Beth Abraham Center for Rehabilitation and Nursing
July 11, 2017 Certification Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status. Specifically, the quarterly minimum data set 3.0 (MDS) assessment did not document the resident's vision status. This was evident for 1 of 3 residents reviewed for vision status out of a Sample of 23 residents reviewed for Accuracy of Assessments. (Resident # 252). The finding is: Resident #252 is a [AGE] year old readmitted to the facility with most recent admission in (MONTH) of (YEAR), with [DIAGNOSES REDACTED]. The quarterly Minimum Data (MDS) Set 3.0 dated 6/13/17, documented that resident had documented the resident had clear speech, usually is understood and can understand, vision is impaired but can see large print but not regular print in newspapers, documented: No for corrective lenses. The cognition was intact. The previous MDS quarterly assessment dated [DATE], documented the following: 'Resident vision is impaired but sees large print, but not regular print in newspapers and Yes for corrective lenses. On 7/11/2017 at 10:58 AM, the resident was observed sleeping, and his glasses were on the floor. The resident quickly woke and stated my glasses feel on the floor and I was waiting for someone to pick them up. I have my glasses for quite a while and I wear my glasses. The Comprehensive Care Plan (CCP) for Visual Function initiated on 11/5/10 documented Highly impaired vision wears glasses. The interventions noted are Administer eye drops as per MD order, assist with ADL's, Ophthalmology and optometry consults, provide clutter free environment and keep call bell within reach. The Optometry consult dated 5/2/17 documented that the resident had positive [MEDICAL CONDITION] for the right eye, and the resident has good vision with current glasses. The [MEDICAL CONDITION] is stable but needs medication. On 7/11/2017 at 11:40AM, The Licensed Practical Nurse (LPN) was interviewed and stated The resident gets eyedrops for his [MEDICAL CONDITION] and is compliant with them. The resident always wears his glasses and he does not refuse to wear them. He has had the glasses since I have been working here on the unit On 7/11/2017 at 12:04 PM, the MDS Registered Nurse (RN) was interviewed. The RN stated that she took over this unit in (MONTH) of (YEAR). The process to complete the MDS is to review the chart, then read the notes and review the previous quarter MDS and review the care plans. Then interview the patient, we bring a newspaper so its regular print first and then we show an object to the resident and then I let them read the big print. I ask how many fingers and if they can identify the object, it is then documented on the MDS in section B 1200. This section is in reference to when the assessment was conducted the resident was not wearing glasses. If the resident has glasses, we let the resident put on the glasses on to accurately answer the question. In the previous MDS it shows that the resident had glasses. I will be covering this unit so I will have to correct this MDS. The Policy and Procedure, last updated 3/2017 titled MDS 3.0 documented that the policy is to ensure Centers Health to follow the guidelines of the most current State-specified Resident Assessment Instrument (RAI) Manuel correctly and effectively according to Centers for Medicare and Medicaid Services (CMS). The procedure will 1- The assessment accurately reflects the resident's status. And 2- The assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. 415.11 (b)

Plan of Correction: ApprovedAugust 5, 2017

1. Corrective Action to be Taken for Affected Residents:
MDS Assessor re-assessed Resident #252 and correction was documented to accurately reflect resident?s vision status. Resident?s vision is impaired but can see large print in newspapers and yes for corrective lenses. Corrected MDS was resubmitted.
The MDS Coordinator was educated regarding conducting a thorough assessment by direct observation, communication with resident and direct care staff on all units, review of chart, review of previous quarterly MDS 3.0 and coding instructions as stated in the policy and procedure titled MDS 3.0.
2. Identification of Other Residents with Potential to be Affected:
A full house audit of comprehensive MDS for the last 3 months was conducted to determine if the MDS accurately reflect their current status. All findings were addressed.

3. Measure Implemented to Prevent Recurrence:
The policy and procedure titled MDS 3.0 was reviewed by the IDCPT. MDS Staff were educated on the policy & procedure that assessments must accurately reflect the resident?s status. A thorough assessment will be conducted by direct observation, communication with resident and direct care staff on all units, review of chart, review of previous quarterly MDS 3.0 and coding instructions as stated in the policy and procedure titled MDS 3.0.
4. Quality Assurance Monitoring:
An audit tool was created for the MDS Regional RN/Designee to conduct monthly audits 10% x3 months to ensure that Comprehensive MDS data specific to section to ensure the MDS assessments accurately reflect the resident vision status. Outcome will be provided to monthly QA committee for review and follow up as needed.
Responsible Party: DON/Designee

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: September 15, 2017

Citation Details

Based on observation and staff interview the facility did not ensure that all drugs and biologicals were stored as per manufacturer's recommendations and discarded in accordance with currently accepted professional principles. This was evident on 3 of 12 units. The findings are: On 07/05/2017 at 9:49 AM during observation of Medication Storage on Unit 8 BR (Baum Rothchild), a vial of Novolin R with an affixed label which documented expired 5/30/17 and a vial of Humulin R with an affixed label which documented expired 6/2/17 was observed in the medication refrigerator. The Licensed Practical Nurse (LPN) #4 was interviewed immediately and stated that insulin is used for a 28 day period and is checked by a nurse on each shift. The LPN stated that the refrigerator was checked by the other LPN who was not available for interview at the time. On 07/05/2017 at 10:26 AM, during observation of Medication Storage on Unit 6 BR (Baum Rothchild), a Lantus pen with an affixed label which documented exp 6/27/17 was observed on the medication cart. The LPN #5 was interviewed immediately and stated that the pen is used for 28 days and then must be discarded. The LPN stated that another pen was discarded earlier and this one must just have been overlooked. On 07/10/2017 at 2:33 PM, an interview was conducted with LPN #1 who was the 2nd LPN assigned to Unit 8 BR on 7/5/17 stated that checking of the insulin vials was an oversight as the insulin vials are used on the night and evening shift and the insulin pens used during the day shift are stored on the medication cart. The LPN stated that the temperature in the refrigerator was checked and the assumption was that only unopened insulin and immunizations were stored in there so those items were not checked. The LPN also stated that all nurses on all shifts are responsible for checking the refrigerator. On 07/10/2017 at 5:41 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who provides supervision for Unit 6 and 8 in the BR building and stated that when insulin is opened it should be dated immediately and discarded after 28 days. The ADON also stated that the onus is on all the nurses to ensure that nothing is expired on the unit and to discard of it immediately. The ADON stated that unit rounding should also be done by the Unit Managers daily to ensure that the process is being followed. The facility policy Insulin Administration documents maximum storage conditions for Insulin as follows: Novolin R- 30 days, Humulin R-28 days, and Lantus-28 days. The facility policy Medication Storage documents nurses must check medication refrigerator for expired drugs Q-shift and discard accordingly and sign-off in Sigma. Surveyor: Shafran,(NAME)I During the initial tour, on 7/5/17 at 10:44 AM, on the 5th floor of the Zahn Pavillion (ZP) building, in the medication refrigerator contained 1 vial of (PPD) Purified Protein Derivative 5TU/0.1ML Lot Number 8 that was opened on 5/31/17. The date of the survey was on 7/5/17 and more than 30 days had passed since the vial has been opened. On 7/5/17 immediately after observing the expired vial, the Licensed Practical Nurse (LPN) was interviewed. Tjheand the LPN stated that usually only keepthe vial once opened for one month so the vial should have expired on 6/30 or 7/1, so today is 7/5/17. I am responsible for discarding the vial so this was an oversight. The manufacturer's package insert for Tuberculin Purified Protein Derivative documents A vial which has been entered and in use for 30 days should be discarded. 415.18 (d)

