Chemung County Health Center-Nursing Facility
June 23, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.20(g)-(j):ASSESSMENT ACCURACY/COORDINATION/CERTIFIED

REGULATION: (g) Accuracy of Assessments. The assessment must accurately reflect the resident?s status. (h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. (i) Certification (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. (j) Penalty for Falsification (1) Under Medicare and Medicaid, an individual who willfully and knowingly- (i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. (2) Clinical disagreement does not constitute a material and false statement.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: August 18, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 2 of 33 residents reviewed for Minimum Data Set (MDS) Assessments accuracy, the facility did not ensure the MDS Assessments accurately reflected the residents' status. Coding issues included dental (Resident #31) and weight loss (Resident #215). This is evidenced by the following: 1. Resident #31 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Dental Consults, dated 11/18/15 and 2/1/17, revealed that the resident was missing all upper teeth, ten lower teeth, and teeth #22 through #28 were fractured at the gum line. The Comprehensive MDS Assessments, dated 1/9/16 and 12/3/16, documented that the resident did not have any dental issues. When interviewed on 6/22/17 at 11:05 a.m., the Licensed Practical Nurse said that the resident has no upper teeth, does not allow them to put in the denture, and has only nubs at the gum line for lower teeth. When interviewed on 6/23/17 at 9:15 a.m., the MDS Registered Nurse (RN) said she would review the chart and complete an oral exam prior to completing the Dental Status section of the MDS Assessment. She said if the resident had fractured teeth, the MDS Assessment should be coded as obvious or likely cavity or broken natural teeth. The (MONTH) (YEAR) MDS Manual defines broken natural teeth or tooth fragments as tooth broken off or decayed to the gum line, or broken teeth (from a fall or trauma) and directs to code if any are seen. 2. Resident #215 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/3/17, documented that the resident's admission weight was 150 pounds (lbs.). The MDS Assessment, dated 4/24/17, documented that the resident's weight was 141 lbs. Both assessments documented that there was no weight loss of 5 percent or more in the last month, or a loss of 10 percent or more in the last six months. Based on the documented weights on the MDS Assessments, the resident had a weight loss of nine pounds or 6 percent within 30 days. During an interview on 6/22/17 at 2:13 p.m., the MDS RN said the weight section of the MDS Assessment is completed by the Registered Dietician. She reviewed the MDS Assessment and stated that it should have been coded as a weight loss. The (MONTH) (YEAR) MDS Manual definitions for 5 percent weight loss in 30 days included: start with the resident's weight closest to 30 days ago, and multiply it by .95 (or 95 percent). The resulting figure represents a 5 percent loss from the weight 30 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost more than 5 percent body weight. (10 NYCRR 415.11(b))

Plan of Correction: ApprovedJuly 13, 2017

Residents Affected by Deficiency:
1. The incorrect coding for resident #31 and Resident #215 was corrected in the MDS Electronic Health Record upon completion of survey exit interview.
2. MDS Coordinators were given an in-service training by the MDS Coordination Manager as to the definition of dental issues and weight loss as defined in the MDS Manual (October, (YEAR)). The in-service emphasized the importance of accuracy of documentation in the medical file.
Identifying Other Residents:
All residents could be at risk for a reoccurrence of this deficiency so that the Measures and Systemic Changes stated below are intended to correct this deficiency for all current and future residents.
Measures and Systemic Changes:
1. MDS Coordination Manager will be in-serviced to audit Initial/Quarterly/Annual MDS Assessments for accuracy of documentation coding as defined in the MDS Manual (October, (YEAR)).
2. In-service training regarding MDS coding as defined by MDS Manual (October, (YEAR)) will be given to all MDS Coordinators emphasizing the importance of accuracy of documentation.
3. MDS Coordination Manager will conduct evaluations of MDS Coordinators competencies regarding accuracy of coding assessment areas of the MDS Electronic Health Record through periodic auditing of MDS coding.
Quality Assurance Program:
Audits of one initial, two quarterly, and one annual MDS assessment will be conducted by the MDS Coordination Manager or designee per month. Audits shall review MDS documentation for accuracy according to MDS Manual (October, (YEAR)) definitions. A report of the audits shall be prepared by the MDS Coordination Manager for presentation to the QAPI Committee monthly for a period of three months. If 100% compliance in accuracy of audits is achieved, the frequency of the audits will be reduced to quarterly for two consecutive quarters. If 100% compliance in accuracy is attained in consecutive quarters, the QAPI Committee may discontinue the quarterly reports.
Person Responsible for Completion:
MDS Coordination Manager

