Wayne County Nursing Home
June 16, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: (a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 16, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #135) of three residents reviewed for Activities of Daily Living, the facility did not provide necessary care and services to maintain personal hygiene. Specifically, fingernail care was not provided. This is evidenced by the following: Resident #135 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/24/17, revealed that the resident is cognitively intact and requires extensive assistance of two persons for personal hygiene. The (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) Treatment Administration Record (TAR) is initialed on 5/15/17 indicating that the resident's fingernails and toenails were checked. The (MONTH) (YEAR) TAR was not initialed as checked through 6/16/17. The resident was observed on 6/13/17 at 10:43 a.m. with long unclean fingernails. When observed on 6/15/17 at 11:26 a.m., the resident was noted to have long fingernails (approximately one eighth of an inch past the fingertips) on both hands. The fingernails on the left hand had dark debris underneath them. Both the index and middle fingernails on the right hand were thick and fungal. When interviewed at that time, the resident said that the nurses are supposed to cut his fingernails. The resident said that his fingernails were too long and looked shabby. On 6/16/17 at 9:15 a.m., the resident was observed seated at a table outside of the dining room with his finished breakfast tray in front of him. The resident's fingernails remained untrimmed and unclean. During an observation of the resident's fingernails on 6/16/17 at 9:16 a.m., the Licensed Practical Nurse (LPN), stated that the resident's fingernails are too long, dirty and fungal. She said the resident's fingernails needed to be cut and cleaned. During an interview with the Registered Nurse (RN) Supervisor on 6/16/17 at 10:33 a.m., the RN Supervisor reviewed the Daily Assignment Book and stated that nurses are to check both skin and nails on bath days. She said that the resident is scheduled on Monday evenings and Wednesday days and that his fingernails should be checked each time. The RN Supervisor said that she expects the Certified Nursing Assistants to clean the resident's fingernails and to notify a nurse when fingernails require trimming. The facility policy, Nail Grooming and Foot Care, last revised 11/28/16, directed that licensed staff will trim diabetic fingernails and toenails unless there is a reason that warrants professional podiatry care. (10 NYCRR 415.12(a)(3))

Plan of Correction: ApprovedJuly 10, 2017

A. For resident # 135 nails were clean and reduced after surveyor exited with RN charge. 6/15/2017
B. A facility- wide sample audit will be conducted by assigned Nursing staff to identify potential nail cleaning issues of the resident that are in need of nail care or nail reduction.
C. Identified staff will be re-educated and discipline for not following Policy & Procedure. Residents whom are diabetics/on anticoagulation precautions are to be managed by licensed staff for finger nails, and frequency of nail checking changed to weekly to co incised with weekly skin checks policy to be updated to reflect this.
D. Ongoing monitor by assigned RNs will be completed within the month for 3 months and determine if there are any new issues identified that were not CCP for &/or carried over to the CNA assignment. RN will report results of the monitoring to the DON monthly. Results of the monitor will be reported at quarterly QA.
E. Responsible Staff: DON
Completion Date: 8/15/17

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 16, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 3 of 35 residents reviewed for Minimum Data Set (MDS) Assessment accuracy, the facility did not ensure the MDS Assessments accurately reflected the resident's status. Specifically, coding issues included urinary incontinence (Resident #250) and resident interviews and pain interviews were not attempted per user manual instructions (Residents #144 and #37) This is evidenced by the following: 1. Resident #250 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/7/17, included that the resident's cognition is moderately impaired and is always incontinent of urine. Review of the MDS Lookback Report for the 3/7/17 MDS Assessment documented that the resident was always incontinent of urine from 3/1/17 to 3/7/17. When interviewed on 6/16/17 at 12:31 p.m., the MDS Registered Nurse (RN) said that she completed the urinary portion of the 3/7/17 MDS Assessment. After reviewing the MDS Lookback Report, the MDS RN stated that she made a mistake and entered the wrong information. 2. Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessments, dated 7/30/16, 10/23/16, 1/16/17, and 4/11/17, all documented under Section B that the resident is understood and usually understands. Section C0100, Should Brief Interview for Mental Status (BIMS) be Conducted? instructions include: the interview should not be attempted if the resident is rarely /never understood (check no), and the area is to be coded, yes, if the resident is at least sometimes understood. All MDS Assessments are coded no revealing the BIMS was not attempted with the resident. The same instructions apply for Section J0200 (pain), and all MDS Assessments are coded no, revealing the Pain Assessment was not attempted with the resident. When interviewed on 6/15/17 at 1:58 p.m., the RN Manager (RNM) stated that she completes Section B to determine if the resident is understood and understands. She said the LPN staff complete the BIMS portion of the MDS Assessment. The RNM said she is trying to teach the LPNs to attempt the resident interview if the resident is coded as understood and/or understands. She said that the LPNs complete the daily pain intake information and the RN Charge completes the pain assessment portion of the MDS Assessment. The RNM said that the interviews should have been attempted. When interviewed on 6/16/17 at 10:01 a.m., the MDS RN stated that she does not complete the MDS Assessment, but she coordinates them. She said the MDS Assessments are completed by the nurses on the floor. The MDS RN said if Section B is marked that the resident is understood and understands, she expects staff to attempt the resident interviews. She said if the interview is attempted and not able to be completed, there is a problem with the Sigma Care software that does not allow the staff to move on to the staff interview portion. She said if an interview is attempted but not completed, she would expect to see this documented in the Progress Notes. 3. Resident #37 has [DIAGNOSES REDACTED]. A MDS Assessment, dated 5/8/17, documented under Section B that the resident has slurred or mumbled words, is sometimes understood (ability limited to making concrete requests) and sometimes understands others. The BIMS interview and the pain interview were coded no, revealing that the interviews were not attempted with the resident. Staff interviews were conducted to indicate the resident's BIMS and pain level. The current Certified Nursing Assistant (CNA) Problem Detail includes that the resident has some confusion but is easily redirected and has chronic pain. During an observation of care on 6/15/17 at 12:00 p.m., the resident was awake, conversing with caregivers, easily understood, answering simple questions with accuracy and recognizing some caregivers by name and voice. The CNA stated at that time, that the resident can converse with staff and is very alert sometimes. When interviewed on 6/16/17 at 11:31 a.m., the RNM stated that they are aware of the inaccuracies with the MDS coding. She said that the LPNs complete the interviews and are being re-educated. She said the interviews should have been attempted. Review of the current Resident Assessment Instrument (MDS Federal Manual) revealed that the BIMS Interview is intended to determine the resident attention, orientation and ability to register and recall new information and that these items are crucial factors in many care planning decisions. Under pain management it includes that the pain interview is to assess the presence of pain, frequency and effect on the resident's function and that most residents capable of communication can answer questions about how they feel. Additionally, it includes that the interviews should be attempted unless the resident is rarely or never understood. (10 NYCRR 415.11(b))

