Oneida Health Rehabilitation and Extended Care
October 7, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.15(h)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the environment was maintained in a sanitary and orderly manner for 4 of 4 resident floors (Floors 2, 3, 4, and 5). Specifically, floors 2, 3, 4 and 5 had multiple areas with damaged walls, wrapped nurse call cords, delaminated/gouged/damaged doors, unhooked room divider curtains, and damaged chairs. Findings include: On 10/4/2016 from 11:12 AM to 12:08 PM, the following was observed on Floor 5: - Room 528, the wallpaper and wall carpet behind the bed was torn/peeling; - Room 527, the ceiling was stained/marked with an unknown substance; - Room 527, there were four 1/4 inch holes behind the window side and door side beds; - Room 504, had torn wall carpet; - Room 504, the wood molding installed on the wall behind the bed was loose/not secure; - Room 506, the door was delaminated/damaged; - Room 505, the edge of a wall was damaged with missing sections of spackle along the metal corner bead; - a chair in the elevator lobby had worn/exposed sharp edges along the back of the chair, and the chair fabric was cracked; - the wooden guard rail in the elevator lobby was deeply scratched/grooved; - Room 513, the wallpaper behind the window side bed was peeling, and the nurse call light cord was wrapped around a grab bar; - the bathing room door was delaminated/damaged; - the tub room door vinyl protection cover was cracked/damaged; and - the divider curtain in the bathing room had 12 grommets that were not connected with hooks. On 10/4/2016 from 1:20 PM to 2:00 PM, the following was observed on Floor 3: - the divider curtain in the bathing room used to separate it from shower #1 had 3 grommets that were not connected with hooks; - the divider curtain in the bathing room to separate it from shower #1 had 4 grommets that were not connected with hooks; - the edge of a wall in the shower room had a broken wall tile; - Room 319, the door side divider curtain had 4 grommets that were not connected with hooks, the window side divider curtain had 2 grommets that were not connected with hooks, and the nurse call cord was wrapped around a grab bar; - the clean linen room door was gouged/damaged; - Room 324, the nurse call cord was wrapped around a grab bar; and - the dining room door was delaminated/damaged. On 10/4/2016 from 2:02 PM to 2:34 PM, the following was observed on the Floor 4: - the cross corridor smoke doors were delaminated/damaged; - a chair in the elevator lobby had a hole in the back of it with exposed metal; - the bathing room door was delaminated/damaged; - the floor in front of the bathing room door was delaminated/damaged; - the soiled utility room door was delaminated/damaged; and - Room 419, the wall carpet behind the door side bed was loose/pulled off the wall, and the bathroom door was delaminated/damaged. On 10/4/2016 from 2:50 PM to 3:22 PM, the following was observed on the Floor 2: - Room 206, the window side divider curtain had 3 grommets that were not connected with hooks, the wall carpet behind the door side bed was loose/pulled off the wall, and the nurse call cord was wrapped around a grab bar; - Room 207, the nurse call cord bathroom was wrapped around a grab bar and the bedroom door was delaminated/damaged; - Room 205, the wall carpet behind the window side bed and door side bed was loose/pulled off the wall, and the nurse call cord in the bathroom was wrapped around a grab bar; - Rooms 203 and 205, a wheelchair located in the hallway between the rooms was torn in multiple spots; - the bathing room door was delaminated/damaged; - Rooms 213, 224, and 221, the nurse call cords in the bathrooms were wrapped around a grab bar; and - Room 221, the toilet stand/assist device in the bathroom had a broken handle. When interviewed on 10/4/2016 at 3:28 PM, licensed practical nurse (LPN) #11 stated the residents in rooms 205, 206, 207, 213, 221, and 224 use the bathrooms and are capable of pulling the nurse call cord. When interviewed on 10/4/2016 at 3:34 PM, the Plant Operations Director stated he was not aware of the above mentioned findings found during tour, and that areas of concern were identified by submittal of work orders and monthly rounding of the the facility. He stated monthly rounding was not documented. 10NYCRR 415.5(h)(2)

Plan of Correction: ApprovedNovember 11, 2016

F253 #1 Items requiring repair
1) During the Survey a number of repair issues were identified. To date work has been completed on Rooms 527 (10/7/16), 505 (10/7/16), 221 (10/7/16) as well as tub room vinyl (10/10/16) Flooring in front of bathing room (10/21/16). The remainder have had Work Orders generated and will be addressed until all are completed.
2) Environment of Care Monthly Inspection process revised to include an Inspection on the Environment of Care Rounds Sheet to document identified issues.
3) From this rounding Sheet, for the issues identified, a work order will be generated by the Maintenance Department immediately following the rounding completion to resolve any identified issues.
a. Departments will continue to generated work orders routinely as well when issues arise.
4) Results of the Environment of Care Rounds Sheet will be reported at ECF QA Committee and reviewed for further action on a monthly basis for 3 months and a quarterly basis thereafter.
a. Employees will be educated by 11/23/16 of process changes.
5) Date of Completion: 11/23/16, Ongoing Responsible party: Director of Plant Operations.

F253 #2 Hooks/Grommets
1) Hooks/Grommets were found missing from curtains on 10/4/16. Housekeeping completed a full unit inspection of all curtains on 10/6/16 and replaced all hooks and grommets to the curtains throughout the building.
2) Housekeeping will be included in TMS work order system (previously this was just Maintenance Work orders) so that a simple work order can be generated by(NAME) Clerks and staff when hooks or grommets are identified as missing.
3) All rooms will be checked monthly by Housekeeping Supervisor of designee and will be recorded in the newly created Cubicle Curtain inspection Log.
4) A report based on findings from the Cubicle Curtain Log will be shared at the Monthly ECF QA Committee monthly for the first 3 months and then quarterly thereafter to assure issue is resolved.
a. Employees will be educated by 11/23/16 of process changes.
5) Date of Completion: 11/23/16, Ongoing Responsible party: Housekeeping Manager

F253 #3 Call (NAME) Cords
1) Call bell cords were identified as being wrapped around grab bars on 10/4/16. On 10/4/16 full building inspection was conducted to assure that no other call bell cords were inappropriately wrapped and corrected if needed.
2) On 10/4/16 full building inspection was conducted to assure that no other call bell cords were inappropriately wrapped and corrected if needed.
3) Call bell Audit is being conducted to assure that call bells/cords are being maintained appropriately.
a. Staff was educated on 10/5 on the Call lights/bells and the safety measure considerations in using them.
4) Call bell Audit results will be reported to the monthly Facility Safety Committee and ECF QA Committee and reviewed for further action. Results will be reported monthly for the first 3 months and quarterly thereafter.
5) Date of Completion: 11/23/16, Ongoing Responsible party: Administrator
F253 #4 Doors
1) A number of doors were identified as being delaminated, gouged or damaged. Maintenance constructed an ECF Door Maintenance plan that divides doors into three categories: In place repair, Remove and Repair and Replace Door. The building wide door inventory was completed on 10/25/16 and includes a room by room listing of the level of repair they require. Work Orders have been generated through the system and work has begun.
2) The building wide door inventory was completed on 10/25/16 and includes a room by room listing of the level of repair they require. Work Orders have been generated through the system and work has begun.
3) Environment of Care Monthly Inspection process revised to include an Inspection on the Environment of Care Rounds Sheet to document identified issues.
4) From this rounding Sheet, for the issues identified, a work order will be generated by the Maintenance Department immediately following the rounding completion to resolve any identified issues.
a. Departments will continue to generated work orders routinely as well when issues arise.
5) Date of Completion: 11/23/16, Responsible party: Director of Plant Operations.