E3BP 402.7(a)(3)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (3) Where the criminal history information of a prospective employee reveals a conviction for any crime other than one set forth in paragraph (2) of this subdivision, the Department may, consistent with article 23-A of the Correction Law, propose disapproval of eligibility for employment. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the prospective employee's criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination from the Department.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: August 18, 2017

Citation Details

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Dietary Aide) of eight employees reviewed for the Criminal History Record Check (CHRC), the facility did not properly remove an employee from physical access to residential living areas upon receipt of a negative determination letter. This is evidenced by the following: On 6/22/17 from 9:00 a.m. to 9:50 a.m., the Human Resources Manager provided the surveyor with eight employee files for review. One of the files showed that a dietary employee was hired on 4/12/17 and received a 'hold-in-abeyance' letter from the CHRC on 5/4/17. The letter instructed the facility to revoke any temporary approval in a position that involved direct care or supervision to patients. Further review of the Employees' Supervision Log revealed the person is currently working and being supervised through the week ending 6/16/17. A subsequent interview with the Food Service Director revealed that the employee in question had duties that involve delivery of supplies to the pantries on the residential living floors. An interview and record review with the Human Resources Director revealed the CHRC legal review was contacted on 5/4/17. The facility was informed that the employee could work if there was no direct resident contact. Part 402 of the CHRC expands the definition of an employee in direct care and supervision to include any unlicensed person employed by or used by a nursing home who has physical access to a residential living quarters. (10 NYCRR Section 402.7(a)(3)(i), 402.3(i)(1))

Plan of Correction: ApprovedJuly 13, 2017

Residents Affected by Deficiency:
No residents were identified as being affected by this deficiency.
Identifying Other Residents:
All residents could be affected by a recurrence of this deficiency so the Measure and Systemic Changes stated below are intended to correct deficiency for the current and future residents.
Measures and Systemic Changes:
1. Criminal History Record Check Policy will be revised to require any employee who receives a Hold-in-Abeyance letter restricting them from any position that involves direct care or supervision to patients, will no longer have access to residential living quarters/corridors.
2. In-service training to all department managers will be provided by Human Resource Manager to explain revision of policy and procedures in place for Criminal History Record Check Policy.
Quality Assurance Program:
A monthly audit of five employees Criminal History Record Check will be completed by the Human Resource Manager for three consecutive months with a report to the QAPI committee. If 100% compliance is attained, the audits will be completed for two consecutive quarters. The QAPI committee may discontinue the reports if 100% compliance is maintained through two consecutive quarters.
Person Responsible for Completion:
Human Resource Manager

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: August 18, 2017

Citation Details

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen and one of five nourishment rooms, the facility did not provide safe and sanitary food storage. Specifically, food in a freezer was potentially contaminated and refrigerators were not maintained at the required temperature. This is evidenced by the following: Observations on 6/20/17 at 10:45 a.m. revealed a temperature log attached to the side of the refrigerator in the sixth floor pantry showed daily temperatures between 50 and 60 degrees Fahrenheit (F) from 6/13/17 through 6/20/17. Each entry on the log was initialed 'GH.' Further observations revealed both the upper and lower door seals were cracked and damaged, and the dial for the temperature setting was at the coldest setting. The internal thermometer showed 60F and the refrigerator contained dozens of food items, including but not limited to, two half gallons of milk, macaroni salad, and chicken. A temperature of the Vitamin D milk was taken at that time and showed 48F. In an interview at that time, the Lead Maintenance Worker II stated that dietary staff checks the refrigerators and they usually tell us if there is a problem. The Food Service Director then voluntarily discarded several of the items in the refrigerator. When interviewed on 6/21/17 at 1:25 p.m., the Dietary Aide, who recorded the temperatures of the sixth floor pantry refrigerator, said that she usually checks the temperatures in the morning. She said the temperature should be about 40F. The Dietary Aide said that she did not tell anyone about the high temperatures. She said that she should have told the Food Service Director. During an observation on 6/20/17 at 11:39 a.m., there was frozen condensation icicles on the ceiling of the walk-in freezer and the temperature in the freezer upon entering was approximately 10F. Multiple boxes and bags of food items were also observed to have frozen condensate on them, including but not limited to, an open bag of chicken, a box containing bags of chicken and a box with an open bag of green beans. A tray including an uncovered cake and a tray of uncovered hot dogs were also located under the condensate icicles. There was a buildup of ice below the entry door to the walk-in freezer located inside of the walk-in cooler. When interviewed at that time, the Production Manager stated that he believed that there was an issue with the defrost cycle running too long in the freezer. He said that he was going to ask the refrigeration technician about it. He said that the freezer was installed incorrectly because the walls were not supposed to be that high. He said that the freezer walls extended below the insulation. The Production Manager stated that the condensate would be distilled, so it would not be a contaminant to the food that it dripped on. When interviewed on 6/20/17 at 11:51 a.m., the Food Service Director stated that it was not ok for condensate to drip onto food items in the freezer. He said that it would be a potential source for contamination. He stated that he would throw away any items that had been dripped on. The Food Service Director said he had put in multiple work orders to have the freezer fixed dating back approximately two weeks. When interviewed on 6/22/17 at 2:07 p.m., the Lead Maintenance Worker II stated that there was no paper work for maintenance requisitions for the freezer. He said there was an issue with the timing of the defrost cycles. (10 NYCRR: 14-1.40(a), 14-1.44, 14-1.95)

