Sunharbor Manor
February 28, 2017 Certification Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (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: February 28, 2017
Corrected date: April 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews during the Recertification survey the facility did not develop care plans to address the needs of each resident for 1 of 1 resident reviewed for Bowel Incontinence from a total Stage 2 sample of 32 residents. Specifically, Resident #255 was assessed as having bowel incontinence; however, a Comprehensive Care Plan (CCP) was not developed to address the bowel incontinence. The finding is: Resident #255 was admitted to the facility on [DATE] and discharged on [DATE]. During this period the resident was discharged to the hospital on [DATE] and readmitted to the facility 10/31/2016, and again was discharged to the hospital on [DATE] and re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 10/18/2016 Nursing Admission Assessment did not document bowel incontinence. The 10/25/2016 Admission Minimum Data Set (MDS) Assessment, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident was frequently incontinent of bowel and was on a toileting program. The 10/31/2016 and 12/22/2016 Readmission Nursing Assessments, done when the resident returned to the facility from hospitalization s, documented that the resident was incontinent of both bladder and bowel and briefs were being used. The 1/19/2017 Quarterly MDS documented that the resident was frequently incontinent of bowel. There was no Comprehensive Care Plan (CCP) created to address the bowel incontinence. On 2/28/2017 at 10:10 AM the Registered Nurse (RN) Unit Manager was interviewed. She stated that if there was bowel incontinence there should have been a care plan developed. She stated that sometimes the bowel incontinence would be combined with urinary incontinence in one care plan; however, there was no documented evidence that this was done. On 2/28/2017 at 11:13 AM an RN MDS Coordinator was interviewed. She stated that Care Area Assessments (CAAs) in the MDS are linked to the development of care plans for full MDS assessments, such as admission and quarterly assessments. She stated the CAA for bowel incontinence in the MDS linked to a care plan for pressure ulcer risk, not a care plan addressing bowel incontinence. She was unable to find a care plan addressing bowel incontinence. 415.11(c)(1)

Plan of Correction: ApprovedMarch 17, 2017

I. Immediate Corrective Actions:
A. The facility respectfully states that resident #255 has been discharged from the facility.

II. Identification of other Residents:
All residents with bowel/bladder incontinence have the potential to be at risk for not having a CP
in place .
A review of each resident with bowel/bladder incontinence will be conducted to determine
proper care plan is in place and will be implement if found non-compliant.
III. Systemic Changes:
1. The Administrator, DON, and Medical Director reviewed policy regarding comprehensive
Care plans will be conducted and re- in-serviced to all license nurses.

The lesson plan will concentrate on the following:
? Resident?s continence will be assessed on admission/readmission, quarterly and upon change in condition.
? Develop and implement individualized CCP
? If incontinent, CCP is implemented to address resident needs
? MDS reflects current resident status regarding continence
All lesson plans and sign in sheets will be kept on file for validation.
IV. Quality Assurance Monitoring:
1. An audit tool will be developed to monitor and ensure the facility?s compliance with
established P/P regarding Comprehensive Care Plans specific to residents toileting needs.
2. DNS/designee will conduct a random sampling of 5 residents per unit per month x3 months and then quarterly thereafter for compliance. All audit findings will be presented to the Administrator and the QA committee quarterly for follow up and review.

