Hilaire Rehab & Nursing
August 15, 2018 Certification Survey

Standard Health Citations

FF11 483.24(a)(1)(b)(1)-(5)(i)-(iii):ACTIVITIES DAILY LIVING (ADLS)/MNTN ABILITIES

REGULATION: §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification survey, the facility did not ensure that each resident was provided the necessary care and services to ensure that the resident's abilities in activities of daily living do not diminish. This was identified for one (Resident # 53) of two residents reviewed for activities of daily living (ADLs). Specifically, for Resident #53, the facility did not follow an Occupational Therapist (OT) recommendation for a Sippy cup to increase independence during eating. The finding is: Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident was unable to complete a Brief Interview for Mental Status (BIMS) and had short and long term memory problems. The MDS also documented the resident required extensive assist for eating. review of the resident's medical record revealed [REDACTED]. The form documented a reason for referral: Eval for Feeding Devices to increase independence ? Sippy cup. The Occupational Therapist documented a response on the form on 6/27/18: Patient requires double handle cup to drink liquids (I) at mealtime. Please have kitchen add double handled Sippy cup to tray. Resident #53 was observed in the unit Dining Room on 8/8/18 at 12:30 PM. The resident was observed being fed by a Certified Nursing Assistant (CNA). The resident's meal tray had a 4 ounce plastic cup with juice, regular plastic mug with coffee and a 4 ounce carton of milk. The resident's tray/meal ticket did not document a double handled Sippy cup and the tray did not have a double handled Sippy cup. The resident opened his mouth when the CNA touched the resident's lips with a fork or the cup. The resident was observed to display no active participation in the feeding process. A CCP for activities of daily living (ADLs), dated 2/2/18 and updated through 7/24/18, documented the resident needed extensive assist with feeding. The CCP also documented that the resident needs encouragement to participate and complete meals. A CCP for Nutrition, dated 11/7/17 and updated through 7/24/18, documented the resident was being fed in the Dining room and had a good appetite. The CCP did not include use of the Sippy cup as part of the interventions. A Dietary Review dated 7/24/18 did not document the use of Sippy cup in the column titled Assistive Device. The Registered Dietitian (RD) was interviewed on 08/08/18 at 1:00 PM regarding the OT referral and recommendation dated 6/27/18 for a Sippy cup. The RD observed the resident's tray and stated she was not aware of any device and would have to review the resident's record. The RD was re-interviewed on 8/08/18 at 1:45 PM and stated that she was unaware of the OT referral and recommendation dated 6/27/18 for a Sippy cup. The Director of Nursing Services (DNS) was interviewed on 8/8/18 at 1:50 PM and stated that the Therapist is supposed to personally hand over the completed consult/referral form to the Nurse on the unit. The Nurse signs the form and incorporates the information in the care plan and informs the Dietitian/Kitchen for implementation. She stated that the form was placed directly in the chart and not handed over to the Nurse on the unit. The Director of Rehabilitation was interviewed on 8/9/18 at 9:00 AM. She stated that the OT who completed the consult is per diem and did not follow the facility policy by not personally handing over the completed consult/referral form to the Nurse on the unit. 415.12(a)(2)

Plan of Correction: ApprovedSeptember 8, 2018

F-676
Corrective Action accomplished for the residents affected: Resident # 53 was immediately given a ?sippy? cup by the OT upon discovery of the deficient practice.
Identify residents potentially affected by the same practice: All residents who are dependent upon an assistive feeding device (ie sippy cup), have the potential to be affected by the deficient practice. The occupational therapist and DNS reviewed all existing OT orders for sippy cups to ensure residents requiring them, had them care planned for and kitchen was aware of same. No other residents were affected by the deficient practice.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence: The policy and procedure for management of therapy referrals/use of eating devices was reviewed and revised by the DNS to include notification to the kitchen staff to provide all eating/drinking related devices on the out-going resident tray. In addition:
- The DNS will provide in-service to all existing and new Rehab staff on the notification process to nursing when they have made a recommendation for an eating/drinking assistive device.
- The DNS will review the policy with the Director of Rehabilitation so that the Director of Rehabilitation can periodically reinforce the policy with the rehabilitation staff.
- The DNS will provide an in-service to all nursing and kitchen staff on the revised policy and procedure.
- The DNS developed an audit tool to ensure compliance with management of therapy referrals and implementation of eating devices.

Quality Assurance Monitoring and Follow-Up:
- The Director of Rehabilitation will conduct weekly audits for one month, then monthly for 6 months, the quarterly on 100% of all residents whom have a recommendation for ?sippy? cups, to ensure therapy has made notifications to the nursing department and the kitchen staff is aware of the implementation of the device.
- The Director of Rehabilitation will immediately correct any negative findings as they occur and report results of audits to DNS at time of audit, as well as present findings at the QAPI meetings.
Date and Person responsible for implementation of P(NAME): The Director of Rehabilitation will ensure the P(NAME) has been followed and audited.

FF11 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: §483.24(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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification survey, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene. This was identified for one (Resident #209) of two residents reviewed for Activities of Daily Living (ADLs). Specifically, for Resident #209, the facility did not ensure that the resident's stump sleeves for the prosthesis were maintained in clean condition and the resident received showers. The finding is: Resident #209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired decision making skills. The MDS documented the resident's ADL status as requiring extensive assist for Dressing and Personal Hygiene. The MDS did not document any behavior, including no rejection of care. A Comprehensive Care Plan (CCP) for Cognition dated 7/19/18 documented that the resident was alert and oriented to person and place with a BIMS score of 12. The CCP documented the resident with no behavior symptoms. A CCP for ADLs dated 7/19/18 documented the resident had weakness, immobility, and a right below knee amputation (BKA), and that the resident needed extensive assist for dressing, personal hygiene, and bathing. The resident was interviewed on 8/6/18 at 10:00 AM and stated that he does all his care himself. The sleeve over his right BKA stump appeared soiled and stained. The resident removed the right BKA sleeve to display the stump which emitted a strong foul odor. The resident stated that he has three stump sleeves and he washes these himself using the pink plastic bowl and hand soap from the dispenser by the hand sink. The sleeve was marked #3. There was a stump sleeve, marked #2, observed on the resident's bed which appeared dirty and stained. Resident #209 was interviewed concurrently with the Rehabilitation Director and Occupational Therapist (OT) on 8/9/18 at 1:30 PM. The resident removed the right stump sleeve, which was marked #3, and a strong foul odor was noted from the sleeve. The resident stated that he has three sleeves and he changes them. The resident also stated, I know how to wash it, I don't want them to wash it, and staff did not offer to wash it. The OT was interviewed on 8/9/18 at 1:35 PM and stated that he had removed the stump sleeve a couple of times but the odor had not been this bad. He stated that most of the time the resident comes for therapy with the stump sleeve on. The Director of Nursing Services (DNS) was interviewed on 8/9/18 at 1:40 PM and stated she was unaware that the resident has a stump sleeve. She stated the CNAs should have washed the stump sleeves with soap and water and air dried. She stated that the resident's BKA care including stump sleeve and prosthetic leg should have been part of the CCP and the Certified Nurses Assistant (CNA) Accountability Records and the staff should have been educated. The DNS stated that the facility currently does not have a Policy for prosthesis care, a policy will be put in place and implemented. The 7:00 AM-3:00 PM CNA assigned to the resident since admission was interviewed on 08/9/18 at 2:07 PM. The CNA stated that the resident does every thing by himself, including washing himself with a basin and cleaning the stump sleeve. She stated that the resident has a problem and get agitated when showers are offered and says, I just washed myself. She further stated that the resident has not taken a shower with her or the Nurses and that she told the 7:00 AM-3:00 PM Medication Licensed Practical Nurse (LPN) about the resident refusing showers. The Medication LPN was interviewed on 8/9/18 at 2:10 PM and stated that she thought the resident pretty much likes to wash himself and to do his own care. She stated that she recalls speaking to him once after being told that he was refusing a shower when he was just admitted . The Medication LPN also stated that she was unaware that he had not received a shower since admission. She stated that had she been aware that it is a constant issue she would have documented his refusals in the 24 hour report, Nurses notes, informed the Social Worker (SW) and encouraged the resident to shower. She also stated that she never noticed that the stump sleeve was dirty. The CNA resident care directions document titled 'Resident Assessment Plan of Care' documented Right BKA-Prosthetic leg with no further care instructions. It also documented Bath Schedule, Wednesday/Saturday. The (MONTH) and (MONTH) CNA Resident Care Accountability documented no care for Right BKA-Prosthetic leg. The (MONTH) and (MONTH) Accountability for Resident Care Bath Record columns were blank. The DNS was interviewed on 8/9/18 at 2:20 PM and stated that the CNAs should have signed the resident shower refusals. The DNS stated we should have involved the SW and should have a Care Plan for refusal of care. The Rehabilitation Director was interviewed on 8/10/18 at 11:00 AM and stated the Physical Therapy (PT) assessment dated [DATE] did not document an assessment of the resident's right lower extremity Prosthetic device. 415.12(a)(3)

Plan of Correction: ApprovedSeptember 8, 2018

F-677
Corrective Action accomplished for the residents affected: Upon identification of the deficient practice, the DNS took the prosthetic sleeves for resident # 209 and had them washed. The resident was also immediately provided with a shower by the aide on assignment.
Identify residents potentially affected by the same practice: All residents who have prosthetic sleeves have the potential to be affected by the deficient practice.
- Resident #209 is the only resident in the facility with a prosthetic device. Therefore, no other residents in the facility were affected by the deficient practice.
- All residents that reside in the facility have the potential to be affected by lack of showering. All alert residents were identified by the by DNS and social worker, and interviewed by the social worker to ensure they were being offered showers and any refusals were properly addressed, documented and care planned for. No other residents were affected by this deficient practice.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence:
- The DNS developed a prosthetic care policy and procedure to include the washing and maintenance of the prosthetic sleeves.
- The DNS will in-service all nursing staff on the policy and procedure for prosthetic care with specific focus on cleaning and maintaining cleanliness of them and that the Charge Nurses will ensure that prosthetic care (including cleaning of sleeves) are included on C.N.A. accountability sheets as well as reflected on the resident CCP.
- The DNS will provide in-service to all rehabilitation staff on the need to report any dirty or foul smelling prosthetic sleeves to the nurse manager.
- The DNS will in-service all certified nursing aides on the need to document and report to the nurse resident refusal of shower.
- The DNS will in-service all nurses on the need to document and then notify Social worker as well as DNS regarding resident refusal of showers. DNS and SW will then discuss additional interventions.
Quality Assurance Monitoring and Follow-Up:
- The DNS/designee will conduct weekly observational audits for the next month, and monthly thereafter, on 100% of all residents with prosthetic sleeves to ensure cleanliness.
- The DNS/designee will perform monthly audits of the CCP and the C.N.A. accountability records for the next month, and quarterly audits thereafter, on 100% of all residents with prosthetic sleeves, to ensure clear documentation on need for prosthetic sleeve care.
- The DNS/designee will interview 25% of alert residents with a BIMS of > 10 on a quarterly basis, to determine if they have been refusing showers. Additionally, the DNS/designee will audit 25% of all charts quarterly, to determine if those residents who have refused showers, have been reported to DNS and SW.
- Any negative findings will be immediately corrected by the DNS/designee and will report results of all audits at the QAPI meeting.
Date and Person responsible for implementation of P(NAME): The DNS is responsible for the correction of this deficiency.