Plan of Correction: ApprovedJuly 13, 2017

Residents Affected by Deficiency:
No residents were identified as being affected by this deficiency.
Identifying Other Residents:
All residents could be affected by a recurrence of this deficiency so the Measures and Systemic Changes stated below are intended to correct thisdeficiency for current and future residents.
Measures and Systemic Changes:
A. Pantry Refrigerators
1. Refrigerator in pantry on 6th floor was removed and discarded. A replacement refrigerator that operates properly was immediately installed.
2. Refrigerators in pantries on all nursing unites have been inspected for proper operation, including gaskets, door closure seals and temperature stability. Repairs or replacement of refrigerators will be done.
3. Facility will purchase wireless, remote temperature sensors for all pantry refrigerators. Sensors will monitor temperatures on an ongoing basis, transmit readings to a computer for permanent logs, and send alarm notifications by email and cell phone to Maintenance, Food Service, and Nursing Supervisor staff when refrigerator temperatures exceed established safety parameters. System will also have a temperature monitor attached to the door of the refrigerator. Food Service Manager shall have access to temperature monitoring system.
4. In-service training will be given to dietary and nursing staff on the importance of maintaining and monitoring proper refrigerator temperatures for sanitation safety and the urgency of reporting above normal temperatures to Maintenance or Food Service Department immediately.
5. Preventive Maintenance Program will be revised to include an inspection of pantry refrigerators on a quarterly basis for proper temperatures and operation.
B. Walk-in Freezer
1. A new, replacement Mullian heater unit shall be installed around threshold and door to the freezer to allow gaskets to seal properly by eliminating frozen condensation accumulation. Proper closure of the door will minimize warm, moist air from condensing and freezing on the ceiling of the freezer.
2. Gaskets around freezer door will be inspected and adjusted to ensure proper closure.
3. Plastic curtain strips will be installed inside door to freezer to reduce influx of warm, moist air when freezer door is opened.
4. Refrigeration technician will investigate and adjust defrosting cycling mechanism to reduce warm, moist air from condensing and freezing on ceiling of freezer.
5. Procedure for stocking food in freezer will be modified to prevent overstocking of top shelf so that food cartons will not be too close to the cooling evaporator which should reduce condensation cause by proximity of frozen food to warmer evaporator unit.
6. Procedure for twice daily check of freezer temperatures shall be modified to include a check of freezer ceiling and food cartons for evidence of frozen condensation. If frozen condensation is present, procedure shall be to report to Food Service Manager, cover food cartons with tarp to prevent contamination from melting condensation, and removal of condensation from ceiling.
Quality Assurance Program:
1. Central Supply Clerk shall prepare a quarterly report on findings of Preventative Maintenance Program inspections of pantry refrigerator conditions and temperatures and present this report to the QAPI Committtee every quarter for one year.
2. Food Service Manager shall make a monthly report to the QAPI Committee on results of pantry refrigerator temperatures reports. If reports show proper temperatures for three consecutive months, the frequency of reports to the committee shall be reduced to quarterly for the remainder of the year.
3. Food Service Manager shall prepare a monthly report to QAPI Committee on results of daily checks of freezer for frozen condensation. If reports show no recurrence of food contamination from melting condensation for three consecutive months, the frequency of reports to the Committee shall be reduced to quarterly for the remainder of one year.
Person Responsible for Completion:
Food Service Manager