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification and abbreviated (NY 252) surveys, it was determined the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated, and reported to the New York State Department of Health (NYSDOH) as required for 1 of 14 sampled residents (Resident #1) reviewed for abuse, neglect, or mistreatment. Specifically, for Resident #1 the facility did not report an injury after a fall when it was determined the resident's care plan was not followed. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 11/17/2015 documented the resident was at risk for falls, as she had significant dementia, poor safety awareness, was disoriented, and non-ambulatory. Interventions were in place including bilateral floor mats, a low bed, and a bed and chair alarm. The 4/20/2016 certified nurse aide (CNA) Assignment Sheet (care instructions) documented the resident was to have bilateral floor mats. The 4/27/2016 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and had not had any falls since the last assessment. The facility Patient Event Report dated 5/5/2016 documented the resident was found on the floor next to the bed lying on her right side. The report documented the resident sustained [REDACTED]. The associated Accident/Incident Investigative Summary signed by the Director of Nursing (DON) documented the resident was found on the floor next to the bed and the floor mat was not present at bedside. The fall occurred while rounds were being conducted at shift change. The Investigative Summary documented the resident sustained [REDACTED]. The Accident/Incident Investigative Summary included a section documenting Action taken to prevent another such accident/incident. This included the resident's care plan was updated and the resident was transferred to the acute care facility for x-rays. The caregiver was interviewed as to why the mat was not in place, and he stated that he forgot and he verbally understood the importance of a care plan. Underneath the DON signature, it was marked that abuse, neglect and mistreatment were not suspected, and that the incident was staff error. The resident was observed on 9/21/2016 from 9:10 AM - 9:20 AM being transferred from her wheelchair to the toilet, and then from the toilet to the bed via a stand lift (mechanical lift) by CNA #9. The resident had a blue mat on the right side of her bed. During an interview with CNA #9 on 9/21/2016 at 9:20 AM, she stated the resident only had 1 floor mat on the floor and it was on the right side of the bed. During an interview with the DON on 9/21/2016 at 3:15 PM, she stated that the investigation was started by the evening shift supervisor, then it was provided to the ADON (Assistant DON), and then she (the DON) received it. The DON was asked how she determined whether abuse or neglect occurred. The DON reviewed the facility investigation and Accident/Incident Investigative Summary and stated that when reading the information again, the resident was care planned to have 2 floor mats. The DON stated it appears the resident did not have the floor mats down, and this was acknowledged by CNA #10. The DON stated that she did not call this incident into the NYSDOH, as education was provided to CNA #10. The DON stated the resident sustained [REDACTED]. During an interview with CNA #10 on 9/27/2016 at 9:50 AM, he stated he was familiar with the resident as she was on his scheduled assignment. CNA #10 stated that he worked the 3 PM - 11 PM shift. He stated on the date of the incident, it was approximately 3:00 PM and he heard the resident's alarm go off. When he went to check on her, she had rolled out of bed and was on the floor. He stated it was the responsibility of the CNA who put the resident to bed to put the fall mat in place, and he did not know who had assisted the resident in bed that day. He stated the staff member he believed assisted the resident to bed was no longer employed by the facility. CNA #10 stated that he did walking rounds at the start of his shift, and he did not remember if he had done walking rounds prior to the resident's fall. CNA #10 contacted the surveyor by telephone on 9/27/2016 at 10:35 AM and stated he believed he was in the process of doing walking rounds when he heard the resident's alarm sounding, and he found the resident on the floor. He believed he did not go into the resident's room prior to finding her on the floor. 10NYCRR 415.4(b)

Plan of Correction: ApprovedNovember 11, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F225: In the recent standard recertification and abbreviated survey it was determined the facility did not ensure all alleged violations involving abuse, neglect or mistreatment were thoroughly investigated and reported to the NYDOH as required for 1 of the 14 residents reviewed for abuse, neglect or mistreatment specifically resident #1 the facility did not report an injury after a fall when it was determined the residents careplan was not followed.
The following steps were taken:
1. Resident #1 had a fall resulting in an injury on (MONTH) 15, (YEAR). The resident sustained [REDACTED]. The incident was not reported to the NYSDOH. The resident was careplanned for bilateral floor mats. One floor mat was not in place at the time of the incident. The resident?s careplan and the CNA assignment sheet were reviewed by the IDT. The resident has bilateral floor mats in place. Education was provided to nursing staff regarding the bilateral floor mats for resident #1.
Facility administrative staff received education on the reporting process.
Date Completed: (MONTH) 10th, (YEAR).
2. Recognizing all residents could be potentially affected for careplan violations and/or failure to report to NYSDOH, residents careplanned for safety devices were reviewed to ensure the safety measures (mats, alarms etc) were correct, correlated with the resident?s careplan and CNA assignment sheet and were in place. Corrections and updates were made as needed.
All incident reports submitted from (MONTH) 1, (YEAR) ? (MONTH) 22, (YEAR) were reviewed to ensure that there had not been a careplan violation, lack of an investigation regarding the incident and/or reporting of the incident to the NYSDOH. All reports submitted in writing during this time period were reviewed to ensure compliance.
There were no reports identified that met the ?reasonable cause? threshold resulting in failure to report.
3. The facility reviewed and revised policies to include: revision to the fall policy/process for ensuring careplan accuracy for safety measures, revision to the A&I procedure and timely determination if the incident meets the guidelines for reporting to the NYSDOH and if guidelines are met, was the incident reported to the NYSDOH timely.
To ensure compliance, staff training began on (MONTH) 23, (YEAR) starting with ?Neglect and Identifying Careplan Violations? with additional training completed on ?Facility Incident Reporting?.
Education was completed on (MONTH) 10, (YEAR) regarding state and federal requirements for identifying, investigating and reporting guidelines for alleged violations of abuse, mistreatment, neglect, injuries of unknown origin, or misappropriation of resident property, the process when the reasonable cause threshold has been met, ensuring the safety measures on the resident careplan correlates with what is in place and the procedure for A&I completion.
Education will be provided on orientation to new nursing employees.
4. Accident and Incident log/audit sheet revised to include: Daily review of the accident and incident investigations to determine if reporting elements were met and determine if the incident is reportable to the DOH.
5. Audit results will be reviewed monthly QA committee. The QA Committee will evaluate the results and adjust the frequency and context of audit as necessary. Beginning with the next QA meeting on (MONTH) 30, (YEAR) and ongoing. Date completed: Ongoing
Responsible party: Quality Management Coordinator (QMC)/ Administrator