V. Responsible party for P(NAME) Involvement:
? DNS/Designee

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2017
Corrected date: April 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that each resident was treated in a manner that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. This was evident for two (Resident #112 and #134) of two residents reviewed for dignity in a total of thirty two Stage 2 sampled residents. Specifically, on two occasions 1) Resident #112 Foley catheter drainage bag was observed from the hallway without a privacy bag. 2) Resident #134 was observed being pulled backwards in a reclining Geri chair. The findings are: 1) Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident has short term and long term memory problems. The resident required total assist for toileting and had an indwelling catheter. A Comprehensive Care Plan (CCP) dated 12/5/16 documented the resident has a Foley Catheter secondary to Pressure Ulcer and Incontinence. During an initial tour conducted on 2/22/17 at 9:20 AM on the 3rd floor nursing unit, Resident #112 was observed from the hallway in bed. The resident's Foley catheter drainage bag was in full view hanging on the bed frame without a privacy bag. A second observation was conducted on 2/23/17 at 9:00 AM. The resident was in bed and the Foley catheter drainage bag was observed in full view from the hallway hanging on the bed frame without a privacy bag. An interview was conducted on 2/23/17 at 11:00 AM with the Licensed Practical Nurse (LPN) regarding why the resident was not provided with a privacy bag for the Foley catheter drainage bag. The LPN stated when the resident is gotten out of bed the bedside drainage bag is switched to a leg bag, however, the LPN could not say why the privacy bag was not provided to the resident while in bed. An interview was conducted on 2/23/17 at 2:10 PM with the resident's assigned Certified Nursing Assistant (CNA). The CNA stated that CNA's are responsible for ensuring the resident's Foley bag is covered in a privacy bag. The CNA further stated that the night shift should have ensured the Foley catheter drainage bag was discreetly covered with a privacy bag. The CNA stated that during the day the resident is gotten up out of bed and the bedside bag is switched to a leg bag. 2) Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 14 which indicated the resident's cognition was intact. The resident is non-ambulatory and requires total assistance of one staff member for locomotion on/off the unit. A CCP for Activities of Daily Living (ADL)s Functional Assistance/Rehab Potential dated 4/20/16 documented the resident requires total assistance of one staff member for locomotion on/off the unit. The goal included to maintain dignity and self esteem. The interventions included for the resident to be out of bed into a Geri-recliner via Hoyer Lift and assistance of two staff members. An observation was made on 2/27/17 at 10:25 AM. The CNA was observed transporting Resident #134 backward in a Geri-recliner from room [ROOM NUMBER] to the end of the hallway into the unit dining room. An interview was conducted on 2/27/17 at 10:29 AM with the assigned CNA. The CNA stated that the reason she was pulling the Geri-recliner backward was because it is difficult to push the chair forward. The CNA stated that it was her first time caring for the resident and that she did not report to the charge nurse that she had difficulty pushing the recliner forward. The CNA stated that she was inserviced to push residents facing forward when in a Geri-recliner. An interview was conducted on 2/27/17 at 10:40 AM with the Unit Registered Nurse (RN) in Charge. The RN stated that the staff was inserviced to transport the residents facing forward in wheel chairs or Geri-recliners. An observation was conducted on 2/27/17 at 11:05 AM. The RN in Charge was observed transporting the resident forward in her Geri-recliner. The Geri-recliner was moving freely without hesitation or difficulty. 415.5(a)

Plan of Correction: ApprovedMarch 17, 2017

I. Immediate Corrective Actions:
A. Resident #112
1. Resident #112 was issued a privacy bag for his foley catheter drainage bay.
2. Nursing staff assigned to resident #112 will receive an educational counseling on resident
dignity and use of drainage bag cover when resident is in a room.
B. CNA who wheeled resident chair backwards received an educational counseling on proper
dignified mode of transport for all residents.
II. Identification of other Residents:
A. On 3/14/17 the DNS obtained a list of all residents:
1. utilizing a foley catheter with bedside drainage
2. utilizing a geri chair
Full review of list was conducted to ensure use of bags were present with privacy bags with foley catheter. All these bags were found to be complaint with proper dignity standards.
The facility respectfully states that all residents were potentially affected, but no other residents were noted to be wheeled backwards in their geri chairs.

III. Systemic Changes:
1. The Administrator, DON, Medical Director and Director of Social Service reviewed current
facility P/P on ?Privacy & Dignity? and found same to be compliant.
All licensed nurses & CNA?s will be re-in serviced on above P/P by the in-service coordinator/designee

