Glengariff Rehabilitation and Healthcare Center
April 24, 2017 Certification Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the Recertification survey, the facility did not ensure that all assessments accurately reflected each resident's current status. This was evident for one of two residents reviewed for urinary incontinence in a total of twenty-one Stage 2 sampled residents. Specifically, Resident #198's Admission MDS and the Significant Change MDS did not reflect that the resident was on a toilet schedule as documented in the medical record. The finding is: Resident #198 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating that the resident had severely impaired cognition. The MDS also documented that the resident is frequently incontinent of urine and is not on a toileting schedule. The significant change MDS dated [DATE] documented that the resident had a BIMS score of 5 indicating severely impaired cognition. The MDS documented that the resident is always incontinent of urine and was not on a toileting schedule. A Comprehensive Care Plan (CCP) dated 1/27/17 documented that the resident is incontinent of bladder and is on a toilet schedule every 2 hours. A Certified Nursing Assistant's Kardex (a form that provides direction regarding resident care needs) dated (MONTH) (YEAR) documented that the resident was toileted every two hours. The MDS Assessments dated 1/8/17 and 3/2/17 documented NO under the titled section urinary toilet program. An interview was held with the Director of Nursing Services (DNS) on 4/24/17 at 1:30 PM. The DNS reviewed the MDS Assessments and stated that the MDSs should have documented that the resident was on a toileting schedule. 415.11(b)

Plan of Correction: ApprovedMay 12, 2017

I. MDS assessment was revised to accurately reflect care provided.
II. A report of all residents currently on a toileting schedule/program will be generated. The list will be cross referenced to the most current MDS to ensure proper coding.
III. The MDS department will be re-educated on the proper location within the EMR to review resident?s toileting schedule/program status in order to code the MDS appropriately.
IV. The MDS coordinator/designee will generate a list of all residents on a toileting schedule/program monthly and audit at random sample to ensure proper coding.
Responsible Party: Director of Nursing Services

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 20, 2017

Citation Details

Based on observation, record review and interview during the Recertification survey, the facility did not ensure that sanitary conditions were being maintained in the main kitchen area. Specifically, the dish machine final rinse temperature was not operating at the required temperature of 180 degrees Fahrenheit (F). Specifically, the final rinse temperature during the initial tour was operating at or below 170 degrees F. The finding is: During the initial tour of the main kitchen on 4/18/17 between 9:15 AM and 10:00 AM the final rinse water temperature of the dish washing machine was observed to be at 170 degrees F, not the required 180 degrees F. An interview was conducted with the Food Service Director (FSD) on 4/18/17 at 10:00 AM. The FSD stated that final rinse temperatures are logged three times per day and there has not been a problem with the final rinse water temperature. The FSD stated that Maintenance Director will be called to address the issue. An interview was conducted with a dietary staff member working in the dishroom who stated that the dish machine had been running for approximately 40 minutes. He stated although there is a backup sanitizer, a key is required to turn on the back up chemical sanitizer and that the back up sanitizer was not turned on. 415.14(h)

Plan of Correction: ApprovedMay 12, 2017

I.
a. The dish machine sanitizer was immediately activated and the key was placed in the machine.
b. The dish machine was examined on 4/19/17 by the facility?s Director of Engineering and subsequently by the service company.
II. The facility respectfully submits that all residents have the potential to be affected by this practice.
III.
a. All kitchen staff will be re-educated on the need to activate the sanitizer and alert the kitchen supervisor when the temperature does not meet the requirements.
b. The facility policy and procedure will be revised related to the dishwasher operation to include the need to keep the activation key in the back up chemical sanitizer.
c. The facility dishwasher temperature log will be revised to include a column for activation of the backup chemical sanitizer.
IV. The facility will develop a QA tool to audit the following:
a. The activation key is present in the backup chemical sanitizer during dishwashing times of operation.
b. The Food Service Director/Designee will continue to audit the dishwashing temperature log to ensure full compliance. Any negative findings will be immediately corrected.
Responsible Party: Director Food Service

