Ross Center for Nursing and Rehabilitation
June 19, 2018 Certification Survey

Standard Health Citations

FF11 483.25(l):DIALYSIS

REGULATION: §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: August 7, 2018

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 ensure that residents who require [MEDICAL TREATMENT] receive services, consistent with professional standards of practice, and the comprehensive person-centered care plan. This was evident for 1 (Resident #53) of 1 resident reviewed for [MEDICAL TREATMENT]. Specifically, Resident #53 receives [MEDICAL TREATMENT] treatment three time a week. Record review, from (MONTH) (YEAR) through (MONTH) 12, (YEAR), revealed that the resident's pre- and post-weights were not documented on [MEDICAL TREATMENT] days. There was no documented evidence that the [MEDICAL TREATMENT] Center communicated with the facility via [MEDICAL TREATMENT] Communication Book post-[MEDICAL TREATMENT] session. Additionally, Resident #53 had a Comprehensive Care Plan (CCP) developed for [MEDICAL TREATMENT] to monitor the resident's right arm Arterio-Venous (AV) shunt every (q) shift for bruit and thrill. The licensed staff did not monitor the shunt from 3/12/18 through 4/17/18 as per the CCP. The finding is: The facility's policy and procedure titled Care of Residents on [MEDICAL TREATMENT] dated (MONTH) (YEAR) documented . A. Pre-[MEDICAL TREATMENT] 3) Weigh daily including before and after treatment at [MEDICAL TREATMENT] center .B. Post-[MEDICAL TREATMENT] 1) Upon resident's return from [MEDICAL TREATMENT], the receiving nurse on the unit will check communication notebook from the [MEDICAL TREATMENT] center for any relevant information/instruction and initial that it was noted. Notify the nursing supervisor for any recommendations that the primary physician should be aware of and follow through . Nursing Home [MEDICAL TREATMENT] Transfer Agreement dated 2/15/17 documented . 3. Designated Resident Information (h) Any information that will facilitate the adequate coordination of care, as reasonably determined by Center . Resident #53 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was independent for cognitive skills for daily decision-making. The MDS also documented the resident received [MEDICAL TREATMENT] treatment during the review period. The Physician' Order dated 4/18/18 documented to monitor right arm AV fistula every shift for bruit and thrill and for signs and symptoms of infection and bleeding every (q) shift. The physician's orders [REDACTED]. The resident had a Right Arm Arterio-Venous (AV) shunt. The Comprehensive Care Plan (CCP) developed for [MEDICAL TREATMENT], active and effective as of 5/19/17, documented to monitor the right arm AVF for bruit and thrill q shift, monitor the right arm AVF for signs and symptoms of infection and bleeding, to provide a renal diet as per the MD order, to monitor for signs of infection and communicate with the [MEDICAL TREATMENT] center any abnormal findings, and to monitor fluid restriction, vital signs, and weight as ordered by the Physician. Review of the [MEDICAL TREATMENT] Communication Book from (MONTH) (YEAR) through (MONTH) 12, (YEAR) revealed that there were no pre- and post-[MEDICAL TREATMENT] weights documented. There were also no communication from the [MEDICAL TREATMENT] Center documented post-[MEDICAL TREATMENT] treatments. Review of the Treatment Administration Record (TAR) from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that the resident's right arm AVF shunt was not monitored for bruit and thrill q shift since re-admission on 3/12/18 through 4/17/18. An interview was held with the Administrator on 6/15/18 at 9:30 AM. The Administrator stated that he had already spoken with the Nurse Practitioner of the [MEDICAL TREATMENT] Center on 6/15/18 at 9:00 AM and that the [MEDICAL TREATMENT] staff would comply with the information needed in the [MEDICAL TREATMENT] communication book post [MEDICAL TREATMENT] session. An interview was held with the Director of Nursing (DNS) on 6/18/18 at 10:00 AM. The DNS stated that the licensed staff should have documented and monitored the resident's right AV shunt's bruit and thrill upon re-admission on 3/12/18. The DNS also stated that when the resident goes out to [MEDICAL TREATMENT], the pre- and post-weights should be done and documented in the [MEDICAL TREATMENT] communication book and that the licensed staff should have reviewed and checked the communication book upon return from [MEDICAL TREATMENT]. An interview was held with the Registered Nurse (RN) on 6/18/18 at 10:10 AM. The RN stated that the resident's right AV shunt's bruit and thrill should have been monitored when the resident was readmitted on [DATE]. The RN stated that there was no documentation that the resident's Right AV shunt was monitored from 3/12/18 to 4/17/18. 415.12**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during Post Survey Revisit #1, the facility did not ensure that for residents who require [MEDICAL TREATMENT] services, communication between the [MEDICAL TREATMENT] center and the facility was complete. This was noted for one (Resident #8) of three residents reviewed for [MEDICAL TREATMENT]. Specifically, for Resident #8, the facility did not accurately implement the plan of correction (P(NAME)). There was a lack of communication between the [MEDICAL TREATMENT] center and the Nursing Home regarding the pre and post [MEDICAL TREATMENT] weights. Additionally, there was no documented evidence that the unit charge nurse checked the [MEDICAL TREATMENT] communication book upon the resident's return to the facility as indicated in the P(NAME). The finding is: Resident #8 has [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The facility's written P(NAME) for the recertification survey, with completion date of 8/17/18, included to address the lack of documentation from the [MEDICAL TREATMENT] center in the resident's communication book. The P(NAME) specified that the [MEDICAL TREATMENT] center will ensure ongoing future communication between the two facilities, including pertinent information such as pre and post weights. The P(NAME) also documented that the [MEDICAL TREATMENT] Policy and Procedure was reviewed and revised specifically in regards to the communication books. Additionally, the P(NAME) documented further the unit Charge Nurse will check the communication book and will initial and date the communication book upon the resident's return to the facility. The [MEDICAL TREATMENT] communication book for Resident #8 was reviewed on 8/21/18. A note from the [MEDICAL TREATMENT] Center dated 8/18/18 (Saturday) documented the resident's vital signs but did not document pre and post weights. Additionally, the note was not initialed and dated by the nurse. An interdisciplinary progress note dated 8/18/18 at 11:18 AM documented that the resident returned from the [MEDICAL TREATMENT] at 11:00 AM. The note did not document the lack of pre and post weights in the Communication book. There were no further notes on 8/18/18. The Director of Nursing Services (DNS) was interviewed on 8/20/18 at 11:00 AM and stated that all the staff were educated to look for pre and post weights in the [MEDICAL TREATMENT] communication book. The DNS also stated that on weekends there is a Registered Nurse (RN) Supervisor but no Nurse managers. He stated that on 8/18/18 the Licensed Practical Nurse (LPN) on the unit was responsible for checking the communication book. The 7:00 AM to 3:00 PM LPN assigned to the unit on 8/18/18 was interviewed on 8/21/18 at 11:00 AM. She stated that she had received several inservices two weeks ago. The LPN stated that the inservices for [MEDICAL TREATMENT] communication book included to check for any recommendations. The LPN also stated that she thought the nurses were supposed to obtain a pre and post weights. She stated that on 8/18/18 she had noted that there was no pre weight in the record. She also stated that she obtained a post weight but did not document it. She stated that she was unaware to look for pre and post weights in the [MEDICAL TREATMENT] communication book and that she was supposed to initial and date the note. The DNS was interviewed on 8/21/18 at 11:30 AM and stated that the Registered Nurse (RN) Manager called the [MEDICAL TREATMENT] center on 8/20/18 and obtained the pre and post [MEDICAL TREATMENT] weights for Resident #8 for 8/18/18. The DNS was interviewed on 8/21/18 at 2:00 PM and stated that the [MEDICAL TREATMENT] center for Resident #8 had not been contacted with regard to communication expectations with the Nursing Home regarding the pre and post [MEDICAL TREATMENT] weights. The DNS also stated that the facility staff inservices were completed by the DNS, Assistant Director of Nursing (ADNS), unit Managers and Supervisors depending on the shifts/staff availability. The DNS also stated that he could not identify the specific staff who delivered specific segments of inservices. The lesson plan for F698 was reviewed with the DNS. It included, Ensuring books are checked after each [MEDICAL TREATMENT] visit, a) review date and initial b) inform MD of any pertinent information. It did not include to specifically look for pre and post [MEDICAL TREATMENT] weights in the communication book. The DNS stated that the lesson plan is not specific and will be revised. The revised [MEDICAL TREATMENT] Policy dated 7/2018 was reviewed with DNS. The Policy procedure section included 1) Monitor weights as directed. Communicate with [MEDICAL TREATMENT] unit to determine if they will do pre and post weights or the facility should do them. The DNS stated that the Policy needs to be revised. The DNS revised the Policy. The revised Policy dated 8/2018 documented in the procedure section, Upon return to the Facility post [MEDICAL TREATMENT] the Licensed Staff on duty must monitor pre and post weights in the communication book. If there is no weight documented, contact the [MEDICAL TREATMENT] center to obtain pre and post weight and include information in the post [MEDICAL TREATMENT] note. 415.12

Plan of Correction: ApprovedAugust 31, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.a) Resident # 53 right arm AV fistula examined by MD on (7/02/18) was patent and had positive thrill and bruit there was no signs or symptoms of infection.
b) On (6/15/18) the Administrator spoke to the Administrator of resident # 53 [MEDICAL TREATMENT] center to discuss the ongoing lack of documentation from the [MEDICAL TREATMENT] center in the resident communication book. The administrator of the [MEDICAL TREATMENT] center indicated that he would speak with the Charge Nurse of the [MEDICAL TREATMENT] center to ensure ongoing future communication between both facilities, including pertinent information such as pre and post weights, lab work, medications administered, etc.
c) The nurse who failed to enter the MD order to monitor the right arm AV fistula for bruit and thrill and for sign and symptom of infection was counselled by the Director of Nursing on (7/9/18). Although it was not entered in physician orders, there was documented evidence that nurses were checking the AV shunt pre and post [MEDICAL TREATMENT] in the progress notes.
2) An audit was conducted by the RN Nurse Managers (6/15/18) on all other residents receiving [MEDICAL TREATMENT]. All other residents had MD orders to check bruit and thrill and monitor for infection q shift. All other communication books were checked and found to have communication documented between facilities.
3) a. The Policy and Procedure on [MEDICAL TREATMENT] was reviewed and revised by the Director of Nursing specifically related to intra-facility communication books. The unit Charge Nurse will be responsible to check the books upon resident return to the facility. At that time the unit charge nurse will date and initial the communication book and inform MD of any pertinent information documented. The policy was compliant related to obtaining MD orders to check shunt for bruit, thrill and signs of infection.
b) All nursing staff will be in-serviced on the newly revised Policy and Procedure of [MEDICAL TREATMENT] by the Director of nursing/designee.
4) The QAPI committee developed an audit tool on 7/6/18 to ensure that nurses are checking the [MEDICAL TREATMENT] communication book, as well as the resident?s access site. The RN Nurse Manager will complete the audit weekly times four weeks, monthly times three months, and then as directed by QAPI committee. Any negative findings will be immediately reported to the Administrator.
5) The Director of Nursing will be responsible for compliance with F 698.