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(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: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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. This was noted for two sampled residents (Resident #209 and # 41). Specifically,1) for Resident #209, the facility did not develop specific Comprehensive Care Plans (CCP) for the Right Below Knee Amputation (BKA) including the stump sleeve and prosthetic leg, and refusal of care including showers; 2) Resident # 41 was readmitted from the hospital with a [DIAGNOSES REDACTED]. The findings are: 1) Resident #209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired decision making skills. The MDS documented the resident's ADL status as requiring extensive assist for transfers, dressing, and personal hygiene. The MDS did not document any behavior, including no rejection of care. The resident was observed and interviewed on 8/6/18 at 10:00 AM. Resident was observed with a right BKA with a prosthetic leg. The resident stated that he does all his care himself, that he does not take showers and that he washes himself. The resident removed the right BKA sleeve to display the stump which emitted a strong foul odor. The sleeve appeared soiled and stained. Another sleeve, which was placed on his bed, also appeared dirty and stained. A Body Skin Checklist dated 7/19/18 documented Right BKA with prosthesis. An Admission/Baseline Care Plan and CCPs for Skin Integrity and Falls dated 7/19/18 documented to monitor the right stump for skin breakdown, but the CCP did not document any care instructions for the stump sleeve and the prosthetic leg. A Comprehensive Care Plan (CCP) dated 7/19/18 documented the resident's Cognition as alert and oriented to time and place. The CCP documented the resident had no behavior symptoms, impaired vision (sees large print), and the resident understands/is understood. A CCP for ADLs dated 7/19/18 documented that the resident had weakness, immobility, and a right BKA, and that the resident needed extensive assist for transfers, dressing, personal hygiene and bathing. The resident was interviewed on 8/06/18 at 11:00 AM and stated that he does washes himself with paper towels and wash cloths and does not take showers. The 7:00 AM-3:00 PM CNA assigned to the resident since admission was interviewed on 8/09/18 at 2:07 PM. The CNA stated that the resident does everything himself. She stated that showers are offered but the resident refuses and gets agitated and says, I just washed myself. She stated that she told the 7:00 AM-3:00 PM Medication Licensed Practical Nurse (LPN) about the resident refusing showers. The Medication LPN was interviewed on 8/09/18 at 2:10 PM and stated that she was unaware that the resident had not received a shower since admission. She stated that she recalls speaking to him once after being told that he was refusing a shower when he was just admitted . The LPN stated that had she been aware that it was a constant issue she would have documented the resident's refusals in the 24 hour report, Nurses notes, informed the Social Worker (SW) and encouraged the resident to shower. There was no CCP documented for the resident's behavior for refusing care/showers. The DNS was interviewed on 8/09/18 at 2:20 PM and stated that a CCP should have been developed for stump sleeve/prosthetic leg care and refusal of care. The Rehabilitation Director was interviewed on 08/10/18 at 12:07 PM and stated that the ADLs Care Plan (Form 5A) did not address the stump sleeve and prosthetic leg care. The Director of Nursing Services (DNS) was interviewed on 08/10/18 at 1:39 PM and stated that the ADLs CCP should have addressed the stump sleeve and prosthetic leg care.
2) Resident# 41 was re admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had long and short term memory problems and had severely impaired cognition for decision making. The MDS also documented the resident was incontinent of bladder and that the resident had an active [DIAGNOSES REDACTED]. A Nursing Progress Note (NPN) dated 6/4/18 at 11:45 AM documented that the resident had hematuria (bloody urine) and was shaking. The Physician was notified and ordered stat (immediate) laboratory tests including an Urinalysis and urine culture and sensitivity test. A NPN dated 6/4/18 documented at 2:00 PM the resident had jerking movements to his upper extremities and periods of gazing. The Physician was notified and ordered to send the resident to the hospital. A NPN dated 6/4/18 documented that the resident was admitted to the hospital with [REDACTED]. A Hospital Discharge Plan of Care dated 6/7/18 documented that the resident's [DIAGNOSES REDACTED]. A Physician order [REDACTED]. A NPN dated 6/7/18 documented that the resident returned from the hospital and was treated for [REDACTED]. The resident returned on [MEDICATION NAME] 500 mg for treatment of [REDACTED]. Review of the medical record revealed that there was no CCP developed for the [DIAGNOSES REDACTED]. An interview was held with the Director of Nursing Services (DNS) on 8/09/18 at 9:10 AM. The DNS reviewed the medical record and stated that a CCP was not developed for the UTI and that a CCP should have been developed upon return from the hospital on [DATE]. 415.11(c)(1)

Plan of Correction: ApprovedSeptember 8, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-656
Corrective Action accomplished for the residents affected: Resident # 209 was care planned for Right BKA stump and prosthetic care, as well as the refusal of showers/bathing by the Charge Nurse upon discovery of the deficient practice. Resident #41 was also immediately care planned for Hx of actual UTI and potential for urinary tract infections by the Charge Nurse.
Identify residents potentially affected by the same practice: All residents with an amputation stump or use of prosthetics have the potential to be affected by this deficient practice. All residents with actual UTIs or the potential for UTIs have the potential to be affected by this deficient practice. The DNS and ADNS generated a list of residents with actual UTIs and documented refusal of showers/bathing, and found that no other residents were affected by the deficient practice. No other residents require stump/prosthetic care.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence:
- The existing policy and procedure for comprehensive care planning was reviewed by the DNS and found to be in compliance.
- All licensed nursing staff will be re-inserviced on the existing policy and procedure for comprehensive care planning by the DNS, in particular: care plan for stump and prosthetic care of a resident with an amputation; care plan for refusal of showers; and care plan for all actual and potential for urinary tract infections.
- The DNS developed an audit tool to ascertain compliance with the care planning policy and procedure; care of the [MEDICAL CONDITION] stump/prosthetic; and refusal of care/bathing/showers.
Quality Assurance Monitoring and Follow-Up: The DNS or designee will perform an audit on a 100% sample of all residents with amputations to ensure stump and/or prosthetic care has been care planned for; the DNS or designee will perform a 100% sample of all residents who refuse ADL care discussed at morning report to ensure such refusal is care planned for; the DNS or designee will perform a 25% audit of all active UTIs or those residents with the potential for a UTI, weekly for one month; then monthly for six months; then quarterly thereafter to ensure no other residents were affected by this practice and assure the P(NAME) has been followed. Negative findings will be corrected immediately by the DNS or designee and all findings will be presented at the QAPI meeting.
Date and Person responsible for implementation of P(NAME): The DNS will ensure the P(NAME) has been followed and audited.

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(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. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations and staff interviews during the Recertification survey, the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was identified for the Emergency food and water storage. Specifically, during a tour of the Emergency food and water storage area on 8/06/18 and 8/08/18 the room was observed to be dirty with dust and cobwebs and had water was on the floor from rain and water pipe condensation. The finding is: A tour of Emergency food and water storage room on 08/06/18 at 8:36 AM with the Food Service Director (FSD) revealed the following observations: Cardboard boxes of Emergency Canned/Packaged foods and emergency water containers were stored in a Basement. The entrance from outside was through a metal door at ground level leading down the stairs into the storage room. The floor next to the stairs and wall to the right (approximately 14') was observed to have approximately 1 centimeter (cm) of standing water. Cardboard boxes of Emergency water containers stored next to the wall facing the stairs were observed to be moist. The sprinkler main pipes under the ceiling were moist and condensation moisture was observed to be dripping and creating a wet floor and moist cardboard boxes which contained water. The store room wall, ceiling and floor was covered with dust and cobwebs. The area was toured again on 8/8/18 at 9:30 AM. The cob webs and dust had been cleaned, however, the water on the floor was still present. There was a dehumidifier being used in the room. The FSD stated on 8/08/18 at 9:45 AM that the basement was recently (7/28/18) converted to an Emergency supply store room. He stated that the water was from the recent frequent rain. He stated that he was still unsure if the water was from the door outside or from a leak in the ceiling. He also stated that he was recently made aware that a tarp cover was supposed to be placed over the metal door for protection from rain water. He stated that a dehumidifier is being used to address moisture. 415.14 (h)

Plan of Correction: ApprovedSeptember 8, 2018

F-812
Corrective Action accomplished for the residents affected: No residents were affected by this deficient practice.
Identify residents potentially affected by the same practice: All residents have the potential to be affected by the deficient practice.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence: The Director of Maintenance has performed a thorough cleaning and performed a water-tight painting of the food storage area. This includes the walls and floor.
- The Director of Maintenance has obtained a work order to replace the concrete surrounding the basement doors which was cracked and had water intrusion and served as a vector for further water intrusion upon hard rainfall. Until work is complete, the doors and surrounding concrete will be covered by a water-proof tarp which has prevented further water intrusion.
- The humidifier will continue to run and be emptied daily and/or as needed to address any further moisture issues.
- The Director of Maintenance has developed a policy and procedure, which includes a schedule for regular cleaning and inspections of the food storage area via use of an audit tool in order to maintain a sanitary environment for the food storage area.
- All housekeeping staff will be in-serviced on the policy and procedure.
Quality Assurance Monitoring and Follow-Up: The Director of Maintenance or designee will perform an audit of the food storage area, weekly x 3 months, then monthly thereafter to assure the P(NAME) has been followed and no residents have been affected by the deficient practice. Negative findings will be immediately corrected by the Director of Maintenance or designee and results of audits will be presented at the QAPI meetings.
Date and person responsible for implementation of P(NAME): The Director of Maintenance is responsible for the correction of this deficiency.

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

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 Resident # 27's representative was provided a copy of the transfer summary and the reasons for the transfer in writing. Specifically, Resident #27 was transferred to the hospital on [DATE] and there is no documented evidence that a written transfer summary was provided to the resident's representative. The finding is: Resident # 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident has a Brief Interview for mental Status (BIMS) score of 9 which indicated moderately impaired cognition. The Nursing Progress Note (NPN) dated 4/9/18 documented the resident had a change in mental status and hallucinations. The NPN documented that prior to this episode the resident was alert and verbal and with no signs and symptoms of distress. The resident was attending activities. The Physician examined the resident and ordered to send the resident to the hospital for an evaluation. The resident's family was notified by phone of the resident's change in condition. There was no documented evidence in the medical record that a written copy of the transfer summary was provided to the resident's representative. An interview was held with the Director of Nursing Services (DNS) on 8/14/18 at 9:00 AM. The DNS stated the resident's representative was not provided written documentation of the resident's transfer to the hospital on [DATE]. The DNS stated that she was not aware of the regulation. An interview was held with the Social Worker on 8/14/18 at 9:15 PM. The Social Worker stated that she was not aware that it was a requirement to send a written notice. 415.3(h)(1)(iv)(a-e)

Plan of Correction: ApprovedSeptember 8, 2018

F-623
Corrective Action accomplished for the residents affected: The representative for Resident # 27 was provided with a notice of transfer and summary for the 4/9/18 transfer to hospital by the Social worker via certifed mail.
Identify residents potentially affected by the same practice: All residents have the potential to be affected by this deficient practice. A review of the past 3 months discharges/transfers reveal no other residents have been affected by the deficient practice.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence: The existing policy and procedure for resident transfer/discharge was reviewed and revised by the DNS to include a new notice of transfers in accordance with CMS requirements. Both the notice and bed-hold policy will be sent with the resident upon transfer and copies sent to the resident representative by the nursing supervisor at the time of the transfer/discharge. In addition, the licensed nursing staff will be in-serviced on the new policy and procedure by the DNS/designee.
Quality Assurance Monitoring and Follow-Up: The DNS or designee will perform an audit on a 25% sample of all residents transferred to the hospital to ascertain that copies of a transfer notice and bed-hold policy has been sent with the resident to the hospital and resident representative, weekly for one month; then monthly for six months; then quarterly thereafter to ensure no other residents were affected by this practice and assure the P(NAME) has been followed. Negative findings will be corrected immediately by the DNS/designee and all findings will be presented at the QAPI meeting.
Date and Person responsible for implementation of P(NAME): The DNS or designee will ensure the P(NAME) has been followed and audited.

FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE

REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview during the recertification survey the facility did not ensure that a resident who was admitted to the facility with a Pressure Ulcer (PU) was appropriately assessed and supplements to aid wound healing were implemented. This was identified for one of five residents reviewed for nutrition. Specifically, (Resident #210) was admitted to the facility on [DATE] with a Stage II Pressure Ulcer to the Coccyx area and a scabbed wound to the right Ankle. The Registered Dietitian's (RD) initial Nutritional Assessment documented the resident's skin was intact and the Nutrition Comprehensive Care Plan (CCP) did not identify the resident's impaired skin or interventions to aid in wound healing. The finding is: Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data (MDS) Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15 which indicated intact cognition. The MDS documented the resident has one unhealed Deep Tissue Injury. A Nurse's Note dated 7/24/18 documented a wound to the Coccyx and the right ankle, and treatment was initiated. A Pressure Ulcer/Impaired Skin Notification Form dated 7/24/18 documented the resident was admitted with a Coccyx Stage II PU 0.5 centimeters (cm), a 2 cm Right Ankle wound (not staged) and dry discoloration to both feet and toes. A CCP for Nutrition dated 7/24/18 lacked documentation of the presence of the Stage II PU to the Coccyx or the scabbed wound to the resident's right ankle. The CCP did not include goals or interventions that would aid in wound healing. An Initial Nutrition assessment dated [DATE] documented in the skin integrity section of the Assessment that the resident's skin was intact. The Assessment did not include any supplements or additional calories that would aid in wound healing. A [MEDICATION NAME] Laboratory report dated 7/27/18 documented a result of 22.2 mg/dl with a reference range of 18-38. During an interview conducted with the RD on 8/14/18 at 11:39 AM, the RD was not able to say why she documented on her Initial Assessment that the resident skin was intact. During the interview the RD reviewed her Assessment and stated, I have intact. The RD stated she was not sure if she was notified by nursing of the resident's PU identified on admission. The RD stated that the protocol is when a resident is admitted with impaired skin Prostat is initiated right away and a calculation of the resident's estimated nutritional needs is completed to ensure the resident is receiving adequate protein and calories to aid in wound healing. The RD stated that when she completed the assessment her calculations were based on intact skin. The RD further stated that the PU should have been addressed in her initial assessment and on the Nutrition CCP and liquid protein supplement initiated. Additionally, the RD stated I did not pick this up. 415.12(i)(1)

Plan of Correction: ApprovedSeptember 17, 2018

F-692
Corrective Action accomplished for the residents affected: Resident # 210 was assessed by the wound care MD and reviewed by the RD for nutritional supplement secondary to pressure ulcer. Dietitian obtained orders to add the nutritional intervention of Pro-stat (protein supplement), to assist with pressure ulcer healing.
Identify residents potentially affected by the same practice: All residents who have pressure ulcers have the ability to be affected by the deficient practice. The DNS and ADNS checked all residents? charts who have pressure ulcers or who are at high risk for skin breakdown to ensure accuracy of initial body assessment and proper nutritional interventions have been implemented. Findings were shared with the RD and it was determined that no other residents were affected by the deficient practice.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence: The DNS reviewed and revised the nursing admission policy and procedure to include a new RN skin assessment and notification to RD, DNS, ADNS, wound care nurse, and attending MD of any skin impairment.
- The DNS will in-service the Dietitian on new policy and procedure and the need for accurate resident assessments, with specific emphasis on admission assessments and nutrition as it relates to skin integrity.
- The DNS amended the wound care nurse job description to include a review of the dietary note to ensure accuracy of skin assessment and resulting appropriate nutritional intervention, if the resident has skin impairment. In addition, the DNS will in-service the wound care nurse on the amended responsibility.
- The DNS will provide an in-service to the licensed nursing staff on the new policy and procedure related to RD/nutritional intervention, notification, and accurate skin assessments.
- An audit tool was developed by the DNS to ensure compliance with accurate RD/RN assessments and provision for nutritional intervention.
Quality Assurance Monitoring and Follow-Up: The DNS or designee will conduct weekly audits for 1 months, then monthly for 6 months then quarterly thereafter on 100% of all residents with pressure ulcers requiring nutritional intervention to ensure accurate dietary documentation of skin integrity and subsequent nutritionally appropriate intervention. The DNS or designee will correct any negative findings immediately at time of audit and report the findings at the QAPI meeting.
Date and Person responsible for implementation of P(NAME): The DNS is responsible for the correction of this deficiency.

FF11 483.10(e)(3):REASONABLE ACCOMMODATIONS NEEDS/PREFERENCES

REGULATION: §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey the facility did not ensure the residents accommodations of needs were met. This was evident for one of one resident reviewed for accommodations of need. Specifically, during an observation Resident # 13's call bell was not functioning and a tap bell was not in reach of the resident. The finding is: Resident # 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. An observation and interview was held with Resident # 13 on 8/6/18 at 9:00 AM. The resident stated that his call bell has not functioned all weekend since Friday 8/3/18. The resident stated that he informed his CNA and Nurse and that as of now (8/6/18) the call bell is still not functioning. The resident rang the call bell and it was observed not to be functioning. A tap bell was observed sitting on the night stand next to the resident's bed but was not within reach of the resident. The resident stated the tap bell has been on the nightstand all weekend, he would ask for it and the CNA would say to use the call bell. An interview with the Director of Nursing Services (DNS) was held on 8/6/18 at 9:30 AM. The DNS observed that Resident # 13's call bell was not functioning and that the tap bell was on the nightstand not within reach of the resident. The DNS asked the resident when the call light was not functioning and the resident stated since Friday. The DNS asked the resident who he informed and the resident stated that he told his CNA and the nurse on the unit. The resident was able to demonstrate the use of the tap bell when it was provided to him. An interview with the DNS was held on 8/6/18 at 9:35 AM. The DNS stated that the resident's tap bell should have been within reach of the resident since his call bell was not functioning. The DNS stated that when a call bell is not functioning a tap bell is provided. An interview with Licensed Practical Nurse (LPN) #1 was held on 8/8/18 at 1:17 PM. The LPN worked on 8/4/18 on the 7:00 AM to 3:00 PM shift and stated that staff did not report any non- functioning call bell to her and that she was not aware Resident # 13's call bell was not functioning. An interview with the Certified Nursing Assistant (CNA) #1 was held on 8/8/18 at 3:00 PM. The CNA stated that Resident # 13's call bell was functioning on 8/4/18 and 8/5/18 on the 7:00 AM to 3:00 PM shift. A call was placed on 8/9/18 at 10:00 AM to the resident's CNA who worked on 8/4/18 and 8/5/18 on the 3:00 PM to 11:00 PM shift. A message was left and no return call was received. An interview with LPN #2 was held on 8/9/18 at 10:15 AM. The LPN worked on 8/6/18 on the 7:00 AM to 3:00 PM shift. The LPN stated the 24 hour report documented that Resident # 13's call bell was not functioning and that he had a tap bell to call for assistance. The LPN stated that the non-functioning call bell was reported in the maintenance log on 8/3/18 on the 7:00 AM to 3:00 PM shift. An interview was held with the Director of Maintenance on 8/9/18 at 10:30 AM. The Director stated that he was aware on 8/3/18 that Resident #13's call bell was not functioning and called an outside company to fix it. The Director stated that they needed more parts to fix the call bell and he had to order them. An interview was held with the DNS on 8/10/18 at 8:13 AM. The DNS stated that she interviewed the resident's CNA #2 who worked on 8/6/18 on the 7:00 AM to 3:00 PM shift. The DNS stated that the CNA stated to her that she did not provide the resident with the tap bell that was sitting on his nightstand, because she was busy because there was not enough staff. 415.5(e)(1)

Plan of Correction: ApprovedSeptember 17, 2018

F-558
Corrective Action accomplished for the residents affected: Resident # 13 was provided with a tap bell within his reach immediately upon surveyor identifying this deficient practice. Call bell was repaired on 8/10/18 by C&H signal (call bell vendor). CNA #2 was given a discipline for failiure to meet the resident's needs; CNA #2 was provided with a 1:1 inservice to provide a tap or call bell within the resident's reach at all times during their assigned shift.
Identify residents potentially affected by the same practice: All residents have the potential to be affected by this deficient practice. The ADNS made rounds the date of the deficient practice throughout the facility and found that no other residents were affected by the deficient practice.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence:
- The DNS developed a policy and procedure for residents call bells and the use of tap bells when a call bell malfunctions.
- The nursing staff will be in-serviced on the new policy and procedure by the DNS/designee.
- The CNAAR will include a section that indicates a q shift check for call bell function and placement in close proximity of resident use.
Quality Assurance Monitoring and Follow-Up: The nursing supervisor will perform an audit on a 25% sample of all residents to ascertain if any residents call bell is malfunctioning or if their call/tap bell is out of their reach, weekly for one month; then monthly for six months; then quarterly thereafter to ensure no other residents were affected by this practice and assure the P(NAME) has been followed. Negative findings will be corrected immediately by the nursing supervisor and all findings will be presented at the QAPI meeting by the DNS.
Date and Person responsible for implementation of P(NAME): The DNS or designee will ensure the P(NAME) has been followed and audited.

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

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 each residents right to be treated in a dignified manner. This was noted for one (Resident #53) of seventeen initial pool residents. Specifically, Resident #53, who required extensive assistance for activities of daily living (ADLs), was observed dressed in hospital gown during the breakfast meal in the unit dining room on 8/7/18. The finding is: Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was unable to complete a Brief Interview for Mental Status (BIMS) assessment. The MDS also documented the resident required extensive assist for transfers, dressing, eating, and personal hygiene. A CCP for activities of daily living (ADLs), dated 2/2/18 and updated through 7/24/18, documented the resident needed extensive assist with transfers, dressing, feeding, and personal hygiene. Resident #53 was observed in the unit dining room on 8/7/18 at 8:30 AM. The resident was observed being fed by a Certified Nursing Assistant (CNA). Resident #53 was observed dressed in double hospital gowns. There were 12 other residents eating breakfast in the dining room. A LPN and 2 CNAs were overseeing the meal service in the dining room. A CNA was observed to wheel Resident #53 out of the dining room at 8:55 AM and stated that she was taking the resident for a shower. The 7:00 AM-3:00 PM shift CNA who had taken the resident out of the dining room on 8/7/18 for a shower was interviewed on 8/8/18 at 10:00 AM. She stated that she has been assigned to Resident #53's care since his admission. She stated that the resident was in the dining room in the hospital gown during breakfast on 8/7/18 because the resident was supposed to take a shower. She stated that he was dressed in two gowns. She stated that she comes in at 7:00 AM and the breakfast meal comes at 7:30 AM. The CNA stated the resident was already up and cannot be left in the room because he is constantly getting up from his chair. The CNA further stated that no one has said anything to her about bringing the resident to the dining room in the hospital gowns. The Director of Nursing Services (DNS) was interviewed on 8/9/18 at 8:30 AM and stated that she did not think it was a dignity issue for the resident being in hospital gown in public/common areas in the facility. The DNS also stated she understands the concern. 415.3(c)(1)(i)

Plan of Correction: ApprovedSeptember 8, 2018

F-550
Corrective Action accomplished for the residents affected: Resident # 53 was provided with dignified and appropriate dress and was assessed by an RN and found to have no ill effects from the deficient practice.
Identify residents potentially affected by the same practice: All residents that are dependent or require assistance with dressing have the potential to be affected by this deficient practice. The ADNS made rounds the date of the deficient practice throughout the facility and found that no other residents were affected by the deficient practice.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence:
- The existing policy and procedure for residents? rights has been reviewed and revised by DNS to include the use of dignified dress for all residents while in common areas of the facility.
- All nursing staff will be in-serviced by the DNS/designee on the revised policy and procedure.
Quality Assurance Monitoring and Follow-Up:
- The DNS developed an audit tool to ensure compliance with appropriate/dignified dress requirements in common areas of the facility for all residents.
- The nursing supervisor will perform an audit on a 25% sample of residents in common areas to ascertain if any residents are wearing gowns or any other undignified garments in common areas weekly for one month; then monthly for six months; then quarterly thereafter to ensure no other residents were affected by this practice and assure the P(NAME) has been followed. Negative findings will be corrected immediately by the nursing supervisor and all findings will be presented at the QAPI meeting by the DNS.
Date and Person responsible for implementation of P(NAME): The DNS or designee will ensure the P(NAME) has been followed and audited.

