Ross Center for Nursing and Rehabilitation
January 31, 2017 Certification Survey

Standard Health Citations

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews and record reviews during the Recertification survey, the facility did not ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. This was noted for 2 of 3 residents reviewed for dignity (Resident #143, #46) in a total sample of 29 Stage 2 residents. Specifically, during resident interviews the staff entered the resident's room abruptly without knocking on the door. The findings are: 1) Resident #143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. An interview was held with the resident on 1/26/17 at 11:57 AM. During the interview at approximately 12:05 PM the resident's door was abruptly opened and a Certified Nursing Assistant (CNA) entered the room without knocking. The resident stated to the CNA that he was busy and the CNA needed to come back later. The resident stated that the facility staff do not knock on the door, they just enter the room. The resident stated that he has expressed the concern to the day supervisor a few times. An observation on 1/26/17 at 11:56 AM revealed that there are door knockers on each residents room. An interview was held with the CNA on 1/26/17 at 1:00 PM. The CNA stated that she should have knocked before entering. An interview was held with the Director of Nursing Services (DNS) on 1/30/17 at 10:45 AM. The DNS stated that the staff are educated that they should be knocking on the resident's door before entering the room. The DNS stated that the CNAs should have knocked before entering the resident's room. 2) Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. An interview was held with the resident on 1/26/17 at 1:00 PM. During the interview at approximately 1:05 PM the resident's door was abruptly opened and a CNA entered the room without knocking. The resident stated to the CNA that he was busy and the CNA needed to come back later. The resident stated that the facility staff never knock on the door, they just enter the room. The resident stated that he has expressed the concern to the supervisor. An observation on 1/26/17 at 12:59 PM revealed that there is a door knocker on the residents room door. An interview was held with the CNA on 1/26/17 at 1:06 PM. The CNA stated that she should have knocked before entering. An interview was held with the Director of Nursing Services (DNS) on 1/30/17 at 10:45 AM. The DNS stated that the staff are educated that they should be knocking on the resident's doors before entering the room. The DNS stated that the CNAs should have knocked before entering the resident's room. 415.5(a)

Plan of Correction: ApprovedFebruary 23, 2017

Part I IMMEDIATE CORECTIVE ACTION
1. Residents #46 and #143 were seen by SW for any untoward effects.

Part II Identification of Other Residents
1. The facility respectfully acknowledges this deficiency affects all residents.

Part III Systemic Changes
1. The DNS reviewed the policy on Resident?s Rights and found no revision necessary.
2. All nursing staff members were re-in serviced on knocking before entering resident?s room.
Part IV Quality Assurance
1. The DNS has developed an audit tool to ensure compliance
2. The RNS will audit 5 resident?s
weekly x 4 weeks then, monthly x 3 months.
3. Any negative findings will have immediate corrective action.
4. The DNS will report all audit results to the QA Committee

Part V Person Responsible for completion
1. The DNS will be responsible to ensure correction of this deficiency.

