Promenade Rehabilitation and Health Care Center
April 24, 2017 Certification Survey

Standard Health Citations

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 2, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey the facility did not ensure that each resident received care in a manner that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality for 2 of 4 residents reviewed for Dignity from a total Stage 2 sample of 32 residents. Specifically, 1) Resident #125 was observed in bed on multiple occasions wearing a hospital gown during the day; and 2) Resident #188's Certified Nurses Assistant (CNA) was observed feeding the resident lunch while standing by the side of the resident. The findings are: 1) Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/25/2017 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score due to severely impaired skills for daily decision making and no speech. The MDS documented that the resident required total care for all areas of Activities of Daily Living (ADLs). A Comprehensive Care Plan (CCP) titled Self Care Deficit Related to [MEDICAL CONDITION], Dementia, Gastrostomy Status, dated 7/1/2016, documented a goal that the resident will maintain a sense of dignity by being clean, dry, odor free, well-groomed, safe, and dressed appropriately. On 4/18/2017 at 12:23 PM and on 4/20/2017 at 12:20 PM Resident #125 was observed in bed. On both occasions the resident was wearing a hospital gown. On 4/20/2017 at 12:23 PM Resident #125's Certified Nursing Assistant (CNA) was interviewed. He stated that the resident always has a hospital gown on. The CNA stated that he was not sure why the resident did not have clothing. The CNA stated that he had never seen the resident wear clothing. On 4/20/2017 at 12:25 PM Resident #125's closet was observed with the CNA. No clothing was observed hanging in the closet. The CNA stated that there were just blankets in the closet. The CNA did not open the lower drawer in the closet. On 4/21/2017 at 11:07 AM the Registered Nurse (RN) Unit Supervisor was interviewed. She stated that Resident #125 does have clothing. On 4/21/2017 at 11:08 AM the resident's closet was observed with the RN. The RN opened the resident's closet and then opened a drawer at the bottom of the closet where clothing was observed. On 4/21/2017 at 11:08 AM the resident was observed out of bed in a geri-chair and was dressed. On 4/21/2017 at 12:45 PM the Director of Nursing Services (DNS) was interviewed. She stated residents are supposed to be dressed every day. She stated she was not sure why the CNA said the resident did not have clothing.
2) Resident #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) Assessments dated 10/27/16, 12/1/16 and 3/3/17 documented that the resident had impaired memory and severely impaired decision making skills. The MDSs also documented that the resident required total assistance for transfers, dressing and eating. A Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) dated 8/2/16 documented that the resident required extensive assist of one person for eating. Resident #188 was observed during the Lunch meal in the unit dining room on 4/18/17 at 12:30 PM. The resident was seated in a Geri recliner chair while being fed by a CNA. The CNA stood by Resident #188's side from 12:30 PM to 12:50 PM and fed the resident. The CNA sat down from 12:50 PM to 12:54 PM and completed the feeding. The unit Licensed Practical Nurse (LPN) was interviewed on 04/20/17 at 1:10 PM. The LPN stated that staff should be seated while feeding. She also stated that the CNA who fed Resident #188 is an agency CNA but is regularly assigned to care for Resident #188. The LPN stated that they noticed that the CNA stood while feeding the resident on 4/18/17 and tried to tell her discreetly to sit down because they did not want to offend her. The CNA was interviewed on 04/21/17 at 1:00 PM. The CNA stated that she is assigned to care for the resident, 3-4 days a week. She stated that the resident's care includes feeding her and that, I should have sat down, sometimes I struggle to reach her, I should have pulled the chair closer to her. 415.5(a)

