Bethany Gardens Skilled Living Center
May 24, 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: May 26, 2017
Corrected date: July 24, 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, it was determined the facility did not ensure the ability to perform activities of daily living (ADLs) did not diminish for 2 of 17 residents (Residents #9 and 17) reviewed for ADLs. Specifically, Resident #9 was not provided with her dentures or adaptive equipment during meals to maintain ADL status. Resident #17 was not assisted timely with toileting to maintain personal hygiene. Findings include: 1) Resident #9 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required supervision with eating. The comprehensive care plan (CCP) updated 4/17/2017 documented the resident was at increased risk for alteration in nutritional status. Interventions included to provide supplements, monitor intake, and provide and encourage use of adaptive equipment to aid in self-feeding. The resident needed assistance with eating and used an inner lip plate and sippy cup, and was to receive set up for meals. On 4/13/2017, the CCP documented the resident had extractions of all of her remaining teeth and full dentures were completed. The certified nurse aide (CNA) care card (care instructions) dated 4/27/2017 documented staff were to ensure proper fitting dentures as applicable, and were to follow the resident's ordered diet, to include the use of the inner lip plate and sippy cup. A physician progress notes [REDACTED]. She was lethargic and appeared generally weak. A speech therapist progress note dated 5/15/207 documented the resident was observed at her morning meal without her dentures and was not eating. The therapist recommended the resident be downgraded to a pureed diet. A dietary progress note dated 5/17/2017 documented the resident was being treated for [REDACTED]. Her intakes of foods and fluids had been poor and she was not meeting her minimum fluid needs. A dental exam note dated 5/17/2017 documented the resident stated she lost her lower dentures. The resident was informed she lost two lower dentures in (MONTH) (YEAR) and a new lower denture was inserted in (MONTH) (YEAR). The current physician orders, with a start date of 12/16/2016, documented the nurse was to check for dentures after meals and make sure the resident's dentures were placed in the denture cup at bedtime, as the resident had a history of [REDACTED]. The treatment administration record (TAR) for 5/1/2017 through 5/25/2017 documented the nurse was to check for the dentures after meals (as ordered) at 9:00 AM, 1:00 PM, 6:00 PM, and 9:00 PM. During an observation of the noon meal on 5/22/2017 between 12:45 PM - 1:15 PM, the resident was observed in the dining room without her dentures and without a lipped plate. The resident's menu slip documented the use of an inner lip plate and sippy cups. On 5/22/2017, the resident was observed at the evening meal at 5:00 PM without her dentures and with one sippy cup for her water. Her 2 other drinks were in regular glasses. The TAR for 5/22/2017, pertaining to checking for dentures after meals, documented at 10:15 AM late administration: resident unavailable. On 5/23/2017 at 9:15 AM, the resident was observed in the unit dining room with her breakfast in front of her, and her coffee was not in a sippy cup. During an interview with the diet technician (DT) on 5/25/2017 at 11:15 AM, she stated the resident was on an altered consistency diet as she had dental problems, with a history of silent aspiration. The resident was to receive sippy cups for all her fluids and the lip plate at all meals. The facility was low on sippy cups and more had been ordered recently. The DT said the caller informs the cook what each resident needs and was to check for the correct items when received, and the person loading the cart was to again check for the correct items. On 5/25/2017 during an interview at 3:05 PM with licensed practical nurse (LPN) #21, she stated the treatment record was to be signed by the nurses to be sure the resident did not throw away her dentures, and she said the resident always had them in. The resident was observed at 3:10 PM on 5/25/2017, sitting in her room watching television. She did not have her dentures in and said she was just lazy and never put them in, and said she lost the bottom dentures. She stated she did not always remember to put them in and she ate better when they were in. The resident stated her dentures were in her bathroom in the denture cup, and the dentures were observed in the denture cup as she stated. The TAR for 5/25/2017, pertaining to checking for dentures after meals, documented at 10:33 AM late administration: resident unavailable. 2) Resident #17 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired, required extensive assistance with toileting, and was frequently incontinent of urine. The comprehensive care plan (CCP) dated 4/5/2017 documented the resident required assistance with toileting. The certified nurse aide (CNA) profile, active in 5/2017, documented the resident required extensive assistance for toileting. The resident was observed on 5/22/2017 at 6:08 PM in the dining room with her dinner meal in front of her, not eating. The resident informed the surveyor that she needed to use the bathroom. The surveyor informed a nursing staff member present in the dining room. Three nursing staff members, including the registered nurse (RN) Unit Manager, stated to the resident to take a couple more bites and then they would take her to the bathroom. The resident attempted to stand, her chair alarm sounded, and staff told her to sit back down. At 6:15 PM, the resident stated please, please, take me. A CNA told her she could not leave the dining room, as other residents were eating. At 6:21 PM, the resident stated to the surveyor, I am totally sopped, I cannot stay. At 6:24 PM, the licensed practical nurse (LPN) asked the CNA what the resident wanted, and the LPN told the CNA to take the resident to the bathroom. The CNA then took the resident to the bathroom. During an interview with LPN #19 on 5/24/2017 at 5:00 PM, she stated if a resident was eating in the dining room and needed to be toileted, she would have a CNA take the resident. She stated, for example, Resident #9 gets anxious and fidgety and may not be able to verbalize her needs. She stated staff should not have the resident wait to finish eating prior to assisting her with her toileting needs. During an interview with RN Unit Manager #20 on 5/25/2017 at 12:50 PM, she stated she did not know the resident needed to be toileted that evening, and if she knew she would have taken her instantly. 10NYCRR415.12 (a)(1)(iii, iv)

Plan of Correction: ApprovedJune 22, 2017

F310
I. IMMEDIATE CORRECTIVE ACTION:
1. Resident # 9, dentures were found and placed.
Resident # 17 was toileted and spoke with resident, no Psychological harm.
2. Reviewed care plan for resident # 9, care plan reflects resident misplaces dentures often.
3. Care profile in place for resident #9 and # 17.
4. Denture audit was performed.
5. Adaptive equipment audit performed, additional supplies ordered following audit.
6. ADL, TAR audit completed.
II. IDENTIFICATION OF OTHERS:
1. Following Denture audit it was noted that 25 others were at risk for providing dentures, zero were affected.
2.Following Adaptive equipment it was noted 4 others were at risk, zero affected.
4. 20 residents severely impaired cognitively were at risk due to an extensive assist with toileting. 1 was affected, care plan reviewed and updated, care profile in place.
III. SYSTEMIC CHANGES:
1. Denture and adaptive equipment procedure to be implemented on CNA care profile.
2. All residents with severe cognitive deficit will be placed on a toilet schedule and linked to the CNA care profile.
3. All clinical staff will be in serviced on procedure changes by the DON or designee by 7/24/17.
4. Lesson plan and attendance will be filed for reference and validated by 7/24/17.
IV: Monitoring for Compliance:
1. The DON shall develop an audit tool to ensure all residents with dentures and adaptive equipment have procedure on CNA care profile.
2. The DON shall develop an audit tool to ensure all severely cognitive impaired residents are on a toilet schedule and on the CNA care profile.
3. Audits with negative findings will have on site correction implemented.
4. Audits will be reviewed by the LNHA and DON and presented to QA committee for evaluation and follow up 7/24/17.
V: RESPONSIBLE PARTY & EXPECTED OF COMPLETION:
1. DIRECTOR OF NURSING OR DESIGNEE
2. 07/24/17

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: May 26, 2017
Corrected date: July 24, 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, it was determined the facility did not ensure comprehensive care plans (CCPs) were developed for 1 of 19 residents (Resident #13) reviewed for abuse and neglect. Specifically, Resident #13's CCP did not reflect the risk for altercations with other residents, or document interventions in place to prevent altercations. Findings include: Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required extensive assistance for bed mobility and transfers, did not walk, and was independent with locomotion. An incident report dated 4/10/2017 documented the resident was found in front of the first floor elevators hitting another resident, and the other resident was hitting her in turn. The Accident/Incident Investigation Report/Summary documented the resident was considered high risk for accidents and incidents due to mood fluctuations and frequent complaints. There was a plan of care with preventive measures in place. Recommendations included to ensure activity aides or staff were present when the residents were confined to small areas, to supervise and ensure altercations did not re-occur. A nursing progress note dated 4/23/2017 documented another resident attempted to go into the resident's room, opening the door and going slightly into the entrance of the room. Resident #13 was very upset, yelling at the other resident. The resident's comprehensive care plan (CCP) was reviewed on 5/24/2017. There was no documentation the resident was at risk for altercations with other residents and what measures were in place to avoid the possibility of altercations. A Velcro Stop sign was observed across the doorway of the resident's room on 5/24/2017 at 1:10 PM, and on 5/25/2017 at 10:50 AM. Licensed practical nurse (LPN) #4 was interviewed on 5/25/2017 at 11:20 AM. She stated they had recently added the Velcro stop sign across the resident's doorway, as another female resident with dementia would frequently enter the room and the resident would become angry and could strike out at the resident attempting to enter. LPN Unit Manager #1 was interviewed on 5/25/2017 at 12:05 PM. She stated another resident with dementia would frequently wander into the resident's room by mistake and the resident would become angry and could lash out. She had made physical contact with the other resident during one episode. She stated the care plan had been updated to reflect this. Certified nurse aide (CNA) #2 was interviewed by telephone on 5/25/2017 at 1:30 PM. She stated the stop sign was placed in the resident's doorway to deter other residents from entering. She was not sure if it was listed on the care instructions for the resident. Some residents were still able to get through the stop sign and get into the room, but there had been no altercations she was aware of. 10NYCRR 415.11(c)(1)