The lesson plan will concentrate on the following:
? Importance of maintaining resident dignity in and out of resident rooms
? All residents utilizing a foley catheter with a bedside drainage bag will be provided a privacy bag while in bed or out of be in a wheelchair.
? Proper mode of transport for residents.
? All residents utilizing a geri recliner must be pushed facing forward
? Any inability to do so must be reported to the nurse or Maintenance Department for intervention right away.
All lesson plans and sign in sheets will be kept on file for validation.
IV. Quality Assurance Monitoring:
1. An audit tool will be developed to monitor and ensure the facility?s compliance ensuring residents dignity is upheld.
? All foley catheter drainage bags are placed in a privacy bag
? All resident in a geri recliner chair are pushed facing forward
2. DNS/designee will conduct a random sampling of 5 residents per month x3 months and then quarterly thereafter for compliance. All audit findings will be presented to the Administrator and the QA committee quarterly for follow up and review.
V. Responsible party for P(NAME) Involvement:
? DNS/Designee

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (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; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2017
Corrected date: April 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen had adequate indications for its use. This was evident in 1 of 5 residents reviewed for unnecessary medication in a total of 32 Stage 2 sampled residents. Specifically, Resident #333 had an order for [REDACTED]. The finding is: Resident #333 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] documented the resident has short term and long term memory problems. The resident had no mood or behavior problems. The resident received Antipsychotic and Antidepressant medication during the last 7 days prior to this assessment. A physician's orders [REDACTED]. A Physician order [REDACTED]. A Comprehensive Care Plan (CCP) dated 7/28/16 for [MEDICAL CONDITION] Drug Use documented the resident is on [MEDICAL CONDITION] medication for Major Neuro-cognitive Disorder Behavior with Affective Symptoms. A Psychiatric Evaluation dated 10/20/16 documented the resident was seen for evaluation. The evaluation documented that the resident was restless and anxious but was no longer abusive to her husband. The resident was diagnosed with [REDACTED]. The Consult further document the [MEDICATION NAME] is being utilized to potentiate the use of [MEDICATION NAME] (Antidepressant). A Nurse's note dated 10/20/16 documented the resident was seen by Psych for behavior of decline in cognition and restlessness and wanting to leave the facility. Recommended to start [MEDICATION NAME] 2 mg po daily. An interview was conducted on 2/28/16 at 12:45 PM with the Psychiatrist regarding the indication for the use of [MEDICAL CONDITION] medications the resident was receiving. The Psychiatrist stated that [MEDICATION NAME] was being used off label. The Psychiatrist stated that consult documented the [DIAGNOSES REDACTED]. The Psychiatrist stated that Age Related Cognitive Decline was not the appropriate indication for the use of [MEDICATION NAME]. 415.12(l)(1)

Plan of Correction: ApprovedMarch 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action:
1. The consulting psychiatrist assessed the current indication use of [MEDICATION NAME] in resident #333. Recommended d/c of [MEDICATION NAME] and continue [MEDICATION NAME] for depression

II. Identification of Other Residents:
1. A report from the computer system of all residents with active orders for [MEDICATION NAME] will be obtained. The indication for use will be assessed in all cases, and corrective actions will be taken where necessary.

III. Systemic Changes:
The facility shall take the following measures and alter the following systems to ensure that the problem does not recur.
1. System Changes:
a. The policy and procedure on antipsychotic medication use will be reviewed and revised as necessary.
b. All medical staff will be re-educated on the policy and procedure.
IV. Quality Assurance Monitoring:
The facility plans to monitor its performance to make sure that solutions are sustained in the following manner:
1. Performance Monitoring:
a. An audit will be conducted of all residents receiving [MEDICATION NAME] and other antipsychotics. The audit will report, at minimum, the medication and the indication for use as listed with the medication order. The audit will be supplied to the Medical Director and Director for review and assessment. Any orders for antipsychotic medications that appear to be potentially inappropriate will immediately be referred to the attending physician for review and any necessary corrective actions. The audit will be conducted monthly for the first three months, then quarterly thereafter for the balance of one year.
V. Responsible party for P(NAME) Involvement:
? DNS/Designee

