Katherine Luther Residential Health Care and Rehabilitation Center
July 27, 2018 Certification/complaint Survey

Standard Health Citations

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: July 31, 2018
Corrected date: September 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 2 residents (Resident #123) reviewed. Specifically, Resident #123 did not have a person-centered care plan. Findings include: Resident #123 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, mood symptoms affecting her appetite and concentration, and required extensive assistance for most activities of daily living (ADLs). The resident received antidepressant, antianxiety, and antipsychotic medications daily. The comprehensive care plan (CCP) updated 07/22/18 documented the resident had potential for mood/behavior changes related to long term care placement and a [DIAGNOSES REDACTED]. Interventions included administer medications as ordered, arrange for psychological consult, follow up as indicated, and reapproach if resident became argumentative or had a verbal outburst. Additional interventions included monitoring/documenting/reporting at risk behaviors, signs/symptoms of depression, and risk of harming others. The undated Kardex (care instructions) for behavior/mood included maintaining resident safety if she became argumentative or had verbal outbursts, reapproach later in the shift, and notify charge nurse. Five psychiatric consultation reports from 01/10/18 through 06/13/18 documented the resident reported frustration, itchy skin, needing more attention from staff, feelings of loneliness and sadness, she welcomed death, and had no reason to live. Behavior Detail Reports documented: - From 05/01/18 - 05/31/18, the resident had 4 instances of frequent crying and 3 instances of screaming/yelling; - From 06/2/18 - 06/30/18, the resident had 5 instances of screaming/yelling; and - From 07/08/18 - 07/20/18, the resident had 4 instances of frequent crying and 2 instances of screaming/yelling. When interviewed on 07/25/18 at 02:46 PM, the resident was crying and stated she felt depressed, no one (staff) came to help her when she needed it, and prayed for God to take her. The resident was observed: - On 07/25/18 from 01:59 PM to 03:00 PM, in her wheelchair in her room, with her head down; - On 07/26/18 at 09:35 AM to 11:59 AM, in her wheelchair in her room, facing her television with her head down; - On 07/27/18 at 09:52 AM to 11:43 AM, in bed; and - On 07/30/18 at 10:05 AM in bed. When interviewed on 07/31/18 at 10:01 AM, CNA #40 stated the resident seemed depressed, sad, was needy at times, and had attention-seeking behaviors such as saying she never got her shower or was not taken to the bathroom, even if those things just happened. The CNA stated she would report to the nurse when she observed the behaviors and sometimes social worker #20 came to talk to her. She was unaware of any specific interventions on the care plan. She stated the Kardex included behavioral interventions for other residents and she was unaware if there were any on Resident #123's care instructions. When asked how staff unfamiliar with the resident would know what was a behavioral symptom related to the resident's depression and how they should address it, she stated other staff would share the information verbally. During an interview on 07/31/18 at 10:20 AM, licensed practical nurse (LPN) acting Unit Manager #22 stated the resident was depressed and sad and the only intervention on the Kardex was to reapproach if the resident became argumentative. She was not responsible for initiating care plan interventions and a per diem registered nurse (RN) helped out at times. She stated the resident saw the psychologist and the social worker received information and updates regarding the resident's treatment and recommendations. During an interview on 07/31/18 at 12:57 PM, social worker #20 stated she did not communicate with the psychologist regarding his treatment with the resident and did not receive any recommendations from him. The social worker initiated the mood/behavior care plan and created the interventions. The resident's behaviors related to her mood and depression included making accusations of staff not providing care, attention seeking behavior, sadness, and self-isolation. The social worker stated a behavior care plan should be individualized and person-centered, meaning the specific behaviors were identified and interventions specific to the resident were included. When reviewing the resident's care plan, she stated it was not specific to Resident #123's needs and it should be reviewed and updated. 10NYCRR 415.11(c)(1)

Plan of Correction: ApprovedSeptember 7, 2018

F656 COMPREHENSIVE CARE PLAN
The facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident?s needs.
1.Corrective Actions:
a.The care plan of Resident #123 was reviewed by the social worker and updated to include all the interventions in place that were discussed with the surveyor during the interview. This was completed on (MONTH) 31, (YEAR) prior to survey exit.
2.Other Residents Potentially Affected:
a.All residents have the potential to have a care plan that is not perceived as person centered.
b.All residents with behaviors have the potential to be at risk of lacking reassessment of the behaviors.
c.The care plans for all residents have been reviewed by the interdisciplinary team to ensure that goals and approaches are individualized to meet the needs of the resident.
3.Systemic Changes to prevent recurrence:
a.Discussions of when to discontinue a resident?s 1:1 status occur at the interdisciplinary morning report meetings. When it is determined that a resident may no longer requires 1:1, documentation shall be made by the social worker or a designee in the electronic medical record and linked to the residents care plan. The care plan will be updated at that time, and anytime changes occur to ensure it is a current reflection of the care the resident is receiving.
b.When a resident is removed from 1:1 the nursing staff shall initiate 72 hour charting specific to any behaviors that a resident is exhibiting. At the end of the 72 hour period the community?s interdisciplinary team will again conduct a review at the morning report and make any necessary changes to the resident?s plan of care.
c.The social worker assigned to the resident will follow up on psychological and psychiatric consultations, and recommendations will be noted in the resident?s plan of care.
d.During scheduled care conferences with the interdisciplinary team, the team will make suggestions and provide input on possible person-centered goals and interventions.
e.Policies for Care Planning and Behavior Management have been updated related to person-centered care, determining the triggers and cause of behaviors, developing non-pharmacological interventions that address the root cause of the behavior.
Clinical staff have received training that care plans must be:
? Person-centered
? Reflect the resident?s goals for admission and desired outcomes
? Focuses on the resident as the center of control, and supports each resident in making his or her own choices.
? Making an effort to understand what each resident is communicating, verbally and nonverbally
- Identifying what is important to each resident with regard to daily routines and preferred
activities
- Having an understanding of the resident?s life before coming to reside in the nursing
home.
The social workers, therapeutic recreation personnel, clinical dietitian, and nurse managers attended a 90 minute webinar entitled Comprehensive Review of Regulations and Interpretive Guidance for Top F-Tags - Comprehensive Care Plans F656-658 which reviewed regulatory guidance, strategies for person-centered care planning, and tools for the leadership team to monitor compliance.
4.Monitoring/Quality Assurance Plan:
a.The Director of Social Services will maintain a log of residents who are placed on 1:1 for behavioral need. An audit of the care plan and documentation will be conducted following removal of 1:1 supervision.
b.The Director of Social Services will maintain a log of residents who have psychiatric and psychology consults. An audit of the care plan and documentation will be conducted to ensure the results of the consultation are incorporated into the resident?s plan of care as appropriate.
c.The Director of Social Services will report the results of the audits monthly to the QAPI committee for review and follow up to ensure ongoing compliance.
Responsible person: Director of Admissions and Social Services

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 31, 2018
Corrected date: September 10, 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 4 of 6 residents (Residents #39, 52, 60 and 116) reviewed for unnecessary medications, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. Specifically, Resident #52 was receiving an anti-psychotic, a Gradual Dose Reduction (GDR) was not attempted annually, and the physician did not document why the GDR was clinically contraindicated. Resident #116 had inconsistent [DIAGNOSES REDACTED]. Residents #39 and 90 had an increase in [MEDICAL CONDITION] medication without documentation non-pharmacological interventions were re-evaluated or implemented prior to the increase in the medication. Findings include: 1) Resident #52 was originally admitted on [DATE] and had [DIAGNOSES REDACTED]. The 05/09/18 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, did not have behaviors, and required extensive assistance for most activities of daily living (ADLs). The resident was receiving anti-psychotics and a GDR had not been completed. The 03/28/17 physician order [REDACTED]. The revised 06/19/17 comprehensive care plan (CCP) documented the resident was agitated, physically combative with staff, received psychiatric medications, and had verbally inappropriate sexual behaviors. Interventions included medications as ordered, and monitor for effectiveness. The 08/01/17 psychiatric nurse practitioner (NP) note documented the resident had been doing well without aggression or agitation. The note documented the resident remained on [MEDICATION NAME] 25 mg twice a day and he had an undated failed GDR in the past. The NP did not document when the last GDR was attempted. The 12/05/17 psychiatric NP note documented the resident did not tolerate GDR in the past and did not specify how long ago the GDR was. The 04/20/18 pharmacy consult following a Medication Regimen Review (MRR) recommended a GDR for [MEDICATION NAME] as the resident had been on the same dose for a year. The physician documented patient needs it on the sheet. The 05/02/18 physician note documented staff reported the resident was doing well. The rationale for use of [MEDICATION NAME] or contraindications for a GDR were not addressed. The 07/05/18 physician note documented that the resident was not aggressive. [MEDICATION NAME] use or GDR contraindications were not addressed. When interviewed on 07/31/18 at 10:13 AM, consultant pharmacist #34 stated she completed a Medication Regimen Review (MRR) monthly and sent the consult sheet to the physician. The pharmacist expected the physician to write on the consult sheet a specific reason a GDR would not be attempted. She expected the rationale to be more than patient stable. She stated the physician wrote a note on 05/02/18 which documented that the resident's dementia was progressing, his behaviors improved, and the resident needed the medications. When interviewed on 07/31/18 at 11:45 AM, registered nurse (RN) unit manager #13 stated the physician responded to pharmacy consult sheets by writing on the bottom of the pharmacist consult form. The physician had been asked to document responses, particularly anti-psychotic medication use and GDR contraindication in the past and he did not. When interviewed on 07/31/18 at 12:15 PM, physician #28 stated he would consider decreasing an anti-psychotic medication if the resident was stable. The physician stated he did not write a progress note after reviewing the consult form. He stated he reviewed all medications at the 60 day review and documented his findings in his progress note. 2) Resident #90 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 05/22/18 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, received anti-psychotic and anti-depressant medication, and required supervision with most activities of daily living (ADLs). The comprehensive care plan (CCP) revised on 01/12/18 documented the resident wandered, had poor safety awareness, changes in mood/behavior and needed help meeting emotional, intellectual, physical and social needs. The resident had the potential for changes in mood related to his placement and [DIAGNOSES REDACTED]. Interventions dated 5/30/17 included diverting resident away from others when his behaviors escalated, and offering pleasant activities and food. A 01/02/18 progress note documented the resident was upset and agitated. The resident calmed after 10 minutes of being allowed to vent feelings, and was provided a snack and drink. A 01/03/18 nursing progress note documented the psychiatric nurse practitioner was on the unit and discussed recent increases in angry outbursts and threatening behavior. The PM dose of [MEDICATION NAME] was increased. A 01/03/18 psychiatric nurse practitioner progress note documented the resident had been threatening and aggressive. The resident was in a pleasant and calm mood during the psychiatric visit. Resident had poor insight. Per the nurse manager, the resident had no actual aggression and had been taking his medication. His mood was stable and his thought processes were rambled and consistent with dementia. She recommended increasing [MEDICATION NAME] at HS (bed time) to 37.5 milligrams. Physicians orders from 04/12/17 through 01/13/18 included [MEDICATION NAME] 25 milligrams (mg) two times daily for depression. On 01/03/18 physicians orders changed to [MEDICATION NAME] 25 mg in the AM and 37.5 mg in the PM for dementia and continue unchanged at present. During an interview with CNA #1 on 07/31/18 at 09:34 AM, she stated the resident was in a pleasant mood most of the time and would become bothered by a specific resident. The resident was calm and sat in his room quietly most of the time. Most of the resident's behaviors were related to other residents entering his personal space. There was not enough staff on the unit to monitor if other residents were near him. During an interview with CNA #2 on 07/31/18 at 10:00 AM, she stated the resident had difficulty with confused residents and he would become upset. She stated no guidance had been provided to direct care staff on what to do or how to assist him when he was upset. During an interview with licensed practical nurse (LPN) #4 on 07/31/18 at 10:29 AM, she stated the resident became agitated when other residents went into his room. He was generally nice and had more difficulty with confused residents. The resident had not had an increase in mood or behaviors since his admission. During an interview with social worker #20 on 07/31/18 at 11:18 AM, she stated the resident could get upset with his surroundings and peers if he was already in an agitated mood. Most of the time he was calm, cool and quiet. The resident's care plan would be updated by the nurse manager to reflect any medication changes or care plan updates. During an interview with RN unit manager #3 on 07/31/18 at 11:34 AM, she stated the resident's evening [MEDICATION NAME] dose was increased in 01/2018 to 37.5 mg. He remained on 25 mg in the AM. When asked if any changes were made to the care plan at the time of the medication change, she stated staff knew how to redirect the resident and they should offer him to go to his room. His primary concern was when other residents were in his personal space and he would become upset. During an interview with physician #28 on 07/31/18 at 12:42 PM, he stated he was not able to recall specifics to the resident as he was not at the facility to review the documentation at the time of the interview. He stated staff should look into non-pharmacological interventions prior to making any changes to anti-psychotic medications. He stated that adding or increasing an anti-psychotic medication could lead to increase risk of falls or death. Staff should observe for the behavior, redirect the resident and leave alone for awhile until the behavior subsided. 3) Resident #116 was originally admitted on [DATE] and had [DIAGNOSES REDACTED]. The 05/30/18 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, had physical and verbal behaviors, and required extensive assistance for most ADLs. The resident received anti-psychotic medications for anxiety and [MEDICAL CONDITION]. The 07/27/17 original physician order [REDACTED]. The 07/1/17 through 08/31/17 nursing progress notes documented the resident was verbally and physically abusive, wandered, was combative, and refused care multiple times. The progress notes did not document the resident had any signs or symptoms of anxiety. The 08/05/17 physician order [REDACTED]. The 08/07/17 psychiatric NP note documented the resident had issues with agitation, mood swings, threatened staff, and resisted care. The NP documented several different anti-psychotic medications had been tried without significant improvement. The NP recommended [MEDICATION NAME] (mood stabilizer). She did not document the resident had anxiety. The 08/07/17 physician progress notes [REDACTED]. The 09/20/17 physician progress notes [REDACTED]. The 10/20/17 medical NP progress note documented the [MEDICATION NAME] was for [MEDICAL CONDITION]. The NP note did not document the resident's behaviors or the indication for [MEDICATION NAME]. The 11/10/17 medical NP progress note documented [MEDICATION NAME] and [MEDICATION NAME] were for dementia. The 12/05/17 psychiatric NP progress note documented resident had dementia with behavioral disturbance and resident was resistant to care. The NP documented to continue [MEDICATION NAME]. [MEDICATION NAME] was not addressed in the documentation. The 01/17/18 physician progress notes [REDACTED]. The 02/15/18 medical NP progress note documented a review of the resident's medications. The NP documented the [MEDICATION NAME] and [MEDICATION NAME] were taken daily for major [MEDICAL CONDITION]. Anxiety was not reviewed or included in the resident's medical history and problem list. The 05/16/18 and 07/18/18 physician notes documented the resident had underlying [MEDICAL CONDITION], which was the rationale for [MEDICATION NAME] and [MEDICATION NAME]. The physician documented the resident had increased confusion, was sometimes physically and verbally aggressive, and resistant to care. The revised 05/21/18 CCP documented the resident had the potential for mood and behavior changes due to Alzheimer's dementia. The CCP documented the resident yelled out, was combative, restless, and was risk for victimization and injury. Interventions included medications as ordered and monitor for effectiveness. Anxiety was not included in the resident's CCP. The 06/13/18 medical NP note documented the resident was negative for anxiety, had dementia with behaviors and was to continue on [MEDICATION NAME] and [MEDICATION NAME]. The 07/18/18 physician order [REDACTED]. The 07/20/18 physician order [REDACTED]. There was no change in [DIAGNOSES REDACTED]. When interviewed on 07/30/18 at 02:25 PM, social worker #12 stated the resident had periods of agitation and was on medications for advanced dementia. During the interview, the social worker did not say the resident had any episodes of anxiety. When interviewed on 07/31/18 at 10:13 AM, consultant pharmacist #34 stated the resident's Medication Administration Record [REDACTED]. When interviewed on 07/31/18 at 12:15 PM, physician #28 stated the resident was difficult to manage and would scream, bite, and was a safety risk to herself and others. He did not state the resident had any episodes of anxiety. 10NYCRR 415.12(l)(1)

