Wingate at Beacon
March 30, 2017 Certification Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recent recertification survey, the facility did not ensure that a care plan with measurable objectives, time frames and appropriate interventions based on comprehensive assessment was initiated for 1 of 3 residents (#119) reviewed for urinary incontinence. Specifically, there was no care plan with appropriate interventions to maintain or improve, to the extent possible, the resident's continency level. The findings are: Resident #119 has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS; a comprehensive resident assessment tool) of 9/30/16 showed the resident had moderately impaired cognition; was occasionally incontinent of bowel and bladder (less than 7 episodes of urinary incontinence); and required extensive assistance of one person with toilet use. The Comprehensive Care Plan (CCP) developed after the completion of this MDS dated [DATE] had a care plan Actual Bladder Incontinence related to impaired mobility, history of [MEDICAL CONDITION], arthritis, and depression. The objectives developed was to keep the resident free from signs and symptoms of infection and/or skin breakdown related to incontinence. The interventions to address incontinence were limited to the following: be aware of changes in (resident's) condition; monitor for constipation; hydration per physician's orders [REDACTED]. This care plan did not include measurable objectives, time frames and interventions to maintain the resident as free of episodes of incontinence to the extent possible. A review of the Point of Care History (documentation provided by Certified Nurse Aides (CNA) which included the number of times the resident is incontinent daily) for the months of (MONTH) (YEAR) to (MONTH) (YEAR) showed the following number of recorded episodes of urinary incontinence per month: (MONTH) - 21; (MONTH) - 25; and (MONTH) - 17. The day shift Certified Nursing Aide (CNA#1) assigned to the resident was interviewed in the morning of 3/30/17 and stated that the resident was toileted upon request. The unit Registered Nurse (RN#1) manager responsible for developing the CCP was interviewed in the morning of 3/30/17 and stated there was no care plan with specific interventions to assist the resident maintain or improve the resident's continency level. Following surveyor inquiry, RN#1 stated she would assess the resident's voiding pattern and then initiate appropriate interventions. 415.11(c)(1)

Plan of Correction: ApprovedApril 26, 2017

The comprehensive care plan of resident #119 has been initiated by the Unit Manager to include measurable objectives, time frames, and appropriate interventions based on comprehensive assessments to maintain or improve, to the extent possible, the resident's continency level.
The Unit Managers will initiate comprehensive care plans with measurable objectives, time frames, and interventions based on comprehensive assessments to maintain or improve the residents' continency level of all residents.
The Director of Nursing/designee will in-service all Unit Managers on the Incontinence Management Policy, including initiating comprehensive care plans with measurable objectives, time frames, and interventions based on comprehensive assessments.
The DON/designee will review 5 resident records per unit each month to ensure residents with incontinence have comprehensive care plans initiated with measurable objectives, time frames, and interventions based upon comprehensive assessments to maintain or improve continency level. The audit results will be presented at the monthly Quality Assurance/Performance Improvement meeting for three months after which time the QA/PI committee will determine the frequency of the audits.

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 30, 2017

Citation Details

Based on observation and interview conducted during a recertification survey, the facility did not ensure that all medications were properly dated and labeled in accordance with accepted professional standard of practice and manufacturer's recommendation. Specifically, an insulin vial and a flexpen (a pre-filled insulin syringe or pen) were not dated when opened. Additionally, the insulin flexpen was not labeled with the resident's name for which it was prescribed. This was evident for 1 of 8 unit medication carts (Putnam) observed during the medication storage inspection. The findings are: On 3/30/17 at 1:00 PM, a medication cart on the Putnam Unit was inspected. A vial of Novolin 70/30 insulin and one Novolin Flexpen were observed to be opened and in use for a resident. Neither insulin containers had dates when they were opened or the respective resident's name or any other identifying information inscribed on the insulin flexpen. The unit medication Licensed Practical Nurse was interviewed at that time and stated that the medications had been taken from the emergency box on 3/29/17 for a resident who had just been admitted . According to the manufacturer's recommendation, Novolin 70/30 insulin should be discarded 42 days after opening and the Novolin Flexpen should be discarded 28 days after opening. The expiration dates change upon opening of the containers regardless of the actual manufacturer's expiration dates inscribed on the medication container. 415.18(d)