Plan of Correction: ApprovedMay 11, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I Immediate Corrections:
Res # 125
1. The DNS identified the CNA who cared for the resident on 4/20/17 and provided the CNA with an educational counseling relative to Dignity and appropriate clothing for this resident. A copy was filed for reference and validation.
2. The DNS in conjunction with the RN and Licensed Nurses informed all CNAs on all shifts where this residents clothing is kept as well as the expectation of appropriate dress daily.
3. The residents CNA plan was revised to reflect a directive for OOB and fully dressed daily
3. Presently, the resident is OOB and appropriately dressed per plan, and the Charge Nurse will monitor compliance daily.
II. Identification of Other Residents:
A.1. The DNS in conjunction with Licensed Nurses and CNAs checked all residents on all units to ensure they were adequately dressed.
2.Any resident identified not dressed properly will be reviewed with the Charge Nurse and CNA staff to ensure clothing is available.
3. Any resident identified without adequate clothing will be referred to the Social Worker in order to order clothes or notify family regarding additional clothing needs.
III. Systemic Changes:
A.1. The CNAs and Licensed Nurses will be inserviced by the DNS and/or RN staff regarding Dignity with a concentration on adequate dressing daily.
2. The Lesson Plan will concentrate on the following:
* Overview of F241 and resident Dignity
* Facility policy to dress residents daily
* Reminder of where clothing is kept
* Communication to the Nurse if clothing is worn, damaged or not available
3. A copy of the Lesson Plan and attendance will be retained for validation.
B. 1.The CNAs and Licensed Nurses will be inserviced by the DNS/ADNS regarding criteria to follow for Speech Therapy consults as well as following the plan of care for residents who require feeding assistance.
2. The Lesson Plan will concentrate on the following:
* Criteria for Speech Therapy Consults
* Review and communication to the MD regarding the consult
* Documentation on the CCP and CNA plan regarding directives for feeding
3. A copy of the Lesson Plan and attendance will be retained for validation.
IV. QA Monitoring:
1. The DNS has developed an audit tool to monitor the dressing of residents, as well as CNA compliance in following the plan of care.
2. Audits will be done on each unit by the RN Charge Nurse/LPN daily over the next month, then weekly to ensure residents are appropriately dressed and groomed.
3. Audits with negative findings will have immediate corrective actions implemented by the Licensed Nurse and the DNS will be informed.
4. Audit findings will be presented at the monthly QA Meetings for evaluation and continuance as needed.
Res. #188
I Immediate Corrections:
1. The Administrator and the DNS did a comprehensive review regarding the Speech Therapists consult. Based on this review the following corrective actions were implemented:
* The Speech Therapist was terminated from the Facility and another Speech Therapist was contracted.
* The Admitting Nurse was counseled by the DNS for not following up on a Speech therapy screen on readmission in view of residents prior history
* The CNA who failed to sit while feeding was counseled by the DNS
* The CNA plan was immediately revised to reflect a directive to sit while feeding the resident
2a. The resident was seen and evaluated by the new speech therapist on 4/21/17 and directives were suggested to position the resident upright during feeding and for 30 minutes after eating to prevent aspiration.
b. The Speech Therapist placed the resident on Speech Therapy 5 days a week, and the MD provided an order for [REDACTED].
3. The Facility held a special review CCP meeting to revise the plan of care and CNA plan to include speech therapy directives for feeding and positioning.
II. Identification of Other Residents:
A.1.a The DNS and Charge Nurses conducted comprehensive meal observation for all meals to ensure staff were feeding residents with dignity while seated.
b. There were no additional quality issues identified from this observation.
2. The DNS ran a computer list of all residents who had Speech Therapy Consults in the past month for swallowing evaluations.
3. This list was used to review the EMR documentation and CCP/CNA plan to ensure appropriate directives have been developed for feeding and positioning .
4. Any quality issues identified by this review will have corrective actions implemented by the Charge Nurses.
III. Systemic Changes:
1.a The DNS and or RNs will inservice all CNAs regarding following the plan of care specific for feeding directives.
b. The Lesson Plan will concentrate on the following:
* Awareness of ST consults and recommendations
* Directives for feeding and positioning
* Following directives on the CNA plan and CCP
c. A copy of the Lesson Plan and attendance will be filed for reference and validation
2. All licensed Nurses will be inserviced by the DNS/ADNS regarding criteria for Speech Therapy Consults including:
* MD orders for Speech Therapy Consults
* MD follow up and documentation
* Nursing documentation ie Progress notes
* Specific CCP and CNA directives relative to Speech Therapy Consults
3. A copy of the Lesson Plan and attendance will be filed for reference and validation
IV. QA Monitoring:
A.1. The DNS has developed an audit tool to monitor meal provision and staff compliance while feeding residents.
2.Audits will be done by the Licensed Nurses during meals on each unit daily for a month then random units thereafter
3. Audits with quality issues identified will have onsite immediate corrections by the Nurse as needed
4.Audit findings will be presented to the QA Committee monthly for evaluation and continuance.
Date of Completion:
Responsible Party: DNS

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 2, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during a Recertification Survey, the facility did not ensure that residents who use [MEDICAL CONDITION] medications receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This was noted for one of five residents reviewed for unnecessary medications in a total of 32 Stage 2 residents. Specifically, for Resident #25, a dose reduction for Klonopin (medication used for Anxiety) recommended by the Pharmacist and approved by the Physician was not implemented. The finding is: Resident #25 was originally admitted to the facility in 2002 and has [DIAGNOSES REDACTED]. The Physician ordered Klonopin 0.5 milligrams (mg) at night since 3/8/16 for Anxiety, [MEDICATION NAME] 7.5 mg at night since 1/29/15 for Depression, and [MEDICATION NAME] 300 mg every 12 hrs since 5/27/16 for [MEDICAL CONDITION]. A Psychiatry Consultation Report dated 10/7/16 documented a plan/recommendation to lower Klonopin to 0.25 mg at night and continue the other Psychoactive medications. The Consult was signed as approved by the Physician on 10/17/16. A Psychiatry Consultation Report dated 3/29/17 documented that the dosage reduction was attempted in the last 4-6 months. A review of the Comprehensive Care Plan, physician's orders [REDACTED]. The unit Registered Nurse (RN) Supervisor was interviewed on 4/24/17 at 10:20 AM and stated she did not know why the dose was not reduced. She further stated that up until (MONTH) or (MONTH) (YEAR) the Consultants were supposed to write their own orders. The Physician was interviewed on 04/24/17 at 11:24 AM and stated that she had agreed with the Psychiatrist's recommendations dated 10/7/16. She further stated that she did not know why the order to reduce Klonopin was not documented. The Physician added that at that point in time the Psychiatrist was writing the orders himself. She stated that, we have changed the policy now and the Consultants do not put in their own orders into the computer any more. The Psychiatrist who completed the Consultation Report dated 10/7/16 could not be interviewed. The Psychiatrist who completed the Consultation Report dated 3/29/17 was interviewed on 04/24/17 at 11:49 AM. He stated that when he completed the consult he only had the past Psychiatry consults to review and he did not have access to the physician's orders [REDACTED]. He stated that he assumed that the recommendations from the Psychiatry Consultation report dated 10/7/16 had been implemented. The Director of Nursing Services (DNS) was interviewed on 04/24/17 at 12:16 PM and stated that she started working in the facility in (MONTH) (YEAR) and she saw that Consultants were writing their own orders. She stated that the facility changed the practice. The DNS stated that now if the Physician agrees with the Consultant's recommendations, they have to write their own orders. 415.12(l)(1)

Plan of Correction: ApprovedMay 11, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrections:
Resident #25
1. The Medical Director reviewed these findings as well as completed a comprehensive chart review. Based on that review the following corrections were implemented:
* An additional Psych Consult was done 5/5/17
* The Klonopin was reduced from 1mg to 0.25mg daily, by the Attending MD
* A progress note was documented by the Attending MD to validate the reduction and plan for monitoring
* The CCP for Klonopin was revised to reflect the reduction.
II. Identification of Other Residents:
1. The DNS compiled a list of all residents on psych meds for the past month who were seen by Psych.
2. This list was used by the Medical Director and DNS to do a comprehensive chart review and also review the Pharmacy regimen review to ensure all directives were followed.
3. Any quality issue identified by this review will warrant immediate notification and follow up with the Attending MD.
4. The DNS will maintain a list of any negative findings and corrections relative to this review.
III. Systemic Changes
1. The Medical Director will reeducate all the Attending MDs regarding requirements for dose reduction of Psych meds and following the Psych recommendations.
2. The Lesson Plan will concentrate on the following:
* MD responsibility to review the Psych consults, sign same and write orders if indicated
* Criteria for dose reduction of Psych meds and required documentation
3. A copy of the Lesson Plan and Attendance will be filed for reference and validation.
IV. QA Monitoring:
1.The Medical Director has developed an audit tool to track compliance with Psych Consults and Attending MD follow up and documentation.
2. Audits will be done over the next month by the Medical Director and /or assigned RNs on all Psych Consults relative to [MEDICAL CONDITION] use to ensure recommendations are followed and documented. Audits will also be reviewed by the Pharmacy Consultant.
3. Audits with negative findings will have immediate corrective actions implemented by the Attending Physician as needed.
4. Audit findings will be reported to the QA Committee monthly for evaluation and continuance over the next quarter .
Date of Completion:
Responsible Party: Medical Director

