Highbridge Woodycrest Center
August 31, 2017 Certification Survey

Standard Health Citations

FF10 483.25(c)(2)(3):INCREASE/PREVENT DECREASE IN RANGE OF MOTION

REGULATION: (c) Mobility. (2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews conducted during the Recertification survey, the facility did not ensure that a resident with Limited Range of Motion to upper extremity received the appropriate treatment and services to improve and/or to prevent a decrease in Range of Motion (ROM). Specifically, a resident was assessed to have limited range of motion to the right hand and no treatment and services were provided for the resident. This was evident for 1 resident that was reviewed for Range of Motion (ROM)Resident # 106. Findings are: Resident #106 is a [AGE] year-old, admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. On 08/30/2017 at 11:17 AM, the resident was observed in the room, alert and awake, was lying in bed, contracture noted to right hand in a form of a V shape, no splint device observed. The resident is non-verbal, unable to follow commands but the resident is able to open their eyes when the name is being called. On 08/30/17 during the Stage One Staff Interview, the Unit License Practical Nurse (LPN) stated that resident has a contracture to the right hand with no splint device and with no range of motion exercise provided. The Minimum Data Sets 3.0 (MDS) admission assessment dated [DATE] revealed that resident's cognitive status is severely impaired. The MDS also documented that resident required total assistance in performing Activity of Daily Livings (ADL'S). The MDS further documented that the resident had impairments to both upper and lower extremities. There is no documented evidence in the medical record that a care plan for contracture or range of motion was developed. The Physician order [REDACTED]. The Physical Therapy (PT) screening form dated 5/9/17 documented that the resident is non-verbal and unresponsive and the resident cannot follow commands. The PT further documented that the resident has a limited ROM to upper and lower extremities and dependent with all Activities of Daily Living (ADL's). The PT determined that the resident is total dependent in Activities of Daily Living (ADL's), nonverbal and cannot follow commands, therefore resident is not a candidate for PT services. The Occupational Therapy (OT) screening form dated 5/12/17 documented that the resident in non ambulatory and non-verbal. The OT evaluation further documented that the resident has a limited ROM to upper and lower extremities and dependent with all ADL's. The OT determined that the resident is total dependent in ADL's, nonverbal and cannot follow commands, therefore resident is not a candidate for PT/OT services. There was no documented evidence in the medical record that rehab made any recommendations to the nursing department for the resident's care. A review of the Certified Nursing Assistant (CNA) accountability records revealed no documented evidence that the resident received or was receiving passive range of motion exercises. On 8/30/17 at approximately 12:20 PM, an interview was conducted with the Certified Nursing Assistant (CNA) who stated that the resident is total care, cannot make needs known, and the resident is non-verbal. The CNA further stated that the resident never received range of motion exercises because it is not in the accountability form. The CNA further stated that the resident's right hand is contracted, and the resident can only move the left hand. On 08/31/2017 at 10:10AM, an interview was conducted with the Physical Therapist (PT), who explained the Rehab procedures as follow: every resident is screened and assessed for functional mobility. The Physical therapist assesses for balance, muscle strength. The PT stated that the resident is placed on restorative rehab program if the resident can follow commands. The PT further stated that resident # 106 was assessed to have limited mobility to upper and lower extremities, however not a candidate for both restorative and/or maintenance therapy. We only give therapy for residents who can follow simple commands. On 08/31/2017 at 10:33AM , an interview was conducted with Occupational Therapist (OT), who stated that all residents are screened during admission and they review the PRI , diagnosis, past medical history, cognitive assessment, the ADL's and of course the physical exams. The OT focuses on self-care assessment, that include feeding, grooming, dressing, toileting and hygiene. The OT further stated that this resident has poor cognition, unable to response to verbal commands, and the right hand is [DIAGNOSES REDACTED], no active movement, on the left hand there is a limited ROM. The OT determined that resident is not a candidate of OT because the resident has a poor cognition, unable to follow commands. On 08/31/2017 at 10:45AM, an interview conducted with the the Unit Licensed Practical Nurse (LPN) who stated that the resident was admitted with a contracture to right hand and had never received maintenance range of motion. The LPN further stated that resident can only receive ROM if recommended by the rehab staff. On 08/31/2017 at 11:05AM , an interview was conducted with the Assistant Director of Nursing (ADNS) who stated that the rehab staff will assess the resident as soon as the resident is admitted to the facility. Then the rehab would make recommendations. The rehab department develops a care plan based on the need of the residents. A restorative PT/OT is needed for resident who can achieve rehab goal. However, those residents who have impaired cognition can benefit from maintainance rehab. There was nothing documented in the resident's medical record to indicate that the resident would not benefit from nursing rehabilitiation services. In addition there was nothing noted by the physician, or rehabilitiation department that indicated that a reduction in mobility was demonstrably unavoidable and as such rehabilitation services such as passive range of motion would not prevent further decline. 415.12(e)(2)