Plan of Correction: ApprovedApril 26, 2017

Under the direction of the Unit Manager the identified medications were discarded. No residents were affected.
The Unit Managers inspected all medication carts to ensure all medications were properly dated and labeled.
The Director of Nursing/designee will in-service all nurses on the Medication Administration Policy, including the dating and labeling of medication.
The Nurse Managers/designee will inspect all medications in all medication carts three times weekly at random times for dates when opened and labels with resident names. Results will be recorded on audit forms. The results of the audits will be presented by the DON at the monthly Quality assurance/Performance Improvement meetings for three months after which time the QA/PI committee will determine the frequency of the audits.

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that the medication regimen was free from unnecessary medications for 1 of 5 residents (#88) reviewed for unnecessary medications. Specifically, the facility did not address continued use of [MEDICATION NAME] (used to treat symptoms associated with [MEDICAL CONDITION]) in the possible presence of side effects (somnolence). The findings are: Resident #88 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident's medical record, specifically the nurses notes, revealed that on 7/28/15 due to increased confusion, the resident was placed on [MEDICATION NAME]. The resident has remained on this medication since that time to the present. The psychiatric consultation report dated 4/18/16 and a nursing note entry on the same date, noted that the resident was sleepy. The resident's medication regimen at that time, included [MEDICATION NAME] 15 mg daily (for depression), [MEDICATION NAME] 0.5 mg. daily (an antipsychotic medication), [MEDICATION NAME] 10 mg daily and [MEDICATION NAME] 15 mg daily (both for dementia) to be given at 9:00 AM. Somnolence or sleepiness was not addressed in the consultation report. The psychiatrist documented the resident had no signs and symptoms of depression, no overt [MEDICAL CONDITION] and that her mood and affect were stable. The psychiatrist's recommendation was to decrease [MEDICATION NAME] to 0.25 mg daily. The nursing notes showed no documented evidence that the nursing staff monitored the resident's sleeping pattern since the psychiatric evaluation on 4/18/16. On 2/17/17, another psychiatric evaluation was requested for review of the resident's medications which included all the medications mentioned above and for sleepiness. The psychiatrist noted that he discussed increased sleepiness with the resident who stated that she was not doing this anymore. This evaluation did not reflect any discussion with the nursing staff in light of the fact that the resident has severe cognitive impairment. On 3/29/17, interviews with the nursing staff and observation of the resident were conducted. At this time, the resident was in bed sleeping in the morning prior to lunch. Two nurse aides (CNA#4 and CNA#5) who regularly take care of the resident were interviewed at 11:45 AM, respectively. These interviews revealed that there were days when the resident wanted to be left in bed and did not want to be bothered. Both CNAs stated the resident had been sleeping a lot of time in bed, sometimes for the whole day. The aides did not know how well the resident slept during the night. The resident's medical record, including the nursing notes, the physician monthly progress, and the interim notes revealed no documented evidence of an assessment regarding the resident's sleeping pattern. The unit manager (RN#1) who was assigned to the unit four days prior to the beginning of the survey on 3/23/17, was interviewed on 3/29/17 at 1:20 PM and stated that she will initiate a sleeping study. The psychiatrist who had conducted the above mentioned evaluations was interviewed via telephone on 3/30/17 at about 8:40 AM and stated that when he conducted the 2/17/17 evaluation, he did not address sleepiness because he did not think that the resident's medications were causing her sleepiness. Interview with the facility consultant pharmacist in morning of 3/30/17 following interview with the unit RN manager stated that [MEDICATION NAME] can cause sleepiness. 415.12(I)(1)