FF09 483.70(h)(4):MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

REGULATION: The facility must maintain an effective pest control program so that the facility is free of pests and rodents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not ensure there was an effective pest control program to maintain the facility free of pests for 1 of 1 kitchens (main kitchen/cafe). Specifically, numerous fruit flies were observed in multiple areas in the kitchen/cafe throughout the survey and there was no documentation the contracted control company's recommendations were followed to prevent continued breeding of the flies. Findings include: The (YEAR)/2016 service reports from a contracted pest control company documented the following: - 10/19/2015: Fruit flies were seen in the same areas as previous months. Flies were breeding around the metal frame of the cartwash pit and behind the cracked baseboard tiles. Recommendations included to repair floor tile, seal around the metal frame of the cart wash grate, and clean in and around drains; - 11/16/2015: Fruit flies were found throughout the dishroom. Findings included low grout under the pot/pan sink and floor tiles loose or missing. Recommendations included to clean in and around the drains and to replace floor tiles; - 12/14/2015: Small flies were found in the dish area of the kitchen. Floor tiles or baseboards were loose or missing, floor drains were in need of cleaning, and spilled food was found on floor. Recommendations included to repair the floors and to clean in and around the drains; - 2/17/2016: Fruit flies were found in the dish room and around the pot/pan wash sinks. Findings included floor tiles loose or missing, and low grout near pot/pan sink where food debris accumulated. Recommendations included to repair the floor and clean around the dishwasher; - 3/1/2016: Fruit flies were found in the dish room and around the triple sink and elevator door corner. Findings included food spills on floor and drains in need of cleaning. Recommendations were to clean around the conduit and motors along the ground of the dishwasher and clean the drains frequently; - 3/22/2016: Fruit flies were found in the dish room and around the triple wash sink. Findings included food debris around the ends of the dishwasher rollers where fruit fly larva was found. Recommendations included to clean drains weekly; - 4/18/2016: Small flies were seen in the kitchen near the triple sink and in the dishroom. All stages of development were found. Findings included fruit fly larva found under floor mat and recommendations included to clean and sanitize all floor mats nightly; - 5/16/2016: Fruit flies were seen in the dishroom around the dishwasher and cartwash pit. Findings included trash cans in need of cleaning and grease build up on/by floor mats. Recommendation included to clean floor mats nightly and hang up to dry; - 6/20/2016: Fruit flies were found in the kitchen, mostly in the dishroom. The dishwasher and cartwash areas were the main source for breeding. Findings included floor drains in need of cleaning. Recommendation were to clean the dishwasher rollers weekly to remove food debris; - 7/13/2016: Fruit flies were found in the dishroom and cafe hallway. Spilled food was found on floor. Recommendations included to keep the door to the dishroom closed and to clean around the cartwash area to reduce breeding sources; - 7/20/2016: Fruit flies were found in the kitchen and cafe hallway outside of the dish room. Findings included a hole/gap around the cartwash grate, which was a main breeding source, and it was recommended the hole be sealed; - 8/22/2016: Fruit flies were seen in the dish room, and some in the kitchen and hallway outside of the dish room. Findings included a hole/gap found around the cartwash frame where the flies were breeding, and the hole was recommended to be sealed to prevent pest entry or harborage; and - 9/19/2016: Fruit flies were found in the kitchen area including the hallway and the dishroom. Recommendations included to remove and clean floor mats 2-3 times per week as fruit fly larva were found under the floor mat, and to clean the cartwash pit regularly to reduce food debris build up On 10/4/2016 at 9:00 AM, a surveyor in the kitchen observed multiple (more than 50) fruit flies. On 10/4/2016 at 12:35 PM, a surveyor in the cafe (adjacent to the kitchen) observed multiple (more than 25) fruit flies on the ceiling. When interviewed on 10/5/2016 at 4:40 PM, the Food Service Director stated the amount of fruit flies decreased in the winter months and increased in the summer months. She stated sanitizer had been poured into the drains and the main drain lines had been cleaned. She stated the daily cleaning was dispensed among the night shift and the kitchen was bombed quarterly to eliminate the flies. She stated there was no written documentation to verify the contracted pest control company's recommendations were being followed for the elimination of fruit flies. On 10/5/2016 at 5:00 PM, a surveyor walking with the Food Service Director in the kitchen observed multiple (more than 75) fruit flies along the path to the dish room, the triple sink, and the dishwasher area. Multiple (more than 40) fruit flies were also observed in the cafe. 10NYCRR 415.29(j)(5)

Plan of Correction: ApprovedNovember 11, 2016

F469
Issues cited relative to vendor recommendations pertaining to repairs (as mentioned from 10/19/2015-2/17/16) were repaired on 3/15/16.
a. Policy and Procedure on cleaning the kitchen has been revised to include both participation from the Dietary Staff and Housekeeping.
b. Dietary continues with their daily cleaning of areas and Matts and pouring sanitizer down drains as recommended by vendor.
c. The cart wash/grated area has had a purchase order approved to replace the existing drainage system with a single center drain. PO approved 11/9/16 by ECF Administrator. Projected is slated to be completed as soon as possible.
d. Once Ecolab/pest control vendor has generated their action report, Housekeeping, Maintenance and Dietary will meet to discuss follow up actions and insure that required follow up occurs.
2) Walk through of facility completed on 10/19/16 to assure that no Fruit flies exist outside of the areas cited within.
3) Once Ecolab/pest control vendor has generated their action report, Housekeeping, Maintenance and Dietary will meet to discuss follow up actions and insure that required follow up occurs.
a. The cart wash/grated area has had a purchase order approved to replace the existing drainage system with a single center drain.
b. Ecolab contacted for further intervention strategies on 11/8/16.
4) Findings from the post pesticide vendor visit will be reported in both safety Committee and ECF QA meetings and reviewed for further action. Audit will be completed on a monthly basis for 3 months and a quarterly basis thereafter.
a. Employees will be educated by 11/23/16 of process changes.
5) Date of Completion: 11/23/16, Ongoing
Responsible party: Director of Plant Operations

FF09 483.25(d):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: Based on the resident's comprehensive assessment, the facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not ensure appropriate treatment and services were provided for 1 of 2 residents (Resident #3) reviewed for catheters. Specifically, Resident #3 did not have a documented rationale for continued use of a Foley catheter (tube inserted into bladder to drain urine) and a plan was not developed to trial the resident without the indwelling catheter until she developed a urinary tract infection [MEDICAL CONDITION]. Findings include: Resident #3 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. The resident required extensive assistance with two person physical assist for toilet use, was always continent of urine, and did not use an indwelling catheter. The admitting physician orders [REDACTED]. The Foley catheter was last changed on 3/23/2016. The comprehensive care plan (CCP) dated 4/20/2016 documented the resident had an indwelling catheter due to [MEDICAL CONDITION]. The goal was to attempt to remove the catheter within 30 days, and the resident would not experience complications from use of catheter through the next review. A physician progress notes [REDACTED]. There was no documented evidence why the resident continued to have an indwelling catheter and there was no plan to discontinue the catheter. The 5/2/2016 and 6/6/2016 physician orders [REDACTED]. A nursing progress note dated 6/10/2016 documented the resident was having hallucinations and required reassurance. A nurse pracitioner (NP) progress note dated 6/14/2016 documented the resident was having hallucinations that had been occuring for several days. The plan was to check a urinalysis to evaluate for a UTI and start the weaning protocol. A 6/14/2016 telephone order documented to obtain a urinalysis with a culture and sensistivity. A nursing progress note dated 6/14/2016 documented a new order to obtain the resident's urine for a urinalysis and to initiate the clamping protocol for possible discontinuation of the catheter. A 6/15/2016 physician telephone order documented to discontinue the resident's Foley catheter and start [MEDICATION NAME] (antibiotic) 250 milligrams (mg) twice a day for 7 days for a UTI. During an interview with registered nurse (RN) Manager #8 on 10/7/2016 at 11:10 AM, she stated when a resident was admitted , she would discuss the resident's [DIAGNOSES REDACTED]. If the resident did not have a supporting diagnosis, a plan would be intitated to discontinue the catheter. She stated she was not aware the resident had a Foley catheter as she was not working on that unit at that time. During an interview with the Medical Director on 10/7/2016 at 11:45 PM, he stated Foley catheters should be removed as soon as possible if the resident did not have a supporting diagnosis, as it posed a risk for UTIs. He stated he would not necessarily expect the physicians to document a plan for a resident with a Foley catheter in their progress notes, as it was part of the facility's protocol to remove the indwelling catheter as soon as possible. 10NYCRR 415.12(d)(2)