Plan of Correction: ApprovedSeptember 7, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F758 FREE FROM UNNECESSARY [MEDICAL CONDITION] MEDS
The facility will ensure that each resident?s drug regimen is free from unnecessary drugs.
1. Corrective Action
a. Resident #52 ? The resident?s plan of care and medication regimen will be reviewed by the pharmacist and the resident?s physician for appropriateness of gradual dose reduction for [MEDICAL CONDITION] medications. If appropriate, the dosage will be adjusted. If it is contraindicated, the physician will document rationale for the contraindication. The use of non-pharmacological interventions will be evaluated by the interdisciplinary team and added to the plan of care as appropriate.
b. Resident #116 - The resident?s plan of care and medication regimen will be reviewed by the pharmacist and the resident?s physician for appropriateness of [MEDICAL CONDITION] medication usage. If appropriate, the [DIAGNOSES REDACTED]. If it is contraindicated, the medication will be titrated then discontinued. The use of non-pharmacological interventions will be evaluated by the interdisciplinary team and added to the plan of care as appropriate.
c. Residents #39 and 90 - The resident?s plan of care and medication regimen will be reviewed by the pharmacist and the resident?s physician for appropriateness of [MEDICAL CONDITION] medication usage. The use of non-pharmacological interventions will be evaluated by the interdisciplinary team and added to the plan of care as appropriate.
2. Others Residents Potentially Affected
Other residents currently receiving [MEDICAL CONDITION] medications have potentially been effected. The resident?s plan of care and medication regimen will be reviewed by the pharmacist for appropriateness of [MEDICAL CONDITION] medication usage, documentation to support the use of the medications, and timeliness of gradual dose reduction attempts. The findings of the pharmacist review will be communicated to the medical providers.
3. Systemic Changes to Prevent Recurrence
The interdisciplinary care planning team was educated about person-centered care planning to identify triggers for resident behaviors and determine individualized non-pharmacological approaches to mitigate those behaviors.
The policies for ?Behavior Management? and ?Antipsychotic Medication Use? have been updated to address person-centered care planning, indications for usage, and gradual dose reductions.
Social workers, licensed nurses and nursing assistants have been trained on non-pharmacological approaches to behavior management.
The medical director will educate medical providers on the appropriate use and oversight of [MEDICAL CONDITION] medications.
Pharmacy will continue to review medications for supporting documentation on indication for usage during review of the medication regime for each resident, with recommendations to the medical provider for any suggested adjustments.
4. Monitoring/QA Plan
The social workers will meet with the pharmacist monthly to discuss residents who may are demonstrating improved behaviors and may be appropriate for additional reductions in [MEDICAL CONDITION] medications.
The pharmacist will provide a list monthly of when gradual dosage reductions (GDR) have been completed to identify residents who may need to be reviewed for GDR. The director of social work and director of nursing will ensure follow up with the medical providers to address the GDR, either by reducing the medication or documenting the contraindication.
The list from pharmacy will be submitted to the QAPI committee monthly for review and follow up as needed. This audit will be ongoing to achieve sustained compliance at 100%.
Person Responsible: Director of Admissions and Social Work


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: July 31, 2018
Corrected date: September 10, 2018

Citation Details

Based on record review and interview 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 directory on 7/27/2018, a surveyor observed multiple directory roles were unassigned. These included, but were not limited to: - Emergency Office Roles: 1. 24/7 Facility Contact 2. Emergency Medical Supplies Receiving Office - Contact Person Roles: 1. Designated Pharmacist 2. Director, Food and Nutritional Services 3. Director, Safety/Security 4. Emergency Response Coordinator When interviewed on 7/27/2018 at 12:00 PM, the Health Information System Director stated she was unaware the roles were unassigned. 10NYCRR 400.10(d)

Plan of Correction: ApprovedAugust 30, 2018

Y4077 HEALTH PROVIDER NETWORK ACCESS AND REPORTING
The facility will ensure sufficient, knowledgeable staff will be available to maintain and keep HPN accounts for emergency communication and alerts 24 hours a day,7 days per week.
1. Corrective Actions:
a. The HCS Coordinator has reviewed and updated the HCS Role Assignments through the Coordinator?s Update Tool. These updates include the Designated Pharmacist, Director of Food and Nutritional Services, Director of Safety & Security and the Emergency Response Coordinator. In addition an update has been completed for the Emergency Office Roles of: 24 by 7 Facility Contact and Emergency Supplies Receiving Office. All of these roles are now filled by the appropriate personnel.
2. Other Residents Potentially Affected
None.
3. Systemic Changes:
a. A full review of all roles for the entire facility has been completed and updates done. A role report has been obtained and the data reviewed and verified for accuracy.
b. A review of all HCS users has also been completed and data verified to assure accuracy.
c. The Use and Maintenance of the Health Commerce System facility policy has been reviewed and updated based on the regulation 10 CRR NY 400.10.
d. The HCS Coordinator has been educated on the requirements to maintain qualified, knowledgeable staff in the defined roles on the HPN.
4. Monitoring
a. The HCS Coordinator shall review the Role Report through the Health Commerce System account on a monthly basis to assure personnel changes are accurately reflected. The HCS Coordinator shall obtain a Role Report quarterly and verify the users and their designated roles through the HCS Role reporting tool.
b. Any users who have been terminated by Katherine(NAME)Residential Healthcare and Rehabilitation center will be removed from all Roles and their account deleted.
c. Audit findings will be reported to the QAPI committee for review and follow up to ensure ongoing compliance.
Responsible Person: Adminstrator

FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 31, 2018
Corrected date: September 10, 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 2 of 2 residents (Residents #201 and 221) reviewed for range of motion and contractures received the necessary services to increase or to prevent further decrease in range of motion. Specifically, Resident #201 did not have interventions for a contracture to her hand, and Resident #221 did not have interventions in place for contractures to the upper body. Findings include: 1) Resident #221 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. A 06/18/18 occupational therapy (OT) evaluation and treatment note documented the resident had an unspecified shoulder contracture, and right and left elbow contractures. OT intructions recommended resident to receive support from staff on the unit. The 06/22/18 physician progress notes [REDACTED]. The physician ordered [MEDICATION NAME] (muscle relaxer) 15 milligrams (mg) every AM for muscle spasms. The 07/19/18 comprehensive care plan (CCP) documented the resident was totally dependent on staff for care and was unable to communicate his needs. There was no documentation in the CCP that a plan was implemented for contracture and/or positioning to the resident's head, neck or arms. The 07/2018 certified nurse aide (CNA) instructions had no documentation that interventions were in place for positioning to the head or neck or for contractures to the resident's arms. The resident was observed with his head and neck tilted down to the right and his left and right arms bent at the elbows and against his chest without any devices or supports: - on 07/25/18 at 10:00 AM; - on 07/26 at 09:05 AM and 10:49 AM; - on 07/26 at 11:29 AM, 11:57 AM, 12:23 PM; 12:36 PM, and 12:41 PM during the noon meal with his high back chair not in the upright position and being fed with a straw, and 01:13 PM; - on 07/27/18 at 09:25 AM and 01:20 PM; and - on 07/30/18 at 11:56 AM. During an interview with CNA #1 on 07/31/18 at 09:34 AM, she stated the resident was totally dependent on staff for all care, and it was difficult to get the resident dressed related to some contractures to his left and right arms. The resident had declined over time and had not had difficulty with his arms a couple years prior. The resident's head and neck would tilt down to the right and there was nothing in place for staff to provide support to his neck. She stated the resident was not provided range of motion (ROM). Therapy had worked with him on loosening him up and there was nothing additional provided for direct care staff to provide him. During an interview with CNA #2 on 07/31/18 at 10:00 AM, she stated the resident would lean forward in his chair and it was difficult to feed him. He leaned to one side a lot and she felt bad trying to lift his head when trying to feed him as it was always down. She stated therapy had seen him at one point and no direction was provided for direct care staff. His left arm was very tight to his chest and it was difficult to get him dressed. She had noticed just this year the resident's head and neck seemed to be lower than it had in the past. Family had brought in different shirts to help staff dress him, but nothing was implemented to try to improve or maintain ROM by direct care staff. During an interview with licensed practical nurse (LPN) #4 on 07/31/18 at 10:29 AM, she stated the resident could barely move his arms as they were tight to his body. The resident was hunched and contracted. She stated it had become more difficult to feed the resident and his head used to be up higher. Now his neck was leaning down more and she was not sure if it was contracted. The resident did not have anything in place to support his arms, neck or head. During an interview with physical therapist (PT) #31 on 07/31/18 at 10:58 AM, she stated the resident was on occupational therapy 06/18/18 - 07/13/18. Per the occupational therapists notes, the resident was provided massaging to his upper extremities to promote and increase ROM. She could not see where recommendations were made for direct care staff. If staff were having increased difficulty at meals therapy should be notified by nursing and she could not see where this had been reviewed by the occupational or physical therapy department. She could not find any documentation that supportive devices or a plan for ROM was in place for direct care to provide to the resident's arms, head or neck. During an interview with registered nurse (RN) Unit Manager #3 on 07/31/18 at 11:34 AM, she stated the resident had a stooped neck and shoulders. The resident had never held his head upright. It was difficult to position him and he required total feeding assistance at meals. The staff sometimes had trouble feeding him. The chair should be in the upright position during meals. She was not aware of any supportive devices or a plan currently in place to the head, neck or arms. 2) Resident #201 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 06/26/18 MDS assessment documented the resident was severely cognitively impaired, required extensive assistance to total dependence on staff for ADLs, and did not have impairment to her upper extremities. The 04/16/18 CCP documented the resident was at risk for developing pressure ulcers. The CCP did not have a plan in place to address the resident's hand contracture. A 05/10/18 OT evaluation documented the resident was evaluated related to a concern by staff that the resident was clenching her palm. OT provided a palm roll to prevent skin break down and contractures. The 07/2018 CNA care instructions had no documentation a palm roll or other interventions were in place to the resident's hand contracture. The resident was observed with her left hand contracted without a device in place on 07/25/18 at 10:00 AM; on 07/26/18 at 09:02 AM, 09:57 AM, 11:07 AM, 11:29 AM, and 11:57 AM; on 07/27/18 at 09:01 AM; and on 07/30/18 at 09:55 AM and 11:56 AM. During an interview with CNA #1 on 07/31/18 at 09:34 AM, she stated the resident had a left hand contracture and there was not a plan in place to include interventions or devices for direct care staff. She had notified both the charge nurse and the RN unit manager regarding the contracture and no changes were made. During an interview with CNA #2 on 07/31/18 at 10:00 AM, she stated the resident was totally dependent on staff for care and had not participated in a occupational or physical therapy program in quite some time. She was not aware of any devices for the resident's hand. During an interview with PT #31 on 07/31/18 at 10:58 AM, she stated there were two occupational therapists that had worked with the resident in the past and they were unavailable to interview this date. She stated per occupational therapy's notes they provided a palm roll to the resident on 05/05/18 for clenching of the resident's left hand. During an interview with RN unit manager #3 on 07/31/18 at 11:34 AM, she stated she was not aware of the resident having a contracture or any interventions to her hand. 10NYCRR 415.12(e)(2)