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: August 18, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of two residents reviewed for food consistency, the facility did not ensure that the residential environment remained as free of accident hazards as is possible. The issue involved the lack of effective monitoring of mechanically altered diets for Residents #138 and #167. This is evidenced by the following: 1. Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/2/17, revealed that the resident's cognition is severely impaired, requires supervision and set-up for eating, and receives a mechanically altered diet. The physician's orders, dated from 9/23/16 to current, included regular diet of mechanical soft texture. When observed on 6/20/17 at 12:31 p.m., the resident's lunch tray contained barbequed pork that was 3 inches long and stringy. Review of the tray ticket revealed the resident is on a mechanical soft diet with ground barbequed pork. The surveyor called over a Certified Nursing Assistant (CNA) before the resident started to eat to question whether this was an appropriate consistency. The CNA said the resident is on mechanical soft foods and the tray ticket included ground pork. The CNA said that she did not know, but did not think the meat was ground. At that time, the CNA called over the Licensed Practical Nurse (LPN) and asked if the pork was ground. The LPN stirred the meat around and said she did not think the pork was ground. The LPN said she would call the kitchen and ask. After calling the dietary office, the LPN removed the meat from the resident's tray and ground pork was later sent from the kitchen. 2. Resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/5/17, revealed that the resident is cognitively intact, eats with supervision and set-up assistance, and receives a mechanically altered diet. The physician's orders, dated from 9/22/16 to current, included regular diet of mechanical soft texture. When observed on 6/20/17 at 12:31 p.m., the resident's lunch tray contained barbequed pork that was 3 inches long and stringy. The tray ticket included mechanical soft diet and ground barbequed pork. This resident's meat was also removed by the LPN and replaced with ground pork. Interviews conducted on 6/22/17 included the following: a. At 11:21 a.m., the Food Service Director (FSD) said he was not aware of a problem with the barbequed pork delivered to the units in the wrong consistency on 6/20/17. He said that ground meat should be the size of a grain of rice. He said the person who puts the food on the tray checks the tray ticket for consistency. He said there is also a team leader at the end of tray line who checks each tray for accuracy. When interviewed at that time, the Baker said she was the person who logged in the call from the LPN who asked if the pork being served was ground. The Baker said she told the LPN no. She said the LPN asked for two servings of ground pork. She said at that time, the cook ground up two portions of pork. The Baker said that the LPN reported that two residents received the wrong consistency of pork. The Baker said she reported it to the Supervisor. b. At 11:32 a.m. the Supervisor said she was not made aware of this incident. c. At 11:34 a.m., the FSD said if he had known about this incident he would have started an investigation, looked at the tray tickets, looked at the production line sheets, and interviewed the cooks. d. At 11:40 a.m., the Dietary Aide said she was the one who served the hot foods on the tray line on 6/20/17 at lunch. She said she was also training another Kitchen Aide at that time. She said there were 10 residents who received ground barbeque pork. She said the pork was three inches or longer and stringy. She said that she thought that was ground consistency meat. e. At 11:46 a.m., the Dietician stated that for a mechanically soft diet the meat should be ground. She said that barbequed pork should not be 3 inches and stringy, it should be ground into very small pieces. The Dietician said that if a resident on a ground consistency diet ate whole pieces of meat, they could choke. When interviewed on 6/23/17 at 9:10 a.m., the Registered Nurse Manager said she expects that when staff set up trays, they make sure the food is the correct consistency. Review of the facility policy, Consistency Alterations, dated 2008, directed that for a mechanical soft diet the meat should be soft, tender, ground, shredded or chopped and well moistened with gravy or cream sauce. (10 NYCRR 415.12(h)(2))