Plan of Correction: ApprovedNovember 11, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F315: In the recent standard recertification survey it was determined the facility did not ensure appropriate treatment and services were provided for 1 of 2 residents reviewed for catheters. Resident #3 did not have a documented rationale for continued use of a foley catheter and a plan was not developed to trial the resident without an indwelling catheter until she developed an UTI.
The following steps were taken:
1. Resident #3 MDS?s were reviewed for accuracy. The MDS dated [DATE] is an entry MDS, therefore, does not require the Bladder and Bowel queries.
The subsequent MDS?s, dated 4/8 & 6/12 were coded correctly, Indwelling catheter present and urinary continence not rated due to catheter.
Resident currently does not have an indwelling catheter as it was discontinued on 6/16/16.
The resident?s careplan dated 4/18/16 mentioned urinary catheter due to [MEDICAL CONDITION].
Date completed: 11/10/2016
The practitioners and nursing staff were educated on assessing the use of foley catheters, ensuring an appropriate [DIAGNOSES REDACTED].
Date completed: 11/10/2016
2. An audit of all current residents with foley catheters was completed to ensure all residents have appropriate [DIAGNOSES REDACTED]. Corrective action taken.
Date completed: 11/10/2016
3. The facility reviewed and revised policies to include Indwelling foley catheter care to prevent UTI?s, Appropriate [DIAGNOSES REDACTED].
Education provided to all nursing and medical staff in obtaining appropriate [DIAGNOSES REDACTED].
Date completed: 11/10/2016
4. QM will conduct audits monthly to ensure compliance with the usage of foley catheters and prevention of CA UTI?s.
Date completed: 11/10/2016
5. Audit results will be reviewed monthly QA
committee. The QA Committee will evaluate the
results and adjust the frequency and context of audit
as necessary. Beginning with the next QA meeting on
(MONTH) 30th, (YEAR) and ongoing.
Date completed: 11/10/2016
Responsible Party: DON, ADON, QMC

FF09 483.40(b):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: The physician must review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; write, sign, and date progress notes at each visit; and sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure the physician reviewed the resident's total program including medications and treatments, and signed and dated orders for 2 of 24 residents (Residents #3 and 19) reviewed for physician services. Specifically, Resident #3's Foley catheter (urinary drainage tube) was not addressed by the physician in a timely manner. Resident #19 was seen by a neurologist and the neurologist's recommendations were not addressed or implemented by the attending physician. Findings include: 1) Resident #3 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She required extensive assistance for most activities of daily living (ADLs) including toileting, was continent of urine, and did not use an indwelling catheter. A physician history and physical dated 4/2/2016 documented the resident had an indwelling Foley catheter. The physician did not document a [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 4/20/2016 documented the resident had an indwelling catheter due to [MEDICAL CONDITION]. The goal was to attempt to remove the catheter within 30 days and the resident would not experience complications from use of the catheter through the next review. physician progress notes [REDACTED]. The physician did not document a [DIAGNOSES REDACTED]. A physician telephone order dated 6/15/2016 documented to discontinue the resident's Foley. Start on [MEDICATION NAME] (antibiotic) 250 milligrams (mg) twice a day for 7 days for a urinary tract infection [MEDICAL CONDITION]. During an interview with the registered nurse (RN) Unit Manager #8 on 10/7/2016 at 11:10 AM, she stated when a resident was admitted to the facility she would discuss the resident's [DIAGNOSES REDACTED]. If the resident did not have a supporting diagnosis, a plan would be initiated to discontinue the catheter. She stated she was not aware Resident #3 had a Foley catheter as she was not working on the unit at that time. During an interview with the Medical Director on 10/7/2016 at 11:45 PM, he stated Foley catheters should be removed as soon as possible if the resident did not have a supporting [DIAGNOSES REDACTED]. He stated he would not necessarily expect the physician to document a plan for a resident with a Foley catheter in his progress notes, as it was part of the facility's protocol to remove the indwelling catheter as soon as possible. 2) Resident #19 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She required extensive assistance with bed mobility, dressing and toilet use, was dependent for transfers, did not walk, and required supervision for eating. The resident had functional limitation in both upper and lower extremities. A physician progress notes [REDACTED]. The physician discussed with the resident the insurance company would not cover the medication as it was not indicated for fatigue. A nursing progress note dated 8/16/2016 at 1:10 PM documented the resident had called her neurologist and he had written her a prescription for [MEDICATION NAME] which a family member would pick up and bring to the facility. The nurse reminded the resident of the conversation she had with the attending physician on 8/12/2016 regarding the [MEDICATION NAME] and the need for a diagnosis. A telephone order was received from the attending physician for a neurology consult. A neurology consultant's report dated 8/24/2016 documented to continue with current medicine, physical and occupational therapy, and begin Ampyra (indicated as a treatment to improve walking in patients with MS) 10 milligrams (mg) twice daily and follow up in 6 months. A nursing progress note dated 8/24/2016 at 9:49 PM documented the physician reviewed the neurology consult. The physician had discussed with the resident a prescription for [MEDICATION NAME], which the resident had presented upon return from the neurologist. The physician explained to the resident the order was not written on today's consult, and it had an earlier date on it. The physician explained to the resident the prescription did not include a required [DIAGNOSES REDACTED]. A physician progress notes [REDACTED]. The neurologist had recommended Ampyra and had signed a prescription for [MEDICATION NAME]. The physician's plan was to discuss the use of Ampyra with the neurologist, as the resident had not walked in many years and was unable to stand. He would also discuss with the neurologist the indications for use of [MEDICATION NAME]. The physician documented the consult sheet did not mention [MEDICATION NAME] or the indication for its use with the resident. The resident had been tapered off of [MEDICATION NAME] in 2/2016 as there was no indication for use and it was not covered by insurance. The physician documented the resident understands the confusion and will wait until I clear up the above with the neurologist when he returns from vacation. There was no documented evidence the physician followed up with the neurologist after 9/2/2016 regarding the resident's medications. During an interview with the registered nurse (RN) Unit Manager #8 on 10/7/2016 at 11:10 AM, she stated she was not sure if the physician had followed up with the resident's neurologist regarding the resident's medications. She stated she documented on the physician communication folder twice to follow up with the neurologist as the Ombudsman had come to her to report the resident was questioning why she was not getting her medication. During an interview with the physician on 10/7/2016 at 11:45, he stated he did follow up with the resident's neurologist and the neurologist was on vacation. He stated he did not receive a call back and he thought the resident had been back to see the neurologist since then. 10NYCRR415.12(b)(1)(i)(ii)

Plan of Correction: ApprovedNovember 11, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F386- In the recent standard recertification survey it was determined the facility did not ensure the physician reviewed the residents total program including medications and treatments and signed and dated orders for 2 of the 24 residents. Resident #3 foley was not addressed in a timely manner and resident #19 neurologists recommendation was not addressed or implemented by the attending physician.
The following steps were taken:
1. Resident #3 currently does not have foley, foley removed 6/16/16
Resident #19-Practitioner reviewed the neurologist recommendations and ordered [MEDICATION NAME] for resident on 10/19/16.
Education was provided to the units nursing staff on the appropriateness of foley catheters.
Education was provided to nursing regarding the importance of documentation of physician follow up from consulting practitioner.
Education provided to physicians regarding the consultation follow up policy and the appropriate indications usage of foley catheters.
Date completed: 11/10/2016
2. An audit of all current residents with foley catheters was completed to ensure all residents have appropriate [DIAGNOSES REDACTED]. Corrective action taken.
Date completed: 11/10/2016
A random audit of 10 medical records were reviewed for outside consult recommendations, no discrepancies found.
Audits of medical records of residents were reviewed for timely follow up on outside consults. No discrepancies found.
Date completed: 11/10/2016
3. The facility reviewed and revised policies to include the appropriateness of a foley catheter, review of prevention of CA UTI?s, and a defined plan to remove of foley catheters, physician progress notes [REDACTED].
Education was provided to licensed and medical staff regarding the revisions to the policies.
Date completed: 11/10/2016
4. A daily audit will be maintained to ensure Physician follow upon consults are documented.
QM will conduct audits monthly x3 then quarterly thereafter to ensure compliance with physician progress notes [REDACTED].
Audit results will be reviewed monthly QA committee. The QA Committee will evaluate the results and adjust the frequency and context of audit as necessary. Beginning with the next QA meeting on (MONTH) 30, (YEAR) and ongoing. Date completed: Ongoing
Responsible Party: QMC

FF09 483.25:PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not provide the necessary care and services to maintain or attain the highest practicable physical well-being for 1 of 24 residents reviewed for quality of care (Resident #2). Specifically, Resident #2 had a change in the status of a leg wound and the treatment to promote healing of the wound was not addressed timely. Findings include: Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired. She had an impairment to one side of her lower extremities, and required extensive assistance for activities of daily living (ADLs). The MDS documented the resident did not have any pressure ulcers, wounds, or other skin problems. The comprehensive care plan (CCP) dated 9/26/2016 documented the resident had impaired skin integrity with a blister on her left outer ankle. The approach included a [MEDICATION NAME] (foam) dressing and no shoes until healed. A nursing progress note dated 9/26/2016 documented the resident had a blister with a dark center on her left outer ankle. A new physician order [REDACTED]. The resident was not to wear her left shoe and was to use a slipper sock only on her left foot. A nursing progress note dated 10/3/2016, and entered on 10/5/2016 at 1:48 PM, documented the resident's blister on her left outer heel was no longer intact and measured 1 centimeter (cm) x 1 cm with a pink wound bed. A new physician order [REDACTED]. A physician telephone order dated 10/5/2016 documented to apply [MEDICATION NAME] to the resident's left outer ankle, cover with a Band-Aid, and wrap with Kling (gauze) daily and as needed (prn) for 2 weeks. The resident was not to wear a shoe on her left foot. The order was not signed by the physician. The treatment administration record (TAR) documented to apply [MEDICATION NAME] on the resident's left outer ankle and cover with a Band-Aid, wrap with Kling, change daily and prn. The TAR documented the treatment was not initiated until 10/5/2016 during the 7 AM - 3 PM shift. An update to the resident's CCP dated 10/6/2016 documented the resident had an ulcer on her left outer ankle measuring 1 cm in diameter with a depth of 0.5 cm, the wound bed contained slough (moist dead tissue), and the surrounding skin was macerated (moisture-related softening). The physician was notified. During a treatment observation on 10/6/2016 at 9:50 AM with licensed practical nurse (LPN) #7, the resident had a wound located just below her left outer ankle. The wound measured approximately 1 cm in diameter. The wound bed was moist and contained yellow slough. The skin surrounding the wound was pink and red. During an interview with registered nurse (RN) Manager #8 on 10/7/2016 at 11:10 AM, she stated she re-assessed the resident's left ankle on 10/3/2016 and she did not know why the documentation and treatment were not done until 10/5/2016. 10NYCRR 415.12

Plan of Correction: ApprovedNovember 11, 2016

F309: In the recent standard recertification survey it was determined the facility did not provide the necessary care and services to provide the necessary care and services to maintain or attain the highest practicable physical well-being for 1 out of 24 residents reviewed for Quality of Care.
The following steps were taken:
1. Resident #2 wound was reviewed and evaluated to ensure appropriate treatment in place per MD order. The MD order obtained on 10/5/16 was signed on 10/06/2016.
Education was provided to nursing regarding the importance of the timeliness of obtaining wound dressing orders and transcription of MD orders to TARS.
Education provided to RN manager in obtaining wound dressing orders in a timely manner.
Date completed: (MONTH) 3, (YEAR).
2. Review of all current skin orders were audited to ensure the timeliness of MD wound dressing orders and treatments. Corrective action taken.
Date completed: (MONTH) 9, (YEAR).
3. The facility revised skin care policy to include all skin wounds are treated in a consistent and timely manner.
Education provided to all licensed staff in obtaining wound dressing orders in a timely manner.
Date completed: (MONTH) 18, (YEAR).
A daily skin treatment audit was initiated to ensure all changes in wounds are addressed with MD and change in treatment orders are obtained in a timely manner.
Date completed: Daily/Ongoing
4. QM will conduct monthly audits to ensure the timeliness and compliance with physician wound orders.
Audit results will be reviewed monthly QA committee. The QA Committee will evaluate the results and adjust the frequency and context of audit as necessary. Beginning with the next QA meeting on (MONTH) 30th, (YEAR) and ongoing. Date completed: 11/10/2016
Responsible Party(s): DON, ADON, QMC

FF09 483.25(c):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure care was provided that prevented residents from developing pressure ulcers and/or did not ensure residents with pressure ulcers received the treatment and services needed to promote healing and prevent infection for 1 of 3 residents (Resident #6) reviewed for pressure ulcers. Specifically, Resident #6, who required assistance with re-positioning, developed a pressure ulcer on her left hip, and a physician-ordered physical therapy consultation for positioning was not performed. Subsequently, Resident #6 developed a pressure ulcer on her right hip. This resulted in actual harm that is not immediate jeopardy to Resident #6. Findings include: The facility policy Skin Care, revised 5/2014 and dated 5/21/2015, documented that pressure ulcers most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People with a medical condition that limits their ability to change positions, requires them to use a wheelchair, or confines them to a bed for a long time are most at risk. Facility standards of care include to use a pressure-relieving cushion in a wheelchair, and educate resident/family on pressure-relieving techniques. Avoidable pressure ulcers means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standard of practice; monitor and evaluate the impact of the interventions; and revise the approaches as appropriate. Resident #6 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She required extensive assistance for bed mobility and transfers and limited assistance for walking. The resident used a walker and a wheelchair for mobility. She was at risk for the development of pressure ulcers, had a pressure reducing device for her chair and bed, and did not have any pressure ulcers. The comprehensive care plan dated 4/5/2016 documented the resident had a BIMS (Brief Interview for Mental Status) score of 14, showing little to no cognitive impairment. The resident had short term memory loss, but was able to make needs known. She needed extensive assistance with ADLs (activities of daily living) due to recent weakness, gait disturbance, and history of stroke. The resident required assist of 1 for turning and positioning at least every 2 hours in bed and in chair. A nursing progress note dated 5/20/2016 at 11:07 AM documented the nurse was informed by the certified nurse aide (CNA) that a quarter-size area was found on the resident's left hip and was bleeding. The physician and nursing supervisor were notified. A wound care nursing note dated 5/20/2016 at 12:45 PM documented the area on the resident's left hip measured 2 centimeters (cm) x 2 cm with a dark, red/maroon-colored partial thickness open area and a small circle of drainage on the dressing. The area was located directly over the left trochanter (hip bone). A nursing progress note dated 5/20/2016, and created 5/23/2016 at 5:21 AM, documented the physician and nurse observed the open area on the resident's left hip. The resident had a circular wound that was red/maroon in color. The resident was lying on her right side and the wound was convex with an open area at the peak. The open area measured 2 x 2 (no units of measurement documented) with the convex area measuring 5 x 5. Physician orders [REDACTED]. An assignment sheet (care instructions) dated 5/20/2016 documented the resident had a pressure ulcer and was to lie on her back and right side only and to keep off the left hip. A nursing progress note dated 5/21/2016 at 1:39 PM documented the physician was aware of the left hip area, and a new order was received for a physical therapy (PT) consult for positioning. A physician order [REDACTED]. A physician progress notes [REDACTED]. The area measured 2 cm x 2 cm with surrounding redness and induration (hardness). The plan was to continue with [MEDICATION NAME], consult PT for educating the resident on positioning, and have the resident lie on her right side and alternate to her back. A physician order [REDACTED]. There was no documentation the PT consultation ordered by the physician on 5/21/2016 for positioning, and on 5/22/2016 for ambulation with walker, was completed. The comprehensive care plan (CCP) dated 5/26/2016 documented the resident had a left hip area with dark brown eschar/scab (dry dead tissue). Approaches included to reposition the resident on her back and right side in bed, treatment per physician order, and pressure relieving cushion and mattress. A nursing progress note dated 7/16/2016 at 11:35 PM documented the resident was observed with an area on right hip. A deep tissue injury was noted, measuring 2 cm x 1 cm darkened area in center of reddened 4 cm x 3 cm, nonblanching. The resident was repositioned off her right side with pillows and cushions, and the physician and dietary were notified. An assignment sheet dated 7/16/2016 documented the resident was to lie on her back only and to keep her positioned off her right and left sides using pillows. The CCP dated 7/16/2016 documented a DTI on the right hip. Approaches included repositioning and evaluation and treatment by physician order. A wound care nursing progress note dated 7/18/2016 at 2:03 PM documented the left hip wound measured 1 cm x 0.7 cm and remained unstageable. The resident had a new circular deep tissue injury to the right hip measuring 2.5 cm with a purple/red center and a golf ball sized firm area. The wound care nurse documented she found the resident to be seated on a thin seat cushion and the wheelchair bars were felt when pressing on the cushion in the chair. The resident remained out of bed most of day and was positioned to the right side and back when in bed. The wound care nurse escorted the resident to occupational therapy (OT) and explained that a new DTI area had developed on the opposite hip and she felt the wheelchair crossbar under the seat may have been a contributing factor. The OT examined the chair and issued a new, thick cushion. The CCP documented on 7/18/2016 the resident received a new wheelchair cushion. A nursing progress note dated 7/19/2016 at 12:36 PM documented the nurse updated the physician about the resident's current skin condition. The nurse reviewed with him that staff were walking with the resident more, and they obtained a new wheelchair cushion and a new and better fitting wheelchair for her. An OT progress note dated 7/21/2016 documented a late entry for 7/19/2016. The resident had a new deep tissue injury and an alternate cushion for the wheelchair was issued and the resident reported it was comfortable. A wound care nurse progress note dated 8/1/2016 documented the staff reported the areas were not improving and the right hip was following the same progression as the left hip had. The staff reported the resident continued to sit tilted to the right side in her wheelchair and the resident did not recognize her altered positioning. The resident would frequently stand for short periods of time and would tire. There was no documentation the resident's positioning concerns were addressed. A nursing progress note dated 8/16/2016 at 2:20 PM documented both of the resident's hips were assessed. The left hip was essentially healed and the Santyl ([MEDICATION NAME] ointment) would be discontinued and [MEDICATION NAME] would be changed every 5 days and prn. The right hip remained necrotic (dead tissue) in the center. The resident was to have her mattress changed to Span America (alternating air mattress that distributes even pressure). Physician orders [REDACTED]. Lightly pack with 2 x 2 gauze, cover with 4 x 4 gauze and secure with Opsite (transparent, adhesive) dressing. Change daily, check every shift, change prn if dressing was saturated, and re-evaluate in 1 week. Physician orders [REDACTED]. A physician progress notes [REDACTED]. It is quite deep and appears to be tunneling. The plan was to refer to the wound care clinic. The resident was seen at the wound care clinic on 9/20/2016. The wound care physician documented the resident had a Stage III (full thickness skin loss) pressure ulcer on the right hip that was debrided (dead tissue removed). The recommendation was to position the resident to off-load the right hip. Physician orders [REDACTED]. The new treatment was to cleanse and dry the wound, apply [MEDICATION NAME] Ag (antimicrobial dressing) or similar product, loosely pack into wound, cover with a 4 x 4 and Opsite, and change every other day and prn if wet. The orders documented to turn and position off the area every 2 hours and to position to off-load the right hip. An assignment sheet dated 9/23/2016 documented to offload right hip when the resident was in bed and in the chair. The resident was seen at the wound care clinic on 10/4/2016. The wound care physician documented the Stage III pressure area on the right hip was debrided. Recommendations included a [MEDICATION NAME] border dressing and positioning on the left side to off load the right hip while in bed or a recliner. Physician orders [REDACTED]. Cleanse the right hip wound with NS, pat dry, pack with [MEDICATION NAME] Ag, cover with [MEDICATION NAME], and change every other day for 2 weeks. On 10/6/2016 at 10:02 AM, the right hip wound was observed during a dressing change with licensed practical nurse (LPN) #1. LPN #1 stated the resident had a bar on her old wheelchair they were not aware of, which may have been pressing against the resident's hips. She did not know when the resident's wheelchair had been changed. She stated the resident had always had a cushion in her wheelchair. She stated the resident was able to transfer herself and participated in the Walk to Dine program. She stated the resident preferred to lie on her right side and required frequent reminders to stay off that side. Registered nurse (RN) Unit Manager #2 was interviewed on 10/7/2016 at 8:45 AM. She stated that when an area of skin breakdown occurred on the resident's right hip, after one had previously occurred on the left hip, they had determined the pressure areas were likely caused by bars on the resident's wheelchair. The first wheelchair cushion had been too thin and the bar was felt through the cushion. A new cushion was obtained, as well as a new wheelchair, after the area developed on the right hip in 7/2016. Wound Care RN #3 was interviewed on 10/7/2016 at 9:10 AM. She stated initially in 5/2016 they thought the area on the left hip was an abscess. The resident was sent for a test, and the area was deemed a pressure ulcer and was located on the left trochanter (hip bone). She had recommended a PT consult for positioning and did not know why it had not been done. She stated the resident developed an identical area on the right side in 7/2016. She stated since the area on the left hip began to heal, she did not feel a more in-depth investigation was needed and the plans which were in place were working. She stated when the area on the right side developed, she determined the crossbar in the wheelchair seat was pressing on the cushion causing pressure, and immediately got a new cushion and wheelchair for the resident. During an interview with PT #4 on 10/7/2016 at 9:35 AM, she stated she had never done a positioning evaluation for the resident, and OT would have done one. She stated the resident had been on a restorative PT program until 4/2016, and was currently receiving maintenance therapy every Monday. During an interview with OT #5 on 10/7/2016 10:15 AM, she stated she had spoken with the wound care nurse regarding the resident's pressure ulcer on her right hip. They had thought it may have been caused by the bar on the wheelchair and the cushion was bottoming out. When the second area developed on the right hip, they determined the chair was not padded correctly. A thicker cushion and a new wheelchair were issued. The physician was interviewed on 10/7/2016 at 11:45 AM. He stated when the first pressure area developed on the resident's left side, he ordered a CT (computed tomography) scan to determine what type of injury it was. He stated it was deep tissue injury and was not sure what could have caused it. He stated he ordered a (physical) therapy consult for movement. He stated when the second area developed on the right side, it was determined it was likely caused by the wheelchair. 10NYCRR 415.12(c)(1-2)