FF10 483.45(d)(e)(1)-(2):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-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (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; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs. This was evident for one (Resident #43) of five residents reviewed for unnecessary medication in a total of twenty nine Stage 2 sampled residents. Specifically, Resident #43 had an increase in [MEDICATION NAME] from 12.5 milligrams (mg) three time daily to 25 mg three times daily without adequate medical justification for the increase of the [MEDICATION NAME], and there was no documented evidence that non-pharmacological interventions were attempted prior to the increase of the [MEDICATION NAME]. The finding is: Resident # 43 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 6, which indicated severe cognitive impairment. The resident exhibited mood symptoms, however, the resident had no indicators for [MEDICAL CONDITION] and no behavior symptoms. The resident received Antipsychotic and Antidepressant medications during the seven days prior to this assessment. A Psychiatric Follow-Up Consultation dated 11/11/16 documented the resident has been in the facility since 2014 and is Spanish speaking with little English and is non-compliant. The resident has cognitive deficits, restless, grinding teeth and limited eye contact. The resident is not crying or tearful. No complaints of pain or Depression. Recommendations are to increase [MEDICATION NAME] to 25 mg po TID. A Comprehensive Care Plan (CCP) developed for the Use of [MEDICAL CONDITION] Medication documented the use of Antipsychotic and Antidepressant medication. The CCP lacked documentation of the [DIAGNOSES REDACTED]. In the response section of the CCP it was documented on 11/12/16 the resident was seen by the Psychiatrist and has new orders to increase [MEDICATION NAME] and [MEDICATION NAME]. There was no documentation in the CCP of the behavior that warranted the increase of the [MEDICATION NAME]. A Behavior Comprehensive Care Plan (CCP) dated 4/26/16, and last updated 11/11/16, documented the resident has [DIAGNOSES REDACTED]. The CCP documented the resident socially disrobes, is non-compliant with safety, resists care, and refuses medication at times. Interventions includes to observe behavior and attempt to determine the cause and diversionary activity: snacks, soda, sandwich and outdoors. In the response section of the CCP it was documented on 11/11/16 Psych adjusted meds, effects to be monitored. There was no documented evidence in the CCP of the behavior that warranted the increase of the [MEDICATION NAME]. A Monthly Physician order [REDACTED]. The order documented the original date for [MEDICATION NAME] 25 mg was 11/11/16. A Nurse's Note dated 11/11/16 documented the resident was seen by the Psychiatrist for follow up and ordered [MEDICATION NAME] 25 mg by mouth (po) three times daily (TID). There was no documented evidence of the behavior that warranted the increase of the [MEDICATION NAME] and no documented evidence of the non-pharmacological interventions attempted prior to the increase. An interview with the Psychiatrist was conducted on 1/31/17 at 8:34 AM regarding why the [MEDICATION NAME] was increased on 11/11/16. The Psychiatrist stated that he did not recall circumstances or the reason for the increase of the [MEDICATION NAME]. The Psychiatrist stated to speak with the staff and the resident's daughter, that they would probably be able to say why the [MEDICATION NAME] was increased. The Psychiatrist further stated when there is an increase in [MEDICAL CONDITION] medication there should be documentation in the medical record of the behavior that warranted the increase. He also stated that non-pharmacological interventions should be attempted prior to the start of the medication. An interview was conducted on 1/31/17 at 8:51 AM with the Registered Nurse (RN) Unit Manager. The RN stated that behavior should be documented in the medical record and if there is an adjustment in [MEDICAL CONDITION] medication, it is documented on the 24-Hour Report and in the progress notes. The RN further stated that with any start or increase of these medications, non-pharmacological interventions must be attempted prior to the start of the medication. 415.12(l)(1)

Plan of Correction: ApprovedFebruary 23, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I IMMEDIATE CORECTIVE ACTION
1. Resident #43 comprehensive Care Plan has been reviewed and revised to include the [DIAGNOSES REDACTED].
2. Resident # 43 was seen and evaluated by the Psychiatrist for a possible reduction of Antipychotropic Drugs.
3. He was monitored for any behaviors and non-drug interventions as needed.

Part II Identification of Other Residents
1. A list of all residents on [MEDICAL CONDITION] medications was compiled and will be evaluated for a Gradual Dose Reduction by the Psychiatrist and MD.
a. Upon identification of resident?s behavior through behavior note documentation. This list will be used by the Psychiatrist and the MD for Gradual Dose Reduction of [MEDICAL CONDITION] Drugs.
Part III Systemic Changes
1. A review of the facilities policy on Gradual Dose Reduction of Residents on [MEDICAL CONDITION] Medication was conducted with the Medical Director and DNS. The Policy and Procedure was found to be compliant.
2. All Medical and Nursing staff will be rein-serviced to the Facility?s Policy on Gradual Dose Reduction of [MEDICAL CONDITION] Medication.

Part IV Quality Assurance
1. An Audit tool was developed l to ensure compliance with Gradual Dose Reduction of [MEDICAL CONDITION] Medications
2. The Medical Director/Designee will audit 5 residents monthly x 3 months, then quarterly x 3 quarters.
3. Any negative findings will have immediate corrective action.
4. The Medical Director/Designee will report all audit results to the QA Committee.