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews during a recertification survey, the facility did not maintain a homelike environment for 2 of 2 (first and second floor) units. Specifically, during three days of the survey observations of strong urine odors were noted in the lobby area, hallways and a resident's room. (Resident#50). Additionally, the second floor hallway was noted to be soiled. The finding is: The lobby was noted to have a strong urine odor on 8/13/18 at 9:00 AM. Observation on 8/14/18 at 10:00 AM and later at 2:00 PM of Resident # 50's room revealed that a strong urine odor was present in the resident's room. Observation on 8/15/18 at 8:00 AM of Resident #50's room revealed a strong urine odor. Observation on 8/15/18 at 10:30 AM of the second floor hallway revealed that the hallway floor was sticky to touch. Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderately impaired cognitive skills. The resident was independent in transfers, ambulation in the room and independently toileted himself. The resident was continent of both bladder and bowel and was not on a toileting program. Resident#50 used hand gestures to communicate on 8/13/18 at 9:45 AM. The resident was in bed, the room had a strong urine odor. The resident indicated with hand gestures that he was good. An interview was held with the Certified Nursing assistant (CNA) that cares for this resident on 8/14/18. The CNA stated that the resident toilets himself. Additionally, the resident does not like his room cleaned and refuses to use a fan to circulate the air. An interview was held on 08/15/18 at 12:44 PM with the Medication Nurse Licensed Practical Nurse (LPN) for Resident #50. The LPN stated that the resident does not come out of his room. An interview was held with Housekeeper #1 (first floor) on 8/15/18 at 1:00 PM. The Housekeeper stated they try to keep the facility clean without odors. An interview was held with Housekeeper # 2 (second floor) on 8/15/18 at 1:30 PM. The Housekeeper stated that she does the best she can. The Director of Environmental Services was interviewed on 08/15/18 at 12:55 PM. The Director stated that the lobby is supposed to be mopped every day and he was not sure why the lobby would have a strong urine odor. The Director stated that he did not know why Resident # 50's room had a strong odor of urine, the room is cleaned every day. Additionally, the Director stated that the second floor hallway is worn and will be replaced. 415.5(h)(2)

Plan of Correction: ApprovedSeptember 8, 2018

F-584
Corrective Action accomplished for the residents affected: Resident #50 was given a shower by aide on assignment and remains independent with toileting. In addition, the room in which resident #50 resides in was terminally cleaned. This included a thorough wash of walls and floors in both bedroom and bathroom. The flooring on the second floor and lobby was immediately washed and polished by the housekeeping department.
Identify residents potentially affected by the same practice: All residents have the potential to be affected by this deficient practice. The ADNS and Director of Maintenance made rounds on the date of the deficient practice throughout the facility and found that no other residents or rooms were affected by the deficient practice.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence:
- The lobby, all rooms, and bathrooms were thoroughly cleaned. All common area floors were also washed and polished.
- The nursing and housekeeping staff will be in-serviced by the Maintenance Director on the existing policy and procedure to properly clean all resident rooms and common areas daily and as needed to maintain a sanitary and comfortable environment.
- An audit tool was developed by the Director of Maintenance.
Quality Assurance Monitoring and Follow-Up: The Director of Maintenance/designee will perform an audit on a 20% sample of all resident rooms and common areas throughout facility to ascertain if any areas have a urine smell or if the floors are soiled or ?sticky?, weekly for one month; then monthly for six months; then quarterly thereafter to ensure no other residents were affected by this practice and assure the P(NAME) has been followed. Negative findings will be corrected immediately by the Director of Maintenance/designee and all findings will be presented at the QAPI meeting.
Date and Person responsible for implementation of P(NAME): The Director of Maintenance or designee will ensure the P(NAME) has been followed and audited.

FF11 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during a recertification survey, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. Specifically, nursing staff were not documenting the Subcutaneous (sq) injection sites when Insulin was administered for 1 (Resident # 26) of 5 residents reviewed for medication review. The finding is: The Policy and Procedure for Injection Site Rotation dated (MONTH) (YEAR) documents Rotation of the injection site help reduce irritation and bruising and improves absorption .The nurse must document the rotation of the injection site of any injectable medication on the Medication Administration Record [REDACTED]. Resident # 26 admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented the resident received 7 of 7 days of insulin injections in the MDS review period. A review of the physician orders [REDACTED]. Inject by subcutaneous route, check finger stick three times/day before meals, and inject sq as per sliding scale: Blood Sugar 0-150= 0 units, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400= 10 units above 400 or below 70 call MD. Review of the MAR from 05/27/2018 to 08/08/2018 revealed that the Insulin injection sites were not being documented after every Insulin sq Injection. The Licensed Practical Nurse (LPN) medication nurse was interviewed on 8/09/18 at 10:15 AM and stated she does not document the site given for insulin and she thought she was to only document the [MEDICATION NAME] sites. The Director of Nursing Services (DNS) was interviewed 08/09/18 at 11:29 AM and stated nurses should be documenting sites and alternating sites when administering Insulin. 415.11(c)(3)(i)

Plan of Correction: ApprovedSeptember 8, 2018

F-658
Corrective Action accomplished for the residents affected: A new Medication Administration Record [REDACTED]?site? for all prescribed insulin injections by the Charge Nurse.
Identify residents potentially affected by the same practice: All residents that require SQ insulin have the potential to be affected by this deficient practice. The ADNS performed an audit of all residents requiring SQ injections and found that no other residents were affected by the deficient practice.
Corrective Measures and Systemic Changes put in place to avoid reoccurrence: The existing policy and procedure for resident SQ insulin injections has been reviewed by the DNS and found to be in compliance. All licensed nursing staff will be re-inserviced on the existing policy and procedure by the DNS/designee to document insulin injection sites and alternate sites when administering insulin.
Quality Assurance Monitoring and Follow-Up: The DNS or designee will perform an audit on a 25% sample of all residents requiring the use of insulin and that sites are being documented as well as alternating, weekly for one month; then monthly for six months; then quarterly thereafter to ensure no other residents were affected by this practice and assure the P(NAME) has been followed. Negative findings will be corrected immediately by DNS/designee and all findings will be presented at the QAPI meeting.
Date and Person responsible for implementation of P(NAME): The DNS/designee will ensure the P(NAME) has been followed and audited.

FF11 483.35(a)(1)(2):SUFFICIENT NURSING STAFF

REGULATION: §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 2 nursing units. Specifically, during two family interviews and two resident interviews, resident council meetings and a facility visitor interview, complaints were made about insufficient staff to care for residents needs in a timely manner, residents having long waits for incontinence care, not enough staff to complete assignments, and to assist with dinner meals. The findings include but are not limited to: On 8/09/18 at 1:17 PM a facility visitor stated she observed call bells not answered for more than 15 minutes many times ( at least 5 to 7 times). The facility visitor visits 2-3 times per week, sometimes during the weekend. There is no intercom at the nurses station so, staff have to physically go to see what each resident needs. Because the call bells are not answered, the visitor had to give the residents the desk phone number so residents can receive assistance. The visitor heard reports of residents as long as an hour before their call bells are answered during the 3 to 11 PM shift. Administration is aware of the staffing concerns. Residents are waiting to get fed, waiting to receive incontinent care and maybe waiting a long time for small things that make a difference to the residents. On 8/13/18 at 12:19 PM a family interview of Resident # 41 complained of poor staffing levels. The family member previously complained of poor staffing levels to the Director of Nursing Services (DNS) and the Administrator. They reported to the family member that the family member may take the resident to another facility, if the family member is unhappy with staffing levels. The family member has observed the resident not fed breakfast on the weekend in (MONTH) (7/7/18) with the tray untouched, food cold due to only having 2 aides on the unit. On 8/6/18 the resident was not transferred out of bed by 10 AM. Normally the resident is transferred out of bed earlier. It was reported to the family member that only 2 CNAs were on the unit and the resident would have to wait because the resident is a hoyer transfer out of bed with 2 people assist and they were unable to transfer the resident out of bed by 10 AM. The family member has observed other residents calling for help without staff to assist them. The family member has found the resident with strong odors and was worried the resident was not provided timely incontinent care. A anonymous family member stated almost half of the residents who reside on the 2nd floor Unit require two staff members for transfer. The family member stated when there are only 3 CNAs, when one of the three CNAs take a break for a 30-minute lunch or either of their two fifteen minute breaks, two CNAs are left on the floor to address care needs. The family member stated that residents are heard asking to be toileted and then not being taken to the bathroom for long periods of time. There are long waits for residents who require a two-person transfer for toileting. The wait for toileting could be longer than a half hour, up to 45 minutes and sometimes even longer. Resident # 26 admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score was 15, indicating the resident's cognition was intact. The resident was totally dependent on staff for transfers, was non-ambulatory, required extensive assistance with hygiene and was always incontinent of bowel. The resident had one Stage 4 pressure ulcer to the sacral measuring 2 x 1 x 0.6 granulation tissue. Resident # 26 was interviewed on 8/6/18 at 11 AM and stated the staffing is poor, that he had to sit in his bowel movement for over one hour before receiving care recently. Sometimes he is transferred out of bed very late and there was one weekend when he did not receive his breakfast tray until 10 AM. On 8/6/18, Resident # 13 was observed without a call bell in reach. This was reported to the DNS by the Surveyor on 8/6/18 at 9 AM. An interview was held with the DNS on 8/10/18 at 8:13 AM. The DNS stated that she interviewed the resident's CNA #2 who worked on 8/6/18 on the 7:00 AM to 3:00 PM shift. The DNS stated that the CNA stated to her that she did not provide Resident # 13 with the tap bell because she was busy because there was not enough staff. The Facility assessment dated [DATE] documented that at least 52 residents required assistance with transfers by 1 -2 staff members, and 5 residents were dependent of staff. Residents required assist of 1-2 staff -54 for dressing, 41, bathing, 37 eating and 37 for toileting. Residents dependent on staff- 6 for dressing, 25 for bathing, 10 for eating, 20 for toileting. The average daily Census was 60. Number of residents licensed to care for was 76. Staffing requirements for Certified Nurse Assistants (CNAs) day shift (7 AM - 3 PM) =7; evening shift (3 PM - 11 PM) =6; and night shift (11 PM - 7 AM)= 4. The Director of Nursing Services was interviewed on 8/13/18 at 11:45 AM and stated that the staffing plan is as follows: during the day shift, 4 CNAs on 2nd floor, 3 CNA on 1st; Evening shift, 3 CNAs on each unit; and on the Night shift, 2 CNAs on each unit. A review of Staffing sheets revealed that from (MONTH) 1 (YEAR) through (MONTH) 9, (YEAR), there were 58 days of short staffing of Certified Nurse Assistants (CNA). The days when there was short staffing of CNAs included call- ins during all three shifts and weekends as well as weekdays. Examples include but are not limited to: 1) (MONTH) 26, (YEAR)- 2 CNAs assigned to the 1st floor during the 7 AM to 3 PM shift instead of 3 and 3 CNAs assigned to the 2nd floor during the 7 AM to 3 PM shift instead of 4. The 3-11 shift had only 2 CNAs instead of 3 CNAs. 2) (MONTH) 16, (YEAR) during the 7 AM to 3 PM shift, 3 CNAs assigned to the 2nd floor instead of 4 and 2 CNAs assigned to the first floor instead of 3. 3) (MONTH) 6, (YEAR) there was 2 CNAs assigned to the first floor during the 7 AM to 3 PM shift when there should have been 3 CNAs. An interview was conducted with the Director of Nursing Services (DNS) on 8/13/18 at 12 PM. The DNS stated when there is a call in we try to get agency staff or try to keep someone on for overtime. There are many days were we were not able to get agency staff or get staff to stay overtime. A CNA (who wishes to remain anonymous) was interviewed on 8/14/18 at 11:30 AM and stated there is too much pressure on CNAs when there are call ins, sometimes 12-14 residents per CNA. The CNAs get written up if we do not bring 6-7 residents into the day room by 830 AM on a daily basis. The CNAs have to give 2 showers daily. When there is a call in, there is more pressure on us. Many times we are not able to complete the assignment of the CNA who called in. Some residents are not given showers, incontinent care and are not transferred out of bed timely. Resident council Meeting Minutes for (MONTH) 7, (YEAR) and (MONTH) 29, (YEAR) complained of short staffing of nursing staff. On (MONTH) 7, (YEAR), the Resident Council president complained how the weekends were short and there is difficulty reaching the supervisor. The DNS responded and told the residents that she will speak to the supervisor scheduled and will reinforce her availability at all times during her shift. Administration responded and explained advantages and disadvantage of agency staffing at this time because of the lack of applications at the nursing home. The resident council meeting minutes documented that Administration is in contract with 2 agencies to resolve the concern of short staff during the weekends and to ensure the quality care for residents. The Administrator was interviewed on 8/15/18 at 1 PM and stated the facility has contracted out with an agency in (MONTH) (YEAR). The Administrator stated it is very difficult to obtain staffing. Sometimes we are staffed without call-ins and residents and families still complain of short staff. We are trying very hard to resolve the short staffing concern. An interview with the Resident (#16) council president was conducted on 8/15/18 at 2:15 PM. The resident stated there has been no Resident Council meetings for (MONTH) or (MONTH) (YEAR) because she was sick and hospitalized . She stated prior to hospitalization , the residents were complaining of short staff. Residents were waiting over 1 hour to receive help with care. Residents are not being cleaned, showered and transferred out of bed in a timely manner. The resident stated that they have told the facility and the problem continues. The resident stated that we really need more staff. The Staffing Coordinator was interviewed on 8/15/18 at 3:41 PM and stated when they are short due to call ins, they try to get someone to stay on overtime or contact the agency. They work with two agencies. One has not sent any staff. The other agency only sent 2 LPNs. They have been having a difficult time staffing the facility. On days there are call ins and there is a low census, the staffing coordinator stated we do not try to get CNA staff because of low census. 415.13(a)(1)(i-iii)

