United Helpers Nursing Home
December 21, 2016 Certification/complaint Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 2 of 25 residents (Residents #10 and 18) reviewed for activities of daily living (ADLs), the facility did not ensure the ability to perform ADLs did not diminish. Specifically, staff did not provide Residents #10 and 18 with proper positioning to facilitate independent eating. Findings include: 1) Resident #10 had [DIAGNOSES REDACTED]. The certified nurse aide (CNA) care plan (care instructions) updated 8/1/2016 documented the resident required set up and supervision for eating with physical assistance as needed (prn). The instructions documented the use of an inner lip plate (high wall keeps food from sliding off plate and can push food on utensil), and commuter cup for hot drinks. The resident was non-ambulatory, required a mechanical lift for transfers, and was in a scoot chair (low positioning chair that reduces fall risk and encourages user to self-propel with feet) when out of bed. The comprehensive care plan (CCP) revised 8/11/2016 documented the resident had dementia resulting in cognitive loss with a loss of the ability to complete ADLs independently. The goal was for the resident to maintain her current level of ADL participation. Fluids were to be encouraged to meet her needs and she was to be observed for changes in her ability and needs at meals, due to the progression of her disease. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, was non-ambulatory, and required extensive assistance with most ADLs, including eating. The CCP updated 11/1/2016 documented the resident was at risk for nutritional decline related to dementia, advanced age, and multiple medical concerns. The interventions included providing an inner lip plate and commuter cups for hot beverages and staff encouragement. A dietary quarterly review note dated 11/11/2016 documented the resident remained at risk for nutritional decline related to dementia, advanced age, and multiple medical concerns. The resident was on a dental soft diet with medium portions and utilized an inner lip plate and commuter cups for hot beverages to help with self feeding. The resident's intake was documented as fair for both foods and fluids. During an observation on 12/19/2016 at 12:24 PM, the resident was observed in the dining room seated in a scoot chair low to the table (chest to chin height). The blue lip plate was placed in front of her by an unidentified CNA. The CNA brought the chair closer to the table, gave the resident one spoonful of food, encouraged her to eat, and left the table. The resident closed her eyes and did not attempt to feed herself. At 12:26 PM, registered nurse (RN) #21 observed the resident not eating and requested CNA #22 assist her. At 12:45 PM, the CNA was continuing to assist the resident by feeding her. On 12/19/2016 at 5:20 PM, the Director of Nursing (DON) was observed sitting next to the resident and feeding her. The resident was in the scoot chair, at chest level to the table. At 5:35 PM, a CNA was observed seated at the table assisting the resident. At 5:47 PM, the DON sat down to assist the resident with her dessert. The meal consumption and fluid intake record for 12/1-12/18/2016 documented the resident refused 1 to 2 meals a day for 16 of 19 days, refused 2 meals a day for 7 of the days, and refused all 3 meals on 1 of the 19 days. The meal consumption and fluid intake record for 12/19/2016 documented the resident ate 50% of her breakfast, lunch, and supper. She drank a total of 28 ounces for the 3 meals. During an interview with occupational therapist (OT) #25 on 12/21/2016 at 12:10 PM, she stated the resident usually fed herself and said if the resident was at a lowered tabled or in a different chair, the resident might do better feeding herself. She said there was a lower table in the unit dining room where other residents were receiving assistance. 2) Resident #18 had [DIAGNOSES REDACTED]. Nursing progress notes dated between 9/16-9/21/2016 documented the resident's assistance with eating varied from feeding herself, needing verbal cuing, needing staff encouragement, and at times needed some feeding assistance. The nutrition assessment dated [DATE] documented observation of meals revealed the resident required staff encouragement and assistance. The comprehensive care plan (CCP) revised 9/28/2016 documented the resident had dementia with memory loss, resulting in a loss of her ability to complete activities of daily living (ADLs) independently. The goal was for the resident to maintain her current level of participation and the plan included encouraging fluid intake, and observing for changes in her abilities and needs at meals due to the progression of her disease. The resident was documented to be at risk for nutritional decline related to dementia and required assistance/encouragement with meals. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive assistance with all ADLs. A dietary progress note dated 11/1/2016 documented the resident needed staff assistance/encouragement at meal time. The note did not specify the amount of assistance needed. An interdisciplinary team quarterly note dated 11/7/2016 and referencing the MDS dated [DATE] documented the resident required staff assistance/encouragement with meals. The note documented the resident had two falls without injury and one fall with a minor injury since the previous assessment of 9/23/2016. A nursing progress note dated 11/11/2016 documented the resident was going to be trialed using a scoot chair (low positioning chair that reduces fall risk and encourages user to self-propel with feet) due to leaning over and poor positioning in a wheelchair. The certified nurse aide (CNA) care plan (care instructions) reviewed 12/14/2016 documented the resident utilized a scoot chair and required physical assistance and encouragement as needed for eating. The CNA documentation of the amount of assistance needed for eating from 12/1-12/22/2016 recorded the resident varied from needing limited assistance to requiring total assistance. The meal consumption and fluid intake record for 12/1-12/22/2016 documented the resident ate 25-50% of most meals. During an interview on 12/19/2016 at 11:30 AM with the Director of Nursing (DON) who was the acting Unit Manager, when asked what residents required feeding assistance, the resident's name was not provided as a resident needing total assistance for eating. On 12/19/2016, the resident was observed at 12:11 PM seated in a scoot chair low to the table, between chest and chin height. The resident was being fed by activity aide #29. As of 12:45 PM, the resident's intake was minimal with continued encouragement and assistance from the aide. On 12/20/2016, the CNA care instructions were updated to document the resident was totally dependent for eating. During an interview with occupational therapist (OT) #25 on 12/21/2016 at 12:10 PM, she stated if the resident was at a lowered table, she definitely may benefit regarding positioning for eating. She stated there was a lower table in the dining room being used by other residents and she would need to look at whether or not all the residents at that table benefited from the lower table. She did not think the resident was easily transferred to a regular dining chair and was concerned the dining chair would be a restraint. 10NYCRR 415.12(a)(1)(iv)

Plan of Correction: ApprovedMarch 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #10 had scoot chair raised for proper positioning at the table. A PT/OT evaluation will be completed to assess positioning at the table, ability to feed self at meals, and interventions for resident/staff to utilize at meals. Resident's care plan has been updated to reflect that she is able to feed self but at times will fall asleep or refuse meals. If resident is not assisting self, staff will sit with resident and assist/encourage her meals. IDT to review resident intake weekly to discuss refusals, level of participation, and staff assistance with feeding. The seat of Resident #10 scoot chair was raised to the highest position and adjusted to a more upright position. This change resulted in an approximate four inches increase in height to ensure proper positioning while at the table.
Resident #18 had scoot chair raised for proper positioning at the table. A PT/OT evaluation will be completed to assess positioning at the table, ability to feed self at meals, and interventions for resident/staff to utilize at meals. The seat of Resident #18 scoot chair was raised to the highest position and adjusted to a more upright position. This change resulted in an approximate four inches increase in height to ensure proper positioning while at the table.

2. How you identify other residents having the potential to be affected by the same deficient practice:
All residents who utilize a scoot chair during meals could potentially be affected.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All Residents who currently utilize a scoot chair will have a PT/OT evaluation to assess positioning at the table, ability to feed self at meals, and interventions for resident/staff to utilize at meals. Any resident who will be considered for a scoot chair will have a PT/OT evaluation prior to implementation.
All recommendations from the PT/OT evaluations will be reviewed by the IDT and interventions will be reflected in the resident's care plan.
Education will be completed to all nursing and rehabilitation staff that a scoot chair cannot be initiated without a proper PT/OT evaluation. No other Residents were identified.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
All residents who utilize a scoot chair will be monitored to ensure that a PT/OT evaluation was completed and they will be monitored to ensure that proper interventions are in place and successful. A audit tool has been developed to ensure that all criteria will be met.
This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the unit managers. The sample will include all residents utilizing scoot chairs. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5. Responsible Party: Director of Nursing or Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure food was stored, prepared, and served under sanitary conditions for the main kitchen and 1 of 5 unit kitchenettes (Knapp Unit). Specifically, the ice machine was unclean; and staff facial hair was not properly restrained. Findings include: 1) Unclean Equipment On 12/19/2016, between 11:20 AM and 11:37 AM, a surveyor observed the ice dispenser ice chute in the main kitchen had visible black material inside it. During an interview on 12/19/2016 at 11:37 AM, the Food Service Manager stated the ice dispenser was cleaned monthly by dietary staff, and maintenance staff changed the filters as needed. She also stated this ice dispenser would be used if someone wanted a glass of ice water, and added, We'll clean that out before it is used again. 2) Hair Not Restrained On 12/19/2016, between 11:20 AM and 11:37 AM, a surveyor in the kitchen observed multiple dietary staff members had facial hair and were working in the kitchen without a beard restraint. On 12/19/2016 at 5:35 PM, a surveyor in the(NAME)Unit kitchenette observed a food server at the hot service line that had a full goatee and it was not restrained. On 12/22/2016 at 5:15 PM, a surveyor in the(NAME)Unit kitchenette observed a food server at the hot service line that had a full beard and it was not restrained. During an interview on 12/22/2016 at 5:45 PM, the Food Service Manager stated: -(NAME)and hair nets were available for staff and located on the kitchen door. - A hair net or cap was required behind the line. - A beard net was required when at the serving line. - When bussing dirty tables or in the dishroom, no restraints were required. - A cook making or prepping food was required to have a beard restraint. - Kitchen staff were trained annually on facility policies and procedures. 10NYCRR 415.14(h)

Plan of Correction: ApprovedMarch 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
The ice dispenser was cleaned and the food service employees donned beard nets at the time of survey.
2. How you identify other residents having the potential to be affected by the same deficient practice:
All ice dispensers were evaluated for cleanliness. All food service employees with facial hair have the potential for the same deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
The cleaning schedules for ice dispensers has been reviewed. The food service department dress code has been reviewed and food service staff education has been provided on the process and schedule for cleaning ice dispensers and expectations for the use of beard nets.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the director of food service or supervisor. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5. Responsible Party: Director of Food Service