Part V Person Responsible for completion
1. The Medical Director/Designee will be responsible to ensure correction of this deficiency.

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 27, 2017

Citation Details

Based on observation and staff interviews during the recertification survey, the facility did not provide maintenance services necessary to maintain a sanitary and comfortable interior for three of three nursing units. Specifically, 1) a black substance was observed on the wall in a Resident's room. 2) Carpets were observed on all three units to be worn and stained. The findings are: 1) Resident #143 was observed on 1/26/17 at 12:32 PM in room 32B. The observation revealed that the resident's radiator cover and right corner of room wall from ceiling to floor had a moderate amount of black colored substance. The resident's bed was approximately 1 foot from the wall and radiator. The resident stated that the black substance had been there since he was brought to room 32 about 6 months ago. The resident stated that the housekeeping staff have cleaned the black substance 3 times already and that it continues to come back. The resident stated that he informed the Registered Nurse (RN) Supervisor and then the housekeeping aide came in the room and cleaned it. An interview and observation of room 32 was held with the Administrator on 1/26/17 at 12:35 PM. The Administrator stated that he was not aware of the black substance on the wall in room 32. An interview was held with the RN Supervisor on 1/30/17 at 10:15 AM. The RN stated that she was not aware of the black substance on the wall. An interview was held with the housekeeping aide on 1/30/17 at 10:25 AM. The housekeeping aide stated that she had cleaned it 2 or 3 times before but never reported it to anyone because she felt it was just dirty and did not feel it was a concern. 2) During the initial tour on 1/25/17 of the facility at 8:30 AM the carpets on all three units were observed to be worn and stained. An interview was held with the Administrator on 1/31/17 at 9:30 AM. The Administrator stated that they will be replacing the carpet soon. 415.5(h)(2)

Plan of Correction: ApprovedFebruary 23, 2017

I. Immediate Corrective Action Taken:
1. Resident removed from room. Room 32 B has been isolated.
2. Resident was assessed and vital signs stable, and MD notified
3. Maintenance Director identified source of water exposure, and took steps to remediate it.
4. A professional inspector has inspected the room in question, and appropriate intervention have been instituted
5. Carpet Cleaning vendors were contacted to provide cleaning services to affected areas.

II. Identification of Other Areas:
1. Maintenance Director and Administrator made rounds to identify any other areas of concern. None found.

III. Systemic changes
1. All staff in serviced on maintaining a safe and clean environment
2. Carpet treatment schedule will be increased as needed to ensure compliance.

IV. Quality Assurance
1. The Maintenance Director developed an audit tool to monitor any discolored, spotting, stains, puddling or moisture build up in all rooms, bathrooms and hallways
2. Audits will be done by the Maintenance Director /Designee in all rooms, bathrooms and hallways, weekly x 4 weeks then monthly x 3 months.
3. Audits with negative findings will be immediately communicated to Maintenance Director and/or Administrator, and the areas in question will have immediate remediation.
4. Audit results will be presented to the QA committee quarterly for evaluation and follow up.

Responsible Person: Maintenance Director

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (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: (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 (facility assessment implementation is Phase 2); (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. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 27, 2017

Citation Details

Based on observations and staff interviews during the recertification survey the facility did not ensure that infection control practices were maintained in a consistent manner to prevent to the extent possible, the onset and spread of infection within the facility. Specifically, two staff members that did not receive the Flu Vaccine were observed in resident areas without a surgical or procedure mask donned during the influenza season (October 1 through (MONTH) 31). The findings are: 1) On 1/30/17 at 10:00 AM a Physical Therapist (PT) Aide was observed on the East Unit with her procedure mask covering her mouth but not her nose. The PT Aide was interviewed immediately. The PT Aide stated that the mask kept falling down below her nose. 2) On 1/30/17 at 1:00 PM a Certified Nursing Assistant (CNA) was observed on the East Unit with her procedure mask covering her mouth but not her nose. The CNA was interviewed immediately. The CNA stated that the mask kept falling down. The Director of Nursing Services (DNS) was interviewed on 1/30/17 at 1:15 PM. The DNS stated that the staff members did not receive the flu vaccine and that they should be wearing the masks. The DNS also stated that she will inservice the staff to apply the masks properly. 415.19(a)(1-3)

Plan of Correction: ApprovedFebruary 23, 2017

Part I IMMEDIATE CORECTIVE ACTION
1. Full facility rounds were made and no other issues noted.
2. Educational counseling was given to the staff members involved.