Plan of Correction: ApprovedApril 26, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Attending Physician discontinued the use of [MEDICATION NAME] on 3/29/17 for resident #88.
All residents on [MEDICAL CONDITION] medications will be reviewed by the Attending Physician if continued use is necessary and consider a gradual dose reduction, unless clinically contraindicated.
All Attending Physicians and the Psychiatrist will receive education on F 329, particularly how it relates to [MEDICAL CONDITION] medication by the DON/designee.
The Unit Managers/designee will audit that all residents on [MEDICAL CONDITION] medications have been assessed monthly by the Attending Physician for medical necessity of the drug and for possible gradual dose reduction, unless medically contraindicated. Results will be presented at the monthly Quality Assurance/Performance Improvement meetings for three months after which time the QA/PI committee will determine the frequency.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that cares and services were provided for 2 of 3 residents (#119 and #226) reviewed for Urinary Incontinence. Specifically, (1.) Resident #119 did not have a care plan to maintain or improve the resident's current continency level and (2.) Resident #226's care plan was not reviewed and revised to address a decline in the bladder continency level. The care and services did not include specific interventions to assist the residents maintain or regain as much bladder function to the extent possible. The findings are: 1. Resident #119 has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS; a resident assessment tool) 9/30/16 showed the resident had moderately impaired cognition; was occasionally incontinent of bowel and bladder (less than 7 episodes of urinary incontinence); and required extensive assistance of one person with toileting. The Comprehensive Care Plan (CCP), developed after the completion of this MDS, dated [DATE], had a care plan for Actual Bladder Incontinence related to impaired mobility, history of [MEDICAL CONDITION], arthritis, and depression. This care plan did not include measurable objectives and interventions to maintain the resident free of episodes of incontinence to the extent possible. The objectives developed was to keep the resident free from signs and symptoms of infection and or skin breakdown related to incontinence. The interventions listed were to: be aware of changes in (resident's) condition, monitor for constipation, hydration per physician's orders [REDACTED]. A review of the Point of Care History (documentation provided by the Certified Nurse Aides (CNA) which included the number of times the resident is incontinent daily) for the months of (MONTH) (YEAR) to (MONTH) (YEAR) showed the following number of recorded episodes of urinary incontinence per month: (MONTH) - 21 times; (MONTH) - 25 times; and (MONTH) - 17 times. The day shift CNA (#1) assigned to the resident was interviewed in the morning of 3/30/17 and stated that the resident was toileted upon request. The unit Registered Nurse (RN#1) manager responsible for developing the CCP was interviewed in the morning of 3/30/17 and stated there was no care plan with specific interventions to assist the resident maintain or improve the resident's continency level. Following surveyor inquiry, RN#1 stated she would assess the resident's voiding pattern and initiate appropriate interventions. (An attempt was made to interview the resident in the afternoon of 3/30/17. The resident, due to being hard of hearing and having some cognitive impairment, had difficulty responding to the questions asked and the interview was aborted.) 2. Resident #226 has [DIAGNOSES REDACTED]. The Quarterly MDS of 10/28/16 indicated the resident had severely impaired cognition; required extensive assistance of two persons in most aspects of activities of daily living including toilet use; and was frequently incontinent of urine (defined in the MDS as 7 or more episodes of urinary incontinence, but at least one episode of continent voiding). The unit RN manager (RN#2) was interviewed in the morning of 3/30/17 and stated that an interim care plan dated 10/21/17 was initiated to address bowel and bladder impairment. This care plan did not include the resident's current bladder continency level and the appropriate interventions to address the resident's current urinary continency level. The resident was subsequently assessed on the Quarterly MDS of 1/25/17 and revealed that the resident had a decline in bladder continence from being frequently incontinent to always incontinent of bladder function (defined in MDS as no episode of continent voiding). There was no documented evidence that the interim care plan to address the resident's continency level was reviewed and revised to assist the resident regain as much bladder continence to the extent possible. The assigned CNA (#2) was interviewed in the morning of 3/30/17 and stated the resident has been incontinent and the only difference is that the resident knows when he needs to be changed. CNA#2 stated that when the resident calls, she comes as quickly as possible because the resident is usually wet by the time she gets to him. CNA#3 who recently took care of the resident was interviewed immediately following interview of CNA#2 and stated that the resident usually calls her attention using the call bell but the resident was already wet. CNA #3 stated the resident knows when he needs to be changed and usually tries a urinal but sometimes the resident is not very successful. 415.12(d)(2)