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 2, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey the facility did not ensure that staff practices were consistent with current infection control principles and that those practices prevent cross contamination. This was identified for 1 of 3 residents reviewed for Pressure Ulcers from a total Stage 2 sample of 32 residents. Specifically, Resident #59 was on contact precautions. During the wound care observation for Resident #59 the Registered Nurse (RN) providing the wound care and the Licensed Practical Nurse (LPN) assisting were not wearing gowns when they were positioning the resident and touching the bed and sheets. In addition, during wound care the RN did not perform hand hygiene after cleansing and dressing the sacrum wound, and then proceeded to perform treatment to the right hip wound. The finding is: Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/9/2017 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview of Mental Status (BIMS) score due to severely impaired cognitive skills for daily decision making. The MDS documented that the resident required total care for all areas of activities of daily living (ADLs), was at risk for developing pressure ulcers, and currently had pressure ulcers. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) titled Impaired Skin Integrity--Unstageable Right Hip, dated 2/13/2017, had an intervention to maintain infection control policy and procedures when providing wound care. A Comprehensive Care Plan (CCP) titled Impaired Skin Integrity--Unstageable Sacral, dated 12/1/2016, had an intervention to maintain infection control policy and procedures when providing wound care. On 4/21/2017 at 9:51 AM the wound care treatment to Resident #59's sacral pressure ulcer and right hip pressure ulcer was observed. The wound care was performed by the RN Charge Nurse who was assisted by a LPN medication nurse. The two nurses began positioning the resident in bed for the wound care treatment. They were observed with gloved hands touching the resident, the sheets, and the bed, however they were not wearing gowns. The nurses were asked if gowns were needed because the resident is on contact precautions. At this time the RN instructed the LPN to get two gowns from the isolation cart outside of the room. The LPN returned with the gowns and the nurses put them on. After donning the gowns and positioning the resident, the RN removed the sacrum wound dressing and cleansed the wound with normal saline. The sacrum wound was observed to be approximately 10 centimeters (cm) by 10 cm by 1 cm. There was a moderate amount of serosanguinous drainage, and no signs and symptoms of infection were noted. The LPN, who was holding the resident in place on his side, allowed the resident to lie back thus causing the open sacrum wound to come in contact with the bed sheets. The RN then had to re-cleanse the wound and instructed the LPN to hold the resident in place. After the RN had cleansed the sacrum wound she applied Santyl and the dry protective dressing but did not perform hand hygiene (no hand hygiene after cleaning the wound and proceeding to apply the wound treatment). After the sacrum wound was dressed, the RN then proceeded to the right hip wound. She removed the right hip dressing and cleansed the wound, the right hip wound was approximately 3 cm by 1 cm by 0.2 cm. There was a small amount of serosanguinous drainage and no signs and symptoms of infection; however, there was no hand hygiene performed since before the sacrum wound was cleaned. After the RN had cleansed the right hip wound she was asked about hand hygiene. She stated that she should have performed hand hygiene after cleansing the sacrum wound and that she forgot hand sanitizer. She then proceeded to wash her hands. On 4/21/2017 at 12:00 PM the Assistant Director of Nursing (ADON), who is also the Infection Control Nurse, was interviewed. She stated that gowns should have been worn, that the nurses were inserviced previously and will have to be re-inserviced. The facility's undated policy on Standard Precautions states that gowns are to be worn to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions or cause soiling of clothing. The facility's undated policy on Contact Precautions states that gowns are to be worn when it is anticipated that there will be substantial contact with resident's body fluids, if the resident is incontinent, had diarrhea, an ileostomy, colostomy, or if wound drainage is not contained by a dressing. 415.19(a)(1-3)

Plan of Correction: ApprovedMay 11, 2017

I. Immediate Corrections:
Resident #59
1.The DNS conducted a comprehensive chart review relative to Pressure Ulcer Care for this resident and Surveyor findings. Based on this review the following corrective actions were implemented:
* The DNS identified the 2 Nurses who performed the treatments on this resident on 4/21/17 and provided an educational counseling to both Nurses for the breech of Infection Control practices.
* The CCP was revised to add specific directives for Infection Control for pressure ulcer care
* The MD was contacted and ordered a follow up sputum culture to validate the continued presence of Pseudomonas and the need for continuing Precautions.
2. Presently the resident continues on precautions and Nurses are following all IC protocols for precautions and treatment when performing pressure ulcer care.
II. Identification of Other Residents:
A.1. The ADNS compiled a list of all residents with pressure sores and all resident on Contact precautions in order to ascertain compliance with Infection Control policies.
2. This list was used to do direct observation of Nurses by the ADNS/assigned RN during pressure sore treatments to ensure all Infection Control directives were followed, including maintaining precautions.
3. Any quality issues identified during these reviews will have immediate corrective actions and education as needed by the Auditor.
4.The ADNS/Designee will keep a list of any quality issues identified for ongoing auditing.
B. 1 The DNS/ADNS have reviewed the CCPs of all residents with pressure sore treatments to ensure appropriate Infection Control directives are in place.
2. Any care plans that need revision will have those revisions documented by the Auditor
III. Systemic Changes:
1.The DNS and ADNS reviewed the Infection Control Policies relative to pressure sore treatments and maintaining Contact Precautions and found same compliant.
2. All licensed Nurses will be reinserviced by the ADNS/Designee on Infection Control protocols including Care Plan directives.
3. The Lesson Plan will concentrate on the following:
* Developing and following the plan of care for Infection Control interventions
* Appropriate glove use including understanding when gloves are contaminated
* Criteria for PPE and Contact precautions
* Appropriate hand washing and when hands should be washed during care and treatments
3. A copy of the Lesson Plan and attendance will be filed for reference and validation
IV. QA Monitoring:
1. The ADNS has developed audit tools to monitor staff compliance with Infection Control protocols during pressure ulcer care and contact precautions.
2.Audits will be done on various shifts by the IC Nurse and assigned RN weekly on those residents to observe Pressure Sore treatments with contact precautions.
3.Audits with negative findings will have immediate corrective actions onsite by the auditor, with follow up as needed.
4. Audit findings will be presented to the QA Committee monthly for evaluation and continuance as needed.
Date of Completion:
Responsible Party: DNS

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 2, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review during the Recertification Survey, the facility did not ensure that each resident receives necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This was noted for one resident (Resident #188) in a Stage 2 sample of 32 residents reviewed. Specifically, for Resident #188, the facility did not put a care plan in place for safe feeding, including feeding in an upright position. The finding is: Resident #188 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. Resident #188 was hospitalized and readmitted on four occasions (9/28/16, 10/15/16, 11/18/16 and 12/21/16). Minimum Data Set (MDS) Assessments dated 10/27/16, 12/1/16 and 3/3/17 documented that the resident had impaired memory and severely impaired decision making skills. The MDSs also documented that the resident required total assistance for transfers, dressing and eating. The resident was observed being fed on 4/18/17 by CNA #1, on 4/19/17 by the resident's daughter and on 4/20/17 by CNA #2 in the unit dining room. On all three observations the resident was seated in a Geri recliner in a reclined position, at approximately 60 degrees visually. The resident was observed to cough on 4/18/17 and 4/20/17 during the feeding. CNA #2 was interviewed on 4/20/17 at 2:00 PM and stated that she is an Agency CNA and knows the resident because she has worked with the resident before. She stated that the resident is repositioned every 2 hours, the resident is fed in Geri recliner during meals but she has not been told to sit her upright during feeding. CNA #1 was interviewed on 04/21/17 at 1:00 PM. She stated that, we try to pull her up in the Geri recliner but she is always sliding as she is trying to move and reach stuff. She stated that the Geri recliner cannot go higher than 45 degrees. A Speech Pathology (SP) Consult report dated 9/13/16 recommended an upright body position, (90 degree angle) during feeding. A SP Consult report dated 10/5/16 recommended upright sitting posture (90 degree angle) only, during feeding. The Physician ordered a SP Consult which was completed on 4/20/17. The report documented to change the diet from Regular to Chopped texture, maintain upright sitting posture and aspiration precautions for feeding. A second SP Consult dated 4/21/17, completed by another Speech Pathologist, documented upright sitting position during and at least 30 minutes after feeding and aspiration precautions. The resident was started on Speech Therapy 5 times a week for Dysphagia (swallowing difficulty). The resident's Comprehensive Care Plan (CCP) was reviewed from (MONTH) (YEAR) to (MONTH) (YEAR). There was no documentation regarding upright positioning during feeding until 4/20/17. The Certified Nursing Assistant (CNA) information sheets for August, September, (MONTH) and (MONTH) (YEAR) updated through (MONTH) 10, (YEAR) documented Choking risk but no instructions for positioning while feeding until 4/20/17. The Director of Nursing Services (DNS) was interviewed on 4/20/17 at 10:00 AM and stated that the information from the SP Report should have been transferred to the CNA information sheets and CCP. The DNS also stated that the Admitting Nurse should have requested a Speech Therapy screen upon readmission. She also stated that the CCPs are to be initiated by admitting nurses and revised and updated by all nurses as necessary. The Occupational Therapy Director was interviewed on 04/24/17 at 9:36 AM and stated that a Geri recliner was recommended for Resident #188 upon her last readmission of 12/21/16. The OT stated that a Geri recliner was recommended because the resident was sliding out of a regular wheel chair due to bilateral amputation. She stated that the Recliner was started with a regular gel cushion which was later changed to a waffle pad cushion 5 days later, due to her inability to relieve pressure off her buttocks. She further stated the there was no referral received by their Department with any concerns related with positioning during feeding. 415.12

Plan of Correction: ApprovedMay 11, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions:
Resident #188
1. In conjunction with plan for F241, the DNS identified the staff responsible for developing the care plan as well as ensuring that the resident was properly positioned during feeding. Subsequently, the following corrective actions were implemented:
* The Admitting Nurse was counseled by the DNS for not following up on a Speech therapy screen on readmission in view of residents prior history
* The CNA who failed to sit while feeding was counseled by the DNS
* The CNA plan was immediately revised to reflect a directive to sit while feeding the resident
2a. The resident was seen and evaluated by the newly contracted speech therapist on 4/21/17 and directives were suggested to position the resident upright during feeding and for 30 minutes after eating to prevent aspiration.
b. The Speech Therapist placed the resident on Speech Therapy 5 days a week, and the MD provided an order for [REDACTED].
3. The Facility held a special review CCP meeting to revise the plan of care and CNA plan to include speech therapy directives for feeding and positioning.
II. Identification of Other Residents:
1. The DNS reviewed all Speech Therapy Consults done in the past month to review recommendations and compare same to the medical record to ensure the following:
* Recommendations made by the Speech Therapist were evaluated by the MD, and the CCP /CNA Plan was developed to reflect the Speech Therapy suggestions.
* There were no additional quality issues identified by this review
2. * The DNS and ADNS compiled list of all residents who are totally fed by staff.
* This list was used to check the CCP and CNA plan to ensure that plans were in place regarding level of assistance needed when feeding including sitting.
* This list was also used by the Licensed Nurses to do onsite meal passes with each meal to ensure all involved staff feeding residents are seated as per plan
* Any quality issues identified by this review will have immediate corrective actions by the Licensed Nurses.
III. Systemic Changes:
1. The DNS reviewed the Policy for care planning in conjunction with the Policy for Consults and carry over to the Care Plan and CNA plan.
2. The Policy was found compliant.
3. All licensed Nurses will be educated by the DNS/ADNS/DESIGNEE on the criteria to follow relative to Speech Therapy Consults and carry over directives to the CCP and CNA Plan
4.The Lesson Plan will concentrate on the following:
* MD orders for Speech Therapy Consults
* MD follow up and documentation
* Nursing documentation ie Progress notes
* Specific documentation on the CCP and CNA directives relative to Speech Therapy Consults, including feeding directives
3. A copy of the Lesson Plan and attendance will be filed for reference and validation
IV. QA Monitoring:
1.The DNS has developed an audit tool to track development of the CCP and CNA plan relative to Speech Consults.
2. Audits will be done by the ADNS/Licensed Nurses after any Speech Consult over the next month to ensure that the Consult was reviewed by the MD and there was a plan of care developed as indicated
3. Audits with quality issues will have onsite corrective actions implemented by the auditor.
4. Audit findings will be presented to the QA Committee monthly for evaluation and follow up as indicated.
Date of Completion:
Responsible Party: DNS

Standard Life Safety Code Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 2, 2017

Citation Details

2012 NFPA101:19.7.1.6 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. Based on observation, staff interview and documentation review, the facility failed to ensure that fire drills were conducted at intervals of one fire drill per quarter per shift. This was noted for the morning shift (7am to 3pm) for the year of (YEAR). The findings are: On 4/19/2017 between the hours of 9am and 3:30pm during the recertification survey the following was noted: During the time of the survey, the fire drill records were not accessible for review. In an interview on 4/19/2017 at approximately 3:30pm with the Director of Nursing, she stated she would submit documentation regarding the fire drills. Review of the documented fire drills revealed that only 2 fire drills were performed between the months from (MONTH) (YEAR) to (MONTH) (YEAR) for the morning shift (7am to 3pm). The recorded drills were conducted on 2/28/2017 at 2pm and on 8/15/2016 at 9:51am. This does not meet the requirement for conducting fire drills quarterly per shift. 10NYCRR 711.2(a)(1) 2012 NFPA 101:19

Plan of Correction: ApprovedMay 11, 2017

I
The facility contacted the licensed service provider to obtain the missing fire drill reports. The contract was canceled and a new service company has been hired.
II
All Residents potentially affected. The facility reviewed all other emergency preparedness documents for accuracy and timeliness. All other documents were correct.
III
The administrator shall review all reports monthly and has a implemented a log for quick reference of fire drill compliance.
IV
Fire reports will be reviewed by QAPI for completeness and timely completion
V
The facility administrator shall be responsible for completion.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 2, 2017

Citation Details

2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 7.1.3.2.2 An exit enclosure shall provide continuous protected path of travel to an exit discharge. 7.1.3.2.3 An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. 7.1.10.1 General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Based on observation and staff interview, the facility failed to ensure that exit stairs were maintained free and clear of obstructions and impediments. This was observed in one of two exit stairwells. The findings are: On 4/18/2017 between 9am- 3pm during the recertification survey, the exit stairwell was noted to contain storage of a wooden ladder, a plastic bucket and a rubber boot. This was observed on the 7th floor north exit stair. In a concurrent interview with a maintenance worker at the time of the findings, he stated they keep the ladder in the stairwell in case there is an issue with the storage tank. He also stated he could remove it. 2012 NFPA 101

Plan of Correction: ApprovedMay 11, 2017

I
On 4/18/2017 the exit stairwell was noted to contain storage of a wooden ladder, a plastic bucket and a rubber boot. This was observed on the 7th floor north exit stair. These items were removed by the maintenance staff and placed in the appropriate location for storage.
II
The Maintenance department reviewed all other stairwells to remove any items which were placed in there for storage and found all other stairs to be clear. No residents were found to harmed and no additional effected.
III
All Housekeeping, and maintenance staff shall be inserviced about the storage of movable equipment on units and storage of the items. The inservice will also review the requirements of exits in accordance with NFPA 101 2012 chapter 7.
The facility shall conduct weekly inspections of all exit paths for compliance and hold additional training for staff in areas found to be out of compliance. All negative findings shall corrected immediately by the reviewer.
IV
The facility will document the findings of the weekly inspections and report the findings to the QAPI committee for review and recommendations for improvement as needed.
V
The responsible party for these items shall be the facility engineer/director of maintenance

