Loretto Health and Rehabilitation Center
February 14, 2017 Certification/complaint Survey

Standard Health Citations

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: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not consistently provide a safe environment and adequate supervision for 1 of 18 residents (Resident #8) reviewed for accidents. Specifically, Resident #8 was on aspiration precautions and was not positioned or provided supervision as care planned when consuming fluids. Findings include: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. She had an upper body impairment on one side, and required extensive assistance of 2 staff for most activities of daily living (ADLs). A 10/9/2014 Aspiration Precautions memo in the resident's chart documented a patient/resident on aspiration (food or liquid breathed into airway) precautions cannot have food/beverages in their room without staff supervision, to include thin liquids. The Safe Feeding Plan policy revised 7/15/2015 documented if a resident was on aspiration precautions, the order from the physician or recommendation from speech therapy would be transcribed by the registered nurse (RN) to the care plan, medication administration record (MAR), and certified nurse aide (CNA) assignment sheet. The policy documented if a resident on an unmodified diet chose to eat in their room, a staff member would observe the resident for the entirety of the meal. The Aspiration Precautions Guidelines policy revised 10/2015 documented measures were implemented to prevent or lessen the risk of food, fluids or other ingested material from entering the respiratory tract. Interventions included encourage resident to eat slowly, maintain an upright position throughout the meal and for 30 minutes afterward, observe for signs of airway obstruction, and monitor for changes in facial color. The comprehensive care plan (CCP) revised 11/11/2016 documented the resident had a history of [REDACTED]. The CCP documented she was at risk for aspiration related to her poor posture, left-sided paralysis, dysphagia (difficulty swallowing foods or liquids), and impaired respiratory and swallowing coordination secondary to morbid obesity. Interventions included following the guidelines for aspiration precautions. A therapy trigger form dated 11/29/2016 requested the resident be evaluated to discontinue aspiration precautions due to being on a regular, unmodified diet. The speech therapist's recommendation dated 11/30/2016 documented the resident was at high risk for aspiration, and to continue with aspiration precautions. The certified nurse aide (CNA) care instructions revised 2/10/2017 documented the resident required total assistance for ADLs. She was set-up assistance with meals, and ate meals in her room with staff present due to being on aspiration precautions. The 2/2017 medication administration record (MAR) documented the resident was on aspiration precautions. The resident was observed: - On 2/10/2017 at 1:55 PM, lying in bed drinking a light-colored beverage. The head of the bed was elevated, and the resident was slouched and leaning to the right. There were no staff or family member of the resident present in the room. - On 2/13/2017 at 12:40 PM, lying in bed drinking a blue-colored beverage. The head of the bed was elevated, and the resident was leaning to the right. There were no staff or family member of the resident present in the room. During an interview on 2/13/2017 at 3:10 PM, CNA #45 stated the resident's husband would come during supper and stay with her during the meal. During an interview on 2/13/2017 at 3:15 PM, CNA #46 stated staff tried to get the resident out of her room, but she preferred to stay in it. She stated the resident's husband visited every day for supper and stayed with her while she ate. She stated a staff person was to be with the resident at all times when she had meals or nourishments because of the resident being on aspiration precautions. During an interview on 2/15/2017 at 9:00 AM, registered nurse (RN) Manager #47 stated staff know the resident cannot be unattended in her room with food and drinks, and these items should not be within her reach when staff were not there. She stated the resident was on aspiration precautions because of her posture, and the head of the bed needed to be up as high as possible whenever she ate. She stated the resident and her husband had been educated by speech therapy and nursing regarding her aspiration risk when eating and drinking in her room. During an interview on 2/15/2017 at 9:25 AM, CNA #48 stated staff were with the resident at all times whenever she ate, but she thought it was okay for her to have drinks when staff were not in the room with her. During an interview on 2/15/2017 at 11:05 AM, speech-language pathologist #50 stated a resident's family member cannot assist with feeding without education first, which is typically done by nursing. She stated the resident was on aspiration precautions and needed to have the head of the bed at 90 degrees when she was eating or drinking. She stated the speech therapy department periodically received referrals from nursing asking for the aspiration precautions to be discontinued, but the resident was not safe to be removed from these precautions because of her posture. During an interview on 2/15/2017 at 11:10 AM, occupational therapist (OT) #51 stated she recalled the recent evaluation requesting the resident be discontinued from aspiration precautions. She stated the resident should have pillows propped under her right side and the head of the bed at 90 degrees when she was eating. She stated the resident should definitely not have food or drinks in the room without staff supervision. 10NYCRR 415.12(h)(1)(2)

Plan of Correction: ApprovedMarch 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8 was assessed for adverse effects in relation to aspiration and no indications are noted.
Residents with order for aspiration precautions were evaluated to ensure the facility policy and procedures are consistent with physician orders.
Staff are to be in the room with residents on Aspiration Precautions as indicated in the facility policy. The family member was previously trained by Speech therapy to ensure safe practice and feeding assistance when he is in the room with the patient. The family member is to report to the LPN when they leave the facility and the LPN checks the room to ensure no food items are left in the room after the visit. The LPN is signing for hourly checks on the medication administration record that room checks were done to ensure no items are present.
Re-education will be completed by the education department to all staff, including all disciplines, regarding the facility policy and procedure regarding Aspiration Precautions and the steps if noncompliance is indicated. Aspiration Precautions is listed on the CNA Assignment Sheet and on a list in the dining room that reflects individuals on aspiration precautions.
Audits will be conducted across all shifts during the work week on all residents with physician orders [REDACTED]. The weekend monitoring is conducted by the LPN with hourly room checks signed on the medication administration record and checking the room after the family member leaves the room. The CNA staff that are assigned to residents and it is indicated on the CNA Assignment sheet that hourly checks are completed to ensure food and beverages are removed from the room. This audit will be completed on all nursing units for a minimum of three (3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings to ensure compliance is met and reoccurrence is prevented. The Quality Assurance Committee will provide input on the need to continue, discontinue, or modify the audits after a three (3) month period.
The date for correction is (MONTH) 14th. The Director of Nursing is responsible to ensure continued compliance.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure it maintained an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection for 3 of 10 employees (Employees #42, 43, and 44), reviewed for influenza (flu) vaccination, and for 1 of 1 residents (Resident #19) reviewed for tracheostomy care. Specifically, there was no documentation 3 staff members either received the flu vaccine or signed a declination form. In addition, Employee #43 was observed wearing a face mask incorrectly. For Resident #19, the tracheostomy tubing's water trap became disconnected and was lying on the floor, and the contaminated water trap was reconnected and not replaced with a new, clean one. Findings include: 1) Resident #19 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired and he was totally dependent for all activities of daily living (ADLs). A physician progress notes [REDACTED]. The comprehensive care plan (CCP) dated 1/17/2017 documented the resident was at risk for aspiration and alteration in respiratory function, as he had a tracheostomy in place. Interventions included to provide the resident with heated, humidified oxygen via the tracheostomy. During an observation on 2/10/2017 at 1:04 PM, the resident was in the unit lounge with a trach collar over his tracheostomy that was delivering heated, humidified oxygen. Attached to the trach collar was blue, fluted tubing that was connected to an oxygen compressor. In the middle of the blue, fluted tubing between the trach collar and the compressor was a white connection, and a small plastic bottle was observed lying on its side underneath the tubing on the floor. A licensed practical nurse (LPN) came over and asked what happened to the bottle. She picked up the small plastic bottle from the floor and reattached it to the white connection on the blue, fluted tubing. The LPN stated it was a water trap that collected excess water so the water did not go up into the resident's tracheostomy. At 1:10 PM, the LPN came back with a new water trap and disconnected the old one from the tubing, threw it into the garbage, and replaced it with a new water trap. During an interview with the infection control nurse registered nurse (RN) #35 on 2/15/2017 at 1:00 PM, she stated she would not expect staff to pick up the water trap and reattach it, as the floor was dirty. She stated she would expect staff to discard the water trap from the floor, and put on a new/clean one. During an interview with RN Manager #3 on 2/15/2017 at 1:30 PM, she stated she was aware the nurse had reattached the water trap after picking it up from the floor. She stated that it was okay as it was only on and reconnected for a minute so she could get a new one to put on. She stated she was told that it was okay to reattach the one from the floor by the Assistant Director of Nursing and a nurse practitioner. 2) On 2/10/2017 at 12:13 PM, Employee #43 was observed talking to an unidentified resident. The resident asked her why she was wearing a mask, she pulled the mask down under her chin and stated, I didn't get a flu shot. I have to wear this stupid thing. At 12:25 PM, Employee #43 was observed passing trays in the dining room and wearing a face mask that was not covering her nose and was placed just above the mouth. During a review on 2/14/2017 of the personnel files for Employees #42, 43, and 44, there was no documented evidence found that the influenza vaccination was offered to the employees. There was no evidence they declined the vaccination and were provided with education on the risks of declination. During an interview on 2/15/2017 at 10:50 AM, Employee Health Nurse Practitioner (NP) #41 stated all employees must either receive a flu vaccine (annually) or wear a face mask once the flu season was called. She stated the influenza season was announced in late 12/2016. She stated staff members had the right to refuse the flu vaccine and then must wear a mask. She stated that would be documented in their employee health file. If the staff member declined to receive the vaccine, they would be required to sign a declination form, which would be placed in the employee's health record. They would be required to wear a mask over their nose and mouth in all resident care areas. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedMarch 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Employees #42, 43 and 44 signed their influenza declination forms and were educated on the benefits of the vaccine and the risks of not receiving the vaccine. Employee #43 was not educated on the proper use and how to wear a face mask and was provided a written copy of instructions on applying, wearing and removal of face mask. Resident #19 had the water trap replaced.
Employee files were reviewed by employee health and any employees that were lacking consent for the influenza vaccine or declination were notified to ensure proper documentation was obtained. The facility census was reviewed and noted that no other residents were residing in the facility with physician orders [REDACTED].
Re-education with be completed by the education department to all staff regarding the facility procedure for obtaining an influenza vaccine or signing a declination within a one month time period of the initiation of flu season of each year and the proper use of a face mask including applying, wearing and removing. If an employee declines the influenza vaccine, the employee health nurse will educate the employee on the proper procedure to apply, wear and remove a face mask and a copy of the procedure will be provided to the employee. A statement will be added to the Facility Employee Influenza Vaccine Declination Form to reflect the employee has been educated. All staff will be re-educated on the facility policy and procedure regarding infection control practices with resident equipment for residents with tracheostomies and humidified oxygen.
Employee Health will complete and maintain audits of all employee health files during the influenza season each year. These audits will be completed weekly to ensure proper documentation is in place. Employee Health will reach out to employees that are not in compliance. Employee Health will complete and maintain audits on employees that have not obtained the influenza vaccination or have signed a declination to ensure the employees are properly applying, wearing and removing face masks. These audits will be completed weekly for the duration of the influenza season. The level of accepted compliance is 100%. The Infection Control RN will complete monthly audits on infection control practices for those residents with tracheostomy appliances. This audit will be completed for a minimum of three (3) months and the level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings to assure compliance is met and reoccurrence is prevented. The Quality Assurance Committee will provide input on the need to continue, discontinue or modify the audits after the three (3) month period.
The date for correction is (MONTH) 14th. The Administrator is responsible to ensure continued compliance.