Plan of Correction: ApprovedJuly 10, 2017

A. For resident #250 the MDS was corrected and resubmitted. For Resident #144, a resident interview and pain assessment will be conducted and if resident is able to self-report their score then the comprehensive care plan will be updated with the score. Resident #37, a resident BIMS interview will be conducted and if resident is able to self-report their score then the comprehensive care plan will be updated with the score. 7/21/2017
B. MDS coordinator will conduct a facility wide MDS audit focusing on residents that are reported as non-interviewable for BIMS assessments, Pain Interviews and Incontinence.
C. MDS in-service will be conducted about Pain Interviews and Incontinence coding to nurses that are completing MDSs. Social workers will be responsible in completing the BIMS assessment, as they are currently doing the mood assessment and are correctly documenting residents ability to be interviewed.
D. Compliance Officer will conduct a monthly MDS audit for 3 months and report results at quarterly QA.
E. Responsible Staff: Compliance Officer
Completion Date: 8/4/2017

FF10 483.20(b)(1):COMPREHENSIVE ASSESSMENTS

REGULATION: (b) Comprehensive Assessments (1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident?s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 16, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #136) of three residents reviewed for dental services, the facility did not code the Resident Assessment Instrument, including the Minimum Data Set (MDS) Assessment, correctly. The issue was incorrect coding and lack of care planning for dental. This is evidenced by the following: Resident #136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Dental Evaluation, dated 7/24/13, documented that the resident has a full upper denture, seven missing teeth, one fractured tooth and seven root tips on the lower arch. A Dental Evaluation, dated 2/15/17, documented obvious or likely cavities and broken natural teeth. The MDS Assessment, dated 4/14/17, revealed no dental issues. Review of the Comprehensive Care Plan (CCP), dated 3/29/11, revealed that the resident received a mechanically altered diet due to difficulty chewing. The CCP did not reflect any other dental issues. An observation on 6/13/17 at 1:47 p.m., revealed that the resident had several visible root tips on the lower front arch. Interviews conducted on 6/14/17 included the following: a. At 1:50 p.m., a Registered Nurse Manager (RNM), stated the Licensed Practical Nurses (LPNs) complete the dental section of the MDS Assessment. The RNM stated she developed the resident's CCP with the interdisciplinary team. The RNM stated that if the resident has root tips staff should monitor for signs of infection, pain and/or eating difficulties. She said the resident's dental issues should have been addressed on the CCP. b. At 1:59 p.m., the LPN who completed the MDS Assessment, stated that she reviews progress notes and dental evaluations. When interviewed on 6/15/17 at 9:00 a.m., the RNM stated a corrected MDS Assessment had been completed to accurately reflect the resident's dental status. She said the LPNs do not perform an oral exam when completing the dental section. Review of the facility policy, MDS Assessment Completion and MDS Accuracy Audit, dated 11/28/16, revealed that documentation of corrections or why the MDS is accurately coded will be documented in the electronic medical record. If the MDS is inaccurately coded, the NM or designee will correct the MDS. The MDS Manual, dated (MONTH) (YEAR), defines broken natural teeth or tooth fragments as: a very large cavity, tooth broken off or decayed to gum line, or broken teeth (from a fall or trauma). The manual instructed to conduct an exam of the resident's lips and oral cavity with dentures or partials removed, if applicable. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth. (10 NYCRR 415.11(a)(2))

Plan of Correction: ApprovedJuly 10, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. For resident #136 the MDS assessment was corrected immediately identifying the dental carries and resubmitted on 6/15/17. The resident?s comprehensive care plan was updated with mention of the dental carries, observing for signs & symptoms of infection, pain and/or eating difficulties to document in progress notes, initiate dental referral and if indicated notification of Medical staff.
B. A facility-wide sample audit will be conducted on all CCP completed in the previous month for accuracy of the dental section. MDS coordinator/designee will conduct this MDS audit. If the MDS is inaccurately coded, the MDS coordinator/designee will correct the MDS.
C. MDS in-service will be conducted about Dental [DIAGNOSES REDACTED]. In-service about dental carries, dental infection and eating difficulties and documentation will be covered by training that will be conducted by the MDS coordinator in conjunction with education department.
D. An RN will be assigned to review a random sample of Dental visits within the month for 3 months and determine if there were any new dental issues identified that were not carried over to the CCP and/or MDS. RN will report results of the monitoring to the DON monthly. Results of the monitor will be reported at quarterly QA.
E. Responsible Staff: MDS Coordinator
Completion Date: 8/15/17

