Horizon Care Center
January 11, 2017 Certification Survey

Standard Health Citations

FF08 483.20(d), 483.20(k)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe 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 §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: March 12, 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 develop a Comprehensive Care Plan (CCP) to adequately address each resident's current condition and plan of care. This was evident for two of 32 Stage 2 residents reviewed for Care Planning. Specifically, 1) Resident #85 was observed for four of six days of the survey wearing the same ripped pants and no CCP was developed to address the resident's non-compliance with wearing appropriate clothing. 2) Resident #249 had four incidents in (YEAR) related to wandering and injuries sustained from unknown causes; however, a care plan was not developed for the injuries. The findings are: 1) Resident #85 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident sometimes can be understood and could sometimes understand. The resident had a Brief Mental Status (BIMS) Score of 13 indicating that the resident was cognitively intact. The signs and symptoms of [MEDICAL CONDITION] included Disorganized thinking. The resident required extensive assistance of one staff person for dressing. On 1/4/2017 at 11:40 AM an attempt was made to interview Resident #85, however the resident refused to be interviewed. The resident was observed in a denim shirt that was labeled down the outside seam with another resident's name and a pair of socks labeled with another residents name. The resident wore burgundy colored pants with the left knee torn (shredded) and the pants were a very short length. The resident was observed with the same burgundy torn pants on: 1/5/2017 at 9:10 AM wheeling himself on the unit. 1/6/2017 at 10:25 AM in the downstairs hallway by the elevators. 1/10/2017 at approximately 2 PM getting on the elevator from the 4th floor nursing unit. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADL) Dressing, Personal Hygiene and Bathing documented needing extensive assist of one staff member for dressing, personal hygiene and bathing. The Goals included: Resident will be dressed properly, weather appropriate daily. The Interventions included but were not limited to: Ensure resident is clean and well groomed daily. The CCP did not address the resident wearing torn clothing, nor did it indicate that there was a problem with the residents' compliance with dressing appropriately. An interview was conducted concurrently with two of the resident's Certified Nursing Assistants (CNA) on 1/10/2017 at 2:30 PM. The CNAs opened the resident's closet and there were approximately 8 shirts and 1 pair of blue jeans in the closet. The CNAs stated that the resident's clothing could be in the wash. They stated that when the resident gets up in the early morning and gets dressed he is assisted but that he can go back to his room and change his clothes. The CNAs stated that if a resident needs clothing the Social Worker (SW) can help them get the clothes they need. On 1/11/2017 at 12:20 PM Resident #85's SW was interviewed. The SW stated that the facility gets donations all the time and that if a resident needs clothing the CNAs are permitted to go to the laundry room where there are racks of donated clothing. The SW further stated that residents should not be wearing clothing with other residents names printed on them. Donated clothing should have the name removed and the recipients name placed on them. The Director of Nursing Services (DNS) was interviewed on 1/11/2017 at 12:30 PM and stated that it is everyone's responsibility to ensure that the residents are dressed appropriately and have the clothing that they need. The DNS stated that if a resident has a compliance issue with not wearing appropriate clothing there should be a Comprehensive Care Plan developed for that issue. 2) Resident #249 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 11/16/2016, documented no Brief Interview of Mental Status (BIMS) score due to short and long term memory problems. The MDS documented that the resident was independent for transfers and locomotion around the unit and that wandering occurred daily. On 1/5/2017 at 11 AM Resident #249's family member was interviewed. She stated that the resident wanders and has sustained injuries that have been identified by the facility staff, but the facility does not let the family member know how they occurred. On 1/9/2017 at 2:24 PM Resident #249 was observed in the third floor dayroom sitting at a table with other residents. The resident was wearing a wanderguard. The following incidents in (YEAR) have been documented: An Accident and Incident (A/I) report dated 2/17/2016 documented that on 2/17/2016 Resident #249 wandered into another resident's room. The A/I report documented that the other resident grabbed and hit Resident #249. Resident #249 sustained redness to her upper back. A Nurse's Note dated 6/8/2016 documented that Resident #249 was observed with swelling to her right lateral ankle and she was limping. The resident was unable to describe what happened and the injury was not observed. On 1/9/2017 at 10:00 AM the Assistant Director of Nursing Services (ADNS) was interviewed. She stated that there was no A/I report generated for the 6/8/2016 incident. An A/I report dated 7/10/2016 documented that Resident #249 was observed with red discoloration to the periorbital area of the right eye and black discoloration on the right outer canthus area (area where the upper and lower eyelids meet). The resident was unable to describe what happened and the injury was not observed. The A/I report dated 7/10/16 documented that the resident likely bumped the left side of her face when getting out of bed. An A/I report dated 11/30/2016 documented that Resident #249 was observed sitting in the dayroom with her left shoe in front of her and a blue/black discolored left second toe. The resident was unable to describe what happened and the injury was not observed. The A/I documented that the Physician was notified and an X-ray was ordered. Resident #249 CCPs were reviewed. There was no CCP developed for the injuries identified on 2/17/16, 6/8/16, 7/10/16 or 11/30/16. A Comprehensive Care Plan (CCP) for Wandering, effective 11/19/2016, documented a goal that the resident would wander in a safe environment. A CCP for Mood and Behavior, effective 8/25/2015 and updated 11/9/2016, documented that the resident had a potential for victimization and wanders aimlessly on the unit. A CCP for Alteration in Behavior, effective 8/25/2015 and updated 1/4/2017, documented that there was evidence of wandering. The CCPs for Wandering, Mood and Behavior, and Alteration in Behavior were not updated to document that these incidents occurred or that any new interventions were implemented. On 1/11/2017 at 9:02 AM the Assistant Director of Nursing (ADNS) was interviewed. She stated that the care plans are supposed to be updated after each incident either by the nursing supervisor completing the A/I report or the unit Registered Nurse (RN). She stated that the care plans should be individualized with specific interventions addressing each occurrence. 415.11(c)(1)

Plan of Correction: ApprovedFebruary 6, 2017

F279
I. Immediate Corrections:
Resident #85
A.1. The staff immediately changed this residents clothes to ensure he was dressed clean and appropriate.
2. The assigned CNA went through the resident?s closet and took inventory of all his clothes. Anything that was ripped torn or not labeled properly was discarded/replaced.
3. The SW for this resident went through the donated clothes and found additional clothing that was appropriate for this resident. Same were labeled and placed in his closet to ensure his clothing supply was adequate.
4. The CCP and CNA plan was revised to reflect a plan to identify that resident needs to be monitored for appropriate clothing and to change his clothes when soiled or damaged.
Resident #249
B.1. The Nurse in charge of the care of this resident was provided an educational counseling from the DNS for not revising the plan of care after each incident as required.
2. The Facility held a special CCP review to document and evaluate this residents risk management interventions and plans for injuries related to wandering. The plan included an evaluation of all the incidents and injuries sustained dated 2/17/16, 6/8/16, 7/10/16 and 11/30/16, as well as a despite note to validate what was done for this resident.
3. The care plan for wandering was also revised to include interventions for monitoring, visual checks for safety and redirection to ensure safety. The CNA plan was revised as well with these interventions.
II. Identification of Other Residents:
A. 1. The DNS and RN supervisors compiled a list of all residents with grooming problems related to appropriate clothing.
2. This list was used to evaluate the resident visually to ensure that the involved residents were appropriately dressed as well as to check their clothing inventory to ensure appropriate clothing was available.
3. Any resident found poorly dressed will have a CCP review and residents in need of new/donated clothing identified and addressed.
4. The DNS will keep a list of these residents for monitoring and discussion with the CCP team
B.1. The DNS and Risk Manager have compiled a list of all wanderers who have sustained injuries in the past quarter.
2. This list was used by the charge Nurses and Risk Manager to review the CCP to ensure that evaluations have been done timely and interventions were in place for all identified incidents.
3. Any care plans in need of revision will have a CCP meeting scheduled for compliance.
4. The DNS will maintain a list of any plan that needed revision for reference and compliance.
III. Systemic Changes:
1. The DNS has reviewed the Facility Policy on Care Planning and CNA plans with concentration on criteria for care plan intervention validation and care plan revision. The Policy was found compliant.
2. All members of the CCP Team and CNAs will be re-inserviced on the Care Plan Policy by the Staff Educator. The Lesson Plan will concentrate on the following:
* Identification of all resident needs and accommodating those needs
* Specific plans for grooming and dressing, and CNA responsibility
* Specific plans for wandering and risk management
* Care Plan evaluation and revision when plans are not working or need revision and evaluation
* Communication to staff regarding care plan interventions
3. A copy of the Lesson Plan and attendance will be filed in the P(NAME) Book for validation.
IV. QA Monitoring:
A1. The DNS has developed an audit tool to track residents with known grooming issues to ensure the CCP is being followed.
2. Audits will be done by the RN supervisors as assigned on each unit 3xweek to track those residents identified
3. Audits with negative findings will have immediate corrective actions.
4. Audits will be presented to the QA Committee quarterly for evaluation and follow up as needed.
B.1. The DNS has developed an audit tool to track residents with wandering behaviors and injuries to ensure the care plan is being followed.
2. Audits will be done by the RN supervisors as assigned on each unit weekly to track those residents identified
3. Audits with negative findings will have immediate corrective actions.
4. Audits will be presented to the QA Committee quarterly for evaluation and follow up as needed.
Date Completed: (MONTH) 12, (YEAR)
The Director of Nursing will be responsible to ensure that corrective action is implemented and followed.