Part II Identification of Other Residents
1. The facility respectfully acknowledges this deficiency affects all residents.

Part III Systemic Changes
1. The facility policy was reviewed and found to be compliant.
2. All staff members who did not receive the flu vaccine were given inservice on applying the mask properly.
Part IV Quality Assurance
1. The DNS has developed an audit tool to ensure compliance with infection control procedures involving wearing of a mask during flu season, if the flu vaccine was not administered.
2. The ADNS will audit 2 random staff member weekly x 4 weeks then monthly x 3 months.
3. Any negative findings will have immediate corrective action.
4. The DNS/ADNS will report all audit results to the QA Committee
Part V Person Responsible for completion
1. The DNS will be responsible to ensure correction of this deficiency.

FF10 483.25(e)(1)-(3):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident?s comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident?s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident?s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the recertification survey, the facility did not insure that bladder assessments are completed for residents identified with a decline in bladder function. The was identified for one (Resident #84) of three residents reviewed for urinary incontinence in a total of twenty nine Stage 2 sampled residents. Specifically, Resident #84 was identified to have a decline in function from frequently incontinent to always incontinent and there was no documented evidence that a bladder assessment was completed to determine the cause for the decline. The finding is: Resident # 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Evaluation dated 9/2/16 documented the resident was continent of bladder. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short term and long term memory problems and was severely impaired for daily decision making. The resident had behavior problems, required total assist of 2 staff members for transfer and toileting and was frequently incontinent of bladder. A Quarterly MDS assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 8, which indicated moderately impaired cognition. The resident had no behavior problem, required extensive assist of two staff members for transfer and toileting, and was always incontinent of bladder. A Comprehensive Care Plan (CCP) dated 9/2/16 for incontinence documented in the response section of the care plan on 12/8/16 that, Quarterly review, incontinent care provided by staff. A Review of the Nurses Notes dated 12/1/16 to 1/30/17 lacked documented evidence that a bladder assessment was completed to determine the cause for the decline in bladder function. An interview was conducted on 1/31/17 at 11:40 AM with the Certified Nursing Assistant (CNA). The CNA stated that a couple of months ago (3-4) the resident was toileted and was at times continent. The CNA stated that the resident is now completely incontinent, is not toileted and wears a diaper. An interview was conducted on 1/31/17 at 12:00 PM with the Director of Nursing Services (DNS). The DNS stated that a bladder assessment should have been completed when the resident was identified to have a decline in bladder function. The DNS further stated that she had previously identified that bladder assessments were not being completed when residents were identified with a decline in bladder function. The DNS stated that she had developed a new Bladder Assessment but had not yet implemented it. 415.12(d)(2)

Plan of Correction: ApprovedFebruary 23, 2017

Part I IMMEDIATE CORECTIVE ACTION
1. Resident # 84 was seen and evaluated by MD when a Bladder Assessment was completed.
Part II Identification of Other Residents
1. The Facility compiled a list of all residents that are incontinent for the past 3 months.
a. This list will be used by the ADNS/Designee to ensure referral to MD for Bladder Assessment and accurate documentation in the medical record of any changes in bladder function.

Part III Systemic Changes
1. The Medical Director and DNS reviewed the policy on Physician Bladder Assessment and found it to be compliant.
2. The policy will be rein-serviced to MD and nurses by the Medical Director and ADNS
3. Residents identified with urinary continence changes will be documented on the 24 hour report.
Part IV Quality Assurance
1. An audit tool was developed to ensure compliance with accurate documentation of resident?s bladder assessment.
2. This audit will be completed on 5 resident?s weekly x 4 weeks, then monthly x 3 months.
3. Any negative findings will have immediate corrective action.
4. The DNS/ADNS will report all audit results to the QA Committee.