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 946) it was determined for 2 of 30 residents (Residents #16 and 18) reviewed for nutritional status, the facility did not ensure all residents maintained acceptable parameters of nutrition status. Specifically, Resident #16 was admitted with multiple comorbidities, there was no documentation the resident's weight was routinely monitored following admission, and the resident had a significant weight loss once weighed. For Resident #18, there was no documentation the resident was provided adequate nutrition and timely services by qualified clinical nutrition staff. Findings include: 1) Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired and he did not have any behaviors. He required extensive assistance for transfers, dressing and personal hygiene, and required supervision with eating. Physician orders [REDACTED]. A nursing progress note dated 6/28/2016 documented the resident was adjusting well to the new unit and his appetite was fair. A nurse practitioner (NP) admission note dated 6/28/2016 documented the resident was recently diagnosed with [REDACTED]. The resident was too weak to return home, so he was admitted for rehabilitation with a goal to return home. The comprehensive care plan (CCP) dated 6/28/2016 did not contain any information regarding the resident's nutritional or hydration status. A social work progress note dated 6/29/2016 documented the resident was admitted to the facility for short term rehab with a goal to return home. A certified nurse aide (CNA) assignment sheet (care instructions) dated 6/29/2016 documented the resident was on a 1500 ml fluid restriction. The 6/2016 Medication Administration Record [REDACTED]tap water restriction and 240 ml with meals. The registered dietitian (RD) initial nutrition assessment dated [DATE] documented the resident was admitted to the facility the day before and was placed on a NAS, low potassium and [MEDICATION NAME], unmodified diet with a 1500 ml fluid restriction. The resident went to [MEDICAL TREATMENT] 3 times weekly. The resident's estimated protein needs were 99 grams per day and 1500 ml of fluid per day. The resident consumed 75% of his first meal at the facility and 25% of breakfast and lunch. Supplements would be Nepro (low potassium/phosphorus/fluid) 8 ounces in the evening and night time. The plan was to follow up with the resident as needed to encourage intakes, a plan of care check to follow in 1-2 weeks, and to follow up with the [MEDICAL TREATMENT] dietitian for weights/labs/recommendations. A nursing progress note dated 6/30/2016 documented the resident had a low grade temperature and had emesis (vomiting). A physician progress notes [REDACTED]. An NP progress note dated 7/5/2016 documented the resident was seen for low blood pressures and was given fluids while at [MEDICAL TREATMENT]. An NP progress note dated 7/8/2016 documented the resident's significant other requested the resident be restarted on his [MEDICAL CONDITION] medications, and a call was placed to the resident's oncologist. It was decided a decision would be made at a follow up appointment, as the resident had a poor generalized condition and poor intake. A dietary progress note dated 7/8/2016 at 5:22 PM documented the resident declined interview and wanted to rest. The resident was reminded to request items as desired. Intakes were encouraged, including the consumption of Nepro. The meals consumption records documented: - On 6/28/2016, the resident consumed 75% of dinner; - On 6/29/2016, the resident consumed 25% of breakfast, 25% of lunch, and 50% of dinner; - On 6/30/2016, the resident was not present for breakfast, and refused lunch and dinner; - On 7/1/2016, the resident consumed 25% of breakfast, refused lunch, and consumed 25% of dinner; - On 7/2/2016, the resident refused all three meals; - On 7/3/2016, the resident consumed 25% of breakfast, 0% for lunch and 50% of dinner; - On 7/4/2016, the resident refused breakfast, consumed 25% of lunch, and refused dinner; - On 7/5/2016, the resident was not present for breakfast, refused lunch, and consumed 50% of dinner; - On 7/6/2016, the resident refused all three meals; - On 7/7/2016, the resident consumed 75% of both breakfast and lunch, and refused dinner; - On 7/8/2016, there was no documentation for the breakfast and lunch meal, and he refused dinner; - On 7/9/2016, he consumed 50% of breakfast, was NPO (nothing by mouth) for lunch, and had 50% of dinner; - On 7/10/2016, he refused all three meals; and - On 7/11/2016, he consumed 25% of breakfast, and refused the lunch meal. A hospital transfer form dated 7/11/2016 at 3:15 PM documented the resident was transferred to the emergency room for low blood pressures and increased confusion, as well as family and resident request. There was no documented evidence in the MAR indicated [REDACTED]. During an interview with CNA #52 on 2/15/2017 at 10:35 AM, she stated if a resident needed food and fluids encouraged, it would be documented on the CNA assignment sheet. She stated CNAs did not attend morning report, as the LPNs (licensed practical nurses) and RNs (registered nurse) on the unit did. During an interview with RN clinical coordinator #37 on 2/15/2017 at 10:40 AM, she stated the CNAs were responsible for inputting food and fluid consumption for meals in the computer, and nourishment consumption was documented on a separate form that was not in the computer. She stated each nurse on the unit was responsible for running an ADL report at the end of each shift for the residents they were responsible for, to review and monitor how much the resident's intake was. She stated if a resident was not eating or drinking well, the CNAs on the unit were very good about notifying the nursing staff, and the nursing staff would notify the NP or physician. During an interview with LPN #54 on 2/15/2017 at 10:55 AM, he stated he was not aware of what an ADL report was and dietary would monitor a resident's intake. He stated CNAs were good about letting him know if a resident was not eating or drinking, and if they needed encouragement, that would be added to the CNA assignment sheet. During an interview with RN #38 on 2/15/2017 at 11:15 AM, she stated if a resident was on [MEDICAL TREATMENT], a weight would be obtained there and not at the facility, as that was facility policy. She stated the RD was responsible for monitoring a resident's intake. She stated the LPNs and CNAs on the unit would also report a low intake, and the LPNs would push fluids, and that would be added to the resident's CNA assignment sheet. During an interview with RD #53 on 2/15/2017 at 11:25 AM, she stated when a resident was admitted , she would check in with them within 24-72 hours after their admission. She would complete a full nutritional assessment at that time, as well as initiate communication with the RD at the [MEDICAL TREATMENT] center. She stated she would do a follow up in another 2 weeks, or as needed if she was notified the resident was not taking in foods or fluids well. She stated she did not run any reports that would let her know how much a resident was consuming and the LPNs or the CNAs would let her know if someone's intake was poor. She stated if she was notified, she would initiate a supplement or update the resident's preferences after she reviewed the resident's consumption records. She stated she could not recall the resident, and had reviewed her emails prior to the interview and did not have a record of any communication with the RD at the [MEDICAL TREATMENT] center. She stated she would keep and document in a progress note any communication with the [MEDICAL TREATMENT] RD. She stated a resident's weight was obtained at [MEDICAL TREATMENT] and she would be notified of the resident's weight by reviewing the [MEDICAL TREATMENT] communication book. 2) Resident #16 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately cognitively impaired. He required extensive assistance with eating, was on a therapeutic (modifies intake of certain foods or nutrients) diet, and had no known weight loss or gain. The physician progress notes [REDACTED]. He had elevated blood pressure and was on [MEDICATION NAME]. The weight report dated 7/8/2016 at 4:16 PM documented the resident's weight was 180 pounds. A diet technician progress note dated 7/8/2016 at 5:29 PM documented the resident fell asleep multiple times during interview and the technician was unable to obtain preferences. The technician noted, per the facility's screen paper work, the resident weighed approximately 180 pounds and it was unknown if it was actual or stated weight. The resident's weight was pending. The comprehensive care plan (CCP) dated 7/8/2016 documented the resident was at nutritional risk. The initial nutrition screen was completed, and the resident was to be weighed monthly and provided adequate nutrients to meet needs. The CCP dated 7/11/2016 documented the resident required minimum assistance of 1 for eating. The resident had the potential for weakness, weight changes, decreased stamina, and alteration in cardiac status. The resident was to be observed for hyper/[MEDICAL CONDITION] by looking at weight changes. A registered dietitian (RD) progress note dated 7/13/2016 documented the resident weighed 180 pounds and had a lack of appetite. An addendum to the note documented there was limited nutrition and weight history and the resident was unable to provide detailed nutrition history. The resident's intake was below 50% at all times, and he needed encouragement at meals. A 7/13/2016 update to the CCP documented the resident consumed 43% of 15 meals since admission. There were no updates to the nutritional care plan between 7/13 and 10/10/2016. A physician progress notes [REDACTED]. The physician would have the facility check orthostatic blood pressure for 5 days and then re-evaluate to see if this was the cause of the resident's falls. A physician progress notes [REDACTED]. An RD progress note dated 7/27/2016 documented the resident was taking 43% at meals. Staff were encouraging intake of food. Efforts to redirect the resident were challenging. The resident would be followed at MR risk at all times. There was no definition of MR in the note. An addendum to the 7/8/2016 RD note added by the RD on 7/27/2016 at 1:48 PM documented the resident weighed 180 pounds and was 68 inches in height. There was no documentation if this was a new weight or the initial weight found on the resident's screen prior to admission. A psychiatric nurse practitioner (NP) progress note dated 8/15/2016 documented the resident was on medication that had risk of decreased appetite and weight loss. It was recommended to monitor for weight loss, and specifically to weigh and track the resident's BMI (body mass index- measure of body fat) monthly for 3 months and then quarterly. The nutrition weight record had no documentation the resident was weighed in 7/2016 or 8/2016. The record documented the resident was weighed week 1 in 9/2016 and weighed 156.8 pounds (23.2 pounds/12.8% significant loss in 2 months). Psychiatric NP progress notes dated 9/1, 9/12, 9/27, and 10/10/2016 had no documentation the resident's weights were reviewed. An RD progress note dated 10/10/2016 documented a quarterly assessment was completed. The resident weighed 154.8 pounds (25.2 pounds/14% significant loss from the noted 180 pounds on admission). The resident would be weighed monthly. The note documented the resident's intake was approximately 33% at meals, and the resident's previous intake was 43%. The note documented the resident weighed 156.6 on 9/16/2016. There was no documentation where this weight was obtained from, as it was not documented on the resident's weight record. There was no documentation in the resident's record regarding the 9/16/2016 weight or if changes were implemented to address the weight loss. During an interview with RD #39 on 2/15/2017 at 10:25 AM, she stated the Unit scale was broken in 7/2016 and the resident's first weight was obtained in 9/2016. She stated residents were generally weighed monthly. She stated she would need residents' weights to complete accurate nutritional assessments. RD #39 stated when the resident was weighed in 9/2016, he weighed in the 150's. The RD did not feel the resident's weight loss started prior to 11/2016. She stated super foods (fortified foods), ice cream, potatoes, and milkshakes were implemented after 11/2016 weights were obtained. 10NYCRR 415.12(i)(1)

Plan of Correction: ApprovedApril 13, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #16 weights were measured monthly once unit scale was repaired and resident allowed. There were nutritional interventions in place. resident is no longer in the facility.
#18 is no longer a resident of the facility.
Identifying others: The Nutrition Staff will review the names of residents whose monthly weights not obtained by the 8th day of the month to the Nurse Manager or designee via email with cc to ADON and Administrator. Audit of food and fluid consumption for all rehab [MEDICAL TREATMENT] residents.
The facility will take the following measures to ensure all residents maintain acceptable parameters if not stated. When scales are broken, the NM, or designee will follow the process for broken equipment. A scale will be used from an alternate unit until the equipment is repaired. The process for newly admitted patients is to weighed weekly for the first month, then monthly unless otherwise indicated with a physician order. To ensure this practice for others residing in the facility, the Director of Nutrition will educate the nutrition staff on this process and if the weights are not completed timely the Director of Nutrition will contact the ADON for follow up. The Nutrition Staff will review the monthly weights. The NM, or designee will communicate to the IDCT via email, that the scale is broken. The NM or designee will let the IDCT know when the scales are repaired. When unit scales are broken, the Registered Dietitian or Dietetic Technician will notify the Director of Clinical Nutrition. The director of clinical Nutrition will report broken scales at Morning Directors? meeting. A part time Diet technician will be assigned to Fahey 2 and 3 to perform percentage of consumption reviews within one week of initial nutrition assessment by the Registered Dietitian. To ensure other potential residents are not affected by decreased intakes the nutrition staff will assess percentage of consumptions weekly, instead of every two weeks, on those indicated that are not meeting estimated needs.
There is a morning director meeting each day throughout the week, any instances of broken scales will be brought up and a plan to fix the equipment or a plan until the equipment can be repaired will be implemented at that time.
The Director of Nutrition will educate staff nutrition staff on the procedural changes for the department. There were no facility policies changed, just procedural changes.
The Nutrition Staff will conduct monthly weight and food and fluid consumption audits will be performed for 3 consecutive months and then quarterly up to 12 months. The percentage of expected compliance is 90%. The results will be reported at the monthly QAPI Meeting for a minimum of three (3) months to ensure the process is sustained.
Date for correction: 4/14/17. Person responsible: Director of Nursing and Director Clinical Nutrition will be responsible for ensuring he corrective plan is implemented.

FF10 483.60(d)(1)(2):NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP

REGULATION: (d) Food and drink Each resident receives and the facility provides- (d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure food was served in a timely way resulting in food that was palatable for 2 of 4 meal observations and for 5 anonymous residents. Specifically, hot and cold food items were not served at palatable temperatures. Findings include: On 2/10/2017 at 12:18 PM, a test tray was conducted on(NAME)Unit 6 during the lunch meal by a surveyor. During the observation of the dining room tray pass, Staff #59 skipped over a tray and stated the resident was in the hospital. The surveyor stated the tray would be used as a test tray, and the following temperatures were observed by a surveyor: - milk was 52 degrees Fahrenheit (F); - rice pudding was 53 degrees F; - vanilla shake was 53 degrees F; and - chicken salad sandwich was 48 degrees F. On 2/13/2017 at 2:40 PM, the Food Service Director stated the facility conducted at least 1 test tray daily and all cold items should have been served at 40 degrees F or below. During an interview with an anonymous Fahey Unit 4 resident on 2/9/2017 at 10:20 AM, the resident stated the food was not always served hot at meals. During the resident group meeting on 2/13/2017 at 2:00 PM, 4 anonymous residents stated the meal was not always served at a hot enough temperature. On 2/13/2017 at 5:42 PM, a test tray was conducted on Fahey Unit 4 during the dinner meal. Dietary staff produced a second thermometer and verified the results. A resident's dinner tray was tested at 5:45 PM. The turkey was measured at 113 degrees F. On 2/13/2017 at 6:02 PM, in the presence of the Food Service Director, the temperature of a second serving of turkey at the steam table was checked. At 6:05 PM, the temperature of the turkey was measured at 110 degrees F by the state thermometer, and 109 degrees F by the facility thermometer. The food was not held at 140 degrees F or above per State Sanitary Code. 10NYCRR 415.14(d)(1)(2), Subpart 14-1.31

Plan of Correction: ApprovedApril 12, 2017

A full assessment of all bur lodge equipment will be performed to access performance of maintaining cold temperatures during re-therm cycles will be completed and issues corrected by (MONTH) 14, (YEAR).
A meal assessment will be completed on each floor to determine that the door of the carts will not be open prior to the start of meal service to prevent the loss of temperature. Meal audits will be performed by the Food Service Managers and Nutrition staff. This multidisciplinary team will report any non-compliant issues to the Food Service Director immediately. The Food Service Director will be responsible for ensuring action is implemented. Any identified corrections will be made by (MONTH) 14, (YEAR).

Regarding the isolated incident on Fahey 4, the temperature of the pot roast was verified on the steam table by the surveyor and Food Service Director at 6:05pm at the proper holding temperature of 142 degrees. The initial documented temperature of the pot roast was at 169 degrees at the start of service. It was then placed on a heated plate and left to sit without a dome and it was verified by the surveyor and Food Service Director to be 109 degrees, the temperature of the pot roast did not maintain once plated.
A review of procedures after plating will be conducted to determine food being delivered to residents at correct palliative temperatures. All appropriate Nursing and Food Service Staff have received re-education by the Food Service Director and Director of Education. In addition to the regularly scheduled test trays, five additional test trays per month will be conducted throughout the facility at various meal times. In addition, a resident satisfaction survey will be implemented by the food service managers, ask elders on various units if their food is being served at appropriate hot and cold temperatures, and results will be reported to the Food Service Director who will provide results monthly to the Quality Assurance Team. This audit will be for 30 elders per month for 3 months facility wide. The threshold for audit compliance will be 95%.