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: June 16, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 3 of 35 residents reviewed for the development of a Comprehensive Care Plan (CCP), the facility had not developed a plan of care for each resident that included measurable objectives and timetables to ensure that services were provided to maintain the resident's highest practicable physical well-being. Specifically, there was no CCPs for [MEDICAL TREATMENT] (Resident #257), for the use of anticoagulants (Resident #206), or for behaviors (Resident #141). This is evidenced by the following: 1. Resident #257 was admitted to the facility on [DATE] with End Stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] three times a week. The (MONTH) (YEAR) Physician Orders included the resident's [MEDICAL TREATMENT] schedule (Tuesday, Thursday, and Saturday) and check thrill and bruit (an assessment to ensure adequate blood flow) of right upper arm fistula site every shift. A review of the current CCP revealed that the resident has a fistula for [MEDICAL TREATMENT]. There are no measurable goals or interventions related to the fistula or [MEDICAL TREATMENT] care. The undated Certified Nursing Assistant (CNA) Assignment Summary, documented do not get Permacath dressing wet - cover with waterproof barrier. A review of the Treatment Administration Record (TAR) for (MONTH) and (MONTH) (YEAR) directed to check thrill and bruit of right upper arm fistula site every shift. During an observation on 6/16/17 at 9:48 a.m., the Registered Nurse Manager (RNM) said that the resident's fistula site on the right upper arm was red and surrounded with dry skin. The Perma Cath (port) site on the right upper chest was covered with a bandage. When interviewed at that time, the resident said that the [MEDICAL TREATMENT] staff check his port. He said that his right arm has been red since the fistula was put in. He said once they start using the fistula it will be better. Interviews conducted on 6/16/17 included the following: a. At 9:22 a.m., the RNM said that she expects the CCP to reflect the resident's [MEDICAL TREATMENT] care. She said the fistula site and port site should be monitored for bleeding and signs and symptoms of infection, such as temperature, redness, odor, or excessive drainage. The RNM said that there should be a physician's order for the port and documentation that it is used for [MEDICAL TREATMENT] only. The RNM said that the CNA Assignment Summary should address the resident's fistula and direct staff not to take blood pressures or blood draws in the right arm. b. At 9:57 a.m., the Licensed Practical Nurse (LPN) stated that she checks the resident's fistula for thrill and bruit, and obtains his weight on non-[MEDICAL TREATMENT] days. The LPN stated that she monitors the fistula for signs or symptoms of infection such as redness or swelling based on her nursing knowledge. The LPN said that nothing is done to the resident's port per [MEDICAL TREATMENT] instructions. 2. Resident #206 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/26/17, revealed the resident is cognitively impaired and received an anticoagulant. Review of the CCP, dated 10/4/16, identified that the resident received [MEDICATION NAME] (an anticoagulant - blood thinner) and was at risk for bleeding/clotting which was monitored with [MEDICATION NAME] (laboratory results indicating clotting time). There are no measurable goals and/or interventions related to the use of [MEDICATION NAME]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of weekly Skin Notes, dated 5/26/17, documented that the resident continues to have bruising to bilateral arms and dry patches of skin, Nutra Shield was applied. Review of the Progress Notes revealed the following: a. A Progress Note, dated 5/30/17, documented bruising to the left hand and top of head. b. A Progress Note, dated 6/1/17, documented the resident continues with scabs to the scalp and multiple bruises to both arms. c. A Progress Note, dated 6/8/17, documented the resident has three scabs located on the top of his head. The note included that the resident's skin is dry, skin repair crème was applied per protocol, and the resident continued with bruising to bilateral lower arms. Review of the undated CNA Assignments Summary did not include special care related to dry skin and/or use of an anticoagulant. During observations on 6/14/17 and 6/15/17, the resident was observed with several scabbed areas on the top of the head and dark purple bruising to the left forearm and right thumb web space. Interviews conducted on 6/14/17 included the following: a. At 2:05 p.m., the NM stated if a resident is on an anticoagulant they would be monitored for bruising and bleeding. She said the resident would be shaved with an electric razor. After review of the resident's care plan, the NM stated the care plan did not include approaches for monitoring the resident's skin and/or approaches related to the use of an anticoagulant and/or dry skin. The NM said she missed it. The NM stated it is not included on the CNA Assignment Summary when a resident is on an anticoagulant. The NM stated one would not know to use an electric razor as it is not on the care plan. She stated that the resident has issues with dry skin and skin repair is applied. The NM stated skin repair is applied to all residents. She stated if a resident has open areas from scratching related to dry skin, they should monitor for infection and whether the current treatment is working or not. b. At 2:19 p.m., CNA #1 stated it is not on the care plan if a resident is on a blood thinner. She stated if a resident is on a blood thinner they do not cut the resident's nails and they shave the male residents with an electric razor. CNA #1 stated the care plan would direct, Do not use a straight razor. c. At 2:25 p.m., a LPN said the resident was on [MEDICATION NAME] and had several bruises on the lower arms and dry patches on the scalp. She stated the policy for dry skin is followed utilizing skin repair crème. The LPN stated if they could not control the dry skin then medical would see the resident. On 6/15/17 at 9:28 a.m., CNA # 2 stated it is on the shower schedule if a resident is on a blood thinner. She stated the shower schedule is kept in the shower room. The CNA stated shaving is done in the resident's room and it should be on the care plan if the resident is on a blood thinner. Review of the facility policy, Comprehensive Care Plan, dated (MONTH) (YEAR), directed that the CCP shall include problems/needs, goals and interventions. 3. Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/11/17, revealed that the resident's skills for daily decision making are moderately impaired and no behaviors. Review of the Incident/Accident Report, dated 4/25/17, revealed that on 4/22/17, the resident was witnessed throwing a cup of cold coffee at another resident, soaking her clothes. Review of the current CNA Closet Care Plan included the following behaviors: wandering, verbally and physically abusive, resists care, repetitive questions, repetitive anxious complaints and concerns, yelling and screaming, kicking and hitting, forgetful, and non-compliant at times. There are no measurable goals or interventions included. When interviewed on 6/15/17 at 1:58 p.m., the NM said that the resident only has a Closet Care Plan. She said there is no other care plan addressing the resident's behaviors. The NM said there should be an intervention like re-approach if upset, move to a quiet area if over stimulated, and to monitor and document behaviors. She said measurable goals should also be included in care plans. The NM said that she does not know why there is not a behavior care plan for the resident. (10 NYCRR 415.11(c)(1))

Plan of Correction: ApprovedJuly 10, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. For residents # 257, # 206 & #144 identified Comprehensive Care Plans and CNA assignment sheets were updated to address [MEDICAL TREATMENT] fistula, infection, bleeding etc., anticoagulation precautions, skin care issues and behavioral as it pertained to each resident?s particular care needs by 6/16/17.
B. A facility- wide sample audit will be conducted to assess the CCP for completeness and follow through document on the CNA assignment for accuracy. RN will be assigned to review random samples of CCP/CNA assignment weekly. If an inaccuracy is found, the RN/MN/designee will correct the CCP / CNA assignment.

C. For new residents with special care needs such as [MEDICAL TREATMENT], Anticoagulation Precautions etc. Admissions Coordinator will meet with the RN NM/designee to highlight these needs in preparation of the admission. All staff will be re- educated in how to utilize the Sigma Care CCP library to with completion of the CCP.
D. Ongoing monitor by assigned RNs will be completed within the month for 3 months and determine if there are any new issues identified that were not CCP for &/or carried over to the CNA assignment. RN will report results of the monitoring to the DON monthly. Results of the monitor will be reported at quarterly QA.
E. Responsible Staff: Compliance Officer
Completion Date: 8/15/17