Part V Person Responsible for completion
1. The DNS will be responsible to ensure correction of this deficiency.

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review during a Recertification survey, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was noted for one of two residents (Resident #126) reviewed for pain management in a sample of 29 Stage 2 residents. Specifically, the facility did not monitor the resident's pain after a pain medication dose reduction. The finding is: Resident #126 was admitted on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident had intact memory and decision making skills. Resident #126 was interviewed on 1/25/17 at 1:00 PM and stated that he was in the facility to recover from a left shoulder injury and has pain in his left upper arm and left shoulder. He stated that his pain medication was reduced recently and the new dose is not enough to give him pain relief. He stated that when he tells the Nurses they tell him to wait until the next dose is due. He also stated that after they give him the pain medication, the nurses do not return to see if the pain medication was effective. He stated that he has told the Doctor, when passing by him in the hallway several times, I got a lot of pain, but he does not stop and discuss the issue and he just says, OK OK and walks away. The Unit Registered Nurse (RN) Manager was interviewed on 01/27/2017 at 2:08 PM stated that the resident was transferred from the East wing to this Wing on 1/18/17. She stated that the resident had an order for [REDACTED]. She stated that the resident did not offer any pain complaints personally to her and no Certified Nurses Assistant (CNA) or Nurse told her that the resident was complaining of ineffective pain management. She stated that resident's pain was assessed and his medication adjusted on 1/25/17 after he had spoken with the surveyor. The Unit RN Manager also stated that the Medication Nurse is supposed to assess pain level before and after administering a PRN (as needed) dose. She stated that for standing pain medication and a Q shift pain assessment is documented in the Medication Administration Report (MAR). She also stated that a pain assessment is completed upon admission and during quarterly and annual assessments. The medical record including the Nurses Admission Assessment, MAR, Nurses Notes, Comprehensive Care Plan and 24 hour 9 (hr) report from 12/1/16 to 1/27/17 were reviewed with the RN Manager. The Nurses Admission Assessment on 12/1/16 documented a pain assessment was completed. The Second Pain Assessment Sheet was completed on 1/25/17. The MAR from 1/1/17 to 1/27/17 documented a N for none in the Q shift pain assessment column. The 24 hr report dated 1/19/17 documented that the pain medication was reduced and pain management was in progress. The 24 hr report dated 1/20/17 did not mention pain management for the resident and there was no report for the resident for 1/21/17 and 1/22/17. There was only one Nurse's progress note dated 1/19/17 at 11 PM documenting that the pain management was in progress and [MEDICATION NAME] 5 mg was tolerated well. Another note dated 1/20/17 at 7:00 AM documented, given meds, adjusting well to unit, no complaints made. There were no further notes until a note dated 1/25/17 at 3:00 PM regarding the resident's pain management being ineffective. The Licensed Practical Nurse (LPN) who worked on 3:00 PM-11:00 PM shifts on 1/19/17 and 1/24/17 was interviewed on 01/30/2017 at 2:25 PM and stated that she is a regular LPN and recalls the resident but does not recall any time that the resident approached her for additional pain medication. The float LPN who worked 3:00 PM-11:00 PM shift on 1/21/17 and 1/22/17 was interviewed on 01/30/2017 at 2:35 PM and stated she does not recall any request for pain medication by the resident. The float LPN who worked 3:00 PM-11:00 PM on 1/23/17 stated she is a float and does not recall the resident. The Director of Nursing Services (DNS) was interviewed on 1/27/17 at 3:00 PM and stated that she has revised the MAR indicated [REDACTED]. She also stated that the staff has been educated to include pre and post medication administration pain assessment. The Physician was unavailable for interview. 415.12

Plan of Correction: ApprovedFebruary 23, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I IMMEDIATE CORECTIVE ACTION
1. Resident # 126 was assessed by MD and pain Medications were addressed.
2. Resident #126 no longer resides in the facility.
Part II Identification of Other Residents
1. The facility compiled a list of all residents on [MEDICATION NAME] and completed pain assessments, no other residents were affected.

