Promenade Rehabilitation and Health Care Center
July 28, 2016 Certification Survey

Standard Health Citations

FF08 483.20(g) - (j):ASSESSMENT ACCURACY/COORDINATION/CERTIFIED

REGULATION: The assessment must accurately reflect the resident's status. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. A registered nurse must sign and certify that the assessment is completed. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. Under Medicare and Medicaid, an individual who willfully and knowingly certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or an individual who willfully and knowingly causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment. Clinical disagreement does not constitute a material and false statement.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey the facility did not ensure that the Minimum Data Set (MDS) Assessment accurately reflected the residents status. This was evident for two of two residents reviewed for Restraints in a total stage two sample of twenty seven residents. Specifically, the latest MDS for Resident's # 268 and # 205 did not document the use of mittens or siderails. 1) Resident # 268 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident was also Ventilator Dependent. The 14 day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognition. The MDS also documented that the resident had functional limitation in Range of Motion on one side of both upper and lower extremities. On 7/2216 at 9:00 AM the resident was observed in bed sleeping. A right hand mitten was observed in place. Physicians Interim Orders dated 6/22/16 documented that the resident was to wear a right hand mitten with no justification documented. physician's orders [REDACTED]. Section P restraints did not identify that Resident # 268 had a right hand mitten or side rails in place. On 7/28/16 at 2:00 PM the MDS Coordinator was interviewed. The Coordinator stated that Section P should have reflected the use of siderails and hand mittens for resident # 268. Additionally, the MDS Coordinator stated that the MDS nurses were responsible to complete that section.
2) Resident #205 is a [AGE] year old female who was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident rarely/ never understood and rarely/ never understands. The resident had short and long term memory problems and severely impaired cognitive skills for daily decision making. The resident had no behavior problems and required total assist of one to two staff members for all areas of Activities of Daily Living (ADL's). Section P (Restraint) documented a zero for bed rail and limb restraint. A physician's orders [REDACTED]. On 7/28/16 at 2:00 PM the MDS Coordinator was interviewed. The Coordinator stated that Section P should have reflected the use of siderails and hand mittens for both residents #268 and 205. Additionally, the MDS Coordinator stated that the MDS nurses were responsible to complete that section. 415.11 (b)

Plan of Correction: ApprovedAugust 22, 2016

F278
I. Immediate Corrective Actions:
Resident 268 and Resident 205:
1. The MDS coordinator was counseled by the Administrator for the errors in coding of resident # 268 and resident # 205. A copy was filed for reference and validation.
2. A corrected MDS assessment was completed for both residents to code the use of the hand mittens and side rails by the MDS Coordinator.
3. The Physician was contacted and the Mitten Restraints were discontinued 7/6/16.
II. Identification of Other Residents:
1.The DNS compiled a list of all residents with current MD orders for Restraints
2. This list was used to review the MDS assessments of residents with restraints to ensure accurate coding in Section P.
3. Any quality issues identified from this review will have correction by the MDS Coordinator and reviewed by the DNS for accuracy.
III. Systemic Changes:
1. The DNS and Administrator reviewed the Policy for MDS completion with a concentration on accuracy and coding of Section P for Restraint use.
2. The MDS Coordinator and Assessors will review the policy and concentrate on the directives for completion of Section P. Each assessor will sign an attendance sheet to validate the review of the requirements for section P. A copy was filed for reference and validation.
3. In addition, the RN/Designee will compile a list of any resident who has a new MD order for a restraint. This list will be shared with the MDS Coordinators weekly for awareness and accuracy in the assessment process. A copy of the list will be filed for reference and validation.
IV. QA Monitoring:
1. The DNS developed an audit tool to track accuracy in coding of Section P.
2.Audits will be done by the assigned RN weekly following the MDS schedule over the next quarter.
3. Audits with negative findings will be reviewed by the DNS and referred to the MDS Assessors for immediate corrective actions; including completing a corrected MDS.
4.Audit findings will be presented to the QA Committee monthly for evaluation and follow up.
Responsible discipline: Administrator.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the recertification, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed for each resident that included measurable objectives and timetables to meet the residents medical, nursing, mental and psychosocial needs that were identified in the Comprehensive Assessment. This was evident for two of five residents reviewed for Unnecessary Medication, one of one resident reviewed for Range of Motion (ROM), and one of three residents reviewed for Physical Restraints in a Stage two sample of 27 residents. Specifically, 1) for Resident #270 a CCP was not developed for the [DIAGNOSES REDACTED]. 2) Resident #268 has a physician's orders [REDACTED]. 3) Resident #107 has a physician's orders [REDACTED].# 87 was admitted on [DATE] with redness to the buttocks area and was noted with worsening of the left buttocks on 7/21/16 and a CCP was not developed for the change in the resident's skin condition. The findings include but are not limited to: 1) Resident #270 had [DIAGNOSES REDACTED]. Resident #270 was observed during 3 days of the survey at various times self propelling in her wheelchair on and off the nursing unit. The resident was observed on 7/27/16 between 11:10 AM and 11:30 AM in her room during observation of wound care to the left heel pressure ulcer. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident could understand, be understood and had a Brief Interview for Mental Status score of 12, indicating that the resident had moderate cognitive impairment. The resident required extensive assistance of one staff member for bed mobility, transfer, ambulation in/out of room, dressing, toilet use, personal hygiene and bathing. The resident required supervision for locomotion on/off unit, and eating. The Physician order [REDACTED]. Review of the CCP section of the medical record revealed that there was no CCP for the [DIAGNOSES REDACTED]. The Licensed Practical Nurse (LPN ) charge nurse was interviewed on 7/26/16 at 12:45 PM. The LPN stated that she does not complete the CCPs. The LPN stated that the nursing supervisor or the MDS nurse would initiate the CCPs for Resident #270. An interview was conducted with the Registered Nurse (RN) Director of Nursing Service (DNS) on 07/26/16 at 3:14 PM. The DNS stated that the CCP for [MEDICATION NAME] should have been completed and that there should be a CCP for a [DIAGNOSES REDACTED]. An interview was conducted with the Registered Nurse (RN) evening nursing supervisor on 07/26/16 at 4:17 PM. The supervisor stated he is responsible to complete the new admission assessments and transcribe the new admission physician orders. The RN supervisor stated that he does not complete the initial CCPs. The supervisor stated that the MDS nurse is responsible to initiate the CCPs unless an interim CCP is needed at which time any nursing staff could initiate one. A second interview was conducted with the DNS on 07/26/16 at 4:22 PM. The DNS stated that she was not sure who was initiating the CCPs on admission. The DNS stated she spoke with the RN nursing supervisors, the MDS nurse and the RN evening nursing supervisor. The DNS stated that none of the staff she spoke with were initiating the care plans and so she was not sure how they were getting done. The RN day Supervisor was interviewed on 07/28/2016 at 10:59 AM. The supervisor stated he had initiated Resident #270's care plans on admission and that he should have initiated a CCP for the resident's [DIAGNOSES REDACTED].
2) Resident # 268 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident has a Tracheotomy and is Ventilator Dependent. The MDS assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status score of 3 indicating severely impaired cognition. The MDS also documented that the resident required extensive assistance of two staff for bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. The MDS also documented that the resident had functional limitation in range of motion on one side of both the upper and lower extremities. On 7/21/16 at 8:30 AM during the initial tour the resident was observed in bed with two full side rails up. The resident was observed sleeping. The current physician's orders [REDACTED]. A review of the CCP's revealed that no CCP had been developed addressing the use of full siderails for this resident. On 7/28/16 at 12:30 PM The RN Unit Manager that covers the unit where Resident # 268 resides was interviewed. The RN stated that the MDS nurse would be responsible to initiate the CCP for siderails.
3) Resident # 107 was originally admitted to the facility on ,[DATE]//16 and was readmitted on [DATE]. The resident has [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] documented the resident usually understood and usually understands. The resident had long term and short term memory problem and was severely impaired for daily decision making. The Restorative Nursing Section of the MDS it was documented the resident required the assistance of a splint or brace. A physician's orders [REDACTED]. A review of the Care Plan section of the medical record revealed there was no CCP developed for the use of the splint. An interview was conducted on 7/27/16 at 1:00 PM with the 6th floor RN Supervisor regarding the CCP for the Splint. The RN stated that the resident was on the 2nd floor before transferring to the 6th floor. The RN stated that there was no CCP for the splint and that one should have been developed for the use of the splint. 415.11(c)(i)

Plan of Correction: ApprovedAugust 22, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F279
I. Immediate Corrective Actions:
I. Resident # 270
1.The DNS identified the Nurse responsible for completing the Care Plan for this resident and provided an educational counseling for not developing the plan timely.
2.The Facility held a special review CCP meeting to develop appropriate plans for the dx. of [MEDICAL CONDITION] and the use of anticoagulants. The CNA plan was revised as well to ensure directives for reporting any signs of bleeding or bruising while on anticoagulants.
2. Resident # 268
1.The DNS identified the Nurse responsible for completing the Care Plan for this resident and provided an educational counseling for not developing the plan timely for the use of side rails
( which have now been D/C?d)
2.The Facility held a special review CCP meeting to evaluate the care plan and document that the side rails and hand mitts were D/C?d.
3. The CNA plan was revised as well to ensure directives that the side rails and mittens were D/C?d.
3. Resident # 107
1.The DNS identified the Nurse responsible for completing the Care Plan for this resident and provided a disciplinary counseling for not developing the plan timely.
2.The Facility held a special review CCP meeting to develop appropriate plans for the use of the right hand splint.
3. The CNA plan was revised as well to ensure directives for the use of the right hand splint.
4. Resident # 87
1.The DNS identified the Nurse responsible for completing the Care Plan for this resident and provided an educational counseling for not revising the care plan to validate intervention for a worsening buttock pressure sore.
2. The Facility respectfully states that this resident was transferred to the hospital and subsequently expired.
II. Identification of other Residents:
1.The DNS directed the RN supervisors to review the care plans on each unit to ensure that plans were completed for:
* Resident Diagnosis
* Use of anticoagulants
* Pressure sore status
* Use of splints and adaptive devices
2. Any care plans found with quality issues will have a Team meeting scheduled for care plan completion and/or revision.
3. Any care plans that required correction will be reviewed by the DNS and a copy will be filed for reference and validation in the P(NAME) Book.
III. Systemic Changes:
1. The DNS has delegated initial care plan development to the RNs who admit the resident within the first 24 hours to ensure timely completion for identified problems including diagnosis, use of anticoagulants, pressure sores as well as use of splints and other resident problems.
2. The DNS reviewed the Policy for Care Plans and revised same to include a directive for the completion of the initial care plan by the RNs within the first 24 hours and daily review until the initial MDS is completed.
3. All Licensed Nurses will be reinserviced on the policies and responsibilities for Care Plans by the DNS. The Lesson Plan will concentrate on the following:
* Developing the initial care plan timely and who is responsible
* What should be included in the initial care plan and care plan building
* Evaluation and revisions of the plan as needed
* Documenting specific care plans including but not limited to
diagnosis, use of anticoagulants, pressure sores and splints
4. A copy of the Lesson Plan and attendance sheet will be filed for reference and validation.
IV. QA Monitoring:
1. The DNS has developed an audit tool to track the completeness of the CCP timely and as needed based on resident care issues.
2. Audits will be done by the assigned RNs weekly on new admissions and those with any change in condition.
3. Audits with negative findings will be referred to the DNS for follow up corrective actions
4. Audit findings will be presented to the QA Committee monthly x 3 then quarterly thereafter.
Responsible discipline: Administrator.

FF08 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that the resident's drug regimen was free from unnecessary drugs. This was evident for one of five residents reviewed for Unnecessary Medication in a stage two sample of 27 residents. Specifically, Resident # 261 was receiving [MEDICATION NAME] (an antipsychotic medication used for [MEDICAL CONDITION] Disorder and [MEDICAL CONDITION]) 25 milligrams (mg) every 12 hours without adequate indications for its use. The Finding is: Resident # 261 is a [AGE] year old who was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. The MDS also documented that the resident required one person assist for bed mobility and transfer. The resident required supervision for ambulation on the unit. Additionally, the MDS documented that the resident exhibited no behavior issues or wandering. The physician's orders [REDACTED]. On 4/8/16 the resident was seen in consultation with the Psychiatrist. The Psychiatrist documented that the resident had impaired cognition, insight and judgement. The consult further documented that the resident's appetite and sleep were stable. The Psychiatrist documented a [DIAGNOSES REDACTED]. Additionally, the Psychiatrist documented that in 2 or 3 months time an evaluation would be made to taper the [MEDICATION NAME] if no agitation was present, after discussion with staff. The nursing progress notes from 4/6/16 through 7/26/16 were reviewed. There was no documented evidence that the resident had displayed any behavior problems except on 7/24/16 when the resident refused [MEDICATION NAME] for an elevated Potassium. The physicians progress notes for the months (MONTH) through (MONTH) (YEAR) were reviewed. There was no documented evidence by the physician ever addressing the use of [MEDICATION NAME] for this resident. On 7/28/16 at 8:10 AM the resident was observed at the nurses station. She was engaged in conversation with staff. She appeared well groomed but did display some confusion. On 7/28/16 the Physician and Psychiatrist were both unavailable for interview. The Policy Titled [MEDICAL CONDITION] Medication Policy and Procedure dated 11/3/15 documented that the primary care physician was responsible to document the rationale and [DIAGNOSES REDACTED]. 415.12(1)(1)

Plan of Correction: ApprovedAugust 22, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F329
I. Immediate Corrections:
Resident #261
1. The Medical Director/Administrator has provided an educational counsel to the Attending MD who failed to document an evaluation for the continued use and tolerance of [MEDICATION NAME].
2. The Attending Physician for this resident was contacted by the RN and a follow up Psych Consult was ordered to evaluate the continued need of [MEDICATION NAME]. The resident was seen by Psych on 7/29/16 and the [MEDICATION NAME] was reduced to 12.5mg BID and then the [MEDICATION NAME] was d/c?d on 8/18/16.
3. The Attending Physician will document a summary progress note to validate the use of [MEDICATION NAME] and [MEDICATION NAME], including indication/[DIAGNOSES REDACTED]. A copy of the progress note will be retained for the P(NAME) book for validation.
II. Identification of Other Residents:
1. The DNS in conjunction with the Vendor Pharmacy compiled a list of all residents on psych meds used for the [DIAGNOSES REDACTED].
2. This list was used by the Medical Director and Pharmacy Consultant to do comprehensive chart reviews to ensure that the Attending Physicians documented a summary note monthly relative to the need, targeted symptoms for the med and tolerance of the psych med as per F329 requirements.
3. Any quality issues identified from this review will warrant corrective action by the Medical Director with the involved Attending Physician.
4. The DNS and Medical Director will maintain a list of any medical records found with quality issues and corrective actions for validation.
III. Systemic Changes:
1. The Facility has contracted with Ruth West RN, BS; (License # 6) who is the Compliance Consultant from West & Restivo Quality Consulting, LLC. The Consultant will assist the Facility in developing a Directed Plan of Corrections and a Directed Inservice Program for F329, as well as F490 and F520 as per DOH requirements.
2. The DNS and Administrator have reviewed the Policy on the use of Psych meds with attention to use of Psych meds for [DIAGNOSES REDACTED].
3.A The Consultant from West & Restivo QC, LLC will provide a Directed Inservice to the Attending Physicians and Clinical staff regarding the requirements for use of Psych meds for residents with Dementia in accordance with Facility Policy and F329 directives.
B. The Lesson Plan ( power point) will concentrate but not be limited to the following:
* Overview of F329 requirements and Facility Policy
* Documentation requirements by the MD
* Effective monitoring of symptoms for Dementia
* Guidelines for dose reduction and documentation of symptoms
C. A copy of the Lesson Plan will be sent to the DOH for approval and awareness of education.
D. A copy of the Attendance and Lesson Plan will be filed for reference and validation.
E. The Education will be videotaped to ensure viewing by off staff or absent staff.
4. All Licensed Physicians were educated on F329 and the use of [MEDICAL CONDITION] Drug use by the Pharmacy Consultant, (NAME) Hallet, Pharm D, of Guardian Consulting Services inc. A copy of the Lesson Plan and Attendance was filed for reference and validation.
IV. QA Monitoring:
1. The DNS and Consultant have developed an audit tool to track the appropriate documentation and usage of psych meds per policy and requirements.
2. Audits will be done by the Medical Director /designee on all residents who have MD orders for Psych meds for the Dx. of Dementia to ensure appropriate documentation by the MD.
3. Audits with negative findings will have follow up by the Medical Director with the involved Physician.
4. Audits will then be done weekly over the next quarter by the designated RNs in accordance with MD monthly summaries to ensure MD summary documentation of psych meds.
5. Audits with negative findings will be referred to the Medical Director and Administrator for follow up evaluations and corrective actions as indicated.
6. All audit findings will be reviewed initially by the Consultant Ruth West RN, and Pharmacy Consultant, and audit findings will be presented to the QA Committee monthly for follow up evaluation.
Responsible discipline: Administrator.

FF08 483.75:EFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING

REGULATION: A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

Based on observation, record review and staff interviews, during the recertification survey, the Administrator did not ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practical well being and safety of each resident. Specifically, the Administrator did not ensure that the Policies and Procedures for the use of siderails were being follow including physician orders, clinical interdisciplinary assessments for use and the development of care plans. The finding is: During initial tour of the facility on 7/21/16 between 8:30 AM and 9:00 AM, it was observed that there were 7 residents observed in bed with full siderails being utilized on the 5th, 6th and 7th floor. The undated Policy Titled Proper Use Of Side Rails documented that an assessment will be made to determine the resident's symptoms or reason for using side rails. When they are to be used for mobility or transfer, an assessment would include a review of the resident's bed mobility and ability to change positions, transfer to and from bed or chair, and to stand and toilet. The use of side rails as an assistive device would then be addressed in the resident's Comprehensive Care Plan (CCP). The Policy also documented that if less restrictive approaches are not successful, prior to considering the use of side rails they must be documented. On 7/27/16 at 10:45 AM the Administrator was interviewed. The Administrator stated that he had a mock survey last week because of the recent siderail issue noted within the industry. According to the Administrator the results of the mock survey found that some beds had full siderails in place. The Administrator was unable to state exactly how many beds had full siderails on the beds at the present time. He further stated that he spoke with the nursing department and had a list of all beds with full rails generated. He stated that he then gave the list to maintenance department to initiate the physical removal of all rails off the beds. The Administrator was not able to provide those lists to the survey team. The Administrator stated that the physical removal of siderails was initiated on 7/6/16 and he thought all rails had been removed to date. The Administrator was unable to state whether a clinical assessment had been made by the Rehabilitation Department prior to the removal of any side rail on a resident's bed. The Administrator stated that after 7/26/16 when it became apparent that full siderails were still on the beds and being used, he generated a audit for maintenance to complete in order to determine the number of full rails still on beds. The Administrator was unable to provide a number of siderails still on beds at this time. On 7/28/16 at 10:50 AM the Administrator was again interviewed. The Administrator stated that he had a meeting last evening with the Registered Nurse (RN) Unit Managers. At that time the Administrator asked the RNs to identify the residents that could have there siderails removed. The RN's were to identify residents who still needed the siderails. The Administrator was asked to provide the list of side rails to be removed to survey team but the list was never provided. 415.26

Plan of Correction: ApprovedAugust 22, 2016

F490
I. Immediate Corrective Actions:
1. The Facility has contracted with Ruth West RN, BS; (License # 6) who is the Compliance Consultant from West & Restivo Quality Consulting, LLC. The Consultant will assist the Facility in developing a Directed Plan of Corrections and a Directed Inservice Program for F329, as well as F490 and F520 as per DOH requirements.
2. The Facility held a special review Quality Assurance Meeting on 8/18/16 to discuss the deficiencies as cited under F329, F490 and F520. A copy of the agenda and attendance will be filed for reference and validation.
2.The Administrator respectfully reaffirms his commitment to the Facility including the direction of the Facilities Policies, Procedures and most importantly resident care outcomes.
3. F221:The Administrator will oversee all plans of correction and implementation for F221 concerning the use of side rails. The Administrator will maintain a current and updated list of all side rail use in house, including full and half rails.
4.The Administrator will attend morning meetings and care plan meetings as possible relative to discussion and use of Side Rails and other restraints to ensure safe Facility practices, and consistent compliance.
II. Identification of Other Residents:
1. F221 The DNS and Administrator made a full house list of all beds with side rails; full and half rails that are in use.
2. This list was then used by the CCP team to ascertain the need for side rails and type of rails needed if any.
3. The residents who required side rails were referred to the RN supervisor to ensure completion of the newly developed Restraint Assessment form, and notification to the MD to ensure an order and medical symptom for side rail use.
4. The Administrator will ensure appropriate MD orders are obtained and Care plans are developed timely for Restraint use.
III. Systemic Changes:
1. The Administrator will attend all Inservice education programs relative to the P(NAME) including Restraint Criteria.
2. The Administrator will receive a One to One Inservice from Consultant Ruth West RN, BS relative to the role of the Administrator and the Directed Plan. The Administrator will sign and retain the Lesson Plan for reference and validation.
3.The Administrator has changed the focus of the Morning Meeting to be QA and CCP oriented. The meeting will now track and discuss any change in condition including restraint use, psych meds, MDS issues and or care plan implementation concerns.
4. The Administrator will attend the Morning Meeting as possible and direct staff accordingly for issues requiring follow up.
5. The Administrator has set up monthly QA meetings to track the implementation of the plan of corrections and troubleshoot any quality issues identified. Attendance and Agenda of all QA Meetings will be filed for reference and validation in the P(NAME) Book.
IV. QA Monitoring:
1. The Administrator will review all audit tools completed with negative findings relative to all tags cited.
2. The Administrator will ensure follow up corrective actions with the appropriate staff as indicated by audit findings.
3. The Administrator will review audit tools as completed weekly and discuss outcome with the DNS, Medical Director and at monthly QA Meetings for ongoing compliance.
Responsible discipline: Administrator.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that residents' environment remained as free of accident hazards as possible. This was evident for one of three residents reviewed for Accidents in a Stage 2 sample of twenty-seven residents. Specifically, Resident #162 had bilateral full siderails (SRs) removed from his bed on the morning of 7/27/16 without documented evidence of an assessment which resulted in a fall from his bed that evening. The findings is: Resident #162 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was sometimes understood and could sometimes understand. The resident had severely impaired cognitive skills for daily decision making with long and short term memory problems and severely impaired vision (no vision or sees only light, colors or shapes; eyes do not appear to follow objects) with no corrective lenses. It was also documented that the resident had no falls. The Resident Accident/Incident (A/I) Report dated 7/27/16 documented that at 8:55 PM the resident was found lying on the floor, face down, next to his bed, crying. The resident sustained [REDACTED]. The A/I Report also documented that the resident lacked awareness of bed boundaries and would be reevaluated for the use of full SRs in bed. The resident's regular 7:00 AM-3:00 PM shift Certified Nursing Assistant (CNA) was interviewed on 7/28/16 at 10:20 AM and stated that she had been taking care of the resident since his admission to the facility. The CNA stated that before yesterday (7/27/16), the resident had two (bilateral) full siderails on his bed. The CNA stated that she had always pulled the resident's both siderails up when she cared for the resident in bed because he rolls. The CNA also stated that now with the resident's SRs removed, she was in fear of him falling out of bed again. The CNA stated that when she turns the resident on his side, he flops to the edge of the bed and because his mattress was so soft, he could easily go over the side of the bed. The resident's regular 3:00 PM-11:00 PM shift CNA was interviewed via telephone on 7/28/16 at 10:35 AM and stated that she had been taking care of the resident for the past year and a half. The CNA stated that before yesterday (7/27/16), the resident had two full (bilateral) SRs on his bed. The CNA stated that she always left the SRs up on the resident's bed when giving him care or when putting him to bed for the evening because he would move from side to side on the bed. The CNA also stated that by the time she would be finished to leave the resident's room, he would already be on the edge of the bed so she could never leave him with his siderails down. The Director of Nursing (DON) was interviewed on 7/28/16 at 10:40 AM and stated that the facility had no system in place to address the use of SRs. The DON stated that a resident's physical function had to be assessed first to see if they needed siderails. Then the Physician would have to write an order indicating if SRs are to used as an enabler for physical function or if they are needed for a medical [DIAGNOSES REDACTED]. The DON stated that the resident's family would also have to be spoken to and restraint reduction assessments would have to be done. The resident's entire current Comprehensive Care Plan dated 3/21/16 was reviewed on 7/28/16 at 11:00 AM and revealed no documented evidence of the use of full SRs on the resident's bed. The resident's CNA (Certified Nursing Assistant) Accountability Record dated (MONTH) (YEAR) was reviewed on 7/28/16 at 11:05 AM and revealed no documented evidence that the resident used two full SRs on his bed. The Administrator was interviewed on 7/28/16 at 11:20 AM and stated that Administration in conjunction with Nursing made the determination of which residents needed SRs and who did not. The Nursing Supervisors were asked to give lists to Administration of who needed full SRs for safety and who needed half SRs to be used as enablers. The Administrator stated that the plan was to remove all full SRs and then assess who needed them. Any assessment made was done verbally as there was no SR assessment form currently in use by the facility. The 2nd and 3rd Floor Registered Nurse (RN) Supervisor was interviewed on 7/28/16 at 1:10 PM and stated that she determined that the resident did not need SRs because he did not have an order for [REDACTED]. The RN also stated that she was not aware that the CNA was using the SRs at night when she put the resident to bed. 415.12(h)(1)

Plan of Correction: ApprovedAugust 22, 2016

F323
I. Immediate Corrections:
Resident #162
1.The DNS completed an investigation to ascertain why the bedrails were discontinued and also why there was no Care plan or order for side rails when same were in use. Based on the investigation the following actions were taken:
* The Nurses who were responsible for the care of this resident were counseled by the DNS for not contacting the MD regarding use of siderails and not developing a care plan or CNA plan for same.
*A full restraint assessment was completed on this resident and subsequently it was concluded that the resident required 2 half rails for defining bed boundaries.
* The MD was contacted and an order was placed for use of 2 half rails when in bed for defining bed boundaries
* Two half rails were applied to this resident?s bed to prevent falls secondary to unawareness of bed boundaries.
II. Identification of Other Residents:
A.1. The DNS and Administrator made a full house list of all beds with side rails; full and half rails that are in use. In addition, the DNS reviewed any accident report that involved the use or the removal of side rails to ensure that residents were free of accident hazards.
2. This list was then used by the CCP team to ascertain the need for side rails and type of rails needed if any for all Residents.
3. The residents who required side rails were referred to the RN supervisor to ensure completion of the newly developed Restraint Assessment form, and notification to the MD to ensure an order and medical symptom for side rail use, as well as development of a care plan and CNA plan.
III. Systemic Changes:
1. The DNS reviewed the Policy on the use of restraints and validated that a side rail assessment tool was in place for compliance.
2. All members of the CCP Team as well as Licensed Nurses will be educated on the documentation criteria for restraint assessment.
3.The Lesson Plan will concentrate on the following:
* Identification for the need /medical symptom for restraint use
* Completion of the side rail restraint assessment form
* Development of a CCP and need for quarterly evaluation
* MD order criteria including the justification/medical symptom for the restraint
4. A copy of the Lesson Plan and attendance will be filed for reference and validation.
IV. QA Monitoring:
1. The DNS has developed an audit tool to track the use and documentation of all Side rail Restraints in use and ordered by the MD to ensure same were used appropriately and needed to prevent accidents.
2. Audits will be done weekly on each unit by the Charge Nurse to ensure accuracy, assessment and documentation over the next quarter.
3. Audits will be reviewed by the DNS and CCP team at the morning meeting if negative findings are identified for immediate corrective actions.
4. Audits will be presented at the QA Meetings monthly over the next quarter then quarterly thereafter for evaluation and follow up.
Responsible discipline: Administrator.

FF08 483.75(h):OUTSIDE PROFESSIONAL RESOURCES-ARRANGE/AGRMNT

REGULATION: If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (h)(2) of this section. Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and the timeliness of the services.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that appointments for consults ordered by the physician, were made in a timely manner. This was evident for one of five residents reviewed for Unnecessary Medications in a Stage two sample of 27 residents Specifically, Resident #270 had Physician order [REDACTED]. There were no appointments made for Resident #270 for Podiatry, Dental, Ophthalmology and Psychiatry Consultations. The findings is: Resident #270 had [DIAGNOSES REDACTED]. On 7/26/2016 12:14 PM an interview was conducted with Resident #270. The resident was pleasant, well groomed and stated she was doing very well. The resident stated she had been around (identifying different nursing homes, and hospitals). The resident stated that she had a wound on her left foot for 4 years and that it finally was healing. She stated that the nurse is putting a protective dressing on her foot just to be safe. Resident #270 was observed on during 3 days, 7/26/2016 through 7/28/16, of the stage 2 survey at various times self propelling in her wheelchair on and off the nursing unit. The resident was observed on 7/27/16 between 11:10 AM and 11:30 AM in her room during observation of wound care to the left heel pressure ulcer. During the wound care observation the resident described the condition of her left foot which included surgery to the left great toe due to gangrene. 07/27/2016 at 11:35 AM the resident was observed and heard to have extreme verbal outburst, using threatening verbal behavior. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident could understand and be understood and had a Brief Interview for Mental Status score of 12, indicating that the resident had moderate cognitive impairment. The resident's mood score was four indicating that the resident had trouble sleeping, was tired, having little energy. The MDS also documented that the resident's behavior included verbal behavioral symptoms toward others and rejection of care. The MDS further documented that Resident #270 had been admitted with an unstageable pressure ulcer to the left heel, which was covered in eschar. The Physician order [REDACTED]. [MEDICAL CONDITION]. The Physician order [REDACTED]. Podiatry, Dental, Ophthalmology and Psychiatry consults. The Licensed Practical Nurse (LPN ) charge nurse was interviewed on 7/26/16 at 11:00 AM. The LPN stated that the nurse that transcribes the physician orders [REDACTED]. The LPN confirmed that Resident #270's consults had not been scheduled. An interview was conducted on 7/26/16 at 2:10 PM with the nursing secretary that schedules appointments for the residents. The secretary stated there were no consult forms or appointments scheduled for Resident #270. On 7/26/16 at 2:40 PM the Registered Nurse (RN) Director of Nursing Services (DNS) stated that the RN nursing supervisor on the 2nd floor nursing unit could not find any completed consult forms for Resident #270. On 7/26/16 at 2:55 PM an interview was conducted with the RN supervisor for the 2nd floor. The supervisor stated she was currently scheduling the consult appointments ordered on [DATE], for Resident #270. An interview was conducted on 07/26/2016 4:17 PM with the RN Nursing supervisor for the evening shift. The supervisor stated that when he picks up the admission orders [REDACTED]. The supervisor stated it seems the consult forms did not get done. The Policy and Procedure last dated 11/14 documented under the Policy: To provide all residents with medical consultations and follow-up in a timely manner as ordered by the Physician. Documentation under the Procedure included: 1) resident's physician will order consultations, necessary care of resident on the MD (medical doctor) order sheet. 2) RN Supervisor/Charge nurse will pick up order and give the report of consultation form to the Nursing secretary on 1st floor. 415.26(e)(i-iv)

Plan of Correction: ApprovedAugust 22, 2016

F500
I. Immediate Corrections:
Resident # 270
1.The DNS identified the Nurse who failed to properly follow up on the MD orders for consults . Subsequently this Nurse received an educational counseling from the DNS.
2. The MD was contacted and new orders were obtained for Podiatry, Dental, Ophthalmology and Psychiatry Consults. On 7/27/16.The orders were transcribed and consult sheets were generated per policy.
3. The Psych consult was completed 7/29/16,Opthalmology was completed 7/29/16 and Podiatry was done 8/16/16 and Dental Consult is pending.
4. The Nursing Secretary has scheduled all ordered consults per MD order.
II. Identification of Other Residents:
1. The DNS compiled a list of all new admissions since 7/1/16.
2. This list was used by the RN Supervisors to conduct medical chart reviews to ensure all MD ordered consults were scheduled.
3. Any quality issues identified from this review will warrant MD contact and follow up education with involved staff by the DNS.
4. The DNS will review all new admissions at the Morning meeting going forwad to ensure all MD orders were carried out.
III. Systemic Changes:
1. The DNS has reviewed the Policy on transcription of MD orders and found same compliant. However, the DNS has requested that whenever Consults are ordered that Consults are immediately brought down to the Nursing Office as well as placed on the 24 hr report for awareness.
2. All Licensed Nurses will be reinserviced on the policy by the DNS/Designee for MD order follow up, with concentration on completion of Consult forms as ordered and informing the Nursing Secretary accordingly for scheduling.
3.In addition, Nurses will document the residents name and ordered consults on the 24 hour report as a reminder to track the scheduling and completion of the Consult.
4. A copy of the Lesson Plan and attendance will be filed for reference and validation.
IV. QA Monitoring:
1.The DNS has developed an audit tool to track the ordering and completion of MD ordered Consults.
2. Audits will be done by the Nursing on each unit following the MD monthly orders as well as any new admissions
3. Audits with negative findings will have onsite corrections by the Nurse and review by the DNS and Administrator.
4. Audit findings will be presented to the QA Committee monthly x3 then quarterly thereafter for evaluation and follow up as indicated.

Responsible discipline: Administrator.

FF08 483.75(o)(1):QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS

REGULATION: A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record reviews during the recertification survey, the facility's Quality Assessment and Assurance Committee (QAAC) did not develop and implement an effective plan of action to correct prior quality deficiencies and to effectively correct newly identified concerns. Specifically, 1) the facility's QAAC did not implement an effective plan of action for deficiencies documented during the prior recertification survey. Plans of correction were not effectively implemented to prevent repeat deficiencies in the area of Unnecessary Medication (F329), Effective Administration (F 490) and QAAC Committee (520) which were documented deficiencies during the (YEAR) recertification survey. Additionally, the QAAC committee did not put an effective plan of action into place when a newly identified concern, regarding the use of side rails, was reported to the committee following a mock survey conducted by consultants hired by the facility. The findings include: Tag F329 Unnecessary Medications was cited during the prior and current recertification surveys. For the current survey, Resident # 261's Medical History and Plan of Care for the months (MONTH) through (MONTH) (YEAR) were reviewed. There was no documented evidence by the physician addressing the use of [MEDICATION NAME] for this resident. Tag F490 Administration was cited during the prior and current recertification surveys. For the current survey the Administrator did not ensure that the Policies and Procedures for the use of siderails were being followed including physician orders, clinical interdisciplinary assessments for use and the development of care plans. Tag F520 QAA Committee-members/meet quarterly/plans was cited during the prior and current recertification surveys. For the current recertification survey, the QAAC did not ensure that the plan of correction from the prior recertification survey was fully implemented to prevent recurring deficiencies. The QAAC did not implement an effective plan for side rail removal when this issue was discovered through a mock survey. The Administrator was interviewed on 7/28/16 at 1:30 PM in reference to the QAAC. The Administrator stated that the committee meets quarterly and that all the department heads, the DNS, Nursing Supervisors, the Medical Director, and the Pharmacy Consultants attend the meeting. The Administrator stated that the facility continues to work on the concerns that were addressed from last years survey deficiencies, including continued concerns in reference to tag F329 Unnecessary Medication. The Administrator stated that it is an ongoing educational process. The Administrator stated that the facility did not have to change any policies. The Administrator further stated that the facility had a mock survey done on (MONTH) 6th and 7th (YEAR) that identified some facility concerns, including the issue on the use of side rails. The administrator also stated that topics are brought to the committees attention by information received through the Greater New York Association of Nursing Homes. (reference to current side rail issue). The Administrator stated that following the mock survey on (MONTH) 8th inservicing of staff started to address the concerns brought forward by the mock survey. The administrator stated that the DNS developed an assessment tool for the use of side rails as a result of the mock survey and that he held an exit QAAC meeting with the staff that completed the mock survey. The administrator stated he had the QA committee, including all the physicians attend the meeting. The Administrator stated that the DNS was new and had not had the time to implement the new assessment tool, complete all the assessments, and inservice staff prior to the start of the present survey. 415.27(a-c)

Plan of Correction: ApprovedAugust 22, 2016

F520
I. Immediate Corrections:
1.The Facility held a special review QA meeting on 8/18/16 to discuss deficiencies as cited including plan for follow up on QA issues identified in last survey. Agenda and Attendance will be filed for reference and validation.
2. The Administrator has mandated monthly QA Meetings going forward to track the plan implementation and troubleshoot quality issues as identified.
3.The Administrator has changed the focus of the Morning Meeting to be a mini QA Meeting and CCP meeting in order to track resident care issues. Signature Attendance will be taken at the meeting and resident care issues will be tracked and documented to ensure timely follow up.
4. The Administrator will attend all morning meetings as possible to ensure ongoing quality assurance.
II. Identification of Other Residents:
1. The Facility respectfully states that all residents are potentially affected by lack of effective Quality Assurance.
2. QA Audit tools have been developed for all deficiencies cited and will be reviewed by the QA Committee for follow up as needed.
III. Systemic Changes:
1. The Administrator and DNS have developed a new criteria for the Morning meeting to function as a mini QA and a Mini CCP meeting.
2. All Clinical Team members and members of the QA Committee will be inserviced on the function of the morning meeting and overall criteria for QA by the Consultant Ruth West RN, BS as part of the Directed Inservice Component.
3. The Lesson Plan will concentrate on the requirement for QA tracking in order to identify potential quality issues for timely resolve.
4. A copy of the Lesson Plan ( power point) will be filed for reference and validation of this education.
5.The education will be videotaped to ensure viewing by off shifts and absent staff.
IV.QA Monitoring:
1.The DNS and Administrator will have weekly QA Meeting to track audit findings for F221, F276, F278, F279, F281, F282, F323, F329, and F500.
2. Audits with negative findings will have directives for corrective actions and follow up as indicated.
3. All audit findings will also be reviewed at the monthly QA meetings set up by the Administrator.
4. The Administrator has set up a P(NAME) Book to track the implementation and completion of the plan of corrections as part of overall QA monitoring.
5. All components of the plan will be placed in the P(NAME) book under the appropriate tag in order to follow the pan and ensure compliance.
6. The P(NAME) Book will also be used at morning meetings and weekly QA meetings to validate the pan completion and overall consistent compliance.


Responsible discipline: Administrator.




FF08 483.20(c):QUARTERLY ASSESSMENT AT LEAST EVERY 3 MONTHS

REGULATION: A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, the facility did not ensure that a resident was assessed using the quarterly review instrument specified by the State and approved by the Centers for Medicaid Medicare Services (CMS) not less frequently than once every three months. This was evident for one of five residents reviewed for Unnecessary Medications in a total sample of twenty-seven Stage 2 residents. Specifically, Resident #54 did not have a quarterly review completed in the three month time frame for (MONTH) (YEAR). The finding is: Resident #54 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) Assessment for (MONTH) (YEAR) was unavailable for review. A quarterly MDS was last completed on 4/19/16. On 7/26/16 at 2:45 PM, the (MONTH) (YEAR) MDS was requested of the Director of Nursing Services (DNS). The DNS stated that the MDS was being completed at the present time. On 7/26/16 at 3:00 PM the Registered Nurse (RN) MDS Coordinator was interviewed and stated that the MDS was not in the computer system as having been completed and that it had just been completed. On 7/26/16 at 3:00 PM the MDS Assessor was interviewed and acknowledged that the MDS had just been completed today and back dated to 7/6/16. On 7/28/16 at 9:30 AM the DNS was again interviewed and stated that she would have never expected the MDS staff to back date the MDS Assessment. On 7/28/16 at 10:45 AM the Administrator was interviewed and stated that he would have never expected his staff to back date any document. The Administrator further stated that the staff just panicked. 415.11(a)(4)

Plan of Correction: ApprovedAugust 22, 2016

F276
I. Immediate Corrective Actions:
The Facility will have zero tolerance for back dating any document and same may result in termination.
Resident #54
1.The DNS/Administrator issued a disciplinary counseling to the RN Assessor who backdated the quarterly MDS. A copy was filed for reference and validation.
2. The MDS was corrected to reflect the accurate date of assessment.
II. Identification of Other Residents:
1. The MDS Coordinator reviewed all the MDS Assessments completed for the last quarter to ensure compatible dates with the last assessment.
2. Any assessments found with late dates or inaccurate dates will warrant further disciplinary action and/or termination.
3. The MDS Coordinator will review the schedule of all MDS Assessments prior to completion to oversee the system to ensure integrity and accuracy.
III. Systemic Changes:
1. The DNS and Administrator reviewed the Policy for MDS completion with a concentration on accuracy of the ARD.
2. The MDS Coordinator and Assessors will review the policy and develop appropriate schedules for MDS start dates as per requirements. Each assessor will sign an attendance sheet to validate the review and understanding of the requirements.
3. As per element #2 the MDS Coordinator will review the schedule for MDS Assessment Reference dates to ensure accuracy and timely completion of the MDS.
IV. QA Monitoring:
1. The DNS has developed an audit tool to track the accuracy of MDS dates and timely completion.
2. Audits will be done weekly by the RNs and /or the assigned staff on MDS assessments prior to electronic submission over the next quarter.
3. Audits with negative findings will have correction assessments done as needed.
4. Audit findings will be presented to the QA Committee monthly for evaluation and follow up, then quarterly thereafter.
Responsible discipline: Administrator.

FF08 483.13(a):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interviews during the recertification survey, the facility did not ensure that three of three residents reviewed for restraints in a total sample of twenty-seven Stage 2 residents were free from physical restraints. 1) Resident #205 was observed in bed with bilateral full siderails and bilateral hand mittens and there was no documentation that an assessment was done for the use of full side rails or the bilateral mittens. 2) Resident # 107 was also observed in bed with bilateral full siderails and there was no documentation that an assessment was done for the use of full side rails. 3) Resident # 268 was also observed in bed with bilateral full siderails on 7/21/16 and there was no documentation that an assessment had been completed for the use of bilateral full side rails. The findings are: 1) Resident #205 is a [AGE] year old female who was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident was being fed via Gastrostomy Tube. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident rarely/never understood and rarely/never understands. The resident had short and long term memory problems and has severely impaired cognitive skills for daily decision making. The resident had no behavior problems and required total assist of one to two staff members for all areas of Activities of Daily Living (ADLs). Section P (Restraint) documented a zero for bed rail and limb restraint. During an initial tour conducted on 7/21/16 at 8:45 AM on the 6th Floor, Resident #205 was observed in bed with bilateral full siderails up and bilateral hand mittens on. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) dated 6/23/16 and last updated 7/21/16 documented that the resident utilizes two 1/2 side rails for physical functioning and during care. In the interventions section of the CCP and PRN Assessment for inability to use siderails to help in turning and further siderails use, was not checked off as part of the interventions for the use of siderails. The CCP did not include the use of full siderails. Further review of the Care Plan section of the medical record revealed there was no documented evidence that a CCP was developed for the use of the full side rails or for the use of bilateral mittens. An interview was conducted on 7/26/16 at 1:00 PM with the 6th floor RN supervisor regarding the use of full side rails. The RN stated that there was no order for full side rails and that she called the covering Physician on the evening of 7/21/16 and obtained an order for [REDACTED]. An interview was conducted on 7/27/16 at 1:15 PM with the 2nd floor RN Supervisor regarding the three day assessment for the use of bilateral hand mittens. The RN stated that the resident was on the 2nd floor when the mittens was first ordered but thought that the mittens were discontinued. On review of the medical record there was a current MD order for the use of [REDACTED]. The RN stated that there was no assessment done for the mittens and that if one was done it would have been placed in the medical record. An interview was conducted on 7/27/16 at 1:30 PM with the day shift Certified Nursing Assistant. The CNA stated that the resident uses mittens but she does not always put the mittens on. The CNA stated that at times she leaves the resident's hands free. The CNA also stated that the resident at times tries to pull her feeding tube out. There was no documentation on the CNA Accountability Record for the use of side rails or hand mittens. 2) Resident #107 was originally admitted to the facility on [DATE], was discharge to the hospital on [DATE] and was readmitted on [DATE]. The resident has [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] documented the resident is usually understood and usually understands. The resident had long term and short term memory problem and was severely impaired for daily decision making. The MDS also documented resident required extensive assist of two staff members for bed mobility, total assist of two staff members for transfer and toileting and extensive assist of one staff for dressing and personal hygiene. The MDS also documented the resident had functional limitation in range of motion on one side, both upper and lower extremity. The MDS did not document the use of side rails for this resident. On 7/21/16 during an initial tour between 8:30 AM and 9:00 AM Resident # 107 was also observed in bed with bilateral full siderails up. The resident was observed to be awake and was being prepared for breakfast. A CCP dated 6/27/16 and last updated 7/21/16 documented siderails as enabler but did not identify the type of side rails used. A Interim Physicians Order dated 7/21/16 documented an order for [REDACTED]. A review of the physician's orders [REDACTED]. A review of the medical record on 7/27/16 lacked documentation evidence that a side rail assessment had been completed. An interview was conducted on 7/26/16 at 2:01 PM with the 6th floor RN supervisor. The RN stated that over the weekend the resident's side rails were changed because the resident did not need full side rails. The RN stated that when the facility bought the beds they came with full side rails. The RN stated that the resident should not have had the full side rails. The RN further stated that she spoke with the covering physician on the night of 7/21/16 and obtain orders for two 1/2 side rails for physical functioning and then updated the the CCP at that time.
3) Resident # 268 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident has a Tracheotomy and is Ventilator Dependent. The MDS assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status score of 3 indicating severely impaired cognition. The MDS also documented that the resident required extensive assistance of two staff for bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. The MDS also documented that the resident had functional limitations in range of motion on one side, both the upper and lower extremity. The MDS did not document the use of the right hand mitten for this resident. On 7/21/16 at 8:30 AM during the initial tour the resident was observed in bed with two full side rails up and a right hand mitten in place. The resident was observed sleeping. An Interim Physicians Order dated 6/22/16 documented an order for [REDACTED]. The current physician's orders [REDACTED]. A review of the CCPs revealed that no CCP had been developed for the use of full siderails for this resident. A review of the medical record on 7/27/16 lacked documented evidence that a side rail or hand mitten assessment had been completed. On 7/27/16 at 11:00 AM the Director of Nursing (DNS) services was interviewed. The DNS stated that a two day mock survey was completed in (MONTH) (YEAR) and it was determined that there was a problem with the use of side rails. The DNS stated that she had the Registered Nurse (RN) Unit Managers that cover the units generate a list of residents who had full and half rails on there beds. She also requested a list of residents who actually needed side rails. The DNS stated that she gave the lists to the administrator of all side rails that needed to be removed. The DNS further stated that as of (MONTH) 9 (YEAR) the removal of side rails started. The DNS stated that she was under the assumption that all side rails had been removed from the beds for residents that did not need them. Additionally, the DNS stated that no RN informed her that any full side rail was still in place on a bed. A Policy Titled Proper Use of Side Rail, undated, documented that an assessment would be made to determine the resident's symptoms or reason for using side rails. The Policy also documented that less restrictive approaches that were not successful prior to the initiation of the side rails would be documented. The Policy did not address who was responsible to complete the assessment for the need of side rails. 415.12 (h)(1)(2)

Plan of Correction: ApprovedAugust 22, 2016

F221
I. Immediate Corrections:
Resident # 205
1.a. The DNS completed an investigation to ascertain who authorized the use full side rails. Based on the findings all Licensed Nurses and CNAs involved in the care of this resident were educated for not following the MD orders for half rails. In addition, the Nurse responsible for developing the care plan was also counseled by the DNS for not documenting an appropriate plan for the use of restraints, ie mittens and side rails. A copy was filed for reference and validation.
b. The Full Side Rails were removed by maintenance and half rails were placed on the bed.
2.The Facility held a special review Care Plan meeting to assess the need for side rails and hand mittens. Subsequently a plan was developed for the use of 2 half rails to define bed boundaries and same was documented into the care plan. In addition, a 3 day assessment was done to ascertain the need for hand mittens. Based on the assessment a care plan was also developed for the use of hand mittens as needed when resident attempts to pull out the G tube.
3. The CNA plan was revised as well for directives for half rails and specific use of mittens by the Charge Nurse.
Resident # 107
1.a. The DNS identified the Nurses and CNAs responsible for the care of this resident and
provided education related to the use of full side rails as opposed to half rails as ordered. A copy was filed for reference and validation.
b. A side rail assessment was completed by the CCP Team and based on this assessment the team agreed that half rails were needed to define bed boundaries due to reduced physical functioning.
c. The full side rails were removed by maintenance and half rails were placed as per MD order.
2. A corrected MDS was completed to code the use of side rails.
Resident #268
1.The MDS Coordinator filed a corrected MDS assessment to validate the use of the hand mitten.
2.The CCP Team met to complete a restraint assessment to evaluate the continued need for use of the side rails and the hand mitt. Based on the assessment the Team conclusion was that the resident did not require two side rails up to define bed boundaries, same were d/c?d 7/21/16 and the hand mittens were noted to be discontinued on 7/6/16.
* The Resident no longer uses side rails or hand mittens.
3. The CNA Accountability record was revised as well to discontinue the use of side rails and hand mittens.
II. Identification of other Residents:
A.1. The DNS and Administrator made a full house list of all beds with side rails; full and half rails that are in use.
2. This list was then used by the CCP team to ascertain the need for side rails and type of rails needed if any.
3. The residents who required side rails were referred to the RN supervisor to ensure completion of the newly developed Restraint Assessment form, and notification to the MD to ensure an order and medical symptom for side rail use.
4. The MDS Coordinator was provided a list of all residents who use side rails as restraints to ensure inclusion on the MDS assessment for accuracy.
B.1. The DNS and RNs compiled a list of all residents who use hand mittens.
2. This list was used by the RNs to review the medical record to ensure that a restraint assessment had been completed as well as care plans in conjunction with an MD order
3. Residents identified with missing documentation will be referred to the CCP Team and MD for corrections.
4.The MDS Coordinator was provided a list of all residents who use hand mitts and the medical symptom for same to ensure inclusion in the MDS assessment.
III. Systemic Changes:
1. The DNS reviewed the Policy on the use of restraints and revised same to include a side rail assessment tool for compliance.
2. All members of the CCP Team as well as Licensed Nurses and CNAs will be educated on the Policy and revisions by the DNS.
3.The Lesson Plan will concentrate on the following:
* Identification for the need /medical symptom for restraint use
* Completion of the side rail restraint assessment form
* Development of a CCP and need for quarterly evaluation
* MD order criteria including the justification/medical symptom for the restraint
* Overview of MDS assessment criteria for coding restraints
3. A copy of the Lesson Plan and attendance will be filed for reference and validation.
IV. QA Monitoring:
1. The DNS has developed an audit tool to track the use and documentation of all Restraints ordered by the MD.
2. Audits will be done weekly on each unit by the RN Supervisor/designee to ensure accuracy, assessment and documentation over the next quarter.
3. Audits will be reviewed by the DNS and CCP team at the Morning meeting if negative findings are identified for immediate corrective actions.
4. Audits will be presented at the QA Meetings monthly over the next quarter then quarterly thereafter for evaluation and follow up.
Responsible discipline: Administrator.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that services were provided in accordance with each residents written plan of care. This was evident for one of five residents reviewed for unnecessary medications in a total stage two sample of 27 residents. Specifically, Resident #112 had a physician's orders [REDACTED]. The finding is: Resident # 112 admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated on 5/516 documented that the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating that the resident was cognitively intact. Current Physicians orders dated 7/22/16 documented that the resident was receiving both [MEDICATION NAME] 5 milligrams (mg) by mouth (po) daily and [MEDICATION NAME] 12.5 mg po twice a day (bid) for Hypertension. The current orders also documented for a daily pulse and weekly blood pressure on Saturdays for this resident. The Medication Administration Record [REDACTED]. There was no documented evidence that a daily pulse had been taken. Additionally, between 4/30/16 and 5/28/16 a blood pressure was recorded only one time. On 7/27/16 at 1:50 PM the Registered Nurse (RN) Supervisor assigned to the unit where Resident # 112 resided was interviewed. The RN stated that the pulse should have been taken and recorded on a daily basis. The RN also stated that the weekly blood pressures should also be taken and recorded. 415.11(c)(3)(ii)

Plan of Correction: ApprovedAugust 22, 2016

F282
I. Immediate Corrections:
Resident #112
1. The DNS identified the Nurses involved and responsible for medication pass for this resident. The Nurses identified were provided an educational counseling for not following the MD orders relative to taking and recording the daily pulse and the weekly blood pressure.
2. Copies of the counseling were retained for reference and validation.
3. The Residents pulse and blood pressure was taken and recorded on the MAR and same will continue as per MD orders.
II. Identification of Other Residents:
1. The DNS had the Pharmacy print a run of all MD orders which included taking the pulse or Blood Pressure.
2.This list was used by the RN supervisors as well as the Pharmacy Consultant to review the MAR to ensure that MD orders were followed.
3. Any quality issue identified from this review will warrant MD notification and follow up by the DNS for corrective actions.
III. Systemic Changes:
1. The DNS and Pharmacy Consultant reviewed the policy on Medication pass with concentration on following the MD orders for taking and recording vital signs ie Pulse or B/P
2.All Licensed Nurses will be reinserviced on the Policy by the Pharmacy Consultant. The Lesson Plan will concentrate on the following:
* Review of the MD Orders
* Following the MD orders
* Taking and recording the Pulse and B/P as ordered
* Notification criteria to the MD as directed for abnormal results
3. A copy of the Lesson Plan and attendance will be filed for reference and validation.
IV. QA Monitoring:
1. The DNS has developed an audit tool to track accuracy in the Medication Pass relative to taking and recording vital signs as ordered.
2. Audits will be done by the RN supervisors and/or the Pharmacy Consultant on each unit weekly over the next month then quarterly thereafter.
3. Audits with negative findings will be referred to the MD and DNS for corrective actions
4. Audit findings will be presented to the QA Committee monthly 3 then quarterly thereafter for evaluation and follow up as indicated.
Responsible discipline: Administrator.

FF08 483.20(k)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: The services provided or arranged by the facility must meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews during the recertification survey, the facility did not ensure that services provided or arranged by the facility met professional standards of quality. This was evident for one of five residents reviewed for unnecessary medications and one of one resident reviewed for range of motion in a total stage two sample of twenty seven residents. Specifically, 1) Resident # 54 did not have a quarterly review completed in the three month time frame for (MONTH) (YEAR), which was then developed and back dated to 7/6/16 and 2) Resident # 107 did not have a Comprehensive Care Plan (CCP) developed for the use of the splint until 7/26/16 which was back dated to 2/24/16. The Findings Are: 1) Resident # 54 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] was reviewed. On 7/26/16 at 2:45 PM the Director of Nursing Services (DNS) was interviewed. A more current quarterly MDS was requested of the DNS. The DNS reported that the MDS was in fact being completed at the present time. On 7/26/16 at 3:00 PM the MDS Coordinator was interviewed. The MDS Coordinator stated that the (MONTH) (YEAR) MDS was not in the computer system as having been completed and that it had just been completed today. The MDS was reviewed and Section Z Assessment Administration documented that all disciplines had back signed the MDS completion to 7/1/16 and 7/2/16. The RN Assessment Coordinator signed and dated the MDS 7/6/16 verifying the assessment completion. On 7/26/16 at 3:00 PM the MDS Coordinator and MDS Assessor were interviewed. The MDS Coordinator and Assessor acknowledged that the MDS had just been completed and that they had back dated the assessment as having been completed by 7/6/16. The Coordinator stated that she was afraid to inform us that the MDS was not available when requested.
2) Resident # 107 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. The resident has [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] documented the resident usually understood and usually understands. The resident had long term and short term memory problem and was severely impaired for daily decision making. The Restorative Nursing Section of the MDS it was documented the resident required the assistance of a splint or brace. A physician's orders [REDACTED]. A review of the Care Plan section of the medical record revealed there was no CCP developed for the use of the splint. An interview was conducted on 7/27/16 at 1:00 PM with the 6th floor RN Supervisor regarding the CCP for the Splint. The RN stated that the resident was on the 2nd floor before transferring to the 6th floor. The RN stated that there was no CCP for the splint and that one should have been developed for the use of the splint. On 7/27/16 at approximately 2:00 PM The 6th floor RN Supervisor was interviewed. The RN stated that she had developed a CCP for the splint on 7/27/16. On review of the CCP it was backdated to 2/24/16. When the RN was questioned regarding the date on the CCP, the RN stated that she dated the CCP 2/24/16 because that was the date the splint was first ordered. 415.11(c)(3)(i)

Plan of Correction: ApprovedAugust 22, 2016

F281
I. Immediate Corrections:
The Facility Administrator will have zero tolerance for back dating any document and same may result in termination.
Resident # 54
1.The Administrator and DNS provided disciplinary counseling to all members of the team who backdated the MDS date for this resident?s quarterly assessment.
2. A copy of these counselings are on file for reference and validation.
3. A corrected MDS was coded with the actual dates of completion by the MDS Team.
Resident # 107
1. The RN who backdated the care plan for this Resident?s splint was provided a disciplinary counseling by the DNS. Same was filed for reference and validation.
2.The Facility held a special review CCP meeting to develop appropriate plans for the use of the right hand splint.
3. The CNA plan was revised as well to ensure directives for the use of the right hand splint.
II. Identification of Other Residents:
A.1. The DNS reviewed all the MDS Assessments completed for the last quarter to ensure compatible dates with the last assessment.
2. Any assessments found with late dates or inaccurate dates will warrant further disciplinary action to the MDS Coordinator and/or termination.
3. The DNS will review the schedule of all MDS Assessments prior to completion to oversee the system to ensure integrity and accuracy.
B.1. The DNS compiled a list of all Residents who use hand splints in conjunction with OT.
2. This list was used by the RNs and Charge Nurses on each floor to review the care plans to ensure a plan was in place for the use of the splint.
3. Any quality issues identified from this review will have immediate corrections by the unit RN and review by the DNS for validation.

III. Systemic Changes:
1. The DNS/ Administrator has provided education via one to one conference on Falsification of the medical record. A copy of this education was retained for reference and validation.
A.1.The DNS reviewed the Policy for MDS completion with a concentration on dating the ARD and found same compliant.
2.The MDS Coordinator and Assessors will review the policy and develop appropriate schedules for MDS start dates as per requirements. Each assessor will sign an attendance sheet to validate the review and understanding of the requirements.
3.The DNS will review the schedule for all MDS Assessment Reference dates to ensure accuracy and timely completion of the MDS.
B.1. The DNS reviewed the Policy for Care Plans and revised same to include a directive for the completion of the initial care plan by the RN and daily review until the initial MDS is completed.
3. All Licensed Nurses will be reinserviced on the policies and responsibilities for Care Plans by the Inservice Director. The Lesson Plan will concentrate on the use and directives for Hand Splints and other adaptive devices.
4. A copy of the Lesson Plan and attendance will be filed for reference and validation.
IV. QA Monitoring:
A.1. The DNS has developed an audit tool in conjunction with the MDS Schedule to track timely completion of all assessments.
2. Audits will be done weekly by the assigned RN following the MDS schedule over the next quarter.
3. Audits with negative findings will be referred to the DNS for follow up corrective actions as needed
4. Audit findings will be presented to the QA Committee monthly x3 then quarterly thereafter for evaluation and follow up as indicated.
Responsible discipline: Administrator.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

Based on observations and staff interview during the recertification survey, the facility did not ensure that the emergency exit from an exterior patio that also serves as an egress to public way for the recreation/dining room was readily accessible at all times. Reference is made to a chain and lock that was not fully accessible to release from the egress side. Additionally the key to the lock was not made readily available at a location near the lock. The finding is: During Life Safety Code inspections conducted on 07/21/16 at approximately 11:30am, it was noted that the exit gate from the exterior patio that serves as an egress to public way for an exit discharge for the main recreation/dining room located on the 1st floor was equipped with a chain and locking mechanism. The lock was partially located on the non-egress side and was not readily accessible on the egress side. A maintenance employee made multiple attempts to open the lock and was unsuccessful. Additionally, the key to the lock was not made readily available at a location near the lock. In an interview at this time, a maintenance employee stated that he would orient the lock in order for it to be readily accessible on the egress side. He further stated that a key would be provided in a lock box located in close proximity to the gate. NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 19, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K038 Immediate correction
It was noted that the exit gate from the exterior patio that serves as an egress to public way for an exit discharge for the main recreation/dining room located on the 1st floor was equipped with a chain and locking mechanism. The lock was relocated to the egress side and was made readily accessible. A new lock and key were provided with a key box in close proximity. 7/23/2016
. II. Identification of Other residents
1. The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
2. The Facility maintains a preventive maintenance for all exits and has reviewed all doors. The inspection has ensured that all exits are in compliance with NFPA NFPA 101.
3. The facility engineer reviewed the egress of all other areas and found no additional areas were impeded.
III. Systematic Changes
1. The facility has added a visual inspection to the daily rounds that will verify all exit conditions.
Staff that is inspecting the exits will be in-serviced on the proper requirements for exit paths.
IV. Q/A Monitoring
1. The Director of Environmental Services will conduct weekly audits over the next 2 months and then monthly to ascertain the effectiveness of the changes implemented.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Environmental Services by [DATE], (YEAR).

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms. 18.7.1.2, 19.7.1.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

Chapter 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. This requirement is not met as evidenced by: Based on observation, staff interview and documentation review during the recertification survey, it could not be determined that fire drills were conducted quarterly on each shift. Reference is made to the lack of fire drill records for 4 of 4 quarters of fire drill records reviewed. The findings are: During a documentation review of the facility ' s fire drill records for the last twelve months on 07/21/16 at approximately 1:00 pm, it was noted that fire drills were missing for the following times: - 4th quarter of (YEAR) was missing a night fire drill record. - 3rd quarter of (YEAR) was missing a day, evening and night fire drill records. - 2nd quarter of (YEAR) was missing a night fire drill record. - 1st quarter of (YEAR) was missing a day fire drill record. In an interview on the same day at approximately 2:15pm, the Assistant Administrator stated that the fire drill conductor has records of the missing fire drills and that they would be provided before the conclusion of the recertification survey. No records of the missing fire drills were provided by the facility by the end of the recertification survey. NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedSeptember 1, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K050 Immediate correction
The missing reports were obtained from the Drill conductor on 7/21/2016 for:
4th quarter of (YEAR) a night fire drill record.
3rd quarter of (YEAR) a day, evening and night fire drill records.
2nd quarter of (YEAR) a night fire drill record.
1st quarter of (YEAR) a day fire drill record.
. II. Identification of Other residents
1. The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
2. The Facility maintains a policy for completion of all required emergency drills and has a contract with a certified conductor.
3. The facility engineer reviewed the records of all fire safety requirements and found no additional areas were missing.
III. Systematic Changes
1. The administrator shall utilize a tracking form to verify the completion of all required drills.
2. The fire drill conductor will be required to leave a copy of all drills with the supervisor of the shift upon completion of the drill.
3. Supervisors shall be inserviced to collect the copy and the security at main entrance will place hte copy in administration
IV. Q/A Monitoring
1. The Administrator will conduct monthly audits to ascertain the effectiveness of the changes implemented.
2. Audits of negative findings will have immediate corrective actions implemented.
Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Environmental Services by [DATE]

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: One hour fire rated construction (with o hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2000 NFPA 101 Life Safety Code Chapter 19.3.2. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2) (3) Paint shops (4) Repair shops (5) Soiled linen rooms (6) Trash collection rooms (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that door openings to hazardous areas were self-closing on 4 of 7 resident use floors. The findings are: During Life Safety Code inspections conducted on 07/21/16 between 8:45am and 1:00pm, the following was noted with doors to hazardous areas: 1. The door to the 7th floor in-service classroom did not self-close when tested . There was a combustible load of paper files and folders kept in the room. 2. The door to the 7th floor dirty linen room hung up on the door frame when tested . 3. The door to the 7th floor soiled linen room did not self-close when tested . 4. The door to a 6th floor storage room (located across room [ROOM NUMBER]) was noted with a malfunctioning latching pin. The door could not be kept in the closed position when tested . 5. The door to the 5th floor soiled linen room did not self-close when tested . The latching mechanism was disabled. 6. The door to the 5th floor wheelchair storage room did not self- closed when tested . The latching mechanism was disabled. 7. The door to the 3rd floor dirty utility room hung up on the door frame when tested . In an interview on the same day at approximately 10:20am, a maintenance employee stated that he is taking note of the issue and that all the doors would be adjusted and made self-closing. NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 19, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K029 Immediate correction
1. Hinges for the door to the 7th floor in-service classroom was ordered and will be made to self-close when tested . 8/31/2016
2. The door to the 7th floor dirty linen room hinges were adjusted and made to self-close when tested . 7/22/2016
3. The door to the 7th floor soiled linen room adjusted to self-close when tested . 7/22/2016
4. The door to a 6th floor storage room (located across room [ROOM NUMBER]) had a new latching pin ordered. The door will be kept in the closed position when tested . 8/31/2016
5. The door to the 5th floor soiled linen room Made to self-close when tested . The latching mechanism was replaced. 7/22/2016
6. The door to the 5th floor wheelchair storage room Made to self-close when tested . The latching mechanism was enabled. 7/22/2016
7. New hinges for the door to the 3rd floor dirty utility room was ordered and will be free swinging when tested .8/31/2016
II. Identification of Other residents
1. The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.

2. The Facility maintains a preventive maintenance for all doors and has reviewed all doors. The inspection has ensured that all doors are in compliance with NFPA 80 and NFPA 101.
3. No other doors were found out of compliance other than those doors noted in state tag K18 and shall be addressed in that area. Completion 8/2/2016

III. Systematic Changes
1. The facility has increased to a monthly inspection of all Hazardous Area doors to the preventive maintenance program. This is an increase from the recommended quarterly inspections.
2. All facility staff shall be in serviced on the fire safety precautions of doors and the importance of not utilizing unapproved door hold open devices such as but not limited to door wedges and bypassing latch mechanisms. The in-service shall also cover how to report a problem or broken door.
3. Records of inspections shall be kept and reviewed by the Environmental Services coordinator. The environmental services coordinator shall assign qualified staff to perform the inspections and any required repairs will be done during this time. All unsatisfactory findings shall be reported to the QA committee and shall be addressed immediately during the review.
Completion (MONTH) 7,2016
IV. Q/A Monitoring
1. The Director of Environmental Services will conduct weekly audits over the next 2 months and then monthly to ascertain the effectiveness of the changes implemented.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Environmental Services by [DATE], (YEAR)

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide records to indicate that the fire suppression system that protects the elevator machine room was inspected and or serviced since it was installed. The findings are: During Life Safety Code inspections conducted on 07/21/16 at approximately 8:50am, it was noted that the fire suppression system that is installed in the elevator machine room on the roof was not provided with a service/inspection tag since the installation of the system. In an interview on the same day at approximately 12:15pm, the Assistant Administrator stated that he would retrieve the requested records and provide it before the conclusion of the recertification survey. No service/inspection records were provided by the facility by the end of the recertification survey. A review of the NYSDOH recertification records revealed that the fire suppression system was installed in (MONTH) of (YEAR). NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 19, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 062 Immediate Correction
Administration contacted the installer and service company for the fire suppression system that is installed in the elevator machine room on the roof. The system will be inspected and tagged in accordance with NFPA 17 chapter 9. Then provided with a service/inspection tag.
. II. Identification of Other residents
1. The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
2. A review of the sprinkler system inspection reports found no additional areas were found to be affected.
III. Systematic Changes
1. The Engineer has added the suppression system to the preventive maintenance schedule for the required items in NFPA 17 Chapter 9.
2. The staff performing the in house monthly inspections shall be inserviced on the requirements of the inspection by the installer.
3. The system inspector will be required to leave a copy of all report with the engineer of the shift upon completion of the inspection.
IV. Q/A Monitoring
1. The Administrator will conduct monthly audits to ascertain the effectiveness of the changes implemented.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Environmental Services by [DATE], (YEAR).

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Clearance between bottom of door and floor covering is not exceeding 1 inch. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.2.3.2.1. Roller latches are prohibited by CMS regulations in all health care facilities. 19.3.6.3

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2000 NFPA 101 Life Safety Code Chapter 19.3.3. Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch thick solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. Doors are provided with a means suitable for keeping the door closed. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that corridor doors were provided with functioning positive latching hardware or were positively latching on 4 of 7 resident use floors. The findings are: During Life Safety Code inspections conducted on 07/21/16 between 8:45am and 1:00pm, the following was noted with corridor doors: 1. The automatic flush bolts on 2 sets of dining room doors to the 7th floor dining room did not function when tested . The flush bolt pins were stuck in the open position and prevented the doors from positively latching into the door frames when tested . 2. The door to the 6th floor pantry room hung up on the door frame when tested . 3. The latching mechanism on the 4th floor pantry room door was disabled rendering the door non-positively latching when tested . 4. The door strike plate for resident room [ROOM NUMBER] on the 3rd floor was taped over rendering the door non-positively latching when tested . 5. The pantry room door on the 3rd floor was missing a positive latching device. In an interview on at approximately 11:15am, a maintenance employee stated that all the identified issues with the doors would be addressed. NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 19, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K18 I. Immediate corrective action:
1. The automatic flush bolts on 2 sets of dining room doors to the 7th floor dining room did not function when tested . The flush bolt pins were serviced and made to function so the doors positively latched into the door frames when tested .
Completed 7/22/2016
2. The door to the 6th floor pantry room Hinges were adjusted to prevent the door from being hung up on the door frame when tested .
Completed 7/22/2016
3. The latching mechanism on the 4th floor pantry room door was ordered and will be made to function; the door will positively latch when tested .
Completion 8/26/2016
4. The door strike plate for resident room [ROOM NUMBER] on the 3rd floor had tape removed; the door positively latches when tested .
Completed 7/21/2016
5. The pantry room door on the 3rd floor had a missing a positive latching device ordered .
Completion 8/26/2016
II. Identification of Other residents
1. The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.

2. The Facility maintains a preventive maintenance for all doors and has reviewed all doors. The inspection has ensured that all doors are in compliance with NFPA 80 and NFPA 101.
3. No other doors were found out of compliance other than those doors noted in state tag K29 and shall be addressed in that area.
Completion 8/26/2016

III. Systematic Changes
1. The facility has increased to a monthly inspection of all corridor doors to the preventive maintenance program. This is an increase from the recommended quarterly inspections.

2. All facility staff shall be in serviced on the fire safety precautions of doors and the importance of not utilizing unapproved door hold open devices such as but not limited to door wedges and bypassing latch mechanisms. The in-service shall also cover how to report a problem or broken door.
3. Records of inspections shall be kept and reviewed by the Environmental Services coordinator. The environmental services coordinator shall assign qualified STAFF TO PERFORM the inspections and any required repairs will be done during this time. All unsatisfactory findings shall be reported to the QA committee and shall be addressed immediately during the review. Completion (MONTH) 7,2016
IV. Q/A Monitoring
1. The Director of Environmental Services will conduct weekly audits over the next 2 months and then monthly to ascertain the effectiveness of the changes implemented.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Environmental Services by [DATE], (YEAR).

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Portable fire extinguishers shall be installed, inspected, and maintained in all health care occupancies in accordance with 9.7.4.1, NFPA 10. 18.3.5.6, 19.3.5.6

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

NFPA 101 Chapter 9 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 1998 NFPA 10 Standard for Portable Fire Extinguishers- Chapter 4-3 Inspection. 4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require. 4-3.2 Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items: (a) Location in designated place (b) No obstruction to access or visibility (c) Operating instructions on nameplate legible and facing outward (d) Safety seals and tamper indicators not broken or missing (e) Fullness determined by weighing or 'hefting' (f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle (g) Pressure gauge reading or indicator in the operable range or position (h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units) (i) HMIS label in place This requirement is not met as evidenced by: Based on observation, staff interview and documentation review during the recertification survey, the facility did not ensure that a portable fire extinguisher was inspected at approximately 30-day intervals. The finding is: During Life Safety Code inspections conducted on 07/21/16 at approximately 10:05am, it was noted that a portable fire extinguisher that is located in the 5th floor Vacuum mechanical room was not inspected at approximately 30 day intervals. The last inspection date noted on the tag on the extinguisher was 02/02/16. The facility did not provide documentation to indicate that the 30 days inspections were completed after this date. In an interview at this time, a maintenance employee stated that the extinguisher inspections were missed and that the extinguisher would be immediately replaced. NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 19, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K064 Immediate corrective
The portable fire extinguisher that is located in the 5th floor Vacuum mechanical room was replaced with a fire extinguisher which had current inspection upon discovery from the spare stock kept on premises.7/21/2016
. II. Identification of Other residents
1. The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
2. The Facility maintains a preventive maintenance for all fire extinguishers in accordance with all local laws. The inspection has ensured that all extinguishers are in compliance with NFPA 10 and NFPA 101.
3. A review of the fire extinguisher inspection reports found no additional areas were found to be affected.
III. Systematic Changes
1. The Engineer has reviewed the fire extinguisher log in the preventive maintenance for completeness and schedule for the required items in NFPA 10 Chapter 4.
2. The staff performing the in house monthly inspections shall be inserviced on the requirements of the inspection.
3. The inspector will be required to leave a copy of all report with the engineer of the shift upon completion of the inspection log.
IV. Q/A Monitoring
1. The Engineer will conduct monthly audits to ascertain the effectiveness of the changes implemented.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Environmental Services by [DATE], (YEAR).

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. 4-3.1.1.2 (NFPA 99), 8-3.1.11.1 (NFPA 99), 18.3.2.4, 19.3.2.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2016
Corrected date: September 16, 2016

Citation Details

Life Safety Code Section 19.3.2.4 requires that medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. NFPA 99 Section 16-3.4.1 requires that if installed where patients are provided mechanical ventilation or assisted mechanical ventilation, patient gas systems shall conform to Level 1 piped gas systems of Chapter 4. NFPA 99 Section 4-3.1.1.2 (a) (10) (b) Storage facilities that are outside, but adjacent to a building wall, shall be in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. NFPA 50 Section 2-2.11 requires that 50 ft in a direct line from the inner container pressure relief device discharge piping outlets and filling and vent connections from areas occupied by non-ambulatory patients. This requirement is not met as evidenced by: Based on observation, staff interview and record reviews during the recertification survey, the facility did not ensure that all bulk oxygen storage locations were in compliance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites in that the bulk oxygen storage location was within 50 feet of resident rooms on two of seven floors. The facility did not provide a policy and procedure for not admitting non-ambulatory residents in the rooms affected by this requirement. The findings are: During Life Safety Code inspections conducted on 07/21/16 between 8:45am and 1:00pm, it was noted that the bulk oxygen system was found to be less than 50-feet from non-ambulatory patient areas, resident rooms 208, 209 and 308. Measurements taken during the 11/24/14 recertification survey from the resident rooms to the bulk oxygen system revealed that the rooms were approximately 26 feet to 43 feet away. The facility did not provide a policy and procedure (P&P) to indicate that non-ambulatory residents were not going to be admitted to the affected rooms. In an interview on the same day at approximately 1:20pm, the Assistant Administrator stated that he would discuss the concern with the Administrator and provide the P&P before the conclusion of the recertification survey. No P&P for this concern was provided by the end of the recertification survey. 2000 NFPA 101: 19.3.2.4 1999 NFPA 99: 16-3.4.1, 4-3.1.1.2 (a) (10) (b), 4-3.1.1.2 (b) (1) 1996 NFPA 50: 2-2.11, 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedSeptember 1, 2016

K18 I. Immediate corrective action:
The facility will not admit non ambulatory Residents to the affected rooms.

II. Identification of Other residents
1. The Facility respectfully states that no residents were potentially affected since all Residents admitted to those rooms were ambulatory as per the policy and P(NAME)
III. Systematic Changes
1. The D.N.S together with Admissions will review every PRI from the Residents prior to Admission to insure resident is Ambulatory.

IV. Q/A Monitoring
1. Admission will conduct audits to insure compliance.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by Admissions Director by Sep 2, (YEAR)