Plan of Correction: ApprovedJuly 13, 2017

Residents Affected by Deficiency:
1. The incorrect food trays cited by surveyors for Residents #138 and #167 were removed and replaced with correct food trays at the time of survey.
2. Tray line supervisors in Food Service Department were instructed to review accuracy of each tray for Resident #138 and #167 before placement on food delivery cart.
3. Direct care staff assigned to nursing units where Residents #138 and #167 reside were given in-service training on how to check the food tray tickets and food trays for accuracy before serving meals to Residents #138 and #167. In-service training also focused on types of diet consistencies and the importance of ensuring accuracy of food consistency to prevent aspiration and choking.
4. Food service workers were given in-service training on proper trayline quality assurance procedures, including the importance of compliance of food tray contents with tray tickets specifying food consistencies.
Identifying Other Residents:
All residents could be at potential risk from a recurrence of this deficiency so the Measures and Systemic Changes stated below are intended to correct this deficiency for all current and future residents.
Measures and Systemic Changes:
1. Policy entitled ?Food Consistency? has been revised to include procedure that the staff persons who remove trays from food delivery cart shall check each item on the tray for accuracy to the tray ticket that specifies food consistency for each resident. Policy now requires the staff member who checks the tray to initial the tray ticket verifying that the tray is in compliance with the resident?s prescribed food consistency.
2. Policy entitled ?Accuracy and Tray Line Service? has been revised to require that Food Service Manager or designee shall supervise tray line accuracy on a periodic basis as part of the food service contractor?s quality assurance program.
3. In-service education on the revised policies for ?Food Consistency? and ?Accuracy and Tray Line Service? shall be provided to all food service staff, direct care nursing staff, and activities aides with emphasis on verification procedures for ensuring tray accuracy in food consistency, reporting of tray errors to food service department and requesting immediate correct replacement items before serving trays to residents.
4. In-service training, on importance of food consistency for resident safety and on procedures for ensuring accuracy of food trays served to residents, shall be provided during orientation process for new hires and annually for all existing direct care and food service tray line staff.
5. Food service contractor shall conduct evaluation of tray line procedures, especially the process for ensuring tray accuracy, and reorganize the tray line system and staff training accordingly. A report of this evaluation and reorganization shall be prepared for the administrator.
Quality Assurance Program:
1. Audits of 35 food trays per week, spread over all 3 meals, shall be conducted by the food service manager or designee. Audits shall review trays before placement in the food delivery carts and verify compliance with the residents? tray ticket, especially for food consistency. All errors shall be documented by type. Food service manager shall summarize audit results by day of week and meal and submit a report of findings monthly to QAPI Committee.
2. Audits of 5 food trays per week, spread over all 3 meals and all 5 nursing units for the same meals being audited by food service department, shall be conducted by nursing or activities staff. Audits shall review trays before serving to residents to verify compliance with the residents? tray ticket, especially for food consistency. All errors shall be documented by type, and the audit reports for each meal shall be submitted to the Director of Nursing. Director of Nursing shall summarize audit reports by day of week, meal and nursing unit and submit a report monthly to QAPI Committee.
3. After each month of weekly audits by food service manager and nursing staff, the QAPI Committee shall compare food service and nursing audit report findings and evaluate the effectiveness of the audit process in decreasing tray errors. A compliance rate of 95% or higher or tray accuracy for food consistency shall be the objective by the end of 3 months of audits. If a compliance rate of 95% or above has been achieved by the end of 3 months, the audits shall be reduced in frequency to 20 food trays per week, spread over all 3 meals, for 3 more consecutive months. If compliance rates fall below 95% in any month or quarter, QAPI Committee shall resume weekly or monthly audits schedule until assured that the system compliance is maintained at 95% or higher.
4. The food service manager shall make a presentation to the QAPI Committee on the food service contractor?s overall quality assurance program and shall submit documentation on the program?s findings as requested by the committee.
Person Responsible for Completion:
Director of Nursing

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: August 18, 2017

Citation Details

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of five residential sleeping units, the facility did not provide housekeeping services necessary to provide a sanitary, orderly and comfortable interior. Specifically, mold and mildew was found on ceiling heating panels in residential rooms. This is evidenced by the following: During an observation on 6/20/17 at 11:58 a.m., the ceiling in Resident Room #404 was noted to have brownish black debris on the ceiling tiles. Observations conducted on 6/21/17 between 12:45 p.m. and 1:04 p.m. revealed the following: a. In Resident Room #404, there was a large amount of black fungus like material found on the metal ceiling panels for the heating system. b. In Resident Room #406, there was black material around the holes in the metal ceiling pan. c. In Resident Room #415, there was black material around the holes in the metal ceiling pan. d. In Resident Room #310, there was black fungus like material around the holes in the metal ceiling panels. e. In Resident Room #309, there was a large amount of black fungus like material found on the metal ceiling panels. Interviews conducted on 6/21/17 included the following: a. At 1:05 p.m., Resident #182 stated that she had lived in Room #309 for approximately one year and that the black material had always been on the ceiling. The resident stated that she had wondered what the material was and that it looked dirty. b. At 1:15 p.m., Lead Maintenance Worker II stated that the metal panels are radiant heating panels. He said they have not had any issues with leaks in this system, but when the windows are opened they have had issues with condensation forming on the panels. He said they try to keep the windows shut for that reason. Lead Maintenance Worker II stated that they have not had issues with mold and mildew. He said they check for mold during the quarterly room audits, which were last done on Friday. He showed surveyor the quarterly room audit which did not mention any issues on the ceilings. c. At 1:31 p.m., Lead Maintenance Worker II used a paper towel and bleach and was able to easily clean the black material from the ceiling panel in Resident Room #309. At that time, he stated that they would have to get a list of the rooms to go around and clean them. He said he thought the black material was mildew. d. At 1:36 p.m., Housekeeper #1 stated that he had not cleaned the ceilings in about a year. He said he knows that when they are sweating, he has to clean them. The Housekeeper then stated that he cleans the ceilings when they catch his eye. He said that he should be looking at them weekly on the thorough cleaning day. When the surveyor showed the Housekeeper the ceilings in Resident Room #309 he stated that they should be cleaned. During an interview on 6/22/17 at 8:16 a.m., the Housekeeping Working Supervisor stated that if housekeepers see black stuff on the ceiling they need to clean it with bleach. The Housekeeping Working Supervisor stated that when the chiller is turned on the black stuff comes. She said it has happened for a long time, but she had not seen it yet this year. The Housekeeping Working Supervisor stated that if staff see the black stuff, they may not clean it right away, but they should return later when they have time and clean it. A review of the deep cleaning document provided by the Housekeeping Working Supervisor revealed that there was no procedure or policy regarding cleaning the ceilings in resident rooms. (10 NYCRR 415.5(h)(2))