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: June 16, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. The issues include: a lack of data analysis for infections, proper infection control techniques for one (Resident #209) of two residents observed for incontinence care; a soiled transfer sling and oxygen concentrator (Resident #122) and a soiled toilet seat and bathroom wall bathroom (room [ROOM NUMBER]). This is evidenced by the following: 1. On 6/16/17 at 10:37 a.m., a review of the Infection Control Program with the Staff Educator Registered Nurse/Infection Control Designee revealed that line listings from (MONTH) (YEAR) to (MONTH) (YEAR) were not consistently completed to include control measures or resolution for infection tracking and did not include information on the use of antibiotics for urinary tract infections that were identified as 'mixed flora' or 'no growth.' The Staff Educator/Infection Control Designee stated that there were no policies or guidelines for completing a line listing. She said that she had a tracking system but had not completed any data analysis of infections since (MONTH) (YEAR). She said that she was unable to provide any guidelines for the Infection Control Program. 2. Resident #209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) Assessment, dated 3/14/17, revealed the resident's cognition is severely impaired, and requires extensive assist of one staff for toileting. A Certified Nursing Assistant (CNA) Closet Care Plan, dated 6/16/17, directs limited assist of one staff for hygiene needs, that the resident wears a pull-up incontinent device and has a Foley catheter. Observations and interviews conducted on 6/15/17 included the following: a. At 4:07 p.m., the resident was incontinent of a large amount of stool. CNA #1 donned gloves and cleansed the rectal area first in a scrubbing motion, front to back and back to front. Without changing gloves or washing her hands the CNA then washed the resident's penis and Foley catheter tubing. When interviewed after the care, CNA #1 stated that the rule is to wash front to back and to wash the perineal area and then the rectum. She said she knows she should only use one stroke with the washcloth but she was trying to hurry. She said that she should have removed her gloves and washed her hands after cleaning the feces and before cleaning the penis and Foley. CNA #1 said that she was hurrying because the resident becomes impatient and gets angry. b. At 4:26 p.m., Licensed Practical Nurse (LPN) #1 said she expects staff to wash a resident from the front to the back and wash their hands when finished. She said it is not right to clean a dirty area like the rectum and then wash a cleaner area like the penis and Foley. Interviews conducted on 6/16/17 included the following: a. At 9:18 a.m., Registered Nurse Manager (RNM) #1 said she expects staff to clean a resident's penis and Foley first because of the possibility of contamination from the feces. She stated that staff should use a separate washcloth for each stroke. She said staff should change gloves and cleanse hands after cleaning the rectal area. b. At 10:37 a.m., the Staff Educator/Infection Control Nurse said if a resident with a Foley is incontinent of stool, staff may provide a shower to the resident. She said new linens should be used during care. She said staff should not wipe back to front, and should change their gloves several times during the process. Review of a facility policy, Peri-Care, dated (MONTH) 2013, directs to provide perineal hygiene to prevent infection and skin breakdown for residents as indicated, (i.e. incontinent, catheterized, etc.) and includes to wash hands and put on clean gloves. Residents with a catheter: wash perineal area thoroughly, clean well around the entire insertion site. Always wipe catheter tubing from insertion site 4 inches toward bag (away from the body). Dispose of equipment and remove gloves and wash hands for infection control. Review of a facility policy, Handwashing/Hand Hygiene, dated (MONTH) (YEAR), directs that adherence to handwashing and/or the use of alcohol based rubs, gloves and proper nail and hand care will be observed at all times. All employees will wash their hands with soap and water at any time they are visibly soiled and other specified occasions, (including) before performing any invasive procedure on a resident, before and after resident contact, and after handling items/surfaces potentially contaminated with blood or body fluids. 3. Observations and interviews conducted on 6/13/17 included the following: a. At 10:42 a.m., on the Orchard Way residential unit, a blue sling that had a foul odor and brown debris on it was left on top of a Medi-Lifter III mechanical lift in the hallway. b. At 3:01 p.m., the sling, with the brown smears, was still draped over the Med-Lifter III. CNA #2, who observed the sling at that time, said it was a hygiene sling and it needed to be cleaned. She said one of the residents had a fall that morning and staff could have used the sling to help the resident up. Interviews conducted on 6/16/17 included the following: a. At 9:20 a.m., Resident #119 said she had fallen on 6/13/17 while trying to use the bathroom and had been in a mess (incontinent). She said that staff had used the lift with the blue pad to get her up. b. At 9:47 a.m., RN #1 stated if a sling is soiled during use, staff should immediately rinse off visible soil, bag the sling and send it to laundry. She said this is an infection control and odor issue, and it was inappropriate to have left the sling on the lift in the hallway because anyone could have come into contact with it. c. At 10:37 a.m., the Staff Educator/Infection Control Nurse said slings are checked daily and before each use for cleanliness. She said staff should have bagged this sling right away and sent it to the laundry. 4. In observations on 6/14/17 at 9:19 a.m., and again at approximately 12:04 p.m., a filter on the back of a New Life Elite oxygen concentrator attached to Resident #122 and in use was observed to be heavily coated in white debris. Review of the Resident's Treatment Administration Records revealed that for the past three months the filter was signed off as changed every two weeks. Review of the owners' manual for the New Life Elite oxygen concentrators revealed that the air intake filters are to be cleaned before every operation, and to clean or wash the air intake gross particle filter with a warm solution of soap and water once per week. In an interview on 6/15/17 at approximately 1:15 p.m., LPN #2 said it is the duty of the 11:00 p.m. to 7:00 a.m. shift to clean the oxygen concentrator filters, and she thinks it is done once every two weeks. When interviewed on 6/16/17 at 10:37 a.m., the Staff Educator/Infection Control Nurse said oxygen concentrators are to be cleaned and filters changed by housekeeping staff or a nurse per manufacturer's recommendation. Review of the facility policy, Oxygen Administration, dated (MONTH) (YEAR), includes that oxygen concentrator filters are to be removed every two weeks and washed with soapy water, rinsed, and dried. 5. In an observation on 6/13/17 at 2:17 p.m., in Resident room [ROOM NUMBER], brown debris was noted on the raised toilet seat and smeared on the back wall behind the toilet. When observed on 6/15/17 at 2:37 p.m., the brown debris and wall smear remained on the raised toilet seat and the wall. LPN #3 stated at that time that it appeared to be stool and that the bathroom should be cleaned daily. In an interview on 6/16/17 at 10:37 a.m., the Staff Educator/Infection Control Nurse said it is the responsibility of the staff who have provided care to clean a commode or bathroom after a resident has defecated. She said Housekeeping is to notify nursing staff if they find stool in a room or on equipment. Review of the facility policy, Standard and Transmission Based Techniques, effective date of (MONTH) (YEAR), directs standard precaution are to be followed at all times with all residents. These include, but are not limited to, hand hygiene and the use of appropriate personal protection equipment. Also, equipment or items in the residential environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents, (e.g. wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another resident). (10 NYCRR 415.19(b)(4))