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

Citation Details

Based on observations and staff interview during a recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the ice making machine and a dish holding rack was observed to be dirty on 6/11/18. The finding is: During the kitchen tour on 06/11/18 at 8:00 AM an ice making machine was observed to be dirty. Specifically, the grill frame and drip container was soiled with a thick layer of a moist black substance. The Food Service Director (FSD) was interviewed on 6/11/18 at 8:15 AM and stated that the ice from this ice making machine is being used for consumption and for cooling food. The FSD also stated the machine is cleaned monthly by the facility staff and was last cleaned on (MONTH) 10th, (YEAR). He added that the next scheduled cleaning is tomorrow (6/12/18). A stainless steel dish cover rack was observed to be soiled on 6/11/18 at 10:00 AM. The FSD stated that this could be better cleaned. 415.14(h)

Plan of Correction: ApprovedJuly 12, 2018

1. Facility immediately cleaned the ice machine grill frame and drip container and dish holding rack on 6/11/18.
2. Food Service Director made rounds on 6/11/18 in Kitchen to identify any other areas of concern. None found.
3. All kitchen staff will be in-serviced on maintaining a safe and clean environment by the Administrator/designee
4. An audit tool was developed by the Administrator on 7/11/2018 to ensure a safe and clean kitchen environment. The audit tool will be completed 3 times a week x 4 weeks, then monthly x 3 months by the Food Service Director/designee.
5. The Food Service Director will be responsible for compliance with this tag.

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews and record review during a Recertification survey, the facility did not ensure that the resident environment remains as free of accident hazards as is possible. This was noted for one resident (Resident #7) of four residents reviewed for accidents. Specifically, Resident #7 was observed with 1/2 (scored) unidentified white pill in a pill cup on her bedside table on 6/11/18. The finding is: Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status Score (BIMS) of 15, which indicated intact cognition. The MDS documented the resident required one person assist for bed mobility and transfer. A Comprehensive Care Plan (CCP) for self care dated 9/13/17 documented deficit in dressing, grooming, feeding, bathing, and toileting. The resident was care planned for independent personal hygiene and grooming/eating and walking in room and corridor. The CCP did not include a plan for the resident to self administer her own medications. During initial tour on 6/11/18 at 9:30 AM Resident #7 was observed in bed. A 1/2 white oblong tablet (scored in half) was observed in a plastic cup placed on the bedside table. When asked about the pill, she looked at the 1/2 tablet in the cup and raised her eyebrows with a surprised expression and asked there is something in it ? She then took the pill with water. She stated that the left over pill was from this morning. A 7:00 -3:00 PM Licensed Practical Nurse (LPN) was observed dispensing medications on the unit on 6/11/18 at 9:40 AM. She stated that the resident took all medications at 8:42 AM. The LPN further stated that the resident does not get any 1/2 pill from her. The LPN also stated that she had personally discarded the empty pill cup after the resident took all her pills. The unit Registered Nurse (RN) Manager was interviewed on 6/14/18 at 8:30 AM and was made aware of the resident being observed with 1/2 pill in a pill cup on 6/11/18. He stated he was unaware of the pill left over with the resident on 6/11/18 and would investigate. The 11:00 PM-7:00 AM LPN who worked the night between 6/10/18 and 6/11/18 was interviewed on 06/15/18 at 10:20 AM. The LPN stated that the resident got a Nebulizer treatment, 2 Tylenol pills and [MEDICATION NAME] from her. She stated that, any time I give them medications I make sure they take it. She added that,I gave her only round tablets, no oblong tablet and did not see any pills on the side table. I even took the empty cup back from her. The 3:00 PM-11:00 PM shift LPN who worked on 6/10/18 was interviewed on 06/15/18 at 10:22 AM. The LPN stated that Resident #7 gets a lot of medications on her shift. The LPN stated that she assures that the residents take all of their medications in her presence. The RN unit manager was interviewed on 6/19/18 at 2:00 PM and stated that during the investigation they failed to find the source or identity of the 1/2 pill found on the resident's bedside table on the morning of 6/11/18. 415.12 (h)(1)

Plan of Correction: ApprovedJuly 25, 2018

1. On 6/27/18 the MD/NP examined resident # 7 with the ½ scored unidentified white pill that was found on the resident bedside table on 6/11/18. Resident was found to be stable with no negative findings. Any necessary changes to her plan of care will be made and her care plan will be updated as needed.
2. a. The RN Nurse Manager made environmental rounds on the unit to ensure there were no leftover medication in any resident room, ensuring the resident environment remains free of hazards. There were no negative findings.
b. All RN Managers made environmental rounds to ensure no medication was left in any resident rooms on their respective units. There were no negative findings.

3.a) The Policy and Procedure for medication pass was reviewed and revised by the Director of Nursing on 7/6/18 to specifically address ensuring residents take all the medication administered prior to leaving the resident?s room. In addition to ensuring the resident swallows the medication, the policy specifies that the nurse must leave the room with the empty medication cup.
b) All medication nurses will be in-serviced by Director of Nursing/designee on the newly revised policy and procedure.
4. The QAPI Committee developed a medication pass competency audit tool on 7/6/18 to ensure ongoing compliance. The Director of Nursing/designee will observe all medication nurses for Medication Pass competency once a month times 3 months and then as directed by the QAPI Committee . Any nurse who is deemed incompetent will be re-inserviced and re-observed. Any future concerns will be immediately reported to the Director of Nursing.
5. Director of Nursing will be responsible for compliance with F689.

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: August 21, 2018
Corrected date: September 12, 2018

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 an infection and control program (IPCP) designed to help prevent the development and transmission of infection was followed. This was evident for one (Resident #35) of 4 residents reviewed for Pressure Ulcer. Specifically, during observation of wound care, the Licensed Practical Nurse (LPN) was observed not following proper technique during dressing change, not changing gloves and washing hands per facility policy and procedure, not using a barrier before placing supplies on the resident open diaper and bed linen and not using a separate applicator for each pressure ulcer. The finding is: An undated facility policy and procedure titled Pressure Sores/Ulcer Prevention and Intervention Program documented clean aseptic technique should be used for all dressing change, and in the event of multiple wounds, each wound is considered a separate treatment. In the Steps section number (3) it documented to prepare a clean, dry work area at bedside. Use Disinfectant solution to prepare the work surface. Key points in the policy documented to cover work surface with clean dry paper or cloth towel to prevent contamination of the supplies. Step (9) document to remove soil dressing, step (10) documented to remove gloves, wash hands, and apply new gloves. Step (12) documented to cleanse wound with normal saline, step (13) pat the tissue surrounding the wound dry and step (14) documented to remove gloves, wash hands, and apply new gloves. Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15, which indicated intact cognition. The resident had mood and behavior symptoms, and required supervision to extensive assist of one to two staff members for all areas of Activities of Daily Living (ADL) and was non ambulatory. The resident was at risk for PU and had one Stage II, four Stage III PU, one Stage IV that is unhealed, and only one PU was present on admission. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) dated 10/11/17 documented the resident has a Stage III skin break down on the Right Hip. The goals included the resident will not experience signs and symptoms (s/s) of infection times (x) 90 days. Interventions included to monitor for s/s of infection and to apply dressing as ordered by the Physician. A CCP dated 5/23/18 documented the resident had a Stage III skin break down on the right buttock. The goals were that the pressure ulcer will show healing process as evidenced by decrease in size and or depth of the wound x 90 days. Interventions included to monitor for s/s of infection and to apply the dressing as ordered by the Physician. During wound care observation conducted on 6/18/18 at 11:45 AM, with the LPN, the following was observed. Without cleaning the overbed table the LPN carried supplies on a tray, including multiple combine dressings and a packet containing four by four gauze. The LPN placed supplies on the unclean overbed table that contained the resident's personal item on half of the table. The combine dressing packets were placed on the resident items on the table. After the resident positioned himself for the treatment, the LPN then placed the container of gauze, a single [MEDICATION NAME] on the resident's bed linen, and a combine dressing on the resident's open diaper without a barrier. The LPN then removed the soiled dressing from the resident's right hip and right buttock pressure ulcer and placed the soiled dressing in the resident's bedside garbage container. Without changing gloves and washing his hands, the LPN then opened the bottle of Normal Saline (NS) and removed gauze from the container on the bed. He poured NS on the gauze and cleansed the wound in multiple directions, not cleansing from the center in a circular motion to outer aspect of the wound. On multiple occasions, the LPN was observed placing the bottle of saline up onto the wound while pouring NS on the gauze. Without changing gloves, the LPN used the same pattern to cleanse the right buttock wound. After cleansing both wound sites, using a cotton-tipped applicator, the LPN applied Santyl Topical Ointment to the right hip wound, then placed the applicator in the cup with the remaining ointment. He poured NS from the same bottle into the packet of a single four by four gauze, squeezed the gauze of excess NS then applied the gauze to the right hip wound. The LPN used the same pattern to treat the right buttock wound using the same tipped applicator and the remaining ointment. During an interview immediately after the treatment on 6/18/18 at 12:20 PM with the LPN, he stated that since LPN school he had not been in-serviced on dressing change. He stated that he was never in-serviced to change gloves and wash hands after removing a soiled dressing and after cleansing the wound and that he was trained by another LPN on hire who no longer works for the facility. The LPN further stated that it was easier to treat the wounds at the same time as they were close together. Additionally, the LPN stated that he did not know he was doing anything wrong. During an interview conducted on 6/18/18 at 12:35 PM with the Unit RN Supervisor, she stated that the expectation is the LPN should have cleansed from the center of the wound to the outer aspect of the wound to prevent contamination of the wound. The RN stated that each wound should have been treated separately, and that glove changes and hand washing should have been done at the start of the dressing, after removing the soil dressing, after cleansing the wound and after completing each treatment. During an interview conducted on 6/18/18 at 2:55 PM with the Director of Nursing Services (DNS), he stated that the LPN was inserviced on 9/8/17 on Pressure Ulcer Management and Treatment which included dressing/treatment technique. The DNS stated when he approached the LPN to ask if he needed to review any area of dressing change, the LPN stated that he was fine. The DNS stated that the LPN would not be administering treatments until he is re-inserviced and competency in that area is completed. 415.19(a)(1-3)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during Post Survey Revisit #1, the facility did not ensure that an infection prevention and control program designed to help prevent the development and transmission of infection was followed. This was evident for one (Resident # 17) of 3 residents reviewed for Pressure Ulcers. Specifically, during observation of wound care, the Licensed Practical Nurse (LPN) #2 was observed not changing gloves and washing hands per facility policy and procedure. The LPN did not remove her gloves and perform hand hygiene after cleansing the wound. The finding is: An Aseptic Dressing Technique Policy and Procedure dated 7/2018 documented in the procedure section number (15&16) that after cleansing the wound from the center outward the nurse was to remove gloves and wash hands. Resident # 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 12 which indicated moderate cognitive impairment. The resident had one unhealed unstageable PU present on admission. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) dated 8/1/18 documented the presence of a skin breakdown to the Mid Back. Interventions included to provide treatment as ordered by the Physician and to monitor for signs and symptoms of infection. A Wound Care progress note dated 8/15/18 documented an Unstageable PU measuring 6 centimeters (cm) x 2.5 cm x 0.1 cm to the Mid Back/Spine with necrotic wound base, white slough and light serous drainage. During a wound care observation on 8/20/18 at 12:10 PM for Resident # 17, LPN #2 was observed to set up a clean field, remove necessary treatment items from the treatment cart and place them on the clean treatment field. LPN #2 was observed to wash her hands and don clean gloves. The LPN then removed the soiled dressing from the resident's mid back wound then removed the gloves and washed her hands. With clean hands the LPN opened three 4-inch x 4-inch gauze pads and applied normal saline to two of the three gauze pads. The LPN then donned clean gloves and cleansed the wound twice from the center to the outer aspect of the wound, then patted the wound dry. After cleansing the wound the LPN did not remove the gloves and did not wash her hands. Using the same gloves, the LPN applied Santyl ointment to the wound and covered the wound with clean a dressing. An interview was conducted immediately with LPN #2 on 8/20/18 at 12:23 PM. The LPN stated she had recently received in-service education with returned demonstration on dressing change. The LPN stated that during dressing change she should wash her hands and don gloves at the start of the treatment. She stated after removing the soiled dressing she should have removed the gloves and washed her hands and that at the end of the treatment she should again wash her hands. When the LPN was asked should she have removed her gloves and wash her hands after cleansing the wound the LPN replied Yes, I should have removed the gloves and washed my hands after cleansing the wound. An Aseptic Dressing Technique Observation Tool dated 8/1/18 documented the LPN was observed and checked off for aseptic dressing technique. An interview was conducted on 8/21/18 at 2:48 PM with the Assistant Director of Nursing Services (ADNS). The ADNS stated that the LPN received inservice education both verbally and through demonstration on dressing change. The ADNS stated that the LPN was in-serviced to change gloves and wash hands four times; before start of the treatment, after removing the soil dressing, after cleansing the wound and at the completion of the treatment. The ADNS further stated the LPN should have removed the gloves and washed her hands after cleansing the wound. 415.19(a)(1-3)