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

REGULATION: WAIVER-RN 8 HRS 7 DAYS/WK, FULL-TIME DON

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey, it was determined for 4 of 25 residents (Residents #3, 12, 14 and 15) and one additional resident (Resident #26), the facility did not ensure each resident received adequate supervision and assistance to prevent accidents, and did not ensure the environment remained as free from accident hazards as possible. Specifically, Resident #3's foot pedals on her wheelchair were not identified as a hazard (fall risk) when the resident attempted to get up out of her chair. For Resident #14, who was on a prescribed fluid restriction and thickened liquid diet, the resident was not adequately supervised and a plan was not implemented to reduce the risk of accidents (potential for fluid overload and choking), as the resident consumed fluids not thickened and exceeding her fluid restriction. For Residents #12, 15 and 26, no plan was developed to maintain the residents' safety: when the residents were found with smoking materials, were found unsupervised in unsafe areas outside, and no receptacles were provided to safely dispose of their discarded smoking materials. Findings include: Lack of Supervision to Prevent Accidents and Unsafe Smoking. 1) Resident #12 had [DIAGNOSES REDACTED]. A 10/6/2015 behavior plan documented by social services, the resident had expressed she wanted to quit smoking and in an effort to help her, the following steps were to be taken: - Visitors were to be explained the resident could go for a walk and not to offer her a cigarette. - If the resident was found smoking she would be transferred to another facility. - She was not to be taken on the highway for a walk. - On dialysis days, Monday, Wednesday and Fridays the charge nurse would make sure transport staff were aware of this plan and the physician would be made aware. - If there were any concerns with the plan, the social worker or nurse manager were to be notified. A 5/19/2016 physician progress notes [REDACTED]. The 7/28/2016 Minimum Data Set (MDS) assessment documented the resident was cognitively intact; the resident required supervision with locomotion off the unit, extensive assistance for most activities of daily living (ADLs); and used a walker and wheelchair for mobility devices. The 7/30/2016 comprehensive care plan (CCP) documented the resident was at risk to fall, had impaired mobility related to a history of a hip fracture, leg pain and osteoarthritis. The resident had a history of [REDACTED]. The resident made the decision to quit smoking and nursing was to help her. The resident was to be provided with activities to keep her busy, and staff were to allow her to express issues or concerns with the smoking plan. The CCP documented It is believed that this resident probably continues to smoke. Nursing progress notes documented: - On 8/19/2016 and 9/16/2016, the resident was propelling herself in the hallway and around the floor and off the floor. - On 9/30/2016 at 3:38 PM, the resident on several occasions in the last 2 weeks had been reminded that it was a non smoking campus. She had been observed outside smoking cigarettes with another resident. Again this date she was observed outside smoking and the registered nurse (RN) approached her to ask that she refrain from smoking as smoking was not allowed on the campus. The nurse documented the resident had recently been given a flag for her wheelchair so she could go outside to ride around in her wheelchair. - On 10/27/2016, the resident was noted to be outside smoking cigarettes last week. The RN re-educated her about the no smoking policy and asked her for her cigarettes and lighter. The resident agreed to give them to the RN and gave her a large round bundle of cigarettes, a partial pack of cigarettes and a lighter. The RN stated if she needed anything to help her quit smoking, she would help her. On 10/24/2016 she found the resident had cigarettes and refused to give them to the RN when requested. The RN was informed today the resident was outside smoking again and was educated by the person who found her. The resident was educated on the no smoking policy and was asked for her cigarettes. The resident gave her the bag and the RN removed the cigarettes and the lighter. When the resident stated the nicotine patch did not work, the RN said she needed to give it a good attempt and told her she should not smoke with the patch as it could make her sick. The resident stated she would try it and the nurse documented she would send this information to dialysis with the resident in the morning. A 10/28/2016 update to the CCP documented nicotine patches were obtained to assist her with not smoking. The 10/29/2016 medication administration record (MAR) documented a Nicoderm patch was to be applied for 28 days and if the resident was observed smoking D Capsule (remove) patch immediately. An 11/1/2016 social service progress note documented the resident was trying to quit smoking again and the social worker assured her that she was there if she needed assistance with anything. An 11/2/2016 update to the CCP documented the resident was using the nicotine patch and had been educated regarding the facility policy for smoking on the premises. There was no further documentation of changes to the resident's care plan to address smoking and leaving facility premises. The MAR documented on 11/5/2016 the resident refused the Nicoderm patch and no reason was documented. An 11/9/2016 physician order [REDACTED]. If the resident was observed smoking to remove the patch immediately. An 11/12/2016 physician progress notes [REDACTED]. The MAR documented on 11/13/2016 the resident refused the Nicoderm patch and did not answer when asked if she had a cigarette today. The MAR documented the Nicoderm patch was ordered through 12/8/2016. The MAR documented the resident refused the patch on 11/24, 11/27, 11/29 and 11/30/2016 with no reason documented. A 12/14/2016 nursing progress note documented the resident was waiting for the dialysis driver to come to the floor for transport. When the nurses were busy, the resident left the floor and the nurse went down and reminded her she was not to leave until the driver came to the floor. The resident stated she did not care and would not return to the floor. The certified nurse aide (CNA) care plan (care instructions) initiated in 2014 and updated through 12/16/2016 by unknown staff, did not document any concerns regarding the resident smoking/leaving the floor. The resident's ambulation status changed from using a 2 wheeled walker to a 4 wheeled walker on 10/19/2016. The resident continued to use a wheelchair. There was conflicting information as to when the resident used a wheeled walker and when she utilized a wheelchair. The resident was observed eating her meal at the dining table on her unit on 12/19/2016 from 5:30 PM - 5:50 PM. At 5:51 PM, the resident wheeled herself in a manual wheelchair out of the dining room. On 12/20/2016 at 8:30 AM and 8:45 AM, the resident was not in her room or in the unit common areas. At 8:51 AM, the resident wheeled from the activity room on the unit, passed the elevators to her room. At 11:45 AM, the resident was wheeling herself out of her room and talking to a nurse. At 12:20 PM, she was seated in the dining room. At 1:02 PM and 1:20 PM she was not observed on the unit or in her room. On 12/21/2016 at 8:40 AM, the surveyor requested a facility smoking policy. The Administrator notified the surveyor at 9:10 AM the facility did not have a smoking policy. He stated information pertaining to the campus being non smoking was in the packet provided to residents and families at admission. During interviews with certified nurse aides (CNAs) #12, 14 and 15 and licensed practical nurse (LPN) #13 on 12/21/2016 from 4 PM through 4:51 PM, they stated: - The resident often went outside and did not say why she was going out; - When the resident stated she wanted to smoke, she was educated it was a non smoking campus, she was encouraged not to smoke, and the charge nurse was notified. - The resident was sometimes seen in the parking lot and had an orange flag on her chair so she could be seen. - The LPN stated she did not say anything to the resident when she saw her smoking in the parking lot as she did not want her smoking rights taken away. - The resident had tried the nicotine patch and it did not work probably because she was still smoking. - Staff saw her at the elevator with her jacket on and, if asked where she was going, stated she was going outside. - CNA #15 said the resident asker her to get her the flag from her room and put it on her chair. The CNA believed it was used as a reflector and said when she started working on the unit,she was not told the resident had a history of [REDACTED]. During an interview with RN Manager #16 on 12/21/2016 at 5:00 PM, she stated she was not told directly the resident was smoking and she heard it in passing from the dialysis transport driver. She stated she had asked the resident if she had any cigarettes and educated her that it was a non smoking facility. The resident did not say how she was obtaining the cigarettes and lighter. If staff saw the resident smoking it was to be immediately reported to the Supervisor, Charge nurse, or to her. She stated the resident did leave the unit on her own to sit outside, and she sometimes wheeled around the parking lot. The resident had an orange flag in place since 7/2016 for her chair so she was able to wheel through the parking lot. The RN said the staff did not go look for the resident to provide care, and would wait until they saw her back on the unit to offer her care. During an interview with Receptionist #17 on 12/21/2016 at 5:11 PM, she stated she worked: one weekday evening and on weekends, and saw the resident whenever she worked. The resident sometimes stayed seated at the reception area to chat and sometimes went outside. She said she was bundling up when she went outside, and did not have a winter jacket. The receptionist stated the resident was going out in the cold weather, and another staff member recently provided her with a jacket. The receptionist stated the resident at times left the patio area, did not say where she was going, and she could not see her from the reception desk when off the patio. She stated she knew the resident sometimes went to the middle of the parking lot and went along the side of the building in the parking lot as the resident would tell her this when she got back. She stated the resident used to smoke months ago and she smelled of smoke when she came back in the building. The resident told her she smoked while she was at dialysis. She stated the resident had a flag on her chair and she used to go outside to smoke with Resident #15. During an interview with the resident on 12/21/2016 at 5:50 PM, she stated she had not been notified prior to this date that she could not go outside or that she needed to notify staff before going outside. She stated she smoked at dialysis and informed the surveyor where she obtained the cigarettes and lighter at dialysis. The resident said she went outside the nursing facility to sit on the porch or the patio, and did go down the ramp that lead off the porch, and wheeled herself backwards up the ramp in order to get back to the porch. The resident stated she went through the parking lot, along the side of the building, around the building, and around a circular area outside of the entrance to the facility. She stated she watched for cars and there were sometimes cars parked against the building and she would have to go around them. She stated she had a flag on her chair for when she went outside. She said she did not mind the cold. There sometimes was slush in the parking lot, and if the weather was real bad she stayed on the sidewalk, and only stayed outside about 20 minutes. During the interview the resident showed the surveyor her flag leaning against the wall in her room and not attached to her chair. The flag was orange in color, triangular in shape, and on a 4 foot long pole one inch in diameter. The triangle measured 4 inches in height and 7 inches at its base. During a follow up interview with RN Manager #16 on 21/21/2106 at 6:35 PM, she stated she did not recall documenting about the resident smoking, or visualizing the resident smoking. She stated the resident had a zip up hoodie and last week started wearing a jacket that was given to her. She stated she did not investigate the incidents when the resident was found smoking. Receptionist #17 stated on 12/21/2016 at 6:53 PM, the resident had just been outside prior to the surveyor approaching the reception desk, and an administrative staff member went out to tell her to come back inside. During an interview with CNA #18 on 12/22/2016 at 7:55 AM, she stated the resident did not have a winter jacket until recently, and would wear a light weight spring jacket when she went out for dialysis. She stated the resident had asked her for a cigarette in the parking lot and said she would turn the CNA in if she did not give them to her. She stated she told the resident she could not and continued to her destination. During an interview with receptionist #19 on 12/22/2016 at 8:30 AM, he stated the resident would go outside on her own, and went out a couple of times last week. A staff member provided her with a winter jacket as she did not go out with a jacket prior to that time. He stated sometimes the resident sat on the patio and sometimes went down the ramp and he did not know where she went after she went down the ramp. He stated the resident had a flag on her chair. The receptionist stated the resident used to go out with Resident #15, who was no longer at the facility. He stated when they would return the resident smelled of cigarette smoke. He stated the resident continued to go outside and he had not smelled cigarette smoke lately. During an interview with employee #20 on 12/22/2016 at 9:34 AM, he stated he would view the resident getting on to the transport van for dialysis wearing a zip up hoodie with no jacket. He stated when he asked the resident if she had a jacket she told him she outgrew it. After asking the resident if he could bring her a jacket, he brought one in within the past two weeks. Employee #20 stated he would see the resident smoking near an awning located across the parking lot. He stated the resident out there even on days of cold temperature and inclement weather. A flag was on the chair and he would tell her it was not safe to be in the parking lot. The resident would ask him for a cigarette and he would tell her not to smoke. He stated he did not personally see her smoke. He knew she had been caught smoking on the campus by a nurse as the nurse notified him to keep an eye out in the parking lot to see if she was smoking. He stated the resident had a history of [REDACTED]. When attending physician #32 was interviewed on 12/22/2016 at 3:20 PM, he stated the resident was non compliant and non directable and people keep her in tobacco. He had not seen her smoking at the facility and frequently observed her smoking when outside the dialysis center, waiting for her transportation. The physician stated he was not previously aware she was out at night and said she was all over the place. The resident did not have reflectors on her wheelchair and going out at night was a recipe for disaster and she should only be out in day light hours. During an interview with RN Supervisor #21 on 12/23/2016 at 9:46 AM, she stated the resident went off the unit, downstairs, and outside during the day and evening shift. She stated she was not aware of the resident going outside or smoking in the cold/inclement weather. She stated if the resident was caught smoking, her nicotine patch was supposed to be removed and nursing staff should have notified her. Lack of Supervision to Prevent Potential Hazards and Unsafe Smoking. 2) Resident #15 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact, she required extensive assistance for bathing and personal hygiene and she had an impairment on one side of the upper extremity. The MDS documented the resident used tobacco. The certified nurse aide (CNA) care plan (care instructions) updated on 6/20/2016 documented the resident required distant supervision with walker for transfers. The comprehensive care plan (CCP) dated 6/21/2016 documented the resident was at risk to fall, and the resident and family were to be involved with decision making. Interventions included: preferences and resident rights were to be upheld and the resident and family were to be educated on safety needs. Nursing progress notes documented: - On 6/30/2016, cigarettes were confiscated from the resident's room and she was educated on the non-smoking policy. - On 7/3/2016, the resident was found to be going outside to smoke, she was educated on the non-smoking policy and the resident dismissed this information. - On 7/5/2016, the resident was observed out in the parking lot smoking and the cigarettes were given to a family member. An update to the CCP on 7/5/2016 documented the resident was provided education upon admission to the facility regarding the non-smoking policy. On two occasions cigarettes had been removed from the resident's room and she was re-educated. The resident was refusing smoking cessations and the nursing staff were to continue to educate the resident on the non-smoking policy. A nursing progress note dated 7/10/2016 at 1:55 AM documented the resident was found kneeling by the exit door. The resident stated she was placing a brick in the door so she would be able to get back in the building without asking for assistance and she was unable to get back up into the wheelchair. The resident was educated on maybe not going outside at this hour due to it being so dark out and safety may be a concern. Asocial work assistant progress note dated 7/11/2016 documented the resident and her family had been educated on the non-smoking policy and despite the education the resident continued to be found with cigarettes and was seen out in the parking lot smoking. The resident was unwilling to allow staff to search her purse for cigarettes and lighter. The resident expressed that she had cravings for nicotine in the evenings and not so much in the mornings as she was distracted by physical therapy. A plan was discussed with the resident to assist with the loss of nicotine and the resident became upset and left the meeting. The assistant offered the resident alternatives to control nicotine cravings and the resident was unwilling. An update to the CCP on 7/12/2016 documented if the resident was observed smoking out in the parking lot, the resident was to be approached and reminded of the facility policy. If the resident refused to allow staff to remove tobacco products,the supervisor was to be notified. A social work assistant progress note dated 7/19/2016 documented the resident continued to be seen outside smoking and the plan was for staff to continue to educate the resident on the non-smoking policy. A CNA care plan dated 7/27/2016 documented upon returning to the facility the resident and the family were to be reminded non-smoking products were not allowed in the facility and if the resident was observed outside smoking and would not surrender the smoking products the supervisor would be notified. A progress note dated 8/8/2016 by the Unit Manager documented the resident was observed outside smoking, she was asked to extinguish the cigarette and the resident did not safely extinguish the cigarette. An update to the CNA care plan dated 8/18/2016 documented to put a flag on the resident's wheelchair when she was going outdoors and the resident was to lock her purse up in her room. A nursing progress note dated 8/31/2016 documented the resident was asked to confine her smoking to a specific area outside the facility since she refused to abide by the facility non-smoking policy. A 10/12/2016 Incident Report documented the resident was outside smoking near the dumpster and sustained a bee sting to her forearm. The incident report documented the resident is outside multiple times a day smoking when educated not to. A nursing progress note dated 10/13/2016 documented an order for [REDACTED]. The resident was educated to not smoke on facility grounds but continues to be non-compliant. A nursing progress note documented the resident was discharged to alternative living on 10/17/2016 at 12:00 PM. During an interview with Unit Manager #1 on 12/21/2016 at 10:17 AM, she stated a resident who expressed a desire to smoke upon admission would be educated that the facility was non-smoking and smoking cessation would be offered. She stated if the resident was determined he/she was going to smoke an evaluation would be completed by staff to ensure the resident could safely smoke and extinguish the cigarette. She stated the evaluation would be documented somewhere in the medical record. She stated the resident was determined she was going to go outside and when she was observed outside smoking she would be asked to extinguish the cigarette. She stated an orange flag was attached to the resident's wheelchair to ensure her safety while in the parking lot. She stated she had observed the resident on an occasion outside in the parking lot smoking. She went out to the resident and asked her to extinguish the cigarette and the resident had not done so safely as she flicked the cigarette on to the ground. She stated the smoking materials were brought in to her by her family and the family had been educated as well. She stated the resident kept her smoking materials in her purse she carried around with her. During an interview with certified nurse aide (CNA) #3 on 12/21/2016 at 10:30 AM, she stated the resident would repeatedly go outside to smoke despite educating her on the facility non-smoking policy. She stated the plan was if the resident was observed outside smoking they were to report it to their supervisor and the supervisor would confiscate the smoking materials. She stated the resident got the smoking materials from her family. She stated she thought the resident was keeping the smoking materials on her or in her room. During an interview with RN #4 on 12/21/2016 at 10:40 AM, she stated the resident frequently went outside to smoke and she would provide the resident with education on the risks of smoking tobacco and the facility non-smoking policy. She stated the resident was determined she was going to smoke. She stated the resident was observed out in the parking lot smoking and they put a flag on her wheelchair so she would be easy to spot by vehicles in the parking lot. She stated the plan for the resident was to remind her to let staff know where she was going and educating her on the risk of smoking. She stated she thought the resident's family brought in the smoking materials for her and resident hid them in her room. During an interview with social work assistant #5 on 12/21/2016 at 11:35 AM, she stated the facility was non-smoking and if a resident expressed a desire to smoke they would offer smoking cessations. She stated Resident #15 went outside to smoke no matter what they said and the plan was to ensure the resident's safety. The social work assistant could not specify how the resident's safety was maintained while she went out to the parking lot to smoke and referred the surveyor to her documentation at the time the resident was in the facility. She stated she was not sure how the resident was obtaining the smoking materials. She thought she had offered the resident a locked drawer at some point and it would be included in the social work documentation if she had. During an interview with receptionist #17 on 12/21/2016 at 5:11 PM, she stated the resident used to come down to the reception area and went outside throughout the day. She stated the resident would not notify her where she was going and she would go out the front door. She stated she was not told to update anyone of the resident's whereabouts. During an interview with receptionist #19 on 12/22/2016 at 8:30 AM, he stated the resident went out a few times a day, she would take her motorized wheelchair around the parking lot and had two flags on her chair. He stated she smelled of smoke when she came back in to the building. When the Director of Maintenance was interviewed on 12/23/2016 at 10:00 AM, he stated there was no place on the grounds to safely dispose of cigarette butts as they were a non- smoking facility. He said he found cigarette butts in the parking lot, and had not observed them anywhere else on the grounds around the building. He stated he never thought about where the residents who were found smoking outside disposed of their cigarette butts. Lack of Supervision to Prevent Accidents and Potential Risk to Resident Health 3) Resident #14 had [DIAGNOSES REDACTED]. The 4/22/2016 comprehensive care plan (CCP) documented the resident had cardiac disease. The resident's fluid intake was to be recorded and monitored, she was to be monitored for signs of fluid overload, and staff were to ensure snacks and beverages offered at activities complied with ordered diet and fluid restrictions The resident's family member was aware the resident sought out fluids and asked for fluids frequently. The family member was spoken to as she was noted to bring in regular bottled water for the resident. She was notified the resident was on a fluid restriction. A 5/2/2016 social services progress note documented the resident continued on a fluid restriction related to kidney disease. The resident was non-compliant with the restriction and she attempted to obtain fluids. Staff found the resident drinking from other residents' fluids, going in to other residents' rooms and taking their water carafes (pitchers) and getting water from bathrooms, the drinking fountain, and she was found at her sink cupping water with her hands. The resident asked residents, staff and visitors for drinks. The resident was to be offered hard candy. Nursing progress notes documented: - On 5/5/2016, the resident drank copious amounts of water, drank other residents' drinks at the dinner table and went in to bathrooms to drink out of the sink. - On 5/9/2016, the resident took fluids off dirty meal trays in the dining room and kitchenette, and entered other resident rooms and drank from their water carafes. - On 5/10/2016, the resident was sent to the emergency room for evaluation with a blood clot from her rectal/vaginal area. A 5/18/2016 nursing admission note documented the resident returned to the facility on the secure cognitively impaired resident unit. A second 5/18/2016 nursing progress note documented the resident returned to the facility with an order for [REDACTED]. The 5/18/2016 at 1:00 PM physician order [REDACTED]. A 5/19/2016 speech language pathologist (SLP) dysphagia evaluation documented the resident returned from the hospital following a [DIAGNOSES REDACTED]. The SLP recommended to continue nectar thick liquids. Nursing progress notes documented: - On 5/22/2016 by a licensed practical nurse (LPN), the resident was on a fluid restriction and was taking other residents' drinks. 1:1 was offered with some effect. The resident displayed slight wheezing through the lung fields. There was no documentation by a registered nurse (RN) for this date to assess the resident's status. - On 5/23/2016 by a LPN, the resident was on a fluid restriction, was non-compliant, tried to steal other residents' drinks at the table during meal time, and the resident was on nectar thickened fluid. - On 5/24/2016 by the Director of Nursing (DON), the resident had been readmitted with a gastrointestinal bleed and aspiration pneumonia that developed in the hospital related to a medical procedure. The resident had no swallowing issues identified since admission and continued on a fluid restriction. - On 5/27/2016, the resident was seen by staff taking the water pitcher from the med cart and drinking from it, and was re-educated related to thickened fluids and fluid restrictions. A family member was in shortly before lunch and staff observed her giving her mother thin fluids. The nurse manager was contacted and came to the unit and educated the family member. There was no documentation by an RN or Unit Manager. - On 6/1/2016, the resident was trying to take peers' drinks from the table at the lunch meal. A 6/1/2016 social services progress note documented the resident was taking drinks when she was not supposed to related to her fluid restriction. Nursing progress notes documented: - On 6