FF10 483.45(c)(1)(3)-(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (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. (4) The pharmacist must report any irregularities to the attending physician and the facility?s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility?s medical director and director of nursing and lists, at a minimum, the resident?s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident?s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident?s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2017
Corrected date: April 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review during the Recertification survey, the facility did not provide one resident reviewed for Pain Management with an accurate Medication Regimen Review (MRR). Specifically, Resident # 36 was receiving Neurontin for a [DIAGNOSES REDACTED]. Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) revealed the resident was accepting Neurontin routinely and only refused three times in (MONTH) and four occasions in December. In addition, the recommendation to discontinue the medication, did not include tapering the dosage before it was stopped. The finding is: Resident # 36 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident's Brief Interview for Mental Status (BIMS) score was 1, indicating the resident's cognition is severely impaired. There were no complaints of pain identified on the MDS assessment. An observation on 2/24/17 at 9:30 AM revealed that the resident was lying in bed and reported to the Charge Nurse that he was experiencing lower back pain. A physician's orders [REDACTED]. A MRR dated 12/20/16 documented a recommendation made by the Pharmacist. The Pharmacist documented that Resident # 36 currently had an active order for Neurontin, which is often refused. Please evaluate continued need and discontinue now, if appropriate. The Physician signed and dated the MRR on 12/23/16, indicating that he agreed with the recommendations to discontinue the medication. The physician's orders [REDACTED]. Neurontin was ordered initially on 12/30/15 and continued for a year until 12/23/16 when it was discontinued by the Physician. The MARs were reviewed for (MONTH) and (MONTH) (YEAR). The Neurontin was documented as being refused a total of three times in (MONTH) (YEAR) and a total of four times in (MONTH) (YEAR). In addition, the resident was showing pain documented by the nurses on the MARs prior to the administration of the pain medication. An interview was conducted with the Director of Nursing Services (DNS) on 2/27/2017 at 3:10 PM. She explained that there was no evidence that the resident had any pain after the medication Neurontin was stopped by review of the nursing progress notes. She further stated that the resident was seen by the managed care nurse practitioner and had no complaints of pain after the medication was stopped. An interview was conducted with the Pharmacist on 2/27/17 at 3:15 PM. The Pharmacist stated that the recommendation that she made was not appropriate since the resident was not refusing the medication often. In addition, the Pharmacist stated that the medication should have been tapered over the course of a week before being discontinued. An interview was conducted with the Physician on 2/28/17 at 11:00 AM. The Physician stated that had the Pharmacist not made recommendations to discontinue the Neurontin, he would not have discontinued the medication. Further, he stated that he was not made aware that the resident was having any pain prior to discontinuing the Neurontin or he would have treated the resident with some other medication. In addition, the Physician stated that there were no rebound or negative side effects from stopping the medication without tapering and that 900 milligrams daily was a low dose of Neurontin. The Physician stated that there was no pain after the medication was stopped. He also stated that when he did his monthly assessments the resident did not have any complaints of pain. The physician further explained that he had placed the resident on the Neurontin for Diabetic Neuropathy for foot pain, not back pain. Epocrates Web site information: If the Neurontin dose is reduced, discontinued, or substituted with an alternative medication, this should be done gradually tapered over a minimum of 1 week (a longer period may be needed at the discretion of the prescriber). 415.18(c)(1)

Plan of Correction: ApprovedMarch 17, 2017

I. Immediate Corrective Action:
? Resident #36 was immediately assessed for the presence of neuropathic pain. The resident was not found to have neuropathic pain, and Neurontin was not restarted. The Consultant Pharmacist was counseled by her supervisor on including Neurontin tapering schedules in her recommendations.
II. Identification of Other Residents:
1. A report from the consultant Pharmacist?s computer software indicated that 14 recommendations regarding Neurontin were made in the last 3 months by the consultant Pharmacist. All 14 were evaluated by the Supervising Consultant Pharmacist and determined to include appropriate language. Additionally, all 14 recommendations were found to specifically include language to taper. None of the 14 recommendations included any language regarding the frequency of medication being refused. It is therefore concluded that no other residents were affected.
III. Systemic Changes:
The facility shall take the following measures and alter the following systems to ensure that the problem does not recur.
1. System Changes:
a. The policy on Drug Regimen Review will be reviewed and revised as necessary.
b. The Consultant Pharmacist was re-educated on Neurontin tapering protocols and being more careful in her choice of words in her recommendations.
IV. Quality Assurance Monitoring:
The facility plans to monitor its performance to make sure that solutions are sustained in the following manner:
1. Performance Monitoring:
a. The consultant Pharmacist Supervisor, Medical Director, and Director of Nursing will review all recommendations made by the consultant Pharmacist for proper use of language and the inclusion of tapering schedules for any recommendations involving Neurontin. This review will occur monthly for three months.