Plan of Correction: ApprovedAugust 23, 2017

1. Corrective Action to be Taken for Affected Residents:
The vial of Novolin R with affixed label of 5/31/17 expiration date & the vial of Humulin R affixed label of 6/2/17 expiration both observed on unit 8BR 7/5/17 were discarded immediately. The Lantus pen with an affixed label of 6/27/17 expiration date observed on unit 6BR 7/5/17 was discarded immediately. The vial of PPD opened 5/31/17 observed in the medication refrigerator on 7/5/17 on Unit 5ZP was discarded immediately.
2. Identification of Other Residents with Potential to be Affected:
All unit medication refrigerators and medication carts were checked for all expired medications including, but not limited to, insulin and PPD. None were observed. Licensed nurses will continue to check all medication refrigerators and medication carts daily Q-shift and remove any expired medications.
3. Measure Implemented to Prevent Recurrence:
All licensed nurses were re-in serviced on facility policies; ?Insulin Administration? and ?Medication Storage? that Drugs and Biologicals must be labelled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and expiration date when applicable, that Drugs and Biologicals must be discarded promptly on expiration, and to check medication storage areas daily q-shift.
4. Quality Assurance Monitoring:
An audit tool was created to check all refrigerators and medication carts; weekly x4 weeks, bi-monthly x1month, and monthly x1month.
Responsible Party: DON/Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: September 8, 2017

Citation Details

Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that food was served under sanitary conditions. Specifically, two dietary aides were observed handling food without serving utensils during the breakfast and lunch meal tray line service. This was evident during the kitchen and food service observation task. The finding is: On 7/6/17 from 11:57 AM to 12:10 PM, the dietary aide (DA#1) was observed wearing three pairs of gloves. She had on a pair of disposable gloves, a pair of hot gloves over the disposable gloves, and another pair of disposable gloves over the hot gloves. DA#1 was observed handling the breaded veal cutlet from the steam table tray without using serving utensils onto the plate. Throughout the observation, she was observed with the same pair of gloves grabbing handles of other serving utensils to plate other food and grabbing clean plates without changing gloves. On 7/7/17 from 8:07 AM to 8:13 AM, the dietary aide (DA#2) was observed with three pairs of gloves. He had on a pair of disposable gloves, a pair of hot gloves over the disposable gloves, and another pair of disposable gloves over the hot gloves. DA#2 was observed handling the bran muffins from the muffin box without using serving utensils onto the plate. Throughout the observation, he was observed with the same pair of gloves grabbing handles of other serving utensils to plate other food and grabbing clean plates without changing gloves. On 7/7/17 at 1:08 PM, DA#1 was interviewed. DA#1 stated she wears three pairs of gloves, disposable gloves, hot gloves over the disposables, and disposable gloves over the hot gloves. She stated she changes gloves when it gets soiled. She further stated she always uses a serving utensil to plate food. DA#1 stated she didn't think about it when she didn't use a serving utensil for the breaded veal cutlet. On 7/7/17 at 1:41 PM, DA#2 was interviewed. He stated he wears three pairs of gloves, disposable gloves, hot gloves over the disposables, and disposable gloves over the hot gloves. He stated he changes his gloves when it gets soiled. He further stated he uses different serving utensils for each food item. He stated he was supposed to use tongs when plating the bran muffin but didn't. On 7/11/17 at 10:49 AM, the Food Service Director (FSD) was interviewed. He stated it is practice for his staff to wear three pair of gloves, disposables first, then hot gloves, and then disposables again. The staff are instructed to change disposables when it is soiled during the tray line and to use serving utensils for all foods when plating and not touch food with gloved hands. The FSD further stated staff are in-serviced annually and daily morning reminders are provided regarding infection control with hand washing and glove use. The FSD stated he is part of the Quality Assessment and Assurance committee and had not reported or identified concerns regarding infection control during tray line service. The facility policy and procedure titled, Food Service Sanitation Conditions Policy, dated 4/2014 was reviewed and documented the following. .Convenient and suitable utensils .are provided and used to .serve food to eliminate bare hand contact and prevent contamination . The State Operations Manual Appendix PP with a revision date of 3/8/17 documented the following. Gloved hands are considered a food contact surface that can get contaminated or soiled. Failure to change gloves between tasks can contribute to cross- contamination . 415.14(h)

Plan of Correction: ApprovedAugust 5, 2017

1. Corrective Action to be Taken for Affected Residents:
DA #1, DA #2 were educated 7/7/17 by the Director of Food and Nutrition Services on the proper handling of food with utilization of suitable utensils.
2. Identification of Other Residents with Potential to be Affected:
All residents have the potential to be affected by this practice.
3. Measure Implemented to Prevent Recurrence:
Review and revision of food service and sanitation policy was reviewed and revised on 7/11/17 to ensure staff members utilize proper procedures for food preparation and handling. All dietary staff members will be educated on proper food handling procedures and ensure utensils are utilized during all food preparation and service. QA audit tool was devised to ensure utensils and proper food handling procedures are maintained.
4. Quality Assurance Monitoring:
An audit of food handling procedures and utilization of proper utensils will be conducted weekly x4 weeks, then monthly x6 months. Results of QA will be submitted monthly to the QA team for review and input.
Responsible Party: Director of Food and Nutrition Services

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during the recertification survey, the facility did not ensure implementation of its Infection Prevention and Control Program in order to prevent, and control, to the extent possible, the onset and spread of infection within the facility. Specifically, 1) Two members of the nursing staff on two different units (Floor 5 of ZP building and Floor 8 of BR building) did not follow hand hygiene procedures while performing dining service; 2) A Licensed Practical Nurse did not perform proper hand hygiene while providing wound care to Resident #12. The findings are : 1. On 7/5/17 at 1:20 PM, lunch meal service on the 5th floor of the ZP building was observed. A Certified Nursing Assistant (CNA#2) was observed opening the garbage bin lid with her bare hands to throw out trash. She proceeded to grab a clean lunch tray from the tray truck to serve another resident without washing her hands before grabbing the clean lunch tray. On 7/7/17 at 8:35 AM, CNA#2 was interviewed. She stated she has been instructed to wash her hands before serving meals, before and after feeding residents, after picking up dirty trays, and after touching garbage can or lid. She further stated she got nervous and did not wash her hands. On 7/11/17 at 12:21 PM, the Director of Nursing was interviewed and stated staff are instructed to wash hands before meal service, in between serving residents and when touching the garbage bin.
On 7/5/17 during an observation of the dining service on 8BR (the 8th floor BR Unit) at 12:59 PM, one of the Certified Nursing Assistants (CNA#6) was observed picking up the garbage with his bare hands and then served another resident lunch without performing hand hygiene. CNA# 6 proceeded to cut another resident's food. On 7/7/17 at 12:23 PM the Certified Nursing Assistant (CNA#6) was interviewed and stated for the dining room I am responsible for serving meals. I should have stepped on the garbage with my foot as I must have done this unconsciously and then I should have washed my hands that is the right procedure. The CNA further stated I do not recall when was the last in-service we had as we did have in-service more often with the previous owners. The facility policy and procedure titled Hand washing/Hand Hygiene dated 1/2017 was reviewed and documented the following. .wash hands with soap .and water .before and after eating or handling food, before and after assisting a resident with meals .
2. During a wound care observation of Resident #12 on 07/11/2017 at 10:45 AM , the resident was observed in bed on her back with 2 1/2 siderails up. The LPN ( licensed practical Nurse ) and CNA ( certified nursing assistant ) came and introduced themselves and the procedure to be done. Both, washed their hands with soap and water and donned gloves. The LPN then proceeded cleaning the working table. She washed her hands, donned on gloves and opened the supply packages of of 4 x 4, normal saline, santyl , alginate pad and tape. She washed her hands and donned on gloves. Resident was positioned by the CNA on her right lateral side, the old dressing was removed . The sacral area was observed with fragile skin , wound on the left medial with necrosis and right upper most with stage 3 with some slough tissue in the middle. A new wound with bleeding was observed on the lower left buttock. The LPN went to wash her hands, donned gloves and started cleaning the wound site with moistened 4 x4 with normal saline solution several times. She patted the site dry. She proceeded to apply the alginate and santyl treatment. The LPN was about to apply the final treatment of [REDACTED]. At this time the State Surveyor stopped the LPN and recommended LPN to wash her hands prior to continuing care. The LPN was immediately interviewed after the procedure and stated I thought I washed my hands when I was applying the treatment. 415.19 (b)(4)