Plan of Correction: ApprovedSeptember 7, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F688 RANGE OF MOTION
The facility will ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident?s clinical condition demonstrates that a reduction in range of motion is unavoidable.
1. Corrective Action
a. Resident #221 with a [DIAGNOSES REDACTED]. The care plan has been updated to reflect the need for daily Passive Range of Motion at AM care to maintain movement. Physical Therapy has assessed the resident to provide corrective cushions in order to improve posture in the wheelchair.
b. Resident # 201 with a [DIAGNOSES REDACTED]. The care plan has been updated to reflect the need for daily Passive Range of Motion at AM care to maintain joint mobility, and the use of an abduction pillow between her knees when in the wheelchair. The resident utilizes a palm roll in both of her hands at all times. It is removed for care and skin inspection. These interventions are on her care plan and the Kardex for communication to caregivers.
2. Other Residents Potentially Affected
a. Residents throughout the community whose range of motion is limited by pain, neurological conditions and clinical conditions, which cause difficulty with wheelchair positioning and the risk, or presence of contractures, could be affected.
b. A list of residents at risk has been developed and residents have been reviewed by the therapy team for the need for treatment or preventative measures. Residents requiring intervention will have their plan of care updated to reflect the intervention.
3. Systemic Changes to Prevent Recurrence
a. The therapy department will maintain a list of residents at risk for contractures or positioning concerns. The list will be distributed monthly to the nurse managers to provide oversight and update interventions on the plan of care as needed.
b. Residents at risk will be screened quarterly by the therapy department. Interventions will be care planned and communicated to the interdisciplinary team.
c. Nursing assistants will be re-educated on the process for performing range of motion exercises for residents. Nursing and therapy staff have been re-educated on the need to continually monitor residents for signs of joint or muscle tightness and/or positioning difficulties.
d. The CNA Competency will be updated to reflect ROM skills following training by the Therapy department.
e. The Quarterly Therapy Screening tool has been updated to reflect improvement/decline/no change in Range of Motion and identify residents more quickly who experience a change in status.
4. Monitoring and QA Plan
a. An audit has been developed to monitor compliance of proper positioning and range of motion for identified residents. The audit will be conducted by the nurse managers weekly for 4 weeks and then monthly for a period of 3 months. Audit findings will be reported to the QAPI committee for review and follow up to ensure ongoing compliance.
Responsible Person: Director of Nursing

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 31, 2018
Corrected date: September 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #215) reviewed for transmission-based precautions. Specifically, Resident #215's contact precautions were discontinued prior to the determination she was asymptomatic for signs and symptoms of [MEDICAL CONDITION] (C. diff, a bacterium causing diarrhea). Findings include: The facility policy Contact Precautions revised date 02/11/11 included: - All facility departments to observe standard precautions in addition to contact precautions. - Precaution sign on door, correct personal protective equipment (PPE) marked, visitor side facing out. - Residents with [DIAGNOSES REDACTED] should have their room cleaned last. - Wash hands before and after each resident contact and after contact with resident belongings and equipment. - When transport of resident is necessary, ensure infective material is contained or covered. The facility policy [MEDICAL CONDITION] Infection Protocol effective date 11/19/13 included: - Resident placed on contact precautions. - Note and follow physician orders, update physician with any new changes. - Contact precautions to be maintained for 48 hours post treatment and last watery stools. Resident #215 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #215 was transferred to the hospital and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 07/06/18 Minimum Data Set (MDS) assessment documented the resident required extensive assistance for toileting and personal hygiene and was always incontinent of urine and stool. A nursing admission screening completed on 06/29/18 documented the resident had a [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 06/29/18 documented the resident would require low residue (fiber) diet due to [DIAGNOSES REDACTED]. There was no documentation of interventions to include contact precautions. Lab results dated 07/19/18 documented the resident tested positive for [DIAGNOSES REDACTED] toxin B. The physician order [REDACTED]. diff until 08/02/18. The 07/2018 Medication Administration Record [REDACTED]. diff from 07/25/18 through 07/31/18. CNA care instructions (undated) documented the resident required a Hoyer (a mechanical lift) for transfers and extensive assistance for toileting and hygiene. The following observations were made: - On 07/26/18 at 10:29 AM the resident was on contact precautions for [DIAGNOSES REDACTED] and was observed in an electric scooter near the nursing station, interacting with staff. - On 07/26/18 at 10:42 AM, the resident was on contact precautions and was observed to be freely mobile throughout the unit and was observed meeting with the facility social worker across from nursing station. - On 07/27/18 at 10:30 AM, the resident was observed wearing an adult brief smeared with stool. The resident stated the staff did not clean her well and every time they cleaned her up she had stool in her brief even when she had not had a bowel movement. The resident stated staff did not offer her extra opportunities to wash her hands. - On 07/30/18 at 9:27 AM, an unidentified nurse was observed at the resident's bedside providing care. No personal protective equipment (PPE, gowns, masks, gloves) were observed being used. - On 07/30/18 at 10:00 AM the resident was observed on an electric scooter, moving freely throughout the unit. Nursing progress notes documented the following: - On 07/17/18 the resident continued with loose stool multiple times per shift. The resident was not aware of loose stools. Pending stool specimen for [DIAGNOSES REDACTED]. - On 07/19/18 lab results were positive for [DIAGNOSES REDACTED], reviewed with medical and an order was obtained for [MEDICATION NAME]. - On 07/20/18 through 07/24/18 nursing notes documented to continue antibiotic for urinary tract infection as well as [DIAGNOSES REDACTED], resident asymptomatic, no adverse effects. There was no documentation of stool consistency or frequency. - On 07/25/18, maintain contact precautions. - On 07/26/18 at 02:27 PM, infection control staff documented the resident was asymptomatic of [DIAGNOSES REDACTED], was experiencing no loose bowel movements and contact precautions would be discontinued. The resident continued taking [MEDICATION NAME]. There was no phone call to update the physician. There was no documentation of stool consistency or frequency in the nursing progress notes from 07/25/18 through 7/30/18. Certified nurse aide (CNA) documentation documented the resident had diarrhea: - On 07/24/18 at 04:23 PM; - On 07/26/18 at 09:44 PM; and - On 07/29/18 at 01:59 PM. On 07/30/18 at 9:30 AM, Resident #215 was reinterviewed and the resident stated she was not assisted with additional opportunities for hand washing and staff did not offer her a wipe or wash cloth even though she could not get to them herself. During interview on 07/30/18 at 10:18 AM, Assistant Nurse Manager, licensed practical nurse (LPN) #17, stated when a resident requiring contact precautions was identified, PPE and other supplies were placed on the resident's door. He stated residents were encouraged to wash their hands when going to the dining room. During re-interview on 07/30/18 at 11:30 AM, Infection Control Nurse and Wellness Coordinator RN #15 stated prior to the current week, when a resident was on isolation precautions they could leave their room. On 07/31/18 at 12:33 PM during an interview with CNA #16, she stated contact precautions were only used when providing care to a resident. If the infection was in urine or stool, the resident could still leave their room because it was contained within the clothing. She stated she did not provide extra hand washing when residents had infected urine or stool. On 07/31/18 at 12:45 PM, Infection Control RN #15 was reinterviewed. She stated when a resident had symptoms of [DIAGNOSES REDACTED] she would call the physician to keep him up to date, but no order was needed to place the resident on or to take them off contact precautions. To determine if a resident could come off contact precautions, the resident must have completed all antibiotics and have had no loose stool for 48 hours. She removed Resident #215 from contact precautions because nursing progress notes 7/25/18 - 7/30/18 revealed she was asymptomatic. 10NYCRR 415.19(a)(1-3)(b)

Plan of Correction: ApprovedAugust 30, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F880 INFECTION PREVENTION AND CONTROL
The facility will continue to maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
1. Corrective Action
a. Resident #215 has been discharged from the facility
2. Others Residents Potentially Affected
a. The infection prevention professional (IPP) conducted a review of all residents that were on Contact Precautions to determine if any other resident had the potential to be affected; review revealed no other residents at risk.
b. Review of all residents on Contact Precautions was completed and the review revealed the residents that were currently on Contact Precautions were not on precautions related to a [MEDICAL CONDITION] infection.
c. The residents that remained on Contact Precautions were evaluated for need of precautions to continue and it was deemed by the IPP that the precautions should remain in place.
3. Systemic Changes to Prevent Recurrence
a. In reviewing the documentation it was noted there was confusion in the descriptors for bowel movements in the EMR. The EMR System was reviewed and revised to better list the types of BMs a resident may have to better evaluate if symptoms of [MEDICAL CONDITION] are continuing.
b. The policy for Contact Precautions was reviewed and revised to state that precautions need to be individualized based on the site and severity of the infection, as well as the resident?s mental status, reliability and hygiene. The goal will be the least restrictive plan possible for any resident in question.
c. All staff will be educated on the revised policy for Contact Precautions.
4. Monitoring/QA Plan
1. An Audit Tool was created to monitor residents placed on Contact Precautions to evaluate if precautions were necessary and maintained for the appropriate period of time.
2. The audit will be done weekly for 4 weeks and then monthly thereafter.
3. Findings will be reported to the QAPI Committee for review and follow up to ensure ongoing compliance.
Responsible Person: Director of Nursing

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 31, 2018
Corrected date: September 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not maintain drug and biological storage and labeling in accordance with currently accepted professional standards for 2 of 4 medication storage rooms (Valley Crest and Mapleview) and for 2 of 5 medication carts (Valley Crest and Willoway) inspected. Specifically, inspection of medication rooms and carts on Valley Crest, Mapleview and Willoway revealed opened vials of [MEDICATION NAME] (used for detecting [MEDICAL CONDITION]), insulin and eye drops that were undated and not discarded after 30 days for Residents #1, 28, 108, 149, 174, 182 and 202. Findings include: The facility policy Medication Storage, Preparation, Administration, and Documentation General Guidelines effective 4/3/18 documented multi-dose medications will be initialed and dated when opened. The policy did not address when the multi-dose vial should be discarded. The facility policy Administration of Eye Medications revised 6/24/13 documented eye medications should be at room temperature and stored in a medication bin separate from topical meds, unless directed to store in refrigerator. There was no documentation regarding labeling eye drops when opened and when to discard. The facility policy Insulin Pens revised 6/24/13 documented to refrigerate unopened flex pens, do not refrigerate opened flex pens. Unrefrigerated flex pens: [MEDICATION NAME] expires in 42 days and [MEDICATION NAME] expires in 28 days. There was no documentation regarding labeling insulin pens, storage and labeling of insulin vials and when to discard both pens and vials. EYE DROPS 1) Resident #149 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired vision and moderate cognitive impairment. The 7/2018 Medication Administration Record [REDACTED]. 2) Resident #174 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident had highly impaired vision and severely impaired cognition. The 7/2018 MAR indicated [REDACTED]. 3) Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident had adequate vision and was cognitively intact. The 7/2018 MAR indicated [REDACTED]. During the Valley Crest medication cart inspection on 7/31/18 at 8:52 AM the following observations were made: - Resident #174's [MEDICATION NAME] was opened and was dated 6/11. - Resident #149's Olopatadine was opened and dated 5/7/18. During the Mapleview medication cart inspection on 7/31/18 at 9:30 AM, Resident #108's artificial tears were opened and dated 6/20/18. INSULIN 1) Resident #28 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 7/2018 MAR indicated [REDACTED]. 2) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident had moderately impaired cognition and received insulin injections. The 7/2018 MAR indicated [REDACTED]. 3) Resident #202 was admitted to the facility 3/14/18 and had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident's cognition was severely impaired and she received insulin. The 7/2018 MAR indicated [REDACTED]. During the Valley Crest medication cart inspection on 7/31/18 at 8:52 AM the following observations were made: - Resident #28's [MEDICATION NAME] vial was opened and there was no documentation when the vial was opened. - Resident #1's [MEDICATION NAME] vial was opened and there was no documentation when the vial was opened. During the Willoway medication cart inspection on 7/31/18 at 11:17 AM, Resident #202's [MEDICATION NAME] pen was opened and there was no documentation when the pen was opened. [MEDICATION NAME] During an inspection of the medication storage room on Valley Crest on 7/31/18 at 8:52 AM, an undated, opened vial of [MEDICATION NAME] was observed in the medication refrigerator. During an inspection of the medication storage room on Mapleview on 7/31/2018 at 9:30 AM, an opened vial of [MEDICATION NAME] was observed in the refrigerator and was dated 5/9/2018. During an interview with licensed practical nurse (LPN) #5 on 7/31/18 at 8:52 AM, she stated she always dated insulin when she opened it, it should always be dated and was good for 30 days after being opened. She thought eye drops were good for 30 days after opening as well, but was not entirely sure. She stated the [MEDICATION NAME] should be dated and the pharmacy person had just been there and had reviewed all the dates on the medications. During an interview with LPN #32 on 7/31/2018 at 9:30 AM, she stated when an insulin box was opened the box should be dated after checking the expiration date. She stated the same was true for eye drops and they were both good for 30 days after being opened. She stated [MEDICATION NAME] should be dated when opened and was good for 24 hours after using. During an interview with Registered Pharmacist #34 on 7/31/2018 at 10:13 AM, she stated a pharmacy technician inspected the med carts and medication storage rooms quarterly for outdated and expired medications. The last inspection had been last week. She stated insulin should be dated when opened and was good for 28 days after opened. Eye drops should also be dated when opened and should also be discarded after 28 days. [MEDICATION NAME] should be discarded 30 days after being opened. During an interview with LPN #23 on 7/31/18 at 11:17 AM, she stated when an insulin vial was opened it should be dated and was good for 28 days after being opened. She stated eye drops should be dated and were good for 28 - 30 days. 10NYCRR 483.45(g)(h)

Plan of Correction: ApprovedSeptember 7, 2018

F761 LABEL/STORE DRUGS AND BIOLOGICALS
The facility will maintain drug and biological storage in accordance with currently accepted professional standards.
1. Corrective Action:
a. The items identified as undated during survey were discarded.
b. No residents were harmed due to the deficient practice.
2. Others Potentially Affected:
a. All residents receiving medications have the potential to be affected.
b. The pharmacy audited all medication and treatment carts on (MONTH) 9, (YEAR) for opened and undated items. Any opened items without a date were discarded.
3. Systemic Changes
a. The policy entitled ?Medication Storage, Preparation, Administration, and Documentation General Guidelines? was reviewed for accuracy and remains appropriate.
b. The pharmacy provided a quick reference guide that has been laminated and placed in all medication rooms to provides guidelines for expiration dates for multi-dose inhalers, injectable medications, insulin, and suppositories. This guide has been attached to the policy as a reference to the guidelines outlined in the policy.
b. The Director of Education/designee will inservice licensed nurses on proper dating and storage of open medications. This education will specifically include placing the open date on multi-dose medications and when the medication can no longer be used.
4. Monitoring and QA Plan:
a. An audit has been developed to monitor the dating of opened medications and discarding of outdated medications. The unit manager/designee will audit medication and treatment carts weekly for 4 weeks, then monthly for 3 months or until 100% compliance is maintained.
b. Audit findings will be submitted to the QAPI committee for review and follow up to ensure ongoing compliance.
Responsible Person: Director of Nursing

FF11 483.70(a)-(c):LICENSE/COMPLY W/ FED/STATE/LOCL LAW/PROF STD

REGULATION: §483.70(a) Licensure. A facility must be licensed under applicable State and local law. §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. §483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 31, 2018
Corrected date: September 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey, the facility did not ensure services were provided in compliance with all applicable Federal, State and local laws, regulations, and codes for 2 of 8 residents (Residents #131 and 174) reviewed for advance directives. Specifically, Residents #131 and 174 had Medical Orders for Life Sustaining Treatment (MOLST) completed by a health care proxy (HCP, a person designated to make health care decisions for someone determined to have a lack of capacity for decision-making) and determination of capacity was not signed by a concurring physician as required by New York State (NYS) Law. Findings include: The facility's Advance Directives policy revised [DATE] documented the health care proxy document was created pursuant to NYS Public Health Law 29-C which delegates authority to another adult to make health care decisions on behalf of the patient/resident and when the patient/resident becomes incapacitated. The policy did not address how lack of decision-making capacity is determined or the type of documentation required for determination of lack of decision-making capacity. 1) Resident #131 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance with all activities of daily living (ADLs), and family or significant other participated in the assessment. The HCP form dated [DATE] documented the resident identified an individual to make healthcare decisions on his behalf in the event he became unable to make his own health care decisions. The comprehensive care plan (CCP) dated [DATE] documented the resident's advance directives were do not resuscitate (DNR, allow natural death) and he had a HCP in place. Interventions included honoring the wishes of the resident/designated representative, review/revise advance directives with the resident/designated representative, and the physician was to place an order for [REDACTED]. The MOLST, dated [DATE], documented the advance directive was DNR, provide limited medical interventions, DNI (do not intubate, no artificial breathing tube), send to the hospital, no feeding tube, trial IV (intravenous) fluids, and use antibiotics. The document was signed by the resident's HCP as the decision maker. The incapacity determination documentation form stated the physician determined the resident lacked the ability to understand and appreciate the nature and consequences of DNR and life-sustaining treatment orders due to dementia. The physician signed the document [DATE] and the concurring signature was that of registered nurse (RN) #29 on [DATE]. The physician's progress note dated [DATE] documented the resident was DNR status. When interviewed on [DATE] at 12:45 PM, RN #29 stated she had signed the lack of capacity determination as a concurring provider for residents when the social worker brought her the form to sign. She stated she signed the resident's lack of capacity determination, as she knew the resident well enough to know he had dementia and lacked capacity to make his own decisions. She was unaware of the legal requirements for a concurring signature when a HCP made the decision on behalf of the resident. When interviewed on [DATE] at 12:52 PM, social worker #20 stated she was aware of the requirement for two physicians' signatures for lack of capacity determination. She stated she left the form in a folder on the unit for the attending physician to sign and then nursing staff or the unit secretary would take the form to someone else for the second signature. The social worker did not go back to verify forms after she sent them to the unit for the resident's chart and she did not have any role in overseeing the completion of the documentation. She stated she had audited records to ensure inclusion of advance directives and lack of capacity documentation but did not verify appropriateness of the concurring signatures. 2) Resident #174 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The [DATE] MDS assessment documented the resident had severe cognitive impairment, required extensive assistance for all ADLs, and family or significant other participated in the assessment. The health care proxy form dated [DATE] documented the resident designated his spouse to make health care decisions on his behalf in the event he was unable to do so. RN unit manager #13 documented in a nursing progress note [DATE] the resident was admitted , MOLST form completed with the HCP, CPR (cardiopulmonary resuscitation) with limited medical interventions, no intubation and no feeding tube. The MOLST documented the resident was to have CPR attempted, limited medical interventions, DNI, send to the hospital, no feeding tube, trial IV fluids, and use antibiotics. The MOLST was signed by the resident's HCP as the decision maker on [DATE]. The CCP initiated [DATE] documented the resident had advance directives in place including MOLST, CPR and HCP. Interventions included discuss and review the advance directives with the resident and his spouse and honor the wishes of the resident and/or designated representative. There was no documentation about the limited medical interventions as decided by the resident's spouse. The incapacity determination documentation form stated the physician determined the resident lacked the ability to understand and appreciate the nature and consequences of DNR and life-sustaining treatment orders due to advanced dementia. The physician signed the document on [DATE]. There was no concurring physician signature on the form. During an interview on [DATE] at 12:25 PM, social worker #12 stated the MOLST was completed with the resident if he/she were able to make their own decisions or the HCP or surrogate made the decision. The procedure for completing the lack of decision-making capacity form was initiated by the social worker and then left for the physician on the resident's unit. The physician evaluated the resident to determine decision-making capacity and often wrote dementia or advanced dementia as the reason the resident lacked capacity. The unit secretary then brought the form to the other physician in the facility to sign if they concurred with the decision the resident lacked capacity. The unit secretary then brought the form back to the resident's unit for scanning into the electronic medical record. The social worker stated ideally, the lack of decision-making capacity form would be completed before the MOLST, and based on the physician's schedules, she would anticipate it to be done within a few days of the initial signature. When interviewed on [DATE] at 02:41 PM, RN Unit Manager #13 stated the process for lack of capacity determination was initiated by the social worker. The physician determined incapacity upon examination of the resident and signed the form, which was then placed in the folder on the unit. The unit secretary was to bring the form to another unit for the second physician to sign. The RN stated when a HCP signed the MOLST as the decision maker, the concurring signature should be from another physician and under no circumstances would an RN be able to sign as a concurring provider for a lack of decision-making capacity determination. 10NYCRR 415.3(e)(1)(ii)

Plan of Correction: ApprovedSeptember 7, 2018

F836 COMPLY WITH FED/STATE/L(NAME)AL LAW/PROF STANDARDS
The facility will ensure services are provided in compliance with all applicable Federal, State, and local laws, regulations and codes.
1.Corrective Action:
a.The incapacity determination documentation form for resident # 174 was reviewed and concurring documentation and signature was obtained on (MONTH) 3, (YEAR).
b. The capacity determination for resident #131 will be reviewed by another concurring physician with knowledge of capacity determinations and who has personally evaluated the resident.
2.Other residents Affected:
Any resident of the facility who is admitted without the ability to consent to an advance directive has the potential to have an incapacity determination documentation form on their medical record that is not fully documented with the individual?s incapacity. Any individual whose capacity changes during their stay at Katherine(NAME)Residential and Rehabilitation Center would have the potential to have incomplete incapacity documentation in the Electronic Medical Record.
The Director of Social Work reviewed the records of all residents of the facility on (MONTH) 4, (YEAR) and determined that there were no other residents of the facility admitted prior to (MONTH) 3, (YEAR) who have an incapacity determination documentation form in the electronic medical record that is incomplete.
3.Systemic Changes to prevent Reoccurrence:
a.Social Workers, Nurse Managers, Attending Physicians and Team Members in the Health Information Department including Unit Secretaries have been educated on completion of determination of capacity forms, who may complete the form as per policy on initiating a MOLST, and review of form prior to upload to the electronic medical record.
b.The facility?s policy on initiating a MOLST was reviewed with the Nurse Managers and the Social Workers to include use of the MOLST checklists to assess capacity, and the ability/desire to choose a health care proxy. The process will include the use of the appropriate checklist to guide the process to assess the patient?s medical decision-making capacity.
-For residents who are determined to have mental illness, two concurring physicians will confirm the lack of decision-making capacity, one of whom will be a qualified psychiatrist.
-For residents who are determined to have a developmental disability, a physician and a concurring physician/psychologist employed by a Developmental Disability Services Office (DDSO) for at least two years will make the determination.
-For residents for whom the lack of capacity is not related to mental illness, and who have no health care proxy, the concurring professional may be a health or social services practitioner employed by, or formally affiliated with, the facility has independently determined that the patient lacks medical decision-making capacity.
-For residents for whom the lack of capacity is not related to mental illness, and who have a health care proxy, two concurring physicians will confirm the lack of decision-making capacity.
4.Monitoring/Quality Assurance Plan
The Director of Admissions and Social Work will review the records relative to advance directives for all new admissions to the facility by their initial care plan date each month. Any indiscretions will be brought to the appropriate team member?s attention for immediate correction and documented as part of the Quality Assurance Reporting.
Additionally at Care Conferences a member of the Social Work Team, or their designee, will review the resident document section for any determination of capacity document during care conferences. Any indiscretions noted will be immediately corrected and reported to the Director of Social Work for Quality Assurance Reporting.
The Director of Social Work will track and trend any determinations that are found to not be in compliance to determine the cause of the non-compliance. A summary report will be submitted monthly to the QAPI committee for review and follow up to ensure ongoing compliance of all capacity determinations.
Responsible Person: Director of Admissions and Social Work

FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE

REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 31, 2018
Corrected date: September 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey, the facility did not ensure residents maintained acceptable parameters of nutritional status or were offered sufficient fluid intake to maintain proper hydration and health for 1 of 8 residents (Resident #163) reviewed for nutrition and hydration. Specifically, Resident #163 had a significant weight loss and was not reassessed timely. Findings include: The Resident Nutrition Status Policy, revised 12/2017, documented the Dining & Nutrition Services Department will be notified by the Nursing Department in a timely manner of any change in resident's nutrition status. Monthly documentation must be completed for any resident at high nutritional risk; significant unplanned weight loss of 5% in one month period, 7.5% in three month period or 10% in a six month period. Resident #163 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 06/18/18 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, and she felt down, depressed and had a poor appetite nearly every day. The resident required extensive assistance with activities of daily living (ADLs) including eating, and she weighed 119 pounds. The Weights and Vitals summary documented on 06/11/18 the resident's admission weight was 119.4 pounds. The 06/15/18 comprehensive care plan (CCP) documented the resident had [MEDICAL CONDITION] affecting gait, mobility and ADLs. Interventions included to monitor, document and report anorexia, nausea and dysphagia (difficulty swallowing). The 06/22/18 Nutrition Assessment documented the resident's weight was 119.4 pounds, her usual weight was 128 pounds and desirable weight was 137 pounds. The resident needed 1600 calories/day, 62-74 grams of protein/day and 1865 mls (milliliters)/day. Supplements used included an 8-ounce Mighty Shake at supper, of which the resident typically consumed 50-100%. The resident was fed by staff, average solid intake was 40% and she was receiving speech therapy to increase oral intake. A goal for the resident included a gradual 1 pound weight gain per week. Interventions included to provide 4-ounces of Ensure Clear (nutritional supplement) at lunch, and nursing was to encourage meal and fluid intake. The 06/25/18 CCP documented the resident had a potential nutritional problem requiring a mechanically altered diet with limited oral intake. Goals included the resident would be free of significant weight changes and she would have gradual, 1 pound-per-week weight gain. Interventions included supplements between meals and snacks, monitoring and updating preferences, and monitoring for intolerance to texture provided such as holding food in mouth and excessive chewing. The Weights and Vitals summary documented: - on 06/25/18, the resident weighed 116.3 pounds; and - on 07/01/18, the resident weighed 113.6 pounds. The 07/06/18 Nutrition Note documented a swallow evaluation was completed and the resident's diet was downgraded to pureed consistency. The Weights and Vitals summary documented on 07/10/18 and 07/18/18, the resident weighed 110.3 pounds (7.62% loss). On 07/24/18, the weight record book documented the resident weighed 108.3 pounds (9.30% total loss). There was no documented evidence the resident's needs were reassessed. Over a 7 day period (07/25 - 07/31/18), the resident's daily oral intake sheet documented she ate: - 0% of her meal on 3 occasions; - 10% of her meal on 1 occasion; - 25% of her meal on 4 occasions; - 50% of her meal on 4 occasions; - 75% of her meal on 4 occasions; and - 100% of her meal on 4 occasions. During an interview on 07/31/18 at 10:09 AM, certified nurse aide (CNA) #32 stated that CNAs were responsible to obtain weights, and compared the newest weight to the previous weight and determined if there was loss or gain. If there was a 3 pound loss or gain, they would reweigh the resident for accuracy and then report the loss or gain to the licensed practical nurse (LPN). She stated the LPN was responsible to report the weight to dietary. During an interview on 07/31/18 at 10:12 AM, LPN #33 stated that CNAs were responsible for weights and they reported weight loss to the unit Manager. During an interview on 07/31/18 at 10:18 AM, CNA #32 stated that lately the resident was eating poorly and pocketed food in her mouth. On some days, the resident ate well at breakfast and then nothing at lunch. CNA #32 stated they tried what they could to get food into the resident, were not always successful, and she believed the resident had lost weight. During an interview on 07/31/18 at 12:03 PM, registered dietitian (RD) #36 stated she learned of weight loss after she collected monthly weights and calculated the weight loss percentage. She stated for residents on weekly weights, she learned of weight loss after nursing notified her and she would reassess if the loss was 5 pounds or greater. She stated she assessed the resident on 6/22/18 using the admission weight and added a supplement at that time. She stated she was not notified on 07/24/18 when the resident's weight decreased to 108 pounds, and she expected to be notified so she could reassess nutritional needs. 10NYCRR 415.12(i)(l)

Plan of Correction: ApprovedAugust 30, 2018

F692 NUTRITION/HYDRATION STATUS MAINTENANCE
The facility will ensure that a resident maintains acceptable parameters of nutritional status, such as usual body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that it is not possible or resident preferences indicate otherwise.
1. Corrective Action
a. RD calculated percentage weight change in the past 30 days for the weekly weights obtained. Nutrition progress note was completed 8/1/18 included all weekly weights obtained, average intake of solids and liquids, supplements already being provided (120ml Ensure Clear at lunch, 240ml Ensure Plus at supper) as well as changes in nutrition interventions (added Ensure Plus 120ml BID with med passes) to help prevent further weight loss and/or achieve gradual weight gain. The RD continues to oversee interventions for this resident and will make additional changes to the plan of care if weight loss persists.
2. Other Residents Potentially Affected:
The deficient practice was determined to be related to the communication process associated with weekly weights. Any resident being weighed weekly could be affected by this deficiency. Residents with weekly weights were reviewed and no other residents were found to have weight loss without intervention.
3. Systematic Changes to Prevent Recurrence:
1) Updated policy entitled ?Resident Weight and Weight Changes ? SS-815? to address the process for entering weekly weights into the Electronic Medical Record (EMR) and subsequent report queries in the EMR by the clinical nutrition staff to identify any significant changes in 30 or 180 days. Per current policy nursing will continue to inform clinical nutrition of any weight changes of 5# or greater.
2) Clinical Nutrition Team, Licensed Nurses, and nursing assistants will be in-serviced regarding policy changes and the necessity of communicating weight changes timely to ensure timely intervention.
4. Monitoring/QA Plan:
1) Complete weekly audit for 100% of LTC residents who are being weighed weekly until threshold of 90% for twelve consecutive weeks is achieved, then monthly audit until threshold of 90% for three consecutive months is achieved, then quarterly audit until threshold of 90% is achieved for three consecutive quarters is achieved. Audit results will be submitted to the QAPI committee for review and follow up as needed to ensure ongoing compliance.
Person Responsible: Registered Dietitian

FF11 483.60(d)(1)(2):NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP

REGULATION: §483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 31, 2018
Corrected date: September 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 2 of 3 residents (Residents #5 and 14) reviewed for personal food storage. Specifically, on multiple occasions Resident #5 had personal food items requiring refrigeration stored at room temperature in her room. Resident #14 had a personal refrigerator with temperatures above the safe limit of 45 degrees Fahrenheit and with multiple expired and/or undated food items in the refrigerator. Findings include: The policy Food from Outside Sources revised [DATE] documented any food brought in from outside the community, which is not going to be eaten right away, should be stored in a clean, sealed container. Dining Service or Nursing will label, date, and store the food in the nursing unit's pantry refrigerator. Food that is not labeled and dated will be immediately discarded. Residents who choose to store personal food items will be educated related to food safety as needed based on non-compliance or evidence of poor food safety awareness. A policy for resident personal refrigerators was requested on [DATE]. The Director of Maintenance stated there was no current policy. 1) Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, required extensive assistance for bed mobility and transfers and required supervision with eating. Undated care instructions did not contain documentation regarding the resident's preference to keep personal food items in her room and in her personal refrigerator, and how to ensure the food items were handled and stored properly. A double-sided environmental services temperature log was observed on top of the resident's refrigerator with instructions to maintain refrigerator temperatures at 43 degrees Fahrenheit (F) or below during stable times, check and record temperatures once a day, complete corrective action column if temperatures are not in proper range and check either an accurate internal probe (hanging or standing refrigerator thermometer). One side of the log was dated (MONTH) (YEAR); temperatures were recorded 20 of 31 days and all temperatures ranged from ,[DATE] degrees F. There was nothing recorded in the corrective action or employee initials column. The second side of the log was dated (MONTH) (YEAR); temperatures were recorded 14 of 28 days and on 9 days the temperature was ,[DATE] degrees F. There was nothing recorded in the corrective action or employee initials column. Additional temperature logs for the resident's personal refrigerator were requested on [DATE] and there were none available. The following observations were made of the personal refrigerator in the resident's room: - On [DATE] at 1:00 PM, the refrigerator thermometer read 48 degrees F and there was an undated box containing a piece of chicken and a biscuit. There were several packages of ring bologna and two were opened, along with cola and Boost (nutritional supplement). The resident's spouse stated he was unsure of when the food was brought in. Several condiments were observed in the door of the refrigerator. - On [DATE] at 10:30 AM, the undated box remained in the refrigerator with a piece of chicken and a biscuit. There were multiple other food items in the refrigerator. The resident's spouse stated it had been there for a couple of weeks. The thermometer in the refrigerator read 48 degrees F. - On [DATE] at 11:00 AM, the refrigerator thermometer read 48 degrees F. There was an opened tub of spread with an expiration date of [DATE], 4 full rings of bologna with a use-by date of [DATE], one opened ring of bologna with approximately ,[DATE] of the ring gone and the remainder of the bologna with a white substance covering it, approximately a half loaf of bread with a best used-by date of [DATE], an undated box with a piece of chicken and a biscuit, a second opened ring of bologna with teeth marks on the missing side, in the door of the refrigerator with no white substance, and a jar of mustard with an expiration date of [DATE]. - On [DATE] at 9:51 AM, the undated box remained in the refrigerator with a piece of chicken and a biscuit. The thermometer in the refrigerator read 49 degrees F. The resident's spouse stated on [DATE] at 9:47 AM, he thought the box of chicken had been there a month. He and his wife had eaten some bologna within the past few days. He stated he and his wife were unable to get out of bed by themselves to take the items from the refrigerator so staff had to get the items for them. He did not think anyone took the temperature of the refrigerator. On [DATE] at 12:15 PM licensed practical nurse (LPN) #5 stated the resident's son brings in food. She stated the only time she gets into their refrigerator was to get the drink supplement out. She stated housekeeping keeps the temperatures. She did not look at the food in there or at dates on the food. On [DATE] at 12:30 PM, housekeeper #6 stated the residents would ask him to open the refrigerator to get out their smoothies. He would only look at the temps then. The temperatures should be kept between ,[DATE] degrees. He stated there was no tracking. He stated he would not throw anything in the refrigerator away, and would ask the nurses if needed. On [DATE] at 12:40 PM, Food Service Supervisor #7 stated food service was only responsible for food in the unit pantries and pantry refrigerator. Housekeeping was responsible for temperature checks for unit refrigerators. Temperatures should be at or below 40 degrees F. Foods brought in had a 3-day window and should be discarded after 3 days. If foods were consumed that were not dated or kept in unsafe temperatures it could pose a safety risk due to possible food-borne illness. During interview on [DATE] at 12:45 PM, Maintenance Director #10 stated maintenance staff were going around now checking temperatures on personal refrigerators with a laser thermometer. Temps should be done daily and should be between ,[DATE] (thermometer reading). He stated housekeeping staff was not trained regarding food safety and he would be reluctant to have them determine what to throw out of a personal refrigerator. If something was taken out of its original container and placed in a separate one, the separate one would need to be dated and would be good for 3 days. The residents could be upset since this is their home and they may not understand about throwing things out after 3 days. He was not aware of any education provided to residents or family regarding personal refrigerators or food safety. On [DATE] at 2:29 PM, CNA #11 stated the only time she went in a resident's refrigerator was when they asked for a can of Boost. She did not pay too much attention to what was in the refrigerator. She stated sometimes the resident would ask for bread and butter and she would get it out of the refrigerator. She stated housekeeping was supposed to keep the temps. If she saw something had gone bad she would throw it out. She never took the temperature of the refrigerator or even noticed if it was cold enough. A family member would either bring in food or order out for them. 2) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, was independent with eating and required extensive assistance with transfers. Physician orders [REDACTED]. On [DATE] [MEDICATION NAME] (an enzyme to help digest lactose) was ordered twice daily with lunch and supper for lactose intolerance. A physician progress notes [REDACTED]. The plan was to discuss the importance of appropriate meal intake to prevent weight loss and start on [MEDICATION NAME] (a bulk-forming fiber product) twice a day for bowel dysfunction. There was no documentation in the resident's CCP addressing the resident's preference to keep personal food items in her room or if education was provided to the resident or to the resident's family regarding safe food storage. The undated resident care instructions did not contain documentation regarding the resident's preference to keep personal food items in her room and how to ensure the food items were handled and stored properly. The following observations were made in the resident's room: - On [DATE] at 10:09 AM, multiple snacks in the resident's room on the bedside table including bleu cheese stuffed olives with several missing and a partial block of cheese in a zip lock bag. - On [DATE] at 10:45 AM, a bottle of opened bleu cheese stuffed olives, with ,[DATE] of the content gone, was on the bedside table. The jar of olives had refrigerate after opening stamped on the label. There was no date marked on the jar indicating when they were opened. There was no cheese observed and the resident stated she had eaten it all. - On [DATE] at 9:52 AM, an unopened jar of bleu cheese stuffed olives and sliced cheese in a zip-lock bag were on the resident's bedside table. There was no date on the cheese indicating when it was opened. On [DATE] at 10:09 AM, the resident stated the olives did not need to be refrigerated since they were in vinegar. She stated she was fine with the cheese not being refrigerated and she would keep eating it until it became slimy or green. She stated her cheese had become green before. During an interview with licensed practical nurse (LPN) #5 on [DATE] at 12:15 PM, she stated Resident #5 insisted the cheese she left out in her room was fine. The resident was aware of what happened when cheese was left out. She stated she had discussions with the resident's family member about the cheese and olives and they stated the resident was with it and knew about the cheese. During an interview on [DATE] at 12:40 PM with Food Service Supervisor #7, she stated the food service department was only responsible for food in the unit pantries and pantry refrigerator. Food brought in from outside the facility should be dated, and should be discarded after 3 days. Outdated or perishable food could pose a safety risk due to possible food-borne illness. CNA #11 stated on [DATE] at 2:29 PM, she did not pay much attention to the food in a resident's room, but if she saw something had gone bad she would throw it out. 10NYCRR 415.14(d)(2)

Plan of Correction: ApprovedSeptember 7, 2018

F804 NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP
The facility will ensure the provision of food and drink is palatable, attractive, and at a safe and appetizing temperature.
1. Corrective Action
a.The personal refrigerators for resident #14 was evaluated to ensure it is in good working order and will maintain temperature in the appropriate range. Outdated food and unlabeled food was discarded. The residents and/or their representatives were educated on the need to label and date food that is being placed in the refrigerator to ensure resident safety.
b. Resident #5 has no food items requiring refrigeration stored in her room. The resident/representative has been educated on the availability of the pantry refrigerator to store any items requiring refrigeration.
2. Other Residents Potentially Affected:
a.All residents with personal refrigerators have the potential to be affected.
b.An immediate audit of all residents with personal refrigerators was done for safe temperatures and food safety. The personal refrigerators for other residents were evaluated to ensure they were in good working order and will maintain temperature in the appropriate range. Outdated food and unlabeled food was discarded. The residents and/or their representatives were educated on the need to label and date food that is being placed in the refrigerator to ensure resident safety. Staff have assessed all resident rooms to ensure food items requiring refrigeration are labeled and stored appropriately, either in personal refrigerators or in the unit pantry refrigerators.
c. No residents were harmed due to the deficient practice.
3. Systemic Changes to Prevent Recurrence:
a. A policy and procedure was created for monitoring resident refrigerators for temperatures and/or expired/undated products. The policy includes daily checks by housekeeping personnel for safe temperature and expiration dates, and a weekly cleaning schedule. Expired or unlabeled products are discarded when found on inspection of the refrigerators. Any refrigerators with a temperature at 40 degrees or above are taken out of service and evaluated by maintenance.
b. Housekeeping, maintenance, and dietary staff have been inserviced about safe temperature ranges for the personal refrigerators, and labeling and dating food products.
c.The facility has notified residents and families that refrigeration is available in all resident unit pantries for resident food that may require refrigeration. Food items are to be brought to the staff to date and label prior to being placed in the unit pantries. Staff have been educated to observe for food items that may require refrigeration while in resident rooms. Food requiring refrigeration will be evaluated by dietary for safe temperature. Any foods found not to be at a safe temperature will be discarded for resident safety.
4. Monitoring and QA Plan:
a. An audit has been developed to monitor the temperature and expiration dates of food products. This audit will be done weekly for 4 weeks, then monthly for 3 months or until 100% compliance is obtained.
b. An audit has been developed to observe for food items that may not be safely stored in resident rooms. The audit will be conducted weekly for 4 weeks, then monthly thereafter.
b. Audit findings will be submitted to the QAPI committee for review and follow up to ensure sustained compliance at 100%.
Responsible Person: Administrator

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: Actual harm has occurred
Citation date: July 31, 2018
Corrected date: September 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 254), it was determined for 1 of 3 residents (Resident #539) reviewed for quality of care, the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, Resident #539 had a choking episode and was not treated according to professional standards of practice. When the resident's airway became obstructed the nursing staff did not continue attempts to relieve the obstruction after she became unresponsive. This resulted in actual harm for Resident #539. Findings include: The American Heart Association protocol for Basic Life Support for Healthcare Providers, relief of foreign-body airway obstruction for an adult, directs providers to give abdominal thrusts/[MEDICATION NAME] maneuver to a choking victim. Repeat the abdominal thrusts until the victim becomes unresponsive and then lower victim to the floor, and if the victim has no breathing or no normal breathing (i.e., agonal gasps) begin CPR. New York State Department of Health Frequently Asked Questions re: DNR's (do not resuscitate, allow natural death), policy #,[DATE], dated [DATE] includes: - If the patient is NOT in cardiac or respiratory arrest, full treatment for [REDACTED]. - Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped, ventilation should not be assisted. Resident #539 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and she required supervision with eating. The resident's Medical Orders for Life-Sustaining Treatment (MOLST) initiated on [DATE] documented Do Not Resuscitate (DNR, allow natural death). Registered nurse (RN) #45 documented on [DATE] a certified nurse aide (CNA) shouted that the resident was choking. The resident had taken another resident's sandwich and was eating it. An RN attempted the [MEDICATION NAME] maneuver and resident progressively became more dusky as the [MEDICATION NAME] was unsuccessful. The resident was removed from the dining room. A pulse was felt and oxygen was started, but agonal breathing (abnormal breath/gasping). The resident's vital signs were a pulse of 45 and blood pressure of ,[DATE]. At 1:34 PM, the resident no longer had a pulse or respirations. An investigative summary of the incident attached with the incident report documented the nurse was in the dining room when the resident choked and the [MEDICATION NAME] maneuver was immediately performed. The resident was found to have part of a sandwich in front of her and she was on a puree diet. After multiple attempts at the [MEDICATION NAME] maneuver, the resident became limp and was placed in the wheelchair and brought back to her room where she was placed in bed. Color became pinker, she had a pulse and respirations were agonal. Statements attached to the summary of investigation included: - CNA #41 documented [MEDICATION NAME] performed on the resident, the nurse in training went to the other unit to get another nurse, who ran over to assist. The resident was quickly taken to her room and 911 was called. - RN #42 documented she was alerted to the resident choking she ran over and began the [MEDICATION NAME] maneuver. Another nurse arrived and took over. By that time the resident was slumped over and dusky. We transported the resident to her room and 911 was called. - Graduate practical nurse (GN) #44 documented she heard the resident gasping and notified the RN who initiated the [MEDICATION NAME]. Another nurse arrived who took over the [MEDICATION NAME] and the resident went limp. We put her in the wheelchair, brought her back to her room and put her to bed. The resident continued to gasp for air and no success clearing her airway. We called 911 and put oxygen on the resident because she still had a pulse. By the time the ambulance arrived the resident was no longer gasping for air and no longer had a steady pulse. - RN #45 documented a nurse yelled the resident was choking and they were doing the [MEDICATION NAME]. Upon entering, the resident was slumped over, dusky and unresponsive. Two more attempts at the [MEDICATION NAME] were made and then the resident was placed in a wheelchair and taken to her room. Oxygen was applied, resident's color was improved at the time and heartbeat heard but respirations was agonal. The resident was a DNR so code protocol not initiated. - RN #46 documented she was alerted by a nurse the resident was choking and when she arrived on the unit the RN was doing the [MEDICATION NAME]. The resident was blue and unresponsive, the [MEDICATION NAME] and finger sweep was performed and the resident expelled what appeared to be bread. The nursing supervisor arrived, attempted the [MEDICATION NAME] and the resident was brought back to her room and put to bed. She had a pulse, oxygen applied and the resident had gargling sporadic breaths. The resident lost her pulse and then emergency medical technicians (EMS) arrived shortly after that. - RN #47 documented she was alerted to the resident choking, arrived on the unit and the resident was unresponsive. The [MEDICATION NAME] was done with success before her arrival on the unit. Resident put in wheelchair and put to bed in a upright position. Her pulse was strong, respirations sporadic and she remained unresponsive. Looked for food in mouth and a blind sweep with no food obtained. Shortly after that the resident was without pulse and respirations. During an interview with RN #47 on [DATE] at 1:20 PM she stated she worked as a nursing supervisor on the weekends and part of her responsibilities included responding to codes. She stated she had remembered the incident with the resident. She responded to a code call and when she arrived in the dining room the resident was unresponsive and the nurse was actively doing the [MEDICATION NAME]. The resident did not have any air movement and she was put in her wheelchair when it became evident the [MEDICATION NAME] was not successful because she did not regain spontaneous respirations and she was dusky. She was placed in bed with her head up. She did have a pulse at the time. She had taken a CPR class recently and if a resident was choking they were to do the [MEDICATION NAME] maneuver until you lose a pulse and then you would initiate CPR. The resident did still have a pulse and chest compressions were not done as they would not have helped as the resident did not have an adequate airway. During an interview with RN #46 on [DATE] at 2:16 PM she stated if a resident choked you would yell for help, activate a code blue and then initiate the [MEDICATION NAME], which were abdominal thrusts from behind, no back blows or blind finger sweep as you could further lodge the obstruction. You continued to do the [MEDICATION NAME] until the resident became unresponsive and when that happened you lie them flat and do chest compressions to attempt to dislodge the obstruction. If a DNR would not do chest compressions. Resuscitation meant to restart the heart. When she arrived on the unit the resident was blue and the RN was doing the [MEDICATION NAME]. Some bread did come out of her mouth but not enough to sustain life. [MEDICATION NAME] was continued and then the resident was taken to her room, put to bed and oxygen applied. She was gargling and was dusky color. She did not regain a normal color, was unresponsive and had a heartbeat. She stated she had not received any training or practice with codes in the facility. During an interview with RN #42 on [DATE] at 3:31 PM she stated she could recall the resident choking on [DATE] as she had never seen someone die from choking before. She was in the dining room when she was alerted the resident was choking. She initiated the [MEDICATION NAME] maneuver as the resident did not have any air exchange and she saw the sandwich in front of her. The [MEDICATION NAME] was unsuccessful and the resident became limp. She continued to not have any air movement. After it was determined the [MEDICATION NAME] was unsuccessful the resident was placed in a wheelchair and taken to her room. She was not sure if the resident had a pulse and that would not matter as the resident was a DNR so they would not have performed chest compressions. During an interview with RN #45 on [DATE] at 9:38 AM she stated part of her responsibilities included responding to codes. She stated she was both basic life support (BLS) and advanced cardiac life support (ACLS) certified and she was very familiar with the guidelines on treating a choking victim. If someone was choking they would do the [MEDICATION NAME] maneuver until food came out or they stopped breathing. Even when a resident became unresponsive you would still do the [MEDICATION NAME] from behind. She had arrived in the dining room, she was blue, they were doing the [MEDICATION NAME] and the resident did not have air movement. She directed the staff to take the resident to her room as the [MEDICATION NAME] was not successful. Oxygen was put on the resident. The resident did have a pulse. Once in her room the resident had some agonal breaths, which were not normal breaths. When the agonal breaths started there was not a lot of hope for her at that point. No chest compressions or abdominal thrusts were done as the resident was a DNR. The resident was choking as she did not have any air exchange. During an interview with the resident's physician #28 on [DATE] at 12:06 PM he stated he could not recall a choking incident with this resident. He stated he felt that if the resident was choking and did have a heartbeat they should attempt chest compressions to clear the airway. Resuscitation means to restart the heart and that is not what they would be trying to do with the chest compressions when trying to clear the airway. 10NYCRR 415.12

Plan of Correction: ApprovedSeptember 7, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F684 QUALITY OF CARE
This plan of correction is being submitted in compliance with a regulatory requirement. The facility has submitted a request for a review of this deficiency by the Informal Dispute Resolution (IDR) process.
The facility will continue to ensure that residents receive care and treatment in accordance with professional standards.
1.Corrective Action:
a.Resident # 539 is no longer a resident of the facility.
b.The Director of Education/designee was re-educated by a consultant from LeadingAge NY who is a certified BLS instructor on procedures for performance of the [MEDICATION NAME] maneuver for a conscious victim, and rescue efforts for an unconscious victim, as per the American Heart Association guidelines.
2.Others Residents Potentially Affected:
a.All residents have the potential to be affected. Residents were reviewed to ensure advance directive identifiers reflect the current wishes of the resident.
b.The Director of Education/designee was re-educated by a consultant from LeadingAge NY who is a certified BLS instructor on procedures for performance of the [MEDICATION NAME] maneuver for a conscious victim, and rescue efforts for an unconscious victim, as per the American Heart Association guidelines.
3.Systemic Changes to Prevent Recurrence
a.The facility policy ?Emergency Procedure ? Choking? has been updated to clearly state the rescue efforts to be utilized for conscious and unconscious victims, as well as individuals with a Do Not Resuscitate order in accordance with the American Heart Association BLS provider manual guidelines and the guidance from the Bureau of EMS guidelines for individual with a DNR order.
b.All licensed nursing staff will have annual education of the [MEDICATION NAME] maneuver and choking rescue with return demonstration as part of the annual recertification for CPR and choking rescue. The Director of Human Resources will maintain a list of certifications and ensure completion annually.
c. All licensed nurses will be re-educated by a consultant from LeadingAge NY who is certified as a BLS instructor in choking rescue techniques in accordance with the American Heart Association BLS provider manual guidelines and the guidance from the NYS DOH Emergency Responder guidelines for individual with a DNR order.
According to the American Heart Association BLS certification guidelines, the rescuer will perform abdominal thrusts on a responsive individual who is standing or sitting. Thrusts are repeated until the object is expelled from the airway or the victim becomes unresponsive.
If the victim becomes unresponsive, the rescuer should shout for help and activate the emergency response system, gently lower the victim to the floor, begin CPR starting with chest compressions and do not check for a pulse. Each time the airway is opened to give breaths, the rescuer will look for the object that may be obstructing the airway. If the object is seen, it should be removed, if not, CPR will continue.
With regard to individuals with a DNR, in accordance with the Bureau of EMS guidelines, the following procedures are followed:
-Do not resuscitate means for the patient in cardiac or respiratory arrest, no chest compressions, ventilation, defibrillation, endotracheal intubation, or medications
-If the patient is NOT in cardiac or respiratory arrest, full treatment for [REDACTED].
-Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped, ventilation should not be assisted.
-CPR must be initiated if no out of hospital or facility DNR is presented. If a DNR order is presented after CPR has been started, stop CPR.
-For unusual situations or questions on individual patient circumstances, contact medical control.
d.The facility orientation plan for licensed nurses has been updated to include education and competency on the facility policy ?Emergency Procedure ? Choking?.
e.The ?Emergency Procedure ? Choking? has been added to the annual nursing competency review.
4.Monitoring and QA Plan:
a.Choking rescue/[MEDICATION NAME] drills will be conducted monthly until 100% compliance is maintained for 3 months, then quarterly.
b.Drill findings will be submitted to the QAPI committee for review and follow up to ensure ongoing compliance and competency of licensed staff.
c.Incidents involving CPR or [MEDICATION NAME] maneuver performance that may occur in the facility will be reviewed by the QAPI committee each month for compliance with the American Heart Association and Bureau of EMS guidelines.
Responsible Person: Administrator

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 31, 2018
Corrected date: September 10, 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 2 of 5 residents (Residents #69 and 178) reviewed for dignity had a dignified existence. Specifically, Residents #69 and 178's protective arm sleeves were unclean. Findings include: 1) Resident #69 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The 02/18/18 comprehensive care plan (CCP) documented the resident had the potential for skin tears as she self-propelled on the unit. The 07/2018 certified nurse aide (CNA) instructions documented the resident was to wear protective arm sleeves at all times. The resident was observed with unclean and stained protective arm sleeves on 07/26/18 at 8:47 AM and 01:03 PM; on 07/30/18 at 11:56 AM; and on 07/31/18 at 09:31 AM and 09:58 AM. During an interview with CNA #1 on 07/31/18 at 09:34 AM, she stated the resident would sometimes dig at her skin and sustained bruises and skin tears easily. The sleeves were to help protect her fragile skin. She stated if the sleeves looked significantly unclean they would be sent to laundry. They had not sent the resident's sleeves to be cleaned recently. During an interview with CNA #2 on 07/31/18 at 10:00 AM, she stated if a resident's sleeves were unclean they should be thrown away and new ones applied. During an interview with registered nurse (RN) Unit Manager #3 on 07/31/18 at 11:34 AM, she stated the resident wore sleeves as she bruised easily and would sustain skin tears. The sleeves should have been sent to laundry when they were stained or soiled. 2) Resident #178 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The 01/04/18 comprehensive care plan (CCP) documented the resident required extensive assistance with dressing. The 07/2018 certified nurse aide (CNA) instructions documented the resident was to wear Posey (protective) sleeves to the arms to protect her skin. The resident was observed with unclean and stained arm sleeves on 07/26/18 at 08:50 AM; on 07/30/18 at 8:15 AM, 09:55 AM and 11:56 AM; and on 07/31/18 at 10:00 AM. During an interview with CNA #1 on 07/31/18 at 09:34 AM, she stated she thought staff had sent the resident's sleeves to be cleaned recently and she had not noticed they were soiled. During an interview with CNA #2 on 07/31/18 at 10:00 AM, she stated the resident had fair skin and wore sleeves. If staff felt the sleeves were dirty, they should be thrown away as there were extra sleeves available on the unit. She had not provided care to the resident on this date and had not noticed they were soiled. The resident was to have sleeves on her legs as well, and she did not have them on when she saw the resident on the unit during survey. During an interview with registered nurse (RN) Unit Manager #3 on 07/31/18 at 11:34 AM, she stated the resident wore sleeves as she bruised easily and would sustain skin tears. The sleeves should have been sent to laundry when they were stained or soiled. 10NYCRR 415.5(a)

Plan of Correction: ApprovedAugust 30, 2018

F550 RESIDENT RIGHTS
The facility will ensure each resident is treated with respect and dignity, and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident?s individuality.
1. Corrective Actions:
a. The Geri Sleeves of residents # 69 and #178 were removed for cleaning and replaced on 8/1/18.
b. It was determined that one employee was assigned to residents #69 and #178 and counseling and remediation was provided to that nursing assistant by the Nurse Manager on 8/23/18.
2. Other Residents Potentially Affected:
All residents have the potential to be affected by this dignity concern. Rounds are performed daily by the charge nurse/nurse manager to ensure residents have a clean and dignified appearance. All facility staff will be re-educated on resident rights and dignity.
3. Systemic Changes:
a. All staff will be re-educated to be cognizant of potential violations of resident rights, especially with regard to dignity. Specifically ALL staff will be re-educated on what to be alert to when interacting or observing residents. This education will include: an overview of resident rights, the overall appearance of the resident, stain free clothing and footwear, clean adaptive equipment, clothing appropriate for weather or to their preference, hair styled to the resident preference and in clean presentable condition.
b. Nursing staff have been reminded to ensure geri-sleeves are laundered and replaced when soiled.
4. Monitoring/Quality Assurance:
The Director of Social Services and his team of Social Workers will conduct observation audits of resident dignity. The department will audit 4 residents per unit/weekly or approximately 10% of the unit population which will translate to greater than 10% of the community?s population on a weekly basis.
The Director of Social Services will report the findings of the dignity audit to the QAPI committee monthly for review and follow up as needed to ensure ongoing compliance.
Person Responsible: Director of Nursing