Plan of Correction: ApprovedJune 22, 2017

F279
I. IMMEDIATE CORRECTIVE ACTION:
1. Care plan was developed by the IDT for resident # 13 to reflect the risk for altercations with other residents and interventions in place to prevent altercations 5/26/17.
II. IDENTIFICATION OF OTHERS:
1. All other residents have been assessed to be at risk for the same deficient practice. Two residents were already affected, care plan reviewed and updated as of 6/18/17.
III. SYSTEMIC CHANGES:
1. The facility implemented a process of bringing laptop to morning report to ensure all care plans are updated in real time to reflect interventions are in place and on the care profile related to A/I's.
2. In addition, clinical report addresses and identifies additional needed information for care plan update and is done in real time.
3. All Nursing staff will be required to complete elearning on Care Plans in Matrix by 7/24/17.
4. An audit of nursing staff and attendance will be filed for reference and validation by 7/24/17.
IV. QA MONITORING:
1. The DON/ADON shall develop an audit tool to ensure all identified residents from weekly IDT A/I' meeting have appropriate care plan and interventions in place.
2. The DON or designee will complete weekly and as needed for 3 months. Audits with negative findings will have real time correction as needed.
3. Audit trends will be reviewed by the LNHA and DON and presented to QA committee quarterly for evaluation and follow up 7/24/17.
V. Responsible party and expected date of completion:
1. DON or designee
2. 07/24/17

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification and abbreviated surveys (NY 599), it was determined the facility did not consistently provide a safe environment and adequate supervision and assistance to prevent accidents for 1 of 8 residents (Resident #2) reviewed for falls. Specifically, an investigation was not completed to determine a root cause when Resident #2 sustained a leg fracture. In addition, when the ankle was observed to be injured, interventions were not initiated to prevent further injury. Findings include: Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired, required extensive assist for toileting and transfers, and was incontinent of bowel and bladder. The comprehensive care plan (CCP) updated 5/23/2017 documented the resident had a self-care deficit and required assistance of two for toileting and transfers. She had poor mobility, strength, and balance. She was at risk for falls, had poor safety awareness, and made attempts to self-transfer. Interventions included to analyze falls to determine pattern and trend. A nursing progress note dated 11/13/2016 at 8:10 PM documented the resident was found sitting on the floor in front of her wheelchair. The resident did not sustain any injury from the fall and could to move her extremities freely. A nursing progress note documented by licensed practical nurse (LPN) #7 on 11/20/2016 at 5:12 PM stated she was called to floor to observe the resident's ankles. She documented the right ankle is very swollen and resident complained of pain when asked which ankle she held up right one. The physician was notified at 5:33 PM and an x-ray of the right ankle was ordered for the next day. A nursing progress noted dated 11/20/2016 at 10:27 PM documented the resident was found sitting on the floor in the hallway and her wheelchair was found in a room down the hall. A radiology report dated 11/21/2017 documented the resident had diffuse soft tissue swelling and a nondisplaced oblique fracture of the right distal fibula (lower leg). A nursing progress note dated 11/21/2016 at 1:04 PM documented an x-ray was obtained that morning that revealed a right distal fibula fracture. The resident was sent to the emergency room for an evaluation and immobilization of the fracture. A hospital transfer form dated 11/21/2016 documented the resident was found on the floor, had edema (swelling) to the right ankle, and an x-ray revealed a distal fibular fracture. The resident was observed on 5/22/2017 at 4:00 PM, self-propelling her wheelchair down the hallway. On 5/23/2017 at 12:45 PM, the resident was observed sleeping in her wheelchair at a table in the dining room. During an interview with licensed practical nurse (LPN) #7 on 5/25/2017 at 10:00 AM, she stated she would initiate an incident report for any injury of unknown origin to attempt to determine what happened. She was supervising the evening she was notified the resident's ankle was swollen, and she went to look at it and noticed one ankle was significantly more swollen than the other one. The resident was not verbal and was not able to tell her if she was in pain. She notified the physician, who wanted an x-ray the next day. She called the physician as she did not know what happened to the resident's ankle and thought maybe she had fallen or bumped it, and she felt the swelling was more than just edema. Sometimes residents would fall and get themselves back up on the wheelchair, and she did not know if the resident had done that. The physician did not order anything other than the x-ray the next day, and she did not elevate or restrict the resident's weight-bearing on the leg until an x-ray was obtained. The resident was able to bear weight on the leg, as she was transferred on and off the toilet. She did not initiate an incident report for the resident's ankle swelling, She did complete one when the resident had fallen a few hours later that evening. She stated she did not know how the resident had sustained a fracture. During an interview with the Director of Nursing (DON) on 5/25/2017 at 1:00 PM, she stated incident reports were completed to rule out any abuse/neglect, to ensure the care plan was followed, and to determine what happened. She was aware the resident had ankle pain and swelling prior to falling. She did not think an incident report needed to be completed for the ankle swelling, as one was done for the fall, and the timeline between events was so close together. She did not know what had caused the fracture, and it may have contributed to the fall later that evening. She thought she had provided education to the LPN at the time regarding not notifying the physician and not getting an x-ray sooner. 10NYCRR 415.12 (h)(1)

Plan of Correction: ApprovedJune 29, 2017

F323
I. IMMEDIATE CORRECTIVE ACTION:
1. IDT reviewed previous 3 months of A/I's for resident # 2 to ensure thorough investigation was complete.
2. An audit of census was performed for review of potential residents at risk for frequent A/I.
II. IDENTIFICATION OF OTHERS:
1. Facility recognizes all other residents could have the potential to be affected.
5 were identified to frequently fall with attempt to ambulate. Care plan was reviewed and interventions in place.
III. SYSTEMIC CHANGES:
1. An addendum to the A/I policy will include residents will receive a safe environment, adequate supervision and assistance and linked to CNA care profile.
2. All staff will be in serviced on A/I policy, Fall policy and addressing potential injuries with prompt, proper interventions by the DON or designee by 7/24/17.
3. A lesson plan and attendance will be filed for reference and validation by 7/24/17.
IV. MONITORING OF CORRECTIVE ACTIONS & QA:
1. The DON shall develop an audit tool to ensure all A/I's are investigated to rule out abuse, neglect and mistreatment and at risk residents have a safe environment and adequate supervision. This audit also to include when a potential injury occurs that prompt intervention was in place, timely and followed through.
2. Audits with negative findings will have on site corrective action implemented.
3. Audits will be reviewed by the LNHA and DON and presented to QA committee quarterly for evaluation and follow up by 7/24/17.
V. CORRECTION DATE & RESPONSIBLE PARTY:
1. DIRECTOR OF NURSING or DESIGNEE
2. 07/24/17

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: May 26, 2017
Corrected date: July 24, 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, it was determined the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 1 of 8 residents (Resident #5) reviewed for falls. Specifically, there was no documented evidence multiple falls for Resident #5 were thoroughly investigated to rule out abuse or neglect or to determine the root cause to attempt to prevent reoccurrence. Findings include: Resident #5 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required limited assistance with transfers and toileting, and was continent of bowel and bladder. The comprehensive care plan (CCP) dated 4/13/2017 documented the resident had a history of [REDACTED]. An incident report dated 3/25/2017 documented the resident tried to self-transfer and acquired a skin tear. The investigation portion of the incident report documented the resident's plan of care had preventive measures in place and included bed and chair alarm that were in place at the time of the fall. An employee statement attached to the report documented the resident was heard yelling out help and the resident's alarm had not sounded. There was not documented evidence the facility investigated why the resident's chair alarm did not sound at the time of the fall or if the alarm was checked to ensure it was functioning properly. The resident sustained [REDACTED]. An incident report dated 3/28/2017 documented the resident was heard yelling out and was found laying on the floor with the wheelchair in front of her. The investigation portion of the incident report documented the resident's plan of care had preventive measures in place and included a chair alarm that was intact but not turned on. A summary of the investigation documentation included the resident's chair alarm was in the off position and she sustained a large hematoma (bruise) on the forehead, laceration to the back of her head, and skin tears to both arms. She was sent to the emergency room for an evaluation. A statement from the employee responsible for the resident's care did not document any information regarding the chair alarm or if she was asked why the chair alarm was not on. The summary documented the investigation revealed there was no cause to believe any alleged abuse or neglect had occurred and the Unit Manager was to educate staff on alarms. The resident was observed on 5/23/2017 at 1:05 PM, self-propelling her wheelchair in the hallway with the chair alarm control dragging on the floor; and at 2:25 PM in bed, with one leg off the side of the bed. Licensed practical nurse (LPN) #4 was interviewed on 5/25/2017 at 11:20 AM. She stated when a fall occurs during her shift, she would begin the incident report and would report what she had seen, find out what the resident was doing at the time of the fall, and make sure the care plan was followed, which included making sure alarms were in place. If the resident was supposed to have an alarm and it was not sounding or was not present, she would notify her Supervisor. She stated the resident was capable of turning her alarm off and had done so in the past. She was unaware if she had turned the alarm off at the time of her recent falls. Certified nurse aide (CNA) #3 was interviewed on 5/25/2017 at 11:40 AM. She stated when a resident had a bed or chair alarm, she would always make sure they were on and working. If the battery was low there would be a warning signal, but the alarm would still function. The resident had both bed and chair alarms and all of the staff would check the functioning when she was placed in her wheelchair and in her bed. LPN Unit Manager #1 was interviewed on 5/25/2017 at 12:05 PM. She stated when she investigated a fall she would make sure all safety measures were in place, and if they were not, she would find out why. She would interview the staff right then and there and immediately educate them about the importance of ensuring alarms were in place and working. She stated when the resident had fallen in 3/2017 and it was noted the chair alarm was not sounding, she immediately spoke to the staff and educated them on the spot. All chair and bed alarms should be in place if care planned, and their functioning should be checked throughout the day. CNA #2 was interviewed by telephone on 5/25/2017 at 1:30 PM. She stated when 2 CNAs were scheduled on the unit and both were in a resident room, the bed or chair alarm in another room would alert them someone needed help. It would not keep the resident from falling, but they would be able to respond faster. Any staff could check the functioning of alarms, but because the CNAs were the ones who put the residents in their chairs or beds, they were usually the one who made sure the alarms were working and on. The Director of Nursing was interviewed on 5/25/2017 at 2:40 PM. She stated all falls are investigated. Investigations included checking the care plan to make sure it was followed and interviewing staff who had cared for the resident. If a resident was care planned for a chair or bed alarm, the investigator would determine if the alarm was in place and functioning properly. If the alarm was not sounding or was off, the staff would be educated immediately on the spot. She would also check the employee's record to see if they had been previously talked to, and discipline would proceed from there. The Unit Manager had submitted a statement to her that day stating the staff had been educated on 3/28/2017 regarding checking alarms for proper placement and functioning. 10NYCRR 415.4(b)(1)(ii)

Plan of Correction: ApprovedJune 22, 2017

F225
I. IMMEDIATE CORRECTIVE ACTION:
1.Reviewed resident # 5's care plan to ensure all interventions were appropriate for risk for fall and were on the care profile. Education that was provided to staff on occurrence of missing chair alarm was obtained and attached to the report.
2. Bed and chair alarm policy was reviewed and revised. Facility audit of bed and chair alarms was completed. The IDT met to review current assessment of need of bed and chair alarms, and 24 alarms were discontinued, 2 laser alarms discontinued, care plans were reviewed and updated.
3. Elder abuse in service began 6/13/17, 1 hour program.
II. IDENTIFICATION OF OTHERS:
1. 43 residents have been evaluated as a potential risk for fall.
2. Out of the 43 at risk, care plans were reviewed to ensure interventions were in place and on care profile.
3. Reviewed previous 3 months of A/I's for verification that abuse, neglect and mistreatment were properly investigated.
III. SYSTEMIC CHANGES:
1. The facility policy of Accidents and Incidents and Abuse and Neglect were reviewed. The DON/ADON were educated by the Corporate DON regarding the need to ensure all A/I's are fully investigated related to the potential for abuse, neglect and mistreatment.
2. Implemented an A/I committee to include IDT to discuss A/I's, trends, root cause, prevention, education and to ensure thorough investigation. IDT will meet once a week or as needed.
3. All staff will be in serviced on the policy and procedure of A/I's and Abuse and Neglect by the DON and/or designee by 7/24/17. All staff will attend the Elder Abuse hour program by 7/24/17 and will be included in new hire orientation. Elder justice act will become part of new hire orientation.
4. Care plan audit done daily (to a minimum of 5 days per week) in its entirety to ensure interventions are in place and on the care profile which is a new process from paper to computer as of recent.
5. A lesson plan and attendance will be filed for reference and validation by 7/24/17.
IV. QA MONITORING:
1. The DON/ADON shall develop an audit tool to review A/I's in the IDT meeting weekly to ensure all A/I's included investigation to rule out Abuse, Neglect and Mistreatment.
2. The DON/ADON will audit as part of the IDT weekly meeting all applicable incidents to ensure they were thoroughly investigated to rule out Abuse, Neglect and Mistreatment. Audits with negative findings will have an on site corrective action implemented.
3. Audit findings will be reviewed by the LNHA and DON as needed and presented to QA committee quarterly for evaluation and follow up 7/24/17.
Date of Correction & Responsible Party:
1. Director of Nursing / Designee
2. 07/24/17

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 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, it was determined the facility did not ensure 2 of 3 sampled residents (Residents #8 and 9), reviewed for weight loss, maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible. Specifically, Resident #8's nutritional needs and interventions for wound healing upon admission and subsequent significant weight loss were not addressed in a timely manner by the nutrition staff. Resident #9 was not provided nourishments as planned and did not receive a meal item as requested. Findings include: 1) Resident #8 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required supervision with eating, and extensive assist to total dependence for most activities of daily living (ADLs). The resident had an unhealed pressure ulcer, was on a mechanically altered diet, and did not have significant weight loss or gain. The comprehensive care plan (CCP) dated 3/7/2017 documented the resident was admitted with a Stage IV pressure ulcer on the sacrum (tailbone area), and did not include nutritional interventions. The weight record documented the resident weighed 253.4 pounds on 3/8/2017. A registered dietitian (RD) assessment dated [DATE] documented the resident was on a low-fat diet, no further weight gain was desired, and she would recommend discontinuing the low fat dietary restriction as it was not warranted. She would recommend starting Prosource (nutritional supplement) 30 cc (cubic centimeters) BID (twice daily) to provide an additional 200 kcals (calories)/30 grams of protein each day. She would provide snacks TID (three times daily) between meals for additional kcals/protein to help meet estimated nutritional needs and to promote wound healing. The CCP was updated on 3/12/2017 and documented the resident was at increased risk for alteration in nutritional status related to potential for weight loss, as the resident was leaving greater than 25% of meals uneaten and had increased nutritional needs secondary to wound healing. The goal was for the resident to maintain current body weight of 258 pounds, plus or minus 3%. Staff were to provide Prosource 30 cc BID, and snacks TID between meals. The resident's weight was to be monitored weekly for 4 weeks, then monthly if stable. The physician was to be updated with significant changes. Staff were to encourage/monitor oral intake at meals, snacks, and medication passes. Staff were to offer alternate foods/beverages if refused, provide specific food preferences, assess intake and weights, and document and report non-compliance. There was no documentation in the CCP regarding the resident's preference for planned weight loss. A diet technician progress note dated 3/28/2017 documented the resident was being treated for [REDACTED]. She would recommend offering the resident Jello for lunch to aid in hydration and yogurt at lunch to support gut flora (normal microorganisms in the intestines). She noted the resident's weight had been stable. The resident's meal intake record documented between 3/7 - 3/29/2017, the resident consumed between 1-25% 8 times, 26-50% 12 times, 51-75% 18 times, 76-100% 23 times, and no refusals. The weight record documented the resident weighed 238.2 pounds (15.2 pounds/6.0% significant loss) on 4/3/2017. The weight record noted 5.0 percent change in weight in 30.0 days. The resident's meal intake record documented a decline in intake between 3/30 - 4/11/2017. The record documented the resident consumed between 1-25% 14 times, 26-50% 12 times, 51-75% 2 times, 76-100% 4 times, and no refusals. An RD progress note dated 4/11/2017 at 1:44 PM documented the resident's nutritional P(NAME) (plan of care) was reviewed and appropriate, including needs assessed for wound status. The note did not document on the resident's weight loss. The resident's meal intake record documented a decline in intake between 4/12 - 5/17/2017. The record documented the resident consumed none 6 times, between 1-25% 31 times, 26-50% 19 times, 51-75% 6 times, 76-100% 6 times, and 8 refusals. The record documented the resident declined or did not consume most of her AM and PM snacks during this time. The (YEAR) weight record documented the resident weighed: - 236 on 4/17 (17.4 pounds weight loss since admission/6.8% significant loss); - 225.8 on 4/24 (27.6 pounds/10.89% significant loss); - 190.8 on 4/27, no re-weight documented, (62.6 pounds/24.7% significant loss); - 229.8 on 5/3 (23.6 pounds/9.31% significant loss); - 212 on 5/8 (41.4 pounds/16.34% significant loss); and - 210 on 5/17 (43.4 pounds/17.13% significant loss). There was no documentation by nutritional or interdisciplinary staff between 4/17 - 5/17/2017 regarding the resident's weight loss. A diet technician progress note dated 5/18/2017 at 1:41 PM documented the resident's weight was down. She had not been eating well and had been making an effort on her own to lose weight. Regaining the weight lost was not indicated; however ongoing rapid weight loss should be avoided. The diet technician would request low fat restrictions be re-evaluated and recommend it to be discontinued. She would refer the resident to the RD for diet counseling and the resident's weight would be monitored weekly. The weight record documented the resident weighed 207.6 on 5/22/2017 (45.8 pounds/18.07% significant loss). A diet technician progress note dated 5/22/2017 at 3:56 PM documented the resident's low fat diet had been discontinued due to weight loss and poor intake. The resident was observed on 5/22/2017 at 12:18 PM, seated in the dining room with her noon meal consisting of a swiss burger, potatoes, and green beans, on a fully rimmed plate. The resident was drinking her liquids out of Kennedy cups (spill-proof cups). At 5:52 PM, during the dinner meal, the resident notified staff she did not want her entree, grilled cheese, carrots, and soup, and wanted an egg salad sandwich in a bowl. At 5:57 PM, the resident was offered a peanut butter and jelly sandwich by another staff member, which the resident declined. During an interview with the resident on 5/23/2017 at 10:50 AM, RD #12 entered the room. The RD notified the resident she recognized the resident had lost a lot of weight at one time, and it would be healthier to lose weight slowly, for example, 2 pounds per week. She asked the resident if she wanted to lose weight, and the resident stated yes. The RD stated she was notified the resident requested supplements at meals. The resident confirmed she wanted to maintain her weight and not continue with rapid loss. The resident stated she was okay with having whole milk added at meals, and she wanted vanilla Mighty Shakes (supplements) in the AM and PM between meals. An RD progress note dated 5/23/2017 at 11:10 AM documented the RD met with the resident to discuss a request for a supplement. Although weight loss was desired, per the resident her appetite was poor and she was requesting a supplement to steady her weight loss and regain her appetite. Low fat milk was changed to whole milk and she would have a Mighty Shake sent BID between meals. During an interview with certified nurse aide (CNA) #13 on 5/24/2017 at 1:42 PM, she stated the resident consumed fluids well and did not consume solids well. CNA #13 stated the resident did not eat good. During a telephone interview with RD #12 on 5/25/2017 at 10:53 AM, she stated she could not recall details about the resident's nutritional status without viewing it in person. She saw the resident recently and could not recall which date. If a resident had a significant weight loss or gain in 1 week, the RD or diet technician should see the resident. They would look to see if the resident had a change in appetite or intake and potentially make changes in a supplement. She would follow up with a resident if there was a concern or change in a resident's status. During an interview with diet technician #11 on 5/25/2017 at 11:15 AM, she stated she had spoken with the resident maybe twice since the resident was admitted to the facility. The RD primarily followed the resident's nutritional status and would see all residents within the first week they were admitted . Another RD had assessed the resident following admission, as RD #12 had not started yet. At that time the RD had recommended Prosource. She was not sure about the resident's acceptance of the Prosource, and they would not check the administration record unless there was a clinical indication to do so. In viewing the record, she felt the resident had accepted the Prosource more than she had declined it and she would continue it as part of the resident's plan of care. She stated stated the facility had weight meetings on Wednesdays that included the diet technician, RD, and nurse Managers. She would print out a report on weights to bring to the meetings. They discussed the resident's weight loss/intake the first or second weekend in 5/2017. When she approached the resident, the resident stated she did not want to feel full and preferred more supplements than regular meal items. The diet technician stated the resident had a history of [REDACTED]. The resident was not eating well and the low fat diet was not helping her, so they discontinued the low fat diet. She had notified the RD to see the resident. They had added Jello and yogurt to the resident's plan of care, specific to the resident's urinary tract infection [MEDICAL CONDITION] and not to address weight loss. She was not aware of other interventions added to the resident's meal plan prior to the 5/2017 weight meeting. During an interview with registered nurse (RN) Supervisor #8 on 5/25/2017 at 12:40 PM, she stated she completes rounds on the 3 PM - 11 PM shift and she did not see the resident out of her room often for dinner time. Since the resident had moved to a new unit, she would often find the resident in her room during the dinner meal. 2) Resident #9 was readmitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required supervision after set-up for eating, and weighed 148 pounds. The MDS dated [DATE] documented the resident's weight was 149 pounds. The comprehensive care plan (CCP) updated 4/27/2017 documented the resident was at increased risk for alteration in nutritional status. Interventions included to provide supplements, monitor intake, and provide adaptive equipment to aid in self-feeding. The resident's weight record (vital report) documented the resident's weight was 140.6 pounds on 5/1 and 5/3/2017, 139.8 pounds on 5/9/2017, and 132.6 pounds on 5/15/2017. A physician progress notes [REDACTED]. A dietary progress note dated 5/15/2017 documented the resident had a significant weight loss, and she refused pureed foods at times. Interventions included pureed consistency diet, provide fortified mashed potatoes and cereal, add shakes twice daily between meals to provide additional calories, and monitor weights weekly. A dietary progress note dated 5/17/2017 documented the resident was being treated for [REDACTED]. Her intakes of foods and fluids had been poor and she was not meeting her minimum fluid needs. A dietary progress note dated 5/22/2017 documented the resident's diet was changed to mechanical soft. Her intakes were sporadic, and pureed food items continued to be provided on her meal trays to allow the resident food consistency choices. The resident was observed on 5/22/2017 at 12:50 PM with her meal in front of her in the unit dining room and she was not eating. The resident's menu slip documented she was on a mechanical soft diet. Attached to the menu slip was a printed slip that documented salt potatoes. The meal observed included the listed mashed potatoes with gravy and did not have the salt potatoes. At 12:55 PM on 5/22/2017, a tray of the PM (afternoon) nourishments was observed on the window sill in the dining room. Licensed practical nurse (LPN) #18 stated she was in the middle of passing them out to the residents in the dining room for lunch. On 5/23/2017 at 9:15 AM, the resident was observed in the unit dining room with her breakfast in front of her, including her AM Mighty Shake. The resident's meal pattern printed on 5/25/2017 documented the resident was to receive nourishments including: a morning (AM) nourishment of Mighty Shake Plus and canned fruit, and an afternoon (PM) snack of a Mighty Shake Plus and a snack, such as ice cream. During a telephone interview with the registered dietitian (RD) on 5/25/2017 at 11:00 AM, she stated the between meal nourishments were to be passed generally at 10 AM, 3 PM, and at bedtime. Fortified mashed potatoes were usually provided with lunch and supper and, depending how the meal pattern was set up, a resident could have a second starch when chosen from the menu. On 5/25/2017, during an interview with the diet technician at 11:15 AM, she stated the resident was to receive fortified mashed potatoes at lunch and supper. The attached slip on the resident's menu was the item the resident ordered for the meal and the resident should have received both the fortified mashed potatoes and the salt potatoes for the meal on 5/22/2017. The checker on the tray line should have seen the menu slips and should have made sure the resident received both items. All the nourishments for the day were sent to the floors at breakfast. Nursing was to pass the nourishments at 10 AM and between 2 to 3 PM. She preferred the nourishments not be passed during meals unless there was a specific reason to do so. She never observed nourishments being passed with meals, as it was important for residents to first eat their planned meal prior to receiving the between meal nourishments. On 5/25/2017 at 12:45 PM, LPN #18 was observed passing the PM nourishments in the dining room while the residents were eating lunch. During an interview at this time, the LPN stated she always passed the AM nourishments with breakfast and the PM nourishments with lunch and was never told to do it differently. 10NYCRR 415.12(i)(1)

Plan of Correction: ApprovedJune 26, 2017

F-325
I) Immediate Corrective Actions:
1. The following was addressed for Resident #8:

a. Supplements with meals were added on 5/23/17

b. HN Two-Cal was increased & added to Med-Pass on 6/01/17 and also increased on 6/15/17

c. Appetite stimulant was added on 6/9/17.

d. Weights are being monitored weekly & as needed.

e. All residents with identified pressure-ulcers will be assessed by the RD or Designee. Appropriate interventions will be conducted as needed.
2. The following was addressed for Resident #9:
a. Worked with SLP to upgrade diet, is not on regular textures with weight-rebounding (up 6# in the past month). Fortified mashed potatoes have been removed from meal pattern due to diet upgrade and regular texture tolerance.
b. LPN #18 was educated on how AM & PM nourishment's should not be passed with meals as a corrective action to those residents whom had been receiving them at the inappropriate time.

II. Identification of Others

a . Facility is in the process of hiring a new
Registered Dietitian.
b. Facility respectfully submits that any resident with a change in intake has the potential for a significant weight loss.

c. Any resident that has consumed <25% of their meals for three days in a row will be weighted on the 4th day and will be added to weekly weight monitoring. Weight will be reviewed by the Interdisciplinary team at the weight meetings on weekly basis for first month and monthly thereafter or as needed.
d. Licensed Nursing Staff will be re-educated / in-serviced on weight policy, including Re-weight policy by the Acting RD or Diet-Tech or Designee.
e. Any resident that receives fortified mashed potatoes at meals has the potential to not receive the other starch at the meal if they request it. Dietary staff was re-educated to give supplemental starch along with starch that is on the menu when the meal ticket indicates both.
f. All residents that have scheduled nourishment's or supplements between meals are at risk for having them provided at meals. As a result, the necessary nursing staff will be educated by RD or Diet-Tech / Designee on the appropriate timing of nourishment passing.
g. In order to update the appropriate IDT staff on any new identified pressure-ulcers, a written & verbal notice will be sent to all applicable members of the Interdisciplinary (IDT) within 48-72 hours.
h. Any Assessments, evaluations for nutritional needs for snacks & supplements will be added as necessary.


III. Measures & Systemic Changes:
1. Policy & Procedures regarding said areas (weight-loss & timing of nourishment's) will be updated or revised if needed.
2. Further In-servicing / education will be provided if to necessary staff as needed.
3. An audit tool & schedule has been implemented for the following:
a. Residents who have had a weight loss of more than 5% during the prior month. Reviewing of weights has been addressed by medical and nutritional staff.
b. Residents who have had a >5# change from their prior weight to ensure that re weights are taking place with in a timely manner.
c. Residents who have fortified mashed potatoes listed on their meal pattern to assure that proper procedure is taking place. Findings will be recorded in a designated binder.
d. On the timing of nourishment passes, the RD, Diet-Tech or Designee will perform audits for this. All Findings on audits in areas listed above will be logged in a separate binder. Purpose is to ensure compliance in these areas.

e. The RD, Diet-Tech or Designee will implement an audit tool to monitor if any new pressure ulcers were identified.

f. The RD, Diet-Tech or Designee will attend along with the Wound-Nurse / Designee during wound-rounds to review. This will be conducted weekly for the first month & monthly for next 3 months & as needed thereafter. In addition, pressure ulcers will be assessed as needed on weekly basis for first month.
IV. Monitoring of Corrections & QA:
1. The Dietary staff will conduct audits weekly for the first month, monthly for the next quarter & as needed thereafter for the following:
a. All residents that have had a weight loss of more than 5% during the prior month.
b. All residents that have had a >5# change from their prior weight to ensure that re weights are taking place with in a timely manner.
c. All residents with fortified mashed potatoes on their meal pattern
d. The timing of nourishment passes

2. All Findings / Results will be reported to the QA committee during its quarterly meetings. At the end of each meeting a decision will be made if any further corrective action or additional auditing is needed.

V. Responsible Party & Expected Date of Completion:
1. RD, Diet Technician, or Designee
2. 07/21/17

FF10 483.60(d)(1)(2):NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP

REGULATION: (d) Food and drink Each resident receives and the facility provides- (d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 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 food was palatable for 2 of 2 meal observations and for 2 additional residents (Residents #22 and 23). Specifically, hot and cold food items were not served at palatable temperatures. During two meals, Residents #22 and 23 received food that was not the consistency ordered by their physician. Findings include: 1) Food Temperatures On 5/23/2017 at 6:08 PM, Resident #22 agreed to provide a surveyor with their dinner tray to test. The following temperatures were measured by a surveyor: - mechanical soft (ground) chicken fingers were 121 degrees Fahrenheit (F); and - mechanical soft coleslaw was 54 degrees F. The chicken fingers were not held at 140 degrees F or above, and the coleslaw was not held at 40 degrees F or below as per State Sanitary Code. On 5/24/2017 at 12:40 PM, a test tray was conducted on the fourth floor during the lunch meal by a surveyor. The following temperature was measured by a surveyor: - the pureed turkey sandwich was 60 degrees F. The pureed turkey sandwich was not held at 40 degrees F or below as per State Sanitary Code. On 5/24/2017 at 3:45 PM, a surveyor with the state thermometer that recorded the 5/23/2017 and 5/24/2017 food temperatures, verified the state thermometer and the facility thermometer were showing the same temperatures. Specifically: - the temperature of mashed potatoes was measured at 193 degrees F by the state thermometer, and 194 degrees F by the facility thermometer; and - the temperature of hot water was measured at 182 degrees F by the state thermometer, and 182 degrees F by the facility thermometer. On 5/24/2017 at 1:25 PM, the Food Service Director stated all hot food items must be served at 165 degrees F or above, and all cold food items be served at 40 degrees F or below. 2) Resident #22 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately cognitively impaired, required supervision with eating, and was on a mechanically altered diet. The physician orders [REDACTED]. The comprehensive care plan (CCP) dated 3/16/2017 documented the resident required set up assistance with eating, required a mechanically altered diet, and staff were to provide specific food preferences. On 5/23/2017 at 6:06 PM, Resident #22 agreed to provide a surveyor with their meal tray to use as a test tray. This tray consisted of mechanical soft chicken fingers. When the replacement tray was delivered at 6:15 PM, the resident was provided with regular consistency chicken fingers. During a review of the facility's recipe for mechanical soft chicken tenders, a surveyor observed instructions that stated, place chicken tenders in robo coupe, adjust robo coupe to low setting, and ground until soft. On 5/24/2017 at 1:17 PM, the Food Service Director stated: - the mechanical soft chicken fingers were supposed to be ground; - when the staff on the floor called down to the kitchen for the replacement tray, they requested regular chicken fingers. The Food Service Director stated she thought the staff were asking for a back-up alternative and was never told this was a replacement tray; and - she told the nursing staff in the past to state the residents' names and food consistencies when requesting food from the kitchen. 3) Resident #23 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired, required extensive assistance with eating, and was on a mechanically altered diet. The physician orders [REDACTED]. On 5/22/2017 at 1:12 PM, the resident was observed with a nectar thickened dessert at the dining table. A certified nurse aide (CNA) attempted to assist the resident, and the resident made a non-verbal expression indicating unhappiness and shook her head no. During the observation, the CNA questioned why the dessert was a pureed consistency when the resident was on a mechanical soft diet. The resident's meal ticket documented the resident was on a nectar thickened fluid diet with mechanical soft consistency solids, and documented the resident was to have a nectar thickened cobbler fruit dessert. On 5/24/2017 at 1:12 PM, the Food Service Director stated fruit cobbler was already of mechanical soft consistency and there was no need to make it any softer. She stated it did not make sense that the resident received a nectar thickened fruit cobbler, and did not know why it was on the resident's meal ticket. During an interview with diet technician #11 on 5/25/2017 at 11:15 AM, she stated the resident's cobbler should not have been thickened and should have been served regular consistency. 10NYCRR 415.14(d)(1)(2), Subpart 14-1.31

Plan of Correction: ApprovedJune 27, 2017

F-364
I. IMMEDIATE CORRECTIVE ACTION:
1. Review of F-Tag 364 was performed by Diet-Tech, Food Service Director.
2. Menu changed from Nectar Thick Cobbler to Cobbler for nectar thick Diets.
3. Residents who received regular chicken fingers on a Mechanical soft diet, were seen by the Speech Therapist. Diets were upgraded to regular textures the next day.

4. Food Temperatures:
a. COLD FOODS: New chest freezers were purchased to place cold food & drink items to keep proper temperatures prior to start of tray-line. In addition,certain foods when out of the fridge will be placed on tray on top of ice to maintain proper temperatures.

b. HOT FOODS: An outside Consultant will be hired to In-service the Cooks & Dietary staff on maintaining proper temperatures for Hot foods during tray line & also once on Unit's.
II. IDENTIFICATION:
1. Facility respectfully submits that all residents on thickened fluids w/ a Mechanical-Soft or Regular Solids had the potential to be affected by this deficiency.
2. The language on the Menu will be changed from nectar thick to drained for those menu items which may have thin-fluids associated with them.
3. Dietary Staff will be In-serviced by RD or Diet-Tech, or Food Service Director (FSD) or Designee on requirements for residents who are on thickened fluids.
4. The necessary nursing staff will be educated on when calling down to kitchen for an item, & how to specify the residents name & diet-order. Kitchen Staff members should then refer to the resident list by phone to verify that diet order stated is correct.
III. Measures & Systemic Changes:
1. The FSD / Designee will develop an Audit tool for taking proper temperatures of food while on Tray-line as well as arrival on unit. Purpose is to maintain proper temperatures.
2. Menu Audits will be performed for all thickened diets to ensure proper language is being used
3. Auditing / Review of Menu's will take place for current menu & for next season's menu.
4. Audits of residents on thickened fluids & Mech.-Soft diet will be conducted to ensure that they are not receiving any pureed items / foods with potential thin fluids associated (i.e. soup, canned fruits).
5. Audits of replacement-trays will be conducted for residents on a Mech. Altered diet 2x weekly
6. Two test trays w/ documentation of Temp's for hot & cold foods will be conducted weekly for first month & monthly thereafter.
7. Findings / results for these audits will be logged in a designated binder.
IV: Monitoring of Corrective Actions & QA:
1. The Test-Trays audits conducted by FSD / Designee will aim for thresh-hold compliance at 95% for the first quarter & then goal is to be at 100% compliance after 3 months.
2. All Audits mentioned above will be conducted weekly for first month, monthly for next quarter & as needed there-after. These findings will also be presented to the QA Committee at the quarterly meetings to determine if any further audit / action is needed.
V. Responsible Party & Expected Date Completion:
1. RD, Diet-Tech Food Service Director or Designee
2. 07/21/17

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 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, it was determined the facility did not ensure care and services were provided to attain or maintain the highest practicable physical well-being for 1 of 20 sampled residents (Resident #8). Specifically, Resident #8 had an order for [REDACTED]. Findings include: Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required extensive assist to total dependence on staff for most activities of daily living (ADLs), had an unhealed pressure ulcer, had moisture-associated skin damage (MASD), and was to have a pressure reducing device applied to her chair and bed. A nursing progress note dated 3/7/2017 documented the resident had quarter-sized ulcers (unspecified type) to her bilateral heels. The comprehensive care plan (CCP) dated 3/9/2017 documented the resident was at risk for impaired physical mobility. The resident had a Stage IV pressure ulcer to her sacrum (tailbone area) and was to receive treatment as ordered by the physician. The CCP was edited on 4/20/2017 and documented the resident was to wear Podus (pressure-reduction) boots when out of bed. The 4/2017 physician's orders [REDACTED]. In addition, the resident was to receive a treatment to the sacral wound that included to cleanse the sacral wound with normal saline, pat dry, apply skin prep to surrounding tissue, follow by packing calcium alginate rope to depth of sacral wound, and cover with bordered gauze daily on the 3 PM - 11 PM shift. The area documenting administration of the treatment to the wound noted 0 on 4/23/2017 with a licensed practical nurse's (LPN's) initials. There was no documentation by the LPN listed on the TAR why 0 was noted for the treatment. Registered nurse (RN) #10 documented in a progress note on 4/23/2017 she assessed the sacral wound. There was a very small opening, the cotton swab would not fit into the opening as the end of the swab was too large, and the dressing had fallen off. The area was cleansed and she attempted to pack the wound with calcium alginate rope and it would not fit in to the area. The RN applied wound gel from the resident's personal treatment box with [MEDICATION NAME] (disinfectant) and covered it with border dressing. The resident care profile (care instructions), last updated by the facility on 5/18/2017, documented the resident was to wear multi Podus boots at all times and they were to be removed for skin checks and hygiene. The resident was to wear Prevalon boots (for heel pressure relief) at HS (bedtime). The resident was observed seated in her tilt-in-space chair wearing Velcro sneakers on 5/22/2017 at 12:18 PM, and on 5/23/2017 at 9:00 AM, from 10:50 AM - 11:15 AM, and at 11:52 AM. The TAR documented on 5/24/2017 the resident was not provided her Podus boots as she was out of bed with shoes on. During an interview with certified nurse aide (CNA) #13 on 5/24/2017 at 1:42 PM, she stated when the resident was out of bed, she was to wear shoes. She stated the resident wore specialized diabetic-like shoes daily. During an interview with licensed practical nurse (LPN) #9 on 5/25/2017 at 11:28 AM, she stated the resident had Prevalon boots to wear in bed. The resident would initially say she did not want to wear them, and if she talked to the resident about them, the resident would say it was okay to wear them. During an interview with CNA #14 on 5/25/2017 at 12:37 PM, she stated the resident had Prevalon boots while in bed. She stated she was not aware of boots during the day, and the resident wore sneakers. The resident did not have any shoes on this date and she was wearing socks as she declined to wear shoes. During an interview with LPN Unit Manager #1 on 5/25/2017 at 12:50 PM, she stated she was not aware of the resident ever having an order in place for wound gel. If the RN was unable to complete the treatment, the medical staff should have been notified. The RN should not have completed the treatment without a physician's orders [REDACTED]. At 2:55 PM, LPN Unit Manager #1 stated the resident's care plan included the resident was to wear Podus boots when out of bed and Prevalon boots when in bed. The resident had her boots available, she had never seen the resident wear her sneakers, and the resident had her boots in place. 10NYCRR 415.12

Plan of Correction: ApprovedJune 29, 2017

F309
I. IMMEDIATE CORRECTIVE ACTION:
1. Education was provided to the RN who provided the treatment without MD order.
2. Skin Team assessed wound on 5/26/2017, noted no negative findings, treatment in place with MD order.
3. ADL audit was performed by ADON.
3. Skin treatment audit was performed by the DON and ADON to confirm treatment in place for all wound treatments.
4. Late entry placed by RN who provided bilateral heel assessment on resident # 8, heels were benign on admission.
II. IDENTIFICATION OF OTHERS:
1. All residents had the potential to be affected. Following treatment audit, all wounds had proper treatment and MD order in place.
III. SYSTEMIC CHANGES:
1. All licensed staff will be required to complete elearning training in Matrix on MD orders and documentation by 7/24/17.
2. Policy and procedure for skin care will have an addendum to to include the DON or designee will verify skin assessment is complete with RN documentation on progress note on each admission, re-admission.
3. All clinical staff will be required to complete care plan profile training in elearning on Matrix by 7/24/17.
4. ADL policy and procedure to be reviewed and revised by 7/24/17.
5. Weekly skin rounds will be conducted weekly.
6. All clinical staff will complete required Matrix training as well as receive an in service by the DON or designee on reviewed, revised policies by 7/24/17.
7. Lesson plan and attendance will be filed for reference and validation by 7/24/17.
IV: QA MONITORING:
1. The DON shall develop an audit tool to ensure treatments have MD order and that treatment was followed.
2. The DON shall develop an audit tool to ensure head to toe skin assessment was verified and documented in medical record.
3. The DON or designee will audit wound treatments weekly for 3 months.
4. The DON shall develop an audit tool to audit CNA care profile to ensure interventions in place are followed.
5. Audits with negative findings will have on site corrective actions implemented.
6. Audit findings will reviewed by the administrator and DON and presented to QA committee quarterly for evaluation and follow up 7/24/17.
V: RESPONSIBLE PARTY & EXPECTED DATE OF CORRECTION:
1. DON or designee
2. 07/24/17

FF10 483.10(c)(6)(8)(g)(12), 483.24(a)(3):RIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES

REGULATION: 483.10 (c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. (g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident?s option, formulate an advance directive. (ii) This includes a written description of the facility?s policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual?s resident representative in accordance with State law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. 483.24 (a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident?s advance directives.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 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, it was determined the facility did not ensure the system developed to ensure implementation of advance directives was documented in a manner that was consistent with resident wishes for 3 of 19 residents (Residents #4, 10, and 20) and one additional resident, reviewed for advance directives. Specifically, Resident #4 had a change in resuscitation code status after a hospitalization and the resident's status was not re-evaluated upon return to the facility, the medical binder identifier was not consistent with the medical orders, and staff mis-identified the resident's code status. Resident #10 did not have a code status identifier on the medical binder, and there was no documented determination of capacity completed by the physician prior to the health care surrogate signing the MOLST (Medical Orders for Life Sustaining Treatment). Resident #20 did not have a code status identifier on the medical binder. Facility staff were unable to provide consistent information on code status identifiers on 3 of 5 resident units and were not aware of a system to identify a resident's code status when the resident was off the unit. Findings include: Facility policy Cardio [MEDICAL CONDITION] Resuscitation (CPR) Code Blue (undated) documented orange stickers are to be placed on the spine of charts for those residents who do not wish to be resuscitated (DNR, do not resuscitate). 1) Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, did not speak, and was sometimes able to express ideas and wants. The resident responded adequately to simple, direct communication only. Physician orders [REDACTED]. A nursing progress note dated [DATE] at 12:56 PM documented the resident had complaints of excruciating pain and requested to be sent to the hospital. She is a full code. A hospital consent to a DNR order, dated [DATE], documented the resident's surrogate was identified and consented to the DNR order and the physician determined to a reasonable degree of medical certainty that the patient has an irreversible or incurable condition. A second physician concurred with the medical determination. The resident returned to the facility on [DATE] at 6:45 PM. There was no documentation of the resident's code status upon readmission to the facility. A physician order [REDACTED]. The resident was readmitted to the hospital on [DATE] at 12:55 AM for respiratory distress. A nursing progress note dated [DATE] at 3:50 PM documented a call was placed to the hospital for an update on the resident's condition. The resident was being treated for [REDACTED]. There is a question over DNR status as it was signed on [DATE] while in the hospital, and was signed by someone other than her health care proxy (HCP). The hospital social worker was looking into this and will notify the facility of a definitive answer. A nursing progress note dated [DATE] at 8:13 PM documented the resident returned to the facility. A physician readmission history and physical dated [DATE] documented the resident was hospitalized for [REDACTED]. The advance directives were reviewed, the resident had a history of [REDACTED]. The comprehensive care plan (CCP) dated [DATE] documented the resident had advance directives of DNR/DNI. Approaches included the advance directives would be reviewed with the resident and/or family as needed, keep the family/health care proxy updated with the resident's condition changes as needed, keep the physician informed with the resident's condition, and social worker involvement. The resident had some short term memory impairment and her long term memory was intact. The resident was non-verbal and would use a white board at times. The resident profile (care instructions) dated [DATE] documented the resident had a code status of DNR/DNI. A nursing progress note dated [DATE] at 3:37 PM documented the Interdisciplinary Team felt the resident was making gains to return to pre-hospital status. At 11:23 PM, the nurse documented the resident was alert, oriented, and non-verbal, but able to make needs known via nodding or gesturing. There was no documentation advance directives were discussed with the resident when she returned from the hospital and had an improvement in her physical status. During the initial unit tour on [DATE] at 11:10 AM, licensed practical nurse (LPN) Unit Manager #1 stated a resident's code status would be documented on the face sheet. If they were a DNR, a red dot would be on the spine of the resident medical record binder and their name would be printed on white paper outside of their room. If a resident was to receive CPR (full code), there would be no dot on the spine of the medical record and their name would be printed on blue paper outside of their room. The resident's medical record binder was observed without an orange dot on the spine on [DATE] at 1:05 PM, and [DATE] at 10:50 AM. The resident's name plaque outside of her room was observed printed on white paper on [DATE] at 10:55 AM. LPN #4 was interviewed on [DATE] at 1:30 PM. She stated a resident's code status could be found on their chart. There would be an orange dot on the outside and an orange DNR sticker on the inside cover of the chart. She pointed to the resident's chart as an example, as there was no orange dot on the outside. The resident would be a full code and CPR would be performed. A white name plate outside of the door meant the resident was a DNR, and a blue name plate meant the resident was a full code. LPN #5 was interviewed on [DATE] at 1:50 PM. She stated the spine of the resident's medical record indicated the code status. A blue sticker would mean the resident was a full code, and a red dot meant DNR. LPN #4 was interviewed a second time on [DATE] at 11:20 AM. She looked at the resident's chart and stated she would be a full code and she would perform CPR on the resident if needed. She opened the chart and there was no DNR sticker on the inside cover, and the face sheet (resident demographic information) documented full code. She looked at the physician orders [REDACTED]. LPN Unit Manager #1 was interviewed on [DATE] at 12:05 PM. She stated the resident was a full code before she went to the hospital in March. The family member had changed the code status during the hospitalization and she had questioned the validity of the change. She had spoken to the hospital social worker for clarification and had documented the conversation on [DATE]. She had also spoken with the social worker at the facility regarding her concerns and had not heard anything since then. The resident was alert and oriented and she had not approached the resident to discuss her wishes since her return in March. The resident's physician orders [REDACTED]. Social worker #6 was interviewed on [DATE] at 1:15 PM. She stated the resident had returned from the hospital as a DNR/DNI and the CCP had been updated to reflect the change. The new advance directives had been completed by a family member and the hospital had an HCP form designating the family member as the HCP. The hospital would be sending the information over via fax. She was aware the Unit Manager had wondered why the decision was made by the family member. The resident had a deterioration in status while in the hospital and had not reached her baseline cognitive status by the time she returned to the facility. The resident was much improved now and she had not spoken to the resident since her return from the hospital. The physician and she would be reviewing advance directives on all residents and would also review the resident's wishes with her. The Medical Director was interviewed on [DATE] at 2:15 PM. He stated he had been the Medical Director at the facility for approximately 2 months. His plan was to initiate the MOLST form for all the residents in the facility. When a resident returned from the hospital, he would initiate a MOLST if they did not have one and review the MOLST for completeness if they already had one. He would interview the resident to determine if they had the capacity to understand advance directives and would include their HCP in the discussion as well. He would review the advance directives during his subsequent visits. He stated he would review the resident and initiate a MOLST form. 2) Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately cognitively impaired and participated in the assessment. The MOLST dated [DATE] documented do not attempt resuscitation (DNR, do not resuscitate, allow natural death) for the resident. The MOLST documented the resident's Health Care Agent provided verbal consent for the DNR. There was no documentation a determination of capacity was completed prior to implementing the MOLST. The comprehensive care plan (CCP) dated [DATE] documented the resident had a short term memory impairment and had a MOLST with a DNR in place. The CCP documented the resident's advance directives would be reviewed with the resident and/or family as needed. The binder of the resident's record was observed on the resident unit on [DATE] at 1:30 PM. The binder of the record did not have a DNR identifier in place. During an interview with licensed practical nurse (LPN) #18 on [DATE] at 2:30 PM, she stated if a resident was found unresponsive in the unit dining room, she would look for an orange or green dot on the binder of the resident's record to determine their code status. She stated the orange dot would indicate the resident's wishes were for DNR. She stated if she found a resident unresponsive in the lobby or outside, she would page for a registered nurse (RN). The LPN stated the residents did not wear identifying bracelets and she did not know if there was a list of residents' code statuses off the units. She stated she had her cardiopulmonary resuscitation (CPR) certification, and did not wear a heart indicating her certification, as the facility did not have a current copy of her certification. During an interview with the resident's attending physician on [DATE] at 2:30 PM, he stated he was aware the resident did not have a determination of capacity, and they would be correcting this. 3) Resident #20 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired and required extensive assist for most activities of daily living (ADLs). A Do Not Resuscitate (DNR/do not perform chest compression if heart stops) form was signed by the resident on [DATE] while the resident was in the hospital. The comprehensive care plan (CCP) updated [DATE] documented the resident had advance directives indicating DNR. Interventions included to respect and honor the resident's wishes. physician's orders [REDACTED]. During an interview with licensed practical nurse (LPN) #16 on [DATE] at 11:05 AM, she stated the resident went to the hospital [DATE], and had a bed hold with a plan to return to the facility. She stated an orange sticker on the binder of a resident's chart indicated DNR status. LPN #4 was interviewed on [DATE] at 1:30 PM. She stated a resident's code status could be found on their chart. There would be an orange dot on the outside and an orange DNR sticker on the inside cover of the chart if the resident was a DNR. LPN #5 was interviewed on [DATE] at 1:50 PM. She stated the spine of the resident's medical record indicated the code status. A blue dot sticker would mean the resident was a full code, and a red dot meant DNR. There was not a DNR identifier (orange sticker) on the spine of the resident's chart during observation on [DATE] at 1:15 PM, and [DATE] at 12:30 PM. During an interview with LPN #18 on [DATE] at 2:30 PM, she stated if a resident was found unresponsive in the unit dining room, she would look for an orange or green dot on the binder of the resident's record to determine their code status. She stated the orange dot would indicate the resident wished for DNR. 10NYCRR 415.3(e)(1)(ii)

Plan of Correction: ApprovedJune 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** P(NAME)- F155
I. Immediate Corrective Action:
1. Resident # 4 -re-evaluated Advance Directives on [DATE]. Medical binder, name plate and order properly identified.
Resident # 10- medical binder and name plate were properly identified to reflect code status and capacity form completed.
Resident # 20- medical binder and name plate were properly identified to reflect code status.
2. An Advanced-Directive Roster was placed in the main dining room as a location to identify code status when residents are off their units.
4. The Cardio [MEDICAL CONDITION] Resuscitation (CPR) Policy & Procedure was revised on [DATE] to reflect code status identifiers.
5. Staff education on the revised Cardio [MEDICAL CONDITION] Resuscitation (CPR) Policy & Procedure along with code identifiers began on [DATE] & will be scheduled by DON or Designee and provided to all staff.
6. In addition, an Advance Directive Code Identifier form was implemented and has also been added to the Orientation packet for new hires and will be done annually.
II. Identification of Others:
1. Facility respectfully submits that all residents and staff have been identified as having the potential of being affected by this practice, however out of resident status, zero were affected. 10 % of staff identified as needing review of revised CPR policy and procedure, 100% will need education on the new Advance Directive form.
2. The Director of Social Work /Designee will perform a full house audit to identify residents that may have been affected by this same practice. Immediate corrective action will be taken if needed, to ensure appropriate documentation/identification & review of Advanced Directives to ensure consistency with AD wishes.
III. Measures/ Systemic Changes:
1. Reviewed and revised the CPR policy, implemented a new Advance Directive form.
The new Medical Group, IPC, began at (NAME)any Gardens in (MONTH) (YEAR), with the focus on ensuring that the MOLST forms on all residents within the facility and corresponding documentation / Capacity form (as needed) are being completed properly.
2.The Director of Social Work, Director of Activities and/or designee will be responsible for appropriate code status identifiers on medical chart and name plate on door. MD order will be verified by Nursing staff.
3.The Director of Social Work will develop an Audit & Tracking tool to ensure Advanced Directives are formulated along with: completion of capacity form as needed, appropriate identification on medical chart & proper colored name plates. Estimated completion date: [DATE].
3. The Director of Social Work and/or Designee will work closely with the new medical team in assisting, formulating and ensuring proper completion of MOLST forms on all residents at the facility. The Medical Director will review policy /procedure related to CPR and ensure all medical staff with in the IPC group have received education and training on above information.
4. The Director of Social Worker and/or Designee will ensure Advance Directives are reviewed with all admission /re-admissions or as needed.
5. The Director of Social Work and/or Designee will maintain an Advance Directive Roster and distribute it weekly and as needed.
6. The Director of Social Worker and/or Designee will place the Advanced Directive roster in main dining room weekly and as needed with current updates.
7. The Director of Social Work, DON and/or Designee will ensure any new hires will be educated on advance directive identifiers. The DON and/or Designee will educate Director of Social Work on revised policy/procedures regarding CPR.
8. All staff will be will be educated on CPR Policy & Procedures by DON/Designee with expected completion by: [DATE].

IV. QA Monitoring
1. The Director of Social Work and/or Designee will ensure code identifiers are placed accurately upon admission. This audit will be performed weekly for the first the month and then monthly for the rest of the quarter.
2. The Director of Social Work and/or Designee will ensure capacity forms are in place as needed. This audit will be performed weekly for the first month and then monthly for the rest of the quarter.
3. The Director of Social Work and/or Designee will complete monthly audit which will involve questioning of staff to ensure they are aware of the Advance Directive code Identifiers.
4. All audits will be reviewed by the LNHA, Director of Social Work and DON and presented to the QA Meeting which are conducted quarterly. At the end of the QA-meeting a determination will be made by the QA-Committee if any additional auditing or corrective actions is needed.
V. Responsible Party and Expected Date of Completion:
1. Director of Social Work or Designee
2. Expected Date of Completion: [DATE]

Standard Life Safety Code Citations

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: May 25, 2017
Corrected date: July 21, 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 did not know the total kVA (kilovolt-amps) of the generator during the full load bank tests (load is the amount of electric power used by devices associated to the essential electrical system). Findings include: During review of the facility's generator logs between 9:00 AM - 11:00 AM on 5/23/2017, a surveyor identified that the weekly full load bank tests did not include documentation of the total kVA used. On 5/24/2017, between 1:30 PM and 4:00 PM, a surveyor in the generator room observed only one transfer switch. During an interview on 5/24/2017 at 10:40 AM, the Facilities Director stated he did not know the total kVA for the facility generator, and could get that information from the third party vendor that services the generator. He stated he did not know the specific amount of kVA that would be required for a type 2 essential electrical system and a type 3 essential electrical system. From 5/23-5/24/2017 the facility could not determine that the weekly load test total kVA was l50 kVA or less, which is the total kVA required for a facility to have only one transfer switch. 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: ApprovedJune 16, 2017

K-915
I. Immediate Corrective Action:
Essential Electrical Systems
i. The Director of Maintenance contacted a vendor to obtain the correct formula in order to calculate the kilovolt-amps (kVA) for generator during full load bank tests.
ii. The Director of Maintenance conducted a test on 6/14/17 by having the facility generator run on full-load and measured the out-put amperage and voltage at the Transfer switch. Results were documented and within proper allowance /range.
iii. The Administrator counseled & educated the Director of Environmental, the Director of Housekeeping & the Maintenance staff on the importance of knowing & documenting the specific amount of kVA that would be required for a Type 2 & Type 3 essential electrical systems. This included a review of the applicable NFPA codes: (2012 NFPA 99 & 2011 NFPA 70)
iv. The documenting of the counseling & education will be kept on file.
II. Identification:
i. The Facility respectfully submits that although residents were potentially affected by this deficiency, no residents were affected or harmed as a result of these findings.
ii. The Director of Environmental Services has identified the correct formula for determining the measurement in of k-VA and ensuring the amount is within the 150- kVA range. Purpose is to ensure that upon load test, the total kVA does not exceed 150 k-VA, as anything above would then require more than one transfer switch.
iii. Should any further issue regarding this matter arise, it will be addressed & corrected immediately.

III. Systemic Changes:
i. The Administrator, Director of Environmental Services, or Designee will review & revise the Policy & Procedure as needed on proper monitoring & measurement reading of kVA on facility generator when running a full-load test.
ii. The facility will develop a Preventive Maintenance program & schedule. This will consist of performing of environmental rounds, including the testing of the facility generator in its scheduled time-frame. Additional testing may be conducted if needed. Purpose is to check & log the findings of the kVA measurements / results and ensure that this is within the proper amount of 150 kVA allowance, as required by said NFPA code.
iii. The findings will then be logged in a designated Binder, which will be reviewed by the Administrator or Designee as needed.
IV. Monitoring of Corrective Actions & Quality Assurance:
i. The facility will also develop on Audit-Tool which will include the findings / results of k-VA readings / results & documented in the designated binder. Purpose here is to monitor compliance.
ii. The Director of Environmental Services / Designee will complete audits for these on a weekly basis for the first month, then on a monthly basis for the next quarter, and then quarterly thereafter till end of year.
iii. Any further review or corrective action will be implemented if needed.
iv. The Administrator or Designee will then report all audit findings to the QA Committee during its quarterly meetings. At the end of each QA meeting a determination will be made by the Committee if any further corrective actions or additional auditing is needed.
V. Responsible Party & Expected Completion Date:
i. Administrator, Director of Environmental Services or Designee
ii. Expected date of completion: 7/21/17

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2017
Corrected date: July 23, 2017

Citation Details

Based on interview conducted during the recertification survey, it was determined the facility did not ensure an emergency generator remote annunciator was properly installed. Specifically, the emergency generator was not connected to a remotely installed alarm annunciator. Findings include: During an interview on 5/23/2017 at 11:46 AM, the Facilities Director stated he inquired in 12/2016 and 1/2017 about adding a remote annunciator panel to the facility generator. The third party vendor told him the facility's 1973 generator pre-dated the need for an annunciator, and a new annunciator could not be installed for the generator. He stated the facility's generator only had an auto-off button and a run button, and did not have any bells. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJune 16, 2017

K-916:
I. Immediate Corrective Action:
i. The Director of Environmental contacted a vendor & received a proposal for a new Control-panel and remote-annunciator for the emergency generator.
ii. The Facility will schedule a date to have this project installed. Estimated date of completion is: 07/22/17.
iii. The Administrator will counsel & educate the Director of Environmental, the Director of Housekeeping & the Maintenance staff on the importance of having a control-panel & remote-annunciator properly installed on the Emergency generator. Education included review of the applicable sections of the NFPA 101 Electrical Systems & Essential Electric System Alarm Annunciator.
iv. The documenting of the counseling & education will be kept on file
II. Identification:
i. The Facility respectfully submits that although residents were potentially affected by this deficiency, no residents were affected or harmed as a result of these findings.
ii. The Director of Environmental Services, or Designee will review proposal & oversee project to ensure the facility generator will have the proper installation of required parts so that we are in compliance upon completion of the project.
iii. Should any further issue regarding this matter arise, it will be addressed & corrected immediately.

III. Systemic Changes:
i. The Administrator, Director of Environmental Services, or Designee will review & revise the Policy & Procedure on the remote-annunciator for the emergency generator as needed.
ii. The facility will develop a Preventive Maintenance program & schedule. This will consist of checking the Emergency-Generator while performing environmental rounds, within a designated time-frame. Purpose is to ensure that the emergency- generator is in compliance.
iii. Results & findings will then be logged in a designated binder, which will be reviewed by the Administrator or Designee as needed.
IV. Monitoring of Corrective Actions & Quality Assurance:
i. The facility will also develop on Audit-Tool which will include the findings / results of the environmental rounds. Purpose is to ensure the emergency generator is operating in compliance.

ii. The Director of Environmental Services / Designee will complete audits for these findings on a weekly basis for the first month, then on a monthly basis for the next quarter, and then quarterly thereafter till end of year.
iii. Any further review or corrective action will be implemented if needed.
iv. The Administrator or Designee will then report all audit findings to the QA Committee during its quarterly meetings. At the end of each QA meeting a determination will be made by the Committee if any further corrective actions or additional auditing is needed.
V. Responsible Party & Expected Completion Date:
i. Administrator, Director of Environmental Services or Designee
ii. Expected date of completion: 7/23/17

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: May 25, 2017
Corrected date: July 21, 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 5/24/2017 at 1:40 PM, the Facilities Director stated he was aware the facility was required to complete a risk assessment procedure for building system categories, and that had not yet been completed. 2012 NFPA 99 - Chapter 4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJune 16, 2017

K-901:
I. Immediate Corrective Action:
i. The identified and current Risk-Analysis Assessment procedure for building system categories was reviewed.
ii. The Director of Environmental Services, Director of Housekeeping, and Maintenance staff, were counseled & educated by the Administrator on the importance of having a completed & up-to-date Risk Assessment / Buildings System Categories Assessment in place. This included reviewing of the applicable Code of NFPA 99.
iii. The Administrator & Director of Environmental Services or Designee will form a multi-disciplinary committee to properly compile the data & sections for the updated NFPA 99 Risk Assessment & Building Systems Categories Assessment.
iv. The documenting of the Counseling & Education will be kept on file.
II. Identification:
i. The Facility respectfully submits that although residents were potentially affected by this deficiency, no residents were affected or harmed as a result of these findings.
ii. The Director of Environmental Services, Designee & new multi-disciplinary committee will continue to compile updated data of areas and new material, if needed, that will be implemented into the updated NFPA 99- Risk Assessment / Buildings System Categories Assessment.
iii. Estimated completion date for this project: 07/21/17 & ongoing if needed.

III. Systemic Changes:
i. The policy & procedure for Risk Assessment / Buildings System Categories Assessment will be reviewed & revised as needed. Further education on Risk Assessment?s will be provided by Administrator or Designee if needed.
ii. The Administrator, Director of Environmental Services, & Designee has developed a preventive maintenance program & schedule. This will include a review & update of the Risk Assessment / Buildings System Categories Assessment by section within a designated time frame to ensure compliance.
iii. The findings will be then be logged in a designated Binder, which will be reviewed by the Administrator or Designee as needed.
IV. Monitoring of Corrective Actions & Quality Assurance:
i. The facility will also develop on Audit-Tool which will include the current updating & findings for the updated Risk Assessment / Buildings System Categories Assessment in a designated binder.
ii. The Director of Environmental Services & Designee will complete audits on a weekly basis for the first month, then on a monthly basis for the next quarter, and then quarterly thereafter till end of year.
iii. Any further review or corrective action will be implemented if needed.
iv. The Administrator or Designee will the report all audit findings to the QA Committee during its quarterly meetings. At the end of each QA-meeting a determination will be made by the Committee if any further corrective actions or additional auditing is needed.
V. Responsible Party & Expected Completion Date: :
a. Administrator, Director of Environmental Services or Designee
b. Expected date of completion: 7/21/17

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2017
Corrected date: July 21, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the building's automatic sprinkler system was maintained in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems, for four isolated rooms (fourth floor phone room, fifth floor phone room, second floor phone room, and laundry room). Specifically, the above mentioned rooms had sections of ceiling tiles missing. Findings include: On 5/22/2017, between 3:50 PM and 5:30 PM, a surveyor observed: - the fourth floor phone room had multiple sections of ceiling tiles missing; - the fifth floor phone room had a 6 inch x 12 inch section of ceiling tiles missing; - the second floor phone room had a 6 inch x 12 inch section of ceiling tiles missing; and - the laundry room had a 2 foot x 12 foot section of ceiling tiles missing behind the washing machines. A surveyor observed that drop-down ceiling grids were present in all four of these room. During an interview on 5/24/2017 at 10:35 AM, the Facilities Director stated he was not aware the ceiling tiles were missing from the fourth floor phone room, fifth floor phone room, second floor phone room and the laundry room. He stated he was aware that missing ceiling tiles within a room could affect the sprinklers from properly functioning. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJune 16, 2017

K-353
I. Immediate Corrective Action:
i. All identified areas with multiple sections of ceiling tiles missing were immediately addressed and fixed / replaced by the Director of Environmental Services & Maintenance Staff.
ii. The Director of Environmental Services & Maintenance staff also performed additional rounds to check & identify if any other sections of ceiling tiles were missing or not properly in place. No other areas where identified at this time.
iii. The Director of Environmental Services, the Director of Housekeeping, along with Maintenance staff, were counseled / educated by the Administrator on the importance of ensuring that all ceiling tiles are to be inserted properly in place so as not to affect the sprinklers from functioning properly. This included a review of applicable sections of the NFPA 101 Sprinkler- System ? Maintenance & Testing.
iv. The documenting of the Counseling & Education will be kept on file.

II. Identification:
i. The Facility respectfully submits that although residents were potentially affected by this deficiency, no residents were affected or harmed as a result of these findings.
ii. Upon performing the additional rounds, to ensure that no other sections of ceiling tiles were missing, the Director of Environmental Services documented that no other areas where identified at this time.
iii. Should any further issue regarding this matter arise, it will be addressed & corrected immediately.

III. Systemic Changes:
i. The policy & procedure for monitoring of Ceiling Tiles will be reviewed & revised as needed and further education on this will be provided by Administrator or Designee if needed.
ii. The Administrator, Director of Environmental Services, & Designee has developed a preventive Maintenance Program & Schedule to ensure that all ceiling tiles in the facility are properly in place. The Maintenance Program & schedule will include the performing of environmental rounds in a designated area of the building within a designated time-frame to check the condition of ceiling tiles & ensure compliance.
iii. The findings will be then be logged in a designated Binder which will be reviewed by Administrator or Designee as needed.
IV. Monitoring of Corrective Actions & Quality Assurance:
i. The facility will develop on Audit-Tool which will include the findings of the environmental rounds to monitor compliance for ceiling tiles.
ii. The Director of Environmental Services will complete audits on a weekly basis for the first month, then on a monthly basis for the next quarter, and then quarterly thereafter for remainder of year.
iii. Any further review or corrective action will be implemented if needed.
iv. The Administrator or Designee will the report all audit findings to the QA Committee during its quarterly meetings. At the end of each QA-meeting a determination will be made by the Committee if any further corrective actions or additional auditing is needed.
V. Responsible Party & Expected Completion Date:

a. Administrator, Director of Environmental Services or Designee
b. Expected date of completion: 7/21/17