Samaritan Keep Nursing Home Inc
October 25, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(a)(b):ADLS DO NOT DECLINE UNLESS UNAVOIDABLE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2017
Corrected date: December 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews conducted during the recertification survey, for 1 of 27 residents (Residents #22) reviewed for activities of daily living (ADLs), the facility did not ensure the ability to perform ADLs did not diminish. Specifically, Resident #22 was not ambulated as planned. Findings include: Resident #22 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 8/17/2017 Minimum Data Set (MDS) assessment documented the resident had intact cognitive function, required extensive assistance with transfers, dressing, and hygiene. The resident required supervision and assistance of one person for walking, had upper and lower body impairment on one side, and utilized a walker and a wheelchair. The 9/2017 resident care record (RCR) documented the resident required assistance of 1 person for ambulation, transferred by standing/pivoting, used a with a rolling walker and gait belt, and was on the restorative CNA (certified nurse aide) program. The walking therapy detail report dated 9/1/2017-10/27/2017 documented the resident received walking restorative care for 15 minutes on 9/4, 9/7, 9/10, 9/12, and 9/14/2017. There was no other walking care documented. The 10/2017 RCR documented the resident required assistance of 1 person for ambulation, transferred with a mechanical stand lift, and there was no restorative CNA program noted. The comprehensive care plan (CCP) initiated 6/14/2017 and updated 10/17/2017 documented the resident had decreased mobility related to [MEDICAL CONDITION]([MEDICAL CONDITION], stroke) and [MEDICAL CONDITION]. The goal was for the resident to maintain her current level of mobility. Interventions included the resident was to be ambulated in the hallway daily for 100 feet with blue platform rolling walker (walker with raised arm supports) with the left brake on with 1 assist and a gait belt. During an interview with the resident and her husband on 10/25/2017 at 8:50 AM, the resident stated a therapy aide was coming to the unit to walk her regularly, the aide positions were cut, and she was no longer walked. She stated she was able to walk using the platform walker and a belt around her waist (gait belt) with the assistance of the aide. She stated she had not been walked in over one month and was not sure if she could still walk. She used to transfer by standing and pivoting, but recently has had difficulty doing so and staff began using a mechanical lift when she was transferred. Her husband stated he was having increased difficulty in assisting her in and out of the vehicle, as he had to lift her. When she was walking, she stood and pivoted into the vehicle. The resident stated she had not been referred back to therapy related to her decline in walking and would like to resume walking. They had notified the registered nurse (RN) Unit Manager and she had told them the resident should be walked on the unit. On 10/25/2017 at 9:40 AM, the resident's husband identified the platform walker in the hallway on the unit and stated that was the assistive device his wife used when she was walked. When interviewed on 10/25/2017 at 9:40 AM, CNA #21 stated she was unaware if the resident used the platform walker, if it was care planned for platform walker, that was what CNAs would use to walk the resident. She stated any CNA was able to use the walker, as long as it was specified in the resident's care plan. During an interview on 10/26/2017 at 2:10 PM, CNA #8 stated the resident was walked to the bathroom sometimes and not walked in the hall. There was a walking program that ended about one month ago and he was unsure if CNAs were supposed to take over walking the residents who were in the program. He stated it had not been communicated to him if the resident was to be walked on the unit, and CNAs on the unit did not have the additional time to walk residents. When interviewed on 10/27/2017 at 11:40 AM, CNA #10 stated there used to be a restorative walking program and the resident was being walked by the aides in the program. The restorative walking aides were sent back to units to address CNA staffing needs and she was unaware of who was responsible for walking residents who were in the program. She was not instructed to pick up the walking program and had not walked the resident using the platform walker. She stated if the resident was walked, there was an area in the CNA ADL documentation to note when it was done, level of assistance, and distance. During an interview with registered nurse (RN) Unit Manager #12 on 10/27/2017 at 12:20 PM, she stated the restorative aides were reassigned back to the units to fill CNA positions about three weeks prior. The walking assignments were picked up by the CNAs on the floor, it was communicated to the CNAs, they should be doing it, and walking residents was not occurring regularly. She stated if a resident was on the walking program, it would be on the RCR, and she was unaware of the reason it was not on the resident's current RCR. She stated if the resident's condition declined, she would expect it to be reported to her, and it had not been reported that the resident had declined. 10NYCRR 415.12(a)(1)(ii)

Plan of Correction: ApprovedNovember 21, 2017

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #22 had a decline in her ADL?s, specifically her ambulation. Physical Therapy is currently working with this resident to bring her to her highest level of functioning with her ambulation.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Multiple residents are affected by this same deficient practice. The care-plan for each resident was reviewed for ambulation recommendations made by the Therapy Department and a report was submitted to the perspective units to ensure that the information is placed on the Resident Care Record and is placed on the Task list for the CNA?s to complete and document as required in Optimus.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur
The Rehabilitation Department will communicate any time a change is made in the recommended care of the resident. The recommendation will be submitted to the unit at the time of the change so that the information may be carried over to the RCR, Medical Record and CNA task list for completion as appropriate.
All Rehabilitation staff (PT, OT, ST), RNs, LPNs, and CNAs will be educated regarding the communication, documentation, and follow-through of the process of the implementing recommendations to prevent resident decline.
4. How the corrective action(s) 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 Rehabilitation or designee will review 30 resident each month to ensure residents have been ambulated as per the Rehabilitation Department?s recommendations and documentation in the medical record included distance ambulated. If the resident is unable to ambulate or refuses the CNA will notify the LPN who will document in the medical record and notify the RN. Auditing will continue until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Rehabilitation and will be reported monthly to the Quality Assurance Quality Improvement Council (QAPI).
5. The date of correction and the title of the person responsible for the correction of each deficiency
Completion date: 12/26/2017
The Manager Physical Therapy will be responsible for this deficiency

FF10 483.60(g):ASSISTIVE DEVICES - EATING EQUIPMENT/UTENSILS

REGULATION: (g) Assistive devices The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2017
Corrected date: December 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews conducted during the recertification survey, it was determined the facility did not ensure 4 of 27 residents (Residents #5, 7, 15, and 24) reviewed for activities of daily living (ADLs) and one additional resident (Resident #35) was provided assistive devices for eating as planned. Specifically: - Resident #5 was not provided dycem (anti-slip material) and two-handled cups; - Resident #7 was not provided a spork and divided dish; - Residents #15 and 24 were not provided built up eating utensils; and - Resident #35 was not provided a green cup with built in straw. Findings include: The facility's Adaptive Equipment Policy revised 1/2017 documents nursing is to assure adaptive devices are provided to each assigned resident per meal and will be documented on resident ticket. 1) Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance for eating, and was on a mechanically altered diet. The speech language pathologist (SLP) progress note dated 9/13/2017 documented the resident had been discontinued from speech therapy with recommendations of a spork, white divided dish, and all items cut up into small pieces. Physician orders [REDACTED]. The comprehensive care plan (CCP) updated 10/20/2017 documented the resident had difficulty chewing related to the inability to chew sold meats. The interventions included oral sweep following meals, level 2 solids (soft textures, ground meats), use of a spork, divided dish, and and food cut up into small pieces. The following observations were made in the dining room: - on 10/23/2017 at 6:25 PM, the resident was seated at the table with her supper meal, and had no divided dish or spork; - on 10/24/2017 at 12:55 PM, the resident was eating lunch with a regular spoon, a regular plate, and had a knife and fork next to her plate; and - on 10/27/2017 at 12:55 PM the resident was eating lunch with a regular spoon, a knife and fork were next to her dish. The resident's meal ticket dated 10/27/2017 documented the resident was to have a level 2 diet, no knives, a spork, and a divided dish. The resident care record (RCR) dated 10/2017 documented the resident used adaptive equipment for eating. During an interview with certified nurse aide (CNA) #8 on 10/26/2017 at 2:10 PM stated kitchen staff brought all adaptive equipment to the unit and CNAs were responsible to set up the resident's tray with any needed equipment according to the resident's meal ticket. He stated half the time, the adaptive equipment was available on the unit. When equipment was not on the unit, staff had to call the kitchen to request it be brought to the unit. When interviewed on 10/27/2017 at 11:40 AM, CNA #10 stated staff provide adaptive equipment based on what is on the resident's meal ticket. The resident fed herself at times, should have a spork, she was unaware of the reason for instructions not to have a knife, and it may have been a safety reason. During an interview on 10/27/2017 at 12:30 PM, registered nurse (RN) unit manager #12 stated residents should be provided adaptive equipment as documented on RCRs and/or meal tickets. If equipment was not available or not used, the nurse should be notified. 2) Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and required supervision and assistance with eating. The dietary progress note dated 8/28/2017 documented the resident used adaptive equipment including built up utensils, scoop bowl, and inner lip plate. The comprehensive care plan (CCP) updated 8/30/2016 documented the resident had decreased independence with activities of daily living (ADLs). Interventions included use of an inner lip plate, scoop bowl, and built up utensils for all meals. The resident care record (RCR) dated 10/2017 documented the resident required encouragement with eating. Use of adaptive equipment was not checked on the RCR. The following observations were made in the dining room: - on 10/23/2017 at 6:05 PM, the resident was eating his supper meal, his meal ticket documented built up utensils, scoop bowl, and inner lip plate. The resident had a regular plate, bowl, and silverware. - on 10/26/2017 at 12:42 PM, the resident was eating lunch, he had regular utensils, a regular plate, and regular bowl; and - and on 10/27/2017 at 12:55 PM, the resident was being assisted by a CNA with his lunch, he had a regular plate, regular bowls, and regular utensils. The resident's meal ticket dated 10/27/2017 documented the resident used built up utensils, inner lip plate, and a scoop bowl. During an interview with certified nurse aide (CNA) #8 on 10/26/2017 at 2:10 PM stated kitchen staff brought all adaptive equipment to the unit and CNAs were responsible to set up the resident's tray with any needed equipment according to the resident's meal ticket. He stated half the time, the adaptive equipment was available on the unit. When equipment was not on the unit, staff had to call the kitchen to request it be brought to the unit. When interviewed on 10/27/2017 at 11:40 AM, CNA #10 stated staff provide adaptive equipment based on what is on the resident's meal ticket. The resident was able to feed himself, he received assistance at times, was to have built up utensils, scoop bowls, and an inner lip plate. She stated if the resident was fed by staff, they did not need the adaptive equipment. During an interview on 10/27/2017 at 12:30 PM, registered nurse (RN) Unit Manager #12 stated residents should be provided adaptive equipment as documented on RCRs and/or meal tickets. If equipment was not available or not used, the nurse should be notified. 3) Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, did not reject care, and was totally dependant on staff for dressing, and required limited assistance for eating. An occupational therapist's (OT) progress note dated 8/4/2017 documented the resident was seen for evaluation following hospitalization . The OT's recommendations included: - encourage resident to complete self feeding, offer assistance as needed; - provide inner lipped plate, two-handled cup with straw, right angled spoon at all meals The resident care records (RCRs) dated 8/8/2017 and 9/7/2017 documented the resident used adaptive equipment for eating and was not to be fed by a paid feeding assistant. The RCR dated 10/2017 documented the resident may be fed by a paid feeding assistant. It was not noted the resident had adaptive equipment for eating. The comprehensive care plan (CCP) updated 9/23/2017 documented the resident required total assistance for activities of daily living (ADLs) related to dementia. Interventions included adaptive equipment for meals and snacks as recommended by therapy department. The CCP was updated on 10/25/2017 and documented the resident had increased nutrient needs for wound healing and dysphagia. Interventions included scoop bowls, dycem, inner lip plate, right angled utensils, and a two-handled spout mug with straw with meals. The resident's 10/27/2017 meal ticket documented the resident was to have dycem, a scoop bowl, right angled spoon, inner lip plate, and a two-handled mug with a lid. The resident was observed in the dining room: - on 10/23/2017 at 6:08 PM eating the supper meal and had no dycem or two handled mug; and - on 10/27/2017 at 7:58 AM with breakfast and no dycem in place. During an interview with licensed practical nurse (LPN), Assistant Nurse Manager #16 on 10/27/2017 at 1:30 PM, she stated adaptive equipment used by the resident would be found on the RCR or the task sheet. During an interview with certified nurse aide (CNA) #24 on 10/27/2017 at 12:15 PM, she stated the adaptive equipment was shown on the meal ticket and whoever passed the tray may have forgotten to put all the adaptive equipment in place. 10NYCRR 415.14(g)

Plan of Correction: ApprovedNovember 21, 2017

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
All adaptive equipment for Residents # 5, # 7, #15, # 24, and # 35 have been added to their meal ticket and staff have been educated to ensure that they have this equipment with every meal.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Multiple residents are potentially affected by this same deficient practice. Meal observations were conducted on all units to ensure residents? meal ticket match therapy recommendations for adaptive equipment and was provided to the resident for the meal
Immediate education will be to staff found not following/providing the recommended adaptive equipment.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recurrence.
The meal process was reviewed and updated to include a read back process which would include ensuring the correct adaptive equipment is provided to the resident. All staff who participates in the meal process will receive education regarding the read back process and the importance of ensuring the appropriate adaptive equipment is provided to the resident.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
An interdisciplinary team (Nurse Managers, Food Service Site Manager, Rehabilitation, Dietician, and Activities Director) will conduct a meal observation on each unit each month to ensure the appropriate adaptive equipment, as recommended by therapy, is provided for each resident?s until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Dietary Site Manager and will be reported monthly to the Quality Assurance Quality Improvement Council (QAPI).
5. The date of correction and the title of the person responsible for the correction of each deficiency
Completion date: 12/26/2017
The Dietary Site Manager Director will be responsible for this deficiency.

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2017
Corrected date: December 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification and abbreviated surveys (NY 410), for 1 of 30 residents reviewed for comprehensive care plans (CCP, Resident #19), the facility did not develop and implement a person centered CCP for the resident. Specifically, for Resident #19 who had a history of [REDACTED]. Findings include: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated 1/2/2017 documented the resident was admitted to the hospital on [DATE] following an alleged assault by a family member who allegedly pushed the resident out of a vehicle. The discharge summary documented the resident's daughter (who was her health care proxy) reported their relationship was turbulent and there was a history of abuse. The 1/3/2017 physician's orders [REDACTED].#5. The comprehensive care plan (CCP) initiated on 1/3/2017, contained no documentation related to the resident's history of being abused and did not contain a plan of care to ensure the resident's safety when visiting with her family or when going out on leave of absence. The 4/20/2017 registered nurse (RN) Unit Manager #3's progress note at 5:00 PM, documented on that day at 2:00 PM, she was notified that the resident went out with her husband on 4/16/2017, was tearful when she returned, and on 4/18/2017, the resident told a staff member that she was sexually abused while she was out. RN Manager #3 documented she immediately informed the Administrator, Director of Nursing (DON), and the police were called. The facility's 4/20/2017 incident report included an email written by RN Manager #3 and sent to the Nurse Managers, Supervisors, and the Director of Social Services on 1/6/2017. The email specified that the resident's hospital paperwork documented she was abused by her husband for many years, emotionally, and physically, and staff were instructed to monitor the resident and call the Supervisor immediately if there were issues when he visited. The 4/21/2017 licensed practical nurse's (LPN) #5's progress note documented a new order to discontinue home visit privileges. On 4/26/2017 RN Unit Manager #3 updated the resident's CCP and documented the resident was at risk for emotional distress related to family interactions. The plan included safety checks when the resident's family visited, no home visits, and the resident was not to leave the unit with her spouse. The resident was observed at lunch on 10/25/2017. She walked herself to the dining room at 12:45 PM and stood in front of her chair at the table. Staff encouraged her to sit down and she did at 12:58 PM. At 1:00 PM, the resident stood up, was crying, and stated to certified nurse aide (CNA) #6 (who was standing with her) stay here, stay here, don't leave. From 1:00 PM-1:10 PM, CNA #6 tried to coax the resident to sit down and eat and at 1:10 PM, CNA #6 assisted the resident to sit at a tray table where she sat and ate. On 10/26/2017 at 12:25 PM, social worker #2 stated in an interview, she did not recall being aware the resident had a history of [REDACTED]. On 10/26/2017 at 1:30 PM, RN Unit Manager #3 stated in an interview, when the resident was admitted to the facility, she sent an email to the Nurse Managers, Supervisors, and Director of Social Services letting them know the history. She stated they determined they would keep an eye on things and see how things went when he visited her. She stated she was not aware the resident had been going out with her spouse on the weekends as she did not work on the weekends and she did not become aware he had been taking her out until after there was an issue on 4/16/2017. On 10/26/2017 at 2:45 PM, LPN #5 stated in an interview, the leave of absence order was standard on new admissions unless they were aware of issues that would prevent a resident form being safe to go out with their family members. She stated they were aware of the resident's history on admission because the hospital paperwork documented the resident's spouse may have pushed her out of a vehicle in the past. She stated when the resident was admitted and she read that, she showed it to social worker #2 and social worker #2 talked to the resident's daughter and determined it would be fine for her to go home with her spouse. On 10/26/2017 at 3:45 PM, the attending physician stated in an interview, the leave of absence order was given to almost all residents on admission and he was not aware there was a history of abuse between the resident and her spouse prior to the incident in 4/2017. He stated now that he was aware, the order was discontinued and that was done in an attempt to prevent abuse from happening again. On 10/27/2017 at 11:20 AM, the Administrator was interviewed and stated the facility was aware of the history of abuse on admission. She stated she knew if the facility had that information, they would have been taken into account but she was not sure how that was done in this case as the DON at the time of the incident was no longer employed by the facility. On 10/27/017 at 11:35 AM, the Director of Social Services stated in an interview, she received the email in 1/2017 from RN Unit Manager #3 and forgot about it until the Administrator forwarded it to her again in 4/2017. She stated when she received it in 1/2017, she did not forward it to social worker #2, it should have been considered when the resident's plan of care was developed, and it was not included in the initial CCP. 10NYCRR 415.11(c)(1)

Plan of Correction: ApprovedNovember 21, 2017

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #19?s care plan was updated to reflect family visitation and risk for emotional stress. Safety checks have been instituted when the family is visiting, no home visits are allowed, and the resident is not to leave the unit with her spouse without a staff escort.
Unit staff has educated to observe Resident # 19 during mealtime and if she becomes anxious and does not want to sit in the dining room, she should be offered the opportunity to move to a quieter environment.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
In (MONTH) (YEAR) the process for completing an incident report was reviewed and revised to include updating the care plan and Resident Care Records (RCR) at the time of the incident. As part of the incident investigation the resident?s care plan will be updated to reflect any identified intervention needed to meet the need of the resident and a copy of the revised care plan and RCR is submitted with the incident report for review by the DON. The DON will ensure that all concerns identified are addressed in the care plan and Resident Care Record by reviewing the submitted documentation. No other residents have been affected by this same deficient practice.
Meal observations were conducted on all units to ensure any resident who was anxious in the dining environment was appropriately addressed and offered to be placed in a quieter/calm environment. No other residents were affected by this deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur
In (MONTH) (YEAR) all RNs who are responsible for investigating incidents received education regarding the revised process for completing an incident report including the review and revision of care plans and Resident Care Records. Any identified intervention is put into the care plan during the initial investigation and submitted with the incident report for review by the DON.
Members of the social services department will be educated to ensure information relayed to them is report and followed up in a timely manner.
The Comprehensive Resident Assessment and Plan of Care policy was updated to reflect the preparation of an interdisciplinary comprehensive assessment of the resident which will include the resident?s needs, strengths, goals, life history and preferences. The information will be used to develop, with the input and participation of the resident and representative, a comprehensive person-centered care plan that promotes and assists the resident to maintain their highest practicable physical, mental and psychosocial well-being.
Members of the interdisciplinary team include the resident?s QMP, a registered nurse responsible for the resident, a CNA responsible for the resident, a member of the social services department, a member of the nutrition services department, a member from the activities department, members of the skilled therapy department, and others as determined by the resident?s needs and preferences.
The meal observation will include an assessment of the resident ability to interact with peers and staff during mealtime. If they are found to be agitated or anxious a plan will be developed to offer them a quiet area for their meal. This will be updated in the care plan.
4. How the corrective action(s) 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 Nursing or designee will conduct an audit of 30 residents to ensure the resident?s the comprehensive person-centered care plan accurately reflects and promotes the resident to maintain their highest practicable physical, mental and psychosocial well-being. Monitoring will continue monthly for 3 months, and then quarterly until 100% compliance. Monitoring for compliance is the responsibility of the Activities Director and will be reported to the Quality Assurance Quality Improvement Council (QAPI).
5. The date of correction and the title of the person responsible for the correction of each deficiency
Completion date: 12/26/2017
The Director of Nursing will be responsible for this deficiency

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

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2017
Corrected date: December 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, the facility did not promote care for residents in a manner and an environment that maintained or enhanced each resident's dignity for 4 of 27 residents (Residents #5, 11, 23, and 28) and 4 additional residents (Residents #31, 32, 33, and 34) reviewed for dignity. Specifically, Resident #5 was not provided a privacy cover for her Foley catheter bag (urinary drainage device); Resident #11 had unwanted facial hair and unkempt fingernails; Residents #23, 31, 32, 33, and 34 were fed by staff who were standing and moving about; and Resident #28 was in a hospital gown while in a public area. Findings include: 1) Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 8/31/2017 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance personal hygiene, and did not reject evaluation of care. The comprehensive care plan (CCP) dated 7/8/2017 documented the resident required assistance and supervision with his activities of daily living (ADLs), and interventions included maximum assistance for oral care and grooming. He was encouraged to be as independent as his condition allowed. There was no documentation in the CCP the resident refused or declined assistance with hygiene. The resident's care record (RCR) dated 9/30/2017 documented the resident was alert and confused, required the assistance of two staff for bed mobility and transfer, and was totally dependant on staff for dressing. There was no documentation noting the level of assistance he needed for grooming. The resident was observed with facial hair and dirty fingernails: - on 10/23/2017 at 6:15 PM in the dining room; - on 10/24/2017 at 12:17 PM in the dining room; and - on 10/25/2017 at 11:25 AM in the hall outside his room. During an interview with Resident #11 on 10/25/2017 at 11:30 AM, he stated he wanted his moustache, but not this other stuff (pointing to the facial hair on his chin and jaw line). As he pointed to his face, his fingernails were observed jagged with dirt underneath. He stated he had an electric razor and staff did not always help him shave. During an interview with certified nurse aide (CNA) #28 on 10/27/2017 at 10:13 AM, she stated the resident was not able to shave himself and needed the assistance of staff. At times the resident could be grumpy. If reapproached he was agreeable to care and had an electric razor available in his room for staff to use. During an interview with licensed practical nurse (LPN) #20 on 10/27/2017 at 10:10 AM, she stated the CNAs were expected to shave residents and clean their fingernails on shower day and fingernails should be looked at daily. During an interview with registered nurse (RN) Unit Manager #18 on 10/27/2017 at 10:13 AM, she stated it was an expectation the CNAs would shave and check/clean fingernails daily with care. She stated she was not sure if Resident #11 could shave himself and would have to check the care plan. 2) The facility's Mealtime Considerations policy and procedure revised 9/2016, documents for residents needing to be fed, caregivers must sit at the resident's level, unless otherwise care planned, and should immediately begin assisting residents when the tray is passed. During the supper meal on 10/23/2017, from 6:05 PM-6:30 PM, Residents # 23, 31, 32, 33, and 34 were observed to be seated at a table together (with an additional 3 residents). Resident care records (RCRs) dated 10/2017 documented Residents #23, 31, 32, 33 and 34 were alert and confused, ate in the dining room, and needed to be fed by staff. The undated Feeding List for 3-11 Shift provided by licensed practical nurse (LPN) #7 on 10/23/2017 at 6:10 PM, documented Residents #23, 31, 32, 33, and 34 were to be fed by staff. An additional 6 residents were listed as needing to be fed, and another 5 residents were listed as needing assistance or cueing. Supper meal observations 10/23/2017 from 6:05 PM to 6:30 PM included: - At 6:07 PM, certified nurse aide (CNA) #8 moved between Residents #33 (seated at the end of the table) and Resident #34 (seated in the middle of the table with a resident in between), feeding each resident one to two bites of food, while standing at their side. - At 6:10 PM, CNA #8 fed a third resident at the table, while standing and then moved to another area of the table to feed Resident #33. - At 6:20 PM, CNA #9 fed Residents #23, 31, and 32 while standing and moving back and forth among them, feeding one to two bites at a time. - At 6:25 PM, CNA #8 moved between Residents #31 and 33 feeding each one to two bites of food while standing. - A total of 4 CNAs and 2 LPNs were feeding/assisting residents in the dining room. During an interview with LPN #7 on 10/23/2017 at 6:35 PM, she stated they had at least 14 residents who needed to be fed or assisted, there were only 4 CNAs, herself, and an LPN who was training. She stated there was not enough staff to feed all the residents and staff had to keep going back and forth to various residents to ensure they were all fed. The LPN added they would need at least 7 staff during the meal for 1 person to sit and feed two residents without having to get up and feed others. When interviewed on 10/26/2017 at 2:10 PM, CNA #8 stated CNAs were supposed to sit down, face residents, and engage with them while feeding. There were too many residents who required feeding assistance and there was not enough staff to enable them to sit to feed, as they had to move about the residents to ensure they were all were fed timely. On 10/27/2017 at 11:40 AM, CNA #10 stated in an interview staff sometimes had to stand and feed multiple residents, especially in the evening because there were not enough staff on the unit to sit and feed just one or two residents. During an interview with registered nurse (RN) Unit Manager #12 on 10/28/2017 at 12:20 PM, she stated staff were assigned to feed 2 residents each. They were to sit and engage with residents while assisting them with meals. She stated the unit had a large number of residents who required feeding assistance and there were not always enough staff to allow them to sit and feed them all. She stated it was not dignified or appropriate to feed while standing and moving about the dining room. 3) Resident #28 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 10/5/2017 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, exhibited no behavioral symptoms, did not reject care, required extensive assist for dressing, and had upper body impairment on one side. The comprehensive care plan (CCP) updated 9/23/2017 documented the resident required total assistance with activities of daily living (ADLs) related to advanced dementia and decreased mobility. The goal was to maintain cleanliness and dignity. Interventions included self care tasks at total assistance. The resident care record (RCR) dated 10/2017 documented the resident required extensive assistance for dressing and needed to be positioned in her Broda chair (specialized wheelchair for positioning). On 10/27/2017 at 7:58 AM, the resident was observed sitting at the dining room table with a hospital gown sliding off her left shoulder without a robe or sweater. Other residents were seated in the dining room, eating breakfast. During an interview with certified nurse aide (CNA) #22 on 10/27/2017 at 11:39 AM, she stated she dressed the resident in a hospital gown because it was the resident's shower day and normally she would not dress the resident until after her shower. She did not believe the resident had a robe and that is why she covered her with a blanket. During an interview with licensed practical nurse (LPN), Assistant Nurse Manager #16 on 10/27/2017 at 1:30 PM, she stated she would expect residents to be dressed when in the dining room and if it was the resident's shower day, she would expect the resident to have a robe or sweater covering the hospital gown while in the dining room. 10NYCRR 415.5(a)

Plan of Correction: ApprovedNovember 17, 2017

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #5 has been issued a privacy cover for her urinary drainage bag and unit staff has been instructed on its use.
Resident #11 has had his fingernails cleaned and trimmed and has been shaved and staff have been re-educated on the importance of keeping residents nails cleaned and trim and shaving residents per their individual wishes.
Staff involved in feeding Residents #23, #31, #32, #33, and #34 while standing have been re-educated on the importance of sitting at the Residents? eye level and conversing with the resident while feeding.
CNA #22 has been re-educated on the importance of proving a robe for residents who chose to wear a covering hospital gown or should dress residents prior to bringing resident to the dining room. Resident #28 has been provided a robe.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
An audit has been completed on all units to ensure residents with a Foley Catheter drainage system were issued a privacy cover and it was in use. No other residents are affected by this same deficient practice.
An audit has been completed on all units to ensure residents have trimmed and cleaned nails and are shaved in accordance with resident?s wishes. No other residents are affected by this same deficient practice.
Meal observations were conducted on all units to ensure residents were appropriately dressed in the dining room and staff was seated while feeding residents. No other residents were affected by this deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur
Education will be provided to all CNAs who provide direct care for residents. This education will stress the importance maintaining the Resident?s dignity and privacy and will specifically address the importance of keeping nails clean and trimmed, residents shall be shaved in accordance to their wishes, ensure resident is dressed or appropriately covered prior to being brought into the dining room, and ensure the use of a urinary drainage bag cover.

Education will be provided for all staff that feed, assist, and supervise Residents during meal time. This education will emphasize the importance of sitting at the resident?s eye level fee l while feeding residents unless otherwise care planned.

4. How the corrective action(s) 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 Nursing or designee will conduct the following audits:
An audit for 100% or 30 Residents (whichever is greater) each month who have a Foley Cather to ensure the drainage bag is covered with a privacy cover;
An audit for 30 Residents each month to ensure the resident is shaved and/or fingernails are cleaned and trimmed;
An audit of each nursing unit monthly, at varying meal times, to ensure residents are fed at eye level unless otherwise care planned and residents are appropriately dressed in the dining room.

Each individual audit will be completed monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Assurance Quality Improvement Council (QAPI).

5. The date of correction and the title of the person responsible for the correction of each deficiency
Completion date: 12/26/2017
The Director of Nursing will be responsible for this deficiency

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: October 27, 2017
Corrected date: December 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews conducted during the recertification survey, it was determined the facility did not ensure 3 of 5 residents (Residents #5, 23, and 28) reviewed for range of motion (ROM) received the appropriate treatment and services to improve and/or to prevent a decrease in ROM. Specifically, Residents #5, 23, and 28 were care planned to have palm guards and were observed without them. Findings include: 1) Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, did not reject care, and was totally dependant on staff for dressing and hygiene. An occupational therapist's (OT) progress note dated 8/5/2017 documented the resident refused range of motion (ROM) to hands and it was difficult to inspect skin of either hand or attempt hand hygiene. It was recommended that staff attempt hand hygiene twice daily and if resident accepted, place rolled wash cloths to both hands with removal for skin inspection and hygiene. An OT progress note dated 9/11/2017 documented the resident no longer required skilled therapy services and recommended the following: - Staff to provide gentle range of motion to both hands and encourage the resident to open her hands during care and while applying and removing the left hand splint (carrot, orthotic device for contractures); and - Resident to wear the left hand carrot per schedule in the RCR (resident care record) and on the schedule posted behind the resident's bathroom door. The comprehensive care plan (CCP) updated 9/23/2017 documented the resident required total assistance for activities of daily living (ADLs) related to dementia. Interventions included: - Resident was to wear left carrot splint per wearing schedule in RCR and the schedule on bathroom door; - Staff to provide gentle ROM to both hands, encourage resident to open her hands; and - One staff to attempt hand hygiene twice per day, if resident was accepting to place rolled washcloth in both hands with removal for skin inspection. There was conflicting documentation regarding which orthotic (carrot or rolled washcloths) was to be utilized. The RCRs dated 9/2017 and 10/2017 documented the staff were to attempt to place rolled wash cloths in both hands with removal for skin inspection and hygiene. A splint wearing schedule was observed on the resident's bathroom door on 10/26/2017 at 12:30 PM. The schedule documented the left carrot splint was issued 3/29/2017 and was to be worn continuously with removal at all meals and during morning and evening care. The resident was observed without rolled washcloths in both hands or a carrot in her left hand: - on 10/24/2017 at 12:11 PM, in bed - on 10/26/2017 at 12:30 PM, seated in her chair; and - on 10/26/2017 at 2:15 PM, lying in bed. During an interview with OT #23 on 10/27/2017 at 10:45 AM, she stated the resident was unable to tolerate the left hand carrot and rolled washcloths in the hands were recommended. During an interview with licensed practical nurse (LPN), Assistant Nurse Manager #16 on 10/27/2017 at 1:30 PM, she stated adaptive equipment used by the resident would be found on the RCR or the task sheet. When the certified nurse aide (CNA) signed that care was provided for their shift, they acknowledged all tasks were completed. 2) Resident #23 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, exhibited no behavioral symptoms, required extensive assistance for dressing, and had upper and lower body impairment on one side. The comprehensive care plan (CCP) initiated 7/27/2017 documented the resident required total assistance for activities of daily living (ADLs). Interventions included the use of a right palm guard. A physician's progress note dated 9/8/2017 documented the resident had deficits noted, right hand clenched in a fist, did not appear to be able to open. A physician's progress note dated 9/26/2017 documented the resident had not had any behavioral issues, his hands were clenched and resisted efforts to passively straighten out his fingers. The resident care record (RCR) dated 10/2017 documented the resident required total assistance of two staff for dressing and had special instructions for a right palm guard. The following observations were made of the resident without a palm guard in his right hand: - on 10/23/2017 at 6:07 PM, in the dining room; - on 10/24/2017 at 1:00 PM, in the dining room; - on 10/26/2017 at 2:10 PM, in bed; and - on 10/27/2017 at 8:45 AM, in the dining room. During an interview with certified nurse aide (CNA) #10 on 10/27/2017 at 11:40 AM, she stated she regularly worked with the resident, had never seen or applied a palm guard to the resident's right hand, was unaware if he had one in his room, and did not think he was care planned for one. During an interview with CNA #11 on 10/27/2017 at 11:55 AM, she stated she regularly worked with the resident, had never seen or applied a palm guard to the resident's right hand, and he was not care planned for use of a palm guard. CNA #11 accompanied the surveyor to the resident's room, verified on his RCR (located inside the closet door, dated 10/2017) the resident was to have a right palm guard. The CNA looked in the resident's drawer and produced a palm guard from the back of the drawer. She stated she did not know the resident was to have it and was not sure if he would refuse it if applied. When interviewed on 10/27/2017 at 12:20 PM, registered nurse (RN) Unit Manager #12 stated specialized devices such as palm guards were noted on RCRs so that CNAs knew to use them. She stated CNAs attempted to use the palm guard, but the resident resisted. If a resident resists care, it should be reported to the nurse and documented. During an interview with the Therapy Services Manager on 10/27/2017 at 1:00 PM, she stated all residents not receiving therapy services were screened every three months. Occupational therapy initiated palm guards, and if the resident was not using the palm guard, it would be picked up during screening. In between the three month screens, nursing could refer the resident for re-evaluation if the resident was not using the palm guard. She sated the resident was last screened in 8/2017, no concerns were brought to her attention, and she had not received any information form nursing since regarding the resident not using the palm guard. 3) Resident #28 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 10/5/2017 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, did not reject care, required extensive assistance for dressing, and was totally dependant on staff assistance for hygiene. The occupational therapist's (OT) progress note dated 7/31/2017 documented the resident no longer required skilled therapy services and recommended the following: - right palm guard to be worn continuously, remove for morning and evening care and meals; - skin care and range of motion as tolerated prior to palm guard application; - observe for reddened or blistered skin areas after removal of palm guard; and - notify OT if splint needs to be reassessed or if splint needs repair. The comprehensive care plan (CCP) updated 9/23/2017 documented the resident required total assistance with activities of daily living (ADLs) related to dementia and decreased mobility. Interventions included: - provide skin care, hygiene, and passive range of motion (PROM) prior to applying palm guard; - removing the palm guard to observe for reddened or blistered areas; - re-refer to occupational therapy per splinting issues/functional decline; and - wear schedule, worn continuously and removed for AM/PM care and meals. The resident care record (RCR) dated 10/2017 documented the resident required extensive assistance for dressing and was to have a palm guard. On 10/26/2017 at 3:15 PM, the palm guard wearing schedule was observed posted on the inside of the resident's bathroom door. The schedule documented a right palm guard with finger separators was issued 7/14/2017 and was to be worn continuously and removed at mealtimes and during morning and evening care. The resident was observed without the palm guard in her right hand: - on 10/26/2017 at 3:15 PM while in bed; and - on 10/27/2017 at 10:57 AM while in her recliner in her room. During an interview with OT #23 on 10/27/2017 at 10:45 AM, she stated she provided 2 splints in a mesh bag so the splint could be washed weekly. She provided staff training with at least one certified nurse aide (CNA) regarding application of splint and followed up visually one week after therapy discharge to determine if there were any problems. During an interview with CNA #22, assigned as the resident caregiver on 10/27/2017 at 11:39 AM, she stated she did not know why the palm guard was not in place, she only saw it on the resident when the therapist came to work with her, otherwise she had never seen the palm guard on the resident. 10NYCRR 415.12(e)(2)

Plan of Correction: ApprovedNovember 17, 2017

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident # 5 has recommendations for rolled up wash cloths to be placed in her hands to be used as a palm guard. The unit staff will be re-educated regarding cleansing the hands, inspecting the skin and ROM then placing rolled up washcloths in place. This information has been sent to the CNA Task List for CNA?s to document as complete.
Resident # 23 and # 28 has recommendations for the use of a palm guard. All unit staff will be re-educated on the process for applying palm guards for this resident and notifying Therapy if the resident refuses to wear the palm guard. The use of the palm guard has been sent to the CNA Task List for CNA?s to document as complete.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Multiple residents are affected by this same deficient practice. An audit of all residents with a splint or palm guard will be completed to ensure the resident is wearing as per the OT/PT recommendation. An audit of the CNA Task List will be conducted to ensure that the task list is complete and accurate.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Rehabilitation Department will communicate any time a change is made in the recommended care of the resident. The recommendation will be submitted to the unit at the time of the change so that the information may be carried over to the RCR, Medical Record and CNA task list for completion as appropriate.
All Rehabilitation staff (PT, OT, ST), RNs, LPNs, and CNAs will be educated regarding the communication, documentation, and follow-through of the process of the implementing recommendations to prevent resident decline.
4. How the corrective action(s) 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 Nursing or designee will review 30 resident each month to ensure residents are wearing palm guards/splints per OT/PT recommendations, the CNA Task list contains the therapy recommendation and the task is documented as complete until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported monthly to the Quality Assurance Quality Improvement Council.
5. The date of correction and the title of the person responsible for the correction of each deficiency
Completion date: 12/26/2017
The Director of Nursing will be responsible for this deficiency

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2017
Corrected date: December 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification and abbreviated surveys (NY 410), for 2 of 25 residents reviewed for abuse (Residents #5 and 19), the facility did not ensure that all alleged violations involving abuse were reported immediately to the Administrator of the facility. Specifically, Resident #19 made an allegation of abuse against her family member and when the allegation was reported to licensed practical nurse (LPN) #1 and social worker #2, they did not report the allegations to the Administrator of the facility immediately. Resident #5 sustained a bruise of unknown origin and the facility did not complete an investigation to rule out abuse/neglect. Findings include: 1) Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/3/2017 physician's orders [REDACTED]. The 4/20/2017 registered nurse (RN) Manager #3's progress note at 5:00 PM documented on that day at 2:00 PM, she was notified that the resident went out with her husband on 4/16/2017, was tearful when she returned, and on 4/18/2017, the resident told a staff member that she was sexually abused while she was out of the facility. RN Manager #3 documented she immediately informed the Administrator, Director of Nursing (DON), and the police were called. The facility's 4/20/2017 incident report documented the incident occurred on 4/16/2017 while the resident was out of the building and attached statements included: -(NAME) Clerk #4's statement documented on 4/18/2017 at 2 PM, she took the resident outdoors and they talked for a while. The resident told ward clerk #4 that her husband yelled at her, made her cry, and sexually abused her when she went home with him on 4/16/2017.(NAME) clerk #4 documented she notified LPN #1 and social worker #2 of the allegations when she returned to the unit. - Social worker #2's statement dated 4/20/2017 documented on 4/19/2017, she was told by the ward clerk that the resident alleged she was sexually abused when she went home. Social worker #2 documented she intended to talk with the Nurse Manager about this allegation on 4/20/2017. - LPN #1's statement dated 4/26/2017 documented on 4/18/2017, she was told by the ward clerk that the resident was upset about her home visit on 4/16/2017 and she reported being sexually abused. The statement did not document what LPN #1 did with the information when an abuse allegation was reported to her. The 4/21/2017 licensed practical nurse's (LPN) #5's progress note documented a new order to discontinue home visit privileges. The resident was observed at lunch on 10/25/2017. She walked herself to the dining room at 12:45 PM and stood in front of her chair at the table. Staff encouraged her to sit down and she did at 12:58 PM. At 1:00 PM, the resident stood up, was crying, and stated to certified nurse aide (CNA) #6 (who was standing with her) stay here, stay here, don't leave. From 1 PM to 1:10 PM, CNA #6 tried to coax the resident to sit down and eat and at 1:10 PM, CNA #6 assisted the resident to sit at a tray table where she sat and ate. On 10/26/2017 at 12:25 PM, social worker #2 stated in an interview, she thought that ward clerk #4 told her about the resident's allegations on 4/19/2017 and she did not do anything with the information when she was told. Social worker #2 stated it was close to the end of the day and after ward clerk #4 told her, she went to another unit to take care of something, and then forgot. She stated she wrote in her statement that she intended to talk to the Nurse Manager about the allegations on 4/20/2017 but by the time she had a chance, the Administrator and DON called her down to the office to talk abut it. On 10/26/2017 at 12:45 PM, ward clerk #4 stated in an interview, she was not working on 4/16/2017 as it was a Sunday but on 4/18/2017, the resident approached her and asked her to talk privately. She stated the resident had dementia but remembered her as they grew up together. She stated she took the resident off the unit and they talked for almost 2 hours. She stated when the resident talked about the allegations she was crying and afraid and told her that she was sexually abused when she went home on 4/16/2017. She stated the resident seemed scared so she provided her with reassurance and told LPN #1 when she got back to the unit. She stated LPN #1 told her that she had to tell social worker #2.(NAME) clerk #4 stated she told social worker #2 and thought the LPN and social worker were taking care of it. She stated a few days later, the topic of the resident came up and she mentioned the allegation to RN Manager #3. She stated it was the first time RN Manager #3 had heard about the allegation and she immediately told the Administrator, the police were called, and an investigation was started. On 10/26/2017 at 1:10 PM, a message was left for LPN #1 and no return call was received prior to survey exit. On 10/26/2017 at 1:30 PM RN Manager #3 stated in an interview, the incident with the resident occurred over the weekend and she did not hear about it until Wednesday or Thursday of the following week. She stated as soon as she was told, she reported it to the Administrator, the police were called, and an investigation was initiated. 2) Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident was totally dependent on staff for transfers, bed mobility, and dressing. The comprehensive care plan (CCP) updated 9/23/2017 documented the resident required total assistance with activities of daily living (ADLs), could be resistive to care, was verbally/physically aggressive at times, and had decreased mobility. Interventions included assessing resident's signs/symptoms for underlying cause, Hoyer (mechanical) lift with two assist, and side rails up for positioning. The resident care record (RCR) dated 10/2017 documented the resident was alert, confused at times, was non-ambulatory, and at risk for falls. A nursing progress note dated 10/6/2017 documented the resident was observed to have a black and blue area on her left temple. The resident's daughter was notified and stated she was aware of the area when she and the resident returned from an earlier appointment that day. The supervisor was notified and came to assess the area. There was no other documentation regarding the bruised area. The resident was observed: - on 10/24/2017 at 12:11 PM, in bed - on 10/26/2017 at 12:30 PM, seated in her chair; and - on 10/26/2017 at 2:15 PM, lying in bed. During an interview with licensed practical nurse (LPN), Assistant Nurse Manager #16 on 10/27/2017 at 1:30 PM, she stated if a bruise on the head was noted on a resident, she would expect staff to report it to the registered nurse (RN), complete an incident report, and perform neuro checks. She stated she was aware of the bruise and a supervisor had assessed the area. The LPN Assistant Nurse Manager was unable to provide an investigation or incident report regarding the bruise of unknown origin. The Corporate Director of Nursing confirmed on 10/27/2017 at 4:15 PM, there was no documentation an investigation was completed to determine the cause of the bruise or to rule out abuse or neglect had occurred. 10NYCRR 415.4 (b)

Plan of Correction: ApprovedNovember 30, 2017

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Investigation cited for resident # 19 occurred in the past. The Resident no longer has unsupervised visits with her family members. Staff is aware to contact the police if family attempts to remove the Resident from the facility.
Investigation cited for Resident #5, although not documented, was immediately investigated by the RN Nursing Supervisor. Based on his interview with the family and staff had ruled out abuse, neglect, mistreatment. The bruise on her temple has resolve without issue. The Nursing Supervisor involved was re-educated to ensure all injuries of unknown origin that occur within and outside the facility will be investigated and documented utilizing our Accident and Incident Investigation Process.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Incident reports from (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) were reviewed and all investigations were complete.
Residents with injuries from (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) were reviewed and multiple residents were identified as being affected by this same deficient practice. It was identified that in some cases injuries were documented in the resident?s chart at the time of the incident but an incident report was not generated. RNs involved were re-educated on the importance of documenting the injury in the resident?s chart, initiating an incident report, and documenting a complete and through investigation. There were no clinical adverse resident outcomes identified in this review.

3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur?
The facility?s Accident and Incident Investigation and Reporting Policy has been reviewed and revised to include the requirement for all staff to notify an RN (Director of Nursing, Nurse Manager, Nursing Supervisor) at the time a resident accident or incident is identified which will included any resident who has been identified as sustaining an accident or injury while out on leave of absence. The facility's Leave of Absence Policy was reviewed with no changes. Mandatory education will be provided for all staff including Social Workers, RNs LPNs, CNAs, and ancillary staff regarding abuse, neglect, mistreatment, and the importance of timely reporting. Education will be provided for all RN?s who conduct incident reporting/investigation and will emphasize the investigation process for to include; conduct interviews, statements obtained from staff development of a timeline, determine last time care was provided, and determination if care plan was followed. Education will include the requirement to investigate and document injuries of unknown origin that occur within and outside the facility utilizing our Accident and Incident Investigation Process.

4. How the corrective action(s) 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 Nursing and/or designee will audit each closed incident report to ensure a complete and thorough investigation occurred in accordance with the NYSDOH Incident Reporting Manual monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Assurance Quality Improvement Council (QAPI).

5. The date of correction and the title of the person responsible for the correction of each deficiency
Completion date: 12/26/2017
The Director of Nursing will be responsible for this deficiency

FF10 483.10(i)(7):MAINTENANCE OF COMFORTABLE SOUND LEVELS

REGULATION: (i)(7) For the maintenance of comfortable sound levels.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2017
Corrected date: December 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews conducted during the recertification survey, the facility did not ensure comfortable sound levels for 1 of 15 residents (Resident #10) reviewed for activities of daily living (ADLs). Specifically, Resident #10 was care planned for a calm, quiet environment and the unit call bell alarm system was outside her door. Findings include: Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 8/8/2017 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired. She was totally dependent on staff for most ADLs, had upper and lower extremity impairments, did not ambulate, and was non-verbal and able to understand others. Her activity preferences included listening to music. The comprehensive care plan (CCP) dated 6/16/2017 documented the resident was often angry and anxious over things she had no control over. Interventions included provide a calm, quiet environment and observe surroundings to rule out things that may be from the environment. The resident's care record (RCR) dated 9/30/2017 documented the resident was alert, non-verbal, required total assistance from staff for her ADLs and had no behaviors. There was no documentation regarding special instructions to maintain a calm, quiet environment. The resident was observed in her bed with the room door open: - On 10/25/2017 from 10:05 AM-10:30 AM, the unit call bell alarm system, directly outside her door on the ceiling, was sounding repeatedly. During that time, the resident was restless and making non-verbal vocalizations. Staff did not attempt to enter her room to see why she was restless and anxious. - On 10/26/2017 from 12:50 PM-1:20 PM, the unit call bell alarm system was sounding repeatedly, with one period of time lasting 5 minutes. The resident was restless and making non-verbal vocalizations. Multiple staff walked by her room and did not enter to see why she was vocalizing. During an interview with hospitality aide #17 on 10/25/2017 at 11:15 AM, she stated the call light system sounds like a lot because it covers all 4 areas on the unit. Many residents and families thought the sound of the call bell system was a phone ringing. It was not the best location for the call bell system for Resident #10 since she was unable to ambulate and get away from the constant ringing. During an interview with registered nurse (RN) Unit Manager #18 on 10/27/2017 at 10:35 AM, she stated she was not aware of any conversations regarding the noise from the call bell alarm system and how it affected the resident's level of agitation and anxiety. Staff had discussed moving her closer to the nursing station for monitoring due to her aspiration risk. The surveyor and RN Unit Manager walked over to the other side of the hall by the nursing station where there was no call bell alarm system on the ceiling. The Manager stated it was much quieter and she could see how the constant sound of the call bells could be annoying to Resident #10. 10NYCRR 415.5(h)(5)

Plan of Correction: ApprovedNovember 17, 2017

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?

Resident # 10 was relocated to a room that is in a calm, quiet environment. The Resident?s Resident Care record (RCR) was updated to include instructions to maintain a calm, quiet environment.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

All resident care plans were reviewed. An assessment of the environment was conducted for any resident who was care planned to provide a calm, quiet environment. No other residents were identified as being affected by this same deficient practice.

3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur
Education will be provided to RNs, LPNs, and CNAs to ensure the RCR matches the care plan and stress the importance of observing residents and their reaction to the environment. If the resident appears to be stressed by his/her environment then action should be taken.

4. How the corrective action(s) 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 Nursing or designee will audit the RCR and the environment of 30 residents to ensure the RCR accurately reflects the care plan and the resident is not restless or anxious as a result of their environment. Monitoring will continue monthly for 3 months, and then quarterly until 100% compliance. Monitoring for compliance is the responsibility of the Activities Director and will be reported to the Quality Assurance Quality Improvement Council (QAPI).
5. The date of correction and the title of the person responsible for the correction of each deficiency
Completion date: 12/26/2017
The Director of Nursing will be responsible for this deficiency

FF10 483.25(b)(2)(f)(g)(5)(h)(i)(j):TREATMENT/CARE FOR SPECIAL NEEDS

REGULATION: (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident?s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident?s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to ? prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident?s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents? goals and preferences, and 483.65 of this subpart. (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents? goals and preferences, to wear and be able to use the prosthetic device.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2017
Corrected date: December 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview conducted during the recertification survey, for 1 of 3 residents (Resident #12) reviewed for special care needs, the facility did not provide the necessary care and services to attain or maintain the highest practicable well-being. Specifically, Resident #12 had an order for [REDACTED]. Findings include: Resident #12 was admitted to the facility on [DATE] had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance for activities of daily living (ADLs), had asthma, [MEDICAL CONDITIONS] or [MEDICAL CONDITION], did not exhibit shortness of breath or trouble breathing, and was on oxygen therapy. The physician's orders [REDACTED]. The resident care record (RCR) dated 5/10/2017 documented the resident was on O2 at 2 L via NC. The nursing progress note dated 5/15/2017 at 3:36 PM documented the resident's respirations were unlabored, lungs were diminished at bases but clear otherwise, no cough noted, O2 via NC at 2 L continuously for history of [MEDICAL CONDITION], denies shortness of breath (SOB). physician's orders [REDACTED]. The 5/2017 treatment administration record (TAR) documented: - O2 at 2 L/min via NC or mask for SOB as needed, date ordered 2/10/2017, with administration time noted as PRN (as needed), from 5/1-5/10/2017 was marked NR (not recorded), 5/11-5/31/2017 were marked X (not to be administered or future date); and - O2 at 1 L/min via NC or mask for SOB as needed, document oxygen monitoring, titrate O2 to keep saturations at 89%, date ordered 5/5/2017, administration time PRN, and marked 5/7-5/31/2017 as NR. - The TAR did not include documentation for monitoring or recording O2 saturations. physician's orders [REDACTED]. The RCR dated 9/7/2017 documented the resident was on O2 at 2 L via NC. A physician's progress note dated 9/12/2017 documented the resident's oxygen was removed for the duration of the visit, his pulse oximetry (monitors O2 saturations) remained between 90 and 93% and no changes were made in his medications. The 9/2017 TAR documented O2 at 1 L/min via NC or mask for SOB as needed, document oxygen monitoring, titrate O2 to keep saturations at 89%. The administration time was shown as PRN and each day from 9/1-9/30/2017 was marked NR (not recorded). The TAR did not include documentation for monitoring or recording O2 saturations. The comprehensive care plan (CCP) updated 9/23/2017 documented the resident was at risk for SOB related to a [DIAGNOSES REDACTED]. Interventions included wear O2 continuous as ordered via NC. Nursing progress notes documented the following: - on 9/5/2017 at 3:27 PM, had increased cough and congestion, O2 saturation at 93% with O2 per order; - on 10/23/2017 at 4:41 AM, O2 saturation was at 97%, on oxygen per order, the resident had a dry cough, no audible wheezing or congestion; - on 10/25/2017 at 1:30 PM, O2 saturation was 96%, oxygen given was 2 L; - on 10/25/2017 at 10:30 PM O2 saturation at 94 (percent) with O2 at 2 L; There was no other documentation found in nursing progress notes from 9/1/2017 to 10/27/2017 O2 saturations were monitored/recorded The RCR dated 10/2017 documented the resident had continuous O2. The 10/2017 TAR documented O2 at 1 L/min via NC or mask for SOB as needed, document oxygen monitoring, titrate O2 to keep saturations at 89%. The administration time was shown as PRN (as needed) and each day from 10/1-10/27/2017 was marked NR (not recorded). The TAR did not include documentation for monitoring or recording O2 saturations. The resident was observed with oxygen on via NC: - on 10/23/2017 at 6:52 PM, set at 2 L/min; - on 10/24/2017 at 12:07 PM and 4:29 PM, set at 2 L/min - on 10/25/2017 at 7:50 PM set at 2 L/min, - on 10/26/2017 at 8:40 AM, set at 2 L/min, - on 10/26/2017 at 12:17 PM and 2:17 PM, set at 2.5 L/min; and - on 10/27/2017 at 8:04 AM, set at 2.5 L/min. When interviewed on 10/26/2017 at 12:30 PM, licensed practical nurse (LPN) #26 stated she was a float on the unit and she thought O2 saturations were checked every shift. She stated the order was for 1 L/min prn, and the resident wore it continuously. During an interview on 10/27/2017 at 9:17 AM, LPN #25 stated O2 saturations were usually checked every shift and documented in the electronic medical record (eMAR). The resident's O2 saturations were not checked every shift as he had been on oxygen forever. His O2 saturations were checked when he received his nebulizer treatment, and only checked if he was having an issue. The LPN checked the order and verified it stated 1 liter and she stated she had always had it on 2 liters. When interviewed on 10/27/2017 at 1:30 PM, LPN Assistant Nurse Manager #16 stated O2 saturations were documented in the electronic medical record on quick view and would show the most recent in the past 45 days. She would expect the medication nurses to check O2 saturations. She stated it was possible the resident did not need the O2 as he was currently receiving. 10NYCRR 415.12 (k)(6)

Plan of Correction: ApprovedNovember 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #12?s was evaluated by the resident?s Nurse Practitioner and the order for oxygen was updated to reflect resident?s current of continuous use of oxygen at 1L per nasal cannula.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Multiple residents are affected by this same deficient practice. The facility has reviewed residents receiving as needed oxygen to ensure that the order is complete and includes monitoring parameters.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur
All Nurse?s will be re-educated on receiving a complete and comprehensive physician order [REDACTED].
4. How the corrective action(s) 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 Nursing or designee will review 100% or 30 resident (whichever is greater) each month to ensure residents with as needed oxygen orders include directions for titration and titration is documented per the order until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported monthly to the Quality Assurance Quality Improvement Council (QAPI).
5. The date of correction and the title of the person responsible for the correction of each deficiency
Completion date: 12/26/2017
The Director of Nursing will be responsible for this deficiency.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2017
Corrected date: December 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, the facility did not ensure care was provided that prevented residents from developing pressure ulcers and/or did not ensure residents with pressure ulcers received the necessary treatments and services needed to promote healing and prevent infection for 5 of 11 residents (Residents #1, 2, 3, 5, and 21) reviewed for pressure ulcers. Specifically: - Resident #1 had a pressure ulcer, treatments were not implemented timely, and treatments were not completed as ordered. - Resident #2 developed multiple pressure ulcers. For a wound on the heel there was no evidence the physician (or nurse practitioner (NP) was notified timely, a treatment change was considered when the pressure ulcer was identified, and when a treatment was ordered, there was no documentation it was done as ordered. For another pressure ulcer, the treatment was done once a day instead of twice a day during survey. - Resident #3 was observed during a dressing change and skin prep was not applied as ordered to the resident's deep tissue injury (DTI). The resident also had an order for [REDACTED]. - Resident #5 was observed not wearing her blue boots (heel protection) as ordered. - Resident #21 had a wound on her coccyx and there was no evidence the treatment was done as ordered. Findings include: 1) Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 7/20/2017, documented the resident's cognition was moderately impaired and she required total dependence on staff for bed mobility, transfers, toilet use, bathing, and hygiene. The resident had an unstageable pressure ulcer and interventions included pressure relief devices to the bed and chair, turning and positioning, ulcer care, non-surgical dressings, and medications/ointments. The nursing progress note dated 7/14/2017 at 11:00 AM, documented the resident had [MEDICATION NAME] dressings on both heels and complained of her heels being sore during the dressing change. The heels were reddened and tender to touch, pillow adjustments were made to keep her heels up off the bed. The wound progression progress note dated 7/17/2017 at 4:28 PM, documented a new pressure ulcer on the left heel and was staged as a deep tissue injury (DTI). The DTI measured 4.5 centimeters (cm) x 4 cm with a black wound base and 100% eschar (dead tissue). The wound progression progress note dated 7/21/2017 at 3:25 PM, documented the DTI on the left heel measured 5.5 cm x 5.2 cm with a black wound base and 100% eschar (dead tissue). Pressure relieving devices were in place and a turning and repositioning program was implemented. The medical provider would not be notified of the present condition of the site, there were no changes in site condition and no recent changes were made to the treatment orders for this site. The treatment administration record (TAR) dated 7/2017 documented the resident had [MEDICATION NAME] applied to both heels every 3 days. The order had a start date of 4/30/2017 and there was not a change in treatment for [REDACTED]. The wound progression progress notes dated 7/27/17, 8/2/2017, and 8/8/2017, documented the measurement of the DTI on the left heel and no changes in treatment. The note documented the medical provider would not be notified of the present status of the site. The wound progression progress note, dated 8/18/2017, documented the left heel DTI measured 4.5 cm x 5.0 cm and was 100% eschar and boggy. A new order was written to apply skin prep and [MEDICATION NAME] to the left heel and change daily. The TAR dated 8/2017 documented the resident had [MEDICATION NAME] applied every 3 days to both heels from 8/1 to 8/22/2017. From 8/23 to 8/31/2017, the resident had skin prep and [MEDICATION NAME] applied daily to the left heel. The nurse practitioner's (NP) progress note, dated 9/8/2017, documented she was asked to look at the resident's left heel. She had [MEDICAL CONDITION] (swelling), there was a small area of eschar with surrounding [DIAGNOSES REDACTED] (redness) and a small amount of green drainage. The plan was to cleanse with Vashe wash (cleanser) and apply [MEDICATION NAME] Ag (dressing), a 4 x 4, foam dressing, and wrap with Kerlix (gauze). The TAR dated 9/2017, documented the resident had skin prep and [MEDICATION NAME] applied daily to the left heel from 9/1/2017 to 9/8/2017. The TAR documented on 9/8/2017 the treatment for [REDACTED]. The dressing was to be changed every Monday, Wednesday, and Friday and this was completed on 9/11, 9/12, and 9/13/2017. There was no documentation on the TAR a treatment was provided to the left heel from 9/14-9/30/2017. A physician's orders [REDACTED]. The instructions included washing the area with normal saline, pat dry, apply hydrogel (wound gel, provides moist environment for wound healing), and cover with [MEDICATION NAME]. During a wound treatment observation on 10/25/2017 at 10:32 AM, licensed practical nurse (LPN) #13 changed the dressing to the resident's left heel. There was an area of hard black tissue and the surrounding skin was red. Bloody drainage was noted on the gauze when LPN #13 cleansed the wound with saline, and a foul odor was present. LPN #13 applied Santyl to the wound, a heel cup, and wrapped the heel with gauze. LPN #13 then took a dressing off the right calf. The dressing she removed was dated 10/24/2017 and had LPN #13's initials on it. The dressing had a small amount of greenish drainage, there were 2 open areas with slough (moist dead tissue). LPN #13 cleansed the wound and applied Solosite (hydrogel) and covered with [MEDICATION NAME]. During a wound treatment observation on 10/26/2017 at 1:47 PM, the dressing on the right calf had LPN #13 initials and was dated 10/25/2017. The dressing had a small amount of greenish drainage from the upper wound, the lower wound was dry and crusty. LPN #13 stated the dressing change was to be done twice a day and the dressing she removed was the one she applied the day before. When interviewed on 10/26/2017 at 2:30 PM, LPN #13 reviewed the resident's TARs dated 9/2017 and 10/2017 and stated it did not look like the resident's left heel was treated between 9/13 and 10/3/2017. She stated the resident would not have gone without a treatment on the heel. She reviewed the progress notes and stated she was not sure what happened. She stated the area on the resident's calf was caused by the pillows they used to float the resident's heels. She reviewed the 10/2017 TAR and stated she was unaware the treatment was not being done on evening shift. The 10/2017 TAR documented the resident's right outer calf treatment was done once a day on 10/23, 10/24, and 10/25/2017. The treatment was signed for on the day shift and not recorded on the evening shift. When interviewed on 10/27/2017 from 12:20 PM to 1:10 PM, LPN #16 stated she was the wound care nurse and did skin rounds with the wound care team that was organized a few months ago. She stated the NP started a couple months ago and when they did rounds, the registered nurse (RN) Unit Manager attended too. She stated she did not know why a new treatment was not ordered when the DTI was found. When she reviewed the TAR for 9/2017 and 10/2017 she stated she could not tell what treatment was done between 9/13/2017 and 10/3/2017 for the resident's left heel. She also stated the treatment for [REDACTED]. She stated if it was only done once a day, the tendon could dry out. When interviewed on 10/27/2017 at 1:50 PM, RN #14 stated he first observed the DTI on the heel on 7/17/2017 and the resident was treated with [MEDICATION NAME]. He stated on 8/18/2017, LPN #16 wrote a telephone order for the physician to sign to change the treatment to skin prep and [MEDICATION NAME] daily for the left heel. He stated he did not know when the resident's heel was first seen by a medical provider. When interviewed on 10/27/2017 at 3:45 PM, LPN #15 stated she worked the evening shift and did not do the treatment everyday as she often did not have time. 2) Resident #3 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired and she required assistance of 2 staff for bed mobility, transfers, dressing, toilet use, hygiene, and bathing. The MDS did not document any skin impairments. The resident's care card, dated 10/11/2017, documented to elevate heels and when out of bed to make sure feet were on a foot rest with a pillow. A wound progression progress note dated 10/17/2017 at 1:59 AM, documented a new unstageable ulcer on the right heel. The wound was purplish black in color and measured 5 centimeters (cm) x 3 cm. The would was a suspected deep tissue injury, surrounding tissue was normal, margins were irregular, no drainage or odor. A physician's orders [REDACTED]. Instructions also included obtaining heel/boot protectors. When observed on 10/23/2017 at 7:10 PM, the resident was lying in bed on her back with the head of the bed elevated. She was on her back and stated she did not get out of bed often. Her heels were directly on the mattress. When observed on 10/24/2017 at 12:10 PM, the resident was out of bed in her chair with her feet dangling. She wore a dress and her lower extremities were only covered with the Kerlix wraps around her heels from the mid foot to the ankle. The resident said they changed the dressings daily and they were to protect her heels. During a dressing change observation on 10/24/2017 at 1:37 PM, licensed practical nurse (LPN) #13 brought her supplies into the room, placed a barrier on the overbed table and placed the supplies on top. Supplies included normal saline packs, gauze, ABD dressings, and Kerlix. She removed the dressings from the resident's heels. The left heel had a bright red area, the right heel had a very dark area on the underside, both heels were boggy and the resident stated the right was tender when touched. LPN #13 washed her hands and re-gloved. She cleansed the heels with normal saline, patted dry, applied the ABD and wrapped the right heel and did the same with the left heel. She ungloved, washed her hands and then was interviewed. She stated she read the order to determine the supplies to bring in the room. When asked about skin prep, she stated she forgot to bring it into the room. She also stated the resident did not have heel protectors as they had to be specially ordered. She stated the registered nurse (RN) Unit Manager was responsible for ordering the heel protectors and she did not know if they were ordered. When interviewed on 10/27/2017 at 12:45 PM, LPN #16 stated she was the wound care nurse and had seen the resident's heel. She stated the heel protectors should have been obtained and her heels should always be off loaded. She stated skin prep was important to toughen up the skin and prevent further breakdown. When interviewed on 10/27/2017 at 1:45 PM, RN #14 stated the resident's heels should always be floated. He stated the skin prep was an important part of the dressing change to prevent the DTI from getting worse. He stated LPN #16 was responsible for getting the heel protectors. 3) Resident #21 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognitive function, required extensive assistance for bed mobility, transfers, and dressing. The resident had one unstageable pressure ulcer, had pressure reducing devices, and received ulcer care. The nursing progress note dated 9/9/2017 at 3:13 PM, documented the resident had new open area on her coccyx. A call was placed to the nurse practitioner (NP) and a treatment was ordered. The wound progression progress note dated 9/15/2017 at 11:26 AM, documented the resident was seen by the wound care team for a new unstageable pressure ulcer on the coccyx. The wound measured 1.0 centimeters (cm) x 0.4 cm x 0.4 cm (length x width x depth). The wound tunneled from 12 o'clock to 1 o'clock and the tunnel was 4 cm deep. Recent changes were made to the treatment orders and the medical provider was aware. The 9/2017 treatment administration record (TAR) and physician's orders [REDACTED]. The nursing progress note dated 9/18/2017 at 4:55 PM, documented LPN #16 changed the dressing on sacrum, the old dressing was removed and the new treatment applied as ordered. The 9/2017 TAR documented the treatment ordered on [DATE], was done on 9/20/2017. The wound progression progress note dated 9/21/2017 at 3:11 PM, documented the resident was seen by the wound care team for an unstageable pressure ulcer on the coccyx. The wound measured 0.6 cm x 0.3 cm x 0.6 cm with tunneling 4 cm deep at 12 o'clock. The wound base was not visible, the treatment order was to pack with 1/2 inch packing impregnated with collagen powder and a wound gel placed loosely into the wound cavity, skin prep to the surrounding skin and cover with [MEDICATION NAME]. The treatment was to be done Monday, Wednesday, and Friday. The NP's progress note dated 9/22/2017 at 3:19 PM, documented the dressing placed by the wound care team on 9/21/2017 fell off and she redressed the wound with [MEDICATION NAME] 1/4 inch packing moistened with hydrogel and collagen powder paste inserted tape as a packing and covered with extra soft [MEDICATION NAME]. The NP documented she would see the resident's wound on 9/25/2017. A nursing progress note dated 9/24/2017 (Sunday) at 10:42 AM, documented the resident stated her patch fell off her bottom. The nurse documented she replaced the [MEDICATION NAME] (outer dressing) and the treatment was ordered to be done by the registered nurse (RN) on Monday, Wednesday, and Friday. The 9/2017 TAR did not document the treatment for [REDACTED]. There was no other documentation in the medical record that the treatment was done during this period, or that the wound was looked at. The wound progression progress note dated 10/1/2017, documented the coccyx wound was seen during wound rounds. The resident was observed during survey on 10/26/2017 at 12:30 PM sitting in her chair eating lunch. The resident was observed on 10/27/2017 from 7:30 AM to 8:15 AM, in bed complaining of pain in her feet. Licensed practical nurse (LPN) #27 came in to see the resident and stated she had medicated the resident for her foot pain. She stated the resident had treatments for her feet and sacrum and she was not sure when she would be doing them. When interviewed on 10/27/2017 at 8:35 AM, LPN #27 stated she was unsure why the treatment was not documented on the TAR for 9/25 to 9/30/2017. She stated the NP was doing the treatments for a while and there was a time when the treatments were done by the LPN #16, the wound care nurse. When interviewed on 10/27/2017 at 1:00 PM, LPN #16 observed the 9/2017 TAR and stated she was unsure why the resident did not have treatments for the coccyx documented. She stated she had done the resident's treatment a few times and if she did not sign the TAR, she always wrote a progress note. She stated the NP sometimes did the resident's dressing change and she did not know if she documented it or when she did it. She stated the NP (during the time in question) left at the beginning of (MONTH) (YEAR). The resident's wound was observed on 10/27/2017 at 1:20 PM with LPN #27. She stated the dressing was taken off by the wound care team and she was going apply a new dressing after the resident's pain medicine was effective. The resident rolled on her right side and the wound was observed on the coccyx. The wound was clean with red surrounding skin and the wound base could not be seen. 10NYCRR 415.12 (c)(1)(2)