Plan of Correction: ApprovedMarch 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #3 has been evaluated by PT/OT for use of scoot chair for positioning and safety. This device does have foot pedals and due to resident's attempts to rise she has been care planned to have foot pedals off in chair except during transport. Staff who assist with transports will be educated regarding #3 need to have foot rests applied during transports.
Resident #14 no longer resides at the facility.
Resident #12 has a care plan in place for checking for smoking materials and removing them if discovered. Resident is no longer going outside and there is plan in place for resident if she wishes to go outside with staff supervision. Resident is making no wishes of wanting to smoke at the facility.
Residents #15 and 26 no longer reside at the facility.
2. How you identify other residents having the potential to be affected by the same deficient practice:
Any resident who utilizes a scoot chair, any resident with cognitive impairment who is on a altered diet and any resident who is admitted to the facility with history/wishes to smoke or go outside without supervision has the potential to be affected.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All residents with cognitive impairment who utilize a scoot chair will be evaluated for safety prior to implementing the chair. This will also include a PT/OT evaluation for interventions, and the potential risk for falls associated with the use of foot rests while in a scoot chair. All residents who are currently in a scoot chair have been care planned appropriately.
All residents who are on an altered diet or fluid restriction have been reviewed to ensure that they are adhering to the MD order. All nursing staff will receive education regarding residents consuming the inappropriate consistency or non-compliance with fluid restriction and this will be reported to the NM/Supervisor immediately for interventions and IDT will develop a care plan for approaches to address non-compliance.
All Residents will be informed upon admission that the facility is smoke free. If a Resident is found to be non-compliant with the facility policy he/she will be educated and the IDT team will develop a plan to ensure safety in the environment. The facility process will include: All residents will be evaluated for
802

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 6 of 16 residents (Residents #2, 3, 10, 12, 13, and 15) and for 2 additional residents (Residents #23 and 26). Specifically, there was no documentation that investigations were thorough and complete to rule out abuse, neglect, or mistreatment when Residents #2, 3, 10, 12, and 23 sustained falls; Resident #13 was found with a bruise of unknown origin; Resident #23 sustained a skin tear; and Residents #12, 15, and 26 were found with unsafe materials and were observed in areas unsafe to residents. Findings include: The Incident Management Program Overview policy dated 11/17/2015 documented all resident incidents will be documented on incident report to rule out potential abuse and/or neglect. For injuries of unknown origin, such as skin tears or bruises, witness statements will be obtained from staff that has direct knowledge related to the incident up to the preceding 3 shifts as applicable. For incidents involving falls, witness statements will be obtained from staff that have direct knowledge related to the incident during that shift. Content of the investigation will contain: the date and time the incident was discovered; who discovered the incident; how the incident was discovered; a description of the resident and the area where the incident occurred; witness statements including names of staff interviewed with their signed and dated statements; staff who the facility decided not to interview and why; a list of questions posed to staff interviewed; and a statement from visitors who may have been in the area. Potential Neglect 1) Resident #26 had [DIAGNOSES REDACTED]. An admission nursing note dated 9/3/2016 documented the resident asked the nurse for cigarettes and the resident was educated that he was in a smoke-free facility. A nursing progress note dated 9/3/2016 at 6:07 PM documented the resident was seen at multiple doors asking for visitors to let him out. The resident was found in the parking lot in his wheelchair sitting behind a parked car after lunch. Staff did not know how he got there and escorted the resident back into the facility. The on-call physician was contacted and informed the supervisor of the recommendation for the resident to stay on the unit. There was no documented evidence an investigation was completed regarding the incident. A nursing progress note dated 9/4/2016 documented the resident was outside without letting staff know on the day shift, and he became aggressive toward staff when they tried to educate him on safety. The resident was found with cigarettes in his room. There was no further documentation regarding the cigarettes. There was no documented evidence an incident/accident investigation was completed to address the resident's safety related to being found outside and having cigarettes. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. He required extensive assistance with transfers, mobility, and dressing, and utilized a walker and a wheelchair. The comprehensive care plan (CCP) reviewed and revised on 9/9/2016 documented the resident had a history of [REDACTED]. Since admission, the resident had been observed smoking outside and declined to allow staff to remove the cigarettes or lighter from his room or give them to the nurse. The resident was admitted with orders for a nicotine patch; however, he refused it. The CCP did not address interventions to maintain the safety of the resident or related to his smoking unsupervised in non-smoking areas. Nursing progress notes documented: - On 9/11/2016, the resident had a lighter and some cigarettes. The resident was reminded the facility was non-smoking. The resident was described as sometimes forgetful. - On 9/12/2016, the resident had gone outside and smoked even when told he shouldn't be smoking outside because it was a non-smoking facility. - On 9/13/2016 on the day shift, the resident spent time out on the patio several times during the shift. - On 9/19/2016 on the evening shift, the resident continued to go outside to smoke. - On 9/22/2016 and 9/23/2016 on the evening shift, the resident continued to go outside to smoke and education had been provided with no effect. - On 9/25/2016, the resident had been smoking in the AM and PM. The resident was reminded of the policy of no smoking but ignores it. - On 9/27/2016, the resident continued to go outside to smoke and education was provided with no effect. There was no documented evidence the cigarettes and lighter were secured or an investigation was completed to develop a plan to maintain the safety of the resident who smoked or the safety of other residents subjected to the resident's unsafe smoking. The physician's daily history and physical progress notes dated 9/3/2016 through 10/2/2016 documented the resident was a current everyday smoker. The resident was discharged [DATE]. During an interview with the Director of Nursing (DON) on 12/21/2016 at 7:00 PM, she stated there was no policy related to smoking, as the facility was a non-smoking facility. She said no incident reports/investigations were initiated for residents who were discovered smoking on the grounds as nothing happened. When certified nurse aide (CNA) #30 was interviewed on 12/23/2016 at 8:15 AM, he stated he recalled the resident and said he would tell him he was not allowed to smoke and the resident said, I have rights. The CNA sometimes assisted the resident in opening the door to go out to smoke on the patio. He said the resident sat to the right of the door away from the entrance. During an interview with housekeeper #31 on 12/23/2016 at 8:25 AM, she stated she remembered the resident and recalled he went outside to smoke. Sometimes he asked for help opening the door, and she would help him go outside. She stated she never saw his cigarettes or lighter in his room. She stated he must have left the cigarette butts outside, as she never saw them in his room. During an interview with registered nurse (RN) #9 on 12/23/2016 at 8:30 AM, she stated she was familiar with the resident and did not know how he obtained cigarettes. She said he often had his robe with him and thought he kept the cigarettes in the pocket of the robe. She was aware the resident often went out in the late morning and after lunch to smoke and someone usually helped him open the door to go outside. She thought he flicked the cigarettes off the side of his wheelchair and did not know where he disposed of the cigarette butts. The RN stated she thought the resident's family brought the cigarettes in to him and was not sure if anyone spoke to the family about doing so. If a meeting was held with family, it would have been documented. There was no documented evidence in nursing or social work progress notes of a meeting with the resident and/or family regarding his unsafe smoking. When the Director of Social Services was interviewed on 12/23/2016 at 9:07 AM, she stated residents and families were informed prior to admission of the facility No Smoking Policy. If a resident refused to stop smoking, the plan would be to assure the resident was safe to smoke and a safe place to smoke was provided. She said the resident was alert and oriented and was told to keep his cigarettes and lighter in a locked drawer. She was not sure if there was anywhere on the grounds to safely dispose of cigarette butts. During an interview with CNA #30 on 12/23/2016 at 9:45 AM, he stated he did not know where the resident disposed of the cigarette butts. He thought maybe he put the butts in his pocket and threw them out in the trash in his room. When the Director of Maintenance was interviewed on 12/23/2016 at 10:00 AM, he stated there was no place on the grounds to safely dispose of cigarette butts, as they were a non- smoking facility. He said he found cigarette butts in the parking lots and had not observed any in other areas around the building. He recalled seeing Resident #26 outside the entrance of the A Wing and never saw any cigarette butts in that area. He stated he never thought about where the residents who were found smoking outside disposed of their cigarette butts. Falls 2) Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive assistance for activities of daily living (ADLs). He used a walker and wheelchair, was frequently incontinent of bladder, was on a toileting program, and had two or more falls without injury since the last assessment. The certified nurse aide (CNA) care instructions updated 7/13/2016 documented the resident was on a two hour toileting plan and was to be toileted first on the toileting rounds. If staff observed him to put himself on the floor, it was not an incident. The comprehensive care plan (CCP) dated 8/26/2016 documented the resident was at risk for falls related to dementia, behaviors, unsteady gait, and a history of self-transferring and ambulating without use of assistive devices. Approaches included a toileting plan with referral to the care sheet for specifics (CNA care instructions). An incident report dated 8/26/2016 at 4:50 AM documented the resident was found on the floor in the hallway. An incident report dated 9/2/2016 at 2:50 PM documented the resident was found on the floor near his door, scooting on his bottom. There were eight staff noted as being on duty in the area the time, and statements were obtained from four of the eight employees. The report did not include the last time the resident was checked or toileted. The report documented to continue with the every two hour toileting schedule. The CCP updated 9/2/2016 documented if the resident was observed lowering himself to the floor, it would not be considered a fall. An incident report dated 9/6/2016 at 10:15 PM documented the resident was found scooting himself on the floor of his room, stating he wanted to get out of there. The CNA statement documented she toileted him every two hours and there was no toileting sheet in the book. The report documented to continue with the every two hour toileting schedule. An incident report dated 9/8/2016 at 3:50 PM documented the resident was found on the floor in his his room trying to get to the doorway. The time the resident was found was documented as 3:50 PM on page 1, and 2:50 PM on page 2. One employee statement was unsigned, two statements were from employees who were not on the unit at the time, and none of the statements included times the resident was last seen or cared for. An incident report dated 9/9/2016 at 6:20 AM documented the resident was found sitting in the doorway of his room, wearing only his briefs, and was incontinent. An incident report dated 9/10/2016 at 3:15 AM documented the resident was found on the floor outside his doorway in the hall, sitting on his bottom. An incident report dated 9/10/2016 at 8:30 PM documented the resident was found sitting on the floor in the doorway of his room, scooting on his bottom. A statement from the CNA documented she provided his care at 7:45 PM and he was toileted every two hours. There was no corresponding toileting schedule to verify when the resident was last toileted. An incident report dated 9/13/2016 at 10:30 PM documented the resident was found sitting on the floor by the door to his room. The CNA statement did not include the time the resident was last cared for or seen. The report documented the care plan was not followed with no further explanation and the resident's care plan was changed to a one hour toileting schedule. A nursing progress note dated 9/14/2016 at 3:15 PM documented the interdisciplinary team reviewed the resident's care plan and made changes including if the resident placed himself on the floor and it was witnessed, it was not considered a fall; the resident had floor mats on both sides of the bed; and the toileting plan was changed to every hour to observe and offer toileting, and the resident was not to be awakened for toileting if sleeping. The CCP updated 9/14/2016 documented the resident was to be toileted every hour if awake, and falls from bed if no injury were safe. An incident report dated 9/15/2016 at 8:25 PM documented the resident was found sitting on the floor in the hallway, scooting up the hall. There were no statements from staff assigned to the resident at the time, and the staff listed as on duty and in the area were the licensed practical nurse (LPN) and a task aide (employee who does not provide direct care to residents). A change to the care plan was noted, and if the resident was found uninjured on the mat next to his bed, the incident would not be considered a fall. The CCP was updated and if the resident was found on the mat by the bed with no injury, it would not be considered a fall (initiated 9/15/2016). An incident report dated 10/5/2016 at 3:00 PM documented the resident was found sitting on the floor in the hall outside of his room. The resident was found to be incontinent of bowel. Four CNA statements were obtained. There was no documentation of who was assigned to the resident or when he was last checked or toileted, and one CNA reported the resident was covered in feces. An incident report dated 10/9/2016 at 9:00 PM documented the resident was found sitting in the hallway, holding onto the hand rail. A nursing progress note dated 10/9/2016 at 9:37 PM documented the resident was in the hallway on the floor, wearing a nightgown, and was not wearing an incontinence brief. A fall risk assessment dated [DATE] documented the resident was at high risk for falls due to history of falls and recent numerous falls. The MDS assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance for ADLs, used a wheelchair, was frequently incontinent of bladder, occasionally incontinent of bowel, was on a urinary toileting program, had two or more falls with injury, and two or more falls without injury since the last assessment. The CNA care instructions dated 10/19/2016 documented the resident was non-ambulatory, required a mechanical lift for transfers, was to be toileted every two hours, and if staff witnessed the resident putting himself on the floor or if he was found on his fall mat without injury, it was not an incident. An incident report dated 10/21/2016 at 8:05 PM documented the resident was found scooting on his bottom in the hallway. Statements from two CNAs who cared for him documented the resident was aggressive during attempts to provide care 20 to 30 minutes prior to being found and they retreated. There was no documentation regarding the type of care provided, how much care they were able to complete, or the time he was last seen. The report documented the resident was on a two hour toileting schedule and the care plan was followed. A nursing progress note dated 10/21/2016 at 11:35 PM documented the resident was found scooting in the hallway outside his room and was stating there was water everywhere. Prior to the incident, he had been extremely aggressive towards staff, the resident self-transferred from wheelchair to straight-back chair, had a bowel movement, staff attempted to clean the resident and get him back in the chair, but the resident was too aggressive. Staff retreated and reapproached twice, and were able to shower the resident. Staff placed him in bed to finish care, he remained aggressive, and staff retreated. A nursing progress note dated 10/24/2016 at 11:44 AM documented follow-up to the 10/21/2016 incident. The note stated the resident had self-transferred from his wheelchair to a straight-back chair and was incontinent of bowel. He was assisted to bed, where he was cleaned, continued to be aggressive, and staff finished their care and retreated. An incident report dated 11/1/2016 at 8:40 PM documented the resident was observed to stand from his wheelchair and sit down on the floor in the unit lounge. Comments included: As per care plan, not a fall, lowered self to floor, was witnessed. Incident reports dated 8/26/2016, 9/2/2016, 9/6/2016, 9/8/2016, 9/9/2016, 9/10/2016 (3:15 AM), 9/15/2016, 10/5/2016, 10/9/2016, and 11/1/2016 did not include the last time the resident was seen, when he was last toileted or checked, or who was assigned to his care. Employee statements regarding the incidents did not include the last time the resident was checked or toileted. The reports documented the care plan was followed, and there was no corresponding toileting schedule to verify when the resident was last toileted. Additionally, the incidents that occurred on 10/9/2016 and 10/21/2016 had further information in the 10/9/2016 and 10/21/2016 nursing progress notes about the incident that was not included in the incident reports. Incident reports dated 10/5/2016 and 10/21/2016 documented the resident was on a two hour toileting schedule. The 9/13/2016 incident report and 9/14/2016 nursing progress note documented the resident's care plan was changed to an every one our toileting schedule. Nursing progress notes documented the following: - On 11/1/2016 at 8:33 PM, the resident as observed at 7:40 PM to stand from wheelchair and sit on the floor in the lounge area. - On 11/1/2016 at 8:53 PM, the supervisor was called to the floor to assess the resident, found him lying on the floor, and the resident was incontinent of bowel at the time. - On 11/2/2016 at 11:30 AM, registered nurse (RN) Manager #23 documented the resident was care planned if he lowered himself to the floor, it was not considered a fall, and the 11/1/2016 incident was not a fall. There was no documentation the care plan was followed regarding the resident's toileting schedule, as he was found to be incontinent of bowel at the time of the incident. - On 11/9/2016 at 6;50 AM, the resident was found sitting on the mat with no injury. A report was not done per care plan as resident was found on the mat. - On 12/17/2016 at 1:50 AM, the resident was found on the floor in his room near the window, on his mat, and had rolled out of bed. The resident had a small abrasion on his right forearm, and a bandage was applied. - On 12/19/2016 at 3:59 PM, the resident was reported to have a fall from bed; however, he was found on the mat without injuries. He was care planned that any fall where he was found on the mat with no injury was not considered a fall; therefore, the incident was not a fall. There was no documentation found that an incident report for the 12/17/2016 fall with injury was completed. During an interview with CNA #26 on 12/22/2016 at 3:13 PM, she stated the resident was on a two hour toileting schedule, and there was a two hour toileting sheet in the CNA book on the unit and the sheet was to be signed when the resident was toileted. CNA #26 stated the resident did not use his call bell for toileting needs. RN Manager #23 and the Director of Nursing (DON) were interviewed on 12/21/2016 at 3:40 PM. RN Manager #23 stated the resident was unable to rise and fall, and was able to safely lower himself to the floor. For that reason, he was care planned if he was found on his mat by his bed, it would not be considered a fall, and if he was witnessed lowering himself to the floor, it was not considered a fall. She stated when the resident lowered himself to the floor or was found on the mat, he would still be assessed, and it would be verified if the care plan was followed because the resident was on a two hour toileting schedule. The DON stated they utilized the signed toileting schedule to determine the care plan was followed and for root cause analysis. She stated if there was no toileting schedule, she would not know if abuse or neglect had occurred. The DON added that there should have been an incident report for the 12/17/2016 fall that resulted in injury, and it was unknown how the resident sustained [REDACTED]. During a follow-up interview on 12/23/2016 at 10:00 AM, the DON stated if a resident was on a one or two hour toileting plan, there would be a toileting flow sheet in the binder on the unit, and the prior months' toileting flow sheets were kept and retained in the resident's medical record. The DON confirmed the incident reports regarding the resident's falls did not include the times the resident was last toileted because the toileting flow sheets were used to verify the care plan was followed. Toileting flow sheets for 8/2016-12/2016 were requested on 12/22/2016 at 6:03 PM and only the sheets for 12/2016 were received. Toileting flow sheets for 8/2016-11/2016 were requested again on 12/22/2016 at 7:50 PM and the facility was unable to provide them. Bruise of unknown origin 3) Resident #13 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately cognitively impaired and required extensive assistance for most activities of daily living (ADLs). The certified nurse aide (CNA) care sheet last updated 10/13/2016 documented the resident was to have routine skin care. Staff were to provide assistance of 2 with bed mobility, and assistance of 1 for toileting. The resident transferred with assistance of 1 staff with a gait belt. The comprehensive care plan (CCP) dated 11/3/2016 documented the resident was at risk to fall, had impaired mobility, and was to have skin inspected daily with personal care. Staff were to provide ADL assistance per care sheet. The registered nurse (RN) progress note dated 11/24/2016 at 10:48 PM documented while administering medication to the resident, the resident notified the nurse of bruising located on the left side of her abdomen. The RN assessed the area that was large in size, deep purple in color and elongated in shape. The resident stated she was unsure how she obtained the bruising. An 11/24/2016 (not timed) incident report documented the resident notified the nurse she had a bruise to the abdomen. There was no documentation on the form the physician or family were notified of the area. The form documented the administrator/designee was notified and did not document the date or time of notification. When the resident was asked if she bumped into something, she stated, Sometimes, I don't know. It was documented the care plan was followed and it was not reasonable to believe the incident was result of abuse. A staff statement included in the report did not document staff title and documented the resident had notified her of a bruise under the left breast around the abdomen, and the resident acted surprised she had the area. The statement documented the RN notified the staff member the resident had a bruise before she could report the bruise to the nurse. A second staff statement included in the report did not document the title of staff, and documented she did not know about the bruise until the RN notified her. The report lacked documentation to rule out if abuse, neglect, or mistreatment occurred when: there was no documentation by staff interviewed if it was determined when care had last been provided; what care had been provided; when the resident was last seen; or if environmental factors that date had been reviewed that could have potentially led to the bruise. An investigation summary completed on 11/28/2016 by the Director of Nursing (DON) documented the bruise did not have a clinical pattern to indicate abuse, documented witness statements were reviewed, the resident had a history of [REDACTED]. There was no additional information in the investigative summary to rule out abuse, neglect, or mistreatment as indicated in the 11/24/2016 findings. A DON progress note dated 11/28/2016 at 3:10 PM documented a follow-up to the bruise noted on 11/24/2016. The DON assessed the area and described it as a dark purple bruise on the resident's lower left abdomen that was in various stages of healing. The resident had no pattern to the bruising, denied transferring on her own, and the bruise was not related to abuse. During an interview with RN Manager #16 on 12/22/2016 at 5:00 PM, she stated investigations were to be started by the nurse working at the time of the incident. She stated if she was working she would start the report, and if it was on an off-shift the report would be on the unit for her to review the next morning she was working. She stated statements should be completed by staff who were in the area and had been assigned to the resident. She stated statements should always be included if a resident sustained [REDACTED].#16 stated the team would decide if abuse/neglect had occurred. The report should include information as to where the resident was at time of the incident, what was the injury, and could the care plan be changed to prevent recurrence. She stated if it was suspected abuse, she would follow up with staff and ask additional questions. She stated she would want to look at the resident's surroundings for potential causes to the bruise. She stated staff should include in their statements what care was provided. RN Manager #16 stated once she reviewed the report, she provided it to the DON for further review. During a combined interview with the DON and Administrator on 12/22/2016 at 6:10 PM, the DON stated incident reports would include staff statements and would include what care was provided to the resident. She stated if information was not included, she would interview staff and determine if abuse or neglect occurred. She stated she had an additional summary for the 11/24/2016 bruise that was not included in the investigation report that had been provided to the surveyor. She stated she would look into additional information and talk to staff, and information may not be included in staff statements provided with the incident report. 10NYCRR 415.4(b)

