Samaritan Senior Village, Inc.
January 25, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.25(n)(1)-(4):BEDRAILS

REGULATION: §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 26, 2018
Corrected date: March 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure the correct installation, assessment, education of risk and benefits, use, and maintenance of bed rails, for 2 of 3 reviewed (Residents #94 and 112) for accident hazards. Specifically, there was no documentation Resident #112 was educated on the risks of bed rail use or that the bed rails were assessed by qualified staff prior to their implementation. Resident #94 had bed rails in place and there was no documentation the bed rails were re-evaluated for use or that the resident was educated on the risks. Findings include: 1) Resident #112 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 12/26/17 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with bed mobility, had a fall with injury and did not have restraint devices in place. There was no documentation an assessment was completed on the resident's use of bed rails in the medical record. The 01/18 Device Risk Assessment in the electronic record was blank. The 01/02/18 and 01/24/18 paper risk assessment signature sheets did not contain information related to the resident's use of bed rails. The comprehensive care plan (CCP) reviewed between 12/19/17 and 01/25/18 had no documentation regarding the risk or use of bed rails for the resident. The 01/18 certified nurse aide (CNA) care instructions documented the resident used 2 half side rails for bed mobility. During an interview with CNA #10 on 01/26/18 at 01:06 PM, she stated all the residents in the facility had bed rails on their bed. She automatically would put them in the upright positioning for residents since they were on the beds. She did not know what a bed rail zone was and she had not been educated on the risk of bed rail use while at this facility. During an interview with CNA #11 on 01/26/18 at 01:16 PM, she stated all resident beds had bed rails. She would automatically put both bed rails up on a bed for a resident. The resident had 2 bed rails located at the top of the bed for safety and turning. The resident had a low bed with fall mats as well. During an interview with licensed practical nurse (LPN) #8 on 01/26/18 at 01:28 PM, she stated it would be on the CNA instructions if a resident required the use of a bed rail. She was responsible for initiating a comprehensive care plan and she had not done this for this resident yet. The resident had gone back out to the hospital since his admission. During an interview with registered nurse (RN) Unit Manager #9 on 01/26/18 at 02:17 PM, she stated a lot of residents used bed rails for bed mobility, turning and repositioning. Resident beds would automatically have bed rails on the bed when a resident was admitted to the facility. A Restrictive Device Assessment was completed on admission and would have been completed by the LPN. The RN was responsible for signing off that the assessment was completed. The assessment would document if it restricted a resident from what they were doing. During the interview, LPN #8 entered the interview and participated. Neither the RN Unit Manager or LPN could find an assessment of the resident's use of bed rails or a discussion on the safety risks of bed rail use. The RN was unable to find a CCP that would include a nursing and activities of daily living (ADL) plan of care for the resident that would include the use of bed rails. The RN stated the Restrictive Device Assessment in the electronic system was blank and incomplete. During an interview with MDS Coordinator #12 on 01/26/18 at 03:27 PM, she stated some of the facility's nurse managers would complete their assessments based on the MDS schedule. She stated regardless of the MDS schedule, assessments would still need to be completed on admission and quarterly thereafter and the resident should have had all his nursing assessments completed. 2) Resident #94 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired and required extensive assistance of staff with transferring and bed mobility. The 05/02/17 comprehensive care plan (CCP) documented the resident was at risk of falls and required the assistance of staff with bed mobility. There was no documentation on the CCP regarding the use of bed rails. The Resident Restrictive Device Assessments documented on 07/14/17 did not have a low bed and on 10/12/17 the resident had a low bed. The areas noting the use of bed rails on both of the assessments were blank. The 01/18 certified nurse aide (CNA) care instructions documented the resident used 2 half bed rails for positioning. During an interview with CNA #10 on 01/26/18 at 01:06 PM, she stated the resident required assistance of staff for care. Her positioning would depend on how the resident was feeling on a given day. Resident beds automatically had bed rails on them. Since the beds have them in place she would use them during care. She did not know what zones of entrapment were and could not recall the specifics of safety risk during training on bed rail use. During an interview with CNA #11 on 01/26/18 at 01:16 PM, she stated the resident leaned a lot and her posture could be better. All residents had bed rails on their beds and if they were not to be used, it would be noted on their care sheet. The resident had bed rails in place and she was not sure if the resident used them. During an interview with LPN #8 on 01/26/18 at 01:28 PM, she stated if a resident was to have bed rails it would be on their CNA care instructions. The resident often leaned in her wheelchair. She was responsible for updating the resident care plans based on the MDS, orders, physical therapy/occupational therapy (PT/OT) recommendations and the CNA instructions. The registered nurse (RN) was responsible for reviewing the CCPs after the LPN completed them. During an interview with RN Unit Manager #9 on 01/26/18 at 02:17 PM, she stated a lot of residents used bed rails for bed mobility and turning and repositioning. A Restrictive Device Assessment was to be completed for use of bed rails. The LPN would complete the assessment and she would sign off on them. Resident beds automatically have bed rails on them and then the resident would be screened for their use. They should be reviewed for use and potential safety risks to the resident every 3 months. The resident used the side rail to turn and repositioning. She recently was ill with pneumonia. When looking at the record she thought the assessments had been completed for (YEAR). The LPNs were responsible for initiating a CCP and the RN would sign off on the CCP and its updates. During an interview with MDS Coordinator #12 on 01/26/18 at 03:27 PM, she stated all assessments should be completed initially and quarterly thereafter. 10 NYCRR 415.12(h)(1)