Plan of Correction: ApprovedAugust 23, 2017

1. Corrective Action to be Taken for Affected Residents:
The two members of nursing staff on Units 5ZP & 8BR were re-in serviced immediately by ADON on hand-washing protocol when handling residents? meals and trays. Return demo was observed to be satisfactory. The licensed nurse who performed wound tx on resident #12 was re-in serviced on hand-washing protocol when removing and applying wound dressing and treatment. Return demo was observed to be satisfactory.
2. Identification of Other Residents with Potential to be Affected:
Random hand-washing competency of 5 nursing staff including CNAs and LPNs on each nursing unit during meals was conducted to identify any infection control violations. Any violation in practice noted was re-in serviced and return demo done until satisfactory. Random treatment pass of total of 12 nurses was conducted to identify any infection control violations deficiencies with regards to hand-washing during wound treatment. All was satisfactory.
3. Measure Implemented to Prevent Recurrence:
All CNAs were re-in serviced on ?Hand Washing Policy? when handling residents? meals and trays. All Licensed nurses were re-in serviced on Treatment pass and Hand-washing Policy.
4. Quality Assurance Monitoring:
Hand washing audit tool will be used to conduct 10 CNA hand washing audits; weekly x4weeks, bi-weekly x 1month, and monthly x 1month. Treatment pass & hand-washing audit tool will be used to conduct 3 Licensed nurse competency observations Weekly x 4weeks, bi-weekly x 1 month, and monthly x 1month.
Responsible Party: DON/Designee

FF10 483.90(g)(2):RESIDENT CALL SYSTEM - ROOMS/TOILET/BATH

REGULATION: (g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area - (2) Toilet and bathing facilities.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: September 15, 2017

Citation Details

Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that all resident room call bells were functioning. Specifically, 3 out of 4 call bells in one- 4 bed resident room were not functioning. This was evident for 3 out of 440 resident call bells located within on one unit in one room. (Floor 4, RM 413 beds A, B, and C of ZP Building). The finding is: On 7/5/17 at 12:28 PM, 7/6/17 at 10:30 AM, and 7/7/17 at 9:09 AM and 12:04 PM, Beds A, B, and C of room 413 in the ZP building call bells were not functioning. There was no sound or light when tested . On 7/7/17 at 11:21 AM, the Certified Nursing Assistant (CNA#3) for Bed A was interviewed. She stated she checks the call bell to see if it works in the morning after she makes the bed. CNA#3 then stated she did not notice the call bell did not work. She further stated she would tell the nurse who will make a slip for maintenance to come and fix the call bell. On 7/7/17 at 11:27 AM, the CNA#4 for Bed C was interviewed. She stated she normally tests the call bell after making the bed but did not test it this morning. CNA#4 stated she would report to the nurse or document in the maintenance log book if the call bell is not working. On 7/7/17 at 11:37 AM, the Licensed Practical Nurse (LPN#2) stated CNA's check the call bells and sometimes she does it herself. She stated she had not checked the call bell today. LPN#2 stated nobody has reported to her that the call bell does not work. She stated she documents in the maintenance log book or would call them. On 7/11/17 at 10:17 AM and 11:43 AM, the Director of Maintenance and Housekeeping was interviewed. There are two maintenance workers assigned to the ZP building. They start their day with checking tickets and work orders that were submitted from the maintenance log book and then respond to work orders. The workers then do continuous rounds on the units which include doing random checking of the functionality of call bells. The director stated that they were not made aware that the call bells in room 413 were not functioning. He stated there is no policy and procedure regarding checking call bells. There is no worksheet or check list for the informal checks that are done daily, weekly, or monthly. They only have a worksheet titled Nurse call inspection report, that is completed formally annually which was last completed 6/1/17. The call bell company, Functional System also conducts annual inspections of the call bells which was last completed (MONTH) (YEAR). The director stated he is part of the Quality Assessment and Assurance committee and had not reported or identified problems with call bells before. The maintenance log book for floor 4 in the ZP building was reviewed. There were no documentation regarding call bells needing to be fixed. 415.29

Plan of Correction: ApprovedAugust 25, 2017

1. Corrective Action to be Taken for Affected Residents:
Call (NAME)s in Rooms 413, A,B,C on 4ZP were fixed immediately by the Maintenance Director.
2. Identification of Other Residents with Potential to be Affected:
All call bells in the facility were checked for functionality. Any non-functional call bell found was fixed promptly.
3. Measure Implemented to Prevent Recurrence:
The call bell policy and procedure was reviewed. Nursing staff was subsequently in-serviced on the call bell policy and procedure. Call bells will be checked by CNAs Q-Shift and will report non-functional call bell immediately to maintenance as well as document problem on maintenance work order log. Call bell checks reminder is on the CNA accountability in Sigma. The Maintenance Director and workers were in serviced to check call bells randomly during weekly environmental rounds.
4. Quality Assurance Monitoring:
An audit tool was created to check all room call bells for functionality; weekly x 4weeks, bi-weekly x 1month, and 1month x 1month.
Responsible Party: Maintenance Director/Designee

FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident?s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident?s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the annual recertification survey the facility did not revise the resident's comprehensive care plan to address healed, and then reopened and worsening pressure ulcers. Specifically, Resident #12 had a history of [REDACTED]. The Comprehensive Care plan to address ulcers was not revised to indicated the presence healed wounds, or the presence of reopened and worsening wounds. In addtion the CCP was not revised to address the resident's allergic reaction to disposable briefs. This was evident in 1 of 3 residents reviewed for pressure ulcer out of a Sample of 33 residents rewviewed for Comprehensive Care Plans. (Resident #12). The finding is: Resident # 12 a [AGE] years old admitted with Diagnoses: [REDACTED]. The MDS ( minimum data set ) 3.0 dated 05/01/2017 assessment identified the resident as moderate with cognition and completely dependant to staff in all levels of activities of daily living including feeding ,turning and positioning and diaper change for incontinent. On skin condition , resident was identified as with risk for pressure ulcer . Resident was observed on several occasions during the survey .On 07/07/2017 at 12:11 PM ,resident was observed on her right lateral position with 2 1/2 siderails (SR ) , appropriately dressed with contractures of bilateral hands and bilateral lower extremities .On 07/10/2017 at 11:18 AM , the resident was observed in bed on semifowler's position with 2 1/2 SR up , asleep . At 2:03 PM , resident was revisited and remains in the same position , on her back. When asked if she is has been turn and position change she shakes her head from side to side . On 7/11/2017 at 10:10 AM , the resident was observed lying in bed with a folded bedsheet wet from urine with direct contact to her skin . The resident's medical records and interdisciplinary notes documented that resident has multiple pressure ulcers on both right and lower buttocks . She was seen by the wound team weekly . The interdisciplinary notes on 5/30/2017 documented both wounds on the right medial buttock and left buttock are healed and to continue current nutritional plan . However, on 5 /31/2017 the professional licensed nurse documented a skin opening on the left buttock area. A telephone call was made to the physician, who then ordered cleansewith nss ( normal saline solution ) then cover with xeroform. On 06/06/2017 the wound team saw the resident and described the wound on the left buttock measuring 6.0 x 2.3 x 0. cm, unstageable with slough and eschar revealing the wound had progressed. The medical record documented from 06/06/2017 to 06/13/2017 wound on the left buttock. On 06/20/2017 the wound team documented a wound on the right buttock. The record stated: Acquired in the facility measurement is 4.0 ( length ) x 2.3 (width ) x 0.2(depth ) cm ( centimeter ). It extends to the level of the subcutaneous tissue making it worsening stage 3. Detailed description wound bed is red with bruised areas, most severe tissue type is necrotic tissues. Wound looks moist , drainage is serous, amount of drainage is scant, debris and necrotic tissue are noted in moderate amount . Overall the wound is worsening. The potential for this wound healing is suboptimal . The resident's medical records and interdisciplinary notes documented that resident has multiple pressure ulcers on both right and lower buttocks . She was seen by the wound team weekly . The interdisciplinary notes on 5/30/2017 documented, both wounds on the right medial buttock and left buttock are healed and to continue current nutritional plan . However, on 5 /31/2017 , the professional licensed professional nurse documented a skin opening on the left buttock area . Telephone call was made to the physician with an order of cleansed with nss ( normal saline solution ) then covered with xeroform. On 06/06/2017 the wound team saw the resident and described the wound on the left buttock measuring 6.0 x 2.3 x 0.2 cm unstageable with slough and eschar . Review of the CNAAR ( certified nursing assistant activities records ) documented the resident was turned once per shift. The Comprehensive Care Plan (CCP ) was initially developed (MONTH) (YEAR). It documented Braden scale of 12, high risk for pressure ulcer. The resident had multiple pressue ulcers. For skin integrity the goal was to achieve wound healing in 90 days. The interventions in place were including but not limited to: pressure relieving mattress ,apply routine barrier A&D ointment to protect skin exposed to urine /saliva /stool and wound drainage. Keep head of bed elevated at or below 30 degree elevation / Incontinent care q (every ) 2-3 hours for soiling and provide skin care. Do not position directly on trochanter when lying on her side. Relieve pressure on heels with pillow under the length of the lowerleg and suspending heels. Turn and Position every 2 hours change of brief every 3 hours. There was no mention of wound observations made on 5/30/17, 5/31/17, 6/06/17, 6/14/17. The CCP was last updated on 07/07/2017 noting that the resident had two Stage 3 pressure ulcers now and are grulating slowly. High risk skin protocol continues, goal and interventions ongoing. There was no mention of resident being allergic to disposable briefs. The CCP documented that resident will be turn and position q 2 hours / change diaper /brief q 3 hours or as needed . However , there are no cloth diaper provided for the resident to use . On 07/11/2017 at 12:07 PM the attending physician was interviewed. The MD stated that the resident had her wound healed on 5/31/2017. Ordered dressing was xeroform and she was receiving antifungal creams. After reviewing the medical records and her orders she stated I don't understand and I cannot explain why there was no documentations /nor an order when the wound was identified on 6/14/2017. We try to do our best and next time it will be better . Review for wound treatment reveals no treatment ordered till 6/20 /2017 for the right buttock after she was seen by the wound doctor. On 7/11/2017 at 11:00AM the CNA( certified nursing assistant ) was interviewed and stated she is using bedsheet because the resident is allergy to diaper . Before they give us clothe diaper , but it has been awhile since that was given to us . The Director of Environmental Services , whose department provides the supplies was interviewed on 07/11/2017 at 1:17 PM and stated I an not aware , she is using clothe diaper . I will check downstairs if there is any available in the building . Our supplier, does not carry any clothes diaper because I have not received any from them in the last couple of months . 415.11 (c)(2)(i-iii) 07/11/2017 1:27:39 PM -- Novlette(NAME)LPN -- when there is a new wound or an incident , we inform the nursing supervisor and they do the SBAR , we fo the focus documentation . With the new wound now , I have been trying to call the brother to no avail , but I let a message for him . Staff was asked if she can go down to check any SBAR done from 06/14/2017 for the new wounds -- she stated there is none . . COMPREHENSIVE CARE PLANS : Update -7/07/2017 ASSESSMENT -- BRADEN SCALE -- 12 - hi-risk --07/13/2013 ADLS FUNCTIONAL/REHABILITATION POTENTIALS : Goals : resident will be clean and dry . resident will maintain rom in all extremities . Interventions: Monitor for increased limitations /proper body alighmnent / proper positioning in wheelchair and bed /ROM during routine ADL care /PROM to bil upper and lower extremities 5 x Use of positioning devices / hand rolls as indicated . Change adult brief q 3 hours and as needed Turn and position q 2- hrs and prn

Plan of Correction: ApprovedAugust 5, 2017

1. Corrective Action to be Taken for Affected Residents:
Resident #12 was cleaned and changed promptly, wet linen removed, and bed changed with dry linen. Resident was turned and re-positioned after care. Cloth briefs were obtained for resident use going forward. Resident care plan was revised to address Rt & Lt Buttock healed ulcers, Lt & Rt buttock re-opened, worsening pressure ulcers, and current status of wounds. Resident?s care plan was also revised to address her allergy to disposable briefs.
2. Identification of Other Residents with Potential to be Affected:
High Risk Management Meeting was conducted and documentation review of all residents with pressure ulcer was done from initial wound observation and RN assessment, wound consult weekly rounds report, RN weekly wound assessment, review of doctor?s orders, care plans, and CNA TASK. Weekly and on-going wound consult rounds were conducted. Care plans were updated as needed to reflect wound history and current status. All residents charts was reviewed to identify those with an allergy to disposable briefs in order to ensure they use cloth diapers. No other residents were identified.
3. Measure Implemented to Prevent Recurrence:
All nursing staff were re-educated on the following policies and procedures: Pressure Ulcer Prevention, Incident/Accident Reporting, Investigation of Incident/Accident, and Care Planning. All nursing staff were also educated to address residents? allergy to disposable briefs by requesting and obtaining cloth diapers. Care plan updated as appropriate.
4. Quality Assurance Monitoring:
An audit tool was created for Nurse Managers to check that residents? care plan is updated to reflect residents? wound progression using the weekly wound consults and RN Weekly Wound Assessment and to check that residents with pressure ulcer are turned and re-positioned, clean & dry when soiled. Audit will be conducted weekly x 4 weeks, then bi-weekly x 1 month, then monthly x 1. An audit tool was created to check that any resident with allergy to disposable brief is provided with cloth diaper.
Audit will be conducted weekly x 4 weeks, then bi-weekly 1 month, then monthly x 1. Findings will be provided to monthly QA committee for review and follow up as needed.
Responsible Party: DON/Designee