Plan of Correction: ApprovedMarch 20, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident (s) #2,3,10,12, and 23 incidents were reviewed for additional documentation needs related to falls to rule out abuse and/or neglect. Resident #13 incident was reviewed for additional documentation needs related to a bruise to rule out abuse and/or neglect. Resident #23 incident was reviewed for additional documentation needs related to skin tears to rule out abuse and/or neglect. Residents #12, 15, and 26 incidents were reviewed for additional documentation needs related to discovery of unsafe materials and observations in unsafe areas to rule out abuse and/or neglect. Upon review of the incidents and discussions with staff members completing the investigations, no evidence of abuse, neglect, or mistreatment was identified.

2. How you identify other residents having the potential to be affected by the same deficient practice: A review of the incident reports was conducted for the past 90 days prior to survey. All incident reports involving falls, bruising, blisters, skin tears, unsafe materials, and unsafe areas that did not include complete witness statements had the potential for the same deficient practice. Upon review of the past incidents and discussions with staff members completing the investigations, no evidence of abuse, neglect, or mistreatment was identified.

3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The policy for Incident Management Program Overview has been reviewed. The policy stipulates that any incident involving a fall will require witness statements/interviews for staff that have direct knowledge related to the incident during that shift,or had contact with the Resident during that shift. Any incident of unknown origin including skin tears and bruising will require witness statements and/or interviews for staff that have direct knowledge or contact related to the incident up to the preceding 3 shifts. The witness statement and/or statement form has been revised to prompt staff for more specific information pertinent to the incident.
All staff education will be conducted regarding the thorough completion of an incident report for all Resident incidents. Education will also be provided related to proper completion of witness statements/interviews for all incidents of unknown origin, falls, unsafe materials, and unsafe areas. Education will be provided through the Staff Development Department.

4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
The facility will determine if the monitoring system is effective by conducting an audit of the thorough completion and analysis of incident reports to rule out potential abuse and/or neglect. The audit will be performed monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The threshold for compliance will be 100%. The sample will include 5 Residents per unit for a total of 25 Residents. If the threshold of 100% is not attained the sample will either be expanded and/or repeated. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.

5. Responsible Party: Director of Nursing or Designee

FF10 483.70(g)(1)(2)(i)(ii):OUTSIDE PROFESSIONAL RESOURCES-ARRANGE/AGRMNT

REGULATION: (g) Use of outside resources. (1) 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 (g)(2) of this section. (2) 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- (i) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and (ii) The timeliness of the services.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

Citation Details

Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure specific services were obtained by an outside agency when the facility did not employe a qualified professional person for 3 of 25 residents (Residents #12, 15, and 26). Specifically, areas of concern specific to accidents and supervision potentially affecting resident behaviors, well-being, and resident rights were not addressed by social services; and the facility did not employee a qualified social worker. An agreement was implemented with an outside social work consultant and the facility did not utilize the consultant's services and resources. Findings include: The Agreement between the facility and the Social Work Consultant documented the agreement was initiated 3/2004 and remained active until termination was provided in writing. The agreement documented the social work consultant would provide consultation for social work services to the facility's social services department and its personnel including: - Periodically reviewing social services department policies and procedures to evaluate their effectiveness and propose revisions as indicated. - Advise the facility administration and the social services department regarding program planning and policy development. - Provide continuing education and staff development training for facility personnel as determined and requested. - Prepare a written social work consultant activities report to the facility. The facility would retain ultimate professional and administrative responsibility for social work services rendered in the facility. The facility provided the surveyor with the Facility Survey Report (FSR) on 12/19/2016. The FSR documented the facility's full time social worker did not have a master's degree in social work and services were obtained from a qualified social work consultant through a contract. The FSR documented no provisions to the contract had been changed since the last annual survey. Refer to F323 Free of Accident Hazards/Supervision. During an interview with the Director of Social Services on 12/23/2016 at 9:07 AM, she stated if she and the other staff social workers had a situation and had exhausted all interventions, were unable to come up with a plan, or had difficulty with family involvement, she contacted the social work consultant and discussed it via telephone. She did not know when he was last at the facility and did not know if he documented any of the communication. She stated the facility Administrator kept a file about the social work consultant. The Administrator stated on 12/23/2016 at 10:12 AM, he did not have any interaction with the social work consultant and the consultant would be in contact with the Director of Social Services. 10NYCRR 415.26(e)(i-v)

Plan of Correction: ApprovedMarch 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #15 and 26 no longer reside in the facility. The Social Work Consultant will be contacted regarding Resident #12 for review.
2. How you identify other residents having the potential to be affected by the same deficient practice:
All residents were reviewed and no residents have been identified with similar concerns.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
A policy has been written to address the use of a social work consultant. Social service staff education will be provided regarding the policy.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
The Director of Social Services will utilize the list of Residents generated from morning briefing to identify a sample for auditing purposes to ensure compliance with corrective actions. This will be completed monthly x 3 and then quarterly until the deficient practice is corrected. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5. Responsible Party: Director of Social Services

FF10 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: (b) Physician Visits The physician must-- (1) Review the resident?s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; (2) Write, sign, and date progress notes at each visit; and (3) Sign and date all orders with the exception of influenza and pneumococcal 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: December 23, 2016
Corrected date: February 20, 2017

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 that the physician reviewed each resident's total program of care, including medications and treatments, for 1 of 25 residents (Resident #6) reviewed. Specifically, Resident #6 had a physician order for [REDACTED]. Findings include: Resident #6 had [DIAGNOSES REDACTED]. The hospital discharge summary dated 11/30/2016 documented the resident had a history of [REDACTED]. A physician progress notes [REDACTED]. A physician order dated 12/3/2016 documented admission labs, lab for Tuesday 12/6/2016 U/A, C&S (culture and sensitivity) if indicated. The physician signed the order on 12/13/2016. There was no documentation in the nurse practitioner (NP) progress notes dated 12/3 and 12/4/2016 indicating why a U/A was ordered. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, fluctuating inattention, and disorganized thinking. The resident exhibited physical behavioral symptoms directed toward others at times. The resident required extensive assistance with most activities of daily living (ADLs) and was frequently incontinent of urine. A facility laboratory worksheet documented the resident was to have a U/A done 12/6/2016. The worksheet was initialed and dated 12/13/2016. There was no documentation in the physician progress notes [REDACTED]. The resident's laboratory results were reviewed by the surveyor on 12/21/2016 and there was no documentation that results of a U/A were received by the facility prior to the surveyor's request for a copy of the results. Registered nurse (RN) Manager #6 was interviewed on 12/21/2016 at 9:05 AM. She stated she would see if the U/A results were somewhere other than the chart. At 9:15 AM, she returned and stated the U/A had not been done as ordered. She stated the resident had been seen every day since admission by the NP or physician and they were not concerned the resident had a UTI. She stated the resident had not had any signs or symptoms of a UTI and the U/A was likely ordered to establish a baseline. She stated if a U/A was ordered, she would expect a urine specimen be collected and the test would be performed. She stated it was her responsibility to ensure all laboratory requests were completed as ordered and she would ensure the results would be reviewed by the physician. RN #7, who had written the verbal order for the U/A on 12/3/2016, was interviewed by telephone on 12/21/2016 at 10:35 AM. She stated she obtained an order for [REDACTED]. She would share the information with the next shift and what needed to be charted on. The physician was interviewed by telephone on 12/21/2016 at 11:15 AM. He stated that when he had seen the resident on multiple occasions, she had no signs or symptoms of a UTI, such as frequency, burning, or discomfort. He stated the resident had a high level of confusion when he had seen her. He stated he would review all ordered laboratory results either by himself or with a nurse when he came to the unit. He did not recall reviewing specific U/A results for the resident, as he reviewed many laboratory results during any given day. He stated by signing orders that were verbal or telephone orders, he was acknowledging the order was accurate. 10NYCRR 415.15(b)(2)(iii)