FF08 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: March 12, 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 the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents reviewed for Dental Services and for 1 of 2 residents reviewed for Accidents. Specifically, 1) Resident #165 has a percutaneous endoscopic gastrostomy (PEG) tube for enteral feeding that was placed on 9/30/2016. Speech Therapy evaluations documented that the resident's swallow reflex was absent and the resident was NPO (nothing by mouth). The resident's NPO status was not effectively communicated to staff and there was no Physician's order for NPO; and 2) Resident #163 was observed positioned in a Geri Recliner chair (G/C) that was in poor condition as evidenced by a laterally tilted seat and bent frame. A gap was observed between the seat and the foot rest. The findings are: 1) Resident #165 has [DIAGNOSES REDACTED]. The 12/13/2016 30-day Minimum Data Set (MDS) assessment documented no Brief Interview of Mental Status (BIMS) score due to long and short term memory problems. The MDS documented that the resident had a feeding tube. A nursing progress note dated 10/3/2016 documented that the resident returned from the hospital with a [DIAGNOSES REDACTED]. A Speech Therapy evaluation on 10/3/2016 documented NPO for diet consistency. There was no Physician's order for the NPO status and no nursing progress notes documenting that there was communication with the Speech Therapist regarding the resident's NPO status. A Comprehensive Care Plan (CCP) for Eating/Feeding, dated 10/5/2016, documented an intervention to refer to Speech Therapy for swallow evaluation as needed. The CCP was updated on 10/6/2016 that the resident had a new PEG placement on 9/30/2016 and that the resident was now on tube feeding. The CCP did not indicate that the resident was NPO. A CCP for Impaired Swallowing/Dysphagia, dated 10/3/2016, had interventions to monitor for signs and symptoms of chewing difficulties and educate resident on safe feeding techniques. The CCP did not indicate that the resident was NPO. A CCP for Alteration in Oral Cavity, dated 9/14/2015 and last updated 6/21/2016, had an intervention to assess chewing ability. It was not updated to indicate the resident was NPO. A nursing progress note dated 10/4/2016 at 9:47 PM documented that the resident was seen trying to steal other residents' food from their trays. Resident redirected as needed. A Speech Therapy evaluation dated 12/8/2016 documented the following: the resident does not verbalize and is NPO. Recent placement of PEG suggests therapeutic intervention targeting regeneration of swallow reflex, which is currently absent. A nursing progress note dated 12/9/2016, written by the fourth floor Registered Nurse (RN) Unit Supervisor, documented that the resident was evaluated by Speech Therapy to rule out aphasia. There was no mention in the progress note regarding the resident's swallowing ability and NPO status. Resident #165's room was changed from the fourth floor to the fifth floor on 12/23/2016. On 1/9/2017 at 10:50 AM the fifth floor RN Unit Supervisor was interviewed. He stated that he believed Resident #165 was NPO, but there was no Physician's order for it. On 1/9/2017 at 10:55 AM Resident #165's Certified Nursing Assistant (CNA) was interviewed. She stated that she was a float CNA and that the resident had a feeding tube and she had not observed the resident eating. She stated that she was not sure if the resident was able to take anything by mouth. Documentation in the CNA Accountability Record (CNAAR) revealed that eating was Not Performed. On 1/9/2017 at 2:01 PM the fifth floor RN Unit Supervisor was re-interviewed. He confirmed that the resident does not get anything by mouth and had no orders for by-mouth feeding. The RN Unit Supervisor stated that the resident should be NPO, but currently there was no order for NPO. On 1/10/2017 at 8:51 AM the Director of Nursing Services (DNS) was interviewed. He stated that on 1/9/2017 the staff had a meeting with the Medical Director. He stated that as long as the resident is not ordered to have any food by mouth, then they are considered NPO. He stated that from now on everyone that is NPO will have a doctor's order for NPO and also a color-coded wrist band will be added indicating the resident is NPO. On 1/10/2017 at 10:18 AM the Speech Therapist was interviewed. She stated that when she performed the assessment on 12/8/2016 the resident was NPO because he had no swallow reflex and very low cognition so he could not follow directions. She stated that she spoke to the nurse on the fourth floor unit at that time and advised the nurse of the resident's NPO status. She stated that today, 1/10/2017, she was asked to do another swallow evaluation because nursing has reported the resident has been attempting to take food from other residents. She stated that we have to improve communication. On 1/10/2017 at 11:02 AM the RN Unit Supervisor from the fourth floor was interviewed. She said after the 12/8/2016 Speech Therapy evaluation the Speech Therapist spoke to her about the resident's NPO status. She stated that she had advised the staff and the Physician about the findings but no Physician's order was written.
2) Resident # 163 had [DIAGNOSES REDACTED]. Resident #163 was readmitted to the facility on [DATE] after a hospitalization for a Severe Upper Respiratory Infection. Review of Resident #163's medical record, including physician progress notes [REDACTED]. The resident had a significant change in activities of daily living and ability to ambulate due to the present symptoms. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #163 could usually understand and could usually be understood. The resident required assist of two staff persons for bed mobility and transfer. The resident did not walk and was dependent on one staff for locomotion on and off the unit. The resident received Occupational Therapy for 250 minutes over 5 days and Physical Therapy for 250 minutes over 5 days. The Physician Monthly General Orders dated 12/30/16 included Out of Bed (OOB) to geri-chair (G/C) with Dycem (anti-slip material), Bilateral armrest padding and a pillow under the legs. The Comprehensive Care Plan titled Huntington's Disease dated 12/31/16 documented a problem of Jerky movements related to Huntington's Disease. Interventions included but were not limited to: Ensure safety precautions, Padded armrests, Ensure equipment being used is in good condition. On 1/4/17 between 9:50 AM and 10:40 AM Resident #163 was observed positioned in a G/C sitting at approximately a 30 degree angle. The resident was observed to have continual severe jerking movements of her torso, arms and lower extremities. The resident's feet were continually banging on the foot rest. The G/C that the resident was positioned in was observed to be malaligned. The metal attaching the foot rest to the chair was observed to be bent and had spacing that the resident would be able to get her foot/leg between. There was no pillow in place under the resident's legs and the resident was observed to be slipping down in the chair. A second observation was made on 1/4/2017 at 1:00 PM, of Resident #163 positioned in the same G/C. At that time there was no pillow under the resident's legs. The condition of the chair was brought to the attention of the staff by the surveyor. The staff responded that the resident would be placed in a new chair. On 1/5/2017 at 10:20 AM Resident #163 was observed in the 5th floor day room in a different G/C. The resident was again observed to be positioned with her upper torso at an approximately 30 degree angle, and to have continual severe jerking movements of her torso, arms and lower extremities. The resident's feet were continually banging on the footrest and there was not a pillow in place under her legs. On 1/6/17 the resident was observed at 9:30 AM in a G/C with her upper torso at an approximately 30 degree angle and to have continual severe jerking movements of her torso, arms and lower extremities and without a pillow under her legs. On 1/9/17 at 12:40 PM Resident #163 was observed positioned in a G/C and had continual severe jerking movements of her torso, arms and lower extremities. There was no pillow under the resident's legs. On 1/10/17 at 2:30 PM Resident #163 was observed in the 5th floor day room in the G/C with her upper torso at an approximately 40 degree angle. The resident continued to have severe jerking movements of her torso, arms and lower extremities. There was no pillow positioned under the resident's legs. Review of the Certified Nursing Assistant (CNA) Accountability Record revealed that there was no direction for the use of a pillow under Resident #163's legs. An interview was conducted on 1/10/17 at 3:30 PM with the Director of Therapy who was a Occupational Therapist (OT). The OT stated that a new chair was ordered for the resident and the chair should arrive this week. The chair should be more comfortable and enable better positioning for the resident. The OT also stated that there should be a pillow in use under the resident's legs and that she would evaluate the positioning in attempt to keep a pillow in place. The OT also stated that the Rehabilitation staff complete the Rehabilitation care plans and that the care plan should have included the use of a pillow under the resident's legs to assist in positioning and protection of the resident's skin. 415.12(h)(1)(2)

Plan of Correction: ApprovedFebruary 6, 2017

F323
I. Immediate Corrections:
Resident #165
I.1. The MD was contacted and provided an MD order for NPO status
2. The DNS provided educational counseling to the Nurses involved in the care of this resident for not updating the CCP and CNA plan
3. The Facility held a special CCP review to develop an appropriate and accurate plan. The CCP and the CNA plan were revised as follows:
*Resident reassessed and NPO discontinued.
* The RN supervisor documented an updated progress note and the CCP and CNA plan were revised to reflect current resident status and discontinuation of NPO status. The Facility identifier arm band was changed to reflect resident status.
Resident # 163:
1. The resident was provided with a new Geri Chair by OT with sheepskin padded leg rest for safety
2. The resident was provided with pillows under her legs as per Rehab Directive. The pillows were secured with a Velcro strap to prevent the pillows from falling off.
3. a. The Facility held a special ccp review to document a specific plan for positioning and safety needs. The CNA Plan was revised as well to ensure directives for all positioning devices including pillow under her legs.
b. Due to ongoing Jerky movements related to Huntington?s disease; the resident also had a plan developed for monitoring, repositioning, comfort, and protection. The CCP and the CNA plan both were documented to reflect this plan.
4. The CNAs were informed by the charge Nurse regarding the change in the plan of care relative to positioning devices and increased positioning needs
II. Identification of Other Residents:
I.1. The DNS compiled a list of all residents in house with GT or PEG feedings.
2. This list was used to review the MD orders for NPO status, the Speech Therapy notes and the CCP and CNA Plan.
3. Residents identified with quality issues from this review will have corrections implemented by the RN Supervisor and review by the DNS
II.1. The DNS in conjunction with the OT compiled a list by unit of all residents with special positioning needs and equipment needed for that positioning
2. This list was used by the RN supervisors and/or charge Nurses to review the CCP and CNA plan for accuracy as well as to perform visual observations to ensure positioning needs were met.
3. Any quality issues identified from this review will have corrective actions implemented by the RN Supervisor/Charge Nurse, and review by the DNS
III. Systemic Changes:
I.1. The DNS developed a new Criteria whereby all residents who are NPO as deemed by the MD will have a color coded armband identifier to ensure staff awareness.
2. The Charge Nurses will also ensure that all residents with Tube Feedings have MD orders for NPO as identified and CCP/CNA Plans per Policy
* All licensed Nurses and CNAs will be in-serviced by the Staff educator on these policy changes including NPO status and Care plan/CNA plan documentation.
* A copy of the Lesson Plan and attendance will be filed for reference in the P(NAME) Book.
II.1 The DNS has developed a Policy for Directives in Positioning for Nurses and CNAs to follow.
2. All Nurses and CNAs will be in-serviced on Positioning of Residents with a concentration on:
* Developing a CNA and Care plan relative to positioning needs
* Visual observations to ensure plans for positioning are implemented
3. A copy of the Lesson Plan and attendance will be filed in the P(NAME) Book
IV. QA Monitoring:
1. The DNS developed an audit tool to track compliance with our plan for residents with PEG/GT feedings
2. Audits will be done by the Assigned Nurses weekly on all residents with Peg/GT feedings to check the MD orders and Care plan/CNA plan.
3. Audits with negative findings will have immediate corrections implemented by the RN supervisor and review by the DNS.
4. Audits will be presented to the QA Committee quarterly for evaluation and continuance as needed.
1. The DNS developed an audit tool to track compliance with resident?s plans for positioning.
2. Audits will be done by the RN Supervisors/Charge Nurses weekly on all shifts on all residents with positioning needs for aspiration precautions to ensure same is being provided .
3. Audits with negative findings will have immediate corrections implemented and reviewed by the DNS
4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as needed.
Date Completed: (MONTH) 12, (YEAR)
The Director of Nursing will be responsible to ensure that corrective action is implemented and followed.

FF08 483.15(h)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: March 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews during the recertification survey, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided. This was evident on 2 of 5 nursing units for 1) housekeeping and maintenance issues and 2) on 3 of 5 nursing units the shower water temperatures were not maintained at a comfortable range. Specifically, 1) observations of the 6th floor nursing unit included heavily soiled floors, strong urine odor, cracked floor tiles, dust coated bathroom vents, dressers in disrepair and missing radiator control covers. The 5th floor nursing unit window sills were in need of cleaning and painting and a rusted bed rail was observed on one bed (Room #537); 2) During interviews with Resident #180, #262, and # 67, the residents stated that the shower water is cold on the 4th, 5th, and 6th floor nursing units. The findings include but are not limited to: 1) During the initial tour of the facility on 1/4/2017 between 8:45 AM and 9:45 AM on the 6th floor nursing unit the following was observed: -Room # 635- the floor was heavily soiled around the perimeter of the room. -Room # 631- the dresser handle was missing. -Room # 630- there was a strong urine odor present in the room. -Room # 626- the floor tile was cracked in front of the sink and the floor was heavily soiled around the perimeter of the room. -Room # 623- the floor tiles from the entrance of the resident's room were cracked. -Room #622- the floor was heavily soiled under the sink and around the perimeter of the room. -Room # 621- there were cracked floor tiles noted just past the entrance of the room, the floor tiles appeared pitted in front of A bed, the floor in front of the A bed dresser and the perimeter of the room was heavily soiled, the lower front panel was peeled off the dresser by A bed. -Room # 620- the cover over the radiator controls was missing. -Room #618 -the walls were scuffed and in need of painting. -Room #616 -the floor was heavily soiled by the A bed dresser, under the sink and around the perimeter of the room. -Room #615- the floor was soiled beneath the sink and around the perimeter of the room, the dresser for B bed was missing the top front panel. -Room # 612- the cover plate over the controls for the radiator was missing, there was unpainted plaster noted on the floor at the corner of the wall to the left of the resident's bed and the wall was plastered near the cove molding. -Room #611- there was a cracked floor tile in front of the sink. -Room #610- the floor was heavily soiled between A & B bed, around the perimeter of the room and under the sink. -Room #609- the floor was heavily soiled around the perimeter, in front of the bathroom and under the sink; the bathroom vent was dust coated. -Room #608- the floor under the sink was in need of cleaning, the bathroom vent was heavily coated with dust, the cover to the radiator controls was missing. -Room #607- there was a hole in wall measuring approximately 3 inches long x 4 inches wide, just above the cove molding across from B bed. To the right of the head of B bed there was a piece of tile missing approximately 2 inches x 2 inches. The end table next to the B bed had 4 screws sticking out from the back where the end table was attached to the wall. -Room #605- the cover plate was missing over the radiator controls. The following was observed on the 5th floor nursing unit on 1/4/2017 between 12:07 PM and 1:57 PM and on 1/6/17 between 9:30 AM and 9:50 AM: -Room #536 was observed on 1/4/17 at 12:07 PM and again on 1/6/17 at 9:50 AM to have what appeared to be multiple coffee stains on the wall and floor near the radiator. The window sill was heavily soiled. -Room #514- the window sill was observed on 1/6/17 at 9:30 AM to be chipped, and in need of painting. -Room #537 on 1/4/17 at 1:57 PM the side rail attached to the left side of the resident's bed was observed to be rusted. An interview was conducted with the Housekeeping Director on 1/11/17 at 11:35 AM. The Director stated that the 4th floor and the 6th floor are heavy behavioral units and that the porters try to keep up with the cleaning. The Director stated that each unit has a porter in the day time but in the evening and the night there are only two for the whole facility. He stated that one overnight staff member is responsible for the day/dining rooms clean up and stocking the linens and the other staff member is assigned to the offices and main hallways. The Director stated that there are two housekeeping aides, one on the 3rd floor and one on the sixth floor. The Director stated that he tries to keep an aide on the 4th and 5th floor as well. The Director stated that he has done inservicing with his housekeeping staff and that he would be reviewing the room cleaning process with the porters. He further stated that the floor tiles in the building were being replaced one unit at a time. 2a) Resident #180 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #180 had a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The resident required extensive assistance of two staff persons for transfer and bathing. Resident #180 was interviewed on 1/5/2017 at 10:00 AM. Resident #180 stated that the shower water is cold and that she had to ask the CNA to stop her shower the other day without finishing washing the soap off her body or out of her hair because the water was too cold. 2b) Resident #262 has [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #262 had a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. Under Section F: Preferences for Customary Routine and Activities, the resident reported that it was somewhat important for her to choose between a tub bath, shower, bed bath or sponge bath. The resident required limited assistance of one staff member for personal hygiene, and extensive assistance of one staff member for bathing. An interview was conducted with Resident #262 on 1/5/2017 at 10:45 AM. The resident stated that sometimes when she gets a shower the water is too cold. 2c) Resident #67 has [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #67 had a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact. Under Section F: Preferences for Customary Routine and Activities, the resident reported that it was somewhat important for him to choose between a tub bath, shower, bed bath or sponge bath. The resident required extensive assist of one staff person for personal hygiene and bathing. On 01/05/2017 at 11:10 AM Resident #67, approached the surveyor in the hallway near the elevators and stated that the water is cold when he takes a shower. The resident stated that when he requests the Certified Nursing Assistant (CNA) to run the water to warm it up she states that she does not have time. On 01/05/2017 at 12:00 PM the water temperature was tested on the 6th floor in the female shower room. The temperature in the 6th floor shower room was 64 degrees Farenheit (F). The Maintenance Director stated that no one had reported to him that water temperatures were cold. The Maintenance Director stated that there might be debris in the water line. A review of the facility maintenance water log on 1/5/17 at 1:00 PM revealed that there were no documented water temperatures of the shower rooms. Room sink temperatures were documented in the log book. The room water sink temperatures last documented on 12/30/16 ranged between 94 and 98 degrees F. Tours were conducted with the Director of Maintenance of the 4th, 5th, and 6th floor shower rooms on 1/6/2017 between 10:05 AM and 10:43 AM. In the fourth floor women's shower room between 10:06 AM and 10:14 AM the shower water temperature was maintained between 84 and 88 F, the temperature reached 91.2 degrees F but would not maintain 91.2 degrees F. The 4th floor men's shower room was observed between 10:15 AM and 10:18 AM with a water temperature range between 87 and and 95 degrees F. The shower water temperature reached 101 degrees F, but immediately dropped down to the range of 88-95 degrees F. The water would not maintain a temperature of 95 degrees F. The water temperature fluctuated between 84 and 88 degrees F. The 5th floor women's shower room was observed between 10:20 AM and 10:25 AM. The water temperature range was between 84 and 88 degrees F, the temperature spiked to 91 degrees F and then dropped down between 84-88 degrees F. The sixth floor men's shower room was observed between 10:27 AM and 10:32 AM. The water temperature ranged between 87-102 degrees F; the temperature would not maintain at 102 F, but dropped down to between 87 and 93 degrees F. The Director of Maintenance was interviewed during the tour on 1/6/2017 and stated that the shower heads had all been replaced a few months ago with water saving, pressure reducing shower heads to save gas and money. The Director stated that there was not enough water pressure coming out to maintain the water temperature. The Director of Maintenance further stated that there is only one valve from the boiler that controls all the showers and that it is set at 110 degrees F, to prevent scalding of the residents. The Director stated that the farther the shower room is from the boiler the harder it is to maintain the water temperature. The Director stated he would be switching the shower heads to ones that have a better flow. On 1/6/17 at 11:43 AM the Director of Maintenance brought the removed shower heads and a new one to present to the survey team. The Director of Maintenance stated that the device that restricts the flow of water was removed from the shower heads. Tours were conducted with the Director of Maintenance of the 4th, 5th, and 6th floor shower rooms on 1/9/2017 between 12:17 PM and 12:45 PM. The 4th floor men's shower room was observed at 12:27 PM to be 100 degrees F. On the fourth floor women's shower room at 12:31 PM the shower water temperature was maintained between 98-100 degrees F. The 5th floor women's shower room was observed at 12:39 PM and the water temperature was 100 degrees F. The sixth floor men's shower room was observed at 12:40 PM and the temperature was 100 degrees F. The sixth floor women's shower room was observed at 12:44 PM and the water temperature was 100 degrees F. During the tour with the Maintenance Director on 1/9/17 between 12:17 PM and 12:45 PM the Director stated he had changed all the shower heads over the weekend and that moving forward the shower water temperatures would be included in the log books. On 1/11/17 between 11:40 AM and 11:55 AM interviews were conducted with 6 CNAs and 2 Licensed Practical Nurses (LPN) on the 4th, 5th and 6th floor nursing units. All CNAs and both LPNs stated that residents had not complained to them about cold water temperatures. The CNA's all stated that they run the water and test it prior to the resident entering the shower. 415.5(h)(2)