Plan of Correction: ApprovedFebruary 19, 2018

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #112 has been assessed by nursing. Based on observation and assessment, the resident?s side rails are used for bed mobility. The Resident has requested the use of side rails for bed mobility and has been educated on the risks which have been documented in the medical record. Resident?s Restrictive Device Assessment has been completed and his care plan updated to reflect the use of a side rails.
Resident #94 no longer resides in the facility.
How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An audit was conducted for residents with use of side rails to determine if the side rails were evaluated, the resident educated, and the Restrictive Device Assessment was completed, and the resident?s care plan reflective the use of side rails. No other residents were affected by this deficient practice.
What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Restraint and Comprehensive Resident Assessment and Plan of Care Policy were reviewed with no changes required. Mandatory education for Therapy and Nursing Staff regarding the Restraint and Comprehensive Resident Assessment and Plan of Care Policy, identification of use of side rails, the resident was educated regarding the risks of side rails and documentation of resident understanding, on-going evaluation, and care planning will be completed.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit 100% or 20 residents who have side rails (whichever is greater) to ensure nursing has educated the resident on the use and risk of side rails, education is documented, the Resident?s Restrictive Device Assessment is complete, and the Care Plan documents the use of the side rails. This audit will be conducted each month until 100% compliance has been reached. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Assurance Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency
Completion date: (MONTH) 26, (YEAR)

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 26, 2018
Corrected date: March 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 1 residents (Resident #112) reviewed. Specifically, Resident #112 was admitted to the facility and did not have a comprehensive person-centered care plan implemented timely to include measureable objects and timeframes to meet a resident's medical and nursing needs. Findings include: Resident #112 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 12/26/17 significant change Minimum Data Set (MDS) assessment documented the resident was cognitively intact; felt tired or had little energy; required extensive assistance for most activities of daily living (ADLs); was occasionally incontinent of bowel and bladder; had a fall with injury; was on a mechanically altered diet; had a 5% weight loss that was not prescribed by the physician; used anti-psychotic medication 7 days of the assessment period; used bed and chair alarm devices; and had a physician order [REDACTED]. The MDS documented multiple active [DIAGNOSES REDACTED]. The 12/19/17 physician's orders [REDACTED]. The resident had as needed (prn) medications and treatments in place including medication for constipation, cream to buttocks for skin protection, services including dental, vision, and a swallow evaluation. Risks assessments were completed by nursing on 01/02/18 and 01/24/18 and documented the resident was at risk for falls and skin breakdown. During surveyor review of the medical record on 01/25/18, the resident's record did not include a comprehensive person-centered comprehensive care plan (CCP). There was no documentation a CCP was implemented to address the resident's nursing and medical needs that would include measurable goals and objectives. During an interview with licensed practical nurse (LPN) #8 on 01/26/18 at 01:28 PM, she stated she was responsible for implemented resident comprehensive care plans and attending care plan meetings. She would use the MDS, CNA care instructions, physician orders [REDACTED]. The resident had a baseline care plan when he came in that would be a one-page document with a summary of care provided to the resident and a copy was provided to the resident. The baseline care plan was completed by the registered nurse (RN). The LPN stated she had not gotten a chance to complete the resident's CCP. During an interview with RN Unit Manager #9 on 01/26/18 at 02:17 PM, she stated she would initiate a baseline care plan within 48 hours of a resident's admission. It was the responsibility of the LPN to complete the comprehensive care plan. The RN Unit Manager reviewed the electronic record, a binder containing printed care plans, and the resident's paper record and was unable to find a full complete CCP for the resident. She stated the facility had not had an official team meeting for the resident as the resident had been sent out to the hospital twice since his admission. She stated there was not a team sign-in sheet in the resident's record. Most often a CCP was completed on the resident's MDS schedule. The LPNs would attend the resident CCP meeting. During the interview LPN #8 entered the interview and participated. The LPN reviewed the plan of care and stated the resident only had a nutrition and social services plan of care and did not have nursing or medical information included to have a comprehensive care plan. During an interview with MDS Coordinator #12 on 01/26/18 at 03:27 PM, she stated the resident was admitted on [DATE] and he had a significant change on 12/26/17. She stated even though the resident had been hospitalized in 12/2017, the resident had more than one significant change MDS, these MDSs' were completed by the interdisciplinary team, and therefore the resident should have a complete CCP in his record. 10 NYCRR 415.11(c)(1)

Plan of Correction: ApprovedFebruary 19, 2018

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #112 has been assessed by Nursing. Based on observation, MDS assessment, and interviews the Resident?s comprehensive person centered care plan has been updated to reflect the Resident?s medical and nursing needs and includes measureable objects and time frames.

How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An audit was conducted for all Residents to determine if each Resident had a comprehensive person-centered care plan that addresses the resident?s medical and nursing needs with measurable objects and timeframes. No other residents were affected by this deficient practice.
What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Comprehensive Resident Assessment and Plan of Care Policy were reviewed with no changes required. Mandatory education will be conducted for Activities, Nursing, Therapy, Dietician, and Social Services regarding the requirement of the Interdisciplinary Team to develop a comprehensive person-centered care plan that promotes and assists the resident to maintain their highest practicable physical, mental and social well-being. The comprehensive Plan of Care will be developed in conjunction with the initial MDS Assessment and shall be reviewed and updated as necessary with each subsequent comprehensive MDS Assessments. The MDS Department will review each care area triggered prior to closing and submitting the MDS to ensure each area is listed in the specific category of the care plan.

How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit 100% or 20 residents, whichever is greater, who have had a comprehensive MDS Assessment Completed to ensure the Resident?s comprehensive person centered care plan has been updated to reflect the Resident?s medical and nursing needs and includes measureable objects and timeframes. This audit will be conducted each month until 100% compliance has been reached. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Assurance Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency
Completion date: (MONTH) 26, (YEAR)

4FGA 400.10 (d):HEALTH PROVIDER NETWORK ACCESS AND REPORTING

REGULATION: The operator of a facility shall obtain from the department ' s health provider network (HPN), HPN accounts for each facility he or she operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, 24-hour, seven-day-a-week contacts for emergency communication and alerts must be designated by each facility in the HPN communications directory. A policy defining the facility's HPN coverage consistent with the facility ' s hours of operation, shall be created and reviewed by the facility no less than annually. Maintenance of each facility ' s HPN accounts shall consist of, at a minimum, the following: (d) current and complete updates of the communications directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 26, 2018
Corrected date: March 26, 2018