V. Responsible party for P(NAME) Involvement:
? DNS/Designee

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

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2017
Corrected date: April 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review during the Recertification survey the facility did not ensure that the resident environment remained as free from accident hazards as possible for 2 of 2 residents reviewed for Accidents from a total of 32 Stage 2 sampled residents. Specifically, Resident #248 and Resident # 56 had a physician's orders [REDACTED]. The findings are: 1) Resident #248 has [DIAGNOSES REDACTED]. The 11/24/2016 Quarterly Minimum Data Set (MDS) Assessment documented that the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating that the resident has moderate cognitive impairment. The MDS documented that the resident required extensive assist of two persons for bed mobility. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP), initiated 8/24/2012 and last updated 12/20/2016, titled Neurological Diseases: Seizure Disorder, had an intervention to maintain seizure precautions by keeping bed in lowest position with padded siderails up. On 2/23/2017 at 9:40 AM Resident #248 was observed in bed. The resident was awake and alert. The siderails were up, but they were not padded. On 2/23/2017 at 12:38 PM Resident #248 was observed in bed. The resident was awake and alert. The siderails were up, but they were not padded. On 2/23/2017 at 12:40 PM the unpadded siderails were brought to attention of the Licensed Practical Nurse (LPN) Charge Nurse. She located the siderail pads on top of the clothing closet. She said the Certified Nursing Assistant (CNA) is supposed to put them back on the siderails after the bed is made. On 2/23/2017 at 12:45 PM Resident #248's CNA was interviewed. She stated that she took the siderails off to make the bed, but that she did not put them back because they would affect the resident's ability to pull himself up and position himself. On 2/27/2017 at 8:19 AM the Director of Nursing Services (DNS) was interviewed. She stated the CNA should have consulted with the nurse before making a decision to not to put the siderail pads back.
2) Resident #56 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident has short term and long term memory problems and was severely impaired for daily decision making. The resident had no behavior problems, and no potential indicators of Psychosis. The resident requires extensive assist of two staff members for bed mobility and total assist of two staff members for transfers. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) dated 9/22/10 documented the resident had a history of [REDACTED]. Interventions included bilateral padded two half side rails up while in bed secondary to unawareness to bed boundaries, Dementia, and Convulsions. The current Certified Nursing Assistant Accountability Record (CNAAR) dated (YEAR) documented bilateral padded two half side rails up while in bed secondary to unawareness of bed boundaries. During initial rounds on 2/22/17 at 8:45 AM. Resident #56 was observed in bed with four half side rails in the up position. There was no padding observed on the side rails. A second observation was conducted on 2/23/17 at 9:15 AM. The resident was observed in bed with four half side rails up and there was no padding in place on the side rails. An interview was conducted on 2/23/17 at 1:50 PM with the Registered Nurse (RN) Unit Coordinator. The RN stated that the resident did have the padding but did not know where the pads were. The RN stated that the Certified Nursing Assistants (CNA) were responsible for making sure the resident's side rails are padded. A search of the resident's room was conducted by the RN and there was no evidence of padding in the room. The RN stated that if the CNA was unable to locate the padding in the resident's room the CNA should have reported it to the Unit Charge Nurse. The RN stated that she would obtain pads right away. An interview was conducted with the resident's assigned CNA on 2/23/17 at 2:51 PM. The CNA stated that she was assigned to the resident for that day but she was a float CNA. The CNA stated that she does not know the resident very well and that the RN may have told her during report that the resident uses padding to the side rails but she did not recall hearing about the padding. The CNA stated that she checked the resident's plan of care in the morning but did not see that the resident was supposed to have padding to the side rails. The CNA stated there were no pads on the side rails when she started morning care and that she found out the resident uses padding after it was brought to her attention by the RN. 415.12(h)(1)

Plan of Correction: ApprovedMarch 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions:
A. The side rail padding of both residents #248 & #56 were properly put in place.
B. The CNA?s who did not secure resident side rail pads as ordered received an educational counseling
on following nurse instructions on resident accountability record and resident safety with specific
focus on padded side rails
II. Identification of other Residents:
A. On 3/14/17 the DNS obtained a list of all residents who utilize padded side rails per physician order [REDACTED].
All were found to be compliant.

III. Systemic Changes:
1. The Administrator, DON, and Medical Director reviewed facility P/P titled ?CNA Accountability? and ?Side rails? for accuracy and appropriateness and found to be intact. Staff failure to
follow P//P and ensure safe environment will be prevented from recurring by re-educating all CNA?s and licensed nursing staff on side rail P/P and accountability.
The lesson plan will concentrate on the following:
? Importance of adhering to resident specific care with special focus on side rail use and padding as per physician order [REDACTED].
? Is there a physician order [REDACTED].
? Is it indicated in the nurse?s instructions
? Is device available for use and in place, if not, notify nurse.
All lesson plans and sign in sheets will be kept on file for validation.
IV. Quality Assurance Monitoring:
1. An audit tool will be developed to monitor and ensure the facility?s compliance with
established P/P regarding CNA Accountability and use of padded side rail per order for resident safety and prevent accidents and injury.
2. DNS/designee will conduct an audit of all side rails with padding monthly x3 months and then quarterly thereafter for compliance. All audit findings will be presented to the Administrator and the QA committee quarterly for follow up and review.
The audit will review:
? physician order [REDACTED].
? listed on resident accountability & on nurse instructions in EMR and
? in place on residents bed when appropriate
Any negative findings will be corrected immediately and reported quarterly at QA meeting.
V. Responsible party for P(NAME) Involvement:
? DNS/Designee

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (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: (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 (facility assessment implementation is Phase 2); (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. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (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: February 28, 2017
Corrected date: April 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews during the Recertification survey, the facility did not ensure that an infection prevention and control program was maintained to prevent and control infections for all residents. This was evident for 1 of 5 Stage 2 residents (Resident #114) reviewed for Pressure Ulcers (P/Us) and 1 resident reviewed for infection control in a total of 32 Stage 2 sampled residents (Resident #226). Specifically, 1) during a wound care treatment observation for Resident #114, the Licensed Practical Nurse (LPN) was noted to not practice hand hygiene and 2) Resident #226 had Physician Ordered contact precautions and there was no signage on the door indicating that the resident was on precautions. The findings are: 1) Resident #114 has [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. During a wound care observation for Resident #114 on 2/27/17 at 10:30 AM, the LPN was observed to wash her hands, don gloves and apply skin prep to the Left Great Toe Bunion, then open another skin prep and wipe the Left Great Toe Medial arterial ulcer. The LPN then opened a package of 4 x 4 gauze and covered both arterial ulcer wounds without cleansing her hands between wounds and prior to dressing the wounds. The LPN was immediately interviewed and stated that she should have removed her gloves and cleansed her hands prior to dressing the wound. An undated facility policy titled Infection Control documented to change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. 2) Resident # 226 has [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. During an initial tour of the 2 North Nursing Unit on 2/22/17 at 9:00 AM, Resident #226 was identified by the LPN Charge Nurse as being on contact precautions for MRSA of the Nares. During an observation of the resident's room at 9:15 AM signage notifying all persons to report to the nurse's station before entering the room was not posted. The LPN was immediately interviewed and stated that she was not sure if signage was needed for this resident, but subsequently, the LPN stated that it was indicated and signage was then posted. An undated facility document titled Policy for the use of Precautions and Isolation documented that in the event of a suspected or confirmed communicable disease, signage will be placed at the resident's room notifying all persons to report to the nurses station before entering the room. 415.19(a)(1-3)

Plan of Correction: ApprovedMarch 17, 2017

. Immediate Corrective Actions:
1. The LPN who did not follow facility?s established P/P regarding infection control/hand hygiene received an educational counseling by the DNS. Copy of same was retained on file for validation.
2. Signage notifying all person?s to report to the nurse?s station before entering the room was posted outside resident?s room in accordance with P/P immediately.
The LPN/Charge Nurse who did not ensure proper posting was in place outside resident?s room
received an educational counseling by the DNS
II. Identification of other Residents:
1. Any resident treated by nurse who failed to follow proper hand hygiene could be at risk. As such, immediate education was provided with nurse expressing competency to secure all residents under her care. A list of all residents receiving wound care treatment was generated for use in audit to ensure proper hand hygiene.
2. On 3/14/17 the DNS obtained a list of all residents on contact precaution and ensured proper
signage was posted
.