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: April 24, 2017
Corrected date: June 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification survey the facility did not ensure that a resident who had a decline in urinary incontinence was assessed for interventions or to determine the cause of the decline in bladder function. This was evident for one of three residents reviewed for urinary incontinence from a total of twenty-one Stage 2 sampled residents. Specifically, Resident #198 had a decline in urinary continence and there was no documented interventions initiated to address the decline. The finding is: Resident #198 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating that the resident had severely impaired cognition. The MDS also documented that the resident was frequently incontinent of urine. The significant change MDS dated [DATE] documented that the resident had a BIMS score of 5 indicating severely impaired cognition. The MDS documented that the resident was always incontinent of bladder which was a decline from the previous MDS assessment. A Comprehensive Care Plan dated 1/27/17 documented that the resident was incontinent of bladder and is on a toileting schedule every 2 hours. Review of the medical record revealed that there was no documented evidence that the resident, who was identified with a change in urinary continence and became always incontinent of urine, was assessed to determine the cause of the decline. No new interventions were implemented to achieve or maintain as much normal urinary function as possible. An interview was held with the Director of Nursing Services (DNS) on 4/24/17 at 2:00 PM. The DNS stated that the Nurse who did the MDS assessment that reflected the decline was not available for interview. The DNS reviewed the medical record and stated that the nurse should have ensured an assessment was completed for the resident to determine the cause of the decline. 415.12(d)(2)

Plan of Correction: ApprovedMay 12, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident?s toileting schedule was changed from Q 2-4 hours to Q 2 hours as a result of the decline in incontinence status.
II. The facility respectfully submits that all residents have the potential to be affected by this practice.
III. An incontinence assessment tool will be developed. Each resident will be assessed with [REDACTED]. Any noted decline will be referred to the physician for further evaluation.
IV.
a. An audit tool will be developed.
b. An audit will be done of a random sample of incontinence assessment tools monthly for three months and quarterly thereafter for one year.
Responsible Party: Director of Nursing Services

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: April 24, 2017
Corrected date: June 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification survey, the facility did not ensure that a resident's care plan is reviewed and revised by the interdisciplinary team after each assessment. This was evident in one of twenty-one residents reviewed for care plans in a total of twenty-one Stage 2 sampled residents. Specifically, Resident #374 had an Minimum Data Set (MDS) assessment that documented the resident was frequently incontinent of urine. The subsequent MDS documented the resident was always incontinent of urine. The Comprehensive Care Plan (CCP) developed for Urinary Incontinence did not reflect the change in the resident's urinary incontinence status. The finding is: Resident #374 has [DIAGNOSES REDACTED]. The MDS 5-day assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact for decision-making. The MDS also documented that the resident had no indwelling catheter, was not on urinary toileting program, and was frequently incontinent of urine. The MDS 90-day assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact for decision-making. The MDS also documented that the resident had no indwelling catheter, was not on urinary toileting program, and was always incontinent of urine. The CCP developed for urinary incontinence of bladder function dated 1/4/17 documented that the patient would have incontinence care rendered and would be free of skin breakdown secondary to incontinence. The interventions included to monitor skin redness or breakdown during toileting/diaper change every 2-4 hours and to lubricate skin every shift and as needed (PRN). The CCP did not document the change in urinary incontinence from frequently to always incontinent to reflect the current status. An interview with the Registered Nurse (RN) MDS Coordinator was conducted on 4/24/17 at 1:00 PM. The RN stated that the CCP should have reflected the change in the resident's urinary incontinence of being always incontinent. An interview with the RN Unit Supervisor was conducted on 4/24/17 at 1:30 PM. The RN stated the resident's CCP for urinary incontinence should have been reviewed and revised to reflect the resident's current status. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedMay 12, 2017

I. Care plan was updated to reflect the change in resident?s incontinence status.
II. The facility respectfully submits that all residents have the potential to be affected by this practice.
III. A list of changes in incontinence status will be generated by the MDS department. The list will be used to ensure care plans are updated appropriately and reflect current incontinence status.
IV. A QA will be developed to ensure all incontinence care plans reflect current incontinence status. A random sample will be audited monthly x 3 months and quarterly thereafter for one year.
Responsible Party: Director of Nursing Services