Citation Details

Based on record review and interview conducted during an Emergency Preparedness survey, the operator did not maintain a current Health Commerce System (HCS) account and did not ensure that current staff were assigned to various HCS roles, to receive information and ensure rapid response to requests for information by the State and/or local Department of Health at the facility. Specifically, complete updates of the current HCS directory were not maintained accurate and/or complete for facility personnel defined roles. Findings include: During review of the current updated HCS on 01/25/18, a surveyor observed multiple directory roles were unassigned. These included, but were not limited to: - Emergency Office Roles: 1. 24/7 Facility Contact; 2. Director of Nursing; 3. Emergency Medical Supplies Receiving Office; and 4. Office of the Administrator. - Contact Person Roles: 1. Medical Director 2. Medical Records Coordinator When interviewed on 01/25/18 at 12:40 PM, the facility's Health Provider Network (HPN) Coordinator stated she was unaware the roles were unassigned. 10 NYCRR 400.10(d)

Plan of Correction: ApprovedFebruary 19, 2018

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
The following HPN Roles were reviewed and updated including:
Emergency Office Roles:
24/7 Facility Contact;
Director of Nursing;
Emergency Medical Supplies
Receiving Office;
Office of the Administrator
Contact Person Roles:
Medical Director
Medical Records Coordinator
How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An audit was conducted the HPN Roles including the Emergency Office Roles and Contact Person Roles. All HPN roles are up to date per the current staffing.
What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
A review of all HPN Roles will be completed monthly.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Administrator and/or designee will audit 100% of the HPN Emergency Office Roles and Contact Person Roles to ensure all the assigned directory roles from HPN are complete and accurate. This audit will be conducted each month until 100% compliance has been reached. Monitoring for compliance is the responsibility of the Administrator and will be reported to the Quality Assurance Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Administrator will be responsible for this deficiency
Completion date: (MONTH) 26, (YEAR)