Plan of Correction: ApprovedFebruary 6, 2017

F253
I. Immediate Corrections:
1. The Director of Housekeeping counseled the Housekeeping staff on the 5th and 6th floors for not keeping the units consistently clean per their job descriptions. A copy of the counseling was placed in the P(NAME) Book for validation.
2. 6th Floor Corrections by Housekeeping/Maintenance Staff:
* All rooms identified on the 6th floor in need of mopping and sanitizing were immediately done by the Housekeeping staff including but not limited to the following rooms: 635,630,626,622, 621,616,610, and 608,
*Rm 631 the dresser handle was replaced by maintenance - 1/31/17.
* Floor tiles in the following rooms were replaced by Maintenance staff: Rooms 626,623,621, and 611 - 2/28/17
* Room 621: the dresser panel will be replaced - ordered 1/12/17.
* Room 620: The cover over the radiator controls will be replaced - 2/10/17
* Room 618: the wall that is scuffed will be cleaned and repainted - 2/10/17
* Room 615: the top front panel of the B bed will be replaced - ordered 1/12/17
* Room 612: the cover plate for the radiator will be replaced and the unpainted plaster will be removed - 2/17/17
* Room 609: the vent in the bathroom was cleansed - 2/3/17
* Room 608: the vent in the bathroom was cleansed and the cover to the radiator controls will be replaced - 2/10/17
* Room 607: the hole in this room will be spackled and painted and the screws protruding from the end table were repaired - 2/3/17
* Room 605 the cover plate for the radiator controls will be replaced - 2/10/17
3. 5th floor corrections by Housekeeping/Maintenance:
* Room 536: the coffee stains were completely removed and the room mopped and sanitized, and the window sill was cleansed of dust and debris
* Room 514: the window sill was sanded and painted
* Room 537: the side rail will be replaced
4. Resident #180, Resident #262 and Resident #67 all complained that the water was cold when taking a shower. These Residents had grievances filed and investigations done to accommodate their needs. Subsequently, the following corrections were done based on findings of low water temperatures in resident care areas:
* The Director of Maintenance removed all the shower heads on all units in order to remove the device that restricted the water flow in order to increase the water temperature during showers.
* Water temps were checked and logged throughout the building including unit shower rooms and Resident sinks. The temperatures were recorded and were compliant for acceptable temps.
5. The Facility Maintenance staff will continue to log water temps three times a week at the boiler and at the shower rooms to ensure compliance.
II. Identification of Other Residents:
1. The Administrator and Director of Housekeeping and Maintenance made full house environment rounds to ascertain compliance with cleanliness of resident rooms as well as the need for any repairs.
2. Any additional rooms noted in need of cleaning will be assigned to housekeeping staff accordingly. In addition, the Director of Maintenance made a list of all rooms in need of items for repair or replacement including radiator covers, bedside table and dresser panels, side-rails and rooms that needed painting or spackling. This list will be used by Maintenance to assign staff for needed repairs or replacements including painting as identified.
3. The Administrator will ensure the completion of any needed painting, repairs or replacements to ensure a homelike atmosphere for residents.
4. The Director of Maintenance checked water temps throughout the building to ensure that temps were acceptable and compliant for warm water showers and washing. All water temps were logged in a maintenance book for validation.
III. Systemic Changes:
1. The Director of Housekeeping has developed a specific assignment for each unit to ensure that the residents rooms are cleaned and sanitized as needed. Rooms that are known to be problematic due to resident issues will be the focus of the assignment to ensure compliance.
2. All housekeeping staff will be in-serviced on the new assignments and cleaning schedules to ensure compliance. The Lesson plan will also concentrate on findings on the SOD and criteria to follow to ensure rooms are maintained. A copy of the Lesson Plan and attendance will be filed for reference in the P(NAME) Book.
3. The Housekeeping and Maintenance Director will make daily rounds on weekdays to ensure compliance and troubleshoot any areas and resident rooms in need of cleaning or repair.
IV. QA Monitoring:
A.1. The Director of Housekeeping has developed an audit tool to monitor the housekeeping efforts with a concentration on the 5th and 6th floor.
2. Audits will be done by the Director of Housekeeping once a week.
3. Audits with negative findings will have immediate corrective actions implemented by Housekeeping.
4. Audit findings will be presented to the QA Committee quarterly for evaluation and continuance.
B.1 The Director of Maintenance has developed an audit tool to identify repair needs.
2. Audits will be done by the Maintenance director monthly.
3. Audits with negative findings will have immediate onsite corrections as needed.
4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as indicated.
C.1The Director of Maintenance has monitored the water temperature logs for the shower rooms and resident rooms for compliance with comfortable temperatures and resident satisfaction.
2. Audits will be done by the Maintenance Director monthly.
3. Audits with negative findings will have immediate onsite corrective actions.
4. Audit findings will be presented to the QA Committee quarterly for evaluation and continuance as needed.
Date Completed: (MONTH) 12, (YEAR)
The Adminstrator will be responsible to ensure that corrective action is implemented and followed.

FF08 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: March 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that 1) resident incidents were thoroughly investigated and reported to the New York State Department of Health (NYSDOH) when appropriate for 1 of 2 residents (Resident #262) reviewed for Abuse and 2 residents (Resident #140 and #83) reviewed during the Facility Abuse Prohibition Review. 2) Additionally, for Resident #262 the facility did not initiate an Accident/Incident (A/I) report for 2 incidents to rule out abuse. The findings are: 1a) Resident #262 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #262 could understand and be understood and had a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. The resident had range of motion impairment to one side of the lower extremities and utilized a wheelchair for mobility. Review of Accident/Incident (A/I) for Resident #262 revealed the following: The A/I dated 2/22/2016 documented that Resident #262 stated she was punched in the face by a peer for no apparent reason. The report documented that the residents were separated, emotional support was provided, a body check was done, the physician was notified and the resident was assured of her safety. The conclusion documented in the A/I report was Resident peer was likely acting in his own way without understanding of cause and effect. Does not understand his actions can cause harm to others, there are no prior incidents between these residents in the past. There was no determination made by the administrative team to rule out abuse/neglect. The report was not called into the NYSDOH. Review of an A/I dated 12/7/16 documented that Resident #262 reported that she was hit in the chest by another resident. The report documented Emotional support provided, body assessment done, vital signs checked, Physician notified, chest x-ray ordered, pain medication ordered and given. Psychological consult ordered and in place. Safety precautions maintained. The conclusion of the report documented, Resident's peer who is cognitively impaired was likely acting in his own way without understanding of cause and effect. Does not understand his actions can cause harm to others, there are no prior incidents between these residents in the past. There was no determination made by the administrative team to rule out abuse/neglect. The report was not called into the NYSDOH. The Director of Nursing Services (DNS) was interviewed on 1/10/17 at 12:20 PM. The DNS stated it was up to the team to determine what should be called into the NYSDOH and that they would do better in the future. 1b) Resident # 140 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 6/15, indicating that the resident's cognition was severely impaired. An Accident/Incident (A/I) report revealed that on 2/2/16 at 12:30 AM the resident was observed lying in bed with left periorbital ecchymosis (bruising). The resident made a statement that somebody hit him yesterday morning. Statements taken from staff members revealed that the resident believed that a peer punched him in the eye the day before. A statement written on 2/3/16 from the Registered Nurse (RN) Supervisor present on the evening of 2/2/16 documented that the resident stated that he was punched in the eye by a peer. This same RN Supervisor made a statement that there was no evidence of abuse/mistreatment or neglect. This same RN Supervisor was interviewed on 1/10/17 at 10:10 AM. She stated that she felt no abuse had taken place because staff was not identified as the abuser. She did state however that when the origin of the injury could not be identified the incident should have been called in to the State. She stated that the Director of Nursing Services (DNS) was the one responsible for making the final determination of which incidents are reportable. The Risk Manager was interviewed on 1/10/17 at 11:10 AM. She stated that she reviews and signs the A/I reports. She stated that she did not consider this incident to be abuse, mistreatment or neglect because staff was not alleged to have hit or mishandled the resident and that the resident was able to deny staff involvement. She stated that the incident was not called in because the resident made the statement that he was hit by a friend. 1c) Resident # 83 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9/15, indicating that the resident's cognition was moderately impaired. An Accident/Incident report revealed that on 9/25/16 the resident was noted with swelling to his left wrist and third finger. The resident was documented as being alert and oriented to person, place and time. There was a statement that he woke up and found his hand like that. He denied falling, banging or attempting to hit someone. X-rays of the left wrist and left hand were taken on 9/25/16 and revealed a healing distal left radial fracture, acute to subacute angulated and mildly displaced 3rd proximal phalangeal fracture with mild [MEDICAL CONDITION] of the hand and wrist. The investigative summary by the Risk Manager documented that the resident likely banged his hand against a hard surface resulting in displaced [MEDICAL CONDITION] third proximal phalanx. Skin tears to the palm and third finger were likely self-inflicted per his statement. The Risk Manager was interviewed on 1/10/17 at 11:20 AM. She stated that she did not consider this incident to be abuse, mistreatment or neglect because staff was not alleged to have hit or mishandled the resident and that the resident was able to deny staff involvement. She stated that the incident would have been called in if abuse was identified. The Director of Nursing Services (DNS) was interviewed on 1/10/17 at 12:15 PM regarding Resident # 262, #140 and Resident #83 A/I reports. He stated that the incidents were not called in because the residents were able to give statements. He further stated that there is always room for improvement in the review process. The Administrator was interviewed 1/10/17 at 3:45 PM. She stated that incidents or accidents should be called in when the origin of injury cannot be identified or when abuse is suspected. Following a review of multiple incidents, including those for Resident #83, #140 and #262, she stated that the incidents should have been called into the State Health Department based on inability to rule out abuse and the inability to establish the origin of injury.
2a) Resident #262 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #262 could understand and be understood and had a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident was cognitively intact. The resident had range of motion impairment to one of the lower extremities and utilized a wheelchair for mobility. Review of a Nursing Progress Note (NPN) dated 5/30/2016 at 6:52 PM documented that Resident #262 reported to the nurse that she was kissed on the lips by a peer in the elevator and was asked to go into the peer's room. The resident stated to the nurse , I did not like that. The NPN documented that the supervisor was made aware, to please follow up with social work and to redirect the peer if seen going in Resident #262's room. A subsequent NPN dated 5/30/16 at 9:25 PM, written by the Nursing Supervisor, documented that at around 6:45 PM the nurse on the unit notified the Nursing Supervisor that Resident #262 reported that the resident was kissed on the lips by another resident while at the elevator and this resident asked her to come to her room. Resident stated I did not like that. Emotional support was provided and the resident was counseled to keep away from the other resident and to immediately report any incident to staff. Resident #262 was placed in a highly visible area for close monitoring. The Medical Doctor (MD) was notified and a psychology consult was ordered. The Registered Nurse (RN) Assistant Director of Nursing Services (ADNS) was interviewed on 1/11/2017 at 10:40 AM and stated that she did not recall initiating an incident report about that incident or even hearing about it. The ADNS stated an incident report should have been completed for the incident and that there was no incident report generated for the incident which occurred on 5/30/2016. The RN supervisor was interviewed on 1/11/2017 at 11:08 AM and stated that she was not aware that she had to complete an incident report for an occurrence of nonconsensual contact. The RN stated that she would normally complete incident reports for falls, injuries, and resident to resident altercations. 2b) Review of the NPN dated 10/4/2016 at 4:15 PM revealed that on 10/4/2016 Resident #262 reported that a male resident came into her room early in the morning and touched her chest area. The NPN note documented that the resident also reported the incident to the Social Worker (SW). Psychological services were offered to Resident #262 to help her recover from any distress but she strongly refused. A subsequent NPN dated 10/4/2016 at 4:32 PM documented that the MD was made aware and a psychological consult order was in place. A Social Work progress note dated 10/4/16 at 5:27 PM documented that Resident #262 came to the social services office to report that a male peer approached her and fondled her breast. She came with another female resident who complained the same thing had happened to her, by the same resident. The SW provided emotional support, and the Director of Nursing Services (DNS) was alerted by the SW with the residents present. The resident was made aware that nursing was aware and was working on ensuring her and her friends safety from this male resident. A psychological services consult to evaluate for status [REDACTED]. The resident was provided time to vent her concerns and provided with cognitive restructuring. The Registered Nurse (RN) Assistant Director of Nursing Services (ADNS) was interviewed on 1/9/2017 at 3:55 PM. The ADNS stated that an incident report should be generated by the nursing supervisor that becomes aware of an incident. The ADNS stated she did not know why an incident report was not initiated for this report from the resident. The DNS was interviewed on 1/9/2017 at 4:15 PM and stated that the facility had been monitoring the perpetrator for a change in mental status and that the resident had been wandering through the facility touching random people but that it was not meant in a sexual manner. The DNS stated that the staff did not see this as intent and did not complete an A/I. The DNS stated that he was not aware that a second resident had complained to the social worker and that he would follow up with her. 415.4(b)(1)(ii)

Plan of Correction: ApprovedFebruary 6, 2017

F225
I. Immediate Corrections:
Resident #262
1a.The Incident investigations of 2/22/16 and 12/7/16 were reopened by the DNS and Administrator and a new summary documented including a conclusion that documented resident to resident abuse in both incidents. The incidents were reported to the DOH by the Administrator via the HCS.
b. Copies of the revised investigations and conclusion summaries were filed in the P(NAME) Book for reference and validation.
Resident #140
1. The A/I report of 2/2/16 was reopened and subsequently the following corrections were implemented:
* The RN supervisor involved in the care of this resident, as well as the Risk Manager were educated regarding the definition of abuse and resident to resident abuse by the DNS. Copies of this education were filed in the P(NAME) Book for validation.
* A new summary and conclusion was documented which included reporting to the NYSDOH via the HCS System.
Resident #83
1. The A/I report of 9/25/16 was reopened and subsequently the following corrections were implemented:
* A new summary and conclusion statement was documented showing a fracture of unknown origin. Subsequently, the Accident was called in to the NYSDOH via the HCS system per requirements.
Resident #262
1. The Facility Risk Manager and Social worker documented an incident report relative to the resident?s complaint on 5/30/16 of being ?kissed by another resident?. Subsequently an investigation was done in view of the resident?s statement that the kiss was not consensual and unwanted.
2. Based on the investigation the following additional corrections were implemented:
* A CCP and CNA plan were developed to ensure residents safety from another resident.
* Additional assessment was developed for all residents to ensure protection from possible peer abuse.
* The CCP and CNA Care Plans were to ensure safety of all residents and appropriate interventions and reporting of any incidents.
* The CNAs and Nurses on the unit were re-educated by the Staff Educator on the definition of sexual abuse, resident to resident abuse and reporting guidelines for understanding and awareness. A copy of this education and attendance was filed for reference and validation in the P(NAME) Book.
* Going forward any sexual aggression reported by Residents or observed by staff will require a full investigation and immediate incident report per policy.
II. Identification of Other Residents:
A.1. The DNS and Risk Manager reviewed all the A/I reports for the past quarter to ensure that conclusion statements were written and evidence supported the conclusions.
2. Any reports that were found to be incomplete will be reopened and reinvestigated to ensure appropriate care and treatment to residents including reporting to NYSDOH as required in the DOH Reporting Manual.
3. The DNS will keep a log of any reopened investigations for validation.
B.1. The Director of Social Work held unit meetings on each unit with residents and staff to ascertain if any residents had unwelcome sexual advances or concerns regarding another resident's aggression.
2. Any residents who report any grievance concerning sexual aggression by another resident will have an Incident report completed and an investigation started per requirements. Any new reports will be filed for reference and validation.
3. All newly hired staff will be in-serviced on the Abuse Prevention Policies by the Staff Educator as part of routine orientation.
III. Systemic Changes:
1. The DNS, Risk Manager and all RN Supervisors reviewed the NYSDOH Incident Reporting Manual to ensure understanding of definitions of abuse, neglect, mistreatment, and exploitation as well as sexual abuse definitions. A copy of the Manual was also provided to each unit for reference.
2. The Facility Staff Educator reviewed and revised the Policy on Abuse to include all definitions and reporting requirements as per the regulations.
3. All staff will be educated by the staff educator on the Abuse regulations with a concentration on the following:
* Definitions of abuse, mistreatment, neglect, exploitation and misappropriation
* Requirements for Facility reporting investigations, timeline and conclusion statements
* Requirements for care planning and keeping residents safe
* Requirements for reporting to NYSDOH per requirements
4. A copy of the Lesson Plan and attendance will be filed in the P(NAME) Book for validation
IV. QA Monitoring:
A.1. The DNS has developed an audit tool to track all incidents to ensure a complete investigation is documented and requirements of F225 are followed by all staff.
2. Audits will be done by the RN Supervisor following the Incident Reports on each unit within the 5 days of investigation.
3. Audits with negative findings will have corrective actions implemented and review by the DNS for follow up as needed.
4. Audits will be presented to the QA Committee quarterly for evaluation and follow up as needed.
B.1. The DNS has developed an audit tool to ensure that staff follow appropriate criteria for documenting and investigating sexual aggressions between residents.
2. Audits will be done by the RN Supervisors on each unit following any reported issue from the 24 hour report.
3. Audits with negative findings will have immediate corrective actions by the RN Supervisor and review by the DNS.
4. Audit findings will be reported to the QA Committee quarterly for evaluation and follow up as needed.
Date Completed: (MONTH) 12, (YEAR)
The Director of Nursing will be responsible to ensure that corrective action is implemented and followed.

FF08 483.20(d)(3), 483.10(k)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: March 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family and staff interviews during the Recertification Survey the facility did not revise the Comprehensive Care Plans (CCPs) for each resident when there was a change in condition. This was identified for 1 of 2 Residents reviewed for Accidents in a total Stage 2 sample of 32 residents. Specifically, Resident #163 had orders for pillows to be placed underneath her legs for protection while out of bed in a geri chair (G/C). The pillows were not observed in place on six observations made of the resident during the survey. The finding is: Resident # 163 had [DIAGNOSES REDACTED]. Resident #163 was readmitted on [DATE] after a hospitalization for a Severe Upper Respiratory Infection. Review of Resident #163 medical record, including physician progress notes [REDACTED]. The resident had a significant change in activities of daily living and ability to ambulate due to the present symptoms. A Significant Change MDS assessment dated [DATE] documented that Resident #163 could usually understand and usually be understood. The resident required assist of two staff persons for bed mobility and transfer. The resident did not walk and was dependent on one staff member for locomotion on and off the unit, dressing, eating, toilet use, personal hygiene and bathing. The resident had range of motion limitations to both of upper extremities and lower extremities. The resident received Occupational Therapy for 250 minutes over 5 days and Physical Therapy for 250 minutes over 5 days. The Physician Monthly Orders for medications dated 12/18/16 included but were not limited to: [MEDICATION NAME] (an antianxiety medication), Duloxetine (an antidepressant medication) and [MEDICATION NAME] (a muscle relaxant medication). The Physician Monthly General Orders dated 12/18/2016 included but were not limited to: use of Bilateral WHFO (Wrist-hand-finger orthosis) and cervical collar at all times except during meal times, skin checks, range of motion and bathing. The Physician General orders were updated on 12/30/16 to include: Out of Bed (OOB) to Geri-chair (G/C) with Dycem (anti-slip material), Bilateral armrest padding and pillow under the legs. Review of the Comprehensive Care Plan (CCP) titled Rehab-Occupational Therapy, dated 10/23/16 and last updated 11/6/16, documented a problem of Abnormal Positioning. The Goal included to sit upright in a G/C with the use of adaptive equipment to facilitate anatomical alignment for greater than eight hours with the use of a positioning device without signs and symptoms of pressure areas times (x) 12 weeks. Interventions included: Restorative Occupational Therapy 5 times a week for Therapeutic activities, exercise, neuromuscular re-education and wheel chair positioning. The CCP did not include the use of a pillow under the resident's legs as indicated on the 12/30/16 physician's orders [REDACTED]. Review of a Rehabilitation progress note dated 12/30/2016 at 2:10 PM, written by the Physical Therapist, documented Patient is provided with a pillow under the legs when OOB to G/C to facilitate intact skin due to involuntary and jerk movements of Bilateral lower extremities. Will screen prn (as necessary). Review of the Certified Nursing Assistant Accountability Record revealed that there was no direction for the use of a pillow under Resident #163's legs. A subsequent Rehabilitation progress note written 1/9/2017 documented that Resident # 163 currently has an OOB order to G/C with extensive assist of 2. The resident is noted with continual involuntary and jerky movements. The resident's G/C is padded on both arm rests, has dycem to prevent from sliding and pillows under the legs to facilitate intact skin. On 1/4/17 between 9:50 AM and 10:40 AM Resident #163 was observed positioned in a G/C at approximately a 30 degree angle. The resident was observed to have continual severe jerking movements of her torso, arms and lower extremities. The resident's feet were continually banging on the footrest. The G/C the resident was positioned in was observed to be tilted downward to the left from the bottom of the seat and the foot rest. The metal attaching the foot rest to the chair was observed to be bent and had spacing that the resident would be able to get her foot/leg between. There was no pillow in place under the resident's legs and the resident was observed to be slipping down in the chair. There was no observation of an attempt by staff to try and reposition the resident. A second observation was made on 1/4/2017 at 1:00 PM of Resident #163 positioned in the same G/C. At that time there was no pillow under the resident's legs. On 1/5/2017 at 10:20 AM Resident #163 was observed in a different G/C. The resident was again observed to be positioned with her upper torso at an approximately 30 degree angle, and had continual severe jerking movements of her torso, arms and lower extremities. The resident's feet were continually banging on the footrest and there was not a pillow in place under her legs. On 1/6/17 at 9:30 AM the resident was observed in a G/C without a pillow under her legs. On 1/9/17 at 12:40 PM Resident #163 was observed positioned in a G/C, without a pillow under the resident's legs. On 1/10/17 at 2:30 PM Resident #163 was observed in the 5th floor day room in the G/C. The resident continued to have severe jerking movements of her torso, arms and lower extremities. There was no pillow positioned under the resident's legs. An interview was conducted on 1/10/17 at 2:30 PM with the Certified Nursing Assistant (CNA) that was caring for Resident #163 and had cared for the resident on a regular basis. The CNA stated that she uses a pillow to position the resident off her back while in the chair and that the resident's chair is raised up at meal times. The CNA was not able to answer why a pillow was not under the resident's legs. An interview was conducted on 1/10/17 at 3:30 PM with the Director of Therapy who was an Occupational Therapist (OT). The OT stated that a new chair that was ordered for the resident should arrive this week and should be more comfortable and enable better positioning for the resident. The OT also stated that there should be a pillow under the resident's legs and that she would evaluate the positioning in attempt to keep a pillow in place. The OT also stated that the Rehabilitation staff complete the Rehabilitation care plans and that the care plan should have included the use of a pillow under the resident's legs to assist in positioning. The OT stated she would update Resident #163's CCP to include the use of a pillow under the residents' legs for positioning. An interview was conducted on 1/11/17 at 11:55 AM with the Licensed Practical Nurse (LPN) on the 5th floor Nursing Unit. The LPN was familiar with Resident #163 and stated that she was not sure why a pillow was not under the resident's legs. The Registered Nurse (RN) Nursing Supervisor for the 5th floor was interviewed on 1/11/17 at 12:05 PM and stated that the new chair was received today (1/11/17) and that the OT instructed that a pillow should still be placed under the resident's legs. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedFebruary 6, 2017

F280
I. Immediate Corrections:
Resident #163
1. The DNS identified the Nurse and OT responsible for updating the CCP and CNA Plan relative to placing the pillows under the residents legs when out of bed in Geri Chair, and provided educational counseling for not documenting the care plan or the CNA plan.
2. The Resident was immediately provided with pillows under the legs when sitting in the Geri Chair as per PT/OT directives.
3. The CCP and CNA plan were revised by OT and Nursing to reflect positioning directives for pillows under both legs when out of bed in Geri Chair.
II. Identification of Other Residents:
1. The Facility OT provided Nursing with a list of all residents who require special positioning devices and/or pillows when out of bed.
2. This list was used to do visual rounds to ensure that the residents were being positioned per directives and all positioning devices were in use. In addition, the CCP and CNA plan will be checked to ensure that the plan has been documented.
3. Residents identified with quality issues will have corrections implemented immediately.
III. Systemic Changes:
1. The DNS and OT reviewed the criteria for documenting positioning needs on the CCP and CNA plan and found same compliant.
2. The Nurses, CNAs and OT staff will be in-serviced by the Staff Educator on the importance of documenting positioning needs in the CCP and carry over to the CNA plan
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 monitor residents with specific positioning directives to ensure same has been documented in the CCP/CNA plan and positioning needs are provided per plan.
2. Audits will be done by the assigned RN supervisor on each unit weekly for three months and monthly thereafter.
3. Audits with negative findings will have immediate corrective actions.
4. Audits will be presented to the QA Committee quarterly for evaluation and follow up as needed.
Date Completed: 3/12/17
The Director of Nursing will be responsible to ensure that corrective action is implemented and followed.

FF08 483.10(f)(1):RIGHT TO VOICE GRIEVANCES WITHOUT REPRISAL

REGULATION: A resident has a right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: March 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews during the recertification survey, the facility did not ensure that a resident's request to receive an extra shower was accommodated. This was evident for one of one resident reviewed for grievances in a Stage two sample of thirty two residents. Specifically, Resident #262 stated that there are times in the evening when she had requested a shower on a day that was not her usual shower day and that the staff did not accommodate her. The finding is: Resident #262 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #262 could understand and be understood and had a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. The resident required limited assistance of one staff member for transfer, dressing, toilet use, personal hygiene, and extensive assistance of one staff member for bathing. The resident had range of motion impairment to one of the lower extremities and was incontinent of bowel and bladder. An interview was conducted with Resident #262 on 1/5/2017 at 10:45 AM. The resident stated that she receives two showers a week, and that is usually ok. The resident stated that due to her incontinence she does not always feel clean and would like to have an extra shower on a day that is not usually her shower day. The resident stated that when she has requested an extra shower she was told by the Certified Nursing Assistant (CNA) that each resident is on a bathing schedule and that the CNA does not have time. Resident #262 stated that she had reported her concern to one of the nurses but could not remember who. The Grievance log was reviewed on 1/5/17 and there was no evidence that a grievance form had been filled out by or for Resident #262. The CNA Accountability Records (CNAAR) for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed. The resident's schedule for showering was two times a week on Mondays and Thursdays on the evening shift. The resident received 6 showers in November, 9 showers in (MONTH) and 3 showers as of (MONTH) 9th. On 1/9/2017 at 4:30 PM an interview was conducted with the CNA on the 6th floor who was caring for, and had cared for, the resident on and off since the resident's admission in (MONTH) (YEAR). The CNA stated that if Resident #262 requested a shower that was not on her bathing schedule, the CNA would assist the resident by providing another shower. The CNA stated that it is the resident's right to receive a shower when they request one. The CNA stated that she could understand how the resident might not always feel clean due to incontinence. An interview was conducted with a second CNA on the 6th floor who was familiar with Resident #262 and had cared for her in the past. The CNA stated that if the resident requested a shower and it was not her shower day that she, the CNA, would assist the resident with another shower. An interview was conducted with the Licensed Practical Nurse (LPN) charge nurse on 1/10/17 at 2:15 PM. The LPN stated that if a resident requests a shower and it is not their shower day, the resident should be accommodated. 415.3(c)(1)(i)

Plan of Correction: ApprovedFebruary 6, 2017

The following Plan of Correction is submitted for continued Medicare/Medicaid Certification.
F165
I. Immediate Corrections:
Resident #262
1. The Social Worker for this resident met with the resident concerning her complaint regarding having an additional shower when requested. Subsequently a Grievance form was filed and an investigation completed. Based on the Grievance investigation the following corrective actions were taken:
* The CNAs involved in the care of this resident were provided educational counseling from the DNS regarding meeting the resident?s needs and requests for additional showers.
* A copy of these counselings were placed in the P(NAME) book for validation
* The Facility had a special review CCP meeting to document a plan for residents hygiene needs including the provision of additional showers as needed or requested. The CNA Plan was revised as well to reflect this plan.
* The social worker met with the resident to discuss the resolution of the grievance and to reassure her that her needs would be met. The Social Worker documented a progress note in the medical record for validation.
2. All CNAs involved in the care of this resident were educated by the RN Supervisor on the revisions in the CCP and CNA Plan regarding the residents increased hygiene needs including providing additional showers as needed. A copy of this education and attendance was filed in the P(NAME) Book for validation.
3. Presently the Resident is provided with additional showers when requested, and same are signed for on the CNA accountability record.
II. Identification of Other Residents:
1. The Facility held a Resident Council Meeting to inform Residents of their rights to voice complaints, as well as to identify if there were any additional grievances or complaints not documented. The Grievance Policy was presented and reviewed with the Residents.
2. Residents who voiced any concerns or complaints during the meeting will have a grievance form documented and a subsequent investigation relative to those complaints by the Social Worker.
3. Any new grievances documented will be logged in the grievance log for tracking and validation by the Social Worker.
4. All new admissions will be informed on admission by the Social Worker of their rights to voice grievances as well as who the Grievance Official is and the criteria to follow.
III. Systemic Changes:
1. The Director of Social Work reviewed the Facility Policy that had been recently revised to reflect the Phase 1 revisions in F165, and found same compliant.
2a.All staff will be reeducated on the Grievance Policy to ensure awareness and respect of residents rights. The Lesson Plan will concentrate on the following:
* Residents right to complain or file a grievance
* Notification to the Social Worker or involved Department Head
* Documentation requirements and investigation of grievances
* Follow up with the resident or complainant and timeline for same
b. A copy of the Lesson Plan and Attendance will be filed in the P(NAME) Book for reference and validation.
IV. QA Monitoring:
1. The Director of Social Work has developed an audit tool to track resident satisfaction with care and awareness of Grievance procedures.
2. Audits will be done by the assigned Social Worker on 5 residents per week over the next month, then monthly thereafter.
3. Audits with negative findings will have immediate corrective actions implemented by the Social Worker
4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as needed.
Date Completed: 3/12/17
The Director of Social Work will be responsible to ensure that corrective action is implemented and followed.

FF08 483.20(k)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: March 12, 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 provide the necessary services as documented in each resident's plan of care. This was evident for one of five residents (Resident #159) reviewed for Unnecessary Medications and for 1 of 1 resident (Resident #224) reviewed for Pressure Ulcers in a Stage 2 sample of 32 residents. Specifically, 1) Resident #159 did not have x-rays of her right pinky finger and an Orthopedic Consult completed timely after a fall; and 2) Resident #224 was observed on multiple occasions in a geri-chair for extended periods of time without being repositioned. The findings are: 1) Resident #159 was admitted to the facility on [DATE] and last readmitted on [DATE]. The resident has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had moderately impaired cognition. The MDS also documented that the resident had impaired vision and had corrective lenses. The resident required limited assistance of one person for bed mobility, transfer, ambulation, dressing and personal hygiene. A progress note dated 3/4/16 at 9:02 PM documented that the resident fell while ambulating due to a wet floor. The resident complained of pain in the right pinky finger and both knees. The physician was notified, x-rays were ordered and [MEDICATION NAME] (non steroidal anti-[MEDICAL CONDITION]) was administered for the pain. The resident Accident/Incident (A/I) Report dated 3/4/16 was reviewed. The A/I report documented that the resident stated that she fell on the floor and complained of pain in her right pinky finger and bilateral knees. The A/I report documented that x-rays of bilateral knees and the right fifth finger were ordered. The A/I Report was completed on 3/8/16 by the Risk Manager. On 3/4/6 at 8:57 PM a physician order [REDACTED]. On 3/7/16 at 8:34 AM a progress note documented that the resident was status [REDACTED]. A progress note dated 4/12/16 at 4:14 PM documented that the resident had complained of pain of the right small finger; redness and swelling of right small finger was observed when compared to the left one. The Nursing Supervisor and Physician were made aware. An order was obtained for an x-ray and Tylenol 325 milligrams (mg) 2 tablets (tab) every 6 hours as necessary (prn) was ordered. A subsequent physician's note dated 4/12/16 at 6:04 PM documented that the physician was contacted at 5:00 PM regarding the swollen right hand fifth digit. The physician ordered [MEDICATION NAME] 600 milligrams (mg) three times a day (tid) for three days. The physician also ordered a x-ray of the right hand and an orthopedic consult. A progress noted dated 4/12/16 at 10:42 PM documented that the x-ray of the right hand fifth digit showed that there was a [MEDICAL CONDITION] aspect of the middle phalanx of the fifth finger. The A/I dated 4/12/16 at 2:50 PM documented that the resident's right small finger hurt. The finger was observed to be red and swollen. When the resident was asked what happened she stated that she fell a couple of weeks ago on the 6th floor and claimed that is when she first hurt the finger. The A/I report documented that an x-ray of the right finger was ordered and a [MEDICAL CONDITION] 5th finger middle phalanx was present. Additionally, an orthopedic consult was ordered. The A/I Report was completed on 4/15/16 by the Risk Manager. A progress note dated 11/1/16 at 1:10 PM documented that a Orthopedic Consult was requested for the fifth digit to determine healed fracture. A transport form documented that the original Orthopedic appointment was scheduled for 5/6/16. The consult was canceled because the physician would not be in. The Consult was rescheduled for 5/13/16. A nursing progress note dated 6/3/16 documented that the 5/13/16 appointment was not kept because of problems with transport. On 12/27/16 an Orthopedic Consult was conducted to determine if the fifth digit was healed. The Consult documented that the resident had fallen months ago. The note further documented that the resident had x-rays at that time and that her right fifth finger was fractured. The consult documented that the resident had a splint for approximately a month and then removed it on her own. The consult documented that she had no pain, normal range of motion and some numbness in all digits. On 1/4/17 at 10:00 AM the Director of Nursing Services (DNS) was interviewed. The DNS confirmed that on 3/4/6 at 8:57 PM the physician ordered x-rays of bilateral knees and right pinky finger. The DNS was unsure as to why the right pinky finger x-ray was not completed. On 1/7/17 at 12:15 PM the Assistant Director of Nursing Services (ADNS) Risk Manager was interviewed. The ADNS stated that on 3/4/16 at 8:57 PM the physician had ordered an x-ray of both the right pinky finger and bilateral knees. The ADNS further stated that when the Licensed Practical Nurse (LPN) initially entered the orders for the x-rays at 8:57 PM, they were entered incorrectly. Record review documented that at 9:17 PM on 3/4/16 the LPN corrected the entry for the x-rays and placed the x-ray for the bilateral knees under diagnostic but forgot to enter the x-ray for the pinky finger. On 1/10/17 at 9:15 AM the Licensed Practical Nurse (LPN) was interviewed. The LPN stated that he remembered the incident of 3/4/16 when Resident #159 fell . The LPN was unable to recall if in (MONTH) (YEAR) that he knew about entering orders under general or diagnostic. The LPN further stated that he could not recall if he had entered the x-ray request for the right pinky finger. On 1/10/17 at 11:00 AM the ADNS Risk Manager was again interviewed. The ADNS stated that it was during her review of the A/I dated 4/12/16 when she first realized that the right pinky finger x-ray had never been completed as ordered on [DATE]. The ADNS stated that she is responsible to ensure the completion of the A/I reports. The ADNS further stated that on a daily basis she reviews all new A/I reports. The ADNS obtains additional information as necessary and completes the conclusion, action taken and summary of plan of care. The ADNS stated that in (MONTH) of (YEAR) she was not waiting for the results of x-rays or blood work before signing off on the A/I reports. Additionally, the ADNS stated there is no reconciliation of diagnostic or general orders after initially ordered, on the following two shifts to ensure accuracy. Reconciliation is only completed on subsequent shifts for medications. On 1/11/17 at 12:05 PM the Physician was interviewed. The Physician stated that he would have expected the x-rays of both the knees and right pinky finger to have been completed together as ordered on [DATE]. The Physician also stated that he would have expected the Orthopedic Consult to have been completed in a more timely manner.
2) Resident #224 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented no Brief Interview for Mental Status (BIMS) score due to long and short term memory problems. The MDS documented that the resident required total assistance for all areas of ADLs, including turning and positioning and transfers. The resident was always incontinent of bowel and bladder and the resident received tube feeding. The resident was at risk for pressure ulcers, and had interventions including a turning and positioning program. A Comprehensive Care Plan (CCP) dated 11/24/2015, titled Skin Impairment-Potential/Actual, documented interventions for a limited out of bed schedule of two hours in the AM and to avoid prolonged sitting. A physician's orders [REDACTED]. On 1/4/2017 at 11:22 AM Resident #224 was observed in his room sitting in his geri-chair with bilateral bolsters and a knee separator present. The roho cushion was not observable. On 1/4/2017 at 1:53 PM Resident #224 was observed in his room sitting in his geri-chair. The bilateral bolsters and a knee separator were present. The roho cushion was not observable. On 1/5/2017 at 12:17 PM Resident #224 was observed in his room sitting in his geri-chair with bilateral bolsters and a knee separator present. The roho cushion was not observable. On 1/5/2017 at 2:15 PM Resident #224's Certified Nursing Assistant (CNA) was interviewed. She stated the resident is transferred with a hoyer lift and requires total care. She stated that the resident has to be turned every two hours while he is in bed. She was asked if the resident is repositioned while he is in the geri-chair and she stated, You cannot position him in the chair. She said that she gets the resident out of bed at about 11 AM and that the 3 PM-11 PM shift CNAs put him back to bed. On 1/5/2017 at 2:20 PM Resident #224 was observed in his room sitting in his geri-chair with bilateral bolsters and a knee separator present. The roho cushion was not observable. On 1/5/2017 at 2:24 PM the Registered Nurse (RN) Unit Supervisor was interviewed. He stated that Resident #224 is prone to pressure ulcers and should be repositioned while he was in the gerichair. The RN stated that the resident gets up out of bed and is transferred to the geri-chair at about 11 AM and is transferred back to bed at about 3 PM. Review of the CNA Assignment Record for (MONTH) 2-5, (YEAR), between the hours of 12 PM and 4 PM under the task of Turn and Position, a W is documented. On 1/6/2017 at 1:14 PM the RN Unit Supervisor was re-interviewed. He stated that the W in the CNA Assignment Record means wheelchair. The RN Supervisor stated that the resident should not be in the geri-chair for more than 2 hours as per the care plan. On 1/10/2017 at 8:54 AM the Director of Nursing Services (DNS) was interviewed. He stated that the resident should be repositioned when he is in the gerichair and that a method to reposition the resident will be explored. 415.11(c)(3)(ii)

Plan of Correction: ApprovedFebruary 6, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F282
I. Immediate Corrections:
Resident #159
1. The DNS and Risk Manager conducted an investigation regarding the [MEDICAL CONDITION] 5th finger, as well as to determine the cause of the late Ortho Consult. Based on the investigation the following corrections were implemented:
* The DNS identified the Nurses involved in the failure to carry the MD order on 3/4/16 for the x-ray of the right fifth finger, as well as those Nurses who should have been reviewing the total plan of care for accuracy relative to the fall with c/o pain. Once identified, the Nurses were given an educational counseling by the DNS. Same was filed in the P(NAME) book for reference.
* The DNS and identified the staff responsible for follow up on the MD order for the Ortho Consult. These Nurses were also provided with an educational counseling due to the lateness of the consult as ordered.
* The Resident was evaluated by the Attending MD to ascertain the cause of the fractured finger. It was noted that the resident had no hx of trauma or fall other than the fall sustained on 3/4/16. In addition, the Ortho consult also confirmed that the fx was healed when consult was done. Consequently, the Medical Director documented a progress note to validate that the fx was consistent with the fall of 3/4/16.
* The Medical Director counseled the Attending MD for not following the outcome of this residents care needs including the x-ray not being done and the Ortho Consult not being done timely.
Resident #224
1. The DNS completed an investigation to identify the staff involved in the failure to provide the roho cushion for positioning as ordered, as well as failure to revise the CNA plan to denote the use of the Geri Chair. Subsequently, the DNS counseled the CNAs involved in the care of this resident for failure to provide the roho cushion as ordered and the Nurse was also counseled regarding the lack of revision in the CNA Plan for the Geri Chair.
* A copy of the counseling?s was filed for reference in the P(NAME) Book
* The CNA Plan was revised by the Charge Nurse to reflect the use of the Geri Chair as well as the directives for specific positioning.
II. Identification of Other Residents:
A.1.a The DNS reviewed all Accident reports from the past quarter to ensure that all the MD orders relative to care and treatment were done timely.
b. There were no additional quality issues identified by this review
B. 1a. The DNS and OT made a list of all residents with specific positioning needs and equipment assigned to facilitate that positioning.
b. This list was used to do onsite visual rounds to ascertain if the plan of care was followed.
c. The List was also used to review the CCP and CNA Plan to ensure all the directives for positioning were documented in the plan
d. Any quality issues identified from this review will have immediate corrective actions by the DNS/OT
III. Systemic Changes:
A.1. The facility DNS has changed the focus of the morning report to be a mini CCP meeting and a QA meeting to track residents with change in condition. With this concept the Risk manager will be responsible for reviewing the A/I report and all orders associated with the incident to ensure compliance. The Risk Manager and or RN Supervisor will present this information to the Morning Report Team.
2. The Criteria for the morning meeting will include a discussion of residents who have had any type of incident so the CCP can be reviewed and the MD orders can be reviewed to prevent quality issues in implementation and follow up.
3. All Nurses and members of the CCP team will be in-serviced on the new concept for the Morning Report by the staff educator. The Lesson Plan will concentrate on:
* What needs to go on the 24 hour report
* Definition of change in condition
* Preparing for the presentation of resident care issues at the report
4. A copy of the Lesson Plan and attendance will be filed for reference and validation.
B1. The DNS has reviewed the policy on care plan and CNA plan development with concentration on CCP implementation. The Policy was found compliant
2. All Nurses and CNAs will be re-educated on following the plan of care by the staff educator. The Lesson plan will concentrate on the following:
* Meeting residents positioning needs
* Documenting positioning needs on the CCP and CNA plan
* Visual rounds to validate implementation of the plan
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 track residents who have MD orders associated with an Incident.
2. Audits will be done by the Director of Rehabilitation/designee using the 24h report on any resident who has an incident where there is MD orders for care and treatment to ensure implementation and accuracy
3. Audits with negative findings will have onsite corrective actions and review by the DNS
4. Audits will be presented to the QA Committee quarterly for evaluation and follow up as indicated.
B. 1. The Rehabilitation Director has developed an audit tool to track residents with positioning directives to ensure consistent plan implementation.
2. Audits will be done by the Director of Rehabilitation/Designee targeting those residents with positioning directives and accuracy review of the CNA and CCP Plans. Audit will be completed weekly for three months and monthly thereafter.
3. Audits with negative findings will have immediate corrections by the RN and review by the DNS.
4. Audit findings will be presented to the QA committee quarterly for evaluation and follow up as needed.
Date Completed: (MONTH) 12, (YEAR)
The Director of Nursing will be responsible to ensure that corrective action is implemented and followed.