Plan of Correction: ApprovedSeptember 17, 2018

F-725
Corrective Action accomplished for the residents affected:
- Upon notification of the surveyor findings for resident #41, the administrator spoke with the family member and addressed all her concerns as stated. The administrator/designee will attend subsequent family council meetings to address all family member concerns.
- Resident #26 was identified and education was provided by the DNS to all direct caregivers on the timeliness of incontinence care and the answering of call bells.
- Resident #13 was identified and the call bell was placed within his reach by ADNS upon notification of the surveyor findings and all direct care staff educated on placing call bells in reach of the resident by the DNS.
Identify residents potentially affected by the same practice: All residents have the potential to be affected by the deficient practice. Social worker will interview all alert residents with a BIMS >10 that could have been affected to ensure no other residents have been affected by this deficient practice
Corrective Measures and Systemic Changes put in place to avoid reoccurrence: The facility assessment was reviewed and revised to adjust the staffing par levels dependent on facility acuity and census.
- The Administrator contacted and obtained a contract with a staffing agency to provide staff when facility staff members call out or any other situation that staffing par level would otherwise be below minimum acceptable level as per facility assessment.
- The DNS in conjunction with the Administrator and staffing coordinator will develop a hiring plan to recruit additional staff on an as needed basis to correct this deficient practice.
- The DNS/designee will initiate progressive discipline for repeat offenders, up to and including termination.
- Administrator will meet with ownership to discuss a temporary enhancement of scheduled workers until the call-out situation is rectified (ie: sick calls/vacancies).
- An audit tool was developed by the DNS to ensure compliance with sufficient staffing levels.
Quality Assurance Monitoring and Follow-Up: The DNS/designee will audit the staffing levels daily x 1 months, then weekly x 3 months, then quarterly thereafter to assure compliance with P(NAME) and negative findings will be immediately corrected by the DNS/designee and will report audit results at the QAPI meetings.
Date and Person responsible for implementation of P(NAME): The DNS is responsible for the correction of this deficiency.

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 16, 2018
Corrected date: November 9, 2018