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 26, 2018
Corrected date: March 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey for 1 of 2 residents (Resident #91) reviewed for precaution measures, 3 of 3 residents reviewed for blood glucose monitoring (Residents #2, 83 and 126), and 1 of 2 residents (Resident #21) reviewed for catheters, the facility did not ensure the facility established and maintained an infection prevention control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, infection control was not maintained for Residents #2, 83 and 126 during blood glucose monitoring; For Resident #21's positioning of his Foley catheter bag, and Resident #91 who was on droplet precautions. Findings include: 1) Resident #91 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The 01/13/18 Minimum Data Set (MDS) assessment documented that the resident was alert and oriented; and required extensive assistance for bed mobility, transferring, dressing, personal hygiene and toileting; and required supervision and set up with meals. The 01/04/18 Speech Therapy Clarification order documented the resident required supervision due to aspiration precautions (choking precautions). The 01/2018 certified nurse aide (CNA) care instructions documented the resident was positive for [MEDICAL CONDITION] and [MEDICAL CONDITION], required toileting every two hours, was an assist of two to reposition in bed and assist of one to turn side to side. The resident was transferred using a rolling walker, a gait belt and an assist of two to transfer to his wheelchair. He was on aspiration precautions and required supervision with all meals. There was no documentation on the CNA instruction the resident was on droplet precautions. A 01/11/18 at 01:45 PM nursing progress note documented the resident [MEDICAL CONDITION] in her sputum and was on contact precautions and droplet precautions for RSV (respiratory [MEDICAL CONDITION]). The 01/15/18 comprehensive care plan (CCP) had no documentation the resident had droplet precautions in place or that a plan was implemented to address the precautions while the resident required supervision for aspiration. The resident was observed by a surveyor without a mask or protective barrier to his mouth or nose: - On 01/24/18 at 11:21 AM, coming out of his bedroom for the noon meal. The resident had a moist productive cough which was frequent when the surveyor attempted to interview him. - On 01/24/18 at 01:30 PM, he had completed his noon meal. He was seated in the hallway three feet from the dining area where residents were seated and 1 foot of the main walkway of staff and residents. The resident remained seated drinking coffee. - On 01/24/18 at 02:24 PM, sitting in the hallway making comments to another resident who was nearby. - On 01/25/18 at 09:00 AM and 11:29 AM, sitting outside his room. - On 01/26/18 at 12:15 PM, sitting in the hallway outside his room. During an interview with CNA #13 on 01/26/18 at 12:15 PM, she stated the resident was on droplet precautions for an upper respiratory infection and the precautions included a mask, gown and gloves. The resident had to wear a mask when leaving the room while on precautions. He was on a level 4 regular diet and he needed to be supervised when eating or drinking. The resident would sit in the door way to his room so he could be seen. Without a mask he was contagious to others. During an interview with licensed professional nurse (LPN) #14 on 01/26/18 at 12:21 PM, she stated the resident was on droplet precautions [MEDICAL CONDITION] in his sputum and staff needed to wear protective equipment when entering the room and the resident was to wear a mask when he came out of the room. She stated he needed to be supervised for meals and was placed in the doorway for each meal. If he was in the hallway without a mask he would be contagious to others. During an interview with registered nurse (RN) #15, who was covering the RN Unit Manager on 01/26/18 at 12:31 PM, she stated that the resident had a swab come back positive [MEDICAL CONDITION] in his nares and staff would have to wear a mask and gown into his room. She stated that the resident requires supervision for eating and sits in the vestibule to his room while eating. She stated if he comes out of the room he should wear a mask. During an interview on 01/26/18 at 01:08 PM with the Director of Nursing (DON), who was acting as the Infection Control nurse, the resident [MEDICAL CONDITION] in both his sputum and his nares. This would require droplet precautions and anyone entering the room would need a mask and possibly gloves and a gown. She stated that the resident would need to wear a face mask when out of the room. If the resident needed to be supervised while eating then her expectation would be to send a CNA into the room to be with him while eating to maintain infection control. 2) Resident #2 was admitted on [DATE], re-admitted on [DATE], and had [DIAGNOSES REDACTED]. The 01/2013 Fingerstick Blood Sugar Monitoring Procedure did not include information pertaining to the use of a barrier or specifics to disinfecting a glucometer before and after each use. The 10/30/17 updated comprehensive care plan (CCP) documented the resident had diabetes. Interventions included fingersticks per physician order [REDACTED]. The 01/09/18 physician orders [REDACTED]. Resident #83 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 09/19/17 updated comprehensive care plan (CCP) documented the resident needed assist with ADLs. Interventions included tests as ordered. There was no diabetes care plan provided. The 01/09/18 physician orders [REDACTED]. Resident #126 was admitted on [DATE], re-admitted on [DATE], and had [DIAGNOSES REDACTED]. The 12/13/17 Minimum Data Set (MDS) assessment documented the resident had full cognition, was extensive assist with most activities of daily living (ADLs), and did not receive insulin injections. The 12/14/17 physician order [REDACTED]. The 12/01/17 comprehensive care plan (CCP) documented the resident had suboptimal nutritional intake and was depressed. Interventions included a no concentrated sweet diet, medications as ordered, and monitor medication effectiveness. There was no diabetic care plan provided. On 01/25/18 at 04:26 PM, certified nurse aide (CNA) #18 was observed placing a glucometer, which he obtained from the other unit (original glucometer was not working properly), directly on a Chux like barrier. He cleaned the glucometer with a disinfectant and placed it back on the same contaminated barrier. The CNA went in to Resident #2's room, placed the glucometer on an over-bed table without a barrier, performed the fingerstick, came out of the room, cleaned the glucometer and placed it back on the contaminated barrier. He then went to do a second fingerstick on a different resident. On 01/26/18 at 11:10 AM, CNA #17 gathered glucometer supplies, entered Resident #83's room, placed the glucometer with its container on the over-bed table, performed the fingerstick, gathered the supplies, entered the resident's bathroom, placed the glucometer and container on the sink and washed her hands. She did not wash her hands prior to entering the resident's room. The CNA then proceeded to Resident #126's room. She brought a box containing the glucometer, a disinfectant wipe, and the rest of her supplies into the resident's room, and placed the glucometer and supplies on the over-bed table without a barrier. She placed the glucometer on the bed while prepping the resident's finger, obtained the blood sample and put the glucometer back on the bed. She then wiped the glucometer and box with the disinfectant wipe, put the box back down on the over-bed table without a barrier, and placed the glucometer in the box. She carried the box, disinfectant wipe, and red syringe/needle container into the bathroom, put them on the counter and washed her hands. She did not disinfect the glucometer box or supplies prior to putting the box on the medication cart. When interviewed on 01/26/18 at 12:25 PM, registered nurse (RN) Educator #3 stated most CNAs were certified for performing fingersticks. She expected that if a glucometer was laid down in a resident room, it had to be put on a barrier. She stated glucometer policy documented the glucometer had to be disinfected only after each use and prior to placing it in the docking station. The policy did not document to clean the glucometer before each use. When interviewed on 01/26/18 at 02:02 PM, CNA #17 stated she did not have a cart available to place the glucometer and supplies on when she went into the resident's room. She stated she was in a hurry, and a barrier was to be used when performing a fingerstick in a room. Staff would be able to ask a nurse to look it up in the computer if they had a question about how to perform a procedure. When interviewed on 01/26/18 at 02:32 PM the Director of Nursing (DON), acting as the Infection Control nurse, stated the infection control policy and procedure did not include using a barrier with the glucometer, it was the facility's practice to use a barrier, and she expected glucometers to be placed on a barrier. 3) The facility Foley Catheter (closed urine system) policy dated 01/2013 documented the catheter bag was to maintain as a closed system with the drainage bag lower that the bladder, and not to be rested on the floor or hung from the side rail. Resident #21 was admitted [DATE] and readmitted on [DATE]. He had [DIAGNOSES REDACTED]. coli and [DIAGNOSES REDACTED] (bacteria) in his urine. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, required extensive assistance with all activities of daily living (ADLs), and had an indwelling Foley catheter. The facility laboratory report dated 10/5/2017 documented the resident tested positive for urinary tract infection [MEDICAL CONDITION] with [DIAGNOSES REDACTED] in his urine. He received Bactrim (antibiotic) for 7 days. On 01/11/18 he tested positive for UTI and [MEDICATION NAME](antibiotic) 250 milligrams (mg) for 7 days. The Medication Administration Record [REDACTED]. The comprehensive care plan (CCP) and certified nurse aide (CNA) resident care guide dated 11/30/17 documented the resident had an indwelling Foley catheter, he was to remain free from complications and infections. Interventions included staff were to monitor for infection and ensure his Foley catheter was draining properly. The resident was observed: - On 01/24/18 at 11:13 AM, in the dining room with his Foley bag resting on the floor. His urine was dark amber in color. - On 01/24/18 at 11:46 AM, his Foley bag remained resting on the floor in the dining room. - On 01/24/18 at 01:25 PM, while in his room asleep, his Foley bag was lying flat directly on the floor. - On 01/24/18 at 03:28 PM, he remained in bed with his Foley bag lying flat on the floor at the right side of his bed. - On 01/25/18 at 07:18 AM, in the dining room his Foley bag rested on the floor throughout breakfast. - On 01/25/18 at 09:44 AM, while in the dining room, his Foley bag was resting on his right wheelchair pedal in direct contact with the wheel. - On 1/25/2018 at 11:30 AM, while in the dining room his Foley bag was in his foot rest on his wheelchair. When interviewed on 01/26/18 at 09:57 AM certified nurse aide (CNA) #1 stated she had been assigned to the resident on 1/24/2018. She stated she was aware of the resident's Foley care needs and followed the resident's care guide for direction. The resident's urine had been dark in color and the nursing staff were aware and he was recently treated for [REDACTED]. She had received training at the facility within the last 3 months for Foley care and positioning. When interviewed on 01/26/18 at 10:12 AM registered nurse (RN) Unit Manager #2 stated the resident required extensive assistance with all ADLs. The staff were responsible to provide Foley catheter care, including to maintain the Foley catheter, ensure the Foley bag was covered with a blue bag, positioned below the bladder and the bag was not to touch the floor as that would be considered an infection control issue. She thought proper Foley care was part of the staff's annual education and she expected staff to ensure the policy was followed. When interviewed on 01/26/18 at 10:52 AM, RN Staff Educator #3 stated Foley catheter education was part of the curriculum for all staff participating in the CNA classes. Other staff received the education on Foley catheter care upon hire and was not continued on an annual basis. The Foley catheter care education consisted of care of the site, the proper positioning of the Foley catheter bag and was expected to be below the bladder, covered and off the floor at all times. If the Foley bag touched the floor it could cause an infection. When interviewed on 01/26/18 at 12:33 PM the Director of Nursing, acting as the Infection Control nurse, stated she assisted with the infection control program at the facility. She was the point person for infection control and collaborated with the Corporate Infection Control Nurse Practitioner (NP). Foley catheter bag and tubing were to be positioned below the bladder, covered and not touching the floor. The bag would be at risk for contamination of infection if resting on the floor, on a wheelchair pedal or positioned in the foot rest of the wheelchair. 10 NYCRR 415.19 (a)(1-3)(b)(1)