Plan of Correction: ApprovedApril 26, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The care plan of resident #119 has been revised by the Unit Manager to include appropriate interventions to maintain or improve, to the extent possible, the resident's continency level. The care plan of resident #226 has been revised by the Unit Manager to include measurable objectives, time frames, and appropriate interventions to address a decline in level of continence.
The care plans of all residents assessed with [REDACTED].
The care plans of all residents assessed with [REDACTED].
The Director of Nursing/designee will in-service all Unit Managers on the Incontinence Management Policy which includes appropriate interventions based upon individual resident assessment.
The DON/designee will review 5 resident records per unit each monthly to ensure residents with incontinence have care plans with interventions to maintain or improve continency level. The audit results will be presented at the monthly Quality Assurance/Performance Improvement meeting for three months after which time the QA/PI committee will determine the frequency of the audits.
The DON/designee will review all residents with a decline in continency each month to ensure their care plans have measurable goals, time frames, and appropriate interventions to address a decline in continency level. The audit results will be presented at the monthly Quality Assurance/Performance Improvement meeting for three months after which time the QA/PI committee will determine the frequency of the audits.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that care and treatment were provided for 1 of 5 residents reviewed for unnecessary medications to maintain the resident's highest practicable level of physical well-being in accordance with the comprehensive assessment. Specifically, the physician's orders [REDACTED]. The findings are: Resident #183 was admitted to the facility with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. This order further indicated that if the resident gained two pounds in three days or three pounds in one week, respectively, the physician was to be notified. Further review of the physician's orders [REDACTED]. ([MEDICATION NAME] is used to treat fluid retention and swelling caused by [MEDICAL CONDITION]). The cardiac care plan of 2/20/17 revealed interventions including to notify the physician of any signs of [MEDICAL CONDITION] and weight gain. The Daily Weight form for (MONTH) (YEAR) revealed that weights were not taken on (MONTH) 4, 5, 10, 12, 14, 20 and 28. On 3/11/17, the resident's weight was 227 pounds. The weight on 3/12/17 and on 3/13/17 was 230 pounds, a gain of 3 pounds. There was no documented evidence in the resident's clinical record, including the nursing progress notes, that the physician was notified of the weight gain. The unit manager (RN#1) was interviewed on 3/30/17 at 3:00 PM and stated that the physician should have been notified of the weight gain. RN#1 further stated that she had been employed by the facility during the last one and a half weeks. The physician was interviewed on 3/30/17 at 3:15 PM and stated that it was vital that the resident's weight is monitored based on the resident's history of diarrhea from a previous intestinal infection and a [DIAGNOSES REDACTED]. 415.12

Plan of Correction: ApprovedApril 26, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Nurse Manager notified the attending Physician of the identified weight gain. The attending Physician has assessed the resident.
All residents with physician orders [REDACTED].
All nurses will be in-serviced by the Director of Nursing/designee on the process of monitoring residents on daily weights and complying with physician orders.
The DON/designee will audit all residents on daily weights for compliance with obtaining daily weights and notifying the physician if indicated by the physician order. Results will be presented at monthly Quality Assurance/Performance Improvement meetings for three months after which time the QA/PI committee will determine the frequency of the audits.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that the care plan was reviewed and revised for 1 of 3 residents (#226) reviewed for urinary incontinence. Specifically, the facility did not revise the care plan with measurable objectives, time frames and appropriate interventions to address a decline in the resident's continency level from frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) to always incontinent (no episode of continent voiding). The findings are: Resident #226 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (a resident assessment tool) completed on 10/28/16 indicated the resident had severely impaired cognition; required extensive assistance of two persons in most aspects of activities of daily living including toilet use; and was frequently incontinent of urine. The unit RN manager (RN#2) was interviewed in the morning of 3/30/17 and stated that an interim care plan dated 10/21/17 was initiated to address bowel and bladder impairment. This care plan did not include the resident's current continency level and the appropriate interventions based on the bladder assessment. The resident was subsequently assessed on the Quarterly MDS of 1/25/17 and revealed the resident had a decline in urinary continency to being always incontinent. There was no documented evidence that the interim care plan to address the resident's continency level was reviewed and revised with measurable objectives, time frames and appropriate interventions to assist the resident regain as much bladder function to an extent possible. The assigned CNA (CNA#2) was interviewed in the morning of 3/30/17 and stated that the resident has been incontinent and the only difference now is that the resident knows when he needs to be changed. CNA#2 stated that when the resident calls, she comes as quickly as possible because the resident is usually wet by the time she reaches him. CNA#3 who recently took care of the resident was interviewed immediately following interview of CNA#2 and stated that the resident usually calls her attention using the call bell but the resident was already wet by the time she gets to him. CNA#3 stated the resident knows when he needs to be changed and usually tries a urinal but sometimes the resident is not very successful. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedApril 24, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The care plan of resident #226 has been revised by the Unit Manager to include measurable objectives, time frames, and appropriate interventions to address a decline in level of continence.
The care plans of all residents assessed with [REDACTED].
The Director of Nursing/designee will in-service all Unit Managers on the Incontinence Management Policy.
The DON/designee will review all residents with a decline in continency each month to ensure their care plans have measurable goals, time frames, and appropriate interventions to address a decline in continency level. The audit results will be presented at the monthly Quality Assurance/Performance Improvement meeting for three months after which time the QA/PI committee will determine the frequency of the audits.

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that care and services were provided for 1 of 5 residents reviewed for unnecessary medications in accordance with the physician's orders [REDACTED]. Specifically, the physician's orders [REDACTED]. The findings are: Resident #183 was admitted with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. This order further indicated that if the resident gained two pounds in three days or three pounds in one week, respectively, the physician was to be notified. Further review of the physician's orders [REDACTED]. daily to treat [MEDICAL CONDITION] related to [MEDICAL CONDITION]. ([MEDICATION NAME] is used to treat fluid retention and swelling caused by [MEDICAL CONDITION]). The cardiac care plan of 2/20/17 revealed interventions including to notify the physician of any signs of [MEDICAL CONDITION] and weight gain. The Daily Weight form for (MONTH) (YEAR) revealed that weights were not taken on (MONTH) 4, 5, 10, 12, 14, 20 and 28. On 3/11/17, the resident's weight was 227 pounds. The weight on 3/12/17 and on 3/13/17 was 230 pounds, a gain of 3 pounds. There was no documented evidence in the resident's clinical record, including the nursing progress notes, that the physician was notified. The unit manager (RN#1) was interviewed on 3/30/17 at 3:00 PM and stated that the physician should have been notified of the weight gain. RN#1 further stated that she had been employed by the facility during the last one and a half weeks. The physician was interviewed on 3/30/17 at 3:15 PM and stated that it was vital that the resident's weight is monitored based on the resident's history of diarrhea from a previous intestinal infection and [DIAGNOSES REDACTED]. 415.11(c)(3)(ii)

Plan of Correction: ApprovedApril 26, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Nurse Manager notified the attending Physician of the identified weight gain. The attending Physician has assessed the resident.
All residents with physician orders [REDACTED].
All nurses will be in-serviced by the Director of Nursing/designee on the process of monitoring residents on daily weights and complying with physician orders.
The DON/designee will audit all residents on daily weights for compliance with obtaining daily weights and notifying the physician if indicated by the physician order. Results will be presented at monthly Quality Assurance/Performance Improvement meetings for three months after which time the QA/PI committee will determine the frequency of the audits.