Plan of Correction: ApprovedMarch 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #6 has routine lab orders that have been reviewed and signed by the MD. Resident now has a routine UA and C+S if indicated order every 6 months that is scheduled. The UA was drawn and is negative.
2. How you identify other residents having the potential to be affected by the same deficient practice:
All residents with written lab orders have the potential to be affected.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:

All telephone orders that are received from the MD for any lab work will have the following process: The nurse taking the lab order will be responsible for doing a written telephone order, the order will be placed in the lab book when to be done, and documented on the 24 hr report sheet. A lab request form will be completed at the time of any specimen/culture order. All written lab orders received from the MD will be placed in the lab book to be scheduled, the written order will be placed in the MD rounds book to await the results. The order will be signed with results to ensure they were completed and that they have been reviewed by the MD.
All nurses and physicians will receive education on the process for ensuring that the lab orders have been processed and that results are reviewed by the physician as stated above.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
A audit tool will be developed to monitor notification of lab results and MD review. This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the unit managers. The sample will include 5 Residents per unit for a total of 25 Residents. This will be completed monthly x 3 and then quarterly. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5. Responsible Party: Director of Nursing or Designee

FF10 483.50(a)(2)(ii):PROMPTLY NOTIFY PHYSICIAN OF LAB RESULTS

REGULATION: (a) Laboratory Services (2) The facility must- (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician?s orders.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

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 appropriate treatment and services were provided for 1 of 15 residents (Resident #6) reviewed for laboratory results. Specifically, the physician ordered a urinalysis (U/A, urine test) for Resident #6, the test was not performed, and the follow up was not timely. Findings include: Resident #6 had [DIAGNOSES REDACTED]. The hospital discharge summary dated 11/30/2016 documented the resident had a history of [REDACTED]. Nursing progress notes dated 11/30/2016 at 5:38 PM and 10:30 PM documented the resident was voiding yellow urine without foul odor. A nursing progress note dated 12/1/2016 at 7:12 AM documented the resident was attempting to toilet herself, and became combative when staff attempted to assist. The resident was incontinent of a large amount of dark yellow urine without odor. A physician progress notes [REDACTED]. A nursing progress note dated 12/3/2016 at 10:48 AM documented the resident declined most of her meals and was very anxious. There was no documentation the resident had any signs or symptoms of a UTI or why there was a physician order [REDACTED]. A nurse practitioner (NP) progress note dated 12/3/2016 documented the resident was not incontinent, did not have blood in the urine, and did not have difficulty urinating. A physician order [REDACTED]. The physician signed the order on 12/13/2016. The Minimum Data Set (MDS) assessment dated [DATE] documented resident had severe cognitive impairment, fluctuating inattention, and disorganized thinking. The resident exhibited physical behavioral symptoms directed toward others at times. The resident required extensive assistance with most activities of daily living (ADLs) and was frequently incontinent of urine. A facility laboratory worksheet documented the resident was to have a U/A completed on 12/6/2016. The worksheet was dated and initialed 12/13/2016. When requested by the surveyor on 12/21/2016, the facility did not have the laboratory results of the U/A in the facility, and there was no documentation the facility had attempted to obtain or review the results. Registered nurse (RN) Manager #6 was interviewed on 12/21/2016 at 9:05 AM. She looked in several spots to see if the U/A was done and could not find evidence it was completed. She stated when physician's orders [REDACTED]. The order would then be written in the laboratory requisition book. The person taking the order would be responsible for ensuring the urine specimen was obtained. RN Manager #6 stated only licensed nurses obtain urine specimens. If the nurse originally taking the order was unable to obtain a specimen, the nurse on the next shift should be asked to obtain it. Second checks of orders would be done by the 11 PM - 7 AM nurse to ensure they were carried out accurately. The urine specimen would then be taken directly to the hospital laboratory by a staff member. The order would then be discussed during the morning interdisciplinary team (IDT) meeting. She stated the resident did not have any signs or symptoms of a UTI, but the U/A would be used to track her. RN #7, who had written the verbal order for the U/A on 12/3/2016, was interviewed by telephone on 12/21/2016 at 10:35 AM. She stated she had not seen any previous laboratory orders when the resident was admitted , and obtained an order for [REDACTED]. She stated a progress note regarding the orders would be included with the admission process, and she would share with the next shift on what needs to be charted. The physician was interviewed by telephone on 12/21/2016 at 11:15 AM. He stated when he completed his admission assessment, the resident had no signs of a UTI, such as frequency, burning, or discomfort. He did not recall reviewing specific U/A results for the resident, as he reviewed many labs during any given day. 10NYCRR 415.20(a,c)

Plan of Correction: ApprovedMarch 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #6 had UA obtained per MD orders and results were negative. Resident will be monitored for signs and symptoms daily of UTI and MD will be notified of any positive findings. Resident now has an order for [REDACTED].
2. How you identify other residents having the potential to be affected by the same deficient practice:
All residents in the facility with written lab orders have the potential to be affected.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All lab sheets have been reviewed in the facility. Each resident's orders have been verified and all labs that are ordered have been drawn for (MONTH) (YEAR) and have been reviewed by the MD.
All telephone orders that are received from the MD for any lab work will have the following process: The nurse taking the lab order will be responsible for doing a written telephone order, the order will be placed in the lab book when to be done, and documented on the 24 hr report sheet. A lab request form will be completed at the time of any specimen/culture order. The nurse will complete the form and obtain the specimen/culture immediately, if the nurse is not able to obtain the specimen/culture before the next shift, the lab request form will be handed to the oncoming nurse to ensure it is obtained. The process of completing the form at the time of the order and the direct hand off will ensure the order is obtained if it was not able to be done immediately. When the specimen/culture has been obtained, it will be transported to the lab for processing. A 24 hr chart review for lab orders will be completed on the midnight shift.
All nurses will receive education on process for obtaining lab/specimen orders on all shifts as stated. All nurses will receive a mandatory education on 24 hr chart checks for lab orders and to ensure that they have been completed. Any lab order that has not been completed within the 24 hr chart review will be reported to the Nurse Manager/Supervisor immediately.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
A audit tool has been developed to monitor lab/specimen orders for completion. This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the unit managers. The sample will include 5 Residents per unit for a total of 25 Residents. This will be completed monthly x 3 and then quarterly. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5. Responsible Party: Director of Nursing or Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

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 care and services were provided to attain or maintain the highest practicable physical well-being for 2 of 25 sampled residents (Residents #2 and 25) reviewed for quality of care. Specifically, the facility did not address a urology consult as recommended for Resident #2 in a timely manner. Resident #25 had a skin impairment, there was no documentation the area was assessed timely following the initial assessment, and a treatment was applied to the area without a physician order. Findings include: 1) Resident #25 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired and required extensive assistance for most activities of daily living (ADLs). She was at risk for development of pressure ulcers and had applications of ointments/medications to her skin. The comprehensive care plan (CCP) dated 12/1/2016 documented the resident was at risk for development of pressure ulcers due to cognitive impairment and impaired mobility. Staff were to inspect skin daily with personal care, notify the physician, and obtain orders if areas were identified. The treatment administration record (TAR) documented weekly skin checks were to be completed on the 3 PM - 11 PM shift to check for any alterations. The TAR documented the resident's skin was checked on 12/1 and 12/8/2016 and there was no documentation of an impaired area on the resident's back. A non-pressure wound evaluation and documentation form documented on 12/9/2016 the resident had an open area caused by previous cyst removal. The area measured 0.6 centimeters (cm) x 0.7 cm x 1.0 cm. The area was on the right upper back and found to be bloody. The treatment was documented as [MEDICATION NAME] (absorbent wound dressing) with island dressing (adhesive at all edges) daily. A registered nurse (RN) progress note dated 12/15/2016 documented an area on the resident's upper back was noted on 12/9/2016. The area had a large amount of firm black debris, removed with a cotton tip applicator. The area measured 0.6 cm x 0.7 cm x 1.0 cm. The family stated the resident had a cyst removed years ago. On 12/11/2016, thick bloody drainage was observed from the area, which was cleansed with normal saline, packed with [MEDICATION NAME], and covered with island dressing. On 12/12/2016, an RN viewed the area and it continued with thick bloody drainage. There was no documentation of a physician order [REDACTED]. The TAR documented [MEDICATION NAME] foam dressing, to pack wound on right upper back and cover with island dressing daily starting 12/15/2016 on the 7 AM - 3 PM shift. The TAR documented the dressing was not applied on 12/15/2016, as the resident was at the hospital on that date. There was no documentation in the physician orders [REDACTED]. The CCP was updated on 12/16/2016 and documented the resident was at risk for altered skin integrity due to an old surgical site on the right upper back. As of 12/15/2016, the area was to be cleansed with normal saline, [MEDICATION NAME] packing applied, and covered with Opsite daily. Staff were to notify the physician and obtain orders if areas were identified. A licensed practical nurse (LPN) progress note dated 12/15/2016 at 6:38 AM documented the resident was found with an open area on the top of the right side of her back. The resident had bloody purulent (pus) drainage coming from that side. The area was approximately the size of a dime in width and when the culture was done the culture stick went into the resident's body. The resident was sent to the hospital. During an interview with the Director of Nursing (DON) on 12/22/2016 at 4:00 PM, she stated she was contacted on 12/15/2016 about the area on the resident's back. Upon reviewing the medical record that day, she became aware RN #2 had not documented in the progress notes on 12/9/2016 when the area was found, and had her document on 12/15/2016. The DON stated the RN should have obtained a physician order [REDACTED]. 2) Resident #2 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 10/17/2016 documented the resident had [MEDICAL CONDITION] and the goal was to prevent urinary tract infection [MEDICAL CONDITION]. Approaches included to monitor urine output, if decrease or foul odor evident to notify the nurse and physician, monitor for changes and notify nurse and physician, and evaluate with physician for need for follow up. Additionally, the CCP documented the resident had a history of [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive to total assistance for activities of daily living (ADLs), and was frequently incontinent of urine. The certified nurse aide (CNA) care instructions dated 10/19/2016 documented the resident was non-ambulatory, was incontinent of urine, used a urinal and incontinence briefs, and was to be toileted every two hours. Physician orders [REDACTED]. A laboratory report dated 12/6/2016 documented the resident's urinalysis (U/A) was negative. An unsigned handwritten note at the bottom of the report stated the urologist was contacted on 12/7/2016, the resident was non-compliant with recommendations in 7/2015, and the urologist would re-open the case if the resident complied. A physician progress notes [REDACTED]. The physician ordered to monitor for bleeding, take vital signs daily, and nursing staff was to report when the U/A returned. The treatment administration record (TAR) dated 12/2016 documented an order for [REDACTED]. There were no daily vital signs documented from 12/8-12/21/2016. Nursing progress notes documented the following: - On 11/30/2016 at 1:20 PM, the resident was hitting and kicking staff during care. - On 12/5/2016 at 11:21 AM, the resident was having increased periods of anxiety and screaming at staff in the morning. - On 12/6/2016 at 11:47 AM, the resident continued to have hematuria, was incontinent of a large amount of urine, the physician was notified and ordered a straight catheter specimen one time, and the urine was collected and sent to the the laboratory. - On 12/7/2016 at 6:16 AM, no hematuria was reported. - On 12/7/2016 at 11:45 AM, the resident was seen by nurse practitioner (NP) #24 for monthly rounds and he was informed of the resident's hematuria. The NP requested the urologist be contacted about the hematuria and the negative results of resident's U/A collected on 12/6/2016. - On 12/7/2016 at 11:54 AM, registered nurse (RN) Manager #23 documented she contacted the urologist regarding the hematuria, the resident refused a scope the physician recommended in 7/2015, and if the resident was willing to follow the recommendations, an appointment could have been made at that time. - On 12/8/2016 at 5:35 AM, there was no hematuria noted during the night shift. During a telephone interview with NP #24 on 12/22/16 at 4:35 PM, he stated he spoke with RN Manager #23 regarding the urology appointment, he was aware the resident was non-compliant in 7/2015, and the urologist requested confirmation the resident would be compliant before making an appointment. He stated the RN Manager was to follow up with the resident's family to determine if they thought the resident was able to proceed or if they felt it would create too much distress for him. He stated he was aware the hematuria had ceased, and wanted the resident's vital signs monitored and family input regarding the decision to follow through with urology. The NP stated if the family wanted to proceed, he would have called the urologist to push the appointment, given the urologist's expressed concerns about the resident's past non-compliance. He stated he had not heard back from RN Manager #23 about the situation. When interviewed on 12/22/2016 at 4:55 PM, RN Manager #23 stated she did not speak to the resident or family about the urology consultation. Her understanding of NP #24's orders were to keep him updated if hematuria returned. She stated she was not asked to follow up with the family about their wishes to pursue an appointment with the urologist, and did not have orders for daily vital signs. During a review of the resident's medical record on 12/22/2016 at 6:25 PM, there was no further documentation found regarding daily monitoring of the resident's vital signs (as ordered on [DATE]), or of any follow-up with the resident, his representative, the physician, or the urologist regarding status of the urology appointment. 10NYCRR 415.12

Plan of Correction: ApprovedMarch 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #2 returned from a hospitalization on [DATE] with a foley catheter in place. A trial removal was done on 1/4/17 that was not successful with foley catheter replaced. Resident has a [DIAGNOSES REDACTED].
Resident #25 area on back is now closed. She has no skin areas that are being followed. She was readmitted with a full skin assessment completed and no new orders for tracking were necessary.
2. How you identify other residents having the potential to be affected by the same deficient practice:
All residents who have an ordered consult have the potential to be affected.
All residents with skin alterations identified on admission or as a new area.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All residents who have an ordered consult will be reviewed in the facility to ensure appropriateness and that routine follow up has been scheduled/followed. All residents with consult orders will be maintained by the unit manager and reviewed quarterly with the MD.
All residents admitted or noted with skin areas will have a skin tracking sheet initiated immediately. MD will be notified of the skin area and obtain order for treatment when the area is identified.
All nurses will receive education on the process for determination of whether identified skin areas are pressure-related or not. Wound referrals will be completed for all pressure wounds. A non-pressure tracking form will be completed for any skin alteration other than a pressure wound. The MD will be notified and telephone order obtained at the time the wound is identified.
The Skin inspections/assessment Policy and Procedure will be updated to reflect that the MD will be notified and an order is obtained at the time a non-pressure area is identified.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
An audit tool will be used to identify all residents in the facility with an active consult. Residents with active consult orders will be audited to ensure that they are being followed routinely and that recommendations have been documented. This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the unit managers. The sample will include 5 Residents per unit for a total of 25 Residents. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis
An audit tool has been developed to monitor skin areas that have been identified in the facility to ensure that a skin tracking sheet has been completed, MD was notified with order obtained, and that weekly documentation has been completed. This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the unit managers. The sample will include 5 Residents per unit for a total of 25 Residents. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis

5. Responsible Party: Director of Nursing or Designee

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident?s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician?s, nurse?s, and other licensed professional?s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