Plan of Correction: ApprovedFebruary 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #91 is no longer having loose stools and is no longer on contact precautions for [MEDICAL CONDITION]. Resident remains on droplet precautions [MEDICAL CONDITION] in his nares although he no longer has a productive cough. The resident is in the process of being cleared [MEDICAL CONDITION] through nasal swab micro study and has had 1 negative screen on 2/12/18. Resident will need 2 additional negative screens one (1) week apart before he can be taken off droplet precautions. Resident has been educated to stay in his room for meals with supervision and to wear a mask if exiting his room. Random monitoring has demonstrated he has been compliant with this requirement. Resident's Comprehensive Care Plan has been updated to reflect interventions for Droplet Precautions.
CNA # 18 and CNA # 17 were re-educated regarding how to properly disinfect the glucometer between resident use and the use of a barrier under the glucometer, both verbalized understanding. Residents #2, 83, and 126 have had no adverse outcome as a result of this deficient practice. Resident # 2 no longer resides in the facility, Resident #126's Comprehensive Care Plan has been updated to reflect interventions for Diabetic Care.
CNA # 1 was re-educated regarding proper care of an indwelling catheter including but not limited to staff should ensure the catheter bag is kept at a level lower than the bladder but should not be allowed to rest on the floor. Resident # 21 has had no adverse outcome as a result of this deficient practice.
How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
Multiple other residents could be affected by this deficient practice.
An audit was conducted for all Residents placed on droplet precautions to determine if the resident and staff were compliant with precaution requirements. No other residents were affected by this deficient practice.
An audit was conducted of CNAs performing Finger Stick Blood Monitoring utilizing the glucometer. Any identified incidence of non-compliance was corrected and the non compliant staff members were re-educated.
An audit was conducted of all residents who have an indwelling catheter to ensure the catheter bag was at a level lower than the bladder and the bag was not resting on the floor. No other residents were affected by this deficient practice.
What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Infection Control Procedures for Droplet and Contact Precautions, The Foley Catheter Policy, and The Care of the Indwelling Catheter Policy were reviewed with no changes required. The Glucometer Policy was reviewed and revised to include the use of a barrier under the glucometer when taking the device into the resident?s room.
Mandatory education will be conducted for all nursing staff regarding Infection Prevention which will include procedures for Contact and Droplet precautions, use of a barrier for the glucometer, and care of an indwelling catheter, specifically staff should ensure the catheter bag is kept at a level lower than the bladder but should not be allowed to rest on the floor.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit 100% or 20 residents, whichever is greater, who are on either Droplet or Contact Precautions to ensure residents and staff are compliant with precaution requirements.
The Director of Nursing and/or designee will audit 100% or 20 residents, whichever is greater, who have an indwelling Catheter in place to ensure the catheter bag is at a level lower than the bladder and the bag is not resting on the floor.
The Director of Nursing and/or designee will audit 100% or 20 residents, whichever is greater, who have Finger Stick Blood Monitoring ordered to ensure the glucometer was properly disinfected between resident use and there was use of a barrier under the glucometer.
These audits will be conducted each month until 100% compliance has been reached. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Assurance Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency
Completion date: (MONTH) 26, (YEAR)

FF11 483.25:QUALITY OF CARE

REGULATION: § 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 26, 2018
Corrected date: March 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 reviewed (Resident #94). Specifically, Resident #94 had a decline in her condition, was observed leaning in her wheelchair and a plan was not implemented to address her positioning. Findings include: Resident #94 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired, required extensive assistance of staff with transferring and bed mobility, and the resident used a wheelchair for mobility. The 05/09/17 comprehensive care plan (CCP) documented the resident had an activities of daily living (ADL) deficit related to a history of stroke and cognitive loss. Staff were to anticipate needs. There was no documentation on the CCP that interventions were in place for the resident's positioning. The 01/18 certified nurse aide (CNA) care sheet documented the resident used a wheelchair. There was no documentation on the care sheet that interventions were in place for the resident's positioning. The resident was observed leaning to the right in her chair on 01/25/18 at 09:00 AM. The resident's right arm was over the wheelchair arm rest and her inner upper arm was touching the wheelchair arm rest and her right hand was reaching the bottom of the wheelchair. The resident stated everyone says I lean to the right. I don't know why I do it. The resident remained in this position through 09:30 AM when the surveyor left the area. The resident was observed seated in her wheelchair at the unit dining table on 01/26/18 at 11:15 AM. The resident was slightly leaned to the right, with her right arm over the wheelchair arm rest with her right hand to the side down near the wheel. During an interview with CNA #10 on 01/26/18 at 01:06 PM, she stated the resident required assistance of staff for most care. The resident would sit in a standard wheelchair. The resident leaned to the right in the wheelchair at times, it depended on how she was feeling, and she had seen the resident leaning a couple times a week. She noticed the resident leaned more relating to recent illness. If she felt like the resident was leaning too much she would put a pillow to the side of her. This may cause her to lean more though as the pillow would be comfortable to lean against. During an interview with CNA #11 on 01/26/18 at 01:16 PM, she stated the resident leans a lot. When she leans, she leans to the right side. Her posture could be better. If a resident had a positioning device it would be in the CNA documentation. The resident did not have a positioning device for her chair. During an interview with LPN #8 on 01/26/18 at 01:28 PM, she stated she sometimes saw the resident leaning in her chair. When she leaned it would be to the right. She stated if staff saw her leaning they could use pillows for positioning. The LPN reviewed the resident's record and stated the resident had not been seen by therapy related to her positioning in the chair. She or the RN would be responsible for making updates to the plan. There was not a plan in place for a specific device or intervention to assist the resident's positioning. During an interview with RN Unit Manager #9 on 01/26/18 at 02:17 PM, she stated the resident was alert and confused. The resident used to sit upright well, but she had pneumonia. She stated the resident had been really sick. There was not a specific plan in place for the resident, and the staff could put pillows in the side of the chair. The RN would update the baseline care plan on admission and the LPN would initiate a CCP and make updates. She would be responsible for reviewing and signing off on information created by the LPN. 10 NYCRR 415.12

Plan of Correction: ApprovedFebruary 19, 2018

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #94 no longer resides in our facility.
How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An audit was conducted for all Residents to determine if there were documented interventions on the Comprehensive Care plan for any resident who had a decline in condition and required assistance with positioning. No other residents were affected by this deficient practice.
What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Comprehensive Resident Assessment and Plan of Care Policy were reviewed with no changes required. Rehabilitation Services Screens Policy was reviewed and revised to include quarterly screens to be conducted to assist in identification of residents who have a decline in condition and would benefit from skilled Therapy Services. A Recognizing and Reporting Changes in Condition Policy was developed to include providing guidance to staff to recognize and report changes in resident?s condition and required follow up by the LPN and RN. The RN will be responsible to assess the resident and implement necessary changes to the Plan of Care including, but not limited to, recommending Therapy screen the resident for potential formal evaluation, treatment, and recommendations. Therapy department will conduct routine resident screens to help identify residents who have demonstrated a decline in status and may benefit from interventions by qualified Therapy personnel. Mandatory education will be conducted for Nursing and Therapy to recognize and report declines in resident condition, the requirement for Therapy to conduct screens on a quarterly basis, how nursing should consider a request for a Therapy screen outside the routine guidelines, and Nursing and Therapy are shall implement and document changes in the Resident?s plan of care as appropriate.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit 100% or 20 residents, whichever is greater, who have had a decline in condition to ensure the Resident?s needs have been addressed, a therapy screen was initiated, and the Resident?s Plan of Care was updated as appropriate. The Manager of Rehabilitation Services and/or designee will audit 20 residents to ensure they have received a quarterly Rehab screen and if the resident has demonstrated a decline in condition they received appropriate skilled Rehab Services, and the Plan of Care was updated. This audit will be conducted each month until 100% compliance has been reached. Monitoring for compliance is the responsibility of the Director of Nursing and The Manager of Rehabilitation Services and will be reported to the Quality Assurance Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing and manager of Rehabilitation Services will be responsible for this deficiency
Completion date: (MONTH) 26, (YEAR)