Plan of Correction: ApprovedAugust 31, 2018

1.a) Resident # 35 was seen by the wound doctor on 6/20/18 and documented that the resident wound was healing nicely. There was no signs nor symptoms of infection present.
b) The LPN was to be counselled by the Director of Nursing for failure to follow aseptic technique and a competency was to be conducted but LPN failed to return to the facility and he is no longer employed at the facility.
2) On 6/20/18 the wound care MD saw the other residents on the unit who had wound care completed by the LPN. There were no negative findings.
3.a) On 7/10/18 the Director of Nursing reviewed the Policy and Procedure on Aseptic technique and found it to be compliant.
b) All nurses will be re- inserviced on the Policy and Procedure by the Director of Nursing / Designee.
4) The QAPI committee developed a wound care competency audit tool on 7/6/18 to be completed by the DNS/designee to ensure that all nurses who are scheduled to perform wound care will be observed monthly times three months, and then at least annually. Any nurse who is deemed incompetent will be re-inserviced and re-observed. Any future concerns will be immediately reported to the Administrator.
5) The Director of Nursing will be responsible for compliance with F 880.

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 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 ensure that an allegation of mistreatment was investigated. This was evident for one resident interviewed in the inital pool process for abuse, neglect and mistreatment. Specifically, Resident #14 informed the Director of Nursing Services (DNS) she was mistreated by a Certified Nursing Assistant (CNA). There is no documented evidence that an investigation was initiated and that the resident was kept safe after the resident's allegation of mistreatment. The finding is: An undated abuse policy and procedure documented when a receipt of information related to allege abuse, neglect or mistreatment occurs, the DNS will ensure an investigation is initiated. The abuse policy and procedure documented the DNS notifies the Administrator and statements will be obtained from the resident. A statement from the staff person identified as being involved in the alleged mistreatment will be obtained and removed from duty during the investigation in order to protect the resident from any type of retaliation or further mistreatment. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS documented the resident required extensive assist with bed mobility, toileting and personal hygiene. During an interview on 06/11/18 at 8:50 AM Resident #14 stated that a CNA was rough with her during care, pushing her over to clean her and being rough when washing her after a bowel movement and brief change. The CNA stated to the resident, what are you eating to make you go to the bathroom so much and always needing a brief change? The resident stated the CNA only works weekends on the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts. The resident stated the CNA was verbally fresh to her stating she does everything for her and she gets upset when she rings the call bell stating to the resident,what do you need now. The resident stated that she talked with the DNS on 5/30/18. The DNS explained to her that the DNS will talk to the supervisor and not schedule the CNA on the unit. The resident stated that the CNA took care of her on the weekend of 6/9/18 on the 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shift and on 6/10/18 on the 3:00 PM to 11:00 PM shift. The resident stated that did not inform staff at that time because she was afraid of repercussions from the staff. A Comprehensive Care Plan (CCP) dated 3/8/18 titled Cognition documented the resident was alert and oriented times three (person, place and time) and can make her needs known. The CCP dated 3/8/18 titled ADL (Activities of Daily Living) Functional/Rehabilitation potential documented that the resident required assistance with toileting and personal hygiene. The CCP interventions were to check and change the resident's incontinent briefs every 2 to 4 hours and when necessary. The CCP documented to provide assistance with dressing, bathing, personal hygiene, bed mobility and grooming. A CCP titled Abuse/Neglect dated 3/8/18 documented the resident will be free of abuse/neglect daily. The CCP interventions were to maintain a safe environment at all times, report any concerns promptly and in-service staff on abuse/neglect. The CNA accountability record for (MONTH) (YEAR) and (MONTH) (YEAR) documented the resident required assistance with activities of daily living, that Resident #14 was incontinent of bowel and bladder and required a brief change every two hours and when necessary. The nursing schedule dated 6/9/18 for the 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shift documented that Resident # 14's CNA was scheduled on the north unit but was re-assigned to the east unit. Resident #14 lives on the east unit. The nursing schedule dated 6/10/18 for the 3:00 PM to 11:00 PM shift documented that Resident #14's CNA was scheduled on the north unit but was re-assigned to the east unit. An interview was held with the DNS on 6/11/18 at 10:00 AM. The DNS stated he spoke with the resident on 5/30/18 and explained to her he would leave written instructions on the calendar on the east unit that the CNA could not provide care to her. The DNS stated that he did not inform the RN Supervisor. The DNS stated he could not explain why he did not initiate an investigation or remove the CNA from the schedule per the facility policy. A written statement was provided by the DNS on 6/13/18. The statement documented that Resident #14 informed the DNS that she did not like the way the CNA spoke to her during care. The DNS stated to the resident that the CNA will not be scheduled on the east unit and will not be caring for her any longer. The statement documented that a follow up with the resident on 6/12/18 revealed the CNA provided care to the resident on the weekend of 6/9/18 and 6/10/18. An interview was held concurrently with the Administrator and the DNS on 6/14/18 at 7:30 AM. The DNS stated that he spoke with the CNA last night (6/13/18), and told her that she was not able to return to work until she comes in to speak with him and that the CNA has not worked since 6/10/18. The Administrator stated the DNS felt moving the CNA to another unit was sufficient. The Administrator stated he was not aware of the allegation until yesterday, 6/13/18. An interview was held with Resident #14's Certified Nursing Assistant (CNA) on 6/15/18 at 11:39 AM. The CNA stated that she was assigned to Resident #14 on 6/9/18 from 3:00 PM to 11:00 PM and on the 11:00 PM to 7:00 AM shift and also on 6/10/18 on the 3:00 PM to 11:00 PM shift. The CNA stated when she cleans the resident after a bowel movement she has to clean good because the fecal material gets stuck. The CNA stated she could not recall any issues with the resident. An interview was held on 6/15/18 at 1:00 PM with the Registered Nurse (RN) Supervisor who worked on 6/9/18 during the 3:00 PM to 11:00 PM shift and on 6/10/18 on the 3:00 PM to 11:00 PM shift. The RN stated that the reason she changed the schedule on 6/9/18 and 6/10/18 and reassigned the CNA to the east unit was because she feels the CNAs should work where they want to make them happy. The RN stated that she did not get a report from the Supervisor from the 7:00 AM to 3:00 PM shift on 6/9/18 or 6/10/18. The RN stated that she was not informed that the CNA could not work on the east wing or that there were any concerns with Resident #14 and the CNA. The CNA, (who cared for Resident # 14 on 6/9/18 on the 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shift and on 6/10/18 on the 3:00 PM to 11:00 PM shift) statement dated 6/15/18 documented the CNA stated she put the resident to bed, did care for her and when the resident needed something the resident would ring the call bell. The CNA also stated that she does not recall any instance that she was not nice to the resident. A CNA (who cared for Resident # 14 on 6/9/18 on the 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shift and on 6/10/18 on the 3:00 PM to 11:00 PM shift) statement dated 6/18/18 documented that the CNA came in to work on 6/9/18 and was not scheduled on the east wing unit. The CNA stated that she asked the RN supervisor to move her to the east wing and the RN supervisor complied. An interview was held with the DNS on 6/18/18 at 8:30 AM. The DNS stated that he did not assess the resident after her complaint of the CNA being rough and rude. The DNS stated that he did not request any staff member to assess the resident. The DNS further stated he has only been here a month and has not been able to review all the policies yet. An interview was held with Resident #14 on 6/18/18 at 8:35 AM. The resident stated that she reported to the DNS on either Monday 6/4/18 or Tuesday 6/5/18 that the CNA was rough and rude. The resident stated to the DNS that the CNA was rough when she was cleaning her after a bowel movement, and that the resident stated to the CNA that she was being rough. The resident stated the CNA stated to her that she had to be rough to clean her. The resident also stated that she had no concerns with any other CNAs that have provided care for her. An interview was held with the RN manager of the east unit on 6/18/18 at 8:50 AM. The RN stated that he was not informed by the DNS to assess the resident at any time or instructed that the CNA could not provide care to the resident. An interview was held with the 7:00 AM to 3:00 PM east unit Licensed Practical Nurse (LPN) on 6/18/18 at 8:55 AM. The LPN stated that the calendar dated 6/9/18 and 6/10/18 documented that the CNA could not take care of the resident. The LPN stated that she does not know if the nurses on the other shifts read the calendar. An interview was held on 6/18/18 at 10:00 AM with the 3:00 PM to 11:00 PM LPN who worked on 6/9/18 and 6/10/18. The LPN stated that she does not read the calendar on the unit. The LPN stated that she was not informed by the previous shift or the nursing supervisor during report that the CNA could not provide care to the Resident #14. The LPN stated the resident did not report any concerns to her. An interview was held with the Social Worker on 6/18/18 at 10:15 AM. The Social Worker stated that she spoke with Resident #14 on 5/29/18 and that the resident verbalized to her a CNA was not nice to her. The Social Worker stated that she reported it to the DNS on 5/29/18. The Social Worker further stated there is no documented evidence that a follow up was conducted with the resident after the incident. A mandatory in-service education dated 5/7/18 documented that the DNS was in-serviced on abuse, neglect and mistreatment. An interview was held with the DNS on 6/19/18 at 10:15 AM. The DNS stated that he was in-serviced on the abuse, neglect and mistreatment protocol, and the policy and procedure was not included in the in-service. The DNS stated he was not able to review the policy and procedure since he has only been employed since (MONTH) (YEAR). An interview was held with Resident #14 on 6/19/18 at 11:05 AM. The resident stated that when she spoke with the DNS on 5/30/18 she did report to him that the CNA was verbally inappropriate and was rough when she was cleaning her after a bowel movement. The resident stated that she again reported the same concerns to the DNS on 6/12/18 after the CNA provided care to her during the weekend of 6/9/18 and 6/10/18. The resident stated that the Social Worker has not visited her to address any of these concerns. An in-service education record dated 1/8/18 documented that the Administrator was in-serviced on abuse and neglect. An interview with the Administrator was held on 6/19/18 at 1:50 PM. The Administrator stated if a resident reports an allegation of abuse, neglect or mistreatment the policy is to ensure the safety of the resident, to start an investigation and to remove the staff member from the schedule. The Administrator stated that the DNS is to be notified and then the Administrator. The Administrator further stated that he was not notified of Resident #14's allegation and should have been. Resident #14's CNA was in-serviced on abuse, neglect and mistreatment on 4/21/16 and 2/15/17. There is no documented evidence the CNA was in-serviced in the abuse policy and procedures until 6/15/18 when it was brought to the attention of the facility. 415.4(b)