In addition, meal timeliness will be reviewed on each unit to prevent delayed meal times and possible loss of temperature by the Operations Manager. The results will be provided to the Food Service Director, Director of Nursing and Administrator. The information will be provided to the Quality Assurance Team for the next 4 months or until the team concludes to continue or discontinue.
Measures the facility will take to ensure that the problem does not re-occur are going to every resident council meeting, conducting satisfaction surveys and test trays.

The Director of Food Service is responsible.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure care and services were provided to attain or maintain the highest practicable physical well-being for 3 of 7 residents (Residents #15, 16, and 20) reviewed for skin impairments. Specifically, Resident #15 was identified to benefit from a specific type of chair to assist with leg elevation and the chair was not provided timely and there was no alternate plan to elevate the legs. In addition, Resident #15 had moisture-associated skin damage (MASD) and the resident was not toileted as planned. Resident #16 had a history of [REDACTED]. Resident #20 was readmitted to the facility with a skin impairment on the ankle and interventions to promote healing were not implemented or identified until the impairment worsened and became infected. Resident #7 did not receive the correct diet consistency as ordered, as the facility did not have an adequate procedure actively in place to ensure diet changes made after-hours were accurately carried out. Findings include: 1) Resident #20 was re-admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. He did not have any behaviors and required extensive assistance with dressing, bathing and personal hygiene. He was at risk for developing pressure ulcers and did not have any unhealed pressure ulcers. A re-admission skin condition report dated 1/21/2017 documented the resident had an abrasion to the left outer ankle. The abrasion was superficial with no drainage or swelling. There was no further assessment of the abrasion documented. The resident also had a Stage II (partial thickness skin loss) pressure ulcer on the coccyx (tailbone) and ulceration to the coccyx there are small open area noted as well. There was no further description of the pressure ulcer documented. The comprehensive care plan (CCP) dated 1/21/2017 documented the resident had an abrasion to the left ankle and a Stage II pressure ulcer on the coccyx. Interventions included to turn and reposition every 2 hours and as needed. There was no documented evidence the resident was provided any pressure relief or protection for the left foot. The certified nurse aide (CNA) assignment sheet (care guide) dated 1/21/2017 documented the resident required extensive assistance with bathing/dressing his lower half and he had a gel foam cushion in his wheelchair and pressure relief mattress. The box to indicate the resident was to be turned and positioned every 2 hours was blank, and there was no evidence on the assignment sheet the resident was provided any pressure relief or protection for the left foot. A physician order [REDACTED]. A skin condition report dated 1/27/2017 documented the abrasion on the left outer ankle measured 3 centimeters (cm) x 2.2 cm, and was present on admission. There were no signs of infection and the wound base was not visible, and the area was left open to air. Pressure relieving devices were in place in the bed and chair, and the resident was turned and repositioned. The Stage II pressure ulcer on the coccyx measured 2 cm x 1.8 cm, and the wound bed was pink with 100% granulation (healing) tissue present. A physician order [REDACTED]. There was no documented evidence in the medical record why the treatment to the left outer ankle was changed. A skin condition report dated 2/4/2017 documented the resident had an abrasion to the left outer ankle that measured 1.8 cm x 1.3 cm, and the center was a brown scabbed area with a few areas of pink/white noted. The report documented the wound base contained 20% pink tissue, 10% white tissue, and 70% black tissue, and there was 100% granulation tissue and the surrounding skin was normal. A skin condition report dated 2/6/2017 documented the resident and his family member had expressed some concern over the weekend the area on the ankle was getting worse. The resident had an abrasion to the left outer ankle that measured 1.8 cm x 1.5 cm, there was red-tinged drainage, the surrounding skin was red, and the wound base contained yellow slough (moist dead tissue). The physician was notified and the resident was started on [MEDICATION NAME] (antibiotic) for [MEDICAL CONDITION] (skin/tissue infection). The resident would be referred to the wound nurse. A physician order [REDACTED]. The left ankle treatment was changed to skin prep to the peri wound, Santyl (chemical wound debrider) to the wound bed, and cover with an [MEDICATION NAME] dressing. The Medication Administration Record [REDACTED]. A skin condition report dated 2/7/2017 dictated by the wound nurse documented the resident was seen by the facility's wound physician. The abrasion on the left outer ankle measured 1.8 cm x 1.6 cm and was debrided by the physician. A consultation note dated 2/7/2017 dictated by the wound physician documented the resident had an ulcer to the outer left ankle. The wound physician requested the ulcer be treated with Santyl, to off-load the foot, and follow up with his vascular surgeon. An update to the CCP dated 2/7/2017 documented to provide off-loading of the left lower leg while in bed. The CNA assignment sheet received by the surveyor on 2/9/2017 at 2:00 PM documented the resident required extensive assistance with bathing/dressing his lower half. The box indicating turning and repositioning every 2 hours was blank, and there was no information regarding off-loading the left lower extremity. During an interview with Resident #20 on 2/14/2017 at 2:45 PM, he stated he was worried about a wound on his left ankle, as he only had one leg left and needed to be careful with it. He stated he was just given a Prevalon (off-loading) boot for his foot the week before when the wound got worse. He stated he went to see his vascular surgeon, who was concerned about the wound and scheduled an angiogram to check the blood flow in his leg. During the interview, the resident was up in his wheelchair and wearing a black sneaker on his left foot. A Prevalon boot was observed on a chair in the room. During a treatment observation on 2/15/2017 at 7:26 AM with wound registered nurse (RN) #35, the resident had a large excoriated area on his buttocks. The surveyor did not observe a pressure ulcer on the coccyx. The resident also had an ulcer to the left outer ankle that was approximately 2 cm in diameter. The wound bed was not visible, as it was covered with moist, whitish/yellow slough and the surrounding skin was bright red. The resident was interviewed again on 2/15/2017 at 7:50 AM, and he stated the area on his ankle was present when he was readmitted and was not provided with pressure relief until the area worsened. He stated the treatment was stopped for 2 days, as a nurse told him that it was healed. Over that next weekend, another nurse looked at it and stated it had become worse. During an interview with RN #35 on 2/15/2017 at 8:00 AM, she stated the ulcer on the left outer ankle was initially a scab, and her assessment was after the scab had come off. She stated she had initiated the off-loading even though she did not think that would have been helpful in the resident's particular situation. She stated she did not know the position of the resident's foot while he was in bed. During an interview with CNA #36 on 2/15/2017 at 8:35 AM, he stated if the resident needed to be turned and repositioned or required off-loading of the feet, he would know that by looking at his assignment sheet. He stated the resident was able to pull himself up in bed with the use of the trapeze, and he required assistance with rolling on to his side. He stated the Prevalon boot was given to the resident a few weeks ago. During an interview with RN Clinical Coordinator #37 2/15/2017 at 10:40 AM, she stated when the resident was readmitted , he had a large scab on his left ankle. She stated she did not believe the area was pressure-related so she did not initiate any pressure ulcer preventive measures for the foot. She stated the resident was very compromised, as he was non-compliant with smoking and he had vascular issues. She stated he was able to move himself in bed. She stated the pressure relief for the foot was not implemented until after the area had worsened and he was placed on an antibiotic for infection. During an interview with RN Manager #30 on 2/15/2017 at 11:15 AM, she stated the resident was at risk for skin breakdown, as he had recent history of a Stage II pressure ulcer on his coccyx, and he was further at risk for breakdown as he had [MEDICAL CONDITION]. During an interview with the wound physician on 2/15/2017 at 1:40 PM, she stated the resident was at risk for pressure ulcer development as well as further limb loss, as he had [MEDICAL CONDITION] and [MEDICAL CONDITION] in the left limb, making it difficult for him to feel sensations in the leg. She stated she did not order off-loading for the resident's leg, as that was already in place when she saw him on 2/7/2017. 2) Resident #15 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired. He required extensive assistance for most activities of daily living (ADLs), was frequently incontinent of urine, and always incontinent of bowel. He was at risk for skin breakdown, and had 1 venous/arterial ulcer. Staff were to provide a pressure-reducing device for the chair, bed, a non-surgical dressing, and ointments/medication. The comprehensive care plan (CCP) dated 12/15/2016 documented the resident had increased needs for healing related to impaired skin, poor circulation, bowel and bladder incontinence, and decreased functional mobility. Staff were to provided toileting per care plan, and reposition every 2-4 hours and as needed (prn). The resident was to receive Prevalon (off-loading) boots as ordered, utilize support devices and padding to protect fragile skin, and use assistive devices to decrease friction. The CCP documented the resident required extensive assistance for toileting, self propelled in wheelchair, had an arterial ulcer, and staff were to provide treatments as ordered, evaluate effectiveness, toilet every 2 hours, as needed, and prior to HS (bedtime). Leg [MEDICAL CONDITION] The nurse practitioner (NP) progress note dated 12/12/2016 documented the resident had [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION]. The physician order [REDACTED]. The certified nurse aide (CNA) care instructions dated 2/1/2017 documented the resident was to be offered periods of elevation for legs, and to use off-load heel protectors when in bed. An NP progress note dated 2/3/2017 documented the resident was seen by the skin nurse who recommended to change his chair to a Broda (positioning) chair, as the resident hung his feet off the end of the chair out of habit, even with frequent repositioning. The physician order [REDACTED]. A nursing progress note dated 2/3/2017 documented a trigger was sent for a new wheelchair as the resident did not sit straight in the wheelchair, and slid down with his bottom hanging off the chair. The note documented the NP was concerned with the resident's legs and wanted them elevated to help decrease [MEDICAL CONDITION] (fluid swelling), and the resident needed an evaluation for a Broda recliner with foot plate. The PT evaluation dated 2/7/2017 documented the resident was referred by nursing for a new chair for positioning to accommodate his lower extremities that were not properly supported. The resident was to be positioned in a Broda chair with bilateral lower extremity support for proper lower extremity positioning and comfort. A physician progress notes [REDACTED]. Staff should continue off-loading the heels and elevating legs when able. A therapy recommendation dated 2/7/2017 documented a Broda chair was ordered. The resident was observed seated in a wheelchair with his legs down resting on footrests on: - 2/10/2017 at 11:00 AM, in the lounge in front of the television; - 2/10/2017 at 12:10 PM, transported from the lounge into the dining room and remaining at the table through 1:05 PM, when he was taken back to the lounge; - 2/10/2017 from 4:15 PM through 5:07 PM in the lounge, and in the dining room from 5:07 PM through 5:35 PM; - 2/13/2017 from 10:35 AM through 12:12 PM in the lounge. At 12:12 PM, the resident's left foot was observed between the left and right footrests with his ankle against the left footrest; - 2/13/2017 in the dining room from 12:17 PM through 1:00 PM; and - 2/14/2017 at 5:40 PM at the table in the dining room. During an interview with registered nurse (RN) Manager #40 on 2/14/2017 at 4:00 PM, she stated the resident had been tried in different chairs and none worked. She stated they sent the request to therapy on 2/3/2017 for better positioning, and she was informed they had to order the correct size chair. During an interview with the Director of Rehabilitation on 2/15/2017 at 9:15 AM, she was unaware of the specific situation with the resident and was aware new Broda chairs had recently been ordered. She expected if therapy evaluated the resident for a different chair for positioning, they would have documented how to best position the resident while waiting for the new chair. Moisture-Associated Skin Damage (MASD) The Skin Condition Report documented the resident had new MASD present on the rectal area, and the area measured 0.3 centimeters (cm) x 0.6 cm on 1/23 and 1/27/2017. The report documented the resident's risk factors included decreased nutrition, inactivity, cognition, immobility, incontinence of bowel and bladder, and history of wounds. The report documented the area continued and measured 0.3 cm x 0.4 cm on 2/3 and 2/10/2017. The CCP was updated on 1/24/2017 and documented the resident had new MASD noted. During an initial tour interview with registered nurse (RN) Manager #40 on 2/9/2017 at 2:15 PM, she stated the resident was incontinent and had a macerated area on his bottom under his brief measuring 0.3 cm x 0.2 cm, and the plan was to toilet the resident every 2 hours. The resident was observed on 2/10/2017 from 11:00 AM to 12:10 PM in the lounge in front of the television. At 12:10 PM, the resident was transported from the lounge into the dining room and remained at the table through 1:05 PM, when he was taken back to the lounge. He remained in the lounge until 1:40 PM, when he was transported back to his room by an RN Manager. On 2/13/2017 from 10:34 AM - 11:11 AM, the resident was observed seated in the lounge in his wheelchair and was sliding down with his buttocks toward the front of the chair. At 11:11 AM, the resident was observed being pulled up in the chair by RN Manager #40 and a certified nurse aide (CNA). The resident remained in the lounge until 12:16 PM, when he was observed being transported into the dining room. He remained at the table until 1:00 PM and was observed wheeling himself around the unit after leaving the table. During a treatment observation on 2/13/2017 at 2:00 PM with wound RN #35, the resident had an small open area resembling a small pressure ulcer. The area was located on the left gluteal fold, the wound base was partially covered with yellow slough (moist dead tissue) and the remaining wound bed was pink granulation (healing) tissue. The surrounding skin was intact and normal color. The RN stated the impaired area was related to moisture and not pressure, as it was located over a bony prominence. The incontinence brief was observed to be dry and the RN stated the resident's brief was checked and changed every 2 hours, and it was just changed about 30 minutes ago. On 2/14/2017 at 5:40 PM, the resident was observed at the table in the dining room and was sliding down in the wheelchair, with his buttocks near the edge of the chair. During an interview on 2/15/2017 at 10:00 AM, CNA #46 stated she sometimes was the CNA responsible for the resident, and he often asked for assistance when he needed to use the bathroom. She was not aware of the resident being on a 2 hour toileting schedule. During an interview with CNA #61 on 2/15/2017 at 10:40 AM, she stated she was the resident's aide today and she toileted the resident around 8:30 AM and was going to take him again at around 11:30 AM, after her lunch break. She stated that was the approximate times she toileted all of her residents, and she did not know he was on a 2 hour toileting schedule. 3) Resident #16 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately cognitively impaired. He was frequently incontinent of urine and required extensive assistance for most activities of daily living (ADLs). He was at risk for skin breakdown, and was to have a pressure reducing device for chair and bed. A therapy recommendation form dated 9/29/2016 documented the resident was issued a Broda (positioning) recliner with lateral trunk support framing with cushions and a head cushion. The resident's chair was to be in lowered and reclined position with the leg rest elevated to decrease his fall risk. The comprehensive care plan (CCP) dated 11/17/2016 documented the resident had alteration in skin integrity, poor circulation, decreased functional mobility, and thin and fragile skin. The resident had a Broda wheelchair with gel foam cushion, foot plates, and a calf pad. The resident was non-ambulatory and unable to self propel. Staff were to provide repositioning every 2-4 hours, and utilize pressure relieving/reducing devices in bed and chair as indicated. A physician order [REDACTED]. There was no documentation in the resident's record detailing the change. A nurse practitioner (NP) progress note dated 12/23/2016 documented she was asked to see the resident related to a discoloration of his lower extremities. The resident had an area that looked like it was a fading old bruise on the top of his right foot. A Skin Condition Report dated 12/27/2016 documented the resident had an abrasion on the right back ankle. The CCP was updated on 12/27/2016 and documented an abrasion to the right ankle measuring 3 centimeters (cm) x 3 cm, red in color, and it was to be left open to air. A dietitian progress note dated 1/5/2017 documented per skin and wound report of 12/27/2016, the resident had an abrasion on the right back ankle. The Skin Condition Report documented on 1/6 and 1/13/2017, the resident's abrasion on the right back ankle remained. The report documented on 1/20/2017, the area to the ankle was resolved. A social services progress note dated 2/9/2017 documented the resident's condition had changed amd the resident was placed on comfort measures. His intake was poor, he was non-ambulatory and required extensive assistance of 2 for care and transfers, and the goal remained for comfort care. The certified nurse aide (CNA) care instructions dated 2/9/2017 documented the resident was in a Broda recliner with foot plate and had off-loading heel protectors when in bed. The resident required extensive assistance with ADLs. The resident was observed on 2/10/2017 at 5:40 PM at the table in the dining room. The resident was in a Broda chair, he had socks on his feet, and was observed with his ankles crossed, right foot over the left foot. During an interview with RN Manager #40 on 2/14/2017 at 4:00 PM, she stated the resident did not like to be repositioned and they often tried to straighten the resident up in the chair, specifically at meals. On 2/14/2017 at 5/40 PM, the resident was observed in the dining room seated in a Broda chair. The resident had a pillow between his knees, and his ankles were crossed with his right foot over the left foot. On 2/15/2017 at 10:00 AM, the resident was observed in the lounge with Prevalon boots on both feet. When certified nurse aide (CNA) #46 was interviewed on 2/15/2017 at 10:00 AM, she stated the resident used to wear sneakers and recently started wearing the black boots. She said he always kicked off the sneakers and the boots were to be on to keep him comfortable. The CNA said the resident crossed his ankles a lot and she knew he could get a pressure ulcer by doing so. She said the boots were to prevent that from happening. During an interview with RN Manager #40 on 2/15/2017 at 10:20 AM, she stated she rewrote the order today for the resident to wear the protecting boots at all times to off-load his heels, as he would not keep the sneakers on. She said his heels were often directly on the chair and the boots were to keep him from digging into the chair. The resident previously had the boots to be worn when in bed only. 10NYCRR 415.12

Plan of Correction: ApprovedMarch 22, 2017

Resident #15 was evaluated by physical therapy for proper positioning and assessed by nursing to ensure no adverse effects in relation to not being toileted as planned. Resident #16 was assessed and pressure relief preventions were implemented and the plan of care was updated. Resident #20 was evaluated to ensure all preventative measures are in place to prevent worsening of skin conditions. Resident #2 was evaluated to ensure the correct diet consistency as ordered. Resident #7 has been discharged from the facility as he was on a respite stay.
A audit will be conducted by the Director of Therapy to ensure proper positioning for residents that are awaiting the arrival of equipment. Residents on specific toileting programs will be evaluated to ensure the most appropriate measures are in place and best care standards are followed. All residents with a Braden Score of 18 or below will be evaluated to ensure preventions are in place to anticipate new or worsening skin conditions. An audit was conducted by the Director of Nutrition to ensure all after hours dietary changes from 2/17/17 to present were correct.
Re-education will be completed by the education department to all staff regarding skin care and pressure relief policies and procedures and the procedure for dietary changes occurring after hours. The Director of Rehabilitation Services will re-educate the therapy staff on initiating an alternate plan of care, if indicated equipment is not available. The Director of Nutrition has implemented hiring a additional staff member, clerk, to work in the dietary office to cover off hours to ensure the deficient practice does not reoccur and the meal tickets will now be printed one day in advance instead of 2 days to ensure any changes are not missed on tickets that have already been printed.
Audits will be conducted by the Assistant Directors of Nursing to ensure timely institution of the plan of care, including toileting and pressure relief. Preventative measures are in place and indicated on the CNA Assignment sheet. These audits will be conducted monthly and will incorporate five (5) residents from each nursing unit. The Director of Rehabilitation Services will audit therapy plans of care monthly to incorporate any resident awaiting equipment. The Director of Nutrition will audit after hours dietary changes monthly and will incorporate ten (10) resident reviews. The above audits will be completed for a minimum of three (3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings to ensure compliance is met and reoccurrence is prevented. The Quality Assurance Committee will provide input on the need to continue, discontinue or modify the audits after the three (3) month period.
The date for correction is (MONTH) 14, (YEAR). The administrator is responsible to ensure continued compliance.

FF10 483.40(d):PROVISION OF MEDICALLY RELATED SOCIAL SERVICE

REGULATION: (d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure medically related social services were provided for 1 of 18 sampled residents (Resident #16). Specifically, Resident #16 displayed adjustment difficulties related to changes in life status, and the facility did not ensure social services met and addressed the resident's physical, mental, and psychosocial well-being. Findings include: Resident #16 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately cognitively impaired; felt down, depressed, or hopeless; had trouble with sleep pattern; felt tired or had little energy; had changes in appetite; and felt bad about self. It was very important to the resident to be involved in daily care decisions, news, activities, and religion. The resident required extensive assistance for most activities of daily living (ADLs), and was on an anti-depressant. The nurse practitioner (NP) progress note dated [DATE] documented the resident was admitted to the facility following a hospital admission for social problems. The resident's spouse was hospitalized and there was no one available at home to care for him. The comprehensive care plan (CCP) dated [DATE] documented the resident was able to recall he was in a nursing home. Staff were to discuss past happenings, encourage participation, and observe non-verbal cues, gestures, and expression. A [DATE] update to the CCP documented the resident was new to the facility and would require a period of adjustment to new living situation. Staff were to encourage socialization, praise safe efforts, and provide 1:1 support as needed (prn). A social services progress note dated [DATE] documented the resident was admitted for long term care, as his primary caregiver was no longer able to care for him. The note documented the resident had fluctuating confusion and no behavior issues. A social services assessment dated [DATE] documented the resident was admitted for long term care. Placement response included expressing adjustment issues and expressed strong desire to return home. The resident could be socially inappropriate and disruptive. The plan by social services included to address psychosocial needs, mood, behavior, communication, and mental status, and to update the care plan. An NP progress note dated [DATE] documented the resident wanted to go home and be with his spouse, who was ill. The CCP was updated by activities staff on [DATE] and documented the resident could be physically and verbally combative during times of agitation. A psychiatric consult report dated [DATE] documented the psychiatric NP was asked to see the resident, related to increased anxiety and depression. The resident was on an anti-depressant medication, and staff reported the resident had anxiety lately and wanted to go home. The family was unable to care for him. The resident's anti-depressant was increased. Staff were to continue to monitor his mood, affect, and behavior, and adjust the medication as indicated. An activities progress note dated [DATE] documented the resident was alert with confusion and verbal and physical combativeness. The resident stated he did not know why his family dumped him there. A psychiatric NP consultation report dated [DATE] documented the resident was referred for reasons including agitation and aggression. The NP suggested a change in medication. The resident's mood and behavior was to be monitored and follow up was suggested within 2 weeks. A [DATE], entered on [DATE], social services progress note documented the family was happy with the care and placement and was concerned about the resident's combativeness and constant requests to go home and not understanding why he was there. A psychiatric NP referral would be completed and family would bring in photos for the resident. A primary NP progress note dated [DATE] documented the resident was very anxious and combative and had been receiving prn anti-anxiety medication Ativan at least once per day. The NP would increase the Ativan and continue to monitor his mood, affect, and behavior. A handwritten update to the CCP documented the resident's spouse passed away [DATE]. No changes were made to the resident's approach or interventions to address the loss. A social service progress note dated [DATE] documented the nurse manager notified her the resident's spouse passed away that week and the family had come in and notified him. The social worker approached the resident and he did not remember the spouse passed away and said he missed her. He would be attending the funeral on Monday and family arranged medical transportation. The care plan was updated and documented social work would continue to monitor and intervene. There was no documentation in the resident's record the resident attended or participated in the funeral services, or that staff followed up and addressed the resident's mood and adjustment following the funeral. A social services assessment dated [DATE] documented the resident had a strong identification with past roles and life status, expressed sadness/anger/empty feeling over lost roles/status, expressed adjustment issues, expressed strong desire to return home, and was verbally abusive. The assessment noted social services would address psychosocial needs and update the care plan. The resident had periods of verbal aggression and yelling out to others. He frequently asked about going home. The assessment documented he recently experienced the passing of his spouse and seemed to be handling it well. A psychiatric NP consult report dated [DATE] documented the resident's spouse passed away a few weeks ago, the resident did not have much awareness, the plan was to continue current medications, monitor for changes in mood or behavior. A ,[DATE] update to the CCP documented the resident continued to want to leave, although improving, had periods of agitation, and to continue to monitor. A [DATE], entered on [DATE], social services progress note documented a quarterly care plan meeting was held on [DATE]. The resident had poor intake, and was on medication for anxiety and depression, with some improvement. The resident was often negative and verbally abusive to visitors, so visits were short. The goal continued to be long term care. On [DATE], activities staff updated the CCP and documented the resident's wife passed away last month and he forgets that at times. The goals remained appropriate and ongoing. A social services assessment dated [DATE] documented the resident had a strong identification with past roles and life status, had a recently loss of family member/friend, and was unable to cognitively process the current situation. He had negative statements, repetitive verbalizations, and insomnia/change in usual sleep pattern. His behaviors and restlessness had been much improved. An ,[DATE] update to the CCP documented to continue to adjust to the facility and continue to monitor. Mood had improved and there were still occasional periods of agitation. A social services progress note dated [DATE] documented a quarterly care plan meeting was held. The resident's weight had decreased. He was on medication for anxiety and depression, and had periods of agitation and anxiety that had improved greatly. Long term care continued. A psychiatric NP consult report dated [DATE] documented the resident ate below average amount at times. Medications seemed to be working to help him have limited agitation. A registered nurse (RN) progress note dated [DATE] documented the NP saw the resident related to a change in condition. At that time, the resident refused meals and fluids. The NP discontinued several medications due to the resident change. The NP wanted a dietary consult due to poor intake, weight loss, and intake refusal. A social service progress note dated [DATE] documented the social worker met with the resident's family to discuss advance directives related to decline in condition and poor intake. Nursing progress notes documented on ,[DATE] and [DATE] the resident received anti-anxiety medication for anxiety and yelling out. On [DATE], the resident was awake most of the night and received anti-anxiety medication. A physician progress notes [REDACTED]. The resident's [DIAGNOSES REDACTED]. A social services assessment dated [DATE] documented the resident did not have any behaviors or unsettled relationships, and was unable to cognitively process the current situation. He would still at times make repetitive verbalizations, and at other times was sleeping/quiet. Social services was to address psychosocial needs. An activities progress note dated [DATE] documented the resident's spouse had passed away and that he was madly in love with her and asked for her often, forgetting that she has passed away. He loved songs and used to sing one in particular to his spouse. A social services progress note dated [DATE] documented a quarterly care plan meeting was held. The resident's weight was decreasing. He was on an anti-anxiety medication. He continued to be verbally aggressive at times. The goal was for long term care and comfort care. During an interview with registered nurse (RN) Manager #40 on [DATE] at 2:15 PM, she stated the resident was now on comfort measures and seemed to have given up his will to live since his spouse died prior to the holidays. The resident was observed on [DATE] at 5:40 PM. The resident was semi-reclined in a Broda (positioning) chair and certified nurse aide (CNA) #56 was attempting to feed him. The resident was observed to eat less than 50% and was resisting the CNA's attempts at encouraging him to eat. During an interview with social worker #60 on [DATE] at 3:50 PM, she stated the resident was initially very angry about being at the facility, as he missed his family and his home. She stated after admission, he would ask for his wife and stated he missed her. She stated she did visit the resident after his wife died and he wasn't one to talk about it. The social worker's visit was not documented in the medical record and she stated no specific changes were made to his plan of care to address his grieving. 10NYCRR415.5(g)(1)(i-vii)

Plan of Correction: ApprovedMarch 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action accomplished for resident #16 that was found to be deficient practice.
- The identified resident #16 will be referred to the CHE licensed psychologist and be seen for evaluation on (MONTH) 10th. When residents are referred to CHE services, the report is initially given to the Director of Social Work, the Director of Social Work provides the report to the Social Worker assigned to the applicable unit. The Social Worker then discusses the report with the Nurse Manager, NP/PA or MD for follow up recommendations. The Social Worker met with the resident on [DATE]. Resident expired shortly after.
- A referral to Pastoral Care was made on (MONTH) 7th for supportive visitation.
- Social work documentation placed in resident #16 record on (MONTH) 7th reflecting his adjustment to the loss of spouse and participation in the funeral service.
How to identify other residents having the potential to be affected by the same deficient practice and what corrective action to be taken:
- Residents who have experienced a significant loss will be identified on 24 hour report and discussed in morning report. Upon notification of a resident loss, The Director of Social Work will discuss with the Social Worker to ensure they are aware and a visit will be made with supporting documentation of the visit and outcome.
Measures put in place/systematic change made to ensure that the deficient practice does not occur:
When a resident is identified to have experienced a significant loss, the social worker will:
- Place a social worker progress note in the residents medical record identifying the event and addressing the residents psychosocial status.
- Place an appropriate care plan in the residents medical record addressing the loss.
- Place a social worker progress note in residents medical record seven (7) days following the event addressing the residents psychosocial status.
The Social Work staff will be educated on the corrective procedure change by the Director of Social Work.
Corrective action will be monitored.
- This area of correction will be audited by the Director of Social Services monthly to ensure any resident or family member that reports a loss, has timely and accurate follow up with interventions, if indicated, in place. This audit will be conducted for a minimum of 3 months with a threshold of 95% and the results will be reported to the Quality Assurance Committee to provide input on the need to continue, discontinue or modify the audits after the 3 month period.
Date of correction and responsible party.
- The date for correction will be (MONTH) 14th.
- The Director of Social Work will be responsible to ensure continued compliance.

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident?s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician?s, nurse?s, and other licensed professional?s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 946), it was determined the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 30 sampled residents (Resident #18). Specifically, the facility was unable to provide documentation of Resident #18's health care proxy (HCP) and [MEDICAL TREATMENT] communication records. Findings include: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired and he did not have any behaviors. He required extensive assistance for transfers, dressing, and personal hygiene, and required supervision with eating. The comprehensive care plan (CCP) dated 6/28/2016 documented the resident went for [MEDICAL TREATMENT] 3 times weekly and had a strong family support. A social service progress note dated 6/29/2016 documented the resident had identified his HCP and an alternate HCP while he was in the hospital, and a copy of the completed HCP form was made for the chart. A nurse practitioner (NP) progress note dated 7/5/2016 documented the resident was seen for low blood pressures and was given fluids while at [MEDICAL TREATMENT]. During a review of the resident's record on 2/10/2017, there was no documented evidence of the resident's HCP form or any communication documentation with the [MEDICAL TREATMENT] center, and there was no documented evidence of the resident's weight. During an interview with medical records personnel #62 on 2/13/2017 at 12:30 PM, she stated she was unable to locate a copy of the resident's HCP and that was part of the resident's medical record. She stated she was having trouble locating communication records from the [MEDICAL TREATMENT] center and she would keep looking. During an interview with registered nurse (RN) #38 on 2/15/2017 at 11:15 AM, she stated if a resident was on [MEDICAL TREATMENT], a weight would be obtained at the [MEDICAL TREATMENT] center and not at the facility, as that was the facility policy. During an interview with registered dietitian (RD) #53 on 2/15/2017 at 11:25 AM, she stated she could not recall the resident and had reviewed her emails prior to the interview. She did not have a record of any communication with the RD at the [MEDICAL TREATMENT] center, and she stated she would keep and document in a progress note of any communication with the [MEDICAL TREATMENT] RD. She stated a resident's weight was obtained at [MEDICAL TREATMENT], and she would be notified of the resident's weight by reviewing the [MEDICAL TREATMENT] communication book. During an interview with the medical records personnel #62 on 2/16/2017 at 9:24 AM, she stated she was unable to locate a copy of the resident's HCP or [MEDICAL TREATMENT] communication records. 10NYCRR 415.22(a)(1-4)

Plan of Correction: ApprovedApril 12, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #18 has been discharged from the facility.
All residents with a potential to be affected, including [DIAGNOSES REDACTED].
Social Work will meet with the resident and/or family member to determine if the resident has a Health Care Proxy. Social Work will check the resident?s medical record to verify a copy of the Health Care Proxy is in the medical record. If the resident has a Health Care Proxy but it is not in their medical record Social Work will ask for a copy to be brought in to be made part of the medical record and will document that the Health Care Proxy has been requested on the Advanced Directive Tracking Sheet. Social Work will follow up to verify the requested Health Care Proxy has been brought in by the family/proxy to be filed in the medical record. To ensure other residents are not effected, the Social Workers update the advanced directive tracking sheet initially then quarterly to ensure copies of advanced directives are obtained and current including any changes. The Director of Health Information Management or their designee will concurrently review all admitted resident?s medical records by the twenty-second day after admission to ensure the Health Care Proxy are in the resident?s medical record, any missing Health Care Proxy?s documented on the Advanced Directive Tracking Sheet but not in the medical record will be reported to the Director of Social Work, Resident?s Social Work and the Director of Nursing or Assistant Director of Nursing. The Director of Social Work and/or the Resident?s Social Work will contact the family/proxy for a copy of the Health Care Proxy. The medical record upon discharge will be checked again to ensure the Health Care Proxy is in the medical records, any missing Health Care Proxy?s will be reported to the Director of Social, the Director of Nursing or Assistant Director of Nursing and the Health Information Management Director.
A procedure was written to ensure any resident who requires [MEDICAL TREATMENT] will have the Interfacility Transfer Patient Report form in their medical record to ensure other residents are not affected. All Social Work Staff received in-service training on this new Policy and Procedure. The Unit Clerk will ensure the Interfacility Transfer Patient Report form is sent with the resident to [MEDICAL TREATMENT] to be completed for continuity of care and returned with the resident. The Nurse Manager for the unit will review to ensure the Interfacility Transfer Patient Report form was completed by the [MEDICAL TREATMENT] center after each visit. The Interfacility Transfer Patient Report form will be placed in the consultation section of the medical record. The Director of Health Information Management or their designee will concurrently review the resident?s medical records for completed Interfacility Transfer Patient Record form monthly. The Health Information Management Department will upon discharge check the medical record for all [MEDICAL TREATMENT] residents to ensure the Interfacility Transfer Patient Report form are in the resident?s medical record. If the forms are missing the Charge Nurse, Director of Nursing or Assistant Director of Nursing and the Director Health Information Management will be notified. The Health Information Management Department will call the [MEDICAL TREATMENT] center to obtain all [MEDICAL TREATMENT] documentation, including weights and laboratory work.
The above policy and Procedure changes and audits will ensure this issue does not reoccur in the future.
This audit will be completed on all [MEDICAL TREATMENT] residents for a minimum of 3 months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings to assure compliance is met and reoccurrence is prevented. The Quality Assurance Committee will provide input on the need to continue, discontinue, or modify the audits after a three month period.
The date for correction is 4/14/17. The Health Information Management Director is responsible to ensure continued compliance.

FF10 483.10(c)(6)(8)(g)(12), 483.24(a)(3):RIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES

REGULATION: 483.10 (c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. (g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident?s option, formulate an advance directive. (ii) This includes a written description of the facility?s policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual?s resident representative in accordance with State law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. 483.24 (a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident?s advance directives.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure the system developed to ensure advance directives was documented in a manner that was consistent with resident wishes for 2 of 18 residents (Residents #5 and 23) reviewed for advance directives. Specifically, the facility did not ensure all resident advance directives identifiers were consistent with the residents' wishes, including for Residents #5 and 23. Findings include: The DNR (Do Not Resuscitate-do not provide CPR if heart stops)/CPR (cardiopulmonary resuscitation-attempt to restart breathing and heartbeat) Bracelets Policy, reviewed by the facility on [DATE], documented resident wishes for DNR and CPR would be identified to assure the residents' desired status is known to staff in the event of an emergency anywhere in the facility. The policy stated residents would wear a red bracelet to alert staff to CPR status or a white bracelet to alert staff to DNR status. The resident wishes for CPR or DNR would be determined by the social worker. When status was determined, the appropriate bracelet would be applied by the unit secretary or designee as determined by the Nurse Manager, and the Nurse Manager/Charge Nurse would then assure the bracelet with correct color was applied. The policy stated staff would also apply the appropriate color bracelet to the wheelchair or equipment provided by PT (physical therapy). 1) Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. She required extensive assistance with activities of daily living (ADLs). The MOLST (Medical Orders for Life-Sustaining Treatment), dated [DATE] and signed by the physician [DATE], documented DNR. The physician's admission orders [REDACTED]. The undated nurse roster (Unit nurse task instructions) documented the resident was DNR. The admission medical [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated [DATE] documented the resident was DNR. The physician admission history and physical dated [DATE] documented the resident was DNR. During an interview with registered nurse (RN) Manager #63 on [DATE] between 1:00 PM and 3:00 PM, she stated if a resident wished for full code (requested CPR if their heart stopped), there would be a red circle on the resident's chart. If a resident wished for DNR, there would not be a sticker located on the resident's chart. The social services progress note dated [DATE] at 4:11 PM documented the resident's MOLST was in the chart, and indicated DNR/DNI. The resident was observed on [DATE] at 12:10 PM in the third floor dining room wearing a red name bracelet on her wrist. A red bracelet was observed on her wheelchair. On [DATE] at 12:15 PM, the resident's chart was observed in the nursing station without a red sticker on the binder of her chart. During interview on [DATE] at 3:25 PM on Unit 3, licensed practical nurse (LPN) Assistant Nurse Manager #34 stated residents wore red bracelets to identify full code, and white bracelets if they had wishes for DNR. She stated if a resident was found unresponsive, the bracelet would be checked first to determine advance directives, followed by checking the MOLST in the chart. She stated certified nurse aide (CNA) assignment sheets and nurse rosters would have the advance directives written on them. She further stated that upon admission, the NP (nurse practitioner) would write the advance directive orders for the residents. Within 24 hours, a nurse would inform the unit secretary of what bracelet to create for the resident to wear, as well as for their wheelchair or walker if used. When she observed the resident's bracelet she stated, That needs to be changed. The Assistant Nurse Manager stated they did not have any routine checks to assure accuracy of residents' bracelet colors. On [DATE] at 3:34 PM, the unit secretary was observed placing a white bracelet on the resident and on her wheelchair, and the red bracelets were discarded. During interview on [DATE] at 3:45 PM, social worker #10 stated she reviewed the information on her new residents upon admission by looking at hospital charts and any other information that was available. She said she passed the resident/HCP (health care proxy, person appointed to make health care decisions for an individual if they are unable to) wishes for advance directives along to the NP, so orders could be written, and then started completing the MOLST form. The social worker said she worked on the advance directives on the day of admission, as she wanted the resident's code status (DNR or CPR) to be clear. She spoke with the resident, or the resident's HCP if the resident was unable to make the decision. 2) Resident #23 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. She required extensive assistance for most activities of daily living (ADLs), and used a wheelchair and walker. The undated nurse roster (Unit nurse task instructions) documented the resident was DNR. The face sheet dated [DATE] documented the resident was DNR. The nurse practitioner (NP) progress note dated [DATE] documented the NP spoke with the resident and her daughter, and they decided to change the resident's advance directives from Full Code (provide CPR) to DNR. The MOLST (Medical Orders for Life-Sustaining Treatment) dated [DATE] documented the resident was DNR. The medical progress note dated [DATE] documented the resident had a status change to DNR since the last review. The comprehensive care plan (CCP) updated [DATE] documented the resident's code status changed to DNR on [DATE]. The physician order [REDACTED]. During an interview with registered nurse (RN) Manager #63 on [DATE] between 1:00 PM and 3:00 PM, she stated if a resident wished for full code, there would be a red circle on the resident's chart. If a resident wished for DNR, there would not be a sticker located on the resident's chart. The resident was observed on [DATE] at 12:12 PM in the Unit 3 dining room, wearing a red name bracelet on her wrist. A red bracelet was observed on her wheelchair. On [DATE] at 12:15 PM, the resident's chart was observed at the nursing station without a red sticker on the binder of the chart. During interview on [DATE] at 3:25 PM on Unit 3, LPN (licensed practical nurse) Assistant Nurse Manager #34 stated residents wore red bracelets who wished for CPR wore red bracelets, and white bracelets if they wished for DNR. She stated if a resident was found unresponsive, the bracelet would be checked first to determine advance directives followed by checking the MOLST in the chart. She stated CNA assignment sheets and nurse rosters would have the advance directives written on them. She further stated upon admission, the NP would write the advance directive orders for the residents, and within 24 hours a nurse would inform the unit secretary of what bracelet to create for the resident to wear as well as for their wheelchair or walkers as used. When she observed the resident's chart she said, Oh, the sticker fell off the chart. She then observed a red bracelet on the resident's wheelchair and said, Let's make sure she's sitting in the right chair. The Assistant Nurse Manager confirmed it was the correct chair and the resident was wearing a red bracelet on her wrist as well. When she reviewed the MOLST in the resident's chart she said, Oh she's DNR. She changed a while ago, [DATE]. We need to change her bracelets. The Assistant Nurse Manager then stated they did not have any routine checks to assure accuracy of residents' bracelet colors. On [DATE] at 3:35 PM, the unit secretary was observed placing a white bracelet on the resident and her wheelchair, and the red bracelets were discarded. During interview on [DATE] at 3:45 PM, social worker #10 stated she reviewed the information on her new residents upon admission by looking at hospital charts and any other information that was available. She said she passed the resident/Health Care Proxy (HCP, person appointed to make health care decisions for an individual if they are unable to) wishes for advance directives along to the NP, so orders could be written, and then started completing the MOLST form. The social worker said she worked on the advance directives on the day of admission as she wanted the resident code status (DNR or CPR) to be clear. She spoke with the resident, or the resident's HCP if the resident was unable to make the decision. 10NYCRR 415.3(e)(1)(ii)

Plan of Correction: ApprovedMarch 20, 2017

Residents #5 and #23 code status was evaluated and the proper bracelet color was applied to the resident and their equipment per their wishes of code status.
An audit was completed on all records to ensure that the correct bracelet was applied to the resident and their equipment per their wishes regarding code status. There were residents that were noted with no bracelet on, not the incorrect bracelet and bracelets were reapplied.
Re-education will be completed by the education department to all staff covering all disciplines regarding the facility policy and procedure of DNR/CPR bracelets. The green dots on the binder was not reflected in the current policy. This was a past practice and this will be included in the staff education that no dots are placed on chart binders.
Audits of DNR/CPR bracelets will be conducted on all residents by the Nurse Manager to ensure the correct bracelet is applied to each resident, equipment and documentation is present if the resident refuses to wear the bracelet or if it is contraindicated due to skin integrity. The residents wishes for DNR/CPR will be evaluated at the time of the audit to ensure accuracy. This audit will be completed monthly on all nursing units for a minimum of three (3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings to assure compliance is met and reoccurrence is prevented. The Quality Assurance Committee will provide input on the need to continue, discontinue, or modify the audits after the three (3) month period.
The date for correction is (MONTH) 14th. The Director of Nursing is responsible to ensure continued compliance.

FF10 483.10(f)(1)-(3):SELF-DETERMINATION - RIGHT TO MAKE CHOICES

REGULATION: (f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. (f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. (f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure residents had the right to make choices about significant aspects of their life for 2 of 30 residents (Residents #22 and 28) reviewed for self-determination. Specifically, Residents #22 and 28 did not receive food items of their preference at meals. Findings include: 1) Resident #28 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, and required supervision with set up help with eating. The comprehensive care plan (CCP) dated 12/13/2016 documented the resident was at nutritional risk and staff were to provide preferences. Between 5:22 PM and 5:25 PM on 2/10/2017, the facility's dinner meal menu was observed to document the first entree as fried fish with tartar sauce and the alternate as Sloppy Joe. During that time, the resident was served her dinner meal by a certified nurse aide (CNA). The resident received a plate containing Sloppy Joe. The resident stated she was not happy with the meal and thought she would be receiving the fish meal. The CNA stated that Sloppy Joe was listed on the resident's ticket. The CNA left the dining room and went to a resident room down the hallway. The CNA did not approach the serving station. The resident began eating her meal, consuming the appetizers, side dishes, and drinks first. The CNA did not return to the resident. The resident ate her Sloppy Joe. At 5:51 PM, the resident left the dining area and was in the hallway. She was telling the registered nurse (RN) Manager that she was not happy with the dinner meal she received, as she had wanted fish. The RN stated she did not know the resident had wanted the alternate meal. During an interview with registered nurse (RN) Manager #25 on 2/15/2017 at 2:00 PM, she stated she recalled the resident being upset with her meal on 2/10/2017. She stated she was not aware the resident had requested an alternate. She stated if the resident notified the CNA she wanted fish at the time of the tray delivery, the CNA should have immediately requested the fish meal for the resident. During an interview with CNA #23 on 2/15/2017 at 4:05 PM, she stated the resident brought herself to and from the dining room. CNA #23 stated the resident was able to eat on her own, and would make requests if she wanted anything different than what was provided. 2) Resident #22 was admitted to the facility 1/13/2014 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. She required extensive assistance for all activities of daily living (ADLs), and received a mechanically altered diet (texture of food or liquids changed). The registered dietitian (RD) progress note dated 12/20/2016 documented the resident received a ground diet, was on aspiration precautions (measures to reduce risk of food or fluids to enter the lungs), and needed encouragement at meals to optimize intakes. The physician orders [REDACTED]. The comprehensive care plan (CCP) updated 2/10/2017 documented the resident was at nutritional risk related to weight loss history, left 25% or more uneaten at meals, had multiple comorbidities (chronic diseases), received ground diet with pureed entrees at lunch and supper, and appeared overwhelmed at meals. The CCP documented the resident received a 1/2 peanut butter and jelly sandwich at lunch and supper daily since 10/24/2016 for variety. On 2/10/2017 at 5:30 PM, a surveyor observed the resident's meal and tray ticket. The resident received a pureed peanut butter sandwich in a bowl and the tray ticket documented pureed peanut butter sandwich with red lettering under the sandwich that read Do Not Puree. During interview on 2/10/2017 at 5:30 PM, certified nurse aide (CNA) #56 stated she had previously worked in the kitchen and dietary staff were supposed to do what was written in red. She did not know why the sandwich was pureed. On 2/13/2017 between 2:25 PM and 2:40 PM, in an interview with the Food Service Director, he stated the facility had recently purchased a colored printer to highlight in yellow diets with modified consistancies (ground and puree). He stated there was a checker on the line who checked all the trays. A dietary supervisor checked the trays after, based on the cart. Some carts had all trays verified, and each cart had a minimum of 1 trays randomly checked against the meal ticket. When the surveyor specfically asked about a meal ticket that included a puree peanut butter sandwich and then was followed by do not puree, the Food Service Director stated his staff would be cautious and the resident would get a puree sandwich. The Food Service Director then directed the surveyor to Staff #58, who inputted information and printed the meal tickets. With the Food Service Director present, Staff #58 stated Resident #22 wanted a whole peanut butter sandwich, but there was a computer software issue that prevented mulitple consistencies on the same ticket. Staff #58 stated it was a very complex diet consistency and the resident wanted certain items ground, certain items pureed, and certain items whole. She stated Resident #22 wanted a whole peanut butter sandwich. She stated the program only allowed the ticket to show puree sandwich, and then she could make a note to not puree. She stated that should have triggered dietary staff to give the resident a whole peanut butter sandwich. During an interview on 2/13/2017 at 1:00 PM, the resident's family member stated she spoke with the facility staff all the time about the resident's food, and requested the entrees be pureed, hoping it would be easier for her to get the needed protein. She stated she did not request the sandwich be pureed and had been requesting for approximately 2 months not to puree the peanut butter sandwich. She thought the resident could pick up the sandwich (regular consistency) and eat it herself. She said she requested to speak to someone again today about the problem. On 2/13/2017 at 5:20 PM, a surveyor observed the resident's tray ticket and it documented pureed peanut butter sandwich highlighted in yellow and crossed off with a green marker. Under the crossed-off documentation, and printed in red letters, was Do Not Puree. The tray ticket was initialed at the bottom. During interview on 2/13/2017 at 5:30 PM, RD #39 stated the resident's family member requested pureed entrees and did not want the sandwich pureed. She stated they were unaware the meal ticket program could make exceptions. She spoke with the meal ticket software company today and they were now able to correct it. She did not know why it came up printed incorrectly for the evening meal. She stated the initials on the bottom of the tray ticket meant the ticket was checked by a supervisor, and she did not know whose initials were on the resident's ticket. The resident's lunch and supper tray tickets dated 2/16/2017 documented 1/2 sand- peanut butter sandwich. During interview on 2/16/2017 at 10:10 AM, Food Service Manager #57 stated the diet office received all diet orders for the residents, printed tray tickets, and prepared them for the tray line. At the end of the tray line, an employee deemed as the checker assessed all trays for accuracy before placing them in the carts for delivery to the units. Some tray tickets were stamped Tray Check, which meant the manager or supervisor responsible for the shift would also look at that tray to assure all items on the tray were correct. This additional step was used if a resident had allergies [REDACTED]. The diet technician or RD usually identified the resident's tray ticket being in need of the Tray Check. During interview on 2/16/2017 at 10:25 AM, Food Service Director #58 stated he was aware recently the resident's ticket stated Pureed Peanut Butter Sandwich and written in under that said Do Not Puree in red lettering. He stated he was not aware this was an issue until another surveyor had discussed it with him on 2/13/2017 at 2:25 PM. He stated the diet office clerks did not have the necessary computer permission to change the sandwich from pureed to regular on the tray ticket. He stated he contacted the software company and they allowed the necessary changes to correct the ticket per the resident's preference (not pureed). He stated anyone in the department could alert the supervisors in case there was an issue with a tray ticket, whether it was a one-time thing or an ongoing problem. 10NYCRR 415.5(b)(1,3)

Plan of Correction: ApprovedMarch 22, 2017

Residents #22 and #28 have met with Nutrition Staff to ensure their choices for meals and supplements are conclusive to their desire. There were no updates the residents requested.
The facility Meal Service Policy has been updated to include that residents will have the right to choose an alternate meal and if indicated, the LPN or CNA will ensure that the alternate choice is provided in a timely manner. This policy change will ensure all other residents that had the potential to be affected, will not have the potential to be affected and will ensure their choice is accommodated. Those resident unable to voice preference, staff will monitor and if decreased intake they will provide the alternate meal. If applicable, family will be re-interviewed by nutrition staff for preferences.
Education in regards to the updated Meal Service Policy will be completed by the education department to all staff to ensure residents choice is met. To ensure correct notation and delivery of consistencies, the Director of Nutrition contacted the meal tracker software vendor to determine a means to provide specific items per request of a alternate consistency than is ordered, ensuring by nutrition staff that the requests of items are safe.
Audits of individuals choice will be completed by the Nurse Manager, for all meals to ensure the correct items were received and an alternate is provided timely if requested. The audit will be conducted monthly on each nursing unit and will incorporate five individuals on each shift for a minimum of three (3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings to ensure compliance is met and reoccurrence is prevented. The Quality Assurance Committee will provide input on the need to continue, discontinue or modify the audits after the three (3) month period.
The date for correction is (MONTH) 14th. The Director of Nursing is responsible to ensure continued compliance.

FF10 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 1 of 30 residents (Resident #26) reviewed for quality of care, the facility did not ensure services provided met professional standards of quality. Specifically, for Resident #26, the nurse did not obtain an apical pulse per physician's orders [REDACTED]. Findings include: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The comprehensive care plan (CCP) updated 12/13/2016 documented the resident had a potential for alteration in cardiac status related to [MEDICAL CONDITION], HTN, and PAF. The approaches included vital signs (VS) as needed (prn) and provide medications as ordered. The physician order [REDACTED]. The 2/2017 Medication Administration Record [REDACTED]. The resident was observed during a medication pass 2/13/2017 at 4:55 PM. Licensed practical nurse (LPN) #30 read the order in the MAR, then stated she needed to get a watch. She came back with a watch, removed the [MEDICATION NAME] from the drawer, and went into the resident's room. She attempted to get a radial pulse (wrist pulse) from the resident's left wrist, and was unable. She then switched to the resident's right wrist and obtained a radial pulse of 68 beats per minute (BPM). She then administered the medication. During an interview on 2/14/2017 at 4:05 PM, LPN #31 stated there was a stethoscope in every medication cart, and prior to administering [MEDICATION NAME], an AP should be taken. She stated if the heart rate was below 60 BPM, the [MEDICATION NAME] should be held (not given). During an interview on 2/15/2017 at 8:55 AM, LPN #32 stated there was a stethoscope in every medication cart. She stated prior to administering [MEDICATION NAME], an AP should be taken. If the heart rate was less than 60 BPM, the [MEDICATION NAME] should be held and the medical provider notified. During a telephone interview on 2/15/2017 at 11:40 AM, LPN #30 stated she knew she had made a mistake and should have taken the AP prior to administering the [MEDICATION NAME] on 2/13/2017, instead of taking the radial pulse. During an interview on 2/16/2017 at 9:20 AM, registered nurse (RN) Manager #33 stated all of the nurses had access to stethoscopes, and the expectation was for nurses to take the AP prior to administering [MEDICATION NAME]. She stated if the AP was below 60 BPM and the [MEDICATION NAME] was held, the physician was called. She stated if the medication was held several times during the course of a week, the physician would be notified to review the medication. 10NYCRR 415.11(c)(3)(i)

Plan of Correction: ApprovedMarch 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #26 was evaluated by medical staff to ensure appropriate medical treatment is in place based on the parameters for apical pulse. The LPN was re-educated on the facility policy and procedure of medication administration.
All resident records with orders for monitoring apical pulse prior to administration of medications were reviewed for accuracy and treatment regimen.
Re-education for licensed nursing staff will be completed by the education department regarding the facility policy and protocol of medication administration and education in relation to obtaining an apical pulse per physician order [REDACTED].
Audits will be completed by the Nurse Manager for medication administration ensuring physician orders [REDACTED]. These audits will be completed monthly on each nursing unit and will incorporate ten medication passes per unit for a minimum of three (3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings to ensure compliance is met and reoccurrence is prevented. The Quality Assurance Committee will provide input on the need to continue, discontinue or modify the audits after the three (3) month period.
The date for correction is (MONTH) 14th. The Director of Nursing is responsible to ensure continued compliance.

FF10 483.25(g)(2):SUFFICIENT FLUID TO MAINTAIN HYDRATION

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (2) Is offered sufficient fluid intake to maintain proper hydration and health.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 946), it was determined the facility did not provide sufficient fluid intake to maintain proper hydration and health for 1 of 6 residents (Residents #18) reviewed for hydration. Specifically, Resident #18 was admitted to the facility and exhibited a poor fluid intake and did not receive timely re-assessment to encourage adequate intake. Findings include: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired, and he did not have any behaviors. He required extensive assistance for transfers, dressing and personal hygiene, and required supervision with eating. Physician orders [REDACTED]. A nursing progress note dated 6/28/2016 documented the resident was adjusting well on the new unit, and his appetite was fair. A nurse practitioner (NP) admission note dated 6/28/2016 documented the resident was recently diagnosed with [REDACTED]. The resident was too weak to return home so he was admitted for rehabilitation with a goal to return home. The comprehensive care plan (CCP) dated 6/28/2016 did not contain any information regarding the resident's nutritional or hydration status. A social service progress note dated 6/29/2016 documented the resident was admitted to the facility for short term rehabilitation with a goal to return home. A certified nurse aide (CNA) assignment sheet (care instructions) dated 6/29/2016 documented the resident was on a 1500 ml fluid restriction. The 6/2016 Medication Administration Record (MAR) documented the resident's diet as NAS, low potassium and [MEDICATION NAME], unmodified diet with 1500 ml tap water restriction and 240 ml with meals. The registered dietitian (RD) initial nutrition assessment dated [DATE] documented the resident was admitted to the facility the day before and was placed on a NAS, low potassium and [MEDICATION NAME], unmodified diet with a 1500 ml fluid restriction. The resident went to [MEDICAL TREATMENT] 3 times weekly. The resident's estimated fluid needs were 1500 ml per day. The resident consumed 480 ml of fluid at his first 2 meals at the facility. Supplements would be Nepro 8 ounces in the evening and at night time. The plan was to follow up with the resident as needed (prn) to encourage intakes, a plan of care check to follow in 1-2 weeks, and to follow up with the [MEDICAL TREATMENT] dietitian for weights/labs/recommendations. A nursing progress note dated 6/30/2016 documented the resident had a low grade temperature and had emesis (vomiting). A physician progress notes [REDACTED]. An NP progress note dated 7/5/2016 documented the resident was seen for low blood pressures and was given fluids while at [MEDICAL TREATMENT]. An NP progress note dated 7/8/2016 documented the resident's significant other requested the resident be restarted on his [MEDICAL CONDITION] medications, and a call was placed to the resident's oncologist. It was decided a decision would be made at a follow up appointment, as the resident had a poor generalized condition and poor intake. A dietary progress note dated 7/8/2016 at 5:22 PM documented the resident declined interview and wanted to rest. The resident was reminded to request items as desired. Intakes were encouraged, including the consumption of Nepro. The resident's total daily fluid intake was documented as followed: - On 6/29/2016, fluid intake was 1180 ml of fluids and 120 ml of 8 ounces of Nepro; - On 6/30/2016, fluid intake was 120 ml; - On 7/1/2016, fluid intake was 600 ml; - On 7/2/2016, fluid intake was 100 ml and 120 ml of Nepro; - On 7/3/2016, fluid intake was 840 ml and 120 ml of Nepro; - On 7/4/2016, fluid total intake was 600 ml and 240 ml of Nepro in the PM and refused the Nepro at bedtime; - On 7/5/2016, fluid intake was 580 ml and 240 ml of Nepro at bedtime; - On 7/6/2016, fluid intake was 240 ml and 240 ml of Nepro and 240 ml of Nepro in the PM and nothing was documented for the Nepro at bedtime; - On 7/7/2016, fluid intake was 600 ml and nothing was documented for the Nepro on the PM and at bedtime pass; - On 7/8/2016, fluid intake was 0 ml; - On 7/9/2016, fluid intake was 360 ml, he refused the Nepro in the PM, and only consumed 60 ml of Nepro at bedtime; - On 7/10/2016, fluid intake was 420 ml and he consumed 60 ml of Nepro in the PM and 60 ml of Nepro at bedtime; and - On 7/11/2016, fluid intake was 480 ml. A hospital transfer form dated 7/11/2016 at 3:15 PM documented the resident was transferred to the emergency room for low blood pressures and increased confusion, as well as family and resident request. There was not documented evidence in the MAR or on the CNA assignment sheets from 6/28 - 7/11/2016 the resident required encouragement to consume fluids. During an interview with CNA #37 on 2/15/2017 at 8:35 AM, he stated if a resident was on a fluid restriction, it would be documented on the CNA assignment sheet or he could ask the LPN how much the resident could have. He stated the amount the resident consumed during a nourishment pass would be documented in the nourishment book located at the nursing station, and they did not input the amount into the computer. During an interview with CNA #52 on 2/15/2017 at 10:35 AM, she stated if a resident needed food and fluids encouraged, it would be documented on the CNA assignment sheet. She stated CNAs did not attend morning report, as the licensed practical nurses (LPNs) and registered nurses (RNs) on the unit did. During an interview with RN clinical coordinator #37 on 2/15/2017 at 10:40 AM, she reviewed the resident's MAR and stated it documented the resident could only have 240 ml of fluids with meals and that would mean the resident was only getting 240 ml of fluids with meals. She stated it should be 240 ml with medications. She stated the CNAs were responsible for inputting food and fluid consumption for meals in the computer, and nourishment consumption was documented on a separate form that was not in the computer. She stated each nurse on the unit was responsible for running an ADL (activities of daily living) report at the end of each shift for the residents they were responsible for, to review and monitor how much the resident's intake was. She stated if a resident was not eating or drinking well, the CNAs on the unit were very good about notifying the nursing staff, and the nursing staff would notify the NP or physician. During an interview with LPN #54 on 2/15/2017 at 10:55 AM, he reviewed the resident's MAR and stated it documented the resident could only have 240 ml of fluids with meals and it should be 240 ml with medications. He stated he was not aware of what an ADL report was and dietary would monitor a resident's intake. He stated CNAs were good about letting him know if a resident was not eating or drinking, and if they needed encouragement, that would be added to the CNA assignment sheet. During an interview with RN #38 on 2/15/2017 at 11:15 AM, she stated if a resident was on [MEDICAL TREATMENT] a weight would be obtained there and not at the facility, as that was the facility policy. She stated the RD was responsible for monitoring a resident's intake. She stated the LPNs and CNAs on the unit would also report a low intake and the LPNs would push fluids, and that would be added to the resident's CNA assignment sheet. During an interview with RD #53 on 2/15/2017 at 11:25 AM, she stated when a resident was admitted she would check in with them within 24-72 hours after their admission. She would complete a full nutritional assessment at that time, as well as initiate communication with the RD at the [MEDICAL TREATMENT] center. She stated she would do a follow up in another 2 weeks, or as needed if she was notified the resident was not taking in foods or fluids well. She stated she did not run any reports that would let her know how much a resident was consuming, and the LPNs or the CNAs would let her know if someone's intake was poor. The RD stated if she was notified, she would initiate a supplement or update the resident's preferences after she reviewed the resident's consumption records in the nourishment book, the computer meal consumption, and the MAR. She stated she could not recall the resident. She reviewed her emails prior to the interview with the surveyor, and did not have a record of any communication with the RD at the [MEDICAL TREATMENT] center. She stated she would keep and document in a progress note any communication she had with the [MEDICAL TREATMENT] RD. 10NYCRR 415.12(j)

Plan of Correction: ApprovedApril 12, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #18 is no longer a resident of the facility.
The Director of Nutrition completed an audit of others with the potential to be affected and one individual was identified and interventions were put into place. To ensure other potential residents are not affected, the Nutrition staff will meet with the Nurse Managers to report any residents that require encouragement and the Nurse Manager will ensure that resident encouragement for fluid and food intake is reflected on the CNA Assignment sheet. The MAR indicated [REDACTED]. An audit was conducted by the ADONs to ensure others on a fluid restriction had the correct transcription.
The procedure was changed to review percentage of intake weekly instead of every two weeks on those individuals not meeting their estimated needs. Upon recognition and assessment, interventions will be implemented. To ensure others received adequate hydration, the Director of Nutrition has provided re-education to all nutritional staff.
Identifying others: Audit of food and fluid consumption for all rehab [MEDICAL TREATMENT] residents. Fluid Restrictions will follow an MD order.
Once the fluid restriction amount is ordered by the MD/NP/PA , the RD will review meal pattern to assure fluid restriction is not exceeded. Foods such as soups, jello, ice cream, sherbet, and watermelon will be considered in meal planning. The fluid restriction shall be documented on the care plan.
The Nutrition Staff will conduct audits to ensure residents are receiving sufficient fluid intake to maintain proper hydration and health. Food and fluid consumption audits will be performed for three (3) consecutive months and then quarterly up to 12 months. The expected compliance will be 90%. The results will be reported at the monthly QAPI Committee Meeting to ensure sustained compliance.
Date for correction: 4/14/17. Responsible: Director Clinical Nutrition

FF10 483.25(b)(1):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 16, 2017
Corrected date: April 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure residents with pressure ulcers received the necessary treatments and services needed to promote healing for 1 of 7 residents (Resident #11) reviewed for pressure ulcers. Specifically, Resident #11 developed a pressure ulcer and was not provided with timely optimal pressure relief as planned. Findings include: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. He required extensive assistance with all activities of daily living (ADLs) except for eating. The resident was frequently incontinent of bowel and bladder. He was at risk for pressure ulcer development and did not have any unhealed pressure ulcers. The certified nurse aide (CNA) assignment sheet (used to guide care) dated 12/9/2016 documented to check, change, and reposition the resident every 2 hours. He utilized a pressure relief mattress and a gel cushion in his wheelchair. The comprehensive care plan (CCP) dated 12/12/2016 documented the resident had macerated skin as evidenced by redness to the coccyx area. Interventions included to turn and reposition every 2-4 hours and check and change for incontinence. A registered nurse (RN) progress note dated 2/6/2017 documented the resident had an open area on his buttock. The area was assessed and he had an area of small skin maceration on the right buttock and an open area on the coccyx (tailbone) that contained slough (moist dead tissue). The wound nurse was notified and came to assess. An alternating air mattress was applied to his bed and a Roho (pressure relief) cushion to the wheelchair. A skin condition report by the wound nurse dated 2/6/2017 documented the resident had recently had a decline in his overall condition and had developed a Stage III (full thickness skin loss) pressure ulcer on the coccyx. The pressure ulcer measured 1.5 centimeters (cm) x 0.8 cm x 0.1 cm, and the wound bed contained 50% pink and 50% yellow slough. A physician order [REDACTED]. The CNA assignment sheet provided to the surveyor on 2/9/2017 at 3:00 PM documented the resident had a gel cushion in his wheelchair. The resident's room was observed on 2/10/2017 at 10:17 PM, and a Roho cushion was observed in a chair in the corner of the room. At 12:00 PM, the resident was observed in the hallway in a wheelchair sitting on a gel foam cushion, and the Roho cushion remained in the resident's room. At 1:53 PM, the resident was observed sitting on a gel foam cushion in the wheelchair in his room, and the Roho cushion remained in the chair in the corner of the room. At 2:33 PM, the resident was observed sleeping in the wheelchair, sitting on the gel foam cushion, and the Roho cushion remained in the chair in the corner of the room. During a treatment observation on 2/13/2017 at 4:05 PM with wound RN #35, the resident had a small pressure ulcer on the coccyx. The wound bed was partially covered with moist yellow slough and the rest was pink granulation (healing) tissue. The RN stated prior to the development of the pressure ulcer, the resident was on a turning and repositioning program and had gel foam cushion in the wheelchair. The RN stated an alternating air mattress was placed on the bed, and he was given a Roho cushion as soon as the pressure ulcer developed. She stated the Roho cushion was the optimal pressure relief cushion for the wheelchair and was not initiated for all residents, as they were expensive. She stated the resident should be using the Roho cushion while he was in his wheelchair. During an interview with CNA #36 on 2/15/2017 at 8:35 AM, he stated if the resident needed to be turned and repositioned or required special pressure relief, he would know that by looking at his assignment sheet. During an interview with RN clinical coordinator #6 on 2/15/2017 at 12:30 PM, she stated when the pressure ulcer developed, an alternating air mattress was placed on the bed and a Roho cushion was placed on the resident's wheelchair. She stated the Roho cushion was brought down by the wound nurse and taken right out of the box and placed in the resident's wheelchair. She stated she did not know why the resident was not consistently seated on the Roho cushion, and he should be. 10NYCRR 415.12(c)(1)

Plan of Correction: ApprovedMarch 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #11 had the gel foam cushion removed from the room and replaced with the roho cushion. The CNA Assignment Sheet and the Plan of Care was updated for resident #11.
The wound care RN completed an audit of all residents with physician orders [REDACTED]. All residents with physician orders [REDACTED].
The Wound Care RN will recommend specialty skin care cushions when appropriate and will bring the cushion to the unit and give it to a nursing management staff member. The nursing management staff member will obtain a physician order [REDACTED].
The infection control nurse will monitor all skin prevention cushions that are ordered to ensure timeliness of the residents receiving the ordered equipment. The process will be the same for all skin prevention cushions ordered to ensure follow up and receiving of the equipment is timely.
To prevent further occurrence, audits will be conducted on all residents by the Nurse Manager for those with physician orders [REDACTED]. The audit will include a review for the physician order, accuracy on the CNA Assignment Sheet, that the Plan of Care has been been updated, the ordered cushion is present in wheel chair and all other cushions have been removed from the residents room. This audit will be completed monthly on all nursing units for a minimum of three (3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings to ensure compliance is met and reoccurrence is prevented. The Quality Assurance Committee will provide input on the need to continue, discontinue or modify the audits after the three (3) month period.
The date for correction is (MONTH) 14th. The Director of Nursing is responsible to ensure continued compliance.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2017
Corrected date: March 6, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure corridor doors were smoke resistant for 7 isolated areas (storage room by room 1309, 13th floor staff lounge, bathroom by room 1222, 5th floor dining room, staff education office, chaplain office, and recreation office). Specifically, the storage room by room 1309, the 13th floor staff lounge, the bathroom by room 1222, the 5th floor dining room, and the staff education office had doors with holes in them; the chaplain office door was held open with an unapproved device; and the recreation office double doors had a large gap between them. Findings include: 1) Holes in Doors On 2/9/2017 at 4:52 PM, a surveyor observed the following rooms had doors with holes in them: - the staff lounge door had a 1/8 inch hole over the doorknob; and - the storage room by room 3009 had a 1/8 inch hole over the doorknob. On 2/9/2017 at 5:00 PM, a surveyor observed the door to the corridor bathroom by room 1222 had an unsealed 1 inch hole in it that was filled with tissue paper and sealed on both sides of the door with duct tape. This area was where an existing locking mechanism had been removed. On 2/19/2017 at 11:16 PM, a surveyor observed a 5th floor dining room door with two 1/8 inch holes in it. On 2/10/2017 at 3:21 PM, a surveyor observed the staff education office door had two holes in it. During an interview on 2/13/2017, between 2:30 PM and 3:24 PM, the Director of Facilities stated he was aware all corridor doors were supposed to be properly sealed and have no penetrations. He stated these holes were missed due to ongoing repairs to the door knob hardware throughout the facility. He stated be believed the door to the corridor bathroom by room 1222 has been in disrepair for less than two weeks. 2) Door Held Open with Unapproved Device On 2/10/2017 at 3:10 PM, a surveyor observed the chaplain office door was held open with a plastic door stop. During an interview on 2/13/2017, between 2:30 PM and 3:24 PM, the Director of Facilities stated doors were checked daily during rounds to ensure they were not being held open with unapproved devices. He stated in the past, notices had been sent to the staff not to use unapproved hold open devices on doors. 3) Gap Between Double Doors On 2/10/2017 at 3:15 PM, a surveyor observed the gap between the recreation double doors was 1/4 inch. During an interview on 2/13/2017, between 2:30 PM and 3:24 PM, the Director of Facilities stated the door gap in corridor doors should be 1/8 inch or less, and was included on monthly checks of the facility. He stated he was not aware the gap between the recreation double doors was greater than 1/8 inch. 2012 NFPA 101: 19.3.6.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 20, 2017

A full house Corridor Door assessment will be completed by (MONTH) 19, (YEAR).