FF11 483.70(f)(1)(2):STAFF QUALIFICATIONS

REGULATION: §483.70(f) Staff qualifications. §483.70(f)(1) The facility must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements. §483.70(f)(2) Professional staff must be licensed, certified, or registered in accordance with applicable State laws.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 31, 2018
Corrected date: September 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification and abbreviated surveys (NY 254), the facility did not ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 5 employees (Employee #44) reviewed for licensure and certification. Specifically, employee #44 did not have the required license and supervision to work as a graduate practical nurse (GPN). Findings include: New York State Office of the Professions, Education Law for limited permits, included: - Graduates of schools of nursing registered by the department may be employed to practice nursing under supervision of a professional nurse currently registered in this state and with the endorsement of the employing agency for ninety days immediately following graduation from a program in nursing and pending receipt of a limited permit for which an application has been filed as provided in this section. Review of staffing sheets from [DATE] - [DATE] documented employee #44 worked as a GPN on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. On [DATE], registered nurse (RN) #42 was listed as the nurse and employee #44 was working as a certified nurse aide (CNA). On ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE] worked as a GPN. Review of employee #44's personnel file showed that it contained: - A signed copy of a certified nurse aide job description. - An online license verification sheet from the New York State Office of the Professions that documented the employee's date of licensure as a licensed practical nurse (LPN) was [DATE]. - The personnel file did not contain any documentation regarding the employee working as a GPN. During an interview with employee #44 on [DATE] at 10:04 AM, she stated she had worked in the facility previously as a CNA and then she received her LPN license. She remembered the choking incident with Resident #539 on [DATE] when the resident expired, as she was working as a GPN and she was the only nurse doing medications and treatments that day. RN #42 was working as a CNA that day and she was supposed to provide a resource for her if she had any questions. Employee #44 had worked as a GPN every weekend from when she graduated [DATE] until she obtained her LPN license ([DATE]). She was not provided with direct supervision from an RN from when she started as a GPN until she took her licensing board exams; she was just assigned someone to ask questions if she had any. During an interview with the nursing scheduler on [DATE] at 02:00 PM, she stated she had scheduled GPNs in the past and did not think there were any special instructions, just that they worked under the direction of the Director of Nurse's (DON) license. The scheduler provided the surveyor with a sheet of paper that documented employee #44 was on orientation as an LPN starting [DATE] and was off orientation on [DATE]. The surveyor requested a copy of the facility's policy regarding GPNs. On [DATE] at 03:55 PM, the Administrator stated she was still looking for the policy. No policy regarding GPNs were provided to the survey team prior to exit. During an interview with the DON on [DATE] at 09:00 AM, she stated for GPNs to work prior to obtaining their LPN license, they required a limited permit and they would have to have the proper supervision. If the supervising RN was working as a CNA, that would not be providing appropriate supervision. During an interview with Human Resources personnel on [DATE] at 09:40 AM, she stated the process for hiring GPNs would be to look at when they graduated and when they were scheduled to take their boards. She did not know if a GPN needed a limited license to practice as a GPN, and employee #44 had not had one. During an interview with RN #42 on [DATE] at 12:49 PM, she stated that on [DATE] employee #44 worked as the nurse and she worked as a CNA on the unit as they were short staffed that day. She stated she worked as the third CNA and would have been responsible for providing direct care to 13 residents. She stated she was available if employee #44 had questions. Employee #44 was working under the license of the DON at the time. 10NYCRR 415.26(c)

Plan of Correction: ApprovedSeptember 7, 2018

F839 STAFF QUALIFICATIONS
The facility will ensure professional staff are licensed, certified, or registered in accordance with applicable State laws.
1. Corrective Action
a. Employee #44 is licensed and registered in the state of New York as a licensed practical nurse since 9/19/17.
2. Other Residents Potentially Affected
a. There are no other graduate nurses employed by the facility at this time. No others have the potential to be affected.
3. Systemic Changes to Prevent Recurrence
a. Graduate nurses are required to have limited permits in order to work as a graduate nurse. A policy has been developed to describe the procedure for employing any nurse as a graduate nurse. This process includes the Director of Nursing completing Section II of the Application for Limited Permit certifying that the applicant will be employed under the supervision of a registered professional nurse who is currently registered in NYS. The Director of Human Resources will approve all new hires or promotions for graduate nurses, and will ensure that a current permit is on file. No unpermitted graduate nurses will be employed as a graduate nurse. Any CNA who graduates from an approved nursing program will not be employed as a graduate nurse without the Director of Human Resources confirming a permit is on file.
b.Human Resources Staff, Director of Nursing, and Assistant Director of Nursing have been educated on the policy and procedure.
4.Monitoring/QA Plan
a.An audit tool has been developed to review the qualifications and authorization to practice for any graduate nurses employed. The audit will be conducted weekly for 4 weeks, then monthly thereafter, and include any nurses that were employed as graduates during the period under review. The results of the audit will be submitted to the QAPI committee for review and follow up to ensure ongoing compliance for all graduate nurses.
Responsible Person: Director of Human Resources

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 27, 2018
Corrected date: September 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during the Life Safety Code Survey, the facility did not properly maintain electrical installations for 4 isolated areas (Applewood unit nursing station, resident room [ROOM NUMBER], staff education office, and the Saul unit nurse conference room). Specifically, unapproved electrical adapters were used in the above referenced areas. Findings include: On 7/25/2018 at 10:40 AM, a surveyor observed a television near the Applewood unit nursing station was plugged into an unapproved 3 prong adaptor. On 7/25/2018 at 10:54 AM, a surveyor in resident room [ROOM NUMBER] observed a bed and an air mattress plugged into an unapproved 6 prong adaptor. On 7/25/2018 at 12:20 PM, a surveyor in the staff education office observed router box plugged into an unapproved extension cord. On 7/25/2018 at 4:26 PM, a surveyor in the Saul unit nurse conference room observed four lift batteries plugged into an unapproved 6 prong adaptor. During an interview on 7/25/2018 at 5:36 PM, the Facility Staff Educator stated the facility could only use approved adaptors, and that she was unaware of the extension cord in her office. She stated that a facility's information technology (IT) staff member installed the extension cord. She knew that extension cords were not allowed within the facility. During an interview on 7/27/2018 at 1:05 PM, the General Manager of Facilities stated resident rooms were checked annually and when resident rooms were turned over. Non-resident rooms/common areas were not checked regularly. He was not aware of the unapproved adaptors observed during survey. 2012 NFPA 99: 10.2.4 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedAugust 18, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K920 ? ELECTRICAL EQUIPMENT ? POWER CORDS and EXTENSION CORDS
The facility will ensure appropriate use of power cords and extension cords throughout the facility.
1. CORRECTIVE ACTION:
Observations that were noted during the survey of improper power cords and extension cords were corrected immediately during the survey. All noted power strips were upgraded to UL1363 for the Applewood unit nursing station, resident room [ROOM NUMBER], staff education office, and the(NAME)unit nurse conference room.
2. RESIDENTS AFFECTED:
All residents can be affected by this deficiency. The remainder of the facility has the potential to be affected. All resident rooms, offices, and other common areas have been examined for the presence of improper power cords and extension cords. Any inappropriate cords that were located were removed. Power cords currently in use in the facility are of the type UL1363.
3. SYSTEMATIC CHANGES TO PREVENT RE(NAME)CURENCE:
Only approved UL1363 or equivalent power cords will be used for all applications in the facility.
All personnel will be re-educated on appropriate use of power/extension cords.
Use of electrical cords will be added to the new employee orientation program.
The facility has updated the process for facility admission to include education of the resident and/or resident representative about the use of power cords and inspection of electrical devices.
Housekeepers will have inspection for inappropriate electrical cord use added to their daily duty list.
4. MONITORING/QA PLAN:
Environmental rounds will be conducted to observe for the inappropriate use of electrical cords by the Safety Committee Chairperson, or designee. Rounds will be conducted weekly for 4 weeks, then monthly thereafter.
A 100% facility electrical inspection assessment will be completed annually by the Facilites/Engineering Operations Manager, or designee, to inspect all resident rooms and common areas for use of extension cords and unapproved power strips. Audit results will be submitted to the Safety committee and QAPI committee monthly for review and follow up as indicated.
PERSON(S) RESPONSIBLE: Administrator

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 27, 2018
Corrected date: September 5, 2018

Citation Details

Based on observation, record review and interview during the Life Safety Code survey, the facility did not ensure the testing of 2 of 2 generators for two separate buildings (Martin building, and(NAME)building) were maintained. Specifically, the weekly load test for all two generators were not conducted at 30% or greater of the generator capacity as required, transfer times were not documented, the run time for the tests were not documented, the total kilowatts (KW) were not documented, and the ampere values were not documented. Findings include: Review on 7/29/2018 of the weekly generator load test reports dated from 1/3/2018 to current indicated the monthly load test for all two generators were not conducted at 30% or greater of the generator capacity as required, specifically there were no documented load percentages on the forms. These forms did not document transfer times, run time of the tests, total kilowatts (KW), or ampere values. When interviewed on 7/27/2018 at 10:40 AM, the General Manager of Facilities stated the weekly generator reports lacked specific NFPA 110 requirements including specific monthly load test information. On 7/27/2018 at 2:19 PM, a surveyor witnessed a weekly generator load test and verified that the load was 175 KW, which was over 30% of the generator capacity. 2012 NFPA 99: 6.4.4.1.1.3 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedAugust 22, 2018

K918 ? ELECTRICAL SYSTEMS ? ESSENTIAL ELECTRIC SYSTEM MAINTENANCE and TESTING (GENERATORS)
The facility will ensure that generators are inspected weekly, exercised under load 30 minutes 12 times per year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Written records will be maintained and readily available.
1. CORRECTIVE ACTION:
The generator has been inspected by facility personnel and found to continue to be in proper working order. A generator test was completed with at least a 30% load and a documentation tool utilized to record start time, stop time, water temperature, battery charging amps, oil PSI, transfer time volts, total kilowatts and ampere values.
2. RESIDENTS AFFECTED:
All residents can be affected by this deficiency. The documentation tool will be utilized each time the generator is tested to ensure written records are maintained of all generator tests that include at a minimum the load testing capacity, run time, total kilowatts, and ampere values.
3. SYSTEMATIC CHANGES TO PREVENT RE(NAME)CURENCE:
Generators are tested weekly. An updated generator preventative maintenance procedure (PM) documentation tool was created for the weekly generator tests to include recording of record start time, stop time, water temperature, battery charging amps, oil PSI, transfer time volts, total kilowatts and ampere values. The percentage of load capacity will be calculated and documented monthly, to ensure evidence of compliance with the 30% load testing requirement is readily available. The Plant Operations Director, Maintenance Mechanics and Maintenance Workers will be re-educated on the requirements for generator testing and documentation required to validate appropriate testing has occurred.
4. MONITORING/QA PLAN:
Documentation of weekly generator tests and monthly load testing will be maintained in the office of the Director of Plant Operations. A copy of the logs will be submitted monthly to the QAPI committee for review and follow-up as needed.
PERSON(S) RESPONSIBLE: Administrator

EP TRAINING PROGRAM

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 27, 2018
Corrected date: September 5, 2018

Citation Details

Based on record review and interview during an Emergency Preparedness (EP) survey, the operator did not ensure there was appropriate EP training and testing for staff. Specifically, staff were not trained at orientation or thereafter at least annually on the EP plan that included all hazards. Findings include: During review of the EP plan on 7/26/2018, there was no documentation staff received training and testing on the entire EP plan that included all hazards. Review of a fire safety quiz revealed the facility only trained staff on fire hazards, not on additional hazard types. Further review of the training materials used at orientation and in-service times revealed staff was only trained on general fire procedures and not all hazard types listed in the EP risk assessment. When interviewed on 7/27/2018 at 10:45 AM, the Staff Education Nurse stated not all disasters/emergencies are covered at orientation or at least annually thereafter. She further stated staff are only trained on the four codes (fire, elopement, manpower and medical emergency) on the back of their badges 42 CFR 483.73(d)(1)

Plan of Correction: ApprovedAugust 18, 2018

E 037 ? Emergency Preparedness Training Program
The facility will ensure staff and volunteers are trained in emergency preparedness policies and procedures initially and annually.
1. CORRECTIVE ACTION
The facility has expanded its emergency training program for staff and volunteers to cover an all hazards approach based on the vulnerability assessment conducted by the facility annually. Current staff, contracted staff, and volunteers will be trained on all hazards identified in the emergency preparedness plan.
2. RESIDENTS AFFECTED
All residents have the potential to be affected so all personnel, including contracted staff and volunteers will be trained upon hire and annually in emergency preparedness plans for all identified hazards.
3. SYSTEMATIC CHANGES TO PREVENT RECURRENCE
Lutheran Care has adopted an updated All Hazards and Emergency Response Plan and has included the Oneida County Mutual Aid Plan. In accordance with that plan we are aligned in support of the program and its overall participants as part of our available resources. Included in the Emergency Response Plan under Section 16 under the heading of Training element (topic 1) that includes coverage of the facility specific hazard vulnerabilities and how they will be addressed. These areas will be covered with all new and existing staff as well as annually, individuals providing services under arrangement and volunteers consistent with their expected roles.
Emergency Preparedness Training will be provided at orientation and annually to all employees and will include a quiz that will demonstrate staff knowledge of emergency preparedness. The record of attendance will be maintained by the Staff Education Coordinator and a copy of the quiz will be maintained in the employee record.
4. MONITORING/QA PLAN
The Emergency Preparedness training will be reviewed annually by the Facility Operations Manager to ensure that it remains current and consistent with the emergency management plan. The Emergency Preparedness Training Program content will then be reviewed annually at the Safety Committee. A summary of the review will be provided to the QAPI committee for review and follow up as needed.
The Staff Education Coordinator will conduct an audit of staff and volunteers monthly to ensure training has been completed and post-tests satisfactorily completed. The results of the audit will be submitted to the QAPI committee monthly for review and follow up as needed.
RESPONSIBLE PERSON: Administrator