FF10 483.35(a)(1)-(4):SUFFICIENT 24-HR NURSING STAFF PER CARE PLANS

REGULATION: 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility?s resident population in accordance with the facility assessment required at §483.70(e). [As linked to Facility Assessment, §483.70(e), will be implemented beginning November 28, 2017 (Phase 2)] (a) Sufficient Staff. (a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. (a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. (a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents? needs, as identified through resident assessments, and described in the plan of care. (a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident?s needs.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a complaint investigation #NY 115 which was conducted as part of the Recertification survey; it was determined the facility did not ensure sufficient nursing staffing levels to maintain the highest practicable level of well-being of each resident. Specifically, there was a recent pattern of understaffing the nursing department particularly during the overnight shift (11 PM to 7 AM) and specifically there was not adequate CNAs (Certified Nurses Assistants) to assist residents in toileting, dressing and other ADLs (Activities of Daily Living). This was evidenced by several anonymous residents and family members comments in addition to grievances presented to facility by the Resident Council, staff interviews and review of staff scheduling over the past month. The findings are: On 6/11/2017 the NYSDOH (New York State Department of Health) received an anonymous complaint via the complaint hotline. The complainant alleged that a resident was being neglected because of insufficient staffing. The complainant alleged that the Resident had decubitus ulcers that were not being properly dressed because of lack of nursing staff. Specifically on 6/10/17 and 6/11/17 the complainant alleged that the nursing staff were mandated to work overtime by covering 3 shifts to make up for the staffing shortage. On 6/12/17 an anonymous person left a message on the hotline complaining that there were only 2 CNA's for 38 residents on a unit on 6/11/17. No specific unit was identified. On 06/20/2017 a complainant who identified herself as a family member of a resident called the hotline and alleged that facility management has cut back on staff from 4 CNA's down to 2 CNA's for 40 residents. The complainant alleged that their family member has to wait 2 hours to be changed and has to wait to be fed and food gets cold. On 6-26-17 an anonymous caller complained via the hotline that staffing has been cut since new owner arrived 3 months ago. As a result there is not enough staff and residents are double diapered because staff cannot get to them often enough. The caller identified the dementia unit as being the unit affected by this issue. On 7/5/17 the State Survey Team entered the facility. The facility has 448 beds and at the time of the survey a census of 429. There are 12 resident units. The patient census on all units ranged from 33-40 residents. Staffing schedules for the past 3 months were requested and reviewed. The the staffing schedules for 12 resident units from a (MONTH) 1 (YEAR) to (MONTH) 4 (YEAR) documented the following in respect to the overnight shift (11:00 PM to 7:00 AM) On 7/4/17, the staffing scheduled documented for the 11PM-7AM shift 12 Licensed Practical Nurses (LPN's) and 23 Certified Nursing Assistants (CNA's) On 6/29/17, the staffing scheduled documented for the 11PM-7AM shift 15 LPN's and 23 CNA's On 6/26/17, the staffing scheduled documented for the 11PM-7AM shift 15 LPN's and 19 CNA's On 6/25/17, the staffing scheduled documented for the 11PM-7AM shift 15 LPN's and 23 CNA's On 6/24/17, the staffing scheduled documented for the 11PM-7AM shift 15 LPN's and 23 CNA's On 6/22/17, the staffing scheduled documented for the 11PM-7AM shift 14 LPN's and 22 CNA's On 6/21/17, the staffing scheduled documented for the 11PM-7AM shift 14 LPN's and 22 CNA's On 6/17/17, the staffing scheduled documented for the 3pm-11pm shift 15 LPN's and 32 CNA's On 6/16/17, the staffing scheduled documented for the 11PM-7AM shift 14 LPN's and 23 CNA's On 6/2/17, the staffing scheduled documented for the 11PM-7AM shift 14 LPN's and 23 CNA's On 6/1/17, the staffing scheduled documented for the 11PM-7AM shift 13 LPN's and 22 CNA's On 5/27/17, the staffing scheduled documented for the 11PM-7AM shift 12 LPN's and 21 CNA's On 5/22/17, the staffing scheduled documented for the 11PM-7AM shift 15 LPN's and 19 CNA's On 5/20/17, the staffing scheduled documented for the 11PM-7AM shift 12 LPN's and 23 CNA's On 5/14/17, the staffing scheduled documented for the 11PM-7AM shift 13 LPN's and 19 CNA's On 5/13/17, the staffing scheduled documented for the 11PM-7AM shift 12 LPN's and 22 CNA's On 6/26/17, the staffing scheduled documented for the 11PM-7AM shift 15 LPN's and 19 CNA's On 4/30/17, the staffing scheduled documented for the 11PM-7AM shift 12 LPN's and 21 CNA's On 4/24/17, the staffing scheduled documented for the 11PM-7AM shift 14 LPN's and 22 CNA's On 4/11/17, the staffing scheduled documented for the 11PM-7AM shift 12 LPN's and 23 CNA's On 4/8/17, the staffing scheduled documented for the 11PM-7AM shift LPN's and 22 CNA's On 4/4/17, the staffing scheduled documented for the 11PM-7AM shift 12 LPN's and 23 CNA's On 4/2/17, the staffing scheduled documented for the 11PM-7AM shift 14 LPN's and 21 CNA's On 4/1/17, the staffing scheduled documented for the 11PM-7AM shift 12 LPN's and 20 CNA's. The facilitiy's Resident Census and Conditions of Residents as documented on the CMS Form 672 (Federal Form) indicate that out of the 429 residents residing in the facility during the time of the survey 227 required assistance of one or 2 staff for toileting, 164 were totally dependent on staff for this function. In addition 245 residents required 1 ore two staff assistance in bathing, 220 were totally dependent on staff, 245 required 1 or 2 staff assistance in transferring, 148 were totally dependent, 245 required 1 or 2 person assist in dressing, 148 were totally dependent, 319 required assistance in eating, 68 were dependent. In addition the facility reported that 40 residents had active pressure ulcers and 320 resident were receiving preventive skin care and 24 residents had skin rashes that required care and monitoring. The facility also documented that there were 183 residents with a [DIAGNOSES REDACTED]. An interview was conducted with a Resident on 07/05/2017 at 04:19 PM. The Admission Minimum Data Set ((MDS) dated [DATE] documented resident with intact cognition and required assistance of one person with Activities of Daily Living (ADL's). The resident stated at night 10 PM they shut the lights and act like you are not here. I have pressed call bell and waited an hour and sometimes they do not come at all, I learned how to get out of bed and go to the bathroom. They are firing a lot of staff, all I ask to be comfortable I am sick and I had [MEDICAL CONDITION] all I want is some help. An interview was conducted with a Resident on 07/06/2017 at 12:36 PM. The Admission MDS dated [DATE] documented resident with intact cognition and required assistance of two persons with ADL's. The resident stated the staffing is at a minimum and you just have to wait a little longer when you call for help. An interview was conducted with a Resident on 07/06/2017 at 1:00 PM. The Quarterly MDS dated [DATE] documented resident with moderately impaired cognition and required assistance of two persons with ADL's. The resident stated the wait can be up to 1 hour for 2 staff to come with the hoyer lift to get the resident into and out of bed. An interview was conducted with a Resident on 07/05/2017 at 12:46 PM. The Quarterly MDS dated [DATE] documented resident with intact cognition and required assistance of one person with ADL's. The resident stated that staff is short all the time with the worst time being during the hours of 3-11. The resident also stated that this happens often and they may wait for over an hour, maybe two in the chair which is very uncomfortable as the resident has a contracted right arm and leg and experiences pain. An interview was conducted with a Resident on 07/06/2017 at 1:00 PM. The Quarterly MDS dated [DATE] documented resident with intact cognition and required assistance of two persons with ADL's. The resident stated that the facility is short of staff on the 3-11PM shift sometimes there are only 2 CNA's. The resident also stated that on a few weeks ago there was only 1 CNA and the facility is better staffed this week. An interview was conducted with a Resident on 07/06/2017 at 11:52 AM. The Quarterly MDS dated [DATE] documented resident with intact cognition and required assistance of two persons with ADL's. The resident showed the surveyor clothing piled on a chair in the corner of the room and stated that there is no one to help me to put them inside or to get what I want. An interview was conducted with a Resident on 07/05/2017 at 4:13 PM. The Annual MDS dated [DATE] documented resident with moderately intact cognition and required assistance of one persons with ADL's. The resident stated they are constantly short on this floor-medication and meals are late. A family member was interviewed for Resident on 7/6/17 at 10:56 AM and stated that their family member sustained a fall and has to wait a long time to be changed as is not able to toilet and has to sit in waste. The family member also stated there was short staff last year and now there have a lot of layoffs so it's worse. A family member was interviewed for Resident on 07/05/2017 at 06:11 PM and stated that the resident has to wait to be changed and the resident takes a long time to feed and there was not enough staff to take the time to feed the resident. The Resident Council gave permission for the State Surveyors to review the minutes of their Resident Town Hall Meeting for 4/25/17, 5/30/17, and 6/27/17. The minutes documented: concerns with nursing staffing (perceived lack) (old agenda). In addition the facility's record of grievances documented 4 of 8 grievances received by facility from (MONTH) (YEAR) to (MONTH) (YEAR) documented concerns regarding adequate staff related to toileting, turning and positioning of residents and activities of daily living. On 07/05/2017 at 4:38 PM, an interview was conducted with CNA #5 who stated that he tries to turn and position every two hours as required but it has become frustrating as staff had been cut since the beginning of the year. The CNA also stated that there is not enough help and staff are disciplined if they leave late because they were not able to complete their work during the shift. He also stated that tasks that require 2 staff such as use of hoyer lift and ADL care are particularly challenging and sometimes residents have to wait longer for a second staff to become available. On 07/05/2017 at 4:54 PM, an interview was conducted with CNA # 6 who stated that staffing levels at the facility are bad and mostly agency staff are used. The CNA also stated that often when agency nurses are used they are unable to get the time to do all dressings and hang feedings in a timely manner. On 07/06/2017 at 3:53 PM, the Administrator was interviewed and stated that 55 CNA's were laid off on 6/20/17 as the corporate leaders stated that staff needed to be reduced. The Administrator stated a Quality Assurance (QA) review was conducted on 6/27/17 looking specifically at CNA staffing levels and the decision was made to postpone pending layoffs and move to revised staffing levels. The administrator also stated that the layoffs did not take into consideration staff that were out on vacation, medical leave or disability, dismissed or retired and once it was identified that the levels were too low the decision was made to rescind the layoffs. In a subsequent interview on 7/10/17 at 6:10 PM, the Administrator stated that another QA review was completed today and 44 of 56 employee terminations have been rescinded. In addition, the Staffing Coordinator will be working on a full-time basis. On 07/10/2017 at 6:14 PM, an interview was conducted with the Director of Nursing who stated that the facility was aware of the staffing shortages and tried to use agency staff and increased use of overtime. The DNS stated that staff was aware of the impending layoffs and were upset so the union was directing its members not to report for work. In addition, vacation time had been approved and the new management was not informed so this further contributed to staff shortages. The DNS stated that they had done what they could to resolve the staffing issues but it was out of their hands. 415.13 (a)(1)(i-iii)