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 maintain clinical records on each resident in accordance with accepted professional standards and practices, and are complete and accurately documented for 2 of 25 residents (Residents #2 and 23). Specifically, the facility was unable to provide documentation that the toileting plans for Residents #2 and 23 were documented and maintained in the residents' records. Findings include: 1) Resident #2 had [DIAGNOSES REDACTED]. The certified nurse aide (CNA) care plan (care instructions) dated 7/13/2016 documented the resident was incontinent and was on an every two hour toileting plan. The comprehensive care plan (CCP) dated 8/26/2016 documented the resident was at risk for falls due to dementia and behaviors. Approaches included a toileting plan, and the CCP documented to refer to the care sheet for specifics. The resident sustained [REDACTED]. Incident reports dated 8/26, 9/2, 9/6, 9/8, 9/9, 9/10, 9/13, 9/15, 10/5, 10/9, 10/21, and 11/1/2016 were incomplete to rule out abuse, neglect, or mistreatment and there was no documentation of CNA care sheets (toileting flowsheets) used by staff during that time period to determine if care was provided as care planned (refer to F225 for details). During an interview with the Director of Nursing (DON) on 12/23/2016 at 10:00 AM, she stated if a resident was on a one or two hour toileting plan, there would be a current toileting flowsheet in the binder on the unit, and the prior months' toileting flowsheets were kept and retained in the resident's medical record. The DON stated the incident reports regarding the resident's falls did not include the times the resident was last toileted, as the toileting flowsheets were used to verify the care plan was followed. Toileting flowsheets for 8/2016 - 12/2016 were requested on 12/22/2016 at 6:03 PM and only the flowsheets for 12/2016 was received. Toileting flowsheets for 8/2016 - 11/2016 were requested again on 12/22/2016 at 7:50 PM, and the facility was unable to provide them prior to the exit of the recertification survey. 2) Resident #23 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 7/27/2016 documented the resident was incontinent of urine, had a history of [REDACTED]. The resident was to become more independent with positioning, exercising, and increase her ability to do more for herself. Staff were to provide activities of daily living (ADLs) as required, including providing toileting on a toileting plan. Staff were to provide care per the resident's care sheet, and were to see the care sheet for any specifics and document any alterations. Incident reports dated 10/2/2016 and 10/16/2016 documented the resident sustained [REDACTED]. The incident reports were incomplete to rule out abuse or neglect and there was no documentation of the certified nurse aide (CNA) care plan (care instructions, care sheets) used by staff during that time period to determine if care was provided as care planned. The resident's CNA care plans active from 10/1/2016 - 12/22/2016 were requested by the surveyor on 12/22/2016. The facility provided the surveyor with a CNA care plan dated 12/22/2016. The facility was unable to provide CNA care plans that were active in 10/2016 and 11/2016. 10NYCRR 415.22(a)(1,3)(f)(3)

Plan of Correction: ApprovedMarch 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #2 toileting flow sheets have been reviewed. Resident is consistently incontinent and is placed on an incontinence management plan.
Resident #23 has an active CNA care plan in place that is maintained in her medical record.
2. How you identify other residents having the potential to be affected by the same deficient practice:
All resident's medical records that require manual data input are potentially at risk for omissions.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All residents will have a CNA care plan that is completed on admission. This will be the residents active plan of care for all staff to follow. This care plan is reviewed on an at least quarterly basis with a new hard copy generated to reflect any changes made. Non-active care plans will be maintained in the medical record.
All members of the IDT and medical records staff will receive education about maintaining active care plan cards for staff to ensure the care plan is being followed and delivered. The education will include assurance that all non-active care plans are filed with medical records.
All residents in the facility who are on a scheduled toileting plan will be reviewed for completion and appropriateness.
All residents on an incontinence management plan will follow a routine toileting protocol.
All nursing staff will receive mandatory education on the proper routine for incontinence management plans. The CNA will initial on the CNA care card that incontinence management was completed.All residents who are on a scheduled toileting plan will have a sheet placed in the care plan to be signed and initialed during the scheduled times for a 24hr time period. The sheets will be reviewed every shift for completion.
All signed incontinence management cards and scheduled toileting flow sheets will be completed and maintained in medical records.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
A single audit tool has been developed to monitor CNA care plan's to ensure they are initiated and active according to the IDT review dates, toileting plans are clearly identified and completed. It will also include a review of resident records that are no longer in the active record to ensure they are appropriately retained. This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the unit managers. The sample will include 10 Residents per unit for a total of 50 Residents. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5. Responsible Party: Director of Nursing or Designee

FF10 483.10(e)(1), 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). 42 CFR §483.12, 483.12(a)(2) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms. (a) The facility must- (1) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident?s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure for 1 of 3 residents (Resident #3) reviewed for restraints, the device was the least restrictive alternative for the least amount of time, and did not document ongoing re-evaluation of the need for the restraint. Specifically, Resident #3 had a scoot chair, it was not determined if it was the least restrictive device for the resident, it was not fully assessed as a restraint when initiated, the physician and health care proxy (HCP) were not notified when initiated, and the device was not thoroughly assessed on a quarterly basis. Findings include: Resident #3 had [DIAGNOSES REDACTED]. The facility's Physical Restraint and Potential Restraint Devices policy revised 2/21/2012 defined a restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. It further documented that a potential restraint device evaluation must include evidence that the least restrictive device had been tried unsuccessfully, a registered nurse (RN) assessment, the physical therapist was to assess the resident's physical status and possible use of a less restrictive device, the social worker was to meet with and educate the resident/designee, and the attending physician was to provide an order for [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive assistance for activities of daily living (ADLs). She was in a restorative walking program, and did not use a restraint. A nursing progress note dated 5/25/2016 at 10:25 AM documented the resident routinely attempted to self-transfer and self-ambulate, resulting in falls. She was provided with a scoot chair (low positioning chair that reduces fall risk and encourages user to self-propel with feet). She could not safely rise or ambulate independently from the scoot chair, and the scoot chair would be a potential restraint. The resident was on a two hour toileting schedule to allow for release, and the resident could self-propel in the chair. There were no progress notes found that documented the resident's HCP or physician were notified regarding the use of the scoot chair or discussion of the risks and benefits. The facility's Potential Restraint Device Evaluation form updated 5/25/2016 documented the resident had a scoot chair, it was a potential restraint, the resident required assistance of two people, she could not safety rise on her own, and the chair provided the safest option for positioning. The form documented the resident was cognitively aware of the device's purpose and she was physically able to unfasten the device. Other areas on the form were incomplete including the resident's medical condition that warranted the use of a restraint, evaluation of less restrictive alternatives, and notification of the responsible party. The comprehensive care plan (CCP) updated 5/25/2016 documented the resident had a scoot chair as a potential restraint. There were no other interventions documented regarding the use of the scoot chair, or notification of the resident's HCP or physician. The certified nurse aide (CNA) care plan (care instructions) updated 5/25/2016 documented the resident used a scoot chair and was on a two hour toileting schedule. There were no release or repositioning instructions documented for the use of the scoot chair. A physical therapy (PT) progress note dated 6/3/2016 documented the resident's positioning in the scoot chair was assessed and found to be safe. There was no documentation regarding the use of the scoot chair as a restraint or the resident's ability to rise from the chair. A social services progress note dated 6/3/2016 documented the resident's HCP attended a meeting and was advised the resident had been using a scoot chair. There was no documentation that the HCP was notified of risks versus benefits of restraint use. Nursing progress notes documented the following: - On 5/31/2016 at 1:41 PM, the resident stood from the scoot chair, grabbed for the hand rail, and slipped to the floor. - On 6/1/2016 at 9:38 AM, follow-up to 5/31/2016 incident report, dietary staff witnessed the resident sliding out of the scoot chair and the incident report documented she tried to stand from the chair. - On 6/2/2016 at 8:25 PM, the resident was agitated, kicking out, and attempting to stand repeatedly. - On 6/25/2016 at 1:06 PM, the resident was in the scoot chair most of the shift and made multiple attempts to climb out of the chair. - On 6/26/2016 at 10:13 PM, the resident was observed sliding out of the scoot chair, kicking her legs out, swinging her arms, and grabbing rails and anything else to help her stand. - On 6/27/2016 at 9:01 PM, the resident continued to attempt to climb out of the chair, and was standing up. - On 6/30/2016 at 10:13 PM, the resident was kicking out and trying to slide out of her chair. - On 7/3/2016 at 5:06 PM, the resident was found sitting in front of her scoot chair. - On 7/15/2016 at 10:15 AM, the resident was found at 8:00 AM laying on the floor in the dining area. She stated she was trying to look out the window, and was placed back in her chair. A nursing progress note dated 7/18/2016 documented the resident's scoot chair was considered a restraint, the interdisciplinary team (IDT) agreed, and the scoot chair provided the safest position to prevent injury from falls. A physician order [REDACTED]. The facility's Potential Restraint Device Evaluation form dated 7/18/2016 documented the scoot chair was a restraint and provided safest positioning, as the resident had multiple falls. The form documented the resident was not physically able to unfasten the device and was not cognitively aware of its purpose. Other areas on the form for assessment included medical condition that warranted use of a restraint, when the condition was exhibited, and evaluation of less restrictive devices. The resident's [DIAGNOSES REDACTED]. A wheelchair was noted as the device evaluated and a less restrictive alternative with no further information included. Additionally, there was no documentation that the responsible party (HCP) was notified/consented to the restraint use or that the interdisciplinary team reviewed the restraint. A physician order [REDACTED]. The CCP initiated 7/19/2016 documented the resident required a restraint due to poor cognition and safety awareness and a scoot chair was used when out of bed. The approaches included to obtain a physician order, evaluate the device at least quarterly to ensure the least restrictive device was being used, obtain consent for the device, release it at least every two hours, and monitor for complications of restraint use. A social services progress note dated 7/21/2016 at 3:22 PM documented the resident's HCP was contacted regarding care related to advance directives, hospice, and comfort care. It was documented the resident was unable to make health care decisions. There was no documentation that the HCP was consulted about the scoot chair being determined as of 7/18/2016 to be a restraint for the resident, or advised of the risks and benefits of use of the device. The MDS assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive assistance for ADLs. She used a restraint daily, which was a chair that prevented rising. The CNA care instructions dated 11/10/2016 documented the resident was ambulatory with assistance, was alert, confused, and may be delusional. She used a scoot chair, and it was to be released every two hours for at least 10 minutes. The resident was observed in the scoot chair in the reclined position during the following times: - On 12/20/2016 from 11:05 AM - 11:29 AM; - On 12/21/2016 at 12:45 PM and 3:12 PM; and - On 12/22/2016 at 8:30 AM and 2:09 PM. When interviewed on 12/21/2016 at 12:50 PM, registered nurse (RN) Manager #23 stated there were no other restraint device assessments in the resident's medical record, quarterly assessments were reflected in the MDS and IDT review documentation, and there was no PT or occupational therapy involvement in assessment of restraint devices. PT assessed for safe positioning in the scoot chair, and the MDS coordinator completed the restraint assessments for the quarterly review. CNA #26 stated during an interview on 12/22/2016 at 3:13 PM that the resident often tried to stand from the chair and it was usually in the reclined position. She was unaware of any specific instructions regarding positioning of the chair. During an interview on 12/22/2016 at 3:28 PM, the MDS Coordinator stated that restraint assessments were completed at admission, quarterly, and when resident's staus changed. She stated she did not complete the restraint assessments for the quarterly MDS, rather she verified it was in use by visual observation of the resident and verification of the restraint sheet in the resident's record. The MDS coordinator stated the IDT reviewed restraints in their meetings and signed off on restraint use and assessment. She stated if the restraint form was not updated at the time of the next MDS assessment, nursing was responsible for updating and assessing the restraint and completing the form. The Assistant Director of Rehabilitation stated on 12/22/2016 at 3:46 PM that a scoot chair was a restraint if the resident was unable to stand up from the chair. The scoot chair was considered a restraint for the resident, as she could not stand from the chair when in the reclined position. He stated the rehabilitation department did not review restraints on a regular basis; a referral would have to come from nursing in order to reassess a device. He stated the resident's chair was assessed for positioning in 6/2016. During a follow up interview with RN Manager #23 on 12/22/2016 at 4:55 PM, she stated restraint devices were evaluated quarterly to determine if appropriate and safe, and the person who did the MDS was responsible for assessment. The rehabilitation department was involved only if referred by nursing, and there was not a quarterly review done for the resident's restraint. She stated when the chair was put into use initially on 5/25/2016, it was a trial for a potential restraint and it was not considered a restraint until 7/18/2016 when the IDT reviewed it. The RN Manager stated the chair was a restraint, as the resident was unable to stand from the chair while in the reclined position. She added when a new device was initiated, the IDT reviewed it, the rehabilitation department assessed it for safety, it would be added to the care plan, and the physician should be notified at that time. She verified the physician was notified on 7/18/2016 for the order, but not prior to that date. During an interview with nurse practitioner (NP) #24 on 12/22/2016 at 4:35 PM, he stated he expected to be notified of a restraint device in use at the time the device was implemented. 10NYCRR 415.4(a)(2-5)

Plan of Correction: ApprovedMarch 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident # 3 utilizes a scoot chair that is considered a restraint. PT/OT will evaluate resident's positioning, safety, and what alternative devices can be trialed if appropriate. The restraint evaluation has been updated to reflect resident's medical condition and what devices were trialed prior to the implementation of the scoot chair. This will be updated with recommendations of PT/OT and the IDT. The resident's HCP and MD are aware that the scoot chair is considered a restraint and the HCP has been advised of the risks and benefits of its use.

2. How you identify other residents having the potential to be affected by the same deficient practice:
All residents that utilize a scoot chair have the potential to be affected.

3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All residents who currently utilize a scoot chair will be evaluated by PT/OT to determine if use of chair is appropriate, and if alternative measures are appropriate. The IDT will evaluate whether the scoot chair is a restraint prior to implementing the device. All of the following will be included once a restraint is determined: What medical conditions warrants use of restraint, what less restrictive alternatives have been used or evaluated, if the responsible party was notified and MD will be notified by obtaining a physicians orders, and a release schedule will be documented. This will be documented on an informed consent/Notification for restraint form signed by the responsible party and MD. This will be maintained in the medical record. A restraint release form will be placed in the care plan to document times and days of release when the chair is in use.
All restraint evaluations will be reviewed on admission, quarterly, annually, and as needed by the IDT. Nurse manager/designee will be responsible for reviewing and updating the form. If no changes are needed it will be dated and initialed.
All IDT staff will receive mandatory education regarding review of restraint evaluations and process for implementation of any scoot chair or other device that can be considered a restraint.