FF11 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). §483.12 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 medical symptoms. §483.12(a) The facility must- §483.12(a)(2) 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: January 26, 2018
Corrected date: March 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure 1 of 1 residents (Resident #93) reviewed for restraints, used the least restrictive alternative for the least amount of time. Specifically, Resident #93 had a scoot chair, a specialized low-seated chair, and a chair alarm in place; there was no documentation the chair was assessed as the least restrictive device for the resident; or that the device was assessed for safety and use on at least a quarterly basis. Findings include: The facility restraint policy, dated 8/2016, documented the least restrictive device shall be used for the least amount of time and there was to be ongoing evaluations towards reducing the restraint. The definition of a restraint was defined as a manual method, physical or mechanical device that the resident cannot remove easily, and restricted movement or freedom. If a restraint was to be used the care plan was to reflect the restraint, the time it was to be released and assessed for the least restrictive device. Resident #93 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, she was not steady when moving from a seated to standing position and had not had any falls since admission. She had a bed, chair and floor alarm used daily, and did not have a restraint in place. The Resident Restrictive Device assessment dated [DATE] documented the resident had memory impairment, had decreased safety awareness, had a fall within the last 60 days, was dependent for transfers, and self-propelled in the wheelchair. There was no documented evidence on the assessment the scoot chair was evaluated to determine if it was a restraint or least restrictive device for the resident. There were no further Resident Restrictive Device assessments completed following this date, nor were there additional assessments of the scoot chair. The comprehensive care plan (CCP) dated 09/11/17 documented the resident was inconsistent with her choices and at risk for falls. Staff were to educate her to rise slowly, and instruct her to ask for assistance before attempting to transfer or ambulate. The resident was not to be left alone in the bathroom or wheelchair and had a fall mat on the side of her bed. The CCP did not document the use of a scoot chair. The fall risk assessments dated 10/18/17 and 01/08/18 documented the resident was confused, disoriented and impulsive and was at high risk for falls. The facility incident and accident form dated 01/10/18 at 3:15 PM documented the resident was found on the floor in the corridor, the fall was not witnessed, she had been visualized and repositioned in her chair prior to the incident, she was unable to state why she attempted to get up. The social services progress notes dated 01/11/18 at 11:41 PM documented the resident was alert with confusion, staff assisted her with ADLs, and she tended to forget she needed assistance and fell . The certified nurse aide (CNA) care guide (care instructions) dated 01/17/18 documented the chair alarm was discontinued, the resident used a scoot chair when out of bed, and she was non-ambulatory. The resident was observed seated in her scoot chair with a chair alarm in place: - On 01/24/18 at 11:57 AM, while in the dining room eating lunch at a bed-side tray table. - On 01/24/18 at 03:25 PM, while in the dining room and the scoot chair was slightly reclined. - On 01/25/18 at 12:40 PM, while in the dining room with her bed-side tray table and the scoot chair was slightly reclined. - On 01/25/18 at 03:25 PM, sitting in the lounge area and the scoot chair was slightly reclined. When interviewed on 01/25/18 at 03:58 PM licensed practical nurse (LPN) #5 stated the resident's scoot chair and chair alarm were initiated as she attempted to self-transfer and it helped prevent her from standing and falling. The alarm was in place on her chair to help alert staff if she attempted to get up so staff were able to respond to prevent her from falling. She had cognitive impairment, she was not able to voice or understand why the chair was in place for her, and would not be able to get out of the chair upon command related to her cognition. The facility did not consider the scoot chair a restraint. When interviewed on 01/25/18 at 04:30 PM certified nurse aide (CNA) #6 stated he provided care for the resident. The resident used a scoot chair as she tended to lean forward and the chair prevented her from falling. She remained in the scoot chair whenever she was out of bed including meal times. The chair alarm was to alert staff to prevent her from falling. She was not able to get out of the chair if you asked her due to her severe cognitive status. She attempted to get up out of the scoot chair a few weeks ago and fell . She was able to get out of the chair, she was not able to do so on command, and it was not considered a restraint. When interviewed on 01/26/18 at 10:26 AM registered nurse (RN) #2 stated the resident required extensive assist with ADLs, had a history of [REDACTED]. The resident first received the alarm then the scoot chair as she tended to bend over and fall. She was not able to get up out of the chair upon command related to her cognition. There was no assessment completed for the scoot chair and the last restraint assessment was completed in 08/17. At that time the facility determined it was not a restraint as she was not able to get up out of the chair without assistance. She was not sure why the resident had both the chair alarm and the scoot chair. She did not evaluate the scoot chair or the alarm quarterly and an assessment should have been completed. She defined a restraint as anything that limited a resident's functional ability. On 01/26/18 at 11:39 AM, the Director of Rehabilitation stated the resident was admitted to the facility after she had a [MEDICAL CONDITION] and she was confused. The resident had previously been in a wheelchair and she continued to scoot towards the edge and she made attempts to climb out of the bed. Alterations were made to the wheelchair; however, they were not effective. The scoot chair was trialed in 08/17 and she did better in the scoot chair and she had a decrease in restlessness. The scoot chair was not evaluated as a potential restraint as the resident required assist of two staff at that time, was not able to stand from any chair, although the resident did make attempts to stand. The resident had severe cognitive impairment and had not been seen by therapy since 09/17. All restraint reviews were completed by the interdisciplinary team for re-evaluation. She did not consider the scoot chair a restraint as the resident was not able to stand independently from any chair. The alarm was used to alert staff if the resident made attempts to stand so they could provide assistance. The resident was considered a high fall risk and she was not able to get out of the chair upon command. The scoot chair did not impede her from standing and the alarm would not stop her if she tried. 10 NYCRR 415.4(a)(2-7)

Plan of Correction: ApprovedFebruary 19, 2018

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #93 has been assessed by physical therapy and nursing. Based on observation and assessment, the resident?s scoot chair, specialized low chair, is the least restrictive device to maintain positioning for this resident and is not considered a restraint. The Resident?s Restrictive Device Assessment has been completed and her care plan updated to reflect the use of a scoot chair.

How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An audit was conducted for residents in a scoot chair to determine if this was the least restrictive device for the resident, the Restrictive Device Assessment was completed, and the resident?s care plan reflective the use of the device. No other residents were affected by this deficient practice.

What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Restraint Policy and Comprehensive Resident Assessment and Plan of Care Policy were reviewed with no changes required. Mandatory education for Therapy and Nursing Staff regarding the Restraint and Comprehensive Resident Assessment and Plan of Care Policy, identification of restraints/potential restraint, use of the least restrictive measures, on-going evaluation, documentation, and care planning will be completed.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit 100% or 20 residents (whichever is greater) who have a scoot chair or specialized low chair to ensure Therapy assessed and has documented the device as the least restrictive measure or a restraint, the Resident?s Restrictive Device Assessment is complete, and the Comprehensive Care Plan documents the use of the chair. This audit will be conducted each month until 100% compliance has been reached. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Assurance Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency
Completion date: (MONTH) 26, (YEAR)

Standard Life Safety Code Citations

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2018
Corrected date: February 9, 2018

Citation Details

Based on record review and interview conducted during the recertification survey, the facility did not ensure that fire drills were held at unexpected times on 1 of 3 shifts (night shift) in (YEAR), as required, and fire drills were not completed for 1 of 3 shifts (night shift). Specifically, the night shift fire drills for the last two quarters of (YEAR), were not conducted at varying times, and first two quarters of the night shift for (YEAR) were not completed. Findings include: 1) Fire Drills Times Not Varied Review on 01/25/18 at 12:14 PM of fire drill reports revealed the third quarter and fourth quarter night shift fire drills were conducted on the following dates and times, not at varying times during each shift: - 09/21/17 at 06:36 AM; and - 12/21/17 at 06:25 AM. When interviewed on 01/25/18 at 12:14 PM, the Director of Facilities stated he was not aware the night shift fire drill times were not completed at varying times. 2) Fire Drills Not Completed Review on 01/25/18 at 12:14 PM of fire drill reports revealed the first quarter and second quarter night shift fire drills for the skilled nursing facility were not completed. The fire drills completed those quarters were not conducted within the nursing home, and were conducted in the assisted living facility attached to it. When interviewed on 01/25/18 at 12:14 PM, the Director of Facilities stated he was not aware the nursing home night shift fire drills were not completed for the first and second quarters of (YEAR). 2012 NFPA 101: 19.7.1 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 9, 2018