FF08 483.25(b):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident in making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: March 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, the facility did not provide an Optometry Consultation (Consult) as ordered by the Physician in a timely manner for one of three residents reviewed for Vision in a total Stage 2 sample of thirty-two residents. Specifically, Resident #245 was ordered an Optometry Consult on 4/14/16, as recommended by the Ophthalmologist on 3/28/16, for an evaluation for glasses which was not completed until 8/4/16. The finding is: Resident #245 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was able to be understood, could understand, and had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident had cognitively intact daily decision making skills. The MDS also documented that the resident had impaired vision (sees large print, but not regular print in newspapers/books) with no corrective lenses. The physician's orders [REDACTED]. The Ophthalmology Consult dated 3/16/16 documented the reason for request was s/p (status [REDACTED]. The recommendations documented final 3 week course of [MEDICATION NAME] times (x) 4 OD (right eye). Will follow-up. The Ophthalmology Consult dated 3/28/16 documented seeing better OD (right eye). Complains of blurry vision OS (left eye). Impression: Excellent surgical result OD (right eye). Mild cataract OS (left eye) - would benefit from surgery. Patient (Pt) only wants glasses OS (left eye). The recommendations included an Optometry eval (evaluation) for glasses. The physician's orders [REDACTED]. The Optometry Consult dated 8/4/16 documented the reason for request was glasses. The recommendations included that pending Medicaid approval will dispense new reading glasses for best corrected vision. The facility's Clinical Coordinator, who is responsible to schedule clinic appointments for residents, was interviewed on 1/9/17 at 1:05 PM and stated that in (MONTH) of (YEAR), the Nurses would fill out the consult request forms and bring them down to her so she could schedule the appointments. The Coordinator stated that the facility's Optometrist was out from mid (MONTH) to the end of (MONTH) for personal reasons. The Coordinator stated that during this time, she tried to schedule Optometry appointments for residents at two hospitals, but they did not have any appointments for 2 months. The Director of Nursing Services (DNS) was interviewed on 1/9/17 at 1:15 PM and stated that when a consult is completed and recommendations are made, the Nurse would call the Physician and get the physician's orders [REDACTED]. The DNS was interviewed again on 1/9/17 at 2:30 PM and stated that the RN Supervisor had made a mistake and did not see the recommendation made by the Ophthalmologist which caused the delay for the physician's orders [REDACTED]. 415.12(3)(b)

Plan of Correction: ApprovedFebruary 6, 2017

F 313
I. Immediate Corrections:
Resident #245
1. The DNS conducted an investigation to identify the root cause of the late Optometry Consult. Based on the investigation, the following corrections were implemented:
*The DNS counseled the Charge Nurse involved in the care of this resident for not notifying the MD of the problem regarding the optometry consult.
* A copy of the Counseling was filed for reference in the P(NAME) Book
II. Identification of other Residents
1. The DNS provided a list of all Medical Consults ordered for the past quarter.
2. This read out was used by the RN Supervisors to review the Medical records to ensure that the consults as ordered were in fact done timely.
3. Any reviews with negative findings will be referred to the Medical Director for follow up
4. The DNS will maintain a list of any late consults if identified for QA follow up
III. Systemic Changes:
1. The DNS reviewed the Policy for Medical Consults and found same compliant. However in view of the deficiency in late consults the DNS has issued a mandate that all orders for consults be followed on the 24hour report to ensure completion.
2. All licensed Nurses will be re-inserviced on the Policy for Consults by the Staff Educator including placing orders on the 24 h report for tracking.
3. A copy of the Lesson Plan and attendance will be filed for reference and validation in the P(NAME) Book
IV. QA Monitoring:
1. The DNS has developed an audit tool to track MD ordered medical consults.
2. Audits will be done by the RN supervisors on each unit tracking the MD orders. Audit will be completed weekly for three months and monthly thereafter.
3. Audits with negative findings will have corrective actions by the RN and review by the DNS
4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up.
Date Completed: (MONTH) 12, (YEAR)
The Director of Nursing will be responsible to ensure that corrective action is implemented and followed.

FF08 483.25(a)(2):TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS

REGULATION: A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: March 12, 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 provide services to maintain or improve a resident's ability to assist with bathing and grooming. This was evident for one of three residents reviewed for Activities of Daily Living (ADLs) in a total sample of thirty-two Stage 2 residents. Specifically, Resident # 248 was observed with dirty fingernails and unclean hair during the survey and the Resident Certified Nursing Assistant (CNA) Documentation Record revealed that the resident had not been showered for 10 days. The finding is: Resident #248 has [DIAGNOSES REDACTED]. On 1/4/17 at 12:15 PM in the 6th Floor Dayroom, the resident was observed seated at a table. The resident had long, dirty fingernails and oily hair. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was understood, could understand and had a Brief Interview for Mental Status (BIMS) score of 10 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The resident also required limited assistance of one person for personal hygiene and supervision and setup help only in bathing. Review of the Resident CNA Documentation Record dated (MONTH) (YEAR) revealed that the resident was last showered on 12/30/16. Review of the Resident CNA Documentation Record dated (MONTH) (YEAR) revealed that the resident had not received a shower from 1/1/17 through 1/9/17. Refused showers were documented on 1/2/17, 1/4/17, 1/6/17, and 1/9/17 by the resident's regular 7:00 AM - 3:00 PM CNA. The resident's regular 7:00 AM - 3:00 PM CNA was interviewed on 1/9/17 at 2:00 PM and stated that he has cared for the resident for a few months. The CNA stated that the resident often refuses to be showered and if pressed, the resident will curse and raise his hand. The CNA stated that he will give the resident time and come back to him later, but the resident often continues to refuse. The CNA also stated that when a resident refuses a shower he informs the Nurse. The Registered Nurse (RN) Supervisor of the 6th Floor was interviewed on 1/9/17 at 2:35 PM and stated that she was only informed once that the resident had refused to shower and was not aware that the resident had not showered in 10 days. The RN stated that if a resident consistently refuses a shower, she would send a message via the computer system to Social Services and they would come and speak to the resident. The RN stated that the resident might also be referred to the Psychologist to address the non-compliance. The RN also stated that fingernails can be trimmed at any time, not just during bath time. The Director of Nursing Services (DNS) was interviewed on 1/10/17 at 1:15 PM and stated that the CNA should have reported to the Nurse that the resident had refused a shower for the past 10 days. The DNS stated that there had been a breakdown in communication. The DNS also stated that fingernails would be cleaned during care, but the resident would have to be in a good mood. 415.12(a)(2)

Plan of Correction: ApprovedFebruary 6, 2017

F311
I. Immediate Corrections:
Resident #248
1. The DNS investigated the poor grooming of this resident and the lack of provisions of showers. Based on the investigation the following corrections were made:
* The resident had his fingernails clipped and cleaned by the assigned CNA
* The resident was provided with a shower
* The CNAs involved in the care of this resident were counseled by the DNS for not providing alternate bathing when resident refused his showers, and for not communicating these refusals to the charge Nurse.
* The resident was referred to the SW for counseling relative to refusing showers.
* The residents CCP and CNA plan was revised to reflect a plan for providing resident with a bed bath or bathing at the sink when a shower is refused. The staff who provide care for this resident were informed of the plan revision by the DNS/Staff educator
II. Identification of Other Residents:
1. The Unit Nurses compiled a list of all residents who are known to refuse showers.
2. This list was used to review and revise the care plan and CNA plan to ensure alternatives were in place when residents refuse showers. The revisions also included directives to inform the Nurse whenever a resident refuses care or showers in the CNA Plan.
III. Systemic Changes:
1. The DNS reviewed the Policy on provision of Showers and following the CNA plan and found same to be compliant.
2. All CNAs will be reeducated on the Policy by the Staff Educator for following the CNA Assignment with concentration on criteria and communication directives to follow if resident refuses care or showers
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 compliance with our P(NAME) for those residents who refuse showers.
2. Audits will be done on each unit weekly by the Charge Nurse following the list developed of residents who are known to refuse care/showers
3. Audits with negative findings will have immediate corrections by the charge nurse and review by the DNS
4. Audit findings will be presented to the QA Committee quarterly
Date Completed: (MONTH) 12, (YEAR)
The Director of Nursing will be responsible to ensure that corrective action is implemented and followed.

Standard Life Safety Code Citations

K307 NFPA 101:PORTABLE SPACE HEATERS

REGULATION: Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: February 7, 2017

Citation Details

2012 NFPA 101: 19.7.8 Portable Space-Heating Devices. Portable spaceheating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met: (1) Such devices are used only in nonsleeping staff and employee areas. (2) The heating elements of such devices do not exceed 212F (100C). Based on observation and staff interview, portable space heaters, with heating elements exceeding 212 degrees Fahrenheit (F), were noted on the 1st floor. This was noted on one of six floors. The findings are: On 1/5/17 between 11:00- 11:30am during the recertification survey, the following was noted: 1) A portable space heater was noted at the desk in the vicinity of the back entrance on the 1st floor. The heating element of the space heater was measured and the temperature was noted to be approximately 252 degrees F. 2) A portable space heater was noted in the maintenance shop on the 1st floor. The heating element of the space heater was measured and the temperature was noted to be approximately 234 degrees F. In an interview on 1/5/17 at approximately 11:15am, the Director of Maintenance stated that he will remove the space heaters. 2012 NFPA 101: 19.7.8 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 20, 2017

The following plan of correction is submitted for continued Medicare/Medicaid Certification.
K 781
No residents were affected by the deficient practice.
The following was implemented to address the findings:
On 1/5/17, both portable space heaters were removed and discarded. On 1/5/17 Director of Maintenance and Administrator made rounds to check if any other portable space heaters are being used. None were found.
Portable space heater policy was updated to ensure continued compliance.
Completed on: 1/5/17
The Director of Maintenance will be responsible to ensure that corrective action is implemented and followed.


K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 11, 2017
Corrected date: February 7, 2017

Citation Details

2011 NFPA 25: INSPECTION, TESTING, AND MAINTENANCE OF WATER-BASED FIRE PROTECTION SYSTEMS. Table 13.1.1.2 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance Item Frequency Reference Inspection. Check Valves Interior 5 years 13.4.2.1 This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility could not provide information of the required five year maintenance of the sprinkler system check valve. The findings are: During the Life Safety Code survey conducted on 01/05/17 at approximately 11:30am, during a documentation review, it could not be determined that the check valve associated with the building's automatic sprinkler system was inspected/maintained at the required five year interval. In an interview at this time, the Director of Maintenance stated that he is not aware of the last five year inspection/maintenance of the check valve and that he would contact the sprinkler company to obtain this information. In a separate interview on the same day at approximately 1:00pm, the Director of Maintenance stated that the required five year maintenance/inspection of the check was not completed and that it would be scheduled. 2012 NFPA 101: 9.7.5, 9.7.7, 9.7.8 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedMarch 20, 2017

The following plan of correction is submitted for continued Medicare/Medicaid Certification.
K 353
No residents were affected by the deficient practice.
The following was implemented to address the findings:
M & S Mechanical Services, Inc. inspected the sprinkler system on 2/7/17. Sprinkler System was shut and drained down. Disassembled alarm check valves on the sprinkler riser. Inspection and cleaning maintenance was performed. Cleaned and refinished all internal valve components. Cleaned and refinished valve face plates, new gaskets and all other necessary materials were installed. Reassembled valves and restored system. tested and checked all work performed. Found all work performed free of leaks and operating properly.
The Director of Maintenance will tag the sprinkler check valve with the date of last inspection as well as the date that the next inspection is due.
Documentation of the sprinkler inspection will be kept on file in a book kept in the Maintenance Office.
Completed On: 2/7/17
The Director of Maintenance will be responsible to ensure that corrective action is implemented and followed.