INFORMATION ON OCCUPANCY/NEEDS

REGULATION: [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 27, 2018
Corrected date: September 5, 2018

Citation Details

Based on record review conducted during an Emergency Preparedness (EP) survey, the operator did not comply with Emergency Preparedness requirements. Specifically, the EP plan did not include how the facility would share information on their occupancy, needs, and its ability to provide assistance. Findings include: Record review of the EP plan on 7/26/2018, revealed there was no documented evidence of a policy and procedure that included how the facility would share information on their occupancy, needs, and its ability to provide assistance. There was also no documentation on what types of services the facility could provide during an emergency. When interviewed on 7/26/2018 at 2:30 PM, the Administrator stated the information should be on the Health Commerce System (HCS). 10 NYCRR 42 CFR: 483.73(c)(7)

Plan of Correction: ApprovedAugust 22, 2018

E 034 - Information on Occupancy Needs
As part of the emergency preparedness plan, the facility will develop and maintain an emergency preparedness communication plan that includes providing information about facility occupancy, needs, and its ability to provide assistance in an emergency.
1. CORRECTIVE ACTION
The facility produces occupancy reports defined by nursing units. This report type supports the Oneida County Mutual Aid Plan (Section 4) and our internal Resident Status Change and Census Reporting Policy. The facility EHR allows the user the ability to identify bed need by unit type, along with total occupancy. This is addressed in the Emergency preparedness and Response Plan (section 6.0) under Long Term Care Capability and Capacity.
2. RESIDENTS AFFECTED
All residents have the potential to be affected. Census reports are produced daily and maintained on paper and electronically.
3. SYSTEMATIC CHANGES TO PREVENT RECURRENCE
The Administrative Census Access Policy has been developed to define the process for management staff to access and produce the Resident Status Change and Census Report at any given time. In the Case of an Emergency or an emerging issue, Management has the ability to produce a Census Report from the Point Click Care EHR that specifies available total beds and beds by unit in real time. This information will be shared with the DOH or Oneida County Mutual Aid authorities as needed to help determine available beds and bed need.
Section 6.0 of the All Hazards and Emergency Plan under Facility and Service description has been revised to include a listing of the types of services the facility can offer during an emergency.
The Administrative Census Access Policy will be reviewed annually as part of the emergency preparedness plan review. This review will be conducted annually at the safety committee meeting and is the responsibility of the Safety Committee Chairperson.
4. MONITORING/QA PLAN
As a measure of Compliance a review of the Administrative Census Access Policy on an annual basis at the Safety Committee and a summary of the review will be submitted to the QAPI committee for review and follow-up as needed.
RESPONSIBLE PERSON: Administrator

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: July 27, 2018
Corrected date: September 5, 2018

Citation Details

Based on record review and interview conducted during an Emergency Preparedness (EP) survey, the operator did not comply with Emergency Preparedness requirements. Specifically, there was no policy and procedure for the use of volunteers in an emergency listed within the EP plan to address surge needs. Findings include: Record review of the of the EP plan on 7/26/2018, revealed there was no documented evidence of a policy and procedure for the use of volunteers in an emergency. When interviewed on 7/26/2018 at 2:17 PM, the Administrator stated they have no policy in place for the use of volunteers in an emergency. 10 NYCRR 42 CFR:483.73(b)(6)

Plan of Correction: ApprovedAugust 18, 2018

E024 Emergency Policies/Procedures - Volunteers and Staffing
The facility will continue to develop and implement emergency preparedness policies and procedures. A policy and procedure for the use of volunteers in an emergency or other emergency staffing strategies will be maintained.
1. CORRECTIVE ACTION
The facility has adopted an updated ?All Hazards and Emergency Response Plan.? Included as part of the plan is the Oneida County Mutual Aid Plan. In accordance with the Mutual Aid Plan, we are aligned in support of the program and its overall participants as part of our available resources. Current employees and volunteers have been educated on their role as a participant in case of an emergency in order to address surge capacity.
2. RESIDENTS AFFECTED
All residents have the potential to be affected. All staff in the facility have been educated on their role in surge capacity and the responsibilities under the All Hazards and Emergency Response Plan.
3. SYSTEMATIC CHANGES TO PREVENT RECURRENCE
New internal volunteers and employees of the facility will be educated during new employee orientation and annually on their role as a participant (manpower pool, etc.) in the case of an emergency in order to address surge capacity. Surge capacity is addressed in the Oneida County Mutual Aid plan section 5.0- Staff and Supply and the use of volunteers as well as the Lutheran Care Surge Capacity-influx of residents Policy which is being revised to express the use of volunteers. The Volunteer role will be educated by and overseen by the Volunteer Director as well as the facility.
The Staff Development Coordinator will track education attendance for each employee and volunteer to ensure everyone is educated upon hire and annually.
The All Hazards and Emergency Response Plan and Oneida County Mutual Aid Plan will be reviewed annually and when significant changes occur to ensure it is a current and applicable plan.
3. MONITORING/QA PLAN
As a measure of Compliance review of the All Hazards and Emergency Response Plan and Oneida Mutual Aid Plan be shared and detailed with the Safety Committee and QAPI Committee and recorded in the minutes.
An audit will be conducted monthly of education on the emergency preparedness plan for volunteers and employees and submitted to the QAPI committee for review and follow up as needed.
Person Responsible: Administrator

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: July 27, 2018
Corrected date: September 5, 2018

Citation Details

Based on record review and interview conducted during the Emergency Preparedness (EP) survey, the operator did not ensure the emergency preparedness requirements were met. Specifically, the EP Plan did not include the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials. Findings include: Record review of the EP Plan on 7/26/2018, revealed there was no policy and procedure for the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials. When interviewed on 7/26/2018 at 2:21 PM, the Administrator stated there was no policy for the facility's role under a waiver declared by the Secretary. She further stated the facility will be creating one. 10NYCRR: 400.10(d) 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedAugust 18, 2018

E026 Roles Under a Waiver Declared by Secretary
The facility will develop and implement emergency preparedness policies and procedures, risk assessment, and the communication plan. As part of this plan the facility will address the role of the facility in the provision of care and treatment at an alternate care site identified by emergency management officials.
1. CORRECTIVE ACTION
The facility has drafted an 1135 Waiver Policy and Procedure that defines the role of the facility in the provision of care and treatment at an alternate care site identified by emergency management officials. This information is also aligned with and in support of the Oneida County Mutual Aid Program.
2. RESIDENTS AFFECTED
All residents have the potential to be affected. Care and treatment at an alternate care site is addressed for all residents as part of the All Hazard and Emergency Preparedness Plan.
3. SYSTEMATIC CHANGES TO PREVENT RECURRENCE
The facility has updated the All Hazard and Emergency Preparedness Plan to include the 1135 Waiver Policy and Procedure. This plan will be reviewed by Administration and Plant Management personnel annually and when significant changes occur to ensure that all elements remains current and appropriate.
Risk assessment is completed annually utilizing the Hazard and Vulnerability Assessment Tool.
All staff have been educated on the existence of the plan and the role of the facility to provide care and treatment to residents should an alternate care site become necessary in an emergency.
Education will be conducted annually and upon hire on the role of the facility should an alternate care site become necessary in an emergency.
4. MONITORING/QA PLAN
The Emergency Preparedness Training Program content will be reviewed annually at the Safety Committee and as needed. Documentation of the review of the plan for all necessary components will be submitted to the QAPI committee annually for review and follow-up as needed.
PERSON RESPONSIBLE: Administrator

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: July 27, 2018
Corrected date: September 5, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 4 areas (Applewood East unit, Applewood West unit, Willow Way East unit, and Willow Way West unit) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2 which 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, all 4 areas contained both quick response and standard response sprinkler heads. Findings include: - On 7/26/2018 at 10:55 AM, there were 14 quick response sprinkler heads and 43 standard response sprinkler heads located within the Applewood East unit. - On 7/26/2018 at 11:00 AM, there 10 quick response sprinkler head and 11 standard response sprinkler heads located within the Applewood West unit. - On 7/26/2018 at 11:50 AM, there were 13 quick response sprinkler head and 34 standard response sprinkler heads located within the Willow Way East unit. - On 7/26/2018 at 11:55 AM, there were 9 quick response sprinkler heads and 12 standard response sprinkler head located within the Willow Way West unit. During an interview on 7/26/2018 at 12:00 PM, the Lead Mechanic stated there was construction that took place at two different time periods within the Applewood and Willow Way units. He further stated he was not aware there could not be mixed sprinkler heads in a compartment. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedAugust 18, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K351 ? SPRINKLER SYSTEM INSTALLATION
The facility will ensure the building is protected throughout by an approved sprinkler system.
1. CORRECTIVE ACTION:
Purchase orders were completed and approved on [DATE] for replacement of the mixed type of sprinkler heads in the Applewood and Willoway units. Standard sprinkler heads currently in use have been scheduled for replacement with quick response sprinkler heads to ensure all sprinkler heads located in those units are of the same type. The contractor, H.J. Brandeles is scheduled to complete the replacement on [DATE] through [DATE].
2. RESIDENTS AFFECTED:
All residents can be affected by this deficiency, and other locations in the building have the potential to have mixed type of sprinkler heads located within a compartment. A full examination of all sprinkler heads in the community will be conducted to ensure 100% compliance throughout.
3. SYSTEMATIC CHANGES TO PREVENT RE(NAME)CURENCE:
As sprinkler heads may need periodic replacement, the facility contractor for maintenance and inspection of sprinkler heads will be educated about the need to maintain the same sprinkler head type in each compartment. The contractor will check in and check out with the Facilities/Engineering Operations Manager, or designee, each time that work is to be completed to ensure inspection of type of sprinkler head utilized.
4. MONITORING/QA PLAN:
A 100% facility assessment will be completed monthly in a different section of the building to ensure that no less than annually there has been inspection of sprinkler heads for compliance including but not limited to; mixed sprinkler heads within the same smoke compartment, dirty sprinkler heads and missing or expired sprinkler heads. In addition, the facility vendor for sprinkler head maintenance will complete and inspection no less than annually, and a copy of the assessments will be maintained in the office of the Director of Plant Operations. Monthly the Facilities/Engineering Operations Manager will submit a summary to the QAPI committee to verify continued compliance.

PERSON(S) RESPONSIBLE:
Administrator

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 27, 2018
Corrected date: September 5, 2018

Citation Details

Based on observation and interview conducted during the Life Safety Code survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for 2 isolated areas (the shaft located in the Applewood unit and the Willow Way unit, and the second floor oxygen room). Specifically, both of the above mentioned locations had unsealed vertical penetrations to the floor below. Findings include: On 7/25/2018 at 10:46 AM, a surveyor in the third floor Applewood dining room observed an open access hatch in a wall that revealed a vertical shaft. There was a six inch sprinkler line, a one inch sprinkler drain, a three inch cast drain, and a 3/4 inch conduit with approximately a one inch unsealed annular space around each passing into the second floor Willow Way unit dining room below. A surveyor in the second floor Willow Way unit dining room also observed the sprinkler line, sprinkler drain, cast drain and conduit were not sealed passing into the first floor. On 7/25/2018 at 11:30 AM, a surveyor in the second floor oxygen room observed a three inch conduit and an unsealed bundle of data wires and cables passing into the the third floor oxygen room above. Also, there were unsealed data wires passing into the floor below. During an interview on 7/27/2018 at 1:20 PM with the General Manager of Facilities, he stated he was not aware of the unsealed vertical penetrations observed. 2012 NFPA 101: 19.3.1, 8.6.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedAugust 22, 2018

K311 ? VERTICAL OPENINGS ? ENCLOSURE
The facility will ensure that vertical openings are properly enclosed with construction having a fire resistance rating of at least one hour.
1. CORRECTIVE ACTION:
All penetrations noted at time of survey were addressed/corrected during the survey process. These included, but not limited to, the vertical penetrations in the 2nd and 3rd floor(NAME)Oxygen rooms (Data Lines), vertical penetrations in the chase way between the Willoway and Applewood units and the(NAME)Elevator Mechanical Room. All repairs to seal the penetrations were visualized and noted by the surveyors during the time of survey. The penetrations were sealed utilizing 3M Fire Barrier Sealant CP 25WB+ which has a 4 hour rating.
2. RESIDENTS AFFECTED:
All residents can be affected by this deficiency, and other areas of the facility may be affected. A complete inspection of smoke barriers was conducted to ensure no other unsealed vertical penetrations are present. Vertical openings are properly enclosed with construction having a fire rating of at least one hour.
3. SYSTEMATIC CHANGES TO PREVENT RE(NAME)CURENCE:
As contractors visit the facility and perform work that may penetrate the smoke barrier, the contractors will be provided with education and a Project Safety Plan which addresses how the facility will maintain a safe and secure environment, including instruction to contractors on sealing of any penetrations in the smoke barrier. The Facilities/Engineering Operations Manager will inspect work areas daily and upon completion of the project to ensure any penetrations have been properly sealed using an approved fire rated sealant.
The facility policy and procedure for Fire Wall Penetrations has been reviewed and updated to allow for signatures of the contractor and building services personnel to sign off on the guidelines and verify penetrations have been sealed.
4. MONITORING/QAPI PLAN:
A 100% facility assessment will be completed annually to inspect all areas for both vertical and horizontal penetrations. This will be accomplished by dividing the facility into 12 sections (7 nursing units and 5 common areas) to thoroughly inspect one area each month. An audit summary will be completed and reported monthly to the QAPI Committee for review and follow-up as necessary.
Each month the summary to the QAPI committee will also include a list of contractors that performed work, whether there was penetration of the smoke barrier, and verification that it was sealed properly utilizing and appropriate fire rated sealant.
PERSON(S) RESPONSIBLE: Administrator