Plan of Correction: ApprovedJuly 10, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. All staff working on units where residents #209, #122 and resident?s room [ROOM NUMBER] live will be in-serviced on infection control, hand hygiene, pericare and proper cleaning of equipment and all resident care areas according to manual recommendations. Infection Control Coordinator has update the current policy I.C. Surveillance and Reporting Healthcare Associated Infections to expand scope practice to include data analysis of ongoing tracking and trending, monthly reporting to the IC/ Antibiotic Stewardship committee, and quarterly to Executive QA.
B. A facility wide random sample audit will be conducted observing pericare, hand hygiene and other infection prevent situations by Infection Control Coord. /designee. Immediately after exiting with the surveyors, all identified soiled areas were thoroughly cleaned. Housekeeping will conduct random audits to check; cubical curtains, & BR for cleanliness/walls. Maintenance will spot check all equipment that is on inventory for cleanliness and needing cleaning of filter, tubing etc.
C. All staff will be in-serviced on current infection control, hand hygiene, PPE policy and procedure and proper equipment cleaning. When purchasing or renting new equipment, the maintenance director will be responsible in obtaining all user manuals and will make recommendations to nursing policy and procedure committee for revisions or updates on any infection control and/or equipment cleaning changes.
D. Ongoing monitor Infection Control Coordinator/ designee will be completed monthly for 3 months and analysis to determine if there are any reoccurring issues that require immediate attention. RN will report results of the monitoring to the DON monthly. Results of the monitor will be reported at quarterly QA.
E. Responsible Staff: Infection Control/Education Coordinator
Completion Date: 8/15/17

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 16, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigations (#NY 086 and #NY 952) completed on 6/16/17, it was determined that for three of seven residents reviewed for abuse, and one of six residents reviewed for accidents, the facility did not thoroughly investigate injuries of unknown origin (Residents #153, #175 and #206) and did not report an incident to the New York State Department of Health (NYS DOH) involving a resident to resident altercation (Resident #144) in order to rule out abuse, neglect, or mistreatment. This is evidenced by, but is not limited to, the following: 1. Resident #206 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS)Assessment, dated 4/30/17, documented that the resident is cognitively intact, requires extensive assist of two staff members for transferring and toileting, does not ambulate and requires extensive assist of one staff member for locomotion on and off the unit, and no behaviors. Review of the current Certified Nursing Assistant (CNA) Assignment Summary revealed that the resident requires extensive assist of staff for transfers, but is independent with locomotion on the unit in a wheelchair. It also includes that the resident's hands are weak and numb making it difficult to use the call system, can be anxious, and to please check on the resident frequently. Review of the Nursing Progress Notes for the past month revealed that on 6/2/17 the nurse documented that the resident had a large bruise on the top of her left hand and several smaller ones on her right forearm and is resistive to care. There were no further notes related to physical behaviors, injuries or bruises. In an observation and interview on 6/13/17 at 2:08 p.m., and again on 6/15/17 at approximately 2:00 p.m., the resident was observed to have two bruises, approximately the size of a quarter, on the tops of both the right and left hands. When interviewed at that time, the resident stated that sometimes the staff members grab her by the hand. The resident said she tells them not to but they do not listen to her. She said the staff just pull and grab on her and they are rough. She later again stated, in front of a visitor, that staff are sometimes rough with her. Interviews conducted on 6/15/17 included the following: a. At 2:10 p.m., the CNA stated that she is the regular aide for this resident and that the resident has never mentioned to her that anyone is rough. The CNA said that she noticed the two bruises on the resident's hands earlier in the week and thought that she got them while self-propelling her wheelchair. She added that the facility has a stop and watch program which is a form they fill out to inform the nurses of any changes in a resident's skin. The CNA said she did not fill one out or let the nurses know about the resident's hand bruises. b. At 2:37 p.m., the Licensed Practical Nurse (LPN) stated that the resident mentioned to her that sometimes the staff yank on her arm when they move her. The LPN said that she was not aware of the bruises on the resident's hands. She said the CNA just told her that the resident has had those bruises for a while. In an interview on 6/16/17 at 11:31 a.m., the Registered Nurse Manager (RNM) said that she was just informed of the bruises on the resident's hands. The RNM said that she needs to do an investigation to determine how the resident got them. She said that the bruises looked old and that she saw the resident bump her hands on a table the week prior. She said she was not aware of the resident's statements about staff being rough. 2. Resident #153 has [DIAGNOSES REDACTED]. A MDS Assessment, dated 2/15/17, included that the resident is cognitively intact, requires extensive assist with bed mobility, transfers and toileting. Review of an Incident/Accident (I/A) Report, dated 1/27/17, revealed that nursing found the resident with a 4.5 centimeter (cm) x 3 cm bruise on the inner right upper arm during cares and that the resident was unaware of it. The I/A Report documented that the resident is on aspirin, bruises easily and that the bruise site is where the arm contacts the stand-lift transfer strap used by staff to transfer the resident. There was no evidence that interviews of staff were completed or that staff were observed during a transfer of the resident to ensure a safe transfer and proper sling size. Review of an I/A Report, dated 2/5/17, revealed that a CNA noted an ecchymotic (bruise) area below the left antecubital (lower forearm) while providing care. The resident was unaware of how it occurred. There was no evidence of a thorough investigation of the bruise to rule out abuse, neglect or mistreatment. When interviewed on 6/15/17 at 11:00 a.m., the Compliance Officer RN stated that she never received the I/A Reports to review. She said she is the one who completes the investigations. She said that staff should have been observed with the use of the stand lift and re-educated if necessary. When interviewed on 6/16/17 at 11:07 a.m., the Director of Nursing (DON) stated they use a Stop and Watch interactive program for bruises of unknown origin and that any employee can fill out the form and report it to any nurse. She said the procedure is that the LPN does an observation and the RN would have to do an assessment. She said staff should check to ensure that an I/A Report was already done and if not one should be started, noted in the 24-hour report and a note in the chart. The I/A Report should include interviews going back 72 hours if needed with the resident and staff, and if possible a conclusion to rule out abuse, neglect or mistreatment. She said right now, it is a fragmented system. When interviewed on 6/16/17 at 12:15 p.m., the Physical Therapist (PT) stated that the resident requires a stand lift for transfer. The PT said that the resident may or may not have received bruising from the sling. 3. Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS Assessment, dated 4/11/17, documented that the resident's cognition is moderately impaired and no behaviors. Review of the I/A Report, dated 4/25/17, revealed that Resident #144 threw a cup of cold coffee at Resident #152, soaking her clothes. The residents were separated and no injuries were found. The facility concluded that because there were no injuries, it did not need to be reported to the New York State Department of Health (NYS DOH). When interviewed on 6/15/17 at 1:58 p.m., the RNM said that although she did not witness the incident, she felt that both residents were probably acting aggressively. She said Resident #152 can be verbally aggressive and Resident #144 has thrown objects at staff before. When interviewed on 6/16/17 at 10:09 a.m., the DON said that she was made aware of the incident but did not make the decision that it was not abuse. She said the Compliance Officer decided it was not abuse and therefore, it was not reported to the NYS DOH. She said the resident reacted in an aggressive manner and that if anyone throws something at a resident, it should be considered aggression. The DON said if the coffee had been hot, it would have caused an injury. She said that when there is resident to resident aggression, it should be reported to the NYS DOH. The DON said that this one was missed and it should have been reported. The facility policy, Incident and Accidents Reports, revised 10/15/90, directs to identify trends in incidents and recommend appropriate corrective, preventative and/or disciplinary action has been taken to protect persons from further harm and safeguard against the recurrence of similar or reportable incidents/accidents. (10 NYCRR 415.4(b)(2)&(3))

