each other and removed the remaining sprinkler head. All sprinkler heads located within(NAME)Pond Nursing and Rehabilitation Center have been checked for corrosion.
IV.QA Monitoring
The sprinkler system is monitored for corrosion and proper sprinkler placement on a semiannual and as needed basis.
Responsible Person: Director of Environmental Services