Plan of Correction: ApprovedSeptember 22, 2017

Plan of Correction
F318
Element 1
Resident # 106 was seen/ re-evaluated by PT on 9/1/17 to address the need for ROM exercises and splinting. Passive Range of Motion was recommended. Nursing staff was educated on ROM technique. Nursing will provide passive range of motion to resident # 108 daily on all extremities. PT/OT will evaluate resident quarterly or whenever necessary to identify any deterioration on the resident?s range of motion and contractures.
Element 2
The facility?s Physical Therapist and Occupational Therapist will continue to evaluate within 72 hrs all residents who are admitted to the facility and quarterly thereafter or whenever necessary to identify all residents who have limitation in ROM and residents who are at risk for deterioration in ROM.
The facility?s Rehab department is conducting a facility-wide review of the residents? most recent quarterly assessments to identify all residents who have limitation in ROM and residents who are at risk for deterioration in ROM.
If appropriate, residents who are identified to have limitations in ROM or who are at risk for deterioration in their ROM and is not currently on any ROM or other modalities will be placed on restorative or maintenance PT/OT for active, active-assistive or passive ROM and/or other modalities as needed i.e. applications of splints and braces if necessary and/or appropriate recommendations will be provided to nursing to address the problems identified.
If appropriate, nursing will provide unit based active, active-assistive or passive ROM and other modalities such as splinting as recommended by PT or OT.
Element 3
Facility will revise its Policy and Procedure on Rehab Services to ensure that all residents who have limitations in ROM or are at risk for deterioration in ROM will be provided with services to improve, maintain or prevent further deterioration in the resident?s ROM and other physical functioning.
Facility-wide nursing in-service on contractures, range of motion techniques, monitoring and reporting of changes in range of motion.
Element 4
The facility has initiated a QAPI Program that will:
? Monitor the Rehab evaluation on all new admission on a weekly basis.
? Monitor the Rehab quarterly evaluation.
? Monitor the identification of all residents who have limitation in ROM and the provision of necessary care to these residents or the appropriate recommendations to nursing.
A tracking form will be completed on a weekly basis by the Director of Nursing or his/her designee to monitor:
o Rehab evaluations on all new admissions
o All rehab quarterly evaluations
o The identification of residents who have limitation in ROM and the provision of the necessary care on these residents or the appropriate recommendations to nursing.
The data from the weekly tracking form shall be presented to the QAPI committee for review to determine facility?s performance on sustaining the facility?s plan of correction.
Element 5
The Director of Nursing will be responsible for overseeing and ensuring that the plan of correction is completed.
Date of completion: Oct. 13, (YEAR)

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2017
Corrected date: October 31, 2017

Citation Details

Based on observation,staff interview and record review, it was determined that the facility did not ensure that all electrical equipment used in resident care rooms were maintained and tested in accordance with NFPA 99. Reference is made to the lack of documentation to show that the resident use electric beds were maintained and tested for safety as per manufacturer instructions and/or as per policies and protocols established by the facility or the contracted agency. The findings include: On (MONTH) 28,2017 at 9:30 AM to 3:00 PM, during the recertification survey, it was observed that the facility had provided electrical beds for residents' use in the resident rooms. The electrical beds were noted to bear inspection tags affixed to the beds that expired in (MONTH) (YEAR). On (MONTH) 28, (YEAR), at approximately 1:30 PM, an interview with the facility's Senior Maintenance Supervisor revealed that the electrical beds in resident rooms are to be inspected yearly by the Biomedical Engineering, as per facility policy. The Supervisor further stated that the facility management will be informed for the timely inspecting and testing of the electrical beds, in accordance with the maintenance and care manuals provided by the manufacturer. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 99

Plan of Correction: ApprovedSeptember 25, 2017

K921
Element 1
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?
The facility will hire a Bio medical company to inspect and provide maintenance on all the beds in the facility.
Element 2
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All electric beds in the facility will be inspected and maintained by a Biomedical company and all inspection tags updated.
Element 3
What measures will be put in place or what systemic changes you will make to ensure the deficient practice does not occur?
The facility shall hire a biomedical engineer to test all patient care related electrical equipment used in the facility before being put into service, after any repair or modification and yearly thereafter
The facility shall maintain a documentation of all PCREE which will include schedules of inspections/maintenance, record of inspections and tags on the PCREE
The engineering supervisor shall maintain and track the schedule of the test and maintenance to ensure that it is done as scheduled.

Element 4
How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what Quality Assurance Program will be put into practice.
The Director of Engineering or his/her designee shall conduct a monthly audit on all PCREE inspections which shall include a review of all records of the PCREE inspection and visual inspection of the inspection tags affixed on all the PCREE.
A monthly PCREE inspection tracking form shall be used to record the monthly audit and shall be kept on file for future reference if needed

Element 5
Date for correction and the title of the person responsible for correction of each deficiency.
Correction of the above deficiency was completed by (MONTH) 1, (YEAR) the person responsible for the completion of the above citation shall be the engineering supervisor

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2017
Corrected date: October 31, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that all means of egress were illuminated as per 7.8. Reference is made to the section of the exterior exit stair at the 2nd floor level that lacked illumination. The findings include: On (MONTH) 28, (YEAR), during the recertification survey conducted between 9:30 AM and 3:00 PM, it was observed that the section of the fire escape stair from the 2nd floor level lacked illumination. All sections of the means of egress must be provided with illumination in accordance with section 7.8. On (MONTH) 28, (YEAR),at approximately 12:30 PM, the facility's Senior Maintenance Supervisor stated that an additional lighting fixture will be installed to illuminate the egress fire escape stair from the 2nd floor level terrace area. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedSeptember 25, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K281
Element 1
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?
The facility has installed lighting fixture on the section of the fire escape stairs from the 2nd floor that was found to lack illumination during the recertification survey conducted on [DATE], (YEAR).
Element 2
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A facility wide inspection of all means of egress including exit discharge in the facility will be conducted by the Engineering Supervisor to ensure that these areas are illuminated and that the illumination in these areas are continuously in operation or capable of automatic operation without manual intervention.
The facility shall install illumination that is continuously in operation or capable of automatic operation without manual intervention in all means of egress including discharge that is found to lack illumination
Element 3
What measures will be put in place or what systemic changes you will make to ensure the deficient practice does not occur?
The Engineering Supervisor will conduct a daily rounds and inspections on all means of egress to ensure that area is illuminated and shall replace any faulty or non-operational illumination system.
Element 4
How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what Quality Assurance Program will be put into practice.
A daily inspection of the illumination in all means of egress in the facility shall be conducted by the designated Facility Fire Monitor using daily inspection check list of all means of egress in the facility.
The Engineering supervisor or his/her designee shall review the checklist weekly to ensure that the inspections are done daily as indicated on the facility plan of correction
Element 5
Date for correction and the title of the person responsible for correction of each deficiency.
The above deficiency was corrected on (MONTH) 12, (YEAR) The person responsible for the correction of the deficiency shall be the Facility?s Engineering Supervisor.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2017
Corrected date: October 31, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7. Reference is made to the lack of sprinklers in the alcove area containing the vending machine on the 4th floor; and the overhang area containing an air conditioning unitat the 1st floor level. The findings include: On 8/28/17, during the recertification survey conducted between 9:30 AM and 3:00 PM, it was observed that an automatic sprinkler system was missing in the following areas: the recessed area on the 4th floor containing the vending machine, located across from the soiled linen room; and the overhang area projecting onto the exterior exit stair (fire escape stair) landing containing an air conditioning unit, in the vicinity of the 1st floor nursing station. On 8/28/17, at approximately 12:00 PM, the facility's Senior Maintenance Supervisor stated that the sprinkler company will be contacted to evaluate and provide sprinklers in all areas of the building . 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedSeptember 27, 2017

K351
Element 1
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?
An automatic sprinkler system will be installed in the recessed area on the 4th floor containing the vending machine located across the soiled linen room.
The air-conditioning unit in the overhang area projecting onto the exterior exit stairs (fire escape stairs) landing in the vicinity of the first floor nursing station shall be removed.
Element 2
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A sprinkler company shall be hired by the facility to re-evaluate the facility?s sprinkler locations and to identify areas that requires an automatic sprinkler system.
An automatic sprinkler shall be installed in all areas without an automatic sprinkler system but identified as requiring an automatic sprinkler system.
Element 3
What measures will be put in place or what systemic changes you will make to ensure the deficient practice does not occur?
The facility shall ensure that findings of the sprinkler company shall be addressed and all recommendations followed.
Element 4
How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what Quality Assurance Program will be put into practice.
The engineering supervisor or his/her designee shall conduct a facility wide inspection of all areas identified by the sprinkler company as requiring a sprinkler to ensure that an automatic sprinkler system is installed by the date of correction indicated on the facility?s plan of correction.
A check list of the areas identified as requiring a sprinkler shall be created and the presence of an automatic sprinkler system shall be used for the inspection and maintained as record of the inspection.