Plan of Correction: ApprovedJuly 13, 2017

Residents and Areas Affected by Deficiency:
Ceiling panels in rooms 404, 406, 415, 310, and 309 have been cleaned with diluted bleach solution to remove all mold, fungus or black material accumulation. All evidence of black material has been cleaned off these ceiling panels.
Identifying Other Residents/Areas:
The individual responsible for the environmental preventive maintenance program has conducted an inspection of all 130 resident rooms. A list of rooms with ceiling panels showing evidence of mold or black material has been prepared. This list will be used for implementation of the Measures and Systemic Changes stated below.
Measures and Systemic Changes:
1. Added Housekeeping staff hours have been authorized to conduct a cleaning of ceiling tiles in every resident room in the facility (130 rooms) to remove accumulation of mold and black material. Upon the completion of this facility-wide cleaning program, a system of regular preventive cleaning measures will be initiated to deter growth of mold throughout the year.
2. Housekeeping cleaning procedures for resident rooms have been revised to incorporate wiping and cleaning of ceiling panels with bleach solution as part of the regularly scheduled full room cleaning done once a week for each resident room.
3. In-service training will be given to every member of the Housekeeping staff on new cleaning procedures for ceiling panels in resident rooms. Training will include presentation on the reasons why mold accumulates, how it should be cleaned off and why the mold poses both appearance and health concerns.
4. Housekeeping Supervisor or designee shall perform walk-through rounds daily on weekdays of every resident room that has undergone full cleaning. A log of these rounds shall be maintained showing date of inspection, room number, and condition of ceiling panels with regard to mold. The weekly logs of the ceiling panel inspections shall be submitted to the Maintenance Supervisor or Administrator on a weekly basis until otherwise directed.
Quality Assurance Program:
The Central Supply Clerk shall perform environmental rounds of each nursing unit, including every resident room, as part of the Preventive Maintenance Program on a quarterly basis. An inspection of ceiling panels in every resident room shall be part of the checklist of items that are recorded in the Preventive Maintenance Program software reports. A report of the ceiling panel inspections shall be prepared and submitted quarterly to the OAPI Committee for at least two quarters. If 100% compliance in ceiling panel cleaning of mold and black material has been attained for two consecutive quarters, the QAPI Committee may discontinue the quarterly reports. However, the weekly reports to Maintenance Supervisor shall be continued indefinitely until otherwise directed by the Administrator.
Person Responsible for Completion:
Maintenance Supervisor

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: June 23, 2017
Corrected date: August 18, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for 2 of 33 residents reviewed for care planning, the facility did not revise the care plan to reflect the current status of a resident. Issues involved a serious head injury and laceration (Resident #123), and weight loss (Resident #215). This is evidenced by the following: 1. Resident #123 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/16/17, revealed that the resident's cognition is severely impaired and a history of falls. When observed on 6/20/17 at 11:57 a.m., the resident had an undated white gauze dressing that was clean and dry on her forehead, secured with paper tape. When observed again on 6/21/17 at 12:44 p.m. and 3:11 p.m., and on 6/22/17 at 8:08 a.m., the resident had the same white gauze dressing on her forehead. The Hospital Discharge Summary, dated 6/19/17, directed to change the dressing as needed and keep the area clean and dry. Review of the current Certified Nursing Assistant (CNA) Care Plan and the Comprehensive Care Plan (CCP) revealed no documentation of the forehead wound. Review of the physician's orders, Medication Administration Record [REDACTED]. Interviews conducted on 6/22/17 included the following: a. At 1:18 p.m., the Registered Nurse (RN) stated that she knew the resident had a dressing on the forehead. The RN said that she is not aware of any orders to monitor or change the dressing. The RN said she thinks there should have been an order to at least monitor the wound every shift. b. At 1:48 p.m. and 6/23/17 at 8:54 a.m., the RN Manager (RNM) said that she changed the resident's dressing on 6/19/17, when the resident was readmitted to the facility. The RNM said that she did not write an order for [REDACTED]. She said she should have updated the resident's care plan. 2. Resident #215 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/24/17, revealed that the resident's cognitive skills for daily decision making is severely impaired and the resident's weight is 141 pounds (lbs.). Review of the Weight Summary Report revealed the resident's weight on admission was 149.9 lbs. On 4/3/17, the resident's weight was 138.6 lbs. and on 6/1/17, the resident's weight was 138.8 lbs. There was a weight loss of 11.1 lbs. since admission. The Nutritional Assessment, dated 4/3/17, revealed that the resident required limited assistance with eating, consumed 75 to 100 percent of solids, and the resident's most recent weight was 149.9 lbs. The Nutritional Care Plan, dated 4/3/17, included a goal to maintain the resident's weight of 150 lbs. (plus or minus 5 percent). A RN documented on 4/13/17 that the resident fed himself after the tray was set up, and his weight was down since admission. There was no further documentation regarding weight loss through 6/23/17. The physician documented on 4/24/17 that the resident's weight was 140.6 lbs. Interviews conducted on 6/22/17 included the following: a. At 10:12 a.m., the Registered Dietician (RD) stated weights are completed every month and reviewed by dietary. She said any resident with a 5 lb. weight loss or gain is addressed in a progress note. The RD reviewed the progress notes and stated there was no documentation regarding weight loss. The RD stated that the resident's weight loss should have been addressed in the CCP. b. At 9:05 a.m., the Nurse Manager (NM) stated that the resident's care plan should have addressed the weight loss. She said a 10 lb. weight loss should be addressed by dietary and nursing. Review of the facility policy, Comprehensive Care Plan, dated (MONTH) 2012, revealed that the Interdisciplinary Team will devise a CCP for each resident, which will be reviewed, updated and changed when there are major changes. The care plan will be revised to meet the status of the resident. (10 NYCRR 415.11(c)(3)(ii))