Standard Life Safety Code Citations

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: March 30, 2017
Corrected date: May 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility did not ensure that extension cords and multiple adapters were used in accordance with NFPA 99 and NFPA 70, National Electrical Code. Reference is made to the use of extension cords and multiple adapters in resident rooms. This was noted on 2 of 3 resident floors. The findings are: During the life safety tour conducted on 3/23/17 and 3/24/17 between the hours of 11:30 AM to 3:00 PM the following issues with extension cords and multiple adapters were noted: - At approximately 1:15 PM, a tour of resident room [ROOM NUMBER] located on Putnam County West was conducted and an extension cord was observed plugged into the electrical outlet. The resident's cell phone was plugged into the extension cord. - At approximately 1:30 PM, a tour of resident room [ROOM NUMBER] was conducted and it was noted that a multiple adapter was plugged into the outlet. The resident's phone charger was plugged into the multiple adapter. - At approximately 1:40 PM, a tour of resident room [ROOM NUMBER] was conducted and a multiple adapter was noted to be plugged into the outlet (B bed). The resident's clock, lamp, and recliner were plugged into the multiple adapter. - On 3/24/17 at approximately 10:50 AM, a tour of resident room G 09 revealed a multiple adapter plugged into the outlet. In an interview at the time of the findings, the Director of Plant Operations stated that the residents' rooms are checked weekly for all issues. 2012 NFPA 99 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedApril 15, 2017

The identified extension cords and multiple adapters will be removed from the resident rooms by the Director of Plant Operations/designee.
All resident rooms will be inspected and cleared of any extension cords and multiple adapters by the Director of Plant Operations/designee.
Ten resident rooms per unit will be audited monthly for extension cords and multiple adapters by the Director of Plant Operations/designee.
The Director of Plant Operations will report audit findings to the monthly Quality Assurance/Performance Improvement meeting after which time the QA/PI committee will determine the frequency of the audits.

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** (j) Housekeeping. The entire nursing home, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment and furnishings shall be clean, the facility shall be maintained in good repair including, but limited to buildings, utilities, fixed equipment, resident care equipment and furnishings. Based on observation it was determined that the ceiling tiles were not maintained clean and in good repair. This was evidenced by ceiling tiles on two of three resident floors and the basement that were missing or stained. The findings are: During the life safety tour conducted on 3/23/17 and 3/24/17 the following issues with ceiling tiles in the basement were noted: - At 11:25 AM the Rehab area on the 3rd floor was toured and three ceiling tiles above the janitor's closet in this area were observed stained. - At approximately 12:05 PM, a tour of resident room [ROOM NUMBER] was conducted and the ceiling tile in the bathroom was observed stained. - At approximately 12:10 PM, a tour of the linen chute on the second floor was conducted and the ceiling tiles in the room were observed stained. - At approximately 1:35 PM, stained ceiling tiles were observed above the smoke barrier doors on Putnam County West. - At approximately 1:45 PM, tour of the linen chute room located on Putnam County North was conducted and one ceiling tile in the room was missing and another was stained. - At approximately 2:40 PM, the soiled workroom located on Dutchess East hallway was conducted and stained ceiling tiles were noted in the room. - On 3/24/17 at approximately 11:10 AM, a tour of 1 of 2 main linen chute discharge rooms on the ground floor and heavily stained ceiling tiles were noted above the chute. - At approximately 11:35 AM, a tour of the medical records storage room was toured and a heavily stained ceiling tile was noted in the room. In an interview at the time of the findings, the Director of Plant Operations stated that the ceiling tiles were being changed throughout the facility. He further stated that additional ceiling tiles have been ordered. 10 NYCRR 711.2 (a)(1) 415.29 (j)(1)(2)

Plan of Correction: ApprovedApril 15, 2017

The stained/missing ceiling tiles in the identified areas will be replaced by the Director of Plant Operations/designee.
The Director of Plant Operations/designee will identify and replace all other stained/missing ceiling tiles.
The Director of Plant Operations/designee will audit 10 ceilings per month for stained/missing ceiling tiles.
The Director of plant operations will report audit findings at the monthly Quality Assurance/Performance improvement meeting for three months after which time the QA/PI committee will determine the frequency of the audits.

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: March 30, 2017
Corrected date: May 15, 2017

Citation Details

2012 NFPA 101 9.5 Rubbish Chutes, Incinerators, and Laundry Chutes. 9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless such installations are approved existing installations, which shall be permitted to be continued in service. Based on observation and interview, the facility did not ensure that the doors to the soiled linen chutes are maintained self-closing and/or latching within the soiled utility rooms, in accordance with NFPA 82. This was evidenced by 1 of 3 doors to the laundry chutes on one of two resident floors that did not latch in the frame when closed. The findings are: On 3/23/17 at 1:45 PM, the soiled linen room on Putnam County North was toured. Upon examination and testing of the soiled linen chute door, it did not latch firmly in its frame after self closing. The latching mechanism appeared to be in disrepair. In an interview at the time of the finding, the Director of Plant Operations stated that chute doors are checked monthly when maintenance rounds are done. He further stated that the chute door will be repaired. 2012 NFPA 101: 9.2, 9.5.2 2009 NFPA 82 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedApril 15, 2017

Under the direction of the Director of Plant Operations the identified linen chute door was repaired to latch upon self closing.
The Director of Plant Operations/designee will inspect and ensure all laundry chute doors latch upon self closing.
All laundry chute doors will be audited monthly to ensure latching upon self closing by the Director of Plant Operations/designee.
The Director of Plant Operations will present findings of the audits at the monthly Quality Assurance/Performance Improvement meeting for three months after which time the QA/PI committee will determine the frequency of the audits.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2011 NFPA 25 Chapter 5 Sprinkler Systems 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). 5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. 5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion 5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. Chapter 8 Fire Pumps 8.3* Testing 8.3.1. Frequency 8.3.1.2* Electric- motor driven fire pumps shall be operated monthly. 8.3.2.3 The electric pump shall run a minimum of 10 minutes. 8.3.2.8 The pertinent visual operations or adjustments specified in the following checklists shall be conducted while pump is running: (2) Electrical system procedures as follows: (a) Observe the time for motor to accelerate to full speed (b) Record the time controller is on first step (for reduced voltage or reduced current starting) (c) Record the time pumps runs after starting (for automatic stop controllers). Based on observation and staff interview, the facility did not ensure that the automatic sprinkler system installed in required areas was maintained in accordance with NFPA 25 as evidenced by: 1. Sprinklers observed with a green oily substance and/or plastic 2. BX cable secured to the sprinkler pipe 3. Documentation for the monthly churn test for the electric fire pump was not available for review The findings are: On 3/23/17 and 3/24/17 between the hours of 11:00 AM and 3:00 PM, a life safety tour of the facility was conducted and the following issues with the sprinklers were noted: 1. Sprinklers observed with a green oily substance and plastic. Examples include: - A green oily substance was observed on one of 3 sprinklers in resident room [ROOM NUMBER] and one sprinkler head in the bathroom of resident room [ROOM NUMBER]. - One of 2 sprinklers in the main linen chute discharge room was noted to have plastic wrapped around the deflector. 2. A tour of the storage room labeled G 09 revealed that the BX cable from the junction box for the light fixture in the room was secured to the sprinkler pipe. 3. During review of the facility's sprinkler maintenance documentation on 3/23/17 at approximately 10:30 AM, it was noted that the documentation for the required monthly churn test for the fire pump was not available for review. In an interview at the time of the findings, the Director of Plant Operations stated that the green oily substance is a part of the sprinkler assembly. He further stated that he will contact the vendor regarding the green oil on the sprinklers. The Director of Plant Operations also stated that the BX cable in the storage room will be removed and that the fire pump test is performed quarterly by the vendor. 2012 NFPA 101 2011 NFPA 25: 5.2, 8.3 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedApril 15, 2017

Under the direction of the Director of Plant Operations the identified sprinkler heads will be cleaned/replaced, BX cable will be removed from the sprinkler pipe, and the fire pump will be scheduled for monthly testing.
Under the direction of the Director of Plant Operations, all sprinkler heads will be inspected and cleaned/replaced as indicated and that all sprinkler pipes are free of attached cable. There is only one fire pump.
The Director of Plant Operations/designee will audit 20 sprinkler heads monthly to ensure they are free from foreign materials, 10 sprinkler pipes monthly to ensure there are no attached cable, and the availability of the monthly fire pump test.
The Director of Plant Operations will present the audit findings at the monthly Quality Assurance/Performance Improvement for three months after which time the QA/PI committee will determine the frequency of the audits.