Plan of Correction: ApprovedAugust 25, 2017

1. Corrective Action to be Taken for Affected Residents:
QA review of staffing was conducted and completed by the Administrator and Nursing Administration. 44 of 56 employee terminations were rescinded on, our before, (MONTH) 14, (YEAR) to provide sufficient nursing staff to maintain the highest practicable physical, mental, and psychological well-being of each resident. Sufficient safe staffing levels were maintained on the units henceforth.
2. Identification of Other Residents with Potential to be Affected:
QA review of staffing was conducted and completed by the Administrator and Nursing Administration. Based on census and acuity, 44 of 56 employee terminations were rescinded to provide sufficient nursing staff to maintain the highest practicable physical, mental, and psychological well-being of each resident. Full time staffing coordinator employed to schedule sufficient staff and communicates schedule with individual staff as needed. DON/ADON & Administrator review staffing schedule daily to ensure sufficient safe staffing is available Q-Shift to provide sufficient nursing staff to maintain the highest practicable physical, mental, and psychological well-being of each resident. Will continue to train new and old employees via orientation, and conduct in-services and competencies to enable staff to render safe competent care.
3. Measure Implemented to Prevent Recurrence:

The staffing coordinator was instructed to review weekly & daily staffing at least 48hrs prior to identify insufficient staffing levels and to notify DON/ADON promptly. Nursing staff were in-serviced on customer service, the importance of good attendance, to feed residents in a timely manner, not to apply double briefs, not to turn off lights on the unit at night and ignore call bells, to answer call bells in a timely manner, to put away residents? laundry in a timely manner, to offer assistance as needed, to toilet residents Q2hr and as needed in a timely manner, and to apply treatment as ordered. A call bell response audit will be conducted weekly x 4 weeks, bi-monthly x 1 month, and monthly x 1 month to address resident needs in a timely manner.
4. Quality Assurance Monitoring:
DON/Designee will review Monthly Master Schedule and Daily staffing sheets on on-going basis. Findings will be provided to monthly QA committee for review and follow up as needed.
Responsible Party: DON/Designee

FF10 483.25(b)(1):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews , during the annual recertification period, the facility did not ensure that a resident identified with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent healed ulcers from recurring. Specifically, Resident #12 was observed on several occasions on her back and not repositioned and buttock wet with urine with no barrier between buttock and bed sheet. In addition the resident's comprehensive care plan was not revised to reflect healing and reopening and worsening of wounds. This was evident in 1 of 3 reviewed for pressure ulcer out of a Sample of 33 residents reviewed for Quality of Care. The finding is : Resident #12 was admitted with [DIAGNOSES REDACTED]. The Quarterly Assessment MDS ( minimum data set ) 3.0 dated 05/01/2017 identified the resident as moderate with cognition and completely dependant to staff in all levels of activities of daily living including feeding, turning and positioning and diaper change for incontinent. On skin condition, resident was identified as with risk for pressure ulcer, with two Stage 2 and one Stage 3 pressure ulcers that were present upon admission noted. The date of the oldest ulcer was 2/7/17. Resident was observed on several occasions during the survey. On 07/07/2017 at 12:11 PM,resident was observed on her right lateral position with 2 1/2 siderails(SR ) , appropriately dressed with contractures of bilateral hands and bilateral lower extremities .On 07/10/2017 at 11:18 AM , the resident was observed in bed laying at a 30 degree angle position, asleep. At 12:30 PM, the CNA (certified nursing assistant ) came to feed the resident who was still in the same position, on her back. At 2:03 PM, the resident was observed in the same position, on her back.When asked if she is had been turned and position changed, she shook her head from side to side. On 7/11/2017 at 10:10 AM the resident was observed lying in bed with a folded bedsheet wet from urine with direct contact to her skin The resident's medical records and interdisciplinary notes documented that resident has multiple pressure ulcers on both right and lower buttocks . She was seen by the wound team weekly . The interdisciplinary notes on 5/30/2017 documented both wounds on the right medial buttock and left buttock are healed and to continue current nutritional plan . However, on 5 /31/2017 the professional licensed nurse documented a skin opening on the left buttock area. A telephone call was made to the physician, who then ordered cleansewith nss ( normal saline solution ) then cover with xeroform. On 06/06/2017 the wound team saw the resident and described the wound on the left buttock measuring 6.0 x 2.3 x 0. cm , unstageable with slough and eschar revealing the wound had progressed. The medical record documented from 06/06/2017 to 06/13/2017 wound on the left buttock. On 06/20/2017 the wound team documented a wound on the right buttock. The record stated: Acquired in the facility measurement is 4.0 ( length ) x 2.3 (width ) x 0.2(depth ) cm ( centimeter ). It extends to the level of the subcutaneous tissue making it worsening stage 3. Detailed description wound bed is red with bruised areas, most severe tissue type is necrotic tissues. Wound looks moist , drainage is serous, amount of drainage is scant, debris and necrotic tissue are noted in moderate amount . Overall the wound is worsening. The potential for this wound healing is suboptimal . The resident's medical records and interdisciplinary notes documented that resident has multiple pressure ulcers on both right and lower buttocks . She was seen by the wound team weekly . The interdisciplinary notes on 5/30/2017 documented, both wounds on the right medial buttock and left buttock are healed and to continue current nutritional plan . However, on 5 /31/2017 , the professional licensed professional nurse documented a skin opening on the left buttock area . Telephone call was made to the physician with an order of cleansed with nss ( normal saline solution ) then covered with xeroform. On 06/06/2017 the wound team saw the resident and described the wound on the left buttock measuring 6.0 x 2.3 x 0.2 cm unstageable with slough and eschar . Review of the CNAAR ( certified nursing assistant activities records ) documented the resident was turned once per shift. The Comprehensive Care Plan (CCP ) was initially developed (MONTH) (YEAR). It documented Braden scale of 12, high risk for pressure ulcer. The resident had multiple pressue ulcers. For skin integrity the goal was to achieve wound healing in 90 days. The interventions in place were including but not limited to: pressure relieving mattress ,apply routine barrier A&D ointment to protect skin exposed to urine /saliva /stool and wound drainage. Keep head of bed elevated at or below 30 degree elevation / Incontinent care q (every ) 2-3 hours for soiling and provide skin care. Do not position directly on trochanter when lying on her side. Relieve pressure on heels with pillow under the length of the lowerleg and suspending heels. Turn and Position every 2 hours change of brief every 3 hours. There was no mention of wound observations made on 5/30/17, 5/31/17, 6/06/17, 6/14/17. The CCP was last updated on 07/07/2017 noting that the resident had two Stage 3 pressure ulcers now and are grulating slowly. High risk skin protocol continues, goal and interventions ongoing. There was no mention of resident being allergic to disposable briefs. On 7/11/2017 at 11:00AM the CNA( certified nursing assistant ) was interviewed and stated she is using bedsheet because the resident is allergy to diaper . Before they give us clothe diaper , but it has been awhile since that was given to us . During an interview with the attending physician on 7/11/2017 at 12:07 PM she stated resident had her wound healed on 5/31/2017. Dressing was xeroform and she was receiving antifungal creams . Reviewing the medical records and her orders she stated I dont understand and I cannot explain why there was no documentations /nor an order when the wound was identified on 6/14/2017 . We try to do our best and next time it will be better . The CCP does not indicate that the wound was healed on 5/31/17. Review for wound treatment reveals no treatment ordered till 6/20 /2017 for the right buttock after she was seen by the wound doctor. The Licensed Practical Nurse on duty were interviwed on 7/11/2017 at 12:24 PM and stated skin check is done by the CNAS every shift . If there is a new wound or skin break , it is reported to the charge nurse who then will call the nursing supervisor to do the asessment and the SBAR , ( situation, background, assessment, resolution ). When asked if an SBAR was genereted on 6/14/2017 for the new wound on the right buttock, she stated there is none . 415.12.(c)(1)

Plan of Correction: ApprovedAugust 25, 2017

1. Corrective Action to be Taken for Affected Residents:
Resident #12 was cleaned and changed promptly, wet linen removed, and bed changed with dry linen. Resident was turned and re-positioned after care.
Cloth briefs were obtained for resident use going forward. Resident care plan was revised to address Rt & Lt Buttock healed ulcers, Lt & Rt buttock re-opened, worsening pressure ulcers, and current status of wounds. Resident?s care plan was also revised to address her allergy to disposable briefs.
2. Identification of Other Residents with Potential to be Affected:
High Risk Management Meeting was conducted and documentation review of all residents with pressure ulcer was done from Initial Wound observation and RN assessment, Wound consult weekly rounds report, RN weekly wound assessment, Review of doctor?s orders, Care plans and CNA TASK. Weekly and on-going wound rounds were conducted. Care plans were updated as needed to reflect wound history and current status. All residents chart was reviewed to identify those with allergy to disposable briefs in order to ensure they use cloth diapers. No other residents were identified.
3. Measure Implemented to Prevent Recurrence
The Pressure Ulcer Prevention policy and procedure which includes bowel and bladder incontinence risk factors and management was reviewed and all nursing staff were re-educated on the policy. All nursing staff were also re-educated on the Incident/Accident Reporting?, ?Investigation of Incident/Accident?, and ?Care Planning? policies and procedures. Furthermore, they were also educated to address residents? allergy to disposable briefs by requesting for, and obtaining, cloth diapers. Care plan was updated as appropriate.
4. Quality Assurance Monitoring:
An audit tool was created for Nurse Managers to check that residents? care plan is updated to reflect residents? wound progression using the weekly wound consults and RN Weekly Wound Assessment and to check that residents with pressure ulcer is turned and re-positioned, clean & dry when soiled. Audit will be conducted weekly x 4 weeks, then bi-weekly 1 month, then monthly x 1. An audit tool was created to check that any resident with allergy to disposable brief is provided with cloth diaper.
Audit will be conducted weekly x 4 weeks, then bi-weekly 1 month, then monthly x 1. Findings will be provided to monthly QA committee for review and follow up as needed.
Responsible Party: DON/Designee