4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
An audit tool has been developed to monitor completion of restraint evaluations, completion of restraint evaluations to include PT/OT evaluation prior to implementing a scoot chair or device that could potentially be a restraint, what medical conditions warrants use, what alternative measures were trialed, care planning, identification of restraint, that responsible party/MD was notified and consented for its use, and proper paperwork was completed. This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the unit managers. The sample will include all residents who utilize a scoot chair or any device that is considered a restraint. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5. Responsible Party: Director of Nursing or Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

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 all residents had the right to participate in care planning for 1 of 15 residents (Resident #11). Specifically, Resident #11 was not invited to attend her interdisciplinary care plan meeting on at least an annual basis. Findings include: Resident #11 had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, it was important for family and close friends to be involved in discussion of care, and the resident participated in the assessment. The certified nurse aide (CNA) care plan (care instructions) documented the plan of care was reviewed on 7/30/2016. The comprehensive care plan (CCP) documented the interdisciplinary team reviewed the CCP on 8/3/2016. The CCP documented the resident had comorbidities and concerns including: [DIAGNOSES REDACTED]. The resident wished to self-direct involvement in daily events and in facility life. Staff were to allow the resident to verbalize concerns regarding plan, involve the resident in decision making, provide choices regarding care, and the resident's preferences would be upheld. An interdisciplinary team (IDT) annual review note dated 8/3/2016 documented the resident's plan of care was reviewed, including medical concerns and resident preferences. There was no documentation the resident was offered or invited to attend the meeting. An IDT quarterly note dated 11/3/2016 contained no documentation the resident was offered or invited to attend the meeting. During an interview with the resident on 12/21/2016 at 11:15 AM, the resident stated she had not attended or been invited to a meeting regarding her planned care within the last year. During an interview with the Director of Social Services on 12/22/2016 at 4:25 PM, she stated the Administrative Assistant sent invitations to the family (designated representative) prior to the initial, annual, and significant change care planning meetings. The social workers from each floor were responsible for inviting the residents, or sometimes the family invited the resident. She stated it should have been documented in the IDT note if the resident was invited, whether they accepted or declined to attend. 10NYCRR 415.11(c)(2)(ii)

Plan of Correction: ApprovedMarch 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #11 will be invited to meet with the interdisciplinary team for all care plan meetings.
2. How you identify other residents having the potential to be affected by the same deficient practice:
All residents and/or resident representative that were noted to not attend a recent interdisciplinary care plan meeting has the potential to be affected. Scheduled care plan meetings from the last 90 days have been reviewed and no other residents have been identified.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
A policy for resident/family participation has been written. Social service staff or designee will be responsible for inviting each resident and/or families to care planning meetings. Social service staff will document in the resident medical record whether the resident and/or resident representative declined invitation to meet if not in attendance. If declined, resident and/or family will have the opportunity to review the plan of care, goals, and recommendations of the care planning team and participate in their care planning process. Social service staff education will be conducted to review the process of inviting residents.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
An audit tool has been developed to monitor compliance with invitations to care plan meetings. This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the social services staff. The sample will include 2 Residents per unit for a total of 10 Residents. The threshold for compliance will be 100% for 3 months, then as directed by the QAPI committee. Results of the audit will be reported to and evaluated by the QAPI Committee
5. Responsible Party: Director of Social Services

FF10 483.10(e)(2)(i)(1)(i)(ii):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- (i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure a safe, clean, comfortable, and homelike environment for 4 of 5 residential units (Knapp Unit, Newell Unit, Bosworth Unit, and Milligan Unit). Specifically, these units had multiple doors that were chipped/disrepaired, and there were multiple loose handrails and damaged/torn equipment. Findings include: On 12/19/2016 at 12:10 PM, a surveyor on the Knapp IJ Unit observed room I5 had a scraped nightstand. On 12/19/2016, between 2:45 PM and 4:13 PM, a surveyor on the Knapp IJ Unit observed the following: - the door to room J4 was chipped; - in the J26 shower room there was a charger box that was secured to a sit to stand device with tape; - in the J24 clean utility room there was a wheelchair with torn/disrepaired foot rest pads; - the door to room J6 was chipped; - the handrail located outside room J13 was loose; - the IJ12 tub room had two 1-1/2 inch holes in the ceiling; and - the handrail located outside room I33 was loose. On 12/19/2016 at 4:46 PM, a surveyor on the Newell A Unit observed the door to A12 was chipped. On 12/20/2016, between 9:45 AM and 9:55 AM, a surveyor on the Newell A Unit observed the following: - the doors to room A21 and A22 were chipped; and - the A unit high side lounge had two torn/damaged chairs in it. On 12/20/2016 at 10:19 AM, a surveyor on the Bosworth B Unit observed the handrails on the wall outside rooms B15 through B27 were loose. On 12/20/2016, between 11:11 AM and 11:15 AM, a surveyor on the Milligan FGH Unit observed the following: - in room H8 there was a foam fall pad on the floor that was torn/ripped; and - the floor around the FGH unit kitchenette refrigerator was dirty/not clean. During an interview on 12/21/2016 at 11:27 AM, the Administrator stated the monthly rounds completed by the facility included rounds on a full unit and random rooms. During an interview on 12/21/2016 at 11:50 AM, the Director of Maintenance stated if housekeeping and other staff on the resident units saw an issue, they would have filled out a work order, which was located at each nursing station. He stated doors were checked for proper latching and general integrity, and were not checked for chipping or damage at the edges of the doors. During an interview on 12/21/2016 at 12:19 PM, the Food Service Manager stated every other week, kitchen staff would pull out the kitchenette refrigerator on every unit and sweep and mop the floor around the area. At least four times a week the Food Service Manager observed the unit kitchenettes. During an interview on 12/21/2016 at 2:16 PM, maintenance worker #11 stated when a door was damaged, it was usually sanded, then stained for cosmetic reasons. If the door was beyond repair, he would bring it to the attention of the Director of Maintenance. 10NYCRR 415.5(h)(1)

Plan of Correction: ApprovedMarch 17, 2017

1.What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
On the Knap neighborhood, the scraped nightstand was replaced. The doors to rooms J4 and J6 were repaired. The tape was removed from the sit to stand device and the charger box was evaluated and found to be appropriately fastened to the machine. The padded footbox found on the wheelchair was replaced. The handrails outside room J13 and I33 were secured to the wall. The holes in the tub room ceiling were repaired.
On the(NAME)neighborhood, the doors to rooms A12, A21, and A22 were repaired. The chairs in the high side lounge were also repaired.
On the Bosworth neighborhood, the handrails between B15 and B27 were secured.
On Milligan neighborhood, the fall pad in room H8 was replaced and the floor was cleaned around the refrigerator.
2.How you identify other residents having the potential to be affected by the same deficient practice:
All areas of the building are at risk for chipped doors, damaged walls/ceilings, torn chairs and pads, and loose handrails due to high traffic and use of mechanical equipment. The kitchenettes located on each neighborhood have the potential for soiled floors due to heavy use.
3.What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All other Resident areas within the facility will be inspected for chipped doors and loose handrails, torn chairs and pads, ceiling damage, and soiled kitchenette floors.
Work orders will be generated for all necessary repairs and will be systematically corrected. Full house staff education will be performed regarding completion of work orders. Food service staff education will be performed regarding cleaning schedules.
4.How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
Environmental rounds will be conducted at least monthly. During rounds, work orders will be generated to address any repairs that are required, including damaged doors, loose handrails, damaged chairs and pads, damaged equipment, ceiling damage, and kitchenette floors.
Environmental rounds, and an audit of timely completion of work orders will be conducted monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5.Responsible Party: Director of Maintenance Services

FF10 483.24(a)(1):TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS

REGULATION: (a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not provide services to maintain or improve the ability for 2 of 25 residents (Residents #17 and 21) to carry out activities of daily living (ADLs). Specifically, Residents #17 and #21 were not provided toileting assistance as care planned. Findings include: 1) Resident #17 had [DIAGNOSES REDACTED]. The certified nurse aide (CNA) care plan (care instructions) updated 12/2/2016 documented the resident required the assistance of 1 person for toileting and was incontinent daily. The resident was on a toileting plan and was to be toileted every 2 hours and as needed (prn). The comprehensive care plan (CCP) revised 12/3/2016 documented the resident had a loss of ability to complete ADLs independently. The resident was on a toileting plan to maintain her current level of continence. Resistance to care was to be documented and she was to be redirected when upset. Prompt toileting was to be provided to prevent agitation. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and wandered most days. She required extensive assistance with toileting, and supervision with transfers and ambulation. The MDS documented the resident was frequently incontinent of urine, occasionally incontinent of bowel, and was on a urinary toileting program. The resident was observed on 12/19/2016 at 5:25 PM walking into the dining room. CNA #10 assisted her in sitting down at the table. The resident was observed wearing light gray pants, with a large wet area in the thigh and peri area of her pants. The CNA toileting flowsheet was observed by the surveyor on 12/19/2016 at 5:28 PM and toileting was documented on 12/19/2016 for the time periods of 12:00 - 12:59 AM, 2:00 - 2:59 AM, and 4:00 - 4:59 AM. There was no further documentation for 12/19/2016 pertaining to toileting the resident on this date. The resident remained at the table until 6:10 PM on 12/19/2016 when the Director of Nursing (DON) was observed walking her back to her room and was heard saying, Let's go to the bathroom. When the resident stated she did not need to go, the DON whispered, You need to be changed, you are all wet. At 9:16 AM on 12/20/2016, the resident's toileting flowsheet was observed and toileting was documented for the night shift for 12/20/2016. The flowsheet was blank for toileting for the day and evening shift for 12/19/2016, and from 5:00 AM - 9:16 AM on 12/20/2016. During the resident group meeting held on 12/20/2016 at 10:00 AM with 11 anonymous residents in attendance, 4 residents stated they frequently did not receive incontinence care as planned. During an interview with CNA #10 on 12/21/2016 from 10:33 AM - 11:10 AM, she stated if a resident was on a toileting plan, the CNAs were to document on the flowsheet as closely to the time they were toileted as possible. She said days began the toileting at 6:00 AM, and she did not know why the resident's flowsheet was blank for the day shift. CNA #10 stated the staff were to document even if the resident refused. CNA #10 was responsible for the resident during one of the shifts on 12/19/2016. She said she informed the DON when she realized she had not documented for that date, and completed the form the following day. No reason was provided for the lack of timely documentation. The resident was observed on 12/21/2016 from 2:55 PM - 5:08 PM and was not toileted during that time period. At 5:08 PM, the resident was seated in the dining room, beginning to eat her supper meal. 2) Resident #21 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 12/3/2016 documented the resident had stress incontinence and was on a toileting plan and to see the care sheet for specifics. The CCP documented that incontinence placed the resident at risk for altered skin integrity, infections, and altered self esteem, and to to utilize the toileting plan. The certified nurse aide (CNA) care plan (care instructions) dated 12/4/2016 documented the resident had stress incontinence, was on a toileting plan, and was not to be left alone in the bathroom. The CNA instructions documented conflicting information. The toileting needs section of the instructions documented that toileting needs were to be provided every 2 hours and every 4 hours, and both had a line crossed through them. The area documenting PRN (as needed) was checked. A handwritten D/C (discontinue) was written next to toilet every 4 hours. There was nothing written next to toilet every 2 hours. The CNA instructions documented the resident transferred with assist of 1 with a guard. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She required extensive physical assistance of two persons for toileting, was frequently incontinent of urine, was currently on a toileting program or trial, and was on a daily diuretic (water pill). A toileting flowsheet for 12/2016, documented as active 12/1-12/19/2016, documented the resident was to be toileted every 2 hours and prn. There was no documentation the resident was toileted every 2 hours as planned on: - 12/1 from 2:00 PM - 11:59 PM; - 12/9 from 6:00 AM - 2:00 PM; - 12/10 from 2:00 PM - 11:59 PM; - 12/11 from 4:00 PM - 11:59 PM; - 12/13 from 6:00 AM - 11:59 PM; and - 12/15/2016 from 2:00 PM - 11:59 PM. During the resident group meeting held on 12/20/2016 at 10:00 AM with 11 anonymous residents in attendance, 4 residents stated they frequently did not receive incontinence care as planned. During an interview with CNA #27 on 12/22/2016 at 4:40 PM, the CNA reviewed the resident's CNA care sheet. She stated it was difficult to read what time frame the resident was to be toileted. She stated the resident should have been toileted every 2 hours and prn. The CNA stated she asked the resident twice per shift if she needed to be toileted and she did not always get to toileting the resident every 2 hours. She stated if toileting was not provided, she would copy the level of assistance from the previous shift/date and write it on the toileting sheet, even if she did not provide the toileting because I know that's her normal routine. During an interview with registered nurse (RN) Manager #16 on 12/22/2016 at 5:00 PM, she stated CNA care instructions would document if a toileting plan was in place. She stated the medication nurse was responsible for making sure that care was provided and care sheets were completed. She stated if a resident was on a toileting plan, it should be provided and documented. She stated if staff were unable to provide care, they should notify the Charge Nurse or Nurse Manager. 10NYCRR 415.12(a)(2)

Plan of Correction: ApprovedMarch 17, 2017

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #17 no longer resides in the facility.
Resident #21's care plan was reviewed by the IDT and determined that a toileting of every 2 hours was appropriate to adequately manage her toileting needs. Staff were informed of the plan.
2. How you identify other residents having the potential to be affected by the same deficient practice:
All residents who are on a scheduled toileting plan could potentially be affected.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All residents in the facility who are on a scheduled toileting plan will be reviewed for completion and appropriateness. All residents who are on a scheduled toileting plan will have a toileting sheet to be signed and initialed during the scheduled times for a 24hr time period. The sheets will be reviewed every shift for completion.
Scheduled toileting plans will be reviewed at the IDT meetings to ensure that the proper plan is in place for each resident and make changes as needed.
Education will be provided to all nursing staff regarding the importance of toileting plans, dignity, and completeness of documentation reflecting care provided. In addition, the education will include the role of the licensed nurse, oversight to ensure toileting plans have been implemented and followed appropriately.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:

An audit tool will be used to review residents who are on a scheduled toileting plan to ensure that it is being followed according to the care plan, that staff are toileting the residents per this plan, and that the plan is being signed appropriately. This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the unit managers. The sample will include 5 Residents per unit for a total of 25 Residents. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5. Responsible Party: Director of Nursing or Designee