Plan of Correction: ApprovedJuly 25, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.a) On 6/18/18 the Director of Nursing completed the investigation for resident #14?s allegation of mistreatment and ruled out abuse neglect and mistreatment.
b) The Director of Nursing met with resident on 7/9/18 and reviewed the summary of the findings with the resident and the findings were met with her satisfaction. Psychotherapy consult was ordered on [DATE] and resident was seen and evaluated on 7/24/18 and per psychotherapy, Patient reported not feeling any negative residual effect of the incident.
2.a) The Director of Nursing reviewed incident reports and grievances for the last 3 months on 7/09/18. There were no other resident/family allegations of abuse neglect or mistreatment.
b) The facility recognizes that all residents have potential to be affected. All grievances, written and verbal complaints will be thoroughly investigated by the Director of Nursing. Involved staff will be removed from the schedule until investigation is complete to ensure all residents are protected from abuse, neglect, mistreatment, and exploitation. If abuse, neglect, mistreatment, exploitation cannot be ruled out the staff member will be terminated from the facility and incident will be reported to the DOH.
c) Director of nursing met with the staff involved and she was educated on abuse, neglect mistreatment and exploitation and she was removed from the schedule indefinitely.
3a. The Policy and Procedure for Investigation of Abuse, Neglect, Mistreatment and Exploitation was reviewed by the Administrator on 7/6/18 and found to be compliant. The Administrator in-serviced the Director of Nursing on the policy and procedure on 7/9/18. All staff will be re-inserviced on abuse, neglect, mistreatment and exploitation policy and procedure by the Director of Nursing/designee to ensure ongoing compliance and prevent reoccurrence.
4. The QAPI committee has developed an audit tool to ensure allegations of abuse, neglect, mistreatment, or exploitation are investigated. The audit tool is to be completed by the Administrator/designee weekly times 4 weeks, monthly times 3 months and then as directed by the QAPI committee.
5. The Administrator will be responsible to ensure compliance with F 610.

FF11 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDER

REGULATION: §483.30(b) Physician Visits The physician must- §483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 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 that for one (Resident #114) of five residents reviewed for unnecessary medication, the physician reviewed the resident's total program of care, including medications and treatments. Specifically, the resident was seen by the Psychiatrist on 5/18/18 and a recommendation to decrease [MEDICATION NAME] to 25 mg at hour of sleep (HS) was made. Review of the medical record lacked documented evidence that the consult was reviewed by the resident's physician. Additionally, further review of the medical record revealed a Licensed Practical Nurse (LPN) on the 3:00 PM - 11:00 PM shift incorrectly entered [MEDICATION NAME] 25 mg twice a day on the resident's electronic Medication Administration Record [REDACTED]. The finding is: An undated Facility Policy and Procedure titled Consultations documented in the second paragraph under policy that a consultant may make recommendations which the attending physician will review and will write orders as he/she deem appropriate. In the procedure section, number fifteen, it documented the completed consults are placed in the physician's book and reviewed and signed by the attending physician. Orders are written by the physician as he/she deems appropriate. Resident #114 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15 which indicated intact cognition. The resident had mood, physical, and verbal behavior symptoms, and required supervision to extensive assist of one staff member for all areas of Activities of Daily Living (ADLs). The resident received Antipsychotic and Antidepressant medication during the last seven days prior to this assessment. Observation conducted on 6/11/18 at 9:30 AM, on 6/12/18 at 11:10 AM and on 6/13/18 at 11:30 AM, revealed the resident was alert and calm lying in bed. The resident responded appropriately to greetings and no behaviors were observed. A Psychiatric follow-up consultation dated 5/18/18 documented a recommendation to decrease [MEDICATION NAME] 25 milligrams (mg) by mouth at hour of sleep (HS) for [MEDICAL CONDITION] and Agitation. A physician's orders [REDACTED]. A Nurse's note dated 5/18/18 at 8:53 PM documented the resident was seen by the Psychiatrist. Orders received and noted to decrease Quetiapine from 50 mg to 25 mg po BID, and follow up in 3 months. An Electronic Medication Administration Record [REDACTED]. A Comprehensive Care Plan (CCP), dated 5/18/17 and last updated 5/23/18, documented the resident uses [MEDICAL CONDITION] medications related to [MEDICAL CONDITIONS] Disorder, Anxiety Disorder and Depression. The goals are that the resident will not manifest adverse effects of the medications. Interventions include to administer medications as per the physician's orders [REDACTED]. The CCP was updated on 5/19/18 and documented the resident was seen by Psych and orders received to decrease [MEDICATION NAME] from 50 milligram (mg) to 25 mg po twice daily (BID) and follow up in 3 months. A review of the electronic progress notes dated 5/9/18 to 6/15/18 was conducted and there was no documented evidence that the Psychiatric consultation dated 5/18/18 was reviewed or addressed by the Nurse Practitioner (NP). A Physician's Monthly progress note dated 6/1/18 documented the resident was seen and examined for monthly review. The Physician documented that the resident was on [MEDICATION NAME], and [MEDICATION NAME] and was stable on these medications and that the resident continued to be followed by Psychiatry for Psychiatric flares. The Physician's monthly progress lacked documented evidence that the Psychiatric consultation dated 5/18/18 was reviewed or addressed by the Physician. During an interview conducted on 6/15/18 at 11:27 AM with the Nurse Practitioner (NP), she stated when consults are completed she does not look through the chart for consults as the process is the consults are placed in her communication book at the nursing station for her to review. The NP stated she was not aware that the Psychiatrist had seen the resident on 5/18/18 and that there were recommendations to be reviewed. The NP stated had she been made aware, she would have reviewed the consult the next day and followed up with the recommendations. The NP further stated that the staff does not usually file the consults in the resident's chart until it is reviewed and signed off by her. During an interview conducted on 6/15/18 at 11:30 AM with the North Unit Registered Nurse (RN) Supervisor she stated when the resident is seen by the Psychiatrist, he should give the consult to the unit nurse or the Supervisor. The Supervisor would notify the NP on call for approval if there are recommendations that need to be addressed at that time. The RN stated that the process is the Unit nurse or supervisor would put the consult in the communication book for review and sign off by the NP following the resident the next day. The RN further stated it appears the consult was filed directly in the resident's chart and not the communication book that is kept at the nurse's station. An interview was conducted on 6/18/18 at 12:04 PM with the 3:00 PM - 11:00 PM Licensed Practical Nurse (LPN). The LPN stated that before the Psychiatrist left the unit she verified if there were any new recommendations for the resident. The LPN stated that the Psychiatrist said he was decreasing the [MEDICATION NAME] to 25 mg. The LPN stated when the Psychiatrist told her he was decreasing the [MEDICATION NAME] she assumed he meant [MEDICATION NAME] 25 mg twice daily (BID). The LPN stated that she did not clarify the frequency of the medication as the resident was previously on [MEDICATION NAME] 50 mg BID. The LPN stated that she did not call the on-call NP or the Physician and that she received the order from the Psychiatrist for [MEDICATION NAME] and entered a Telephone Order into the resident's Electronic Medical Record. The LPN stated that she usually tapes the consult to the desk at the nurse's station or flags the consult in the Physician's book for review. The LPN stated that the Psychiatrist always gives the orders for [MEDICAL CONDITION] medications and she enters the order into the computer. During an interview conducted on 6/15/18 at 3:42 PM with the Psychiatrist, he stated that the plan is to take the resident off the [MEDICATION NAME]. He stated when he saw the resident on 5/18/18 he reduced the [MEDICATION NAME] to 25 mg once daily at HS and in three months on his next follow-up visit the [MEDICATION NAME] will be discontinued. The Psychiatrist stated that he makes the recommendations regarding [MEDICAL CONDITION] medications and that his recommendations are usually followed by the facility. The Psychiatrist stated that if he has recommendations for changes in medications that they are documented in his consults and also on an interim order sheet and given to the nurse for follow-up. During an interview conducted on 6/19/18 at 11:55 AM with the resident's Physician, he stated that the Psychiatrist makes the recommendation for [MEDICAL CONDITION] medication and that he agrees with his recommendations. The Physician stated when he completes his monthly evaluation of the resident, he reviews consults that were completed in that time frame and they are reflected in his notes. The Physician stated that the Psychiatrist consult dated 5/18/18 should have been addressed in his monthly, however the resident is also followed by the NP who reviews the consults and follows up with the recommendations. The Physician further stated that the Psychiatrist does not have privileges to write or give direct orders to the staff. During a follow-up interview on 6/19/18 at 12:15 PM with the NP she stated that the Psychiatrist does not have privileges to order medication independently of the Physician or the NP. The NP stated that the Psychiatrist makes recommendations and the NP or Physician must review and agree with the recommendation before an order is given. The NP stated that there are times when she had observed the staff picking up orders directly from a consultation prior to her reviewing the consult. The NP stated that there have been times where she had to discontinue an order that was picked up prior to her review. The NP further stated that she was responsible for the day to day operation of the resident care and the Attending physician does the monthly evaluation and progress notes. During an interview conducted on 6/19/18 with the Medical Director (MD), he stated that all recommendations from Consulting Physicians must be reviewed by the NP or the Attending Physician. The MD stated that the Consultant can have the nurse call the NP or the Attending Physician if recommendations are urgent for approval. The MD stated that the Psychiatrist cannot write orders or give Telephone Orders independent of the NP and the Attending Physician. The MD further stated that the consults are not physician's orders [REDACTED]. 415.15(b)(2)(iii)

Plan of Correction: ApprovedJuly 12, 2018

1.a) Resident # 114 was evaluated by MD/NP and found to be stable without negative effects. Medication was change to correct dose and time on 6/18/18 and the resident was seen and examined by NP on 6/20/18 and continue Quetiapine at 25 mg HS.
b) The nurse who entered the psychiatrist recommendation without a review by the MD/NP approval was counselled by the Director of nursing on (7/9/18). A medication error form was completed on (6/15/18).
c) The physician who completed the monthly progress note dated on 6/1/18 and did not address the psychiatrist recommendations will be counselled by the medical director/Administrator.
2) The Director of Nursing/ Designee will review psychiatric recommendation for the last 30 days to ensure that MD/NP had reviewed the recommendations and to ensure that all approve recommendation were transcribed accurately. Any negative findings will be brought to the attention of the Medical Director.
3.a) The Policy and procedure for Psychiatry Consultations was reviewed by the Director of Nursing on 6/19/18 and found to be compliant specifically related to the physician/NP review of consultant recommendations and nurse communication to the physician/NP for medication orders recommended by psychiatrist.
B) All Nursing staff and MD?s/NP?s will be re-inserviced on the Policy on Procedure by the Director of Nursing/designee.
4. An audit tool developed by the QAPI committee on 7/6/18 to ensure that MD/NP reviewed the recommendation and to ensure that the recommendations are transcribed accurately. The audit is to be completed by the Director of Nursing/ Designee weekly times one month, monthly times three months, and then as directed by QAPI committee. Any negative findings will be reported to the Administrator.
5. The Director of Nursing will be responsible for compliance with F 711.