Plan of Correction: ApprovedNovember 11, 2016

F314: In the recent standard recertification survey, it was determined the facility did not ensure care was provided that prevented residents from developing pressure ulcers and/or did not ensure residents with pressure ulcers received the treatment and services needed to promote healing and prevent infection for 1 of 3 residents.
The following steps were taken:
1. Resident #6 skin risk assessment was reassessed to determine residents risk for skin breakdown, and appropriate therapy evaluations of resident?s mobility and the suitability of her wheelchair and cushion. Based upon the PT/OT evaluation, individualized interventions were careplanned for resident to promote healing and prevent further skin breakdown.
Date completed: (MONTH) 9, (YEAR).
2. Education was provided to PT/OT regarding their referrals, evaluations and the applicable documentation required for follow up for resident?s referrals.
An audit of all current residents in the facility with pressure ulcers were audited to ensure appropriate and timely PT/OT documentation regarding positioning and mobility is current. No corrective action taken.
Date completed: (MONTH) 9, (YEAR).
3. The facility revised the Skin Care and Therapy Evaluation policies to include the team?s responsibilities in preventing pressure ulcers. This includes the timeliness of therapy evaluations for mobility, positioning and appropriate cushions for the prevention of pressure ulcers.
Education provided to all licensed staff in the responsibilities in preventing pressure ulcers.
Date completed: (MONTH) 18, (YEAR).
4. A daily audit was initiated to ensure all MD orders for PT consults are addressed in a timely manner as per policy.
QM will conduct audits monthly to ensure compliance with PT referrals, documentation of evaluations and individual interventions in the medical record.
5. Audit results will be reviewed monthly QA committee. The QA Committee will evaluate the results and adjust the frequency and context of audit as necessary. Beginning with the next QA meeting on (MONTH) 30th, (YEAR) and ongoing. Date completed: 11/10/2016
Responsible Party(s): DON, ADON, QMC

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: October 7, 2016
Corrected date: December 1, 2016

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 7 exits were readily accessible at all times (the Central Dining Room emergency exit). Specifically, the Central Dining Room emergency exit door did not open when the panic bar was pushed. Findings include: On 10/5/2016 at 10:57 AM, a surveyor in the Central Dining Room observed an emergency exit door that did not release when the panic bar was pushed. The surveyor observed the panic bar was not United Laboratories (UL) listed as required. When the facility entered the electronic code to bypass the magnetic door sensor, the door opened. When interviewed on 10/6/2016 at 11:40 AM, the Maintenance Supervisor stated the facility's emergency exit doors are checked on a regular basis and there was no official documentation that it was done. He stated the other emergency exit door in the Central Dining Room is usually checked. He verified the panic bar did not have any UL listed documentation on it. 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 11, 2016

KO38
1) Door repaired by vendor on 10/11/16. Door operating as intended.
a. Panic bar to be replaced with UL listed panic bar by 12/1/16.
2) Doors with panic bars throughout building were inspected to insure they were operating appropriately on 10/19 during ECF Environmental Rounding by Maintenance/Housekeeping and Administration.
3) Doors will be checked as part of a scheduled event by Maintenance on a bi-monthly basis.
4) Results of the Scheduled event door Inspection will be reported at ECF QA Committee and reviewed for further action on a monthly basis for 3 months and a quarterly basis thereafter.
a. Employees will be educated by 11/23/16 of process changes.
5) Date of Completion: 12/1/16, Responsible party: Director of Plant Operations.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not ensure corridor doors were maintained to resist the passage of smoke for one isolated door (physical therapy room door). Specifically, the door to the physical therapy room was held open by an unapproved hold open device. Findings include: On 10/4/2016 at 1:00 PM, a surveyor observed the door to the physical therapy room was being held open with a wooden chock. On 10/5/2016 at 8:55 AM, a surveyor observed the door to the physical therapy room was being held open with a wooden chock. When interviewed on 10/6/2016 at 11:39 AM, the Maintenance Supervisor stated he was not aware of the physical therapy room door being held open with an unapproved device or that the magnetic hold open device was not working. He stated the last service call work order for the door was dated 4/16/2013, and he provided a copy of the work order to the surveyor. When interviewed on 10/6/2016 at 12:25 PM, the Physical Therapy Director stated the magnetic door hold open device had not been working for approximately a year, and she thought another service call work order was submitted. She stated the maintenance staff gave her the wooden chock to use until the door hold open device was repaired. 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 11, 2016

KO18
1) Chock was removed from PT door and door opener magnet added 10/6/16
2) Building checked for other hold open devices on 10/7/16.
3) Environment of Care Monthly Inspection process revised to include hold open door devices as an item of inspection on the Environment of Care Rounds Sheet. From this rounding, if such usage is identified, a work order will be generated to resolve issue.
4) Results of the Monthly Environment of Care Inspection will be reported at ECF QA Committee on a monthly basis for 3 months and on a quarterly basis thereafter and reviewed for further action. Audit will be completed on a monthly basis for 3 months and a quarterly basis thereafter.
a) Employees will be educated by
11/23/16 of process changes.
5) Date of Completion: 11/23/16, Responsible party: Director of Plant Operations.