Plan of Correction: ApprovedJuly 10, 2017

A. After a thorough review of Resident #206, Resident #153, Resident #175 and Resident #144 observations; the following causative factors were identified by the QAPI committee, lack of knowledge, lack of training, lack of follow-through on the process, time management, staffing, lack of communication and unexpected external factors.

B. QAPI committee reviewed current incident and accident policy and procedure and is in agreement with the current process. QAPI committee identified that the CNA and LPN that were interviewed at the time of the observation will receive specific one-on-one training in conjunction with a performance improvement plan. Training will be conducted by the education department covering the following topics; incident/accident reporting and investigation, skin assessment, 24 hour report and the STOPANDWATCH tool. The performance improvement plan will be conducted by the ADON and reviewed weekly with the employee for period of (3) months. Assistant Director of Nursing will report results of the performance improvement plan at quarterly QA meeting.
c. All nursing staff will receive a SigmaCare Memo in regards to incident/accident reporting, investigation and documentation when a bruise or injury is found. Additionally, all staff will be in-serviced on incident/accident reporting, investigation, skin assessment, 24 hour report, STOPANDWATCH tool and NYSDOH reporting guidelines.
d. An RN will be assigned to review a random sample of skin checks weekly for 3 months and determine if there were any new injuries that were of unknown origin that were not reported using the incident/accident form. RN will report results of the audit to the DON weekly. Results of the audit will be reported at quarterly QA.
e. Completion Date: 8/15/2017, Responsible Staff: DON

Standard Plan of Correction
A. For Resident #206, Resident# 153 and Resident #175 a thorough investigation will be completed including review of all skin checks, progress notes and completed STOPANDWATCH from 4/13/2017 to make sure if an injury of unknown origin was observed and was documented in the electronic medical record that an incident and accident report was completed. If there is documentation of injury without a thorough investigation, then an investigation will be completed for resident #206, resident #153 and resident #175. Completion Date: 7/21/2017
For Resident #144 all progress notes will be reviewed from 4/13/2017 to make sure if there were any signs of behaviors, if any noted, then a behavioral plan will be developed and the residents comprehensive care plan will be updated to reflect these changes. 7/21/2017
B. A facility wide audit will be conducted on all skins checks and incident and accident reports for the last three months to make sure proper incident/accident and NYSDOH reporting policies and procedures were followed. If any other residents had injuries of unknown origin that were not thoroughly investigated, then an investigation will be completed and reported if it meets the NYSDOH reporting guidelines.
C. All staff will be in-serviced on incident/accident reporting, investigation, skin assessment, 24 hour report, NYSDOH Reporting Requirements and the STOPANDWATCH tool.
D. RN audits will be reported to DON weekly. Audits will be reported at quarterly QA
E. Responsible Staff: DON
Completion Date: 8/15/2017

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: June 16, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 747) completed on 6/16/17, it was determined that for one (Resident #7) of six residents reviewed for accidents, the facility did not provide the necessary care or services to attain or maintain the highest practical physical well-being. Specifically, the resident had a fall and the medical team was not notified in a timely manner to assess injuries and provide adequate pain relief. This is evidenced by the following: Resident #7 has [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 2/23/17, revealed that the resident's cognition is moderately impaired, requires extensive assist of two staff for transfers and toileting, and had a recent fall resulting in a major injury. Review of an Incident and Accident (I/A) Investigation, dated as completed on 2/28/17 and signed by the Registered Nurse (RN) Compliance Officer revealed the following: a. An I/A Report, dated 2/13/17, included that on 2/13/17 at 7:55 p.m., the resident fell out of her wheelchair while exiting the bathroom with her Certified Nursing Assistant (CNA). The resident sustained [REDACTED]. The report documented that family was notified on 2/13/17 at 8:10 p.m., and the Nurse Practitioner (NP) was notified on 2/14/17 at 8:10 a.m. b. In a statement, dated 2/14/17, the CNA documented that the resident leaned forward when exiting the bathroom falling out of her wheelchair onto the floor face first. Nursing was notified and the resident was lifted to the bed using a mechanical lift. c. The resident's Nursing Care Plan at the time of the fall revealed that the resident required extensive assist of one staff member for transfers and toileting. d. A statement and a Nursing Progress Note, both dated 2/13/17 and signed by the RN Supervisor, documented that when she arrived the resident was rolled onto her back and had an approximate 6 centimeters (cm) x 4 cm hematoma on her forehead, a small laceration on the bridge of her nose, bruising to one finger and an open area to the second right finger on the right hand. Additionally, the resident's pupils were equal and responded to light, and that she was able to squeeze both hands with equal strength. The RN documented that the family was contacted by the Licensed Practical Nurse (LPN) and that family declined transporting the resident to the hospital. There is no mention in the Progress Note of notification to the on-call medical provider. e. In a Progress Note, dated 2/13/17, and a statement, dated 2/15/17, the LPN documented that when she arrived the resident was on the floor face down in the bathroom doorway. When the RN, arrived they rolled the resident over and the RN assessed her injuries. The resident did not complain of pain at that time and the family was notified. The statement did not include any mention of medical being notified or that the family declined transferring the resident to the hospital. f. A Neurological Assessment, dated 2/13/17, was performed every two hours from 8:00 p.m. through 2/14/17 until 8:00 a.m. The assessment revealed that as of 12:00 a.m. the resident was unable to squeeze her right hand due to pain. g. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The medication was administered on 2/13/17 at 9:07 p.m. for complaints of pain rated at a two, and again at 12:58 a.m. for pain rated at an eight. There was no as needed pain medication ordered for pain level higher than a three or documentation that medical was notified of increased pain levels. h. A Nursing Progress Note, dated 2/14/17 and signed by the RN Manager, revealed that at 7:30 a.m., both of the resident's eyes were swollen shut and the Nurse Practioner (NP) was notified. i. A Progress Note, dated 2/14/17 at 8:43 a.m. and signed by the NP, documented that the resident was assessed for facial injuries and multiple contusions and transferred to the hospital for head and neck injuries. j. Review of the hospital emergency room records, dated 2/14/17, documented that the resident had a nasal fracture, a [MEDICAL CONDITION] hand third digit and a head contusion. In an interview on 6/15/17 at 4:17 p.m., the RN Supervisor stated that physicians are on call 24/7 but that they do not necessarily call the physician with head injuries. She said staff would monitor the resident and if there were any changes then they would call medical. She said that it is the responsibility of the LPN on duty to call the family and the physician. Interviews conducted on 6/16/17 included the following: a. At 10:45 a.m., the Director of Nursing stated that medical should have absolutely been notified of this resident's injuries by the RN, especially with a head injury. She said that she is restructuring the notification policy and is in the process of evaluating it. b. At 11:31 a.m., the RN Manager stated that medical should have been notified immediately and neuro checks should have been instituted every 15 minutes for several hours instead of every 2 hours. Current facility policies, Supervisor 24-hour Report/Shift to Shift Clinical Report, Change in Resident Status, and Reducing Hospital Readmissions, did not include any policy on when to notify the medical team. (10 NYCRR 415.3(e)(2)(ii)(b)(c))