FF11 483.75(g)(2)(ii):QAPI/QAA IMPROVEMENT ACTIVITIES

REGULATION: §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: September 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during Post Survey Revisit #1, the facility did not ensure that appropriate plans of correction to correct identified quality deficiencies were implemented and followed. Specifically, 1) the plan of correction for monitoring [MEDICAL TREATMENT] residents was not followed for one of three residents (Resident #8) by not monitoring pre and post weights and not dating and initialing the communication book upon the resident's return from the [MEDICAL TREATMENT] Center. 2) Proper infection control technique was not followed for one of three residents (Resident # 17) observed for treatments. The findings are: 1) The facility's written P(NAME) for the recertification survey, with completion date of 8/17/18, included to address the lack of documentation from the [MEDICAL TREATMENT] center in the resident communication book. The P(NAME) specified that the [MEDICAL TREATMENT] center will ensure ongoing future communication between the two facilities, including pertinent information such as pre and post weights. The P(NAME) also documented that the [MEDICAL TREATMENT] Policy and Procedure was reviewed and revised specifically in regards to the communication books. Additionally, the P(NAME) documented further that the unit Charge Nurse will check the communication book and will initial and date the communication book upon the resident's return to the facility One of three residents (Resident # 8) reviewed for [MEDICAL TREATMENT] did not have documented evidence of pre and post weights, and the note in the communication book was not initialed and dated by a nurse indicating the communication book was checked as documented in the P(NAME). A Lesson Plan Titled [MEDICAL TREATMENT] Essentials documented under number (5) of the agenda that the facility staff was to ensure that the communication books are reviewed, dated, and initialed after each [MEDICAL TREATMENT] visit. The sign-in sheet documented the signature of LPN #1. 2) The facility's written P(NAME) for the recertification survey with a correction date of 8/17/18, documented that all nurses will be re-inserviced on the policy and procedure on aseptic technique by the Director of Nursing Services (DNS). The P(NAME) documented that an audit tool for wound care competency was developed on 7/6/18 by the QAPI committee which will be completed by the DNS/designee to ensure all nurses who are scheduled to perform wound care will be observed for three months and then annually. An Aseptic Dressing Technique Policy and Procedure dated 7/2018 documented in the procedure section number (15&16) that after cleansing the wound from the center outward the nurse was to remove gloves and wash their hands. For one of three residents (Resident # 17) observed for dressing change, LPN #2 was observed not following proper aseptic technique as documented in the facility's policy and procedure. An Aseptic Dressing Technique Observation Tool dated 8/1/18 documented LPN #2 was observed and checked off for aseptic dressing technique. During an interview conducted with the DNS on 8/21/18 at 2:56 PM the DNS stated that LPN #2 was inserviced and the competency assessment on aseptic technique was completed. The DNS stated that several nurses had to receive follow up in-services, however LPN #2 was not one of the nurses who had to be re-inserviced. A subsequent interview was conducted on 8/21/18 at 3:00 PM with the DNS who was responsible for the compliance of both F-Tag 698 and F-Tag 880. The DNS stated that the facility staff in-services were completed by the DNS, Assistant Director of Nursing Services(ADNS), unit Managers and Supervisors depending on the shifts/staff availability. The DNS also stated that he could not identify the specific staff who delivered specific segments of in-services. The DNS further stated that regarding the [MEDICAL TREATMENT] audit tool, the audit tool did not include the pre and post weights and that the audit tool will be revised. Additionally, the DNS stated the facility's [MEDICAL TREATMENT] policy will also be revised to address the pre and post weight. 415.27(a-c)

Plan of Correction: ApprovedAugust 31, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Administrator, DNS and ADNS convened on 8/27/18 to review the statement of deficiencies received from the 8/21/18 NYS DOH recertification post survey revisit. The QA Committee met on 8/28/18 and reviewed and revised the Plan of Correction to ensure compliance.
1. a. On 8/20/18, the facility acknowledges pre and post weights were not documented in Resident # 8?s [MEDICAL TREATMENT] communication book for the 8/18/18 [MEDICAL TREATMENT] visit. On 8/20/18 the covering RN manager contacted the [MEDICAL TREATMENT] center and obtained the pre and post weights. The [MEDICAL TREATMENT] center nurse stated she forgot to document the pre and post weight in the [MEDICAL TREATMENT] communication book and will be more careful in the future.
b. LPN # 1 who failed to ensure pre and post [MEDICAL TREATMENT] weights were communicated to the facility will be counseled and re-inserviced on the policy and procedure which was revised to include ensuring pre and post [MEDICAL TREATMENT] weights are documented in the [MEDICAL TREATMENT] communication book.
c. LPN # 2 who failed to correctly perform aseptic technique will be counseled and re-inserviced on proper aseptic technique. The ADNS will observe her technique to ensure competency has been achieved.
d. Resident #17 was seen by the wound physician on 8/22/18 who found him to be free from infection that could have resulted secondary to a breach in aseptic technique.
2. a. The ADNS reviewed the [MEDICAL TREATMENT] communication books of the other [MEDICAL TREATMENT] residents to ensure communication included pre and post [MEDICAL TREATMENT] weights. There were no other negative findings.
b. The QA Committee sent a written letter to the [MEDICAL TREATMENT] centers of the 3 residents on [MEDICAL TREATMENT] reminding them to include the pre and post weights in the [MEDICAL TREATMENT] communication books after each treatment.
c. The ADNS will conduct competencies on all licensed staff to ensure proper aseptic technique is used. Any nurse who does not perform aseptic technique correctly will be re-inserviced and re-observed immediately and weekly times four weeks by the DNS/ADNS.
3a. The policy and procedure for [MEDICAL TREATMENT] was reviewed and revised by the DNS to include ensuring pre and post [MEDICAL TREATMENT] weights are documented in the communication book and using the newly developed communication form in the [MEDICAL TREATMENT] communication book for [MEDICAL TREATMENT] residents. If no pre and post weight are documented, the licensed nurse on duty must call the [MEDICAL TREATMENT] center and obtain the weights. The QA Committee reviewed and approved the newly revised policy and procedure.
b. All RN and LPN?s will be inserviced on the newly revised policy and procedure by the ADNS/designee. Whomever gives the inservice must sign the attendance sheet indicating he or she was the instructor to ensure awareness of who provided the inservice.
c. The policy and procedure for aseptic technique was reviewed by the DNS and found to be compliant. The QA Committee also reviewed and approved the policy and procedure. A lesson plan has been created to ensure consistency in educating all licensed staff. All RN?s and all LPN?s will be rei-nserviced on the policy and procedure by the DNS/ADNS.
d. All licensed staff will be observed doing wound care by the DNS/ADNS designee to ensure proper aseptic technique is used. The observer must sign each observation tool to ensure awareness of who conducted the observation.
4. a) The DNS developed an audit tool on 8/21/18 to ensure that there is communication in the resident?s [MEDICAL TREATMENT] communication book, including pre and post weights and signatures by the unit licensed nurse. The ADNS/designee will complete the audit tool weekly times four weeks, monthly times three months, and then as directed by QAPI committee. Any negative findings will be immediately reported to the DNS/ Administrator.
b) The observation/competency audit tool for aseptic technique was reviewed by the DNS/ADNS and was found to be compliant. All licensed staff will be observed by the ADNS/designee doing wound care monthly x 3 months and then as recommended by QA committee. All observation/ competency audit tools will be presented to the QA Committee upon completion. The QA committee will make recommendations for improvement as needed. Any licensed staff who breaches aseptic technique will be re-educated and re-observed immediately and will be monitored for competency weekly times 4 weeks by the DNS/ADNS.
c) The Administrator, the ADNS and the DNS will be responsible to audit the effectiveness of the audit tools.
5. The Administrator will be responsible for compliance with this F 867.

E3BP 402.5(c):REQUIREMENTS BEFORE SUBMITTING A REQUEST FOR

REGULATION: Section 402.5 Requirements Before Submitting a Request for a Criminal History Record Check. ...... (c) The provider shall obtain the signed, informed consent of the subject individual in the form and format specified by the Department which indicates that the subject individual has: (1) been informed of the right and procedures necessary to obtain, review and seek correction of his or her criminal history information; (2) been informed of the reason for the request for his or her criminal history information; (3) consented to the request for a criminal history record check; and (4) supplied on the form a current mailing or home address.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not ensure that a signed informed consent form was obtained for all employees subject to Criminal History Record Check (CHRC). Specifically, four of five personal records of employees hired in the last four months revealed the signed CHRC forms were not on file. The finding is: The facility CHRC Compliance review was conducted on 6/14/18 at 8:45 AM. Five files of employees hired in the last four months were reviewed. Four of the five sampled employees were subject to CHRC compliance. The CHRC files for Sampled employee #1, #2, #4, and #5 (three Certified Nursing Assistant and one Dietary Aide) did not contain documented evidence of a completed consent form on file as required. During an interview conducted on 6/14/18 at 9:25 AM with the Human Resource Coordinator (HRC), she stated that she oversees the CHRC portion of the paper work for all new hires. The CHRC stated that she reviews the forms to ensure they are appropriately completed and signed and that she was responsible for initiating the fingerprinting process for new hires through the facility's CHRC System. The HRC stated that when she obtained the CHRC packet that was used by the previous Human Resource Coordinator it did not include the consent form, and that she was not aware the consent form should be a part of the new hire file. The HRC further stated that she was not aware that she should have obtained written consent from new hires. During an interview conducted on 6/14/18 at 2:11 PM with the Administrator, he stated a signed consent (102) form should have been obtained for all new hires. The Administrator stated that he was not aware that a consent was not being obtained. He stated moving forward a signed informed consent for all new hires will be obtained and kept in their files. 402.5(c)

Plan of Correction: ApprovedJuly 12, 2018

1. The facility recognizes that it cannot go back in time to get CHRC 102?s signed on previous new hires #1, 2, 4, and 5. The facility acknowledges that it should be completed on all applicable candidates for hire.
2. The CHRC 102 form will be completed on all applicable candidates for hire in the future by the HR department.
3. The CHRC policy and procedure was reviewed by the Administrator on 7/11/18 and found to be compliant. The HR director will be in-serviced on the policy and procedure by the Administrator.
4. An audit tool was developed by the QAPI Committee on 7/11/18 to ensure the CHRC 102 form is completed on all applicable new hire candidates. The audit tool will be completed by the Administrator/designee monthly x 3 months, and then as directed by the QAPI Committee.
5. The Administrator will be responsible for compliance with R 610.

FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during a recertification survey the facility did not maintain medical records for each resident that are accurately documented. This was identified for three resident records. Specifically, 1) Resident #75 did not accurately document the [DIAGNOSES REDACTED].#6 had 6 missing CNA signatures for Range of Motion (ROM) for (MONTH) (YEAR); 3) Resident #64 had an inappropriate medical indication for the use of [MEDICATION NAME]. The findings are: 1) Resident #75 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated intact cognition for daily decision making. The physician's orders [REDACTED]. A Medication Regimen Review (MRR) Sheet dated 5/8/18 included a Pharmacy Recommendation, Indication for Klonopin order is restlessness/agitation which is incorrect for this drug. Please correct indication for [MEDICATION NAME]/Klonopin ( e.g. Anxiety). The Physician checked Agreed, dated 5/15/18, on the MRR. The MRR was signed further by the Director of Nursing Services (DNS), Administrator and the Medical Director. The Registered Nurse (RN) Manager was interviewed on 06/18/18 at 10:56 AM and stated that he did not see the MRR recommendations. He also stated that the evening and night shift RN Supervisors on 5/15/18 should have followed up on the Physician's response to the MRR recommendations. The Resident's Physician was interviewed on 06/18/18 at 12:36 PM and stated that the order and [DIAGNOSES REDACTED]. The Physician stated further that he does not always check the diagnosis. He also stated that we need to have the correct [DIAGNOSES REDACTED]. The Director of Nursing Services (DNS) was interviewed on 06/18/18 at 12:37 PM and stated that the RN Manager gets the MRR after the Physician signs it and makes sure the necessary follow up is carried through. He stated that he did not have a chance to look if the recommendations were implemented.
2) Resident #6 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The physician's orders [REDACTED]. The CCP dated 3/5/18, developed for Activities for Daily Living (ADL's) for Mobility, Ambulation, and Transfer, documented a goal to maintain PROM to bilateral Lower extremities/upper extremities (LE/UE) and tolerance to positioning x 90 days. Review of Certified Nursing Assistant Accountability Record (CNAAR) revealed that for ROM there were 6 missing signatures for (MONTH) (YEAR). An interview was held with the Director of Nursing Services (DNS) on 6/18/18 at 9:00 AM. The DNS stated that the CNA should have documented the resident's ROM in the CNAAR. An interview was held with the 7:00 AM- 3:00 PM assigned CNA on 6/18/18 at 10:00 AM. The CNA stated that she might have forgotten to record the ROM. 3) Resident #64 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The CCP developed for [MEDICAL CONDITION] Drug Use secondary to Personality Disorder and [MEDICAL CONDITION] Disorder dated 4/23/18 documented to encourage verbalization of feelings, observe for any signs of decline in functional or cognitive status, monitor for changes in behavior and mood and adverse drug reaction. The physician's orders [REDACTED]. An interview was held with the Pharmacist on 6/14/18 at 10:00 AM. The Pharmacist stated that it was an incorrect medical indication use for [MEDICATION NAME]. The Pharmacist also stated that the staff might have used the wrong choice from the [DIAGNOSES REDACTED]. An interview was held with the Attending Physician on 6/18/18 at 11:00 AM. The Physician stated that the staff who wrote the electronic order must have chosen the wrong [DIAGNOSES REDACTED]. 415.22(a)(1-4)

Plan of Correction: ApprovedJuly 25, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.a) Resident # 75 had inaccurate [DIAGNOSES REDACTED].?s medical care.
b. Resident # 64 had [DIAGNOSES REDACTED].?s medical care.
c) The Director of Nursing/ Designee reviewed psychiatric recommendation for the past 30 days to ensure that MD/NP had reviewed the recommendations and to ensure that all approved recommendations were transcribed accurately with correct diagnoses.
d) The Rehabilitation department will assess resident # 6 for ROM to ensure there were no negative outcomes from omissions. Any necessary changes to the plan of care will be completed and the CNA record and care plan will be updated accordingly.
e. The CNA?s responsible for the charting omissions will be counselled by the Director of Nursing/designee.
2) a. The MD orders of all other residents on Klonopin and [MEDICATION NAME] will be checked by the RN Nurse Managers to ensure accurate and appropriate diagnosis/indications are in place. Any inappropriate [DIAGNOSES REDACTED].
b) RN Nurse Managers will review CNA record for all residents on ROM for the last 3 months for charting omission and any negative finding will be referred to rehab for evaluation and recommendation.
3) a. A Policy and Procedure will be developed by the Director of Nursing to ensure MD orders are transcribed with accurate and appropriate [DIAGNOSES REDACTED].
b) All nurses will be in-serviced on the newly developed Policy and Procedure by the Director of Nursing/Designee.
c) All CNA?s will be in-serviced by the RN Unit Managers/designee on timely and complete documentation before the end of every shift.
4.a) The QAPI Committee developed an audit tool on 7/6/18 to ensure that [MEDICAL CONDITION] medication have accurate diagnosis. Nurse Managers will complete the audit weekly times four weeks, monthly times three months, and then as directed by QAPI committee.
b) The QAPI Committee developed an audit tool on 7/6/18 to ensure that CNA?s are documenting ROM timely without omissions. The audit tool will be completed by RN Managers weekly times four weeks, monthly times three months, and then as directed by the QAPI committee.
5. The Director of Nursing will be responsible for compliance with F 842.

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

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 a safe, clean, comfortable and homelike environment was maintained on 1 of 3 nursing units. Specifically, Resident #67's room was noted with dirty sheets and with a strong urine odor on three separate observations. The findings are: Resident # 67 has [DIAGNOSES REDACTED]. The 5/14/18 Minimum Data Set (MDS) Assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognition. The resident required no assistance with Activities of Daily Living (ADL) including transfers, dressing, walking and eating, and was frequently incontinent of bowel and bladder. The MDS also documented the resident exhibited Physical behavioral symptoms directed toward others, Verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. On 06/12/18 at 11:44 AM the resident was observed in his bed lying on a dirty sheet, with a strong urine odor present. On 6/14/18 at 11:00 AM and 1:30 PM, the resident was again observed in his uncleaned room, lying on a bed without sheets. The bed sheets were on the floor, and the room had a strong urine odor. The Registered Nurse (RN) Supervisor was interviewed on 6/14/18 at 11:09 AM and stated the resident's non-compliant behavior is difficult to control. He stated the resident dribbles on himself, refuses showers and is non compliant with care. He stated that there is a care plan to address his behavior. Record review reveals that there is a Comprehensive Care Plan (CCP) dated 5/23/18 which documented the resident was incontinent of bladder function. Interventions included to check and change incontinent briefs every 2-4 hours and PRN (as needed), monitor mental status and behavior changes and report to the physician promptly, and to provide incontinent care after every diaper change. A CCP for Behavioral Symptoms dated 7/10/2017, documented that the resident exhibits verbal behavioral symptoms directed toward others, was threatening others and was resistive to care at times. The resident refuses ADL assistance and refuses bed sheets to be put on, refuses use of pillows. Interventions included to allow ample time for the resident to calm down and when resident refuses ADL care/to change clothes, re-approach at a later time. The housekeeper was interviewed on 6/14/18 at 1:40 PM and stated she was unable to clean the resident's room because the resident argues with the housekeepers. The housekeeper stated that she waits to clean the room when the resident calms down. The Certified Nurse Assistant (CNA) was interviewed on 6/14/18 at 1:42 PM and stated she was unable to clean the resident earlier because the resident was refusing care. She stated she reported this to the RN charge nurse. 415.5(h)(2)

Plan of Correction: ApprovedJuly 25, 2018

1. a) Resident # 67 received a shower on 6/17/18 on 7-3 shift and the resident's room was thoroughly cleaned. Clean sheets were placed on the resident?s bed.
b) Interdisciplinary team will have a CCP with the resident/family to discuss ongoing compliance with room cleanliness and hygiene. The care plan will be revised/updated as needed.
2. a.) The RN Unit manager made environmental rounds on 7/11/18. No other room/resident was found to be out of compliance with F 584.
b.) Nurse Managers on all units made rounds to ensure that residents? rooms are clean and beds have clean linen. There were no negative findings.
c.) Housekeeping will ensure that every room is cleaned daily and ensure an odor free environment. If a resident is non-compliant the interdisciplinary team will meet to discuss an action plan to ensure a clean/safe/comfortable/homelike environment.
3. a) The QAPI committee has developed and implemented a policy and procedure on 7/6/18 to ensure that resident?s rooms are clean/safe/comfortable/Homelike Environment.
b) All nursing staff will be in-serviced by the DNS/designee on the newly developed policy and procedure.
4. The QAPI committee has developed and implemented an audit tool that will ensure ongoing compliance with resident rooms being clean/safe/comfortable/homelike environment. The audit tools will be completed by the Nurse Managers and the housekeeping director weekly times 4 weeks, then monthly times 3 months, and then as directed by the QAPI Committee. Any negative findings will be immediately addressed.
5. The Director of Nursing/designee will be responsible to ensure compliance with F584.

FF11 483.35(a)(1)(2):SUFFICIENT NURSING STAFF

REGULATION: §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

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 sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well being for 1 of 3 nursing units. Specifically, during an initial tour conducted on 6/11/18 at 9:00 AM on the North Unit two residents (Resident #3 and Resident #35) complained that their treatment was not administered on 6/10/18. The residents stated that there was only one nurse on the unit and she was unable to do the dressing. Additionally, there were thirteen residents who did not receive scheduled afternoon medications. The findings are: 1) Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15, which indicated intact cognition. The resident required extensive assist of two staff members for bed mobility, limited assist of one staff member for transfer and extensive assist of one staff member for toileting. The resident was at risk for PU development, and had unhealed PU, at Stage I or higher. The resident had one Stage II, four Stage III PU, and one stage IV PU. The resident had one Stage II PU that had worsened, one PU that had healed. During an interview conducted on 6/11/18 at 10:46 AM, Resident #35 complained that his pressure ulcer dressing was not changed since Saturday 6/9/18. The resident stated that the nurse did not have time to do his dressing. The resident was observed in bed awake and alert to person, place and time. On 6/11/18 at 12:30 PM an observation of the resident's dressing was completed prior to wound care which revealed dried drainage and slight odor. The dressing was undated. A physician's orders [REDACTED]. A physician's orders [REDACTED]. NSC to right hip PU, pat dry, apply Santyl topical followed by (f/b) moist dressing daily and PRN. A CCP dated 8/31/17 documented resident has a Stage III PU to Left Lower Buttock. Interventions included to apply dressing as ordered by the Physician. A CCP dated 10/11/17 documented the resident has a Stage III skin break down on Right Hip. Interventions included to monitor for s/s of infection and to apply dressing as ordered by the Physician. A CCP dated 10/27/17 documented the resident has a skin break down to Right Lateral Calf. Interventions included to apply local treatment as ordered by the Physician. A CCP dated 5/23/18 documented the resident has a Stage III skin break down on Right Buttock. Interventions included to monitor for s/s of infection and to apply dressing as ordered by the Physician. The Treatment Administration Record (TAR) dated 6/2018 was reviewed and there was no documented evidence that the treatment was administered on 6/10/18. There was no initial in the signage box on 6/10/18 to indicate if the treatment was completed. Review of the Not administered/Completed section of the TAR lacked an explanation of why the treatment was not completed. 2) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15, which indicated intact cognition. The resident was independent in all areas of Activities of Daily Living (ADLs), except the resident required set-up help of one staff member for toileting and personal hygiene. During an interview with Resident #3 on 6/11/18 at 10:51 AM he stated that he was looking for the nurse to do his dressing. After accompanying the resident into his room, the resident stated on Sunday, 6/10/18, there was one nurse on the unit and she was not able to do his dressing. On 6/11/18 at 11:45 AM an observation of the resident's dressing was completed prior to the dressing change and revealed a date of 6/9/18 on the dressing bandage indicating the last time the treatment was completed. A Comprehensive Care Plan (CCP) dated 5/30/18 documented the resident had a Right Lower Extremity Venous Wound. Interventions included to monitor ulcer sites and dressing placement every shift and apply local treatment as ordered by the Physician. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) dated 6/2018 was reviewed and there was no documented evidence that the treatment to the Resident's Right Leg was administered on 6/10/18. There was no initial in the signage box on 6/10/18 to indicate if the treatment was completed. Review of the Not Administered/Completed section of the Treatment Record lacked an explanation of why the treatment was not administered. A Review of the Sign in sheet for LPN #4 dated 6/10/18 to 6/16/18 revealed on 6/10/18 the LPN signed in at 7:00 AM and signed out at 11:00 AM. A review of the day shift daily staffing sheet dated 6/10/18 documented two LPNs were scheduled on the East unit and one LPN scheduled on the North unit. It was circled and documented sick next to the name of the North unit LPN. During interview with the DNS on 6/15/18 at 2:49 PM he stated that the RN Supervisor had forgotten to transcribe that LPN #4 was sent to the North unit on the staffing sheet. A review of the Residents Medication Administration Records on the North Unit revealed thirteen residents who were scheduled to have medications administered at 1:00 PM or 2:00 PM did not receive their medications as ordered by the Physician. During an interview conducted on 6/14/18 at 2:43 PM with the Certified Nursing Assistant (CNA), the CNA stated that on 6/10/18 two residents on her assignment complained that their dressing was not administered (Resident #3 and Resident #35). The CNA stated she asked another staff member why the resident's dressings were not done and was told the nurse that was supposed to do the dressing left at 12 Noon. The CNA stated this occurred at the end of her shift and she was not able to report it to her Supervisor. An interview was conducted on 6/14/18 at 3:04 PM with the Licensed Practical Nurse (LPN #4) who was on duty on 6/10/18. The LPN stated that she was a new graduate and worked as an LPN since 10/2017. The LPN stated that on 6/10/18, on the day shift, the medication nurse had called in (sick) and she was left to work alone on the North wing. The LPN stated that she was supposed to be the Treatment Nurse that day. However, because the Medication Nurse called in (sick) she was reassigned to administer the medication for the unit. The LPN stated that her duties for the day was to pass medications and that there was one Registered Nurse (RN) that covered the building. The LPN stated on 6/10/18 the facility was short staffed and that a week in advance she told the Supervisor she was not able to work the full shift, and had to leave before 12 noon on 6/10/18. The LPN stated that she left the unit at 11:45 AM on 6/10/18 that the RN Supervisor took over the unit when she left. The LPN stated that on Saturday, 6/9/18, she reminded the RN Supervisor that she had to leave before 12 Noon on Sunday. The LPN stated that usually, there is one Medication Nurse and a Treatment Nurse. The LPN stated that she had completed her morning medication pass for that day prior to leaving. The LPN stated that this was not the first time she has worked by herself and in the past when she worked by herself that her priority was to complete the treatment for [REDACTED]. The LPN stated that she would make sure his treatment is done but the other treatments were not done for her shift. An interview was conducted on 6/14/18 at 4:26 PM with RN #1 who stated that she worked on 6/10/18 during the day shift covering the building. The RN stated that LPN #4 worked on the North unit and left at 12 Noon. The RN stated that she took over for the nurse in addition to covering the other units, dealing with families, administering Intravenous medication and monitoring a peripherally inserted central catheter (PICC) line. The RN stated that she made every attempt to get staff from the evening shift to come in at an earlier time but was unable to get staff to come in. The RN stated that when the LPN left she reported that she did everything. The RN stated that she did not not specifically question the nurse regarding what was completed, that when she told her she did everything she assumed the nurse completed all the treatments and all her medications were administered. The RN stated that she did not administer any treatments on the day shift. During a subsequent interview with RN #1 conducted on 6/15/18 at 1:10 PM, she stated three CNAs and one LPN had called in and one LPN was leaving at 12 Noon. The RN stated her attempts to call in additional staff were unsuccessful. The RN stated that she spoke with the Director of Nursing Services (DNS) between 1:00 PM and 2:00 PM. The RN stated that she had reported to the DNS that she was covering the North Unit and that there were no emergencies or falls. The RN stated that LPN #4 had reported to her the day before, on 6/09/18, that she was not coming in on Sunday 6/10/18 but the Supervisor asked her to come for a couple of hours. The RN Supervisor stated that she did not ask LPN #4 if there were residents that required medications or treatments to be administered. During a subsequent interview conducted on 6/15/18 at 9:15 AM with LPN #4 she stated when she left at 11:45 AM she had passed all her morning medications and that there were residents that required afternoon medications. The LPN stated that she informed the RN Supervisor that there were residents that required afternoon medications. The LPN stated that she was not able to complete any treatments and that she had informed the RN Supervisor that there were treatments to be done. During an interview conducted on 6/15/18 at 2:49 PM with the DNS, the DNS stated that he was newly hired to the facility. The DNS stated there is one RN Supervisor that covers the house for each shift on the weekend. The DNS stated for each unit there is one LPN on the day shift and 4 CNAs. On the evening shift there is one LPN and 3 CNAs and for night shift there is one LPN and 2 CNAs. The DNS stated that the duties of the LPNs is to conduct medication pass, complete treatments as ordered, monitor residents, and notify the RN Supervisor of any changes in residents' condition. The DNS stated If there are staff call outs, it is the Supervisor's responsibility to call for replacement and sometimes the Staffing Coordinator would assist in calling staff for replacement. The DNS stated if the RN is unable to replace staff she should assess the other units to see which unit can work with less staff. He stated that has not happened but if all attempts had been made to replace a nurse she should call the DNS. The DNS stated he would come in, cover the house and the Supervisor would cover the unit. The DNS stated that the Supervisor did not call him until after 2:00 PM to inform him that a nurse had left at 12 Noon. The DNS stated the Supervisor informed him that the nurse was not going to call in, she made her come in knowing that she was unable to complete the shift. The DNS stated when he inquired about the stability of the residents the Supervisor reported everything was ok on the units/ in the building, and that the residents were stable. The DNS stated that there were no complaints made to him by any resident regarding dressings not being done. The DNS stated that he was not made aware that the nurse was going to work 1/2 a shift. The DNS further stated that the RN should have informed him of the situation and he would have asked one of the managers to come in to cover for that unit. During an interview conducted on 6/15/18 at 3:30 PM with the Staffing Coordinator, she stated that the LPN spoke to her on 6/7/18 at the end of the shift informing her that on Sunday 6/10/18 she had to leave early. The Staffing Coordinator stated that she told the LPN on that day (6/7/18) that she was not authorized to give permission for her to leave a half a day. The Staffing Coordinator stated that she told the LPN to speak with her Supervisor. During an interview conducted on 6/19/18 at 12:06 PM with the Physician he stated if a resident misses a dose of their scheduled medication, the RN supervisor should have been notified and the Physician should be called to evaluate the medication that was missed, and if a time change was warranted. During an interview conducted on 6/19/18 at 1:20 PM with the Administrator, he stated that the Facility Assessment was last reviewed 11/20/17 that there are (19) available LPNs that are facility hired. The Administrator stated there are nine LPN on the weekend and one RN Supervisor for each shift on the weekends. The Administrator further stated that the RN Supervisor should have reached out timely to the DNS if she was unable to find a replacement for the unit. 415.13(a)(1)(i-iii)

Plan of Correction: ApprovedJuly 25, 2018

1a. Resident # 35 was examined by the Wound Care MD on (6/13/18) and his wounds were found to be stable without signs and symptoms of infection.
b) Resident # 3 was examined by the Wound Care MD on (6/13/18) and his wound was found to be healing nicely without signs and symptoms of infection.
c) One attending physician is responsible for the medical care of the thirteen residents. He was notified by the RN Manager on 6/18/18 of each individual resident (13) on the north unit that did not receive their afternoon medications on 6/10/18. The physician acknowledged same and did not give further orders. None of the 13 residents sustained any negative outcomes.
d) On (7/10/18) the Director of Nursing counselled and reminded LPN # 4 on the importance of giving a comprehensive report, including what medications/treatments were not yet completed, to the RN Supervisor before leaving the facility at the end of her tour.
3) The RN Supervisor will be counselled by the Director of Nursing specifically related to failure to supervise/monitor the unit after the LPN left and for assuming everything was done without checking to ensure residents received the care and services as ordered by the physician. Additionally, she was counselled to call the Director of Nursing for any staffing issues/concerns for immediate intervention to ensure appropriate staffing levels are met.
2. The nursing Staff on the other two units was checked by the Director of Nursing on (6/11/18) for the same weekend in question and it was found that appropriate staffing levels were maintained. There was no report or evidence that medications and treatments were not completed on those units.
3a) On (6/19/18) the Administrator signed a contract with another staffing agency to ensure appropriate availability and coverage to maintain sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents.
b) On (6/20/18) the Administrator hired a new Assistant Director of Nursing to assist the nursing department to achieve ongoing regulatory compliance.
c) The Administrator reviewed staffing levels and found them to be appropriate to maintain sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents. The staffing coordinator and nursing supervisors will be inserviced by the Director of Nursing/designee on maintaining the levels at all times.
d. On (7/10/18) the Director of Nursing reviewed the policies and procedures for medication administration and treatment administration specifically related to the notification of the medical provider if the medications and/or treatments are not administered or not administered on time. The policies were found to be compliant.
e. All nurses will be re-inserviced on the policies and procedures by the Director of Nursing/designee.
f. All nurses will have competencies conducted by the Director of Nursing/designee on Treatment and Medication Administration. Any nurse who is deemed incompetent will be re-inserviced and re-observed. Any future concerns will be immediately reported to the Administrator.
4. a. On (7/9/18) the QAPI committee developed an audit tool to ensure sufficient nursing staff at all times. The audit will be conducted by the Director of Nursing/designee weekly x 4 weeks, monthly x 3 months and then as directed by the QAPI Committee. Any negative findings will be reported to the Administrator.
b. On (7/9/18) the QAPI committee developed an audit tool to ensure treatments and medications are administered on time as per MD orders. In the event they are not administered on time, the tool addresses the proper procedure to be followed, specifically notifying the medical provider for further orders. The audit will be conducted by the RN Unit managers weekly x 4 weeks, monthly x 3 months and then as directed by the QAPI Committee. Any negative findings will be reported to the Administrator.
5. The Director of Nursing will be responsible for compliance with F 725.

FF11 483.25(g)(4)(5):TUBE FEEDING MGMT/RESTORE EATING SKILLS

REGULATION: §483.25(g)(4)-(5) Enteral Nutrition (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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the recertification survey, the facility did not ensure that appropriate care was provided for one resident that meets professional standards of quality care. Specifically, Resident #316 did not received consistent care for his Gastrostomy Tube (GT). There was no documented evidence that the Resident's GT was monitored for placement or patency on a consistent basis for six days. Additionally, there was no documented evidence that a baseline care plan was developed for the use of a Gastrostomy tube until 10 days after his admitted . The finding is: The Policy and Procedure revised 6/2018 documented that all residents who no longer require nutrition through a Gastrostomy tube will have Physicians orders in place for flushing the tube. Flushing the tube is necessary to maintain patency in the event that the resident will need to receive nutrition through the tube at a future time. Flushes will continue until the tube is determined no longer necessary and is removed by the Physician. The licensed nurse who receives the physician order [REDACTED]. The licensed nurse will be responsible to ensure the physician order [REDACTED]. The licensed nurse will be responsible to ensure the physician order [REDACTED]. Resident #316 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A GT is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the Resident's Brief Interview for Mental Status (BIMS) was 11/15, which indicated moderately impaired cognition. The Physician order [REDACTED]. (all three shifts) to maintain patency. Review of the medical record revealed that there was no documented evidence that the GT was flushed or assessed for patency until 6/14/18. The Registered Nurse (RN) Manager was interviewed on 6/18/18 at 10:00 AM. The RN stated that the order for the GT was transcribed by the Dietitian and with the current computer system the Dietary order was not transcribed to the Medication Administration Record [REDACTED] The MAR for the period of 6/08/18- 6/13/18 revealed that there was no schedule or frequency of flushes noted for the GT. Nurses Notes from 6/08/18 - 6/18/18 revealed that there was no documented evidence that the GT was flushed or assessed for patency by a licensed nurse. An interview was held on 6/19/18 with the RN supervisor, who was the admission nurse who had completed Resident #316's admission. The RN stated that she had completed the admission, documented the information into the computer and thought that she had transcribed the order for the GT care. Additionally, the RN stated that she did not check her work after completion. An interview was held with the Director of Nursing Services (DNS) on 6/19/18 at 10:00 AM. The DNS stated that the admission nurse (RN) should have checked the admission orders [REDACTED] An interview with a Licensed Practical Nurse (LPN) 7:00 AM - 3:00 PM shift was held on 6/19/18 at 10:30 AM. The LPN, who cared for the resident, stated that she did not remember if she flushed the GT. An interview was held with the Certified Nursing Assistant (CNA) from the 7:00 AM-3:00 PM shift on 6/19/18. The CNA stated that she did not see any licensed nurse flush the GT. 415.12(g)(2)

Plan of Correction: ApprovedJuly 12, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The MD order to flush gastrostomy tube (G.T) for resident # 316 was transcribed to the MAR by the Nurse Manager on 6/14/18.
b) G.T remained patent and resident sustained [REDACTED].T. was removed by MD on 7/3/18.
c) The Nurse who failed to enter the transcribed order for the G.T flush to the Medication Administration Record will be counselled by the Director of Nursing.
2. All residents with G/T?s in place and not being used for nutritional purposes were reviewed by the Nurse Managers on 6/14/18. All orders were appropriately transcribed on the MAR and were being appropriately flushed as per MD order.
3.a) On 6/14/18 the Director of Nursing reviewed and revised the policy and procedure for Gastrostomy tube care specifically addressing flushes when tube is not being used for nutritional purposes while ensuring the MD order is properly transcribed onto the Medication Administration Record.
On 6/14/18 the Director of Nursing reviewed the policy and procedure on Baseline Care Plans and it was found to be compliant.
b) The comprehensive Care Plan team will be re- inserviced on the policy and procedure on Baseline Care Plans by the Director of Nursing/ designee.
c) All nursing staff will be in-service on the newly revised policy and procedure on G.T flushes by the Director of Nursing/designee.
4. a. An audit tool was developed by the QAPI committee on 7/6/18 to ensure compliance with gastrostomy tube flushes. The audit tool will be complete by RN Managers weekly times four weeks, monthly times three months and then as directed by the QAPI committee. Any negative finding will be corrected immediately and will be reported to the Administrator.
b. An audit tool was developed by the QAPI Committee on 7/6/18 to ensure with timely completion of Baseline Care plans. The audit tool will be completed by the MDS Coordinator weekly times 4 weeks, monthly times 3 months, and then as directed by the QAPI Committee. Any negative findings will be immediately reported to the Administrator and QAPI Committee.
5. The Director of Nursing will be responsible for compliance with F 693.

Standard Life Safety Code Citations

K307 NFPA 101:EMERGENCY LIGHTING

REGULATION: Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

Citation Details

2012 NFPA 101: 7.9 Emergency Lighting. 7.9.2.7 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that emergency egress lights were arranged for repeated automatic operation without manual intervention on 2 of 5 emergency exit discharges. The findings are: During the Life Safety Code survey on 06/15/18 between 9:00am and 12:00pm, it was noted that the emergency exit discharge lighting for the North and East unit exits were controlled by timers that would require manual intervention to adjust under changes in lighting conditions. In an interview on the same day at approximately 11:15am, the Director of Environmental Services stated that lights with photocells would be installed at the identified emergency exit discharges. 2012 NFPA 101: 7.9, 19.2.9.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 13, 2018

1. Facility ordered lights with photocells on 6/15/18 to be installed on the emergency egress exits. Lights were installed on 6/18/18
2. Maintenance director checked emergency egress lighting on 6/18/18 to identify any other areas of concern. None found.
3. Proper emergency egress lighting will be added to maintenance monthly audit tool to address areas of concern
4. An audit tool was developed by the Maintenance Director on 7/11/2018 to ensure proper lighting on all emergency egresses. The audit tool will be completed monthly x 3 months by the Maintenance Director/designee and then as directed by the QAPI committee.
5. The Maintenance Director will be responsible for compliance with this tag.

ESTABLISHMENT OF THE EMERGENCY PROGRAM (EP)

REGULATION: The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

Citation Details

Based on documentation review and staff interview during the recertification survey, the facility did not establish a comprehensive Emergency Program (EP) that complied with all applicable Federal, State and Local EP requirements. The findings are: During a review of the facility's emergency preparedness manual on 6/15/18 between 8:55am and 2:30pm, it was noted that a comprehensive Emergency Program (EP) was not developed that complied with all applicable Federal, State and Local EP requirements. The EP plan did not include policies for addressing the following items (not all inclusive): -Policy and procedures including strategies for addressing all emergency events identified by risk assessments. Specifically, for moderate risk threats identified in the facility's Hazards Vulnerability Analysis (HVA). Examples are: Communication/Telephone Failure and IT System Outages. -Policy and procedures for volunteers in addressing surge needs that includes the process and roles for integrating State and Federally designated health care professionals. -Roles under a waiver declared by the Secretary. Specifically, the coordination with outside officials at an alternate care site. -Development of a communication plan. For example, a review of the facility's Communications Directory on the HPN revealed that the contact information for the role under the Director of Nursing was last updated on 3/6/17 and the provided email address was for a previous Director of Nursing. This is contrary to the requirements of 10NYCRR 400.10 in that 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, are completed on a monthly basis. -Primary/alternate means of communication. -Long term care family notifications. Specifically, a method for sharing information from the emergency plan with residents and their families or representatives. In an interview on 6/15/18 at approximately 2:30pm, the Administrator stated that they had some of these policies and that they would provide them by the exit date. There was no documentation provided by the exit date. 10NYCRR 400.10

Plan of Correction: ApprovedJuly 13, 2018

1. Facility immediately reviewed the findings by the DOH to ensure a comprehensive Emergency Program (EP) was in place. On 6/28/18, the facility implemented the DOH findings to comply with all applicable Federal, State and Local EP requirements including the p & P identifying strategies for addressing moderate risk threats identified in the HVA, the P & P for volunteers in addressing surge needs, roles that coordinate with outside officials at an alternate care site, development of a communication plan, primary/alternate means of communication, and resident/family notification.
2. The Emergency Preparedness Manual was reviewed on 6/28/18 and found to be compliant.
3. The Emergency Preparedness Manual will be reviewed annually and updated as needed.
4. An audit tool was developed by the Administrator on 7/12/18 to ensure the Emergency Preparedness Manual complies with all applicable Federal, State and Local EP requirements The audit tool will be completed monthly x 3 months by the Administrator/designee and then as directed by the QA Committee.
5. The Administrator will be responsible for compliance with this tag.

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 17, 2018

Citation Details

2012 NFPA 101: 7.2.1.1.1 A door assembly in a means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 80: 4.8.4.1 The clearance under the bottom of a door shall be a maximum of 3/4 in. (19 mm). This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that fire-rated doors were in accordance with NFPA 80 in that the clearance under the bottom of the door (undercut) on smoke barrier doors were greater than ¾ inch on 2 of 3 units. The findings are: During the Life Safety Code survey on 06/15/18 between 9:00am and 12:00pm, it was noted that the undercut on the smoke barrier doors were greater than ¾ inch in the following locations: - the entrance to the East Unit (measured to be 1 ½ in.) - the entrance to the North Unit (measured to be 1 in.) In an interview on the same day at approximately 9:45am, the Director of Environmental Services stated that the carpet was removed from the units and that might have created the gaps at the door undercuts. He further stated that he would order rated door sweeps to be installed on the doors. 2012 NFPA 101: 7.2.1.1.1, 7.2.1.15.2 2010 NFPA 80: 4.8.4.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 13, 2018

1. Facility ordered rated door sweeps on 6/15/18 to be installed on the 2 doors. Door sweeps were installed on 6/18/18
2. Maintenance director checked the undercut on smoke barrier doors on 6/18/18 to identify any other areas of concern. None found.
3. Smoke barrier door undercuts will be added to maintenance monthly audit tool to address areas of concern
4. An audit tool was developed by the Maintenance Director on 7/11/2018 to ensure proper clearance on all smoke barrier doors. The audit tool will be completed monthly x 3 months by the Maintenance Director/designee and then as directed by the QAPI committee.
5. The Maintenance Director will be responsible for compliance with this tag.