Plan of Correction: ApprovedNovember 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident # 1 no longer resides at the facility.
Resident # 2 no longer resides at the facility.
Resident # 3 all unit LPN?s have been educated regarding the Policy and Procedure for completing a dressing change. This policy includes gathering all equipment and supplies based on the physician order. The resident has received her heel/boot protectors and wears them per MD order. The resident's has been reassessed and there has been no adverse outcome as a result of the skin prep not being applied per order.
Resident # 5 unit staff have been re-educated on the expectation of following the care plan and RCR. The resident does not have an order for [REDACTED].
Resident # 21 no longer resides at the facility.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
An audit was conducted for all Residents who have heel boots ordered to ensure boots were on residents as ordered. No other residents were identified with the same deficient practice.
An audit was conducted for all Residents who have wound care treatment orders to ensure treatments were completed as ordered. Any deficiencies identified were promptly followed-up on, with education provided to staff as appropriate.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur?
The Pressure Ulcer Prevention and Treatment Protocol has been reviewed with no changes required. The facility?s Wound Team has been restructured to include Certified Wound Care NP, Physical Therapist, Wound Certified LPN, Bedside LPN and Unit RN Manager. The resident's Nurse Pratitioner participates in wound rounds at least monthly. It is expected wound rounds will be completed weekly, wound progression evaluated during rounds, recommendations made for treatment, and notification to the provider with any significant changes. It will be the responsibility of the unit RN/LPN to notify the provider, obtain treatment orders, and ensure implementation of orders.
All RNs, LPNs, and CNA will receive mandatory education regarding the wound care team, wound rounds process, the application of treatments as ordered specifically including wound care and application of heel boots.
4. How the corrective action(s) 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 Nursing or designee will conduct the following audits:
An audit for 100% or 30 Residents (whichever is greater) each month who have heel boots ordered to ensure the heel boots are applied as ordered;
An audit for 100% or 30 Residents (whichever is greater) each month who have wound treatments ordered to ensure wound care is completed and documented as ordered;
An audit of 100% or 30 Residents each month to ensure the provider has been notified for all wounds which demonstrated a deterioration.
Each individual audit will be completed monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date of correction and the title of the person responsible for the correction of each deficiency
Completion date: 12/26/2017
The Director of Nursing will be responsible for this deficiency

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey, the facility did not properly maintain electrical installations for 6 isolated areas (seventh floor nursing station, resident room [ROOM NUMBER], sixth floor nursing station, fifth floor nursing station, resident room [ROOM NUMBER], second floor nursing station, and resident room [ROOM NUMBER]). Specifically, the seventh floor nursing station, resident room [ROOM NUMBER], sixth floor nursing station, fifth floor nursing station, resident room [ROOM NUMBER], and second floor nursing station had power taps/extension cords plugged into another power tap; and resident room [ROOM NUMBER] had a oxygen concentrator plugged into an unapproved adaptor. Findings include: 1) Improper Use of Extension Cord On 10/24/2017 at 11:12 AM, a surveyor in the seventh floor nursing station observed a pencil sharpener and a telephone that were plugged into a 6 outlet relocatable power tap extension cord that was plugged into a 6 outlet relocatable power tap (daisy chained). On 10/24/2017 at 11:30 AM, a surveyor in the resident room [ROOM NUMBER] observed a television and a fan that were plugged into a 6 outlet relocatable power tap extension cord that was plugged into an unapproved extension cord. On 10/24/2017 at 11:41 AM, a surveyor in the sixth floor nursing station observed a computer, a monitor and a paper shredder that were plugged into a 6 outlet relocatable power tap extension cord that was plugged into a 6 outlet relocatable power tap. Also, another daisy chain with a computer and monitor was found at this nursing station. On 10/24/2017 at 12:00 PM, a surveyor in the fifth floor nursing station observed a computer, a monitor, a printer, and a paper shredder that were plugged into a 6 outlet relocatable power tap extension cord that was plugged into a 6 outlet relocatable power tap. On 10/24/2017 at 2:40 PM, a surveyor in the resident room [ROOM NUMBER] observed a television, and a cable box that were plugged into a 6 outlet relocatable power tap extension cord that was plugged into an unapproved six prong outlet adaptor. Also, another daisy chain with a monitor and a light was found in this resident room. On 10/24/2017 at 3:36 PM, a surveyor in the second floor nursing station observed a computer, a monitor, a printer, and a phone that were plugged into a 6 outlet relocatable power tap extension cord that was plugged into a 6 outlet relocatable power tap. Also, another daisy chain with a computer and monitor was found at this nursing station. During an interview on 10/25/2017, between 3:00 PM and 3:45 PM, the Director of Facilities stated as per the facility's extension cord policy extension cords can only be used during emergencies, and that staff are aware and trained not to daisy chain power taps. On 10/25/1017, during review of the facility's Use of Extension Cords last revised in (MONTH) (YEAR), had section that stated The Joint Commission Hospital Acceditation Standards prohibits the use of extension cords on patient care equipment except in emergency, and At no time with two extension cords be plugged together (daisy-chain) to accommodate a longer distance. 2) Patient Care Related Electrical Equipment On 10/24/2017 at 2:51 PM, a surveyor in resident room [ROOM NUMBER] observed an oxygen concentrator plugged into a unapproved three prong adaptor. During an interview on 10/24/2017 at 2:58 PM, LPN #13 stated oxygen concentrators are required to be plugged into the wall directly, and the last time she was in the room the oxygen concentrator was plugged directly into a wall outlet. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The oxygen concentrator found plugged into a power strip was immediately unplugged from the unapproved power strip in room [ROOM NUMBER] and plugged directly into a wall outlet.
The extension cord was immediately removed from room [ROOM NUMBER].

2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Resident room multi-strips were replaced with UL approved type strips.
An audit was completed and all connections of multiple power strips have been removed.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
The Environment of Care Rounding check list has been modified to check for non-compliant power strips and any daisy-chaining of power strips.
Staff will be educated that all clinical equipment is required to be plugged into wall outlets and that the use of extension cords is prohibited in resident rooms. Staff will also be educated that connecting multiple power strips is prohibited.
Purchase Order # 63 was issued to Graybare for the purchase of 50 additional UL Listed power strips to be used in resident rooms.
Purchase order # 84 was issued to E.D. Young to add four (4) quad outlets at each nurse's station on Units 2-8 to eliminate the use of multi-plug strips.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
All findings will be reported to the E(NAME) Committee meetings quarterly. Results will be monitored for three months to ensure 100% compliance.
5. The date for correction and the title of the person responsible for correction of each deficiency.
Responsible Person: Mark Cote, Director of Facilities.
Completion date: 12/22/17

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 24, 2017

Citation Details

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 1 generators had a compliant essential electrical system. Specifically, the facility generator had one transfer switch and the facility's total kVA (kilovolt-amps) of the generator during the four hour generator test, and the monthly load test (load is the amount of electric power used by devices associated to the essential electrical system) was greater then 150 kVA. Findings include: During an interview on 10/25/2017 at 10:19 AM, the Director of Facilities stated the facility generator only had one transfer switch. On 10/25/1017, during review of the facility's 7/29/2016 four hour generator test, a surveyor identified: - at 9:00 AM (the start of the test) the power used was 1250 kilowatts. The kilovolt-amps (kVA) conversion from kilowatts on the generator test form was 1562 kVA. - at 1:00 PM (the end of the test) the power used was 1086 kilowatts. This converts to 1357.5 kVA. On 10/25/2017, during review of the facility's monthly load test reports from 10/26/2016 to 9/20/2017, a surveyor identified: - on 10/26/2016 the power used was 1633 amps, which converts to 979.80 kVA; - on 11/30/2016 the power used was 1581 amps, which converts to 948.60 kVA; - on 12/27/2017 the power used was 1734 amps, which converts to 1040.40 kVA; - on 1/30/2017 the power used was 1817 amps, which converts to 1090.20 kVA; - on 2/27/2017 the power used was 1773 amps, which converts to 1063.80 kVA; - on 3/30/2017 the power used was 1684 amps, which converts to 1010.40 kVA; - on 4/29/2017 the power used was 1399 amps, which converts to 839.40 kVA; - on 5/30/2017 the power used was 1698 amps, which converts to 1018.80 kVA; - on 6/28/2017 the power used was 1670 amps, which converts to 1002 kVA; - on 7/28/2017 the power used was 1759 amps, which converts to 1055.40 kVA; - on 8/29/2017 the power used was 1739 amps, which converts to 1043.40 kVA; and - on 9/26/2017 the power used was 1921 amps, which converts to 1152.60 kVA. During an interview on 10/25/2017, between 3:00 PM and 3:45 PM, the Director of Facilities stated he talked to an electrical engineer and stated the life safety/critical systems on the generator need to be split. He stated the facility power usage is greater the 150 kVA, and did not know if the facility was grandfathered due to the generator install date of (MONTH) 1999. 2012 NFPA 99: 6.3.2.2.10, 6.5.2, 6.6.2, 2011 NFPA 70 - National Electrical Code 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Purchase Order # 50 was issued to Jade(NAME)Engineering on (MONTH) 10, (YEAR) to assess the current electrical system and develop a corrective solution to add and split life safety and critical branch systems to meet NFPA requirements.
Time limit waivers will be requested with cost/time frames to meet compliance.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Electrical one line will be completely reviewed to ensure NFPA compliance.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
Life safety and critical branches will be separated to ensure compliance.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Upon completion of project, all inspections required will be completed to ensure compliance.
5. The date for correction and the title of the person responsible for correction of each deficiency.
Completion date: TBD based on Time Limited Waiver submission.
Responsible Person: Mark Cote, Director of Facilities

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

REGULATION: Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 24, 2017

Citation Details

Based on interview conducted during the recertification survey, it was determined the facility did not ensure a formal and documented risk assessment procedure for the building system categories was performed. Specifically, the buildings system categories assessment was not completed. Findings include: During an interview on 10/25/2017 at 12:48 PM, the Director of Facilities stated a formal and documented risk assessment procedure for the building system categories had not been completed for the facility. 2012 NFPA 99 - Chapter 4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
A risk assessment was completed by the Director of Facilities on (MONTH) 10, (YEAR).
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All aspects of the building in regard to fire, utility and security have been assessed.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
This risk assessment will be updated on an annual basis.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
All findings will be reported to the E(NAME) Committee meetings. Each year the annual assessment will be reported to E(NAME) Committee.
5. The date for correction and the title of the person responsible for correction of each deficiency.
Completion date: 12/24/17
Responsible Person: Mark Cote, Director of Facilities

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 24, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the fire rating of 2 isolated hazardous areas were maintained (basement storage room, basement mechanical room). Specifically, both the basement storage room and basement mechanical room had unsealed wall penetrations. Findings include: On 10/25/2017, between 11:11 AM and 11:21 AM, a surveyor in the basement observed the following hazardous areas had walls with unsealed penetrations: - in the basement storage room the inside of a 3/4 inch conduit was not sealed with 8 fire alarm wires running through it. The annular space from the edge of the wall cutout to the 3/4 inch conduit was not sealed. Also, there was an unsealed pneumatic wire penetration. - in the basement mechanical room the annular space from the edge of the wall cutout to the 1 inch water line pipe was not sealed. Also, there was a 6 inch x 6 inch hole in a wall with a 1 1/2 inch drain line and a 2 inch drain line running through it. During an interview on 10/25/2017, between 3:00 PM and 3:45 PM, the Director of Facilities stated he was not aware of the unsealed wall penetrations in the basement storage room and the basement mechanical room, and was not aware the last time these rooms have been checked for unsealed penetrations. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Penetrations are being sealed with appropriate fire rated materials (90% complete a this time, 100% no later than 12/24/17).
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Above Ceiling Policy for monitoring of vendors and/or sealing of penetrations has been implemented. All work completed requires a final sign-off and approval by Facilities Department to ensure all penetrations have been sealed.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
Visual checks for penetrations has been added as part of the Environment of Care Rounding log sheet. Any non-compliant penetrations found will be input into the work order system as a Life Safety issue and will be corrected immediately.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
All findings will be reported to the E(NAME) Committee meetings. Results will be report to E(NAME) until 3 consecutive months of compliance has been achieved.
5. The date for correction and the title of the person responsible for correction of each deficiency.
Completion date: 12/24/17
Responsible person: Mark Cote, Director of Facilities.

K307 NFPA 101:PORTABLE SPACE HEATERS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview conducted during the recertification survey, it was determined the facility did not ensure portable space heaters were prohibited from all health care occupancies for 1 isolated location (resident room [ROOM NUMBER]). Specifically, there was a portable space heater located in resident room [ROOM NUMBER]. Findings include: On 10/24/2017 at 2:45 PM, a surveyor observed a non-approved portable space heater being stored in resident room [ROOM NUMBER]. On top of the portable space heater was the user manual with a note that included the residents name, room [ROOM NUMBER], and a message to plug into wall outlet only. During an interview on 10/24/2017 at 2:51 PM, LPN # 13 stated she was not aware of the portable space heater in resident room [ROOM NUMBER], and did not remember seeing it this morning. During an interview on 10/24/2017 at 2:53 PM, RN #14 stated he was not aware of the portable space heater in resident room [ROOM NUMBER], and that space heaters are not allowed in resident rooms. During an interview on 10/25/2017, between 3:00 PM and 3:45 PM, the Director of Facilities stated he was not aware of the portable space heater in resident room [ROOM NUMBER], and that space heaters are not allowed in any resident areas. 2012 NFPA 101 19.7.8 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The portable space heater found was immediately removed from resident room [ROOM NUMBER].
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A survey was completed to verify that there were no other space heaters being used in resident rooms.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
A check was added to the Environment of Care rounding log sheet to ensure compliance on this policy continues in regards to resident rooms and space heaters.
Staff will be educated on the policy for space heaters.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
All findings will be reported to the E(NAME) Committee meetings. Results will be reported to E(NAME) Committee until three consecutive months of 100% compliance is achieved.
5. The date for correction and the title of the person responsible for correction of each deficiency.
Completion date: 12/24/17
Responsible person: Mark Cote, Director of Facilities

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 24, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure that 4 of 8 smoke barriers observed were constructed to a 1/2 hour fire resistance rating (eighth floor barrier near room 808, seventh floor barrier near room 719, third floor barrier near room 309, and second floor barrier near room 220). Specifically, these smoke barriers had unsealed penetrations. Findings include: On 10/25/2017, between 1:19 PM and 1:54 PM, a surveyor observed the following 1/2 hour fire rated smoke barriers had unsealed penetrations: - in the eighth floor smoke barrier near room 808 the annular space from the edge of the wall cutout to the 3/4 inch conduit was not sealed; - in the seventh floor smoke barrier near room 719 there was a bundle of data wires that were not sealed; - in the third floor smoke barrier near room 309 there was a 3 inch hole with a bundle of data wires passing though it; and - in the second floor smoke barrier near room 220 there was a 3 inch hole with a bundle of data wires passing though it. During an interview on 10/25/2017, between 3:00 PM and 3:45 PM, the Director of Facilities stated he was not aware of the unsealed penetrations in the observed smoke barrier walls, and was not aware of the last time the smoke barriers have been checked for unsealed penetrations. 2012 NFPA 101: 19.3.7.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Penetrations are being sealed with appropriate fire rated materials (90% complete at this time).
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Above Ceiling Policy for monitoring of vendors and/or sealing of penetrations has been implemented. All work completed requires a final sign-off and approval by Facilities Department to ensure all penetrations have been sealed.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
Visual checks for penetrations has been added as part of the Environment of Care Rounding log sheet. Any non-compliant penetrations found will be input into the work order system as a Life Safety issue and will be corrected immediately.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
All findings will be reported to the E(NAME) Committee meetings. Results will be reported to E(NAME) Committee until three consecutive months of 100% compliance is achieved.
5. The date for correction and the title of the person responsible for correction of each deficiency.
Completion date: 12/24/17
Responsible person: Mark Cote, Director of Facilities.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 24, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for one isolated area (eighth floor electrical room, seventh floor electrical room, fifth floor electrical room, fourth floor electrical room, third floor electrical room, second floor electrical room, first floor electrical room, basement mechanical equipment room, and west emergency stairwell). Specifically, these areas had unsealed penetrations. Findings include: 1) Electrical Closet Penetrations On 10/24/2017 at 9:26 AM, a surveyor in the seventh floor electrical room observed two unsealed pneumatic lines passing into the eighth floor electrical room. On 10/24/2017, between 9:30 AM and 10:00 AM, a surveyor observed unsealed vertical penetration in the electrical room: - in the fifth floor electrical room there was an unsealed bundle of television and data wires passing into the fourth floor electrical room below; - in the fourth floor electrical room there was an unsealed bundle of television and data wires passing into the third floor electrical room below; - in the third floor electrical room there was an unsealed bundle of television and data wires passing into the second floor electrical room below; - in the second floor electrical room there was an unsealed bundle of television and data wires passing into the first floor electrical room below; and - in the first floor electrical room there was an unsealed bundle of television and data wires passing into the basement mechanical equipment room below. During an interview on 10/25/2017, between 3:00 PM and 3:45 PM, the Director of Facilities stated he was not aware of the unsealed floor penetrations in the electrical rooms, and was unsure of when the data wires and cables were installed. 2) West Emergency Stairwell On 10/25/2017 at 11:25 AM, a surveyor on the basement level of west emergency stairwell observed an unsealed two inch drain line, an unsealed 2 1/2 inch drain line, and a two foot long section of the head of the wall joint was not sealed. Also, there was a 10 inch x 10 inch square hole within a fire rated wall with seven thick cables passing through it. During an interview on 10/25/2017, between 3:00 PM and 3:45 PM, the Director of Facilities stated he was not aware of the unsealed wall penetrations in the west emergency stairwell. 2012 NFPA 101: 19.3.1, 8.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 17, 2017

1.What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Penetrations are being sealed with appropriate fire rated materials (90% complete at this time).
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Above Ceiling Policy for monitoring of vendors and/or sealing of penetrations has been implemented. All work completed requires a final sign-off and approval by Facilities Department to ensure all penetrations have been sealed.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
Visual checks for penetrations has been added as part of the monthly Environment of Care Rounding log sheet. Any non-compliant penetrations found will be input into the work order system as a Life Safety issue and will be corrected immediately.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
All findings will be reported to the E(NAME) Committee. Results will be reported to E(NAME) Committee until three consecutive months of 100% compliance is achieved.
5. The date for correction and the title of the person responsible for correction of each deficiency.
Completion date: 12/24/17
Responsible person: Mark Cote, Director of Facilities.