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 two of four residents reviewed for pressure ulcers received necessary assessment and care to prevent the development of new pressure ulcers and deterioration of pressure ulcers (Residents #46 and # 210). Specifically: 1) A Braden Scale pressure ulcer risk assessment was not completed on admission, and the use of heel pressure devices was not implemented based on assessment of mobility deficit, according to facility policy and procedure for Resident #46. Subsequently, Resident #46 developed a Stage 2 pressure ulcer to the left heel that deteriorated to a Stage 4 pressure ulcer. 2) Resident #210, with [DIAGNOSES REDACTED]. The facility did not fully assess and monitor the pressure ulcer, and did not implement use of a specialty mattress to promote healing. The wound subsequently deteriorated to a Stage 3 pressure ulcer. Additionally, Resident #210 was admitted without pressure ulcers to the heels. The facility did not ensure that the use of heel pressure devices was implemented timely, as per policy and procedure, to minimize the risk of pressure injury resulting in a Deep Tissue Injury (DTI) of the right heel. This resulted in actual harm for Resident #46 and Resident #210 that is not immediate jeopardy. The findings are: The facility Policy and Procedure for Skin Ulcers/Wound updated 6/2015 documented residents with mobility/activity deficits to utilize heel pressure devices while in bed and a specialty mattress. Residents are identified for specific factors that may place them at risk for developing pressure ulcer on admission. All residents are assessed for pressure ulcer risk using the Braden Scale. Scoring of the Braden Scale - Very high risk - total score less than 9, high risk score 10-12, moderate risk 13-14, and mild risk score 15-18. The evaluation/care of pressure ulcers requirements included re-evaluation at least every seven days and all pressure ulcers to be assessed by a Registered Nurse. 1) Resident #46 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 9 out of 15 indicating moderate cognitive impairment. The MDS assessment noted the resident required extensive physical assistance of two persons for bed mobility, extensive assistance of one person to transfer and was totally dependent on one person for locomotion. The MDS assessment also noted that the resident was admitted without any pressure ulcers, was at risk for pressure ulcer development, and pressure reducing devices for chairs and bed were in place. The Admission Body Skin Checklist dated 10/13/17 was completed by a Registered Nurse (RN #5) and documented that the resident's skin was intact. There was no documented evidence that a Braden Scale pressure ulcer risk assessment was completed at the time of admission. The Comprehensive Care Plan (CCP) for Skin Integrity dated 10/13/17 identified the problem of potential for skin impairment related to skin failure secondary to failure to thrive secondary to End Stage Dementia. The CCP did not include interventions for the use of pressure reduction devices to off-load pressure to the resident's heels. physician's orders [REDACTED]. A Licensed Practical Nurse (LPN #6) documented in the progress notes on 10/29/17 that a blood-filled blister was noted to the left heel. A Wound Care Physician consult note dated 10/30/17 documented a left heel assessment and described a Stage 2 left heel pressure ulcer measuring 4 centimeters (cm) x 8 cm x 0.1 cm - intact serosanguinous (clear, yellowish pale red liquid that occurs in wound healing) blister - drained of fluid, intact [MEDICATION NAME] tissue underneath. The consultant documented a plan for treatment with [MEDICATION NAME] (an antibiotic ointment used to avoid or treat skin infection) and a dry, clean dressing daily and to, Off load with heel booties. The CCP was updated to include interventions for use of heel boots on 10/30/17 and to off-load heels on 10/31/17. A 7 AM - 7 PM LPN entry documented that heel booties were in place on 11/1/17. The Physician ordered comfort measures only on 10/31/17 including but not limited to Do Not Intubate (DNI), Do Not Resuscitated, No Tube Feeding, and Pain Management. Wound Care Physician notes documented deterioration and persistence of the left heel pressure ulcer as follows: 11/6/17 - Deep Tissue Injury (DTI: a localized area of intact skin with dark discoloration such as purple/maroon, or a blood-filled blister) measuring 4 cm x 9 cm. 11/13/17 - 7 cm x 9 cm x (unavailable measurement of wound depth) with 50 % black necrosis (death of body tissue) and 50 % Deep Tissue Injury (DTI) .enlarging area, complaints of pain barely touching foot/leg .(resident) needs arterial work up to rule out (r/o) [MEDICAL CONDITIONS] and r/o Osteo ([DIAGNOSES REDACTED], infection of the bone). 8/8/18 - Stage 4 measuring 4.4 x 3.5 x 0.2 with light serosanguinous drainage, 75 % slough and 25 % granulation. Apply Santyl ointment (an enzymatic agent used to break up dead skin and tissue and promote healing) once daily, cover with dry protective dressing and wrap with gauze, bilateral boots, float heels. A Braden Scale assessment dated [DATE] (10 months after admission) documented a score of 10 which indicated that the resident was at high risk for the development of pressure ulcers (A score of 12 or less represents high risk). A Physician order [REDACTED]. Wound care to the left heel was observed with the Wound Care Physician and two LPN's on 8/15/18 at 2:30 PM. The left heel pressure ulcer was assessed as a Stage 4 measuring 4 x 3 cm x (unavailable measurement of wound depth). The wound was covered with slough (90%) and had a strong odor. The wound care physician debrided the ulcer (removal of dead, damaged or infected tissue to promote healing of remaining tissue). The Registered Nurse Supervisor (RNS) was interviewed on 8/14/18 at 2 PM and stated that the resident should have been high risk for heel skin breakdown because the resident was immobile in bed and because of the resident's admitting [DIAGNOSES REDACTED]. The Director of Nursing Services (DNS) was interviewed on 8/14/18 at 3 PM and stated a Braden Scale should have been completed by the admission RN. The resident was admitted without any pressure ulcers. The resident was at high risk for skin breakdown due to limited bed mobility and should have had his heels off loaded to prevent a pressure ulcer. The RN that completed the Admission body skin checklist on 10/13/17 (RN #5) was interviewed on 8/15/17 at 3:30 PM. She stated she worked on a per diem basis and could not recall why she did not off load the heels. The attending Physician was interviewed on 8/15/18 at 10:30 AM and stated, because of the resident's low protein levels on admission, decreased mobility and comfort care, staff should have ensured to offload the resident's heels from the bed to prevent pressure ulcers. The Wound Care Physician was interviewed on 8/15/18 at 2 PM and stated residents who are immobile in bed should have their heels offloaded to prevent pressure ulcers to the heels.
2) Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS assessment dated [DATE] documented the resident's BIMS Score as 15 which indicated intact cognition. The resident had no assessed behavior problems or rejection of care. The resident was not incontinent, required extensive assistance of one staff member for bed mobility, transfer, and toileting. The MDS documented the resident had one unhealed area of DTI. The presence and location of a DTI was not noted in Nurse's notes, physician progress notes [REDACTED]. A Braden Scale pressure ulcer risk assessment dated [DATE] documented a score of 16 which indicated the resident was at mild risk for developing pressure ulcers. A Pressure Ulcer/Impaired Skin Notification Form dated 7/24/18 completed by RN #4 documented the resident was admitted with pressure ulcers described as Coccyx Stage 2 that measured 1.5 cm and Right Ankle that measured 2.0 cm, and dry discoloration to both feet and toes. The coccyx and ankle ulcer descriptions lacked complete assessment data for measurements of length X width X depth of the ulcers and there was no documented assessment of the Stage of the ankle ulcer. There was no documented evidence in the Resident Baseline Care Plan Summary, physician's orders [REDACTED]. A physician's orders [REDACTED]. An Admission Nurse's Note dated 7/24/18 documented the wound to the coccyx and the right ankle were assessed, and treatment was initiated. A CCP dated 7/24/18 for Pressure Ulcer documented a right ankle scabbed area and a Stage 2 to the coccyx on admission secondary to [MEDICAL CONDITION]. A Resident Baseline Care Plan Summary dated 7/25/18 documented to administer treatment to Coccyx wound as ordered. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) dated 7/27/18 for Skin Integrity documented the resident had the potential for impairment related to immobility related weakness and [MEDICAL CONDITION]. Interventions included to turn and position the resident every two to four hours and PRN (as needed), provide Panacea mattress, provide foam wheel chair cushion, treatment as ordered by the Physician. The CCP was updated on 8/2/18 to include a Stage I Pressure Ulcer to the bilateral heels and noted non-blanchable redness to bilateral heels. The interventions included to turn and position the resident every two hours, provide pressure relief mattress, Roho (a pressure relief device for wheelchairs) cushion, vitamins/supplements and treatments per order and right and left heel offload boots were initiated, 9 days after admission. A physician's orders [REDACTED]. The CCP documented on 8/3/18 use of a specialty mattress, an Alternating Air mattress, was initiated, 10 days after admission. A Nurse's note dated 8/6/18 at 10:00 PM documented the coccyx wound was assessed and the wound bed was pink with dark area in the middle. Santyl daily was continued and the Physician was aware. The right ankle wound was noted to be healing nicely, and the condition of the right heel was changed; a DTI was noted. Skin prep with bulky dressing applied. Heel booties to be applied at all times, may remove with care. Staging of the coccyx and ankle ulcers was not assessed and documented. Description of the right ankle wound bed and surrounding tissue was not done. Assessment of coccyx, ankle and heel wound measurements were not documented. The physician's orders [REDACTED]. A physician's orders [REDACTED]. The CCP was updated on 8/6/18 and noted the status of the right heel pressure ulcer deteriorated to a DTI. The Registered Nurse Supervisor in training (RN #3) was interviewed on 8/14/18 at 12:28 PM. RN #3 stated he accompanied the Wound Care Physician on weekly wound rounds. RN #3 stated the pressure ulcer CCP was last updated 8/2/18 when orders were received from the Physician to initiate heel booties for the resident. Resident #210 was observed with heel booties in place seated in her wheel chair and interviewed on 8/15/18 at 1:55 PM. The resident stated that she had a pressure ulcer prior to admission and was concerned that it was not getting better. The resident stated that she had a regular mattress for more than a week when she was first admitted . The resident further stated that her wound was measured on admission and then once more sometime last week and that she was never seen by the Wound Care Physician. The 3:00 PM - 11:00 PM RN Supervisor (RN #4) was interviewed on 8/14/18 at 2:32 PM and stated she completed the Admission Assessment and that the resident had a stage 2 pressure ulcer to the coccyx. RN #4 stated that she completed the Pressure Ulcer/Skin Notification Form and documented the measurements when she completed the form. RN #4 stated that the Director of Nursing Services (DNS) and Physician were notified. RN #4 stated that the process was that she verbally notified the Physician and the DNS and then placed copies of the Notification Form in the mail boxes of the designated disciplines. RN #4 stated wounds were measured weekly on wound rounds by the Wound Care Physician, however last week she and RN #3 completed the treatment and measurements. RN #4 stated that she could not recall if she did the measurement for Resident #210 or if RN #3 did the measurement and why the measurement was not documented in the Nurse's note. RN #4 stated that there was a deterioration of both the coccyx wound and right heel. The RN stated the Coccyx was now a Stage 3 and the right heel was now a DTI. The DNS was interviewed on 8/14/18 at 3:09 PM and stated that she was not aware the resident was admitted with a pressure ulcer. The DNS stated that RN #4 told her she made copies of the the Pressure Ulcer/Skin Notification Form on admission and put them in the appropriate mailboxes but she did not get one. The DNS stated there was a delay in doing weekly wound measurements. The DNS stated when she became aware the resident had pressure ulcers, she instructed RN #4 to assess the wound which included measurements. The DNS stated the expectation was that the measurements be included in the Nurse's note when the assessment was done. The DNS further stated that an air mattress is ordered for residents who are at high risk for pressure ulcer, who have an existing pressure ulcer, and residents with multiple comorbidities. The DNS stated that the resident had a regular mattress on admission and that there was a delay in initiating the air mattress. The DNS stated she would have ordered a specialty air mattress on admission if she knew about the wound. The Wound Care Physician was interviewed on 8/15/18 at 2:26 PM. The Physician stated that he had not spoken to the resident himself, but the staff reported to him the resident had refused to be seen on two occasions. The Physician stated that he was sure the resident had seen him in passing in the hallway but did not know he was the Wound Care Physician and that he had not followed up to introduce himself to the resident to let her know who he was as he had several other residents waiting to be seen. The Physician stated that the resident might have been in therapy or at activity at the time of his visit and that he did not go back to the resident at a later time. The Physician stated that he had not actually met the resident until 8/15/18, and that it was his first time seeing the residents wounds. The Physician presented the following measurement and description of the resident's wound: right heel measured 1.5 cm x 1.5 cm dark colored DTI. Left heel intact, Sacrum Stage 3 measured 1 cm x 1cm x .3 cm and wound bed clean, no undermining. 415.12(c)(2)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during Post Survey Review (PSR) #1, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure ulcers for one (Resident #3) of two residents reviewed for pressure ulcers. Specifically, Resident #3 had care plan interventions and wound care physician recommendations to offload heels while in bed; however, the resident was observed in bed with his heels resting directly on the mattress and there was no pillow on the mattress for the resident's feet. The finding is: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/2/2018 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) of 15, indicating the resident was cognitively intact. The MDS documented the resident had one Stage 4 pressure ulcer; required extensive assist of two staff members for bed mobility, and was totally dependent on two staff members for transfer. A Comprehensive Care Plan (CCP) titled Pressure Ulcer effective 2/14/2018 documented that the resident had a right Ischial Stage 4 pressure ulcer upon admission. Interventions in the care plan included pressure relief low-air-loss mattress and to offload both heels on pillows. There was no documentation in the care plan that the resident refused to have his heels offloaded. A Weekly Pressure Ulcer Healing Record, effective 9/26/2018, documented that the resident should have heel booties and to offload heels. The Braden Scale for predicting pressure sore risk, dated 10/8/2018, scored the resident at 15, indicating the resident had mild risk for developing a pressure ulcer. A Pressure Ulcer Prevention Checklist, dated 10/8/2018, documented that the resident had a Braden score of 15 and that the resident's heels should be offloaded with pillows. A wound physician Wound Evaluation and Management Summary, dated 10/10/2018, documented recommendations for a Group 2 mattress (powered pressure reducing mattress), a Roho cushion for the wheelchair, and a pillow for feet. The current Certified Nursing Assistant (CNA) Accountability Record (CNAAR) documented under special instructions to offload heels in bed. The resident was observed in bed on 10/16/2018 at 10:17 AM. The observation was made with the Registered Nurse (RN) unit supervisor. The resident had an air mattress. There was no pillow supporting the resident's feet and the heels were in direct contact with the mattress. The RN stated there should be a pillow supporting the resident's feet. The RN could not find a pillow in the room to support the resident's feet. The resident's CNA was interviewed on 10/16/2018 at 11:35 AM. The CNA stated the resident's feet get elevated on a pillow and that there was a pillow under the resident's feet when she saw the resident earlier in the morning. She stated that maybe the resident took the pillow away because he is able to in order to make himself comfortable. A Behavioral/Non Compliance CCP, effective 11/21/2017, did not document that the resident removed the pillow that offloads his heels. The resident was observed in bed on 10/16/2018 at 11:45 AM. The resident's feet were being supported by a pillow and his heels were floated off the bed. The resident was interviewed twice with two different translators on 10/16/2018 at 12:10 PM and 1:11 PM. The resident stated both times that today was the first time that the staff put a pillow under his feet. The Assistant Director of Nursing (ADON) and acting wound care nurse was interviewed on 10/16/2018 at 12:26 PM. She stated that the resident was supposed to have pillows under his feet to offload the heels. She stated the Weekly Pressure Ulcer Healing Record, effective 9/26/2018, should not say heel booties for the feet. The wound care physician was interviewed on 10/16/2018 at 1:28 PM. He stated the resident was at risk for heel injury and that it benefits the resident to float the heels. He stated that even though there was an air mattress, the heels should still be offloaded with a pillow. 415.12(c)(2)

Plan of Correction: ApprovedOctober 31, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-686: Directed Plan of Correction
Hilaire Rehab and Nursing submits that its policies, procedures and systems are in place to ensure residents do not develop pressure sores and/or they are healed timely. This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements.
I. The following actions have been taken for the residents identified in the sample:
Hilaire Rehab and Nursing will ensure proper skin risk assessments are completed and care is provided to prevent residents from developing pressure ulcers and ensure residents with pressure ulcers receive the necessary assessment, treatment and services needed to promote healing and prevent infection.
Resident # 46 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE].
Resident # 210 was admitted on [DATE] with [DIAGNOSES REDACTED].
The resident had a complete skin assessment on [DATE] with a Braden Score of 12 - high risk.
The resident is on weekly pressure ulcer (PU) tracking with PUs on: coccyx and right heel.
The resident?s care plan was reviewed and revised to reflect current interventions and treatments. The Physician Wound Care Consultant sees the resident during weekly wound rounds and the wounds are measured, evaluated and documented.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same deficient practice:
All residents have the potential to be affected by this deficient practice. All residents at Hilaire will have complete skin assessments completed and those without Braden Skin Assessments in the last 30 days will be assessed and treated appropriately. All residents will have Braden Skin Assessments completed on admission, readmission, quarterly and upon significant condition change.
All residents with pressure ulcer?s will be reviewed to determine the physician?s order is clear and accurately reflected on the treatment plan, comprehensive care plan and plan of care. Resident?s pressure ulcers will be assessed to determine they are accurately measured and recorded. Inconsistencies will be immediately clarified and corrected.
III. The following systemic changes will be implemented to ensure the deficient practice does not recur:
The Administrator, Medical Director, and Director of Nursing will review and revise the facility?s pressure ulcer policies and procedures to reflect skin and risk assessment, prevention, identification, treatment, and documentation.
All licensed nurses and CNAs will be educated on:
- Revised Skin Care Policy
- Maintenance of Resident?s Skin Integrity
- Residents at risk for skin breakdown
- Prevention of skin breakdown
- Early identification of skin breakdown
- Reporting and communication of any changes in skin
- treatment of [REDACTED].
Weekly Wound Rounds tracking record will be updated to include:
- Current treatment order
- Measurements
- Last Wound Consult completion with recommendations to ensure each resident?s pressure ulcer care plan is current.
All new pressure ulcers or changes in orders will be included on the 24-Hour Report and shared with the Nurse Supervisor, Director of Nursing and discussed at morning meeting each day and an investigation of the PU will be initiated immediately.
The Unit Manager will ensure a skin assessment is completed for all new admissions & readmissions, quarterly and upon significant condition change. Residents at risk for pressure ulcers will have the prevention protocol initiated timely.
Unit Managers will participate in weekly wound rounds with the Wound Care Consultant to identify changes in the wound(s) and recommendations in PU treatment:
- Are accurately documented on the wound tracking sheets
- Are reviewed by the Physician/NP
- If new or revised Physician orders [REDACTED].
- Changes in PU orders are accurately reflected on the treatment kardex, care plan and implemented as part of the plan of care.
IV. Quality Assurance & Improvements with On-going Monitoring:
The facility?s compliance in the prevention of pressure ulcers, timely identification, documentation, treatment and monitoring of pressure ulcers will be completed utilizing the following quality assurance system:
1. All new PUs will be reported to the Director of Nursing and/or designee and put on 24-hour report.
All new PUs will be documented and investigated timely to determine the root cause of the development of the PU, if it was unavoidable, if the Braden Skin assessment was completed and protocols initiated timely.
Inconsistencies will be immediately corrected.
PU investigations will be reported and reviewed at the monthly QAPI meeting. Results of the PU investigations will be track and trended to determine if subsequent changes in policies are necessary or if the PU Audit Tool should be revised based on findings.
2. Random audits will be conducted using the PU Audit Tool to determine if residents with pressure sores and/or those at high risk for pressure ulcer development are appropriately treated.