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: April 24, 2017
Corrected date: June 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification survey, the facility did not ensure that services provided by qualified persons are in accordance with each resident's written care plan. This was evident in 1 of 3 residents observed for medication pass in a total of 21 Stage 2 sampled residents. Specifically, a medication pass was observed for Resident #517. The Licensed Practical Nurse (LPN) administered an as needed (PRN) [MEDICATION NAME] (pain medication) tablet without assessing the resident's pain level prior to its administration. The finding is: Resident #517 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Minimum Data Set ((MDS) dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact for decision-making. The MDS also documented that the resident received PRN pain medication and had presence of pain with a numeric rating scale of 6 (0 to 10 pain scale with 10 being the worse pain). The physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) developed for Pain dated 3/30/17 documented interventions that included to assess for signs and symptoms of pain via verbalization, facial grimacing, or moaning. During the medication pass observation for Resident #517, with the LPN Medication Nurse conducted on 4/21/17 at 9:30 AM, the following was observed: - after preparing a [MEDICATION NAME] tablet, the LPN placed the medication in a souffle cup. - the LPN proceeded to administer [MEDICATION NAME] to the resident. - the LPN documented in the electronic Medication Administration Record [REDACTED] An interview with the LPN Medication Nurse was conducted on 4/21/17 at 9:45 AM. The LPN stated that she should have assessed the resident's pain level before administering [MEDICATION NAME]. An interview with the Director of Nursing Services (DNS) was conducted on 4/24/17 at 1:40 PM. The DNS stated that the LPN should have asked the resident to rate his pain level prior to the administration of [MEDICATION NAME]. The undated facility's policy and procedure titled Medication Pass documented . under General Procedures: 8) Monitor resident's vital signs and pain level when indicated prior to medication administration . 415.11(c)(3)(ii)

Plan of Correction: ApprovedMay 12, 2017

I. Resident received pain medication as ordered with no adverse effect. LPN identified was re-educated regarding the need to establish a resident?s pain level prior to administering prn pain medication.
II. The facility respectfully submits that all residents on prn pain medication have the potential to be affected by this practice.
III.
a. The facility policy and procedure regarding med pass compliance was reviewed and deemed compliant.
b. All licensed nursing staff were re-educated on the need to ask/evaluate a resident?s pain level prior to administering prn pain medication.
IV. The DNS/Designee will audit a random sample of residents receiving prn pain medication (across all shifts). This will be done monthly for three months and quarterly thereafter for one year.
Responsible Party: Director of Nursing Services

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 20, 2017

Citation Details

2012 NFPA99: 10.4.2.1 Non- patient care- related electrical equipment including facility or patient owned appliances that are used in the patient care vicinity and will, in normal use, contact patients, shall be visually inspected by the patient's care staff or other personnel. 10.5.2.1 Testing Intervals. 10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. 10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety. 10.5.3.1.2 Service manuals, instructions and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. Based on observation and staff interview, the facility failed to ensure that policies and procedures were established for testing patient care related electrical equipment in accordance with NFPA 99. This was observed in 2 of 2 buildings of the facility. The findings are: On 4/20/2017 and 4/21/2017 between the hours of 9am and 3pm during the recertification survey, the following was observed: On the 2nd floor of the(NAME)building, a pulse machine was observed behind the nursing station. It could not be verified that the equipment was inspected by staff prior to being put into service. In an interview conducted 4/21/2017 at approximately 10:20am, the Director of Maintenance stated that the facility will do in house repairs on equipment, but a record is not kept of what was repaired and there is no policy or procedures on when medical equipment is to be tested . 2012 NFPA 99: 10.5.2.1.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 12, 2017

I.
a. The pulse machine was inspected by the Director of Engineering. No quality issues were noted.
b. Policy and procedure regarding Preventive Maintenance was reviewed and revised to reflect Preventive Maintenance schedule.
II. All other pulse machines were audited and no quality issues were noted.
III.
a. Newly purchased equipment will be inspected and tagged prior to use.
b. All maintenance /appropriate staff will be educated on the need to inspect patient care related equipment.
IV. An audit tool will be developed to monitor compliance. Audits will be conducted monthly on a random sample of patient care related equipment. Audits will be conducted monthly for three months and quarterly thereafter for one year.
Responsible Party: Director of Engineering

K307 NFPA 101:ELECTRICAL SYSTEMS - OTHER

REGULATION: Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 20, 2017

Citation Details

2011 NFPA 70: 408.4 Field Identification Required. (A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy. Based on observation and staff interview, the facility failed to ensure that electric panels contained directories to identify the circuits. This was observed in 1 of 2 buildings of the facility. The finding is: On 4/21/2017 between the hours of 9am and 3:30pm during the recertification survey, the following was observed: In the Electric Rooms on the 1st and 2nd floors of the Glengariff building, emergency electrical panels were observed. Upon inspection, it was revealed that the emergency electrical panels were missing directories. In a concurrent interview with the Director of Maintenance at the time of the findings, he stated he could label the electrical directories. 2011 NFPA 70 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 12, 2017

I. The identified electrical panel will have the required directories re-applied.
II. All electrical panels were inspected and no other quality issues were noted.
III. All maintenance staff will be re-educated on the need to verify proper placement and accuracy of the electrical panel directory.
IV. An audit tool will be developed. Audits will be done monthly for three months and quarterly thereafter for one year. Any negative findings will be resolved immediately.
Responsible Party: Director of Engineering