Part III Systemic Changes
1. The DNS reviewed the policy on pain assessment and found it to be compliant.
2. All nurses have been rein-serviced on pain assessment.
3. The DNS reviewed and revised the Medication Administration Record [REDACTED]. Every shift pain assessment continues on all residents.
4. All nurses have been in-serviced on the new Medication Administration Records.
Part IV Quality Assurance

1. The DNS has developed an audit tool to ensure compliance with pain assessment.
2. The RNS will audit 5 residents? weekly x 4weeks, then monthly x 3months.
3. Any negative findings will have immediate corrective action.
4. The DNS/ADNS will report all audit results to the QA Committee.

Part V Person Responsible for completion
1. The DNS will be responsible to ensure correction of this deficiency.

FF10 483.10(d)(1)(2)(4)(5):RIGHT TO CHOOSE A PERSONAL PHYSICIAN

REGULATION: (d)(1) The physician must be licensed to practice, and (d)(2) If the physician chosen by the resident refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in paragraphs (d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment. (d)(4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the resident?s preferences, if any, among options. (d)(5) If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility must honor that choice.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and residents interviews during the standard recertification survey the facility did not ensure that the residents had a choice of their Physician. This was evident for two of two residents interviewed in a total of 29 Stage 2 sampled residents. Specifically, Resident #46 and #143 had requested a change of Physician and their request was not addressed. The findings are: 1) Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. An interview was held with Resident # 46 on 1/26/17 at 1:15 PM. The resident stated that he requested a change in his Physician in (MONTH) (YEAR), approximately 12/10/16. The resident stated that the facility could not provide a Physician change due to the facility on ly providing one Physician in the facility. The resident stated that he had signed a petition with other residents on 1/17/17 and it has not been addressed by the facility. A Petition Paper dated 1/17/17 documented 17 residents signatures regarding the Physician. The Petition documented that the Physician was not meeting the residents needs, had poor bedside manner, was disrespectful and that the residents would like the petition looked at. An interview was held with the Director of Nursing Services (DNS) on 1/27/17 at 11:15 AM. The DNS stated that there is only one Physician employed by the facility and he is also the Medical Director. An interview was held with the Administrator on 1/27/17 at 11:20 AM. The Administrator stated that he was aware of the petition from the residents about the Physician. The Administrator stated that they addressed the petition by speaking with the Physician, but did not address the residents rights to request another Physician. An interview was held with the Resident on 1/27/17 at 1:00 PM. The resident stated that there was no discussion with him from the facility staff that the petition was addressed. The resident stated that he is still requesting another Physician. 2) Resident #143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. An interview was held with the Resident #143 on 1/26/17 at 12:32 PM. The resident stated that he requested a change in his Physician in (MONTH) (YEAR), approximately 12/10/16. The resident stated that the facility could not provide a Physician change due to they only had one Physician in the facility. The resident also stated he had asked the Social Worker on at least two occasions for the Physician change sometime in (MONTH) (YEAR) and (MONTH) (YEAR). The resident stated that some of the residents signed a petition documenting that the Physician were ignoring the residents medical needs. A Petition Paper dated 1/17/17 documented 17 residents signatures regarding the Physician. The Petition documented that the Physician was not meeting the residents needs, had poor bedside manner, was disrespectful and that the residents would like the petition looked at. An interview was held with the Resident on 1/27/17 at 10:00 AM. The resident stated that there was no discussion with him from the facility staff that the petition was addressed. The resident stated that he is still requesting another Physician. An interview was held with the Director of Nursing Services (DNS) on 1/27/17 at 11:15 AM. The DNS stated that there is only one Physician employed by the facility. An interview was held with the Administrator on 1/27/17 at 11:20 AM. The Administrator stated that he was aware of the petition from the residents about the Physician. The Administrator stated that they addressed the petition by speaking with the Physician, but did not address the residents rights to request another Physician. 415.3(e)(1)(iii)