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 2, 2017

Citation Details

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. (j) Housekeeping. (1) The entire nursing home, including but not limited to the floors, walls windows, doors ceilings fixtures, equipment and furnishings, shall be clean. The facility shall be maintained in good repair including, but limited buildings, utilities, fixed equipment, resident care equipment and furnishings. Based on observation and staff interview, the facility failed to ensure that the physical environment was maintained in good repair. Specifically, ventilation louvers in ceilings were noted to contain an accumulation of dust and dirt. This was observed on 2 of 7 floors of the facility. The findings are: On 4/18/2017 between the hours of 9am and 3:30pm during the recertification survey, the following was observed: Exhaust vents located within the ceiling tiles were noted to contain a heavy accumulation of dust and or dirt. Locations include but are not limited to: (1) Storage Room on the 7th Floor (2) Locker Room on the 7th Floor (3) Med Room on the 3rd Floor In an interview at approximately 9:55am with a maintenance worker, he stated the vent is dirty and he will have it cleaned. 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 11, 2017

(1) Storage Room on the 7th Floor) Locker Room on the 7th Floor were cleaned of all debris.
II
The head of housekeeping reviewed all additional vent grills for dust and dirt and assigned staff to clean all grills. There were no other grills found to heavily soiled and the routine cleaning was performed.
Iii
The head of housekeeping has scheduled the routine cleaning of ventilation grills fto prevent future build up. Staff were trained in the proper procedure for the cleaning of vent grills.
IV
Monthly inspection of the grills will be accomplished by housekeeping to determine if additional scheduling is required. Reports of the inspection shall be presented to the QAPI for comments and additional input if requiresd.
V
The responsible person for the completion shall be the executive housekeeper

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 2, 2017

Citation Details

713-1.9 Mechanical Requirements (d) Bathing rooms, soiled workrooms, soiled linen rooms and janitors' closets shall have mechanical exhaust ventilation or a wall or, if approved by the department, window exhaust fan with back - draft louvers. Based on observation and staff interview, the facility failed to ensure that soiled workrooms had a functioning mechanical exhaust. This occurred on 1 of 7 floors of the facility. The finding is: On 4/18/2017 between the hours of 9am and 3:30pm during the recertification survey, the following was observed: In the Soiled Utility Room on the 2nd Floor, an exhaust vent located in the ceiling was observed. When tested , the vent was not functioning. In an interview on 4/18/2017 at approximately 1:40pm with a maintenance worker, he stated the vent works only when the air conditioning is on. If the air conditioning is not turned on, the exhaust vent will not work. 10 NYCRR 713-1.9

Plan of Correction: ApprovedMay 11, 2017

I
The facility contacted the licensed electrician to wire the Soiled Utility Room on the 2nd Floor exhaust vent located in the ceiling to operate independent from the ac control. When tested , the vent was functioning
II
All exhaust vents were checked for proper operation as required and none were found to be nonoperational.
III
Staff which service the exhaust fans were inserviced on the requirements and weekly testing and inspection shall be accomplished by engineering.
V
Any deficient items shall be reported to the QAPI meeting for further recommendations.
Responsible:
engineer

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 2, 2017

Citation Details

2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on six of seven floors. The findings are: On 4/18/2017 between 9am- 3pm during the recertification survey, fire-rated doors were not provided with legible fire-rated labels and/or lacked fire-rated labels. This was observed on smoke barrier doors (cross corridor doors) on floors 2 through 7. In an interview on 4/18/2017 at approximately 9:45am, a maintenance worker stated the doors are old and would check to see if they have the fire rating labels underneath the paint. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2

Plan of Correction: ApprovedMay 11, 2017

On 4/19/2017 the administrator contacted a certified fire door inspection company to recertify and provide legible fire-rated labels and/or lacked fire-rated labels on smoke barrier doors (cross corridor doors) on floors 2 through 7.
II
The facility conducted a review of all other areas where rated doors would be required and has determined no other areas or residents were found to be effected.
III
The staff who do painting shall be inserviced about the importance of keeping fire tags clear for review.
the rated doors shall have the annual inspections accomplished in accordance NFPA 80. Any doors replaced, The facility shall require all replacement doors to be fire rated or 13/4 in bonded doors in any replacement or upgrades and shall be done in accordance with the requirements of NFPA 101 2012 and NFPA 80
IV
Monthly inspection of the smoke barrier doors Records of inspections shall be kept and reviewed by the Environmental Services coordinator. The environmental services coordinator shall assign qualified staff to perform The inspections and any required repairs will done during this time. All unsatisfactory findings shall be reported to the QAPI committee and shall be addressed immediately during the review
V
The responsible party for these items will be the Facility Engineer.