The facility will utilize the PU Audit Tool to monitor that all residents with pressure sores are receiving:
- Accurate treatment in accordance with the Physician?s Order
- Correct treatment is in place upon observation of the resident
- Treatment is accurately reflected on the Treatment Kardex and in the CCP
Inconsistencies will be immediately corrected.
The ADNS/designee will be responsible for auditing a minimum of 20% of all residents with pressure ulcers and those residents at high risk for pressure ulcer development on a monthly basis until 100% accuracy is obtained throughout the house.
After full compliance is obtained 5% of all new admissions, residents with PUs and those at high risk for PU development will be audited on a quarterly basis to determine consistency in implementation. Audit data will be tracked, trended and reported to the QA Committee.
V. Date and person responsible for completion of P(NAME):
Completion Date: [DATE]
Responsibility: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver (s) to be continued. Include your request for renewal of this waiver or plan of correction in the space provided on this form. The West Building (Old Bldg.) is two stories, fully sprinklered, and is Type V (000) construction. The building should be at least Type V (111) construction. 483.70(a), 711.2(a)(1), NFPA [PHONE NUMBER]: 19.1.6.2

Plan of Correction: ApprovedAugust 31, 2018

K 161 ? NFPA 101 Building Construction Type and Height 2012 Existing
Formerly K-012 Building type v (000). Hilaire Rehab and Nursing is requesting that the waiver on file be continued in accord with the recommendation from the DOH plan of correction dated 8/31/18.

K307 NFPA 101:CORRIDOR - DOORS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not ensure that a door protecting a corridor opening was provided with a means suitable for keeping the door closed and was maintained to resist the passage of smoke. Additionally, the facility did not ensure that there was no impediment to the closing of corridor doors. This was noted on 1 of 2 resident sleeping floors in 2 of 2 nursing home buildings. The findings are: During the Life Safety Code survey conducted on 08/09/18 between 9:00am and 12:00pm the following was noted: 1. The horizontal sliding corridor door to the recreation storage closet on the 2nd floor of the West building was not provided with the means suitable for keeping the door closed. There was no approved latching device or other device to keep the door in the closed position or from rebounding. Additionally, the door undercut was noted to be greater than one inch (approximately1.25inches). This would not prevent the passage of smoke. 2. The corridor door to resident room 207 of the 2nd floor East building jammed on the floor and was difficult to close. 3. One of two corridor doors to the dining room located on the 2nd floor of the West building jammed on the floor and was difficult to close. In consecutive interviews on the same day at approximately 10:15am and 10:30am, the Director of Environmental Services stated that the doors would be adjusted for any impediments to closing and that the recreation storage closet door would be addressed for compliance. 2012NFPA101: 7.2.1.9, 19.3.6.3.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 31, 2018

K 363 ? NFPA 101 Corridor - Doors
A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. - The Maintenance Director/designee will install an approved latching device for the recreation closet on the 2nd floor. Additionally, the Maintenance Director/designee will replace the recreation closet door so that the undercut is not greater than 1.
- The Maintenance Director/designee will assess the corridor door to room 207 and the corridor door to the dining room on the 2nd floor of west building and rectify jamming issue.
- The Director of Maintenance will assess all doors to ensure that they close without jamming.
- The Director of Maintenance will conduct on-going monthly audits on 50% of all corridor doors to ensure that they close without issue. Maintenance Director will resolve any issues as they arise.
D. The Maintenance Director will report monthly audit findings at the quarterly QA/QAPI meeting.
E. The Maintenance Director is responsible for the correction of this deficiency.

DEVELOP EP PLAN, REVIEW AND UPDATE ANNUALLY

REGULATION: The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

Based on documentation review and staff interview during the recertification survey, the facility did not develop and maintain an Emergency Program (EP) that included all of the required elements under the standard, and the EP was not updated at least annually. The findings are: During a review of the facility's emergency preparedness manual on 08/10/18 between 10:00am and 11:00am, it was noted that the plan did not address all the required elements under the standard and was not updated at least annually. The facility did not address the following items (not all inclusive): - Annual updates that documented accurate facility-based and community-based risk assessments. There was no current hazard vulnerability assessment. - Process for EP collaboration. No policy for collaboration and contact with local, Regional, State, Federal EP officials etc. The plan included a list of emergency official contacts but no policy for collaboration. - Development of EP Policies and Procedures for all risks assessed. - Policy for subsistence needs for staff and residents as far as maintaining temperatures to protect patient health and safety. The facility's policy did not address the lack of an alternate source of energy to maintain temperatures during a heat advisory. The generator plan did not list any Air-conditioning on the system or did not include the procurement of an emergency back-up generator or A/C systems for the building. The plan did not establish any cooling zones in the bulding. - Policy for an alternate means of communication with external sources of assistance. - Policy for arrangement with other healthcare facilities to maintain the continuity of services to evacuated residents. There were no transfer and transportation agreements provided. - Policy and Procedures for Volunteers in addressing surge needs that includes the process and roles for integrating State and Federally designated health care professionals. - Names and contact information for Staff, Residents Physicians, other LTC facilities, and volunteers. - Method for Sharing Information and medical documentation for residents with other health care providers to maintain the continuity of care. - Policy for emergency preparation testing and training. No staff in-service or drill records provided for (YEAR). - Policy to address the lack of an onsite storage of an alternate fuel source sufficient to allow full output of the Essential Electric System (ESS). The natural gas for the facility's generator is supplied by a utility company. In an interview on the same day at approximately 11:15am, the Administrator stated that the emergency plan is a work in progress and that all the identified areas of concern would be addressed in a revised plan.

Plan of Correction: ApprovedAugust 31, 2018

E 004 ? Develop EP Plan, Review and Update Annually
A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. - The Administrator and Director of Maintenance will revise and amend the emergency plan for the facility to include all of the required elements set forth by the NYSDOH. A hard copy will be delivered to the DOH office prior to P(NAME) completion dates.
- The Director of Maintenance will be responsible for updating the manual on an as needed basis but no less than annually.
- The Director of Nursing or designee will provide in-service to pertinent staff on any changes to EP manual.
D. The Director of Maintenance will report any revisions to the EP at the quarterly QA meetings.
E. The Administrator and Director of Maintenance are responsible for the correction of this deficiency.

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 minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver (s) to be continued. Include your request for renewal of this waiver or plan of correction in the space provided on this form. The ramp on the 2nd floor between the East and West buildings has a slope ranging from 1:8 to 1:10. Existing ramps are only permitted to be 1:10. 483.70(a)(1), 711.2(a)(1), NFPA [PHONE NUMBER]: 7.2.5.2

Plan of Correction: ApprovedAugust 31, 2018

K 271 - NFPA 101 Discharge from Exits
Formerly K-038 ramp. Hilaire Rehab and Nursing is requesting a continuation with the waiver on file for this deficiency in accord with the recommendation from the DOH plan of correction dated 8/31/18.


K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the facility did not ensure the following: 1. That the approved UL listed power strip was used for movable patient care related electrical equipment (PCREE). 2. That the power strip that is used for PCREE is not used for a non-PCREE device. 3. That an extension cord was not used as a substitute for fixed wiring. This was noted in a resident room in 1 of 2 buildings. The findings are: During the LSC survey conducted on 08/09/18 at approximately 10:20am, the following was noted in resident room [ROOM NUMBER]W2 of the West building: 1. A power strip of undetermined UL listing was used to plug in an electrical extension cord that was used to connect a fan and an Oxygen concentrator. A resident was noted in the room and was being administered oxygen from the Oxygen Concentrator at the time of the observation. In an interview at this time, the Director of Environmental Services stated that a family member may have brought in the power strip and extension cord. He took note of the issue and stated that extra outlets would be provided in the room. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 10NYCRR 711.2(a)(1) 10 NYCRR 415.29 2012NFPA101: NYCRR 711.2(a)