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2016
Corrected date: February 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure residents with pressure ulcers received the necessary treatments and services needed to promote healing for 2 of 3 residents (Residents #4 and 5). Specifically, Resident #4's skin impairments were not identified and treated timely after admission. Additionally, the resident's pressure ulcer was not treated as care planned, and when a treatment was administered, it was done without a physician order. Resident #5 had a deep tissue injury (DTI) on her right heel that was not adequately assessed to ensure healing. Findings include: The facility policy Skin Inspections/assessment dated [DATE] documented the resident's skin would be evaluated by a licensed practical nurse (LPN) or registered nurse (RN) on the day of admission or readmission to the facility and documented on the Nurses' Admission Evaluation form. If an alteration in skin was identified, the licensed nurse would notify the physician to obtain a treatment, the RN would stage the wound and update the care plan, and the pressure ulcer would be assessed by an RN weekly. 1) Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. She was at risk of developing pressure ulcers and required extensive assistance for bed mobility, transfers, toileting and bathing. The comprehensive care plan (CCP) dated 10/27/2016 documented the resident was at risk for developing pressure ulcers. Interventions included to turn and position every 2 hours while in bed, and provide a pressure reduction mattress and chair cushion. ADMISSION SKIN ASSESSMENT The nursing progress note dated 10/19/2016 documented Resident #4 was admitted after a surgical repair of the left femoral neck. The admission note did not contain any documentation regarding the status of the resident's skin. A non-pressure wound evaluation and documentation form documented on 10/19/2016 the resident had a surgical incision to the left hip and treatment included [MEDICATION NAME] (foam dressing). There was no documentation a full assessment including status of the surgical site was completed on the evaluation. The nursing admission evaluation form dated 10/19/2016 included an area for nursing to complete a full skin assessment. This portion of the admission evaluation was left blank. There was no documentation regarding the status of the resident's skin, the surgical site, or if the site had a non-removable dressing. The 10/19/2016 Braden Scale Plus (tool used to assess risk of developing pressure ulcers) documented the resident's sensory perception was slightly limited, she was chair fast, mobility was very limited, nutrition was probably inadequate, and friction and shearing was a potential problem. The tool documented the resident did not have a history of pressure ulcers and she was identified as at high risk for pressure ulcer development. The admission physician order [REDACTED]. There was no documentation regarding the resident's skin status until 10/21/2016. A nursing progress note dated 10/21/2016 documented the dressing on the left hip had come off and the resident had a surgical incision containing 4 staples on the left hip. A nursing progress note dated 10/23/2016 documented the resident had some areas of excoriation on her left and right ischial (sitting bone). Will track as pressure. The areas on her right ischial were open and the left ischial had some redness. In addition, the resident had an incision on her left hip that did not have any signs or symptoms of infection. A wound referral form dated 10/23/2016 documented the resident had a Stage I (skin alteration) pressure ulcer on the left ischium. On the right ischium the resident had 2 Stage II (partial thickness skin loss) pressure ulcers that measured 0.7 centimeters (cm) x 0.5 cm, and 0.5 cm x 0.6 cm. Extra protective cream treatment was ordered and the resident's wheelchair cushion was changed to a Roho cushion (pressure reducing cushion). During an interview with registered nurse (RN) #4 on 12/21/2016 at 10:40 AM, she stated a skin assessment was completed on every resident admitted to the facility. RN #4 stated the resident's skin assessment would be documented on the nurses' admission evaluation form and in the nursing admission progress note. She stated if the resident did not have any skin issues, she would document no issues in both places. During an interview with RN #2 on 12/21/2016 at 11:05 AM, she stated she was the clinical leader on the unit and she would expect a skin assessment to be completed on each resident upon admission to the facility. She stated the skin assessment would be documented on the nurses' admission evaluation form. She was not sure if the resident had come to facility with pressure ulcers or if she had developed them after admission. RN #2 reviewed the resident's admission skin assessment, and stated it did not look like a skin assessment was completed on admission. During an interview with RN #9 on 12/21/2016 at 11:20 AM, she stated when a resident was admitted she would document her skin assessment on the nurses' admission evaluation form, as well as in a nursing progress note. She stated if she observed any pressure related areas, she would fill out a skin referral form to ensure the areas were monitored weekly and get an order for [REDACTED]. The RN stated the admission skin assessment should have been filled out. She stated the skin referral form was not completed until 10/23/2016, as that was when she decided the excoriation on the buttocks should be tracked weekly as pressure related. TREATMENT ORDERS The treatment administration record (TAR) documented to apply extra protective cream to Resident #4's right and left ischium (hip sitting bones) skin areas for protection. The TAR documented the treatment was initiated on 10/24/2016 and discontinued on 12/13/2016. A wound referral form dated 12/13/2016 documented the resident had an Unstageable pressure ulcer on the left ischium that was covered with 100% slough (moist dead tissue). The pressure ulcer measured 0.7 centimeters (cm) x 1.6 cm. The treatment was extra protective cream. A physician telephone order dated 12/13/2016 documented to apply extra protective cream to the area on the left ischium and cover with a protective dressing daily. There was no documented evidence the physician order [REDACTED]. A nursing progress note dated 12/15/2016 documented the resident had an Unstageable pressure ulcer on the left ischium that measured 0.7 cm x 1.6 cm and the wound bed was covered with whitish slough. The progress note documented the pressure ulcer was treated with [MEDICATION NAME] Ag (antimicrobial dressing) and covered with a protective dressing daily. There was no documented evidence in the medical record of an order for [REDACTED]. The resident's physician orders [REDACTED]. During a treatment observation on 12/20/2016 at 1:50 PM with registered nurse (RN) #2, she removed a protective dressing from the resident's left ischium. The top of the dressing was partially covered with smeared black ink, making the date of the dressing illegible. The dressing contained a small amount of brownish drainage. The pressure ulcer had a pinkish-red moist wound bed. The RN stated the pressure ulcer was no longer Unstageable, as the slough had been removed. The RN measured the pressure ulcer and stated it measured 0.7 cm x 0.6 cm. The RN cleaned the pressure ulcer with normal saline, applied [MEDICATION NAME] Ag to the wound bed, and covered it with a protective dressing. The electronic physician orders [REDACTED]. ischium. During an interview with registered nurse (RN) #4 on 12/21/2016 at 10:40 AM, she stated when the physician wrote a treatment order, he would write it on the telephone order sheet. The nurse would sign the order, indicating she put the order in the computer so it would show up on the TAR. RN #4 stated the electronic TAR was what told the nursing staff what treatments needed to be done and when. She stated there was no other process to alert staff what needed to be administered. During an interview with RN #2 on 12/21/2016 at 11:05 AM, she stated if a treatment order was not input into the computer, it would not show up on the TAR and the treatment would not be completed. She stated she looked at the resident's pressure ulcer on 12/19/2016 and the pressure ulcer was covered with slough, so she decided to try the [MEDICATION NAME] Extra on it and reassess the next day. She stated when she reassessed it the next day on 12/20/2016, the pressure ulcer had improved. She notified the physician, who wrote the order for the [MEDICATION NAME] treatment daily. During an interview with RN #9 on 12/21/2016 at 11:20 AM, she stated when an order for [REDACTED]. She stated she had signed the telephone order for the resident's 10/23/2016 treatment, and could not recall if she had put it in the computer. She stated when she had worked over the past weekend, the treatment did not come up on the TAR indicating it needed to be administered. She stated at that time she figured the treatment was getting completed by the night shift. 2) The facility policy Pressure Ulcer Treatment dated 2/13/2016 documented a suspected deep tissue injury (DTI) was a purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure or shearing. Resident #5 had [DIAGNOSES REDACTED]. The nursing admission evaluation form included a skin assessment dated [DATE] and documented the resident had a DTI on the right heel. A wound referral form dated 12/9/2016 documented the resident had a DTI on the right heel that measured 1.5 centimeters (cm) x 1.5 cm. The comprehensive care plan (CCP) dated 12/12/2016 documented the resident was admitted to the facility with a DTI on the right heel. Interventions included to float heels off the bed and to wear a foam boot when out of bed. A nursing progress note dated 12/13/2016 documented the resident was admitted to the facility with a DTI on the right heel. The injury remained darkened and closed. There was no further assessment of the DTI documented. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and she required extensive assistance for bed mobility, transfers, toileting and bathing. The MDS documented the resident was at risk for developing pressure ulcers, and she was admitted with a Unstageable pressure ulcer with suspected DTI in evolution. During a skin observation on 12/20/2016 at 2:40 PM with registered nurse (RN) #2, the resident had a large DTI on the bottom of her heel that was discolored. The DTI was round in diameter, with the middle a darkish purple color and the surrounding skin was dark red. The RN palpated the area and stated the skin was non-blanchable (congested circulation). The RN stated the DTI was getting better. She stated she did not measure the the DTI as she did not measure DTIs. She stated she would determine the injury was getting better by comparing it to the size of a coin and she would documented that in her progress note when she assessed the area. She stated she would only obtain measurements if the injury opened up. A wound assessment progress note dated 12/20/2016 documented the area remained dark red and was approximately the size of a 50 cent piece. During a follow up interview with RN #2 on 12/21/2016 at 7:25 AM, she stated she had consulted the facility's wound care specialist and was told she should be measuring DTIs to ensure healing and she was going to measure the DTI on the resident's right heel. During an interview with the Director of Nursing (DON) on 12/21/2016 at 8:45 AM, she stated she would expect the RNs to complete measurements on all pressure ulcers when assessed, including DTIs, as that was how they were able to ensure the DTI was improving and not worsening. 10NYCRR 415.12(c)(2)

Plan of Correction: ApprovedMarch 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #4 is currently being treated for [REDACTED]. Her skin tracking sheets and orders have been reviewed and accurate. No new skin alterations have been identified. Measurements are reviewed by wound nurse weekly to monitor for improvements and to verify all steps have been completed in the wound treatment plan.
Resident #5 is currently being treated and assessed weekly for a deep tissue injury on the right heel. Area is being measured weekly by an RN to determine improvement or worsening. Measurements are sent to wound nurse weekly to monitor for improvements and to verify all steps have been completed in the wound treatment plan.
2. How you identify other residents having the potential to be affected by the same deficient practice:
Residents who are admitted with skin alterations or develop new skin alterations (pressure and non-pressure skin areas).
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
On admission each Resident will have a full body visual inspection completed which includes a skin assessment by an RN to ensure that all tracking sheets and orders have been obtained and initiated. The Skin Inspection/Assessments policy will be revised to reflect this. The Pressure Ulcer Treatment Policy will be updated to include that all areas greater than a stage one will be assessed weekly for improvement by visualizing the wound bed, drainage, amount, color, odor, peri-wound, and measuring for size on the tracking sheet. All pressure areas including stage one areas will be visualized during weekly skin rounds to ensure the area has not worsened, and care plan interventions are being followed. If a Resident is assessed with [REDACTED]. Residents with intact skin, who are at risk for developing pressure ulcers will have specific interventions implemented for prevention. The Braden score will be utilized to identify Residents who are at risk for developing pressure ulcers. The licensed nursing staff will be responsible for updating the plan of care, Resident care card with interventions/changes in the Resident specific care plan.
All nurses will receive education on skin admission/readmission evaluations and changes in policy for RN review within 24 hours for accurate staging, tracking, and to ensure all steps have been completed in the skin tracking process including all assessment data that is needed for improvement/worsening. CNA staff will receive education regarding pressure ulcer prevention, and individualized strategies will be located on the Resident care card.
Measurements are sent to wound nurse weekly to monitor for improvements and to verify all steps have been completed in the wound treatment plan.

4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
An audit tool has been developed to monitor admission/readmission skin evaluations, skin areas that have been identified in the facility to ensure that a skin tracking sheet has been completed, MD was notified with order obtained, and that weekly documentation has been completed. This will be audited monthly for 3 months, and then quarterly thereafter until the deficient practice has been corrected. The audits will be completed by the RN unit managers. The threshold for compliance will be 100%. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5. Responsible Party: Director of Nursing or Designee

WAIVER-RN 8 HRS 7 DAYS/WK, FULL-TIME DON

REGULATION: (1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. (2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. (3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: 2016-12-21
Corrected date: 2017-02-20

Citation Details

Details not available

Plan of Correction: N/A

Plan of correction not approved or not required

Standard Life Safety Code Citations

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2016
Corrected date: February 20, 2017

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not ensure the means of egress was continuously maintained free of all obstructions in case of emergency for 1 of 23 exit stairwell exterior discharge pathways (BJI stairwell). The BJI exit stairwell was utilized as an emergency exit stairwell for 2 of 5 units (first floor Bosworth Unit and second floor(NAME)Unit). Specifically, there was snow that was not cleared on the BJI stairwell exterior discharge pathway to the sidewalk. Findings include: On 12/20/2016 at 10:15 AM, after exiting out the first floor exit door within the BJI stairwell, a surveyor observed the exterior discharge pathway to the sidewalk was obstructed by snow that was not cleared off the pathway. The pathway was 295 feet long. At the time of observation, the surveyor identified three emergency exit locations on the first floor Bosworth unit. On 12/20/2016, during review of an undated facility code compliance diagram, a surveyor identified the BJI exit stairwell was utilized as an emergency exit stairwell for the first floor Bosworth Unit and the second floor(NAME)Unit. The Boswell Unit and(NAME)Unit each had a total of three accessible emergency exit stairwells to access in case of emergency. During record review and interview on 12/21/2016 at 11:07 AM, the Administrator stated the facility had a total of 23 exit stairwells, and identified all exit locations on the undated facility code compliance diagram. During an interview on 12/21/2016 at 11:22 AM, the Director of Maintenance stated the uncleared snowfall was from Monday (12/19/2016), and was not aware the BJI stairwell exit exterior discharge pathway was not cleared of snow. He confirmed the snow was about 3 inches in depth and stated this snow would not prevent a resident requiring mobility using a wheelchair from getting to the sidewalk. On 12/21/2016 at 1:37 PM, a surveyor observed the BJI stairwell exterior discharge pathway to the sidewalk was cleared of snow. During an interview on 12/21/2016 at 1:50 PM, maintenance worker #11 stated on Sunday (12/18/2016), the maintenance staff were called into the facility to clear the exit exterior discharge pathways. 2012 NFPA 101 19.2.1, 7.1.10.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 13, 2017

PLAN FOR AFFECTED RESIDENTS:
The identified pathway was cleared of snow at the time of survey.
HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN:
All residents have the potential to be affected.
MEASURES/SYSTEMIC CHANGES TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR/MONITORING OF CORRECTIVE ACTIONS:
All exterior exit pathways will be cleared of snow following a snowfall accumulation that could obstruct exit from the facility. Maintenance staff will be educated on snow removal expectations and all exits will be reviewed. This will be monitored following every snowfall by the Director of Buildings and Grounds to ensure pathway has been cleared for the duration of this winter season.
RESPONSIBLE PARTY:
Director of Maintenance Services

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2016
Corrected date: January 13, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure all smoke barrier doors were smoke resistant for 4 of 16 one hour fire rated smoke/fire barriers observed (Newell Unit entrance fire doors,(NAME)A Unit fire doors, Claxton CDE Unit fire doors, and Milligan H Unit fire doors). Specifically, the(NAME)Unit entrance fire doors,(NAME)A Unit fire doors, Claxton CDE Unit fire doors, and Milligan H Unit fire doors were not smoke resistant. Findings include: On 12/20/2016 at 9:44 AM, a surveyor observed the(NAME)Unit entrance one hour fire rated double doors had an approximately 3/16 inch gap between them, and were not smoke resistant. On 12/20/2016 at 10:00 AM, a surveyor observed the(NAME)A Unit one hour fire rated double doors had an approximately 3/16 inch gap between them, and were not smoke resistant. On 12/20/2016 at 11:11 AM, a surveyor observed the Claxton CDE Unit one hour fire rated double doors had an approximately 3/16 inch gap between them, and were not smoke resistant. On 12/21/2016, between 9:45 AM and 10:00 AM, a surveyor observed the Milligan H Unit one hour fire rated double doors had an approximately 3/16 inch gap between them, and were not smoke resistant. During an interview on 12/21/2016 at 11:38 AM, the Director of Maintenance stated he was not aware the gaps found between the above mentioned double doors were greater than 1/8 inch. He stated maintenance staff had been trained that all fire doors were required to be smoke resistant. During an interview on 12/21/2016 at 2:08 PM, maintenance worker #11 stated when required to check fire doors he checked for gaps between doors, if the doors latched, and if the doors released and closed when the fire alarm was activated. He stated gaps between doors should be 1/8 inch or less. 2012 NFPA 101 19.3.7.6 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 13, 2017

PLAN FOR AFFECTED RESIDENTS:
The unsealed gaps in the identified areas will be addressed with the installation of an astragal.
HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN:
All residents have the potential to be affected as this is a life safety issue.
MEASURES/SYSTEMIC CHANGES TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR/MONITORING OF CORRECTIVE ACTIONS:
All smoke barrier doors will be assessed for gaps and astragals will be installed as needed. This will be monitored at least monthly through environmental rounds. Maintenance staff will be educated on identifying gaps.
RESPONSIBLE PARTY:
Director of Maintenance Services