All identified issues to include room 1309, 13 floor lounge, 1222 room by bathroom, 5th floor dining room, staff education, Chaplin office, and recreation office will be completed by (MONTH) 14, (YEAR). Corrections will include repair of gaps between doors, inappropriate hold open devices, and holes in doors.
In addition, an audit tool and door numbering system was created and implemented on (MONTH) 22, (YEAR) to adhere to the compliance standards. This audit is completed monthly by the Manager and Director of Facilities.
Training on both inappropriate hold open devices will be completed facility wide by (MONTH) 14, (YEAR), Training on NFPA 101 - Corridor-doors will be completed by all maintenance staff by (MONTH) 31, (YEAR).
The results of audits will be reported to the Quality Assurance team for the next six (6) months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.
The Director of Facilities is responsible to ensure corrective action is implemented.

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2017
Corrected date: March 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during the recertification survey, it was determined the facility did not properly maintain electrical installations for 4 isolated areas (room [ROOM NUMBER], room [ROOM NUMBER], mail room, and executive office). Specifically, extension cords and multi-plug adapters were in use in these rooms. Findings include: On 2/9/2017 at 2:08 PM and 4:55 PM, a surveyor in room [ROOM NUMBER] observed a wall duplex outlet with a 6-prong adapter in it. On 2/9/2017 at 2:43 PM and 4:00 PM, a surveyor in mail room observed a plugged-in power strip with an extension cord plugged into it. On 2/9/2017 at 4:01 PM, a surveyor in executive office observed a plugged-in power strip with another power strip plugged into it. Specifically, 1 power strip that acted as an extension cord was daisy-chained to another power strip. On 2/9/2017 at 5:14 PM, a surveyor in room [ROOM NUMBER] observed a wall duplex outlet with a 6-prong adapter in it. During an interview on 2/13/2017, between 2:30 PM and 3:24 PM, the Director of Facilities stated staff, visitors, and residents have previously been educated on allowable extension cords and adapters, and this was an ongoing issue within the facility. 2012 NFPA 101: 19.5.1, 9.1.2 (NFPA 70) 2012 NFPA 99: 10.2.4.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 20, 2017

A full house assessment was completed and the identified extension cords and multiple plug adaptors were removed facility wide by (MONTH) 2, (YEAR). This was completed by the in-house electrician.
A full house training and communication will be completed by (MONTH) 14, (YEAR) to include all staff, elders, and families on our electrical compliance standards. This will also be discussed with elders at the next scheduled full house resident council.
In addition, the in-house electrician will perform facility wide monthly audits as well as inspect all new admitted resident rooms for compliance. A tagging system on all electrical will be implemented to control compliance facility wide.
The results of audits will be reported to the Quality Assurance team for the next six (6)months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.
The Director of Facilities is responsible to ensure corrective action is implemented.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2017
Corrected date: March 6, 2017

Citation Details

Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not ensure the fire rating of 2 of 25 hazardous area doors was maintained (trash room and linen storage room). Specifically, the trash room fire rated double doors and frame were damaged, and the linen storage room one hour fire rated walls were not maintained. Findings include: On 2/10/2017 at 3:52 PM, a surveyor observed the panic bar hardware on the 45-minute fire rated trash room doors was missing parts. The trash room door frame had a 3 inch x 4 inch cut-out that was covered by an unsecured metal plate and duct tape. On 2/10/2017 at 4:25 PM, a surveyor observed the one hour fire rated linen storage room walls were not sealed to the floor deck above, and there were two unsealed holes in a wall. During an interview on 2/13/2017, between 2:30 PM and 3:24 PM, the Director of Facilities stated he was not aware of the cut-out in the trash room door frame. He stated missing panic bar hardware had been an ongoing issue within the facility. He stated during a walk-through of the linen storage room earlier on 2/13/2017, he noted the walls within this room should have been sealed. He stated the linen storage room walls on the floor plan were not listed as 1 hour fire rated construction. Record review of a floor plan (plan date unable to be determined from the copy), received on 2/13/2017, showed the linen storage room walls were not listed for 1 hour fire rated construction. 2012 NFPA 101: 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 20, 2017

The identified trash room door in need of repair was accessed by a certified door contractor on (MONTH) 22, (YEAR) and quote is being obtained. Repairs to the hole in the door frame causing open penetration and the panic bar for proper closure will be repaired by (MONTH) 14, (YEAR). A full assessment was completed on all chute doors to include both trash and linen was completed on (MONTH) 22, (YEAR).
The isolated linen storage area room identified for 1-hour fire rating was repaired and work completed by BRAND Fire Protection during the survey on (MONTH) 14th and 15TH. This area is fully compliant.
In addition, an audit tool and door numbering system was established to better monitor and audit hazardous area doors. This on-going audit will be performed by the Manager and Director of Facilities monthly.
Training and education will be conducted by the Director of Facilities for all maintenance staff on NFPA 101 ? Hazardous Areas ? Enclosure. This will be completed by (MONTH) 31, (YEAR).
The results of audits will be reported to the Quality Assurance team for the next six (6) months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.
The Director of Facilities is responsible to ensure corrective action is implemented.
The Director of Facilities is responsible to ensure corrective action is implemented.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2017
Corrected date: March 6, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the means of egress was continuously maintained free of all obstructions in case of emergency for 1 of 10 outside emergency exit doors (Fahey cafeteria). Specifically, 1 of the exit double doors would not open when tested . Findings include: On 2/10/2017 at 10:07 AM, a surveyor in the Fahey cafeteria observed 1 of the outside emergency exit double doors did not open. The surveyor attempted to open the door 3 times. During an interview on 2/10/2017 at 10:09 AM, the Director of Facilities stated he did not know the last time this door was checked to ensure it opened. He stated outside emergency exit doors were not included on the weekly and monthly door checklists. He stated the door was currently being repaired. 2012 NFPA 101 19.2.1, 7.1.10.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 20, 2017

A full house assessment of all egress doors was completed on (MONTH) 20, (YEAR). The identified café door was repaired on (MONTH) 20, (YEAR) by a certified door contractor. The exit door is fully operational.
A newly implemented full house means of egress audit tool was created with a door numbering system to be completed monthly by the Manager and Facility Directors.
Training on NFPA 101 ? Means of Egress ? General will be provided to all maintenance staff. This will be provided by the Director of Facilities by (MONTH) 31, (YEAR).
The results of audits will be reported to the Quality Assurance team for the next six(6) months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.
The Director of Facilities is responsible to ensure corrective action is implemented.

K307 NFPA 101:RUBBISH CHUTES, INCINERATORS, AND LAUNDRY CHU

REGULATION: Rubbish Chutes, Incinerators, and Laundry Chutes 2012 EXISTING (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.) (4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2017
Corrected date: March 6, 2017

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not properly maintain the 45 minute fire rated linen chute in 1 of 14 floors of the(NAME)building (13th floor soiled linen room). Specifically, the linen chute within the 13th floor soiled linen room had two doors that would not self-close. Findings include: On 2/9/2017 at 4:35 PM, a surveyor in the(NAME)13th floor soiled linen room observed two doors, the linen chute hatch door and an access door above, that would not self-close. The access door did not have a self-closure device installed on it. Review of a purchase order, received on 2/13/2017, revealed the facility purchased six trash doors on 10/24/2016. During an interview on 2/13/2017, between 2:30 PM and 3:24 PM, the Director of Facilities stated in the past 3 months, the facility had tried to replace the obsolete doors. They were hard to match, and it had been an ongoing issue at the facility. He stated the ordered doors were on back-order, and there was no documentation regarding this. 2012 NFPA 101: 19.5.4, 8.4 2010 NFPA 80 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 20, 2017

A full assessment of all chute doors was completed on (MONTH) 20, (YEAR). The latch on one of the two chute doors identified was fully repaired and operational on (MONTH) 15, (YEAR). The other chute door that was backordered and not available was re-ordered with another company on (MONTH) 4, (YEAR) with a two week lead time. This repair will be completed by (MONTH) 14, (YEAR).
A chute door audit tool was created to monitor all chute doors monthly, ongoing by the Manager and Facility Directors. In addition training on NFPA 101 - Shoot Doors for all maintenance staff will be completed by the Director of Facilities by (MONTH) 31, (YEAR).
The results of audits will be reported to the Quality Assurance team for the next 6 months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.
The Director of Facilities is responsible to ensure corrective action is implemented.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2017
Corrected date: March 6, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure all 45 minute fire rated barrier doors were smoke resistant for 4 isolated fire doors observed (fire doors by employee health office, main kitchen, freight elevator room, and dish room). Specifically, the doors to these rooms had holes in them. Findings include: On 2/10/2017, between 3:25 PM and 4:04 PM, a surveyor observed the following 45 minute rated fire doors had holes in them: - 1 of 2 fire barrier doors near employee health office had 2 holes in it; - the freight elevator room door had 2 holes in it; - 1 of 2 main kitchen doors had 2 holes in it; and - the dish room door had 6 holes in it. During an interview on 2/13/2017, between 2:30 PM and 3:24 PM, the Director of Facilities stated he was aware all fire doors were supposed to be properly sealed and have no penetrations. He stated these holes were missed due to ongoing repairs throughout the facility, and the facility did not visually check fire rated doors for holes. 2012 NFPA 101: 19.3.7.6 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 20, 2017

A full building assessment was completed by a certified door company on (MONTH) 21, (YEAR). Identified repairs are in progress and will be fully completed by (MONTH) 14, (YEAR). In addition, an audit door tool was created with a door numbering system to be completed monthly by the Manager and Facility Directors for compliance.
Training on NFPA 101 Building Spaces Smoke Barrier ? Smoke Barrier Doors will be provided to all maintenance staff by the Director of Facilities and will be completed by (MONTH) 31, (YEAR).
The results of audits will be reported to the Quality Assurance team for the next 6-months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.
The Director of Facilities is responsible to ensure corrective action is implemented.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2017
Corrected date: March 6, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for 2 of 2 exit stairwells in the(NAME)building (north stairwell and south stairwell) and 2 of 4 exit stairwells in the Fahey building (south stairwell and west stairwell). Specifically, doors to these exit stairwells had holes in them. Findings include: On 2/9/2017 at 1:20 PM, a surveyor in the(NAME)north stairwell observed the 13th floor access door had a 1/2 inch hole on one side of the door and two 1/4 inch holes on the other side of the door. On 2/9/2017 at 1:46 PM, a surveyor in the(NAME)south stairwell observed the 13th floor access door had a 1/2 inch hole on both sides of the door. On 2/9/2017 at 2:23 PM, a surveyor in the(NAME)north stairwell observed the 11th floor access door had a 1/2 inch hole on both sides of the door. During an interview on 2/9/2017 at 4:25 PM, the Director of Facilities stated regular walk-throughs of the facility included checking to ensure the stairwell doors self-closed and latched. He stated the facility did not visually check fire rated doors for holes. On 2/13/2017 at 10:58 AM, a surveyor in the Fahey south stairwell observed the 3rd floor access door had a 1/8 inch hole on both sides of the door. On 2/13/2017 at 11:07 AM, a surveyor in the Fahey west stairwell observed the 3rd floor access door had a 1/8 inch hole on both sides of the door. During an interview on 2/13/2017, between 2:30 PM and 3:24 PM, the Director of Facilities stated he was aware all fire doors were supposed to be properly sealed and have no penetrations. He stated these holes were missed due to ongoing repairs to the door knob hardware throughout the facility. 2012 NFPA 101: 19.3.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A full building assessment of all stairwell doors was completed by the Director of Facilities on (MONTH) 17, (YEAR).
An audit tool was created to document and record current status of necessary repairs.
All identified stairwell doors in need of correction were repaired on [DATE], (YEAR) by a certified door contractor (Midstate Doors).
A newly created audit form with a door numbering system will be utilized monthly (on-going) to inspect and adhere compliance. This will begin immediately and be performed by the facility manager and director.
In addition to making the corrections and repairs, Training and education will be provided to all maintenance staff on NFPA 101- vertical openings ?Enclosure and compliance. This will be completed by (MONTH) 31, (YEAR).
The results of audits will be reported to the Quality Assurance team for the next six (6) months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.
The Director of Facilities is responsible to ensure corrective action is implemented.