Plan of Correction: ApprovedJuly 13, 2017

Residents Affected by Deficiency
1. The revisions to the comprehensive care plans for Resident #123 and Resident #215 have been corrected to reflect changes in condition in the Electronic Health Record Comprehensive Care Plan.
2. RNM and Dieticians where Resident #123 and Resident #215 reside were given in-service training regarding updating the Comprehensive Care Plan and Certified Nursing Assistant Care Plan to reflect a change in Resident condition in the Electronic Health Record
Identifying Other Residents
All Residents could be at potential risk from a recurrence of this deficiency so the Measures and Systemic Changes stated below are intended to correct this deficiency for all current and future residents.
Measures and Systemic Changes
1. Policy entitled ?Comprehensive Care Plan? will be modified to include revision of the Resident Comprehensive Care Plan when a resident returns from the hospital or experiences a change in condition.
2. In-service education on the revised policy for ?Comprehensive Care Plan? with emphasis on modification for a change in condition or hospital re-admission to all clinical staff who are involved in formulation and revision of the Comprehensive Care Plan.
3. In-service education will be provided to Admission Coordinator?s, Registered Nurses, and Licensed Practical Nurses to review hospital discharge orders; consult with the facility medical provider to obtain orders based upon hospital recommendations, and to enter received medical orders in the Electronic Health Record that will populate received orders on the Medication Administration Record/Treatment Administration Record.
4. In-service education will be provided to MDS Coordinators to evaluate Resident Comprehensive Care Plans for revisions upon discharge from the hospital or Resident a change in condition.
5. MDS Coordinators will conduct evaluations of Resident Comprehensive Care Plan?s emphasizing documentation in the plan upon return from the hospital or a change in condition.
Quality Assurance Program
1. Audits of eight Comprehensive Care Plans will be conducted by the MDS Coordinator or designee per month. Audits shall review hospital discharge summary recommendations for consultation with the facility medical provider and entry into the Resident Electronic Health Record for accuracy. A report of the audit findings shall be prepared by the MDS Coordination Manager for presentation to the QAPI Committee monthly for a period of three months. By the third month of the audits, if the findings show 100% accuracy, the QAPI Committee will reduce the audits frequency summary report to the QAPI Committee to once per quarter for two consecutive quarters. If the findings continue to show 100% compliance with Comprehensive Care Plan revisions accuracy, the QAPI committee may discontinue quarterly reports.
Person Responsible for Completion:
Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:ALCOHOL BASED HAND RUB DISPENSER (ABHR)

REGULATION: Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: August 18, 2017