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
New fire drill schedule has been implemented to ensure varied testing times.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken
All fire drills will follow new schedule.
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 fire drill dates and times will be recorded and reported monthly to the QA committee for 12 consecutive months.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
All fire drill dates and times will be recorded and reported monthly to the QA committee for 12 consecutive months.
5. The date for correction and the title of the person responsible for correction of each deficiency.
2/9/18 Mark A Cote Director of Facilities

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2018
Corrected date: February 9, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the fire ratings of 1 isolated hazardous area was maintained (physical therapy storage room). Specifically, the door and door frame for the physical therapy storage room was not fire rated as required. Findings include: On 01/24/18 at 02:10 PM, a surveyor in the physical therapy area revealed the door to the storage room was not 45 minute fire rated, and the door frame was not 1 hour fire rated. The physical therapy storage room was approximately 120 square feet, and contained miscellaneous physical therapy equipment and combustibles. During an interview on 01/25/18 at 10:30 AM, the Director of Facilities stated he was unaware the door and door frame for the physical therapy storage room was not rated. He was aware all hazardous rated rooms were required to have fire rated doors and door frames. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 9, 2018

**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?
A new fire rated door for the physical therapy storage room was ordered on [DATE]. Once delivered the unrated door will be replaced and the frame will be properly labeled.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken
All facility storage room doors were inspected to ensure that the space and doors were compliant with NFPP regulation.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
Monthly environmental (Environment of Care) rounds will include inspection of all door labels to ensure compliance. Facilities Director will report to Quality Assurance and Environment of Care Committees when fire rated door and frame has been installed.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Monthly environmental (environment of care) rounds
The date for correction and the title of the person responsible for correction of each deficiency.
Inspection of all facility storage rooms was completed on 1/25/18
Fire Rated Storage room door is projected to be delivered and installed within 10 weeks.
Mark A. Cote Director of Facilities

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2018
Corrected date: February 9, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure all fire-barrier doors latched when closed for 2 of 8 fire barrier double doors (fourth floor neighborhood B fire door, and first floor neighborhood B fire door). Specifically, the above mentioned doors did not latch when closed from an open position. Findings include: On 01/24/18 at 11:25 AM, a surveyor observed one of two 45 minute fire-rated doors for the fourth floor neighborhood B 1 hour fire-rated barrier did not latch when closed from an open position. During all three attempts made, the door did not latch. On 01/24/18 at 02:22 PM, a surveyor observed one of two 45 minute fire-rated doors for the first floor neighborhood B 1 hour fire-rated barrier did not latch when closed from an open position. During all three attempts made, the door did not latch. During an interview on 01/25/18 at 10:30 AM, the Director of Facilities stated the quarterly fire door checks were last done by maintenance staff within the last month, and he recalled the fourth floor neighborhood B fire door, and first floor neighborhood B fire doors had no deficiencies. Review on 01/25/18 of the quarterly asset detail form documented the fire doors near the fourth floor by stairwell D (the neighborhood B fire doors) were checked on 01/19/18. Review on 01/25/18 of the quarterly asset detail form documented the fire doors near the first floor by stairwell D (the neighborhood B fire doors) were checked on 01/17/18. 2012 NFPA 101 19.2.1, 7.2.1.15 NFPA 80: 5.2.4.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 9, 2018

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Fourth floor neighborhood B and first floor neighborhood B fire-rated barrier doors were repaired on 1/24/18 and were in good working order
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All doors have been re-inspected. As of 2/9/18 all doors were found to be in working order per Mark A. Cote facilities manager.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
Preventative maintenance inspection of all facility doors will be completed on a monthly basis and reported to the Administrator, Quality Assurance and Environment of Care Committee.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Preventative maintenance inspection of all facility doors will be completed on a monthly basis. All findings will be reported to the Quality Assurance and Environment of Care Committee until three consecutive months of 100% compliance is achieved.
5. The date for correction and the title of the person responsible for correction of each deficiency.
2/9/18 Mark A. Cote Director of Facilities

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2018
Corrected date: February 9, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 1 isolated area (emergency exit stairwell F), in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2. Section 8.3.3.2 states Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, emergency exit stairwell F contained both quick response sprinkler heads and standard response sprinkler heads. Findings include: On 01/24/18 at 02:38 PM, a surveyor on the first floor level of emergency exit stairwell F observed a quick response head and a standard response sprinkler head. The other four floors of the stairwell contained 3 quick response sprinkler heads. During an interview on 01/24/18 at 02:38 PM, the Director of Facilities stated the vendor should have identified the issue during the quarterly maintenance tests, and was not sure why the facility had any standard response sprinkler heads in it. This facility was fully completed in 2013 and there were no added building sections in which to introduce other types of sprinkler heads. He did not know why the facility had a dedicated metal box of spare standard response sprinkler heads, and was not aware the facility had spare standard response sprinkler heads. 2012 NFPA 101 19.3.5.1, 9.7.1.1 2010 NFPA 13 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 9, 2018

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The standard response sprinkler head in stairwell was replaced with a quick response sprinkler head on 2/5/18 by abj Fire Protection Co.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
Visual inspection of all sprinkler heads was completed on 2/5/18 and 2/6/18 by abj Fire Protection Co. who verified that there were no other standard response sprinkler heads installed.
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 spare standard response heads were replaced with quick response sprinkler heads. Quarterly inspection of sprinkler system by outside vendor will be personally monitored by director of facilities or designee. All maintenance personnel were educated on the difference between quick versus standard response sprinkler heads and that only quick response sprinkler heads will be installed in building.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Monthly fire drill reports to QA committee will include notations of any sprinkler head that was replaced along with receipt that specifies that the sprinkler head was quick response.
5. The date for correction and the title of the person responsible for correction of each deficiency.
Completed on 2/6/18 Mark A. Cote and abj Fire Protection Co.