Element 5
Date for correction and the title of the person responsible for correction of each deficiency.
The above deficiency shall be corrected by (MONTH) 31, (YEAR). The person responsible for the correction of the deficiency shall be the Engineering Supervisor.

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2017
Corrected date: October 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Section 7.2.8.5.1, 2012, NFPA 101 states that all fire escape stairs shall have walls or guards and handrails on both sides in accordance with 7.2.2.4. This standard is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that the guards provided at the open side of the fire escape stair landings were at least 42 inches high as per 7.2.2.4.5.2. Reference is made to the guards provided at the open side of the fire escape stair landings and the central exit stair that were 30-36 inches above landing floor instead of the minimum of 42 inches high from the landings floor. The findings include: On (MONTH) 28, (YEAR), during the recertification survey conducted between 9:30 AM and 3:00 PM, it was observed that the facility had provided guards at the open side of a number of fire escape landings and the central exit stairway. The guards on the stair landings measured approximately 30-36 inches from the landings. Examples include: the South side fire escape stairs on the 4th floor; an approximately 12 feet long landing within the central exit stairway between North and Sough wings on the 4th floor; the fire escape stair landing in the vicinity of suite #03-311; the fire escape stair landing in the vicinity of room # 03-314 P; the fire escape landing in the vicinity of room [ROOM NUMBER]-212 P; the fire escape stair landing in the vicinity of the 2nd floor nursing station; the fire escape stair landings in the vicinity of the 2nd floor terrace; and the fire escape stair landing in the vicinity of room [ROOM NUMBER]-109 P. On (MONTH) 28, (YEAR) at approximately 1:00 PM, the facility's Senior Supervisor stated that the facility Maintenance Management will be informed with regards to the improper height of the guards in the fire escape stair landings and the central exit stair landing. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedSeptember 27, 2017

Life Safety Plan of Correction
K225
Element 1
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?
The following fire escape guards identified during the survey with less than 42 inches in height will be replaced with guards that are at least 42 inches high from the landing floor:
? South side fire escape stairs on the 4th floor
? An approximately 12 feet long landing with in the central exit stairway between the North and South wings on the 4th floor
? The fire escape stair landing in the vicinity of Rm# 02-212P
? The fire escape stair landing in the vicinity of the 2nd floor nursing station
? The fire escape stair landing in the vicinity of the 2nd floor terrace
? The fire escape landing in the vicinity of Rm# 01-109P
Element 2
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A facility wide inspection of all the fire escape walls or guards and handrails shall be conducted by the Engineering Supervisor or his/her designee to identify guards and hand rails that are less than 42 inches in height from the landing floor.
All fire escape guards or handrails identified with less than 42 inches in height from the landing floor shall be replaced with a handrail or guard that are at least 42 inches high from the landing floor.
Element 3
What measures will be put in place or what systemic changes you will make to ensure the deficient practice does not occur?
The facility shall only install or replace fire escape guards or handrails with guards or handrails that are at least 42 inches in height from the landing floor.


Element 4
How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what Quality Assurance Program will be put into practice.
The Engineering Supervisor or his/her designee shall monitor all future construction or replacements of the fire escape guards and handrails to ensure that all guards and handrails are in compliance with the minimum height requirement of 42 inches from the landing floor
After all fire escape guards are replaced to meet the minimum height requirement, the Engineering Supervisor or his/her designee shall conduct an inspection on all fire escape guards in the facility to ensure that all fire escape guards has met the minimum height requirement of 42 inches from the landing floor.
A record of all fire escape guards/wall/handrails indicating their corrected height of no less than 42 inches from the landing floor shall be maintained.
Element 5
Date for correction and the title of the person responsible for correction of each deficiency.
The above deficiency shall be corrected by (MONTH) 31, (YEAR). The responsible person for correction of the deficiency is the Engineering Supervisor.