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: October 7, 2016
Corrected date: November 23, 2016

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not maintain one hour fire rated walls for 2 of 10 hazardous areas observe (the services unpacking/assembly room, and the generator room). Specifically, the services unpacking/assembly room and the generator room had unsealed penetrations, and the double doors to the services unpacking/assembly room had unapproved hold open devices. Findings include: 1) Unsealed Penetrations On 10/5/2016 between 11:26 AM and 11:40 AM, a surveyor observed: - the 45 minute hour fire rated door to the services unpacking/assembly room had an unsealed hole in it; and - the generator room had a 2 inch conduit passing through a wall and the outside annular space around this conduit was not sealed. There were two unsealed data wires running through the unsealed gap. 2) Unapproved Hold Open Devices On 10/5/2016 at 11:26 AM, a surveyor observed both doors to the services unpacking/assembly room had metal door kick stops installed on them, which were unapproved door hold open devices. When interviewed on 10//2016 at 3:50 PM, the Plant Operations Manager stated he was not aware of the unsealed penetrations in the services unpacking/assembly room and the generator room. 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 16, 2016

KO29 #1
1) Penetration holes were repaired/filled with *approved fire rated materials on 10/5/16 for all areas identified during survey.
2) Building was inspected by Maintenance on 10/4/, 10/5/, 10/6, 10/12/16 to assure all potential smoke penetrations had been identified and repaired.
3) Inspection of at risk penetration areas (i.e. Electrical rooms, smoke Doors/walls and basement) (Penetration Risk Inspection) have been added into as a quarterly inspection into the facility Maintenance Software. This scheduled ?planned event? will be completed on 10/12 and be ongoing thereafter.
a. Policy is being revised to reflect
changes to process. Completed 11//21/16
4) Findings from Penetration Risk Inspection
will be reported on at both the facility Safety Committee and ECF QA Committee Meetings and reviewed for further action. Audit will be completed on a monthly basis for 3 months and a quarterly basis thereafter.
a. Employees will be educated by 11/23/16 of process changes.
5) Date of Completion: 11/23/16, Ongoing Responsible party: Director of Plant Operations.
KO29 #2
1) Hold open devices removed and door repaired on 10/5/16.
2) Building checked for other hold open devices on 10/7/16.
3) Environment of Care Monthly Inspection process revised to include hold open door devices as an item of inspection on the Environment of Care Rounds Sheet.
a. From this rounding, if such issues are identified a work order will be generated to resolve issue.
4) Results of the Monthly Environment of Care Inspection will be reported at ECF QA Committee reviewed for further action. Audit will be completed on a monthly basis for 3 months and a quarterly basis thereafter.
a. Employees will be educated by 11/23/16 of process changes.
5) Date of Completion: 11/23/16, Responsible party: Director of Plant Operations.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. 8.3, 19.3.7.3, 19.3.7.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not maintain the fire rating for 3 of 8 smoke barrier walls observed (the first floor west corridor, the fourth floor north corridor, and the fourth floor east corridor). Specifically, three smoke barrier walls had unsealed penetrations. Findings include: On 10/5/2016 between 2:37 PM and 3:00 PM, a surveyor observed: - the first floor west corridor smoke barrier had a 1/2 inch unsealed hole with five data wires passing through it. The outside annular space of a 1/2 inch conduit passing through the wall was not sealed; - the fourth floor north corridor smoke barrier had a 2 inch hole with a 1 1/2 inch pipe passing through it, and the outside annular space around the pipe was not sealed; and - the fourth floor east corridor smoke barrier had a 3/4 inch hole with a 1/2 inch pipe passing through it, and the outside annular space around the pipe was not sealed. Additionally, there was an unsealed data wire penetration. When interviewed on 10/5/2016 at 3:15 PM, the Plant Operations Director stated he was not aware of any penetrations within the smoke barriers of the facility. 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 16, 2016

KO25
1) Penetration holes were repaired/filled with *approved fire rated materials on 10/5/16 for all areas identified during survey.
2) Building was inspected by Maintenance on 10/4/, 10/5/, 10/6, 10/12/16 to assure all potential smoke penetrations had been identified and repaired.
3) Inspection of at risk penetration areas (i.e. Electrical rooms, smoke Doors/walls and basement) (Penetration Risk Inspection) have been added into as a quarterly inspection into the facility Maintenance Software. This scheduled ?planned event? will be completed on 10/12/16 and be ongoing thereafter.
a. Policy is being revised to reflect
changes to process. Completed 11//21/16
4) Findings from Penetration Risk Inspection
will be reported both at the facility Safety Committee and ECF QA Committee Meetings and reviewed for further action. Audit will be completed on a monthly basis for 3 months and a quarterly basis thereafter.
a. Employees will be educated by 11/18/16 of process changes.
5) Date of Completion: 11/21/16, Ongoing Responsible party: Director of Plant Operations.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5, 8.2.5.6, 19.3.1.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 23, 2016

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not ensure vertical openings between floors were enclosed with construction to provide a one-hour fire resistance rating for 5 of 5 floors (first floor, second floor, third floor, fourth floor, and fifth floor). Specifically, the west wing of each floor had an unsealed vertical penetration. Findings include: On 10/4/2016 between 12:15 PM and 12:23 PM, a surveyor in the fifth floor west wing electrical room observed an unsealed vertical data wire penetration within a 3 inch conduit. Upon further observation, a surveyor observed this conduit ran vertically down to the first floor west wing electrical room. Unsealed vertical data wire penetrations were also observed in the west wing electrical rooms on floors one through four. When interviewed on 10/4/2016 at 12:23 PM, the Plant Operations Director stated he was not aware of the unsealed vertical data wire penetration in the facility's west wing electrical rooms. He stated the data wires observed were related to a cable provider upgrade and he did not know when the wires were installed. On 10/5/2016 at 10:30 AM, a surveyor reviewed a Pre-Construction Safety Agreement with a communications company. Section 6-7 stated All penetrations performed for purposes of running wiring or cabling will be sealed utilizing conduit and/or caulk, as appropriate. This agreement was signed by the contractor on 5/9/2016 and completed on 9/28/2016. On 10/5/2016 at 10:30 AM, Planned Event Work Order for the Semi-Annual Inspection of Fire and Smoke Walls completed on 7/28/2016 was reviewed. The remarks on this form documented inspect and repair all penetrations through fire and smoke walls with an approved United Laboratories (UL) fire and smoke stop product. 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedNovember 11, 2016

KO20
1) All vertical shaft Penetration holes were repaired/filled with approved smoke stop materials on 10/4/16 by contractors for all areas identified during survey. ECF Maintenance then inspected the contractors work and added more smoke stop material where needed.
2) Building was inspected by Maintenance on 10/4/, 10/5/, 10/6, 10/12/16 to assure all potential smoke penetrations had been identified and repaired.
3) Inspection of at risk penetration areas (i.e. Electrical rooms, smoke Doors/walls and basement) have been added into as a quarterly inspection (Penetration Risk Inspection) into the facility Maintenance Software. This scheduled ?planned event? will be completed on 11/12/16 and be ongoing thereafter.
a. Contractors will sign a pre-construction safety agreement, agreeing to reseal any disturbed smoke penetration areas.
b. During work completion, Oneida Healthcare Maintenance will inspect contractor work areas for compliance on a daily basis to assure that areas remain appropriately sealed.
c. Policy is being revised to reflect
changes to process. Completed by 11/23/16
4) Findings from Penetration Risk Inspection
will be reported on at both the facility Safety Committee and ECF QA Committee Meetings and reviewed for further action. Audit will be completed on a monthly basis for 3 months and a quarterly basis thereafter.
a. Employees will be educated by 11/18/16 of process changes.
5) Date of Completion: 11/23/16, Ongoing Responsible party: Director of Plant Operations.