Citation Details

Based on observations and interviews conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain alcohol based hand rub solutions (ABHR) dispensers. This is evidenced by the following: 1. Observations during the initial tour of the facility on 6/20/17 at 11:15 a.m. revealed an ABHR dispenser located directly above a duplex electrical outlet in the hallway between Resident Rooms #515 and #516. 2. Observations on 6/21/17 between 8:40 a.m. and 9:40 a.m. revealed ABHR dispensers located directly above duplex electrical outlets in the hallways at the following locations: between Resident Rooms #615 and #616, between Resident Rooms #415 and #416, between Resident Rooms #419 and #420, between Resident Rooms #315 and #316, between Resident Rooms #318 and #319, and between Resident Rooms #223 and #224. 3. Observations on 6/21/17 at 10:30 a.m. revealed the bags containing the ABHR were marked with a label that stated the contents were 62 percent ethyl alcohol. Further interview with the Lead Maintenance Worker II revealed an outside company had come in and installed the ABHR dispensers. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.3.2.6(8))

Plan of Correction: ApprovedJuly 13, 2017

Residents/Areas Affected by Deficiency:
All Alcohol dispensers cited in SOD were removed at time of survey and re-installed at locations situated away from electrical outlets.
Identifying Other Residents/Areas:
An inspection of all alcohol dispensers in the facility has been conducted to determine if any other dispensers were installed above electrical outlets. Two dispensers above electrical outlets were located on one nursing unit, and they have been removed and re-installed at locations away from electrical outlets.
Measures and Systematic Changes:
1. Safety Policy will be revised to require that all alcohol dispensers are installed in locations that are not above or adjacent to electrical outlets. Policy will further require that all installations or removal of alcohol dispensers must be coordinated through the Central Supply Clerk who will designate exactly where dispensers can be installed to ensure that no dispensers are installed above outlets.
2. In-service training will be provided by Central Supply Clerk to all Maintenance and Housekeeping staff on the requirements for safe installation of alcohol dispensers. Training will include a review of the Safety Policy revision and procedures for having the installation, removal or relocation of all dispensers coordinated through the Central Supply Clerk.
3. The Preventive Maintenance Program will be revised to include a quarterly inspection of each nursing unit's and ground floor alcohol dispensers to verify proper placement with documentation of the findings.
Quality Assurance Program:
The Central Supply Clerk shall perform environmental and equipment rounds of each nursing unit, including resident rooms, as part of the Preventative Maintenance Program on a quarterly basis. An inspection of alcohol dispensers for proper installation and location shall be a component of the Program rounds, and a report of the inspection findings shall be prepared and submitted quarterly to the QAPI Committee for two quarters. If 100% compliance in inspection reports has been attained for two consecutive quarters, the QAPI Committee may discontinue the quarterly reports.
Person Responsible for Completion:
Central Supply Clerk

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: August 23, 2017

Citation Details

Based on observations conducted during the Life Safety Code Survey, it was determined that for one of two exits from the first floor cafeteria, the facility did not properly maintain an exit discharge pathway. Specifically, a discharge pathway was uneven and lacked a proper step-down. This is evidenced by the following: Observations in the presence of the Lead Maintenance Worker II on 6/21/17 at 10:47 a.m. revealed a designated exit from the first floor cafeteria opens to a blacktop exit discharge pathway that was uneven. The pathway was observed to have multiple cracks and dips along the surface leading to the public way. Additionally, the exit door opened to a level surface that only extended out approximately 24-inches from the doorway before a single step-down to the blacktop pathway. The exit door from the cafeteria was observed to be approximately 43 ¾-inches wide. Further observations at that time revealed a resident in a wheelchair with a family member seated in the cafeteria. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.2.7, 7.7.4, 7.2.1.3.1, 7.2.1.3.2, 7.1.6.3)

Plan of Correction: ApprovedJuly 17, 2017

Residents/Areas Affected by Deficiency: No residents were identified as being affected by this deficiency.
Identifying Other Residents/Areas: All other exits and discharge pathways were reviewed to determine that they had a proper step-down and an even surface was maintained on the pathway. A review of the exits found the North Hall exit to be lacking a proper step-down in accordance with Life Safety Code. All other exits and discharge pathways were found to be in compliance.
Measures and Systemic Changes:
The step-down for the first floor cafeteria and North Hall exit will be replaced by concrete pads that will meet Life Safety Code Regulations. The discharge pathway from the first floor cafeteria will be repaved to ensure an even pathway that will comply with Life Safety Code Regulations.
The facility will submit a time-limited waiver request to the Bureau of Architecture and Engineering Review (BAER) in Albany by a Monday, (MONTH) 17, (YEAR). The waiver will request a finish date of 12/31/17, at which time all corrective actions will be complete.
Quality Assurance Program:
Upon completion of the project, the Lead Maintenance Worker will perform a monthly inspection of all exit discharge pathways from the facility to ensure they maintain a proper step-down and the pathways maintain an even surface. The report of these inspections will be submitted to the QAPI Committee for two consecutive quarters. If 100% compliance in both quarters, the QAPI Committee may discontinue the reports.

Person Responsible for Completion:
Lead Maintenance Worker