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 31, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that exits were readily accessible at all times without impediments to their full instant use in the event of an emergency. This was evidenced by a locked horizontal sliding door.This was observed on 1 out of 4 floors. The Findings include: On (MONTH) 07 (YEAR) at approximately 10:00 am during the recertification survey, observations in the canteen area on the first floor (Farkas building) included horizontal sliding doors that lead to an outside patio. However, when tested , these two sliding doors did not operate as designed. When the breakaway feature was tested , only one of the two door leaves opened. In an interview conducted on 07/07/17 at approximately 10:05 am, Maintenance Director stated that this concern will be corrected immediately. 10NYCRR711.2 (a)(1) 2012 NFPA 101 - 19.2.1

Plan of Correction: ApprovedAugust 21, 2017

1. Corrective Action to be Taken for Affected Residents:
On (MONTH) 8, (YEAR), both horizontal sliding doors in the canteen area that failed the breakaway test were repaired. Maintenance personnel cleaned and greased the tracks on both sliding doors. Both sliding doors were subsequently tested and the breakaway features were found to be in good working order. In accordance with surveyor recommendation, signage was posted on both sliding doors that instructs how to utilize the breakaway feature in the event of an emergency.
2. Identification of Other Residents with Potential to be Affected:
All residents have the potential to be affected. A facility-wide inspection of all sliding doors will be completed to ensure that the breakaway features are in good working order.
3. Measure Implemented to Prevent Recurrence:
Director of Maintenance and Director of Environmental Services will inspect all sliding doors during Environmental Rounds. Director of Maintenance will educate maintenance personnel on discharge from exits in accordance with NFPA 101. Any deficient findings will be immediately corrected.
4. Quality Assurance Monitoring:
Director of Maintenance will report findings of Environmental Rounds to the Quality Assurance committee for review and follow up as needed. Audit will be conducted weekly x 4 weeks, bi-monthly x 1 month, and then monthly x 1.
Responsible Party: Director of Maintenance

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL -1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 Based on observation and staff interview, it was determined that the facility did not ensure that extension cords and power strips were used in accordance with NFPA 99 and NFPA 70 National Electrical Code. Reference is made to unapproved power strips in use within the BR building in 3 out of 8 floors. The findings are: On (MONTH) 06 (YEAR) at approximately 10:00 am during the Life Safety Recertification Survey, surge protectors were observed in areas in the BR building. The UL listing could not be verified for use with the equipment plugged into it. Examples include but are not limited to: -room [ROOM NUMBER]. -Information Technology (IT) closet on the third floor. -room [ROOM NUMBER] -room [ROOM NUMBER] On (MONTH) 06, (YEAR) at approximately 11:00 a.m, in an interview with the Maintenance Director, he stated that these concerns will be corrected. 2012 NFPA 101 2012 NFPA 99 10.2.3.6, 10.2.4 NFPA 70 400-8 590.3(d) 711.2(a)(1)

Plan of Correction: ApprovedAugust 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective Action to be Taken for Affected Residents:
Director of Maintenance directed maintenance personnel to remove unapproved power strips in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and the IT closet. Unapproved power strips were replaced with UL1363(A) power strips that are compliant with NFPA 99 and NFPA 70 guidelines.
2. Identification of Other Residents with Potential to be Affected:
All residents have the potential to be affected. A facility-wide audit will be completed to identify, and replace, all unapproved power strips from patient care areas with UL1363(A) power strips that are compliant with NFPA 99 and NFPA 70 guidelines.
3. Measure Implemented to Prevent Recurrence:
Director of Maintenance will inspect for UL1363(A) power strips that are compliant with NFPA 99 and NFPA 70 guidelines during Environmental Rounds. Director of Maintenance will educate maintenance personnel on usage of approved power strips in accordance with NFPA 99 and NFPA 70 guidelines. Any deficient findings will be immediately corrected.
4. Quality Assurance Monitoring:
Director of Maintenance will report findings of Environmental Rounds to the Quality Assurance committee for review and follow up as needed. Audit will be conducted weekly x 4 weeks, bi-monthly x 1 month, and then monthly x 1.
Responsible Party: Director of Maintenance

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility had established policies and protocols for testing intervals for patient care-related electrical equipment in accordance with NFPA 99. However, not all resident equipment was on the preventive maintenance schedule. This was noted in the ZP building. The findings are: On (MONTH) 05 (YEAR) between the hours of 09:30 am and 02:30 pm during the recertification survey, within the ZP building, three electrical beds in resident room [ROOM NUMBER] were observed with inspection dates of: 1. (MONTH) (YEAR). 2. (MONTH) (YEAR). 3. Oct (YEAR). In an interview with the Director of Maintenance on 07/05/2017 at approximately 12:45 pm, he stated that the beds were rental units and that they will be inspected accordingly. 2012 NFPA 99: 10.5.2.1.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 23, 2017

1. Corrective Action to be Taken for Affected Residents:
Director of Maintenance directed maintenance personnel to inspect rental beds identified with expired inspection stickers. All identified beds were inspected and found to be in good working order.
2. Identification of Other Residents with Potential to be Affected:
All residents have the potential to be affected. A facility-wide audit was conducted to ensure that all beds have current safety inspection stickers. Any deficient finding will be serviced to ensure that current safety inspection stickers can be, and are, applied.
3. Measure Implemented to Prevent Recurrence:
Director of Maintenance and Director of Environmental Services will inspect beds for current safety inspection stickers during monthly Environmental Rounds. Director of Maintenance will educate maintenance personnel on a new policy for electrical testing of beds. Any deficient findings will be immediately corrected.
4. Quality Assurance Monitoring:
Director of Maintenance will report findings of monthly Environmental Rounds to the Quality Assurance committee for review and follow up as needed. Audit will be conducted monthly x 6 months.
Responsible Party: Director of Maintenance

K307 NFPA 101:FIRE DRILLS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 31, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that a staff member was trained in fire safety drills. Reference is made to the smoking supervisor who did not take part in fire safety drills. The Finding is: On (MONTH) 07, (YEAR) at approximately 09:30 am during the recertification survey, it was observed that on the first floor outside patio, a smoking area was located and residents were observed smoking. A staff member was observed from the recreation department to supervise the smokers. However, when questioned regarding the protocols for fire alam and fire drills, the staff member was not knowledgeable in the policies and procedures. She further stated that she did not take part in any fire drills by the facility. On 7/7/2017 at approximately 2:30 pm, this concern was shared with the Administrator and it was not clear to the surveyor as to what actions the facility will take to correct this concern. 2012 NFPA 101: 19.7.1.4 through 19.7.1.7

Plan of Correction: ApprovedAugust 21, 2017

1. Corrective Action to be Taken for Affected Residents:
Director of Maintenance contracts East Coast Site Safety, Inc. to conduct monthly fire safety drills, quarterly per shift. All recreation staff will be re-educated on the facility's fire safety guidelines and protocols.
2. Identification of Other Residents with Potential to be Affected:
All residents have the potential to be affected. Both the Director of Maintenance and the Director of Recreation will ensure that all staff monitoring our smoking program are trained in our fire safety guidelines and protocols.
3. Measure Implemented to Prevent Recurrence:
Director of Maintenance will question 10 randomly selected staff during Environmental Rounds to ensure proficiency and competency with regard to fire safety guidelines and protocols.
4. Quality Assurance Monitoring
Director of Maintenance will report findings of Environmental Rounds to the Quality Assurance committee for review and follow up as needed. Audit will be conducted weekly x 4 weeks, bi-monthly x 1 month, and then monthly x 1.
Responsible Party: Director of Maintenance