Plan of Correction: ApprovedFebruary 23, 2017

I. Immediate Corrective Action Taken:
1. Affected residents immediately switched to an alternate covering physician.
2. Physician in question terminated
3. New Physician group hired to begin on or about Feb. 6, (YEAR)
4. Residents made aware of alternate physicians
II. Identification of Other Areas:
1. All residents had the potential to be been affected
III. Systemic changes
1. Facility hired a physician group with available alternate physicians.
2. Social Work and Nursing staff in serviced on the availability of providing alternate physicians
IV. Quality Assurance
1. Facility created an audit tool to sample resident knowledge of the availability of an alternate physician.
2. Social Worker or designee will audit 5 residents weekly x 4 weeks, then monthly x 3 months.
3. Any negative findings will have immediate corrective action.
4. Audit results will be presented to the QA committee quarterly for evaluation and follow up.

Responsible Person: Administrator


FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident?s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident?s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that after each assessment, the Comprehensive Care Plan (CCP) was reviewed and revised as needed. This was evident for one (Resident #50) of five residents reviewed for unnecessary medication in a total of twenty nine Stage 2 sampled residents. Specifically, Resident #50 had a Gradual Dose Reduction (GDR) of his [MEDICAL CONDITION] medications on 11/11/16 and there was no documented evidence that a CCP developed for the use of [MEDICAL CONDITION] medications was updated to include the GDR. The finding is: Resident # 50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score was 15, which indicated intact cognition. The resident had no behavior problems, however, the resident exhibited mood symptoms of feeling down, depressed, hopeless. The resident received Antidepressant medication during the seven day look back period. A Psychiatric Follow-Up Consultation dated 11/11/16 documented to change [MEDICATION NAME] only to 250 mg by mouth (po) at HS and change [MEDICATION NAME] to 100 mg po at HS. A Nurse's note dated 11/11/16 documented the resident was seen by Psychiatrist on 11/11/16 and [MEDICATION NAME] was changed to 250 mg po at HS and [MEDICATION NAME] was changed to 100 mg po at HS. A CCP dated 8/23/16 documented the use of [MEDICAL CONDITION] medications for Depression and Impulsive Control Disorder. Interventions included medication per the physician's orders [REDACTED]. In the response section of the CCP it was documented on 11/23/16; Quarterly review, no change and continue Plan of Care (P(NAME)). A review of the medical record revealed the resident had a gradual dose reduction on 11/11/16 of his [MEDICAL CONDITION] medications [MEDICATION NAME] and [MEDICATION NAME] and the GDR was not updated on the CCP. An interview was conducted on 1/31/17 at 12:45 PM with the MDS/ Registered Nurse (RN). The RN stated there was nothing in the regulation that states the CCP must be updated after a Quarterly MDS Assessment. The RN further stated that the Social Worker had updated on the mood CCP that the medication was adjusted. An interview was conducted on 1/31/17 at 12:20 PM with the RN Unit Manager who stated that the MDS/RN is responsible for updating the long term CCP at the time of the care plan meeting. The RN stated that the CCP should have been updated to reflect the resident had a GDR of his [MEDICAL CONDITION] medications. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedFebruary 23, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I IMMEDIATE CORECTIVE ACTION
1. Resident # 50 Comprehensive Care Plan has been reviewed and revised to include Gradual Dose Reduction of his [MEDICAL CONDITION] medication.
2. The nurse responsible for the documentation on the CCP is no longer employed by the facility.

Part II Identification of Other Residents
1. The DNS obtained a list of all the residents on antipsychotic medications for review of the CCP and noted that there are no other residents affected.

Part III Systemic Changes
1. The DNS reviewed the facility policy on CCP and found it to be compliant.
2. All nursing staff responsible for updating the CCP was rein-serviced by ADNS

Part IV Quality Assurance
1. The DNS has developed an audit tool to ensure compliance with accurately updating CCP
2. The ADNS/Designee will audit 5 residents weekly x 4 weeks then monthly x 3 months

3. Any negative findings will have immediate corrective action
4. The DNS/ADNS will report all audit results to the QA Committee
Part V Person Responsible for completion
1. The DNS will be responsible to ensure correction of this deficiency.

Standard Life Safety Code Citations

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

REGULATION: Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2010 NFPA 10: 8.3 Frequency. 8.3.1 General. At intervals not exceeding those specified in Table 8.3.1, fire extinguishers shall be hydrostatically retested . Table 8.3.1 Hydrostatic Test Intervals for Extinguishers Extinguisher Type Test Interval (years) Stored-pressure water, water mist, loaded stream, and/or antifreeze 5 Wetting agent 5 AFFF ([MEDICATION NAME] film-forming foam) 5 FFFP (film-forming fluoroprotein foam) 5 Dry chemical with stainless steel shells 5 Carbon [MEDICATION NAME] 5 Wet chemical 5 Dry chemical, stored-pressure, with mild steel shells, brazed brass shells, or aluminum shells 12 Dry chemical, cartridge- or cylinder-operated, with mild steel shells 12 Halogenated agents 12 Dry powder, stored-pressure, cartridge or cylinder-operated, with mild steel shells 12 8.3.1.1 The hydrostatic retest shall be conducted within the calendar year of the specified test interval. Based on observation and staff interview, the facility failed to ensure that K type fire extinguishers were hydrostatically tested every 5 years. This was observed in the kitchen of the facility. The finding is: On 1/27/2017 between the hours of 8:30am and 2:00pm during the recertification survey, the following was observed. A K type fire extinguisher was observed near the range hood in the kitchen of the facility. The extinguisher lacked a hydrostatic test sticker with test date. The manufacture date was 2007. In an interview at approximately 12:00pm with the Director of Maintenance, he stated he would call the fire extinguisher company to come and test or replace the K type fire extinguisher immediately. 2010 NFPA 10:8.3 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 1, 2017

I. Immediate Corrective Action Taken:
1. On 1/27/2017 the K fire extinguisher was replaced in the kitchen.
II. Identification of Other Areas:
1. The Maintenance Director checked all K Fire extinguishers to ensure compliance. No other areas noted.
III. Systemic changes
1. K fire extinguisher hydrostatic testing added to Maintenance monthly audit tool to address areas of concern.
IV. Quality Assurance
1. Facility created an audit tool to ensure hydrostatic test stickers visible on all K fire extinguishers
2. Maintenance Director or designee will audit the K fire Extinguishers monthly x 3 months.
3. Any negative findings will have immediate corrective action.
4. Audit results will be presented to the QA committee quarterly for evaluation and follow up.
Responsible Person: Maintenance Director

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2017
Corrected date: March 31, 2017

Citation Details

2012 NFPA 101:19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. 19.3.1.1 Where enclosure is provided, the construction shall have not less than 1- hour fire resistance rating. Based on observation and staff interview, the facility failed to ensure that dumbwaiters were protected according to NFPA 101, 2012 edition. Specifically, the access hatch door lacked a self- closing device. This occurred in the vertical opening located between the storage room in the basement and the kitchen on the first floor. The findings are: On 1/27/2017 between the hours of 8:30am and 2:00pm during the recertification survey, the following was observed. A dumbwaiter was observed in use within the kitchen of the facility. The dumbwaiter was being used to transport items from the storage room in the basement to the kitchen, located on the 1st floor. In the kitchen above the dumbwaiter door opening, an access hatch door was observed. Upon further inspection, the access hatch door lacked the required self- closing device. In an interview on 1/27/2017 at approximately 11am with the Director of Maintenance, he stated he can install a self -closing device on the door. 2012 NFPA 101:9.4.2.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 1, 2017

I. Immediate Corrective Action Taken:
1. On 1/27/2017 the self closing door was installed on dumbwaiter hatch.
II. Identification of Other Areas:
1. The Maintenance Director checked all access hatch doors had a self closing door. No other areas noted.
III. Systemic changes
1. Door location added to maintenance monthly audit tool to address areas of concern.
IV. Quality Assurance
1. Facility created an audit tool to ensure self closing door on dumbwaiter
2. Maintenance Director or designee will audit the door monthly x 3 months.
3. Any negative findings will have immediate corrective action.
4. Audit results will be presented to the QA committee quarterly for evaluation and follow up.
Responsible Person: Maintenance Director