III. Systemic Changes:
1. The Administrator, DON and Medical Director reviewed current facility P/P on hand hygiene
and infection control including transmission based precautions
All licensed nurses will be re-in serviced on above P/P by the in-service coordinator/designee

The lesson plan will concentrate on the following:
? Dressing change:
- nurses must wash hands between wounds and prior to dressing the wounds
? All residents rooms with an identified infection specifically regarding residents with transmission based precautions and PPE will have posted signage indicating that all person to report to the nurses station before entering the room.
All lesson plans and sign in sheets will be kept on file for validation.
IV. Quality Assurance Monitoring:
1. An audit tool will be developed to monitor and ensure the facility?s compliance with established infection control program regarding pressure ulcer wound care dressing changes with focus on hand hygiene and placement of proper signage on room when warranted.
2. DNS/designee will conduct a random sampling of 5 residents per month x3 months for hand hygiene and then quarterly thereafter for compliance. All audit findings will be presented to the Administrator and the QA committee quarterly for follow up and review.
3. DNS/designee will conduct an audit of all residents for proper signage on contact precautions
per month x3 months and then quarterly thereafter for compliance. All audit findings will be presented to the Administrator and the QA committee quarterly for follow up and review.
V. Responsible party for P(NAME) Involvement:
? DNS/Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2017
Corrected date: April 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification survey the facility did not update and revise care plans to address the needs of each resident for 1 of 1 residents reviewed for Urinary Incontinence and 1 of 5 residents reviewed for Pressure Ulcers (P/U) in a total Stage 2 sample of 32 residents. Specifically, 1) Resident #255's Urinary Continence status had changed from continent to frequently incontinent; however, the Comprehensive Care Plan (CCP) was not updated to address the decline in urinary continence; and 2) during a wound care treatment observation for Resident #114, the Licensed Practical Nurse (LPN) was observed to treat the P/U without following the physician's orders [REDACTED]. The findings are: 1) Resident #255 was admitted to the facility on [DATE] and discharged on [DATE]. During this period the resident was discharged to the hospital on [DATE] and readmitted to the facility 10/31/2016, and again was discharged to the hospital on [DATE] and re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 10/18/2016 Nursing Admission Assessment documented that there was no bladder incontinence. The 10/25/2016 Admission Minimum Data Set (MDS) Assessment documented a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident was always continent of urine and was on a toileting program. A CCP, dated 10/26/2016, titled At Risk for Urinary Incontinency, documented the resident was continent of urine. The 10/31/2016 and 12/22/2016 Readmission Nursing Assessments, done when the resident returned to the facility from hospitalization s, documented that the resident was incontinent of bladder and briefs were being used. The 1/19/2017 Quarterly MDS documented that the resident was frequently incontinent of urine and was on a toileting program. There was no documented evidence that the CCP titled At Risk for Urinary Incontinency was updated to address the change in urinary continency status or that interventions were implemented. On 2/27/2017 at 11:08 AM a Registered Nurse (RN) MDS Coordinator was interviewed. She stated that the unit nurses are responsible for updating the care plans, and the care plan and interventions should reflect the resident's continency status. On 2/27/2017 at 11:32 AM the RN Unit Manager where Resident #255 resided was interviewed. She stated the nurses on the unit are responsible for updating care plans. She stated when residents return from the hospital the care plans are supposed to be re-evaluated and updated to reflect the resident's continency status. She further stated that the only bladder assessment that is done is part of the general admission/re-admission nursing assessment. On 2/28/2017 at 9:00 AM the Director of Nursing (DNS) was interviewed. She stated that the At Risk for Urinary Incontinency care plan should have been updated with appropriate interventions to address the changes in the resident's continence status.
2) Resident #114 has [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. During a wound observation on the 3 South Nursing Unit on 2/27/17 at 10:30 AM, the LPN was observed to wipe the entire wound with skin prep, remove her gloves and wash her hands, don gloves and cover the wound with a Hydrogel dressing. The LPN then removed her gloves, washed her hands, donned gloves and covered the wound with a DPD. The LPN was observed to not cleanse the wound with NS and was observed to cover the entire wound with skin prep. The LPN was interviewed on 2/27/17 at 11:30 AM and stated that she did print out physician's orders [REDACTED]. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedMarch 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Immediate Corrective Actions:
A. Resident #255 was discharged from facility on 1/31/17
B. The LPN who failed to follow physician order [REDACTED].
educational counseling on adhering to resident plan of care and to follow physician orders [REDACTED].
II. Identification of other Residents:
1. The facility respectfully states that all residents were potentially affected by the deficient practice of not updating CCP as indicated. The MDS report will be utilized to identify residents at risk for change in continent status and reviewed to ensure updates of CCP.
residents. Any identified not having an appropriate CP will be updated to reflect changes.
2. The nurse who did not follow physicians order properly was counseled and addressed on 3/1/17 to safeguard all resident receiving care who could be at risk for treatment without following orders. Nurse expressed competency in lesson.
III. Systemic Changes:
1. The Administrator, DON, and Medical Director reviewed policy regarding ?comprehensive
care plans/revising? and found P/P to be appropriate.
2. All licensed nursing staff will be re in-serviced on P/P by in-service coordinator/designee

The lesson plan will concentrate on the following:
? Resident?s continence will be assessed on admission/readmission, quarterly and upon change in condition.
? Develop and implement individualized CCP
? If incontinent, CCP is implemented to address resident needs
? MDS reflects current resident status regarding continence
All lesson plans and sign in sheets will be kept on file for validation.
IV. Quality Assurance Monitoring:
1. An audit tool will be developed to monitor and ensure the facility?s compliance with
established P/P regarding Comprehensive Care Plans.
2. DNS/designee will conduct a random sampling of 5 residents per month x3 months and then quarterly thereafter for compliance. All audit findings will be presented to the Administrator and the QA committee quarterly for follow up and review.
V. Responsible party for P(NAME) Involvement:
? DNS/Designee

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: February 28, 2017
Corrected date: N/A

Citation Details

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued. Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction. The building is three stories fully sprinklered, and is not at least Type II(III) construction. The floor ceiling assembly is not at least one-hour rated. 483.70(a), 711.2(a)(1), NFPA101-2012: 19.1.6.2, 19.1.6.3, 19.1.6.4

Plan of Correction: ApprovedApril 6, 2017

The facility requests that the waiver (s) be continued

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: February 28, 2017
Corrected date: N/A

Citation Details

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued. Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction. In several areas, corridor doors project more than 7 inches into the corridor when they are fully open. 483.70(a), 711.2(a)(1), NFPA [PHONE NUMBER]:18.2.1, 19.2.1 The paths of travel between the terminations of some exits and their associated public ways do not meet 5-1.6 with respect to changes in elevation. 483.70(a), 711.2(a)(1), NFPA [PHONE NUMBER]: 19.2.1 Paths of travel to reach a paved walkway that discharge to the public way require travel across approximately 80 foot section of ground surfaced with grass and soil. NFPA [PHONE NUMBER]: 19.2.1, 7.1.6, 7.1.10.1, 10NYCRR: 711.2(a)(1)

Plan of Correction: ApprovedApril 6, 2017

The facility requests that the waiver (s) be continued

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: February 28, 2017
Corrected date: N/A

Citation Details

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued. Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction. Some smoke partitions were not constructed to provide at least a half-hour fire resistance rating. Non-protected steel structural members are incorporated into some smoke partitions. 483.70(a), 711.2(a)(1), NFPA [PHONE NUMBER]:19.3.7.3, 19.3.7.5,19.1.6.3, 19.1.6.4

Plan of Correction: ApprovedApril 6, 2017

The facility requests that the waiver (s) be continued