Plan of Correction: ApprovedAugust 31, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 920 ? NFPA 101 Electrical Equipment ? Power cords and extension cords
A. No residents were affected by the deficient practice. The power strip in room [ROOM NUMBER]W2 was immediately removed by the Director of Maintenance.
B. All residents have the potential to be affected by the deficient practice. The maintenance department surveyed the entire facility for any other
unauthorized/improper power strips. None were found.
C - The DNS or designee will provide in-service to all staff on power strips and extension cords. Specifically, staff must remove and report all extension cords that they find. All power strips must be provided by maintenance in accordance with acceptable standards and for specific uses.
- Maintenance Director/designee will conduct weekly rounds to ensure there are no extension cords or improperly used power strips on 50% of all rooms for the first month and 25% of rooms monthly, thereafter.
- The Administrator will amend Admission paperwork to include the phrase, Extension cords are strictly prohibited. Please speak with the Maintenance Director if you feel you need a power strip for yourself or your loved one.
D. The Maintenance Director will report findings of audit to the quarterly QA/QAPI meetings.
E. The Maintenance Director is responsible for the correction of this deficiency.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1999 NFPA 99, Standard for Health Care Facilities section ,[DATE].3.2 requires that free standing nursing homes have a Type 2 Essential Electrical System unless they meet all of the requirements of the listed exception. The exception to ,[DATE].3.2 allows a Type 3 Essential Electrical Systems provided that the facility has specific written admitting and discharge policies and procedures that preclude the provision of care for any patient or resident who needs to be sustained on electrical life support, offers no surgical treatment requiring general anesthesia, and provides an automatic battery-powered system or equipment that will be effective at least 1.5-hours and otherwise in accordance with NFPA 101, Life Safety Code , and NFPA 70 , National Electrical Code , and that will be capable of supplying light of at least 1-foot candle to exit lights, exit corridors, stairways, nursing stations, medication preparation areas, boiler rooms, and communications areas. This system must also supply power to operate all alarms systems. NFPA 99 section ,[DATE].1.2.2 (a) (5) specifically requires that Local, master, and area alarms that are components of the medical gas warning system shall be powered from the life safety branch of the emergency system as described in Chapter 3, Electrical Systems. In addition, NFPA 99 section ,[DATE].2.2.3 requires the design, arrangement, and installation of wiring for the Type 3 Essential Electrical System is in compliance with the requirements of NFPA 70, National Electrical Code. Article ,[DATE] (d) of NFPA 70 requires that a separate automatic transfer switch be provided for NFPA 70 Article 700 Emergency Stem loads (e.g., fire alarm, emergency lighting) only and that separate automatic transfer switches would be needed to serve Non- Article 700 loads (e.g., loads that are not essential to safety to human life such as Article 701 Legally Required Standby Systems loads and Article 702 Optional Standby Systems loads). NFPA 70 Article ,[DATE] (b) states that: Unless otherwise permitted in (1) through (4), wiring from an emergency source or emergency source distribution overcurrent protection to emergency loads shall be kept entirely independent of all other wiring and equipment. Wiring of two or more emergency circuits supplied from the same source shall be permitted in the same raceway, cable, box, or cabinet. 1. The normal power source wiring shall be permitted to be located in transfer equipment enclosures. 2. In exit or emergency lighting fixtures, wiring supplied from two sources shall be permitted. 3. In a common junction box, attached to exit or emergency lighting fixtures, wiring supplied from two sources shall be permitted. 4. The wiring within a common junction box attached to unit equipment, containing only the branch circuit supplying the unit equipment and the emergency circuit supplied by the unit equipment shall be permitted. NFPA 70 Article 701 Legally Required Standby Systems are those systems required and so classed as legally required standby by municipal, state, federal, or other codes or by any governmental agency having jurisdiction. These systems are intended to automatically supply power to selected loads (other than those classed as emergency systems) in the event of failure of the normal source. Legally required standby systems are typically installed to serve loads, such as heating and refrigeration systems, communications systems, ventilation and smoke removal systems, sewerage disposal, lighting systems, and industrial processes, that, when stopped during any interruption of the normal electrical supply, could create hazards or hamper rescue or fire-fighting operations. The legally required standby system wiring shall be permitted to occupy the same raceways, cables, boxes, and cabinets with other general wiring. NFPA 70 Article 702 Optional Standby Systems are intended to protect public or private facilities or property where life safety does not depend on the performance of the system. Optional standby systems are intended to supply on-site generated power to selected loads either automatically or manually. The optional standby system wiring shall be permitted to occupy the same raceways, cables, boxes, and cabinets with other general wiring. This requirement is not met as evidenced by: Based on observations, document review (i.e., posted electrical panel schedules), and staff interviews during the recertification survey, the nursing facility was not provided with a 1999 NFPA 99 - Health Care Facilities and NFPA 70 - National Electrical Code conforming Type 3 Essential Electrical System (EES). Emergency power and lighting in most areas was provided via a generator and the installation was not in full accordance with NFPA 70 - Article 700 Emergency Systems and NFPA 110 - Emergency Power Systems. A Time Limited Waiver for this issue expired on [DATE] and the facility did not fully correct this issue. The findings are: In an interview on [DATE] at approximately 09:30am, the Director of Environmental Services stated that the work to separate the branches of the EES has started and has not been completed. In a separate interview on the same day at approximately 12:45pm, the Administrator stated that she filed for an extension to the time limited waiver and is awaiting a reply. The facility was previously cited for not maintaining a confirming NFPA 99 - Health Care Facilities and NFPA 70 - National Electrical Code conforming Type 3 Essential Electrical System (EES). Examples included: 1. The generator set single transfer switch served both Emergency System loads and non-Emergency System loads. 2. Article 700 - Emergency System wiring was not completely independent of all other wiring and equipment. Examples included: - Emergency power panel board 2A located in a basement electrical room in Building #2 - East Building, this panel served both Article 700 - Emergency System loads (e.g., South Exit Stair lights) and Non-Article 700 - Emergency System loads (e.g., air conditioner). - The panel directory for emergency power panel board 3A located in a basement electrical room in Building #2 - East Building panel served both Article 700 - Emergency System loads (e.g., the building ' s fire alarm system, emergency stairway lighting, elevator lights and Non-Article 700 - Emergency System loads (e.g., the boiler, and circulator pumps). - The panel directory for emergency power panel board 2 located in a basement electrical room in Building #2 -East Building, served both Article 700 - Emergency System loads (e.g., exit signs, corridor lights, exterior exit discharge lighting, the phone system) and Non-Article 700 - Emergency System loads (e.g., heating system controls). During the LSC tours on the same day between 9:00am -12:30pm, it was noted that the facility had made progress in installing the electrical panels on the floors. A second transfer switch was not installed and connected at the time of the survey. NFPA ,[DATE] Standard for Health Care Facilities: ,[DATE].3.2 Exception , ,[DATE], ,[DATE].2.2.3, ,[DATE].1.1, NFPA ,[DATE] National Electrical Code: Articles ,[DATE], 700, 701, 702, NFPA [PHONE NUMBER] Standard for Emergency and Standby Power Systems NYCRR711.2 (a) (1) 10NYCRR, 415.29

Plan of Correction: ApprovedAugust 31, 2018

K 915 ? NFPA 101 Electrical Systems ? Essential Electrical System Categories
A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. - The Administrator will immediately contact the electrical/generator vendor to have them come and complete the partially completed task. Specifically:
NFPA 70 requires that a separate automatic transfer switch be provided for NFPA 70 Article 700 Emergency Stem loads (e.g., fire alarm, emergency lighting) only and that separate automatic transfer switches would be needed to serve Non-Article 700 loads (e.g., loads that are not essential to safety to human life such as Article 701 Legally Required Standby Systems loads and Article 702 Optional Standby Systems loads). NFPA 70 Article 700-9 (b) states that: Unless otherwise permitted in (1) through (4), wiring from an emergency source or emergency source distribution over-current protection to emergency loads shall be kept entirely independent of all other wiring and equipment. Wiring of two or more emergency circuits supplied from the same source shall be permitted in the same raceway, cable, box, or cabinet.
- The Administrator will speak with the vendor and have him read the regulation to ensure his understanding of the project.
- The Administrator will dictate a timeframe and will ensure that the vendor understands the necessity of completion for this project within the time frame.
D. The Administrator will report progress or completion of project at the next QA/QAPI meeting.
E. The Administrator is responsible for the correction of this deficiency.

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

2012 NFPA 101: 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This requirement is not met as evidenced by: Based on observation, staff interview and record review during the recertification survey, the facility did not ensure that fire drill times and dates were varied within the last twelve months. The findings are: During a documentation review of the fire drill records for the last twelve months on 08/10/18 at approximately 12:15pm, the following was noted: 1. Evening and night fire drill times were now varied and took place at similar times. Examples included: Evening drills: 4/30/18 - 3:25pm 1/31/18 - 3:43pm 10/26/17- 3:45pm 7/27/17- 4:40pm Night Drills: 05/19/18-11:30pm 11/09/18- 11:10pm 08/30/18-11:45pm 2. The fire drill dates were not varied. Examples included the following: - 06/29/18 - 05/29/18 - 04/30/18 - 03/29/18 - 12/29/17 - 09/28/17 - 08/30/17 In an interview on the same day at approximately 2:30pm, the Director of environmental Services stated that the planned fire drill schedule would be changed to reflect a varying of times and dates. 2012 NFPA 101: 19.7.1.6 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 31, 2018

K 712 ? NFPA 101 Fire Drills
A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. - The Director of Maintenance will conduct fire drills on all three shifts and alternate the times within the shifts, as well as the dates within the month.
- The Administrator will review the proposed times and dates of the fire drills with the Director of Maintenance to ensure randomization of dates and times.
- The Administrator will review the fire drill log book on a quarterly basis to ensure fire drills have been scheduled and executed on random times/dates.
D. The Administrator will report the findings of his quarterly fire drill log audit at the quarterly QA/QAPI meeting.
E. The Administrator and Director of Maintenance are responsible for the correction of this deficiency.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not ensure that means of egress was maintained free of all obstructions and was provided with a level walking surface. This was noted for 2 of 2 emergency exit stairwell discharges in the West building (not all inclusive). The findings are: During the LSC survey conducted on 08/09/18 and on 08/10/18 at between 9:00am and 2:00pm, the following was noted: 1. The emergency exit discharge that serves the 1West Out stairwell was noted with two cracked and uneven areas along the path to public way. Additionally, there were overgrown shrubs in one area along the path to public way. 2. The emergency exit discharge that serves the 7W2 room was noted to be cracked and uneven in most areas of the path to public way. In an interview on 08/10/18 at approximately 1:45pm, the Director of Environmental Services stated the cracked uneven surfaces for the identified emergency exit discharges would be addressed. He further stated that the overgrown shrubs were cut away from the egress path. 2012NFPA101: 7.1.10.1, 19.2.1, 19.2.11, NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 31, 2018

K 211 ? Means of Egress - General
A. No residents were affected by the deficient practice. The overgrown shrubs were immediately cut away from the path by the maintenance director.
B. All residents who use, or would have to use emergency exit 1 west out stairwell or 7W2 exit have the potential be affected by the deficient practice.
C. - The maintenance worker/designee will restore the cracked and uneven surfaces along the path of these exits.
- The maintenance worker will trim all shrubs along the path to ensure there is a clear egress from these exits.
- The Director of Maintenance will do on-going weekly observational audits of all emergency exit egress paths (100% of them) to ensure level and clear walking surfaces. The Director of Maintenance will resolve any issues that he identifies as they occur.
D. The Director of Maintenance will report findings of the weekly audit at the quarterly QA/QAPI meetings.
E. The Director of Maintenance is responsible for the correction of this deficiency.

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure the nursing home building was maintained to provide a safe and comfortable environment for residents, personnel and the public. Reference is made to the following: 1. The disrepair condition of the corridor flooring tiles on 1 of 2 floors of the East Building. 2. The non-functional ventilation system in the main kitchen. The findings are: During the tours of the resident floors and the main kitchen on 08/09/18 between 12:00pm the following was noted: 1. The corridor floor tiles on the 2nd floor of the North wing of the East building was noted to be raised and buckling in some areas in between room [ROOM NUMBER] and the set of smoke barrier doors separating the North and South wings. In an interview on the same day at approximately 9:45am, the Director of Environmental Services stated that the floor tiles will need to be replaced. 2. During a tour of the main kitchen located on the ground floor, it was noted that the ventilation system was not in operation. Two portable fans were noted in use in the kitchen. In a separate interview on the same day at approximately 11:30am, the Director of Environmental Services stated that he is not aware if there is an issue with the kitchen ventilation system and that it would be looked into. 10 CRR-NY 415.29

Plan of Correction: ApprovedAugust 31, 2018

I 310 ? Physical Environment
A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. - The Maintenance Director/designee will replace the flooring on the 2nd floor of the north wing of the east building.
- The Maintenance Director/designee will evaluate the ventilator system in the kitchen. He will repair if possible, or contact a ventilation company for assistance if necessary.
- The Maintenance Director/designee will make monthly walking rounds of entire facility to assess flooring and ensure surfaces are in good repair. He will rectify any issues as they occur.
- The Administrator instructed the Dietary Director to report any issues with ventilation immediately to Administrator and Director of Maintenance for immediate resolution.
D. - The Director of Maintenance will report findings of monthly flooring audit at the quarterly QA/QAPI meetings.
- The Administrator will report any ventilator issues in the kitchen at the quarterly QA/QAPI meeting.
E. The Director of Maintenance is responsible for the correction of this deficiency.