Plan of Correction: ApprovedJuly 10, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. At the time of the incident, Resident #7 was immediately assessed by the Registered Nurse and neurological assessments were initiated and family was notified. Resident #7 was assessed by the nurse practitioner in the early morning of 2/14/2017 and was sent out to the hospital for further evaluation. Resident #7 was readmitted to the facility on [DATE] at 3:29PM and was stable and doing well.
B. Facility will use 60 days of CASPER data to capture residents that were identified as ?falls with major injury? to make sure communication was appropriate and timely with the medical team. 7/21/2017
C. All staff will be in-serviced on incident/accidents and proper notification of medical staff. 8/15/2017
D. Compliance Officer will conduct a monthly audit for 3 months on incidents/accidents with injury and make sure medical staff were appropriately and timey notified and report results at quarterly QA.
E. Responsible Staff: Compliance Officer
Completion Date: 8/15/2017

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 16, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #133) of six residents reviewed for care planning revisions related to accidents, the facility did not ensure that a resident's care plan was reviewed or revised to reflect the resident's current condition. Specifically, the resident's care plan was not revised to reflect a decline in transfer and ambulation abilities. This is evidenced by the following: Resident #133 has [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 3/12/17, included that the resident is cognitively intact, requires extensive assist of two staff for transfers and has had two or more falls. Additionally, it is documented that the resident ambulated in the corridor with assist of one staff member in the previous seven days but only on one or two occasions. Review of the Certified Nursing Assistant (CNA) Assignment Summary (Closet Care Plan), dated 5/18/17, revealed that the resident required extensive assist of one staff for transfers and ambulation using a wheeled walker in both the resident's room (to and from the bathroom) and in the corridor. Additionally, the resident frequently refuses to ambulate. A Fall Risk Assessment, dated 6/3/17, revealed that the resident scored an 11, which indicated that she is at high risk for falls. In an observation and interview on 6/15/17 at 10:12 a.m., the resident was in her room sitting in her wheelchair. The resident stated that she does not walk anymore due to her legs giving out on her and because she is too weak. Interviews conducted on 6/16/17 included the following: a. At 9:29 a.m., the Licensed Practical Nurse stated that the resident does not walk anymore. b. At 9:30 a.m. and again at 10:26 a.m., the CNA stated that she does not have this resident on a regular basis. She said that the resident used to walk a few months ago but she does not walk anymore. She said the resident is a one assist for transfers but she was unable to transfer her that morning because her leg buckled. The CNA said she had to call for assistance stating that sometimes that happens and sometimes we can transfer her alone. c. At 9:42 a.m., the Physical Therapist (PT) stated he assessed the resident earlier in the week and changed her to a two person transfer due to her increased difficulty but did not evaluate her for walking as staff did not report any changes in her walking. The PT stated he would like staff to attempt to walk the resident with two staff members and let therapy know if she cannot do it. The PT said that he had not had time to document the changes to the resident's care plan yet. d. At 11:31 a.m., the Registered Nurse Manager stated that she asked therapy to evaluate the resident, but was told the evaluation was not done yet and that the resident may have to change to a lift transfer due to a tendency for her legs to buckle. She said the CNAs follow the Closet Care Plan and it should be updated immediately. She said therapy needs to give her the documentation so she can change the care plan. (10 NYCRR 415.11(c)(2)(iii))

Plan of Correction: ApprovedJuly 10, 2017

A. Resident #133, was assessed by physical therapy and resident closet care plan was updated to reflect two person assist in both the residents room (to and from bathroom) and in the corridor.7/14/2017
B. A facility wide sample audit will be conducted comparing C.N.A documentation data in S-cores to the residents closet care plan. If any discrepancies are found then the close care plans will be updated. 7/28/2017
C. All staff will be in-serviced on identifying changes in resident ambulation and the INTERACT- STOPANDWATCH tool. 8/11/2017
D. Compliance Officer will conduct a monthly audit on the MDS and Closet Care Plans for 3 months and report results at quarterly QA.
E. Responsible Staff: Compliance Officer
Completion Date: 8/11/2017

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: June 16, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #144) of six residents reviewed for accidents, the facility did not ensure that care was provided in accordance with the resident's written plan of care. Issues involved the lack of non-skid socks, floating heels, and anti-embolic stockings (reduce swelling and incidence of blood clots) per plan of care. This is evidenced by the following: Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/11/17, revealed that the resident's cognition is moderately impaired and requires extensive assistance with dressing. The Certified Nursing Assistant (CNA) Closet Care Plan, dated 6/13/17, included slipper socks (non-skid) at all times, apply anti-embolic stockings to bilateral legs on in the morning and off at bedtime, and to offload heels. Observations conducted on 6/15/17 included the following: a. At 9:34 a.m., 10:29 a.m., and 1:05 p.m., the resident was sitting in her wheelchair wearing anti-embolic stockings but she was not wearing slipper socks. b. At 1:48 p.m., the resident was observed lying on her back in bed wearing anti-embolic stockings but no slipper socks. The resident's heels were flat on the mattress. During an interview on 6/15/17 at 1:50 p.m. the CNA observed the resident and said that she was not wearing slipper socks. The CNA said the resident should be wearing slipper socks but she did not put them on the resident. The CNA then looked in the resident's room and was unable to find the slipper socks. After the CNA found a pair of slipper socks, she applied them and removed the resident's anti-embolic stockings. The CNA said she did not know whether or not the resident's heels should be elevated. The CNA then checked the Closet Care Plan and said the resident's heels should be floated. When interviewed on 6/15/17 at 1:58 p.m., the Registered Nurse Manager (RNM) said the resident is at risk for falls and has very dry and fragile skin. She said the resident should have slipper socks on at all times, especially in bed. She said the resident's heels need to be floated on a pillow when in bed to prevent skin breakdown. The RNM said that if the resident is care planned for anti-embolic stockings on in the morning and off at bedtime, she expects that they are on all day. The RNM said if the stockings are removed at nap time, it is likely the staff will forget to put them on again when she gets up. She said that her expectation is that staff follow the care plan. (10 NYCRR 415.11 (c)(3)(ii))

Plan of Correction: ApprovedJuly 11, 2017

A. Care plan will be reviewed with all staff caring for Resident #144. All staff caring for Resident #144 will review and initial Resident #144?s care plan. Staff will be in-serviced on the importance of paying close attention to the resident?s care plan and this will be reviewed in nursing huddle with all three shifts. C.N.A that was caring for the resident on 6/15/2017 will be placed on a performance improvement plan. 7/21/2017

B. All residents that are care planned to wear slippery socks will be reviewed to make sure they are wearing them at the times that are identified by their care plan. 7/28/2017
C. Education coordinator will conduct in-servicing for all staff on all aspects of care planning, following a care plan and properly placing and removing ted stockings and slippery socks on a resident. 8/15/2017
D. Compliance Officer will conduct a monthly sample audit on residents care planned to wear slippery socks and if the residents had their slipper socks on or off according to their care plan. This will be done for a period of 3 months and results will be reported at quarterly QA.
E. Responsible Staff: Compliance Officer
Completion Date: 8/15/2017

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 16, 2017
Corrected date: August 15, 2017

Citation Details

Based on observations, interview, and record reviews conducted during the Life Safety Code Survey, it was determined that for two (#120 Stairwell, #130 Stairwell) of nine exit stairwells, the facility did not provide safe exiting and egress. Specifically, the discharge pathways were too steep. This is evidenced by the following: Observations conducted on 4/27/16, in the presence of the Maintenance Director and Administrator, revealed the following: a. The Maintenance Director said that the pathways used for egress came from the #120 and #130 Stairwells and converged into a single path which then traveled onto the parking lot. b. The exit pathway from the #120 Stairwell had a slope of 1 7/8 inches of fall in 20 inches. c. The exit pathway from the #130 Stairwell had a slope of 1 7/8 inches of fall in 20 inches. d. Where the pathways from the #120 and #130 Stairwells meet and continue on towards the parking lot the slope of the pathway was 2 inches of fall in 20 inches. Interviews with the Administrator on 6/15/17 revealed they were working on a final plan to be approved so that construction on the pathways can be started. After the conclusion of the 4/27/16 Life Safety Code survey, the facility applied for and received a time limited waiver from the Bureau of Architecture and Engineering Review, which expires on 10/31/17. (10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.2.1, 7.1.6.3)

Plan of Correction: ApprovedJuly 10, 2017

A. Maintenance Director obtained quotes from licensed contractors to complete pathway grading work. Due to the cost of the project(NAME)County Nursing Home has to go out to bid for the pathway grading project. The point where pathway 120 and pathway 130 were redirected to an area of a compliant slope and proper signage was posted. Facility received an approved Time Limited Waiver through (MONTH) 31, (YEAR) to allow for enough time for this work to be completed. Facility is working with(NAME)County Highway Department to complete all necessary architectural work before a bid package is advertised.
B. All exterior pathways were measured to obtain slope measurements. If necessary, additional pathway grading will be conducted. All staff was in-serviced to use extra caution and provide assistance to anyone with adaptive equipment when using egress pathway 120 and egress pathway 130. Adaptive equipment such as wheelchairs, walkers or canes.
C. All maintenance staff was in-serviced on proper slope of egress pathways
D. Maintenance Director will conduct monthly audits of all egress pathways and report at quarterly QA. Maintenance Director to follow up with(NAME)County High Department on a weekly basis for status of the architectural work. A plan for construction will be created and followed closely to make sure the facility meets all the conditions of the Time Limited Waiver.
E. Responsible Party: Maintenance Director

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 16, 2017
Corrected date: July 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview conducted during the Life Safety Code Survey, it was determined that for three (Ground, First, and Second) of three residential use floors, the facility did not properly maintain the portable fire extinguishers. Specifically, fire extinguishers were overdue on their six-year maintenance procedure. This is evidenced by the following: Observations on 6/13/17 from approximately 12:30 p.m. to 2:36 p.m. revealed the following: a. There were portable ABC type fire extinguishers marked with six-year maintenance stickers and collars that showed (MONTH) 2010 as the last date the procedure was conducted. The extinguishers were located in the following areas: in the corridor just outside Canal Side (second floor), in the corridor outside the first floor Residential Services Director Office, and outside the first floor Country Cut and Curl. b. On the ground floor level were additional ABC type fire extinguishers marked with (MONTH) 2010 six-year maintenance stickers and collars in the following locations: the chiller room, mechanical room (091), elevator equipment room (093), in the hallway outside of the kitchen, in the hallway between the men's and women's restrooms, elevator equipment room [ROOM NUMBER] (005), Physical Therapy, in the hallway outside of Physical Therapy, near the loading dock (030D), in the hallway outside of clean holding (034), and in the maintenance shop (032). In an interview at that time, the Director of Maintenance stated that they do not check for the six-year maintenance when performing monthly inspections of the extinguishers. The 2010 edition of NFPA 10, Standard for Portable Fire Extinguishers, requires every six years, stored pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable internal examination procedures as detailed in the manufacturer's service manual and this standard. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.3.5.12, 9.7.4.1, 2010 NFPA 10:7.3.1.2.1)

Plan of Correction: ApprovedJuly 10, 2017

a. All fire extinguishers that were identified during inspection have been replaced with current fire extinguishers. 6/29/2017
b. Maintenance Director conducted a facility wide audit of all fire extinguishers to ensure they are all current; all fire extinguishers that were identified have been replaced. 6/29/2017
c. All maintenance staff will be in-serviced on policies and procedures for proper inspection of the fire extinguishers.
d. Maintenance Director will conduct monthly audits for (3) months and report results at quarterly QA meeting.
e. Responsible Staff: Maintenance Director.
Date of Completion:7/21/2017