Samaritan Keep Nursing Home Inc
July 14, 2016 Certification Survey

Standard Health Citations

FF09 483.25(a)(3):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined for 4 of 14 residents (Residents #13, 16, 21, and 30) reviewed for activities of daily living (ADLs), the facility did not ensure residents unable to carry out ADLs received the necessary services to maintain good nutrition, grooming, and personal hygiene. Specifically, - Resident #13 was not provided with care planned assistive devices including sneakers, Dycem (anti-slip material) and a positioning pillow, and was not assisted with toileting when needed; - Resident #16 had a plan to be fed by staff if she did not eat well and this was not implemented; - Resident #21 was observed in the dining room for extended periods of time prior to the meal without being offered a drink. He requested a drink and was not provided with one timely. When staff fed the resident, they did not offer him every item served, and did not allow adequate time for the resident to finish the meal; and - Resident #30 waited an extended period of time to be fed by a staff member. Findings include: 1) Resident #30 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) last updated 3/18/2016 documented the resident had difficulty with communication/making needs known, and had impaired vision. She had dysphagia, and foods and liquids should be alternated with small bolus presentation (small bites). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, and was on a mechanically altered diet. She required extensive assistance for transfers, dressing, hygiene, and eating. The dietary progress note dated 6/7/2016 documented the resident was on a mechanically altered diet with nectar thickened liquids. The nutrition [DIAGNOSES REDACTED]. Staff needed to prevent involuntary weight loss as evidenced by trend of weight loss. Interventions included high protein cereal, [MEDICATION NAME] (protein supplement) at breakfast, high protein milk, 4 ounces of Ensure (supplement) at lunch and dinner, high protein potatoes, 6 ounces of nectar thick soup at lunch, and Magic Cup (high protein ice cream) at dinner. The 7/2016 certified nurse aide (CNA) resident care record (care instructions) documented the resident was confused and alert. She required extensive assistance with hygiene and dressing, and required total assistance with eating. During an interview with registered nurse (RN) Manager #5 on 7/11/2016 between 11:45 AM and 12:05 PM, she stated the resident needed to be fed at meals. On 7/11/2016, the resident was observed in the dining room: - at 4:40 PM in her geri chair (padded positioning chair); - from 6:10 PM to 6:42 PM, with her dinner tray in front of her, unable to reach her food or drinks, and no assistance was offered by staff; - at 6:46 PM, calling out with a raised arm and did not receive assistance from staff; - at 6:53 PM, had her left hand partially in her plate of food, attempted to reach her food unsuccessfully, and continued to call out (inaudible); - at 6:54 PM, CNA #10 approached the table, commented/asked the resident if she did not want anything to eat, removed her meal ticket, and did not offer any assistance; and - at 7:00 PM, RN Manager #5 sat down and began feeding the resident. CNA #17 stated during an interview on 7/14/2016 at 10:15 AM that the resident was totally dependent for all of her care, was unable to make her needs known, required total assistance for eating, and could use one finger to try to feed herself and was often unsuccessful. During an interview with RN Manager #5 on 7/14/2016 at 11:50 AM, she stated the resident required total feeding assistance, that food should not be left for more than 15 minutes before feeding a resident, and food should be reheated or replaced if left longer. She stated she was present during the supper meal on 7/11/2016, began feeding the resident at 7:00 PM, did not heat her meal, and did not know how long it had been there. She stated that a hospitality aide was usually assigned to feed the resident and had been on vacation that week, and that someone should have sat with resident to feed her during the entire meal. 2) Resident #21 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. He rarely/never understood others, and rarely/never made himself understood by others. He needed extensive assistance with eating. The registered dietitian's (RD) progress note dated 6/20/2016 documented the resident consumed an average of 1518 milliliters (ml) of fluid per day, which was 61% of his fluid goal. He received a puree diet with nectar thick liquids, and was fed by staff. The RD noted the resident had increased nutritional needs related to a recent significant weight loss, and received nutritional supplements. Observations of the supper meal on 7/11/2016 included: - at 4:45 PM, there were 18 residents in the unit dining room including Resident #21. None of the residents had drinks in front of them; - at 5:22 PM, there were 24 residents in the dining room, including Resident #21 and none of the residents had drinks in front of them; - at 5:30 PM, the first meal tray was served to a resident eating in their room; - from 5:30 PM to 6:16 PM, the unit staff served meals to residents in their rooms and in the dining room; - at 6:17 PM, the resident yelled, I need some water please. He repeated this twice; - at 6:20 PM, the resident asked, Can I have water please? - at 6:26 PM, the resident yelled loudly and repeated himself several times, Hey, water; and - at 6:28 PM, the resident was the last resident in the dining room served a meal. At that time, the certified nurse aide (CNA) delivering the tray gave the resident some thickened water. On 7/11/2016 at 6:30 PM, the CNA began feeding the resident his meal. At 6:46 PM, the CNA verbally asked the resident if he wanted more salad, tomatoes, broccoli, or pie. The resident did not respond and the CNA did not attempt to bring those foods to the resident's mouth and determine if he would eat them. As the CNA was standing up, she told the resident she would leave his chocolate milk on the table in case he wanted more. The resident said, I'll have more milk. The CNA gave him a sip of the milk and left the table. The resident ate some of the pureed salad, none of the pureed tomatoes, a bite of the pureed broccoli, bites of the pureed pie, and none of the pureed fruit. The Magic Cup (high protein ice cream) was not opened by the CNA who fed the resident. The consumption record dated 7/11/2016 documented the resident ate 25% of the evening meal. On 7/14/2016 at 10:09 AM, the resident's assigned CNA, CNA #6, stated in an interview the resident needed to be fed and accepted his meals fairly well. She stated he loved water and drank a lot of it. She stated prior to the meals, staff were in the dining room and circulated. She stated at times the staff offered the residents drinks, and if not, the residents could ask for one and it would be provided. On 7/14/2016 at 11:50 AM, registered nurse (RN) Manager #5 stated in an interview, the unit usually had a hospitality aide who passed out beverages before the meal. Since that person was off this week, the residents did not receive drinks before the meals. The RN also stated if a resident needed to be fed, then someone should sit with them during the entire meal and feed them. 3) Resident #13 had [DIAGNOSES REDACTED]. The physician order [REDACTED]. The 6/25/2016 updated comprehensive care plan (CCP) documented the resident had needed assistance with bathing/dressing/hygiene each day. She wandered aimlessly and was frequently incontinent of bladder and bowel. She was to be toileted in the morning, before and after meals, at bedtime, and after naps. She was at risk for falls, and had verbal communication impairment. The resident used a Lap Buddy (inflatable device to prevent falls), required Dycem (anti-slip material) under and over the wheelchair cushion, needed a positioning pillow at her right side, and was to wear sneakers to ease self-propelling in the wheelchair. The physician order [REDACTED]. It was to be released every 2 hours and as needed for exercise and toileting, and not removed for meals. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. She required extensive assist for bed mobility, transfer, dressing, toileting, and hygiene. She was incontinent of bowel and bladder, and had a fall with no injury during the assessment period. The resident had an altered diet, required supervision with moving about the unit and eating, had pressure reducing devices in place, and had a physical restraint. The 7/2016 certified nurse aide (CNA) resident care record (care instructions) documented the resident was confused. She was at risk for falls and used a Lap Buddy. She had an alarming fall mat, a low bed, and a chair alarm. She required total assistance by staff with hygiene and dressing, and was a set-up assist for meals. The resident was to receive finger foods to eat while self-propelling on the unit. She used incontinence briefs and wore Geri Sleeves (to prevent skin injuries). She transferred via gait belt and hand held assist, and wandered. On 7/11/2016 from 4:51 PM - 6:55 PM, the resident was observed in her wheelchair, self-propelling in the hall, with white ankle socks and no sneakers; only the tips of her toes were reaching the floor. On 7/12/2016 at 9:08 AM, 12:50 PM and 2:27 PM, the resident was observed leaning to her right side in her wheelchair without a positioning pillow in place. On 7/13/2016, the resident was observed leaning in her wheelchair from 1:16 PM - 2:40 PM with only socks on her feet and without a positioning pillow. At 2:40 PM, CNAs #16 and 19 were observed to bring the resident to her room, where they washed her hands with a wet washcloth over her soiled Geri Sleeves, did not remove the wet Geri Sleeves, and assisted the resident to bed. Upon standing, the resident's pants were observed to have a large wet area from her right buttock down to the back of her right leg. The CNAs placed the resident into bed without toileting her or changing her. The cushion in the resident's wheelchair was observed to be wet, with a strong odor of urine. Under the cushion was a soaked and stained hand towel, and there was no Dycem present above or below the cushion. The resident was observed to remain in bed, without continence or hygiene care until 3:55 PM. On 7/13/2016 from 3:55 PM - 4:05 PM, the resident was observed during care. CNA #10 and 22 removed the resident's pants and a saturated incontinence brief, and a large wet area was observed on the right side of the pants by the surveyor and CNAs. The resident was washed, a red area was noted on the right hip, CNA #10 touched the area, and the skin blanched. An incontinence brief and clean dry pants were put on the resident. The CNAs were interviewed and stated the prior shift put the resident in bed before leaving, and they were unsure if she was checked for incontinence as her brief and pants were very wet. The resident was transferred to the wheelchair using a gait belt and 2 person assist. The Lap Buddy was put in place and the resident was wheeled out of the room. The resident's wheelchair and Lap Buddy were not cleaned, and the soiled Geri Sleeves were left on. On 7/13/2016, the resident was observed leaning to the right side in her wheelchair from 4:10 PM - 4:53 PM. There was not a positioning pillow in her wheelchair, and the resident wore socks and did not have sneakers on. On 7/13/2016 at 4:45 PM during an interview with registered nurse (RN) Manager #5, she stated the expectation was residents were toileted or checked for incontinence every two hours, and the CNAs should clean and change a resident before putting them to bed. On 7/14/2016 at 9:03 AM, the resident was observed leaning to her right side in her wheelchair without a positioning pillow or Geri Sleeves in place. On 7/14/2016 at 10:30 AM, CNA #16 stated the resident went back to bed after lunch and should be provided incontinence care before going back to bed. She stated she assisted in the care of the resident on 7/13/2016 at 2:40 PM. She did not notice the wet clothing or soiled chair, was behind on her work that day, and did not clean the resident prior to putting her back to bed. The CNA stated she did not know if the resident used any positioning devices in her wheelchair, and did not know where the Dycem was located. During an interview with CNA #18 on 7/14/2016 at 11:30 AM, she stated the resident required extensive assistance in dressing, hygiene, and toileting. The resident could not choose her own clothing, and had not refused getting dressed. She stated the resident needed to wear sneakers in order to propel herself in her wheelchair and did not use any positioning devices in her chair. She did not know if the resident was to use Dycem in her wheelchair, or how it was to be used. She found one piece of Dycem in the resident's room when asked to locate it. During an interview with RN Manager #5 on 7/14/2016 at 11:50 AM, she stated the resident was supposed to have sneakers on every day, and the Dycem and positioning pillow should have been in place in accordance with the care plan. The expectation for CNAs was to check and change residents when placing them back to bed, and the resident should not have been put back to bed with wet clothing. 10NYCRR415.12(a)(3)

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #13 care plan for geri-glove use, lateral support pillow while in the wheelchair, and dycem remain appropriate. The geri-gloves were replaced with two (2) new pair to ensure a clean pair is always available. Unit staff received education regarding proper cleansing for geri-gloves, soiled clothing, wheelchairs, cushions, the use of the lateral support pillow for comfort and positioning, and dycem to prevent sliding in wheelchair. Resident #16 care plan was reviewed for assistance required during feeding no revisions were required or made. The Resident is seated at a staff table and that plan remains appropriate. Unit staff received education to ensure Residents who are dependent and require assistance at meals receive proper assistance to complete the meal. Resident #21 care plan was reviewed for level of assistance and cueing required and no revisions were required or made. Unit staff received education regarding the expectation fluids will be offered before meal service, or when requested if the Resident is not on a fluid restriction. Additional education included verbal prompting as well as aiding the Resident in tasting a food item before determining if the Resident has completed the meal. Resident #30 was observed for positioning during dining. The Resident will now be seated in a stationary dining room chair to enable her to reach her food with ease. The plan of care was reviewed, revised to reflect seating needs, and remains appropriate for the level of staff assistance she requires to complete a meal.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
The Mealtime observation was completed on all nursing units to monitor for appropriate assistance being offered, cueing, meal service, seating, positioning, cleanliness, and offer fluids before meal service, strategies to determine if the Resident is enjoying the meal, dignity and the seating assignment to facilitate staff assistance during meals. All concerns were corrected at the time of observations, and continued monitoring during meals service will be provided to ensure the Resident?s needs are met.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
A policy for mealtime considerations was developed. This policy addresses appropriate assistance during meals, proper feeding techniques/strategies, pre-meal fluids, positioning, and monitoring to ensure the Resident?s needs are being met during the dining experience.
Mandatory education will be provided for all staff that feed, assist, and supervise Residents during meal time. This education will emphasize the importance of providing the necessary degree of assistance during meals, fluids being offered before meals, proper seating and posture to promote intake, cueing and assistance as required completing the meal, identification of satisfaction with food choices, cleanliness, and dignity.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit each nursing unit monthly, at varying meal times, until 100% compliance has been achieved for 3 consecutive months. This audit will be conducted by the multi-disciplinary team. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency

FF09 483.15(a):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 4 of 30 sampled residents (Residents #7, 13, 21, and 30) and 5 residents in the expanded sample (Residents #35, 36, 37, 38, and 39), the facility did not promote care for residents in a manner and an environment that maintained or enhanced each resident's dignity. Specifically: - Residents #7 and 35 were not treated with dignity when their blood pressures were checked in the dining room with multiple residents present and during a meal; - Resident #13's Geri-Sleeves (protective limb sleeves), Lap Buddy (inflatable device to prevent falls), and wheelchair were heavily soiled during survey; - Resident #30 was not assisted with changing soiled clothing when needed; and - Residents #21, 36, 37, 38, and 39, who were all seated at the same table, were not served meals at the same time. Findings include: 1) Resident #13 had [DIAGNOSES REDACTED]. The physician order [REDACTED]. The comprehensive care plan (CCP) updated 6/25/2016 documented the resident needed assistance with bathing, dressing, and hygiene. She was frequently incontinent of bladder and bowel, and she used a Lap Buddy on her wheelchair for safety. The physician order [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. She required extensive assistance with most activities of daily living (ADLs). The 7/2016 resident care card (care instructions) documented the resident used a Lap Buddy in her wheelchair, was total assist with hygiene and dressing and used incontinence briefs, and she wore Geri-Sleeves (to prevent skin injuries). On 7/11/2016 from 6:09 PM to 6:46 PM, the resident was observed with food (lettuce, hard boiled eggs, mashed potatoes) on her hands and Lap Buddy, and in the right side of her wheelchair. On 7/12/2016 at 9:31 AM, the resident was observed in her wheelchair with Geri-Sleeves on her arms and hands. Her hands were in her plate (oatmeal, eggs, oranges), and food was spilled on her Lap Buddy and wheelchair. On 7/12/2016 at 2:03 PM, the resident was observed in her wheelchair in the hall. She had most of her lunch on her plate and food on her Geri-Sleeves. On 7/13/2016 at 2:40 PM, the resident was observed in her wheelchair in the hall, with food and spaghetti sauce on her Geri-Sleeves. Certified nurse aides (CNAs) #16 and 19 were observed to bring the resident to her room. They washed her hands with a wet washcloth over her soiled Geri-Sleeves, removed the Lap Buddy (soiled with food and spilled drinks). They stood the resident up and her pants were observed with a large wet area from her right buttock down to the back of her right leg. The CNAs placed the resident into bed without toileting or changing her and her wet Geri-Sleeves were not removed. The cushion in the resident's wheelchair was observed to be wet, with a strong urine odor. Under the wheelchair cushion was a hand towel with large, brown circular stains. The towel was wet and had a strong urine odor. There were dried food, liquids, and a buildup of grime in the seat of the wheelchair and the crevice between the right arm and seat. The Lap Buddy was on the floor and observed to have sticky dried liquids and food in the seams. The CNAs left the room without cleaning the Lap Buddy or wheelchair. The resident remained in bed and was not provided care until 3:55 PM. On 7/13/2016 from 3:55 PM to 4:05 PM, the resident was observed during care with CNAs #10 and 22. They removed the resident's pants and saturated incontinence brief, and a large wet area was observed on the right side of the pants. The resident was washed and a red area was noted on the right hip. CNA #10 touched the reddened area, the skin blanched (circulation check) and the resident was dressed. The CNAs stated the prior shift put the resident in bed before they left for the day, and they were unsure if the resident was checked for incontinence, as her brief and pants were very wet. The CNAs transferred the resident into the soiled wheelchair, applied the soiled Lap Buddy, and wheeled the resident out of the room. The resident's soiled Geri-Sleeves remained on. On 7/13/2016 at 4:45 PM, registered nurse (RN) Manager #5 stated in an interview that she expected residents to be checked for incontinence or toileted every two hours, and expected CNAs to clean and change a resident before putting them to bed. On 7/13/2016 at 4:53 PM, RN Manager #5 and an unidentified licensed practical nurse (LPN) accompanied the surveyor to observe the resident's wheelchair. The resident was assisted to stand. RN Manager #5 removed the cushion from the chair and observed a soiled towel and food particles. She stated that staff should be checking under the cushion and the wheelchair should be cleaned. She stated housekeeping cleaned wheelchairs every other month by taking them to be sprayed off. If a chair needed cleaning before then, CNAs should notify housekeeping or a supervisor. On 7/14/2016 at 10:30 AM, CNA #16 stated in an interview that the resident often spilled her food and drinks on her wheelchair, and she should be provided incontinence care before going back to bed. She stated the staff try to clean the wheelchair or tell housekeeping when it was dirty. She did not know when it was last cleaned. She stated she provided care for the resident on 7/13/2016 at 2:40 PM and did not notice the resident's wet pants or the soiled wheelchair. She stated she was behind on her work that day and did not clean the resident prior to putting her back to bed. On 7/14/2016 at 10:30 AM, Housekeeper #7 stated in an interview that there was no cleaning schedule for wheelchairs. She monitored them when she was on the unit, and she cleaned them when needed. She stated she cleaned the wheelchairs on the unit using a spray bottle cleaner and a sponge, and they could be brought downstairs and sprayed with a hose when very dirty. She stated the resident's wheelchair was difficult to keep clean because she was often seated in it. 2) Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and required limited assistance with most activities of daily living. The physician orders [REDACTED]. During an observation on 7/12/2016 at 8:00 AM, licensed practical nurse (LPN) #3 entered the dining room and approached Resident #7. The resident was finished with his breakfast meal, while 2 other residents continued to eat. LPN #3 explained the procedure to the resident, then obtained the blood pressure and exited the dining room. LPN #3 was interviewed on 7/14/2016 at 9:10 AM, and she stated nurses were not allowed to administer medications in the dining room during meals. She stated the resident was finished with his meal, and on the dementia unit you try to catch them when you can. Registered nurse (RN) Manager #4 was interviewed on 7/14/2016 at 9:25 AM, and she stated medication administration was allowed in the dining room as long as it did not interrupt the meal. 3) During the supper meal on 7/11/2016, beginning at 5:22 PM, Residents #21, 36, 37, 38, and 39 were observed to be seated at a table together. Minimum Data Set (MDS) assessments documented: - for Resident #36, on 5/21/2016, the resident had moderately impaired cognition and was independent for eating with set-up; - for Resident #21, on 6/15/2016, the resident had severely impaired cognition and needed extensive assistance for eating; - for Resident #39, on 6/15/2016, the resident had severely impaired cognition and needed total assistance for eating; - for Resident #38, on 6/16/2016, the resident had severely impaired cognition and needed extensive assistance for eating; and - for Resident #37, on 6/17/2016 the resident had severely impaired cognition and needed extensive assistance for eating. Supper meal observations on 7/11/2016 included: - at 5:45 PM, Resident #36 was observed eating her dinner meal and was feeding herself. Residents #21, 37, 38, and 39 were seated at the same table and did not have their meals; - at 6:17 PM, Resident #37 was served his meal and began feeding himself; - at 6:17 PM, 6:20 PM, and 6:21 PM, Resident #21, who did not have a meal yet, yelled out asking for water; and - at 6:27 PM, Residents #21, 38 and 39 were served their meals, and a few minutes later, staff members sat down and started feeding them. On 7/14/2016 at 10:09 AM, certified nurse aide (CNA) #6 stated in an interview, residents at the same table should all be served at the same time. She stated one resident should not be eating while the others waited. She stated prior to serving, the CNAs went through the meal tickets and made sure they were in order with how the residents were sitting so that whole table of residents would be served at the same time. During an interview on 7/14/2016 at 11:50 AM, registered nurse (RN) Manager #5 stated sometimes residents did not sit in their assigned seats. When that occurred, staff should wait and serve those residents with the residents who were at the table with them. She stated she was not aware that Resident #36 was served before everyone else at the table on 7/11/2016. She stated that occurred because the CNAs were making those decisions during the meals. 10NYCRR 415.5(a)

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident(s) #7 and #35 blood pressures are monitored daily, and will be taken in a non-public area. Resident #13 was issued two (2) new pairs of geri-gloves and the soiled geri-gloves were discarded. Resident #13 lap buddy and wheelchair were cleaned, and will be inspected daily after each meal, and as needed for cleanliness. Resident #30 clothing was cleaned, and will be inspected after meals and as needed to ensure clean and dry clothing is provided. Resident(s) #21, 36, 37, 38, and 39 table seating assignment was reviewed, and no changes were made. All Residents seated at the same table will be served meals together, and in a timely manner. The unit nursing staff associated with the nursing unit(s) for Residents #7, 35, 13, 30, 21, 36, 37, 38, and 39 were re-educated by the unit nurse Manager or their designee(s) on their role and responsibility to be attentive to Residents? clothing, durable medical equipment, and service time to maintain and enhance Resident dignity.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
All Residents who require blood pressure monitoring, utilize geri-gloves, lap buddy devices, wheelchairs, and dine in a communal environment could potentially be affected by the same deficient practice.
The Mealtime observation was completed on all nursing units to monitor for procedures being completed in public areas, soiled geri-gloves, clothing, lab buddy devices, wheelchairs, and meal delivery/service time. This audit was conducted for all three meals on all nursing units. Any discrepancies identified were promptly followed-up on as required, with re-education provided to any staff as appropriate.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The policy addressing Resident dignity was reviewed, and no changes were made. A policy for mealtime considerations was developed. This policy addresses care and services to maintain the environment, activities, socialization, assistance during meals, proper feeding techniques, positioning, cleanliness, and monitoring to ensure the Resident?s needs are being met during the dining experience. The Director of Nursing verified that completing Resident specific testing/monitoring; prompt management of soiled Resident clothing and equipment is a well-established nursing standard of practice for proper grooming and to promote Resident dignity. All nursing staff at the facility is expected to follow these standards.
Mandatory education will be performed for all staff that performs Resident testing/monitoring to ensure the procedure(s) is conducted in a non-public area. Mandatory education will be performed for all staff that apply and/or clean geri-gloves to ensure cleanliness is maintained. All Residents who utilize geri-gloves will be issued two (2) pair to ensure daily cleaning is completed. Mandatory education will be performed for all staff regarding cleanliness and dignity. A cleaning schedule has been developed for all equipment and devices (including wheelchairs, and lap buddy devices) to be completed each day by the certified nurse aides, or as needed. A monthly cleaning of all durable medical equipment will be performed by Environmental Service staff. All staff will be educated regarding appropriate service time, serving all Residents in a timely manner, and ensuring Residents are assisted with hygiene after meals to maintain his/her dignity.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit each nursing unit monthly, at varying meal times, until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure resident drug regimens were free from unnecessary medications for 2 of 12 residents (Residents #7 and 12) reviewed for [MEDICAL CONDITION] medications (alter brain function), and for 1 of 1 residents (Resident #7) reviewed for infections. Specifically, Resident #12 was started on [MEDICATION NAME] (anti-anxiety medication) without documented evidence of non-pharmacological interventions attempted prior to implementation of the medication. For Resident #7, [MEDICATION NAME] and as needed [MEDICATION NAME] (antipsychotic medication) were administered without documented evidence of interventions attempted prior to the medication and without documentation of the effect of the medication. Additionally, Resident #7 was ordered [MEDICATION NAME] (antibiotic) for a urinary tract infection and the urine culture documented resistance to [MEDICATION NAME]. Findings include: 1) Resident #7 was diagnosed with [REDACTED]. [MEDICAL CONDITION] medications: [REDACTED] The physician orders [REDACTED].#7 [MEDICATION NAME] (antianxiety medication) 0.5 milligrams (mg) every 8 hours as needed for anxiety/agitation, and [MEDICATION NAME] (antipsychotic medication) 1 mg intramuscularly (IM) every 6 hours as needed for severe agitation. The 2/29/2016 comprehensive care plan (CCP) documented the resident had verbal and physical behaviors. He resisted care and was prescribed antipsychotic medications. Interventions included the resident should be reapproached when not receptive, snacks or fluids offered, time allowed to vent feelings/voice concerns, and the environment should be assessed for factors that may cause behaviors to occur. The resident's record documented: - on 4/28/2016 at 2:49 PM, [MEDICATION NAME] 0.5 mg by mouth was given for an increase in agitation; - on 4/30/2016 at 8:39 PM, [MEDICATION NAME] 1 mg was given IM for physically and verbally aggressive behaviors. The resident was verbally aggressive with staff, refused his insulin, slapped a glass of water from the nurse's hand when it was offered to him, and threatened to kill everyone; and - on 5/8/2016 at 2:16 PM, [MEDICATION NAME] 0.5 mg by mouth was given for anxious and aggressive behavior that was not easily redirected. The resident's record did not document what interventions were attempted prior to medication administration, did not document why [MEDICATION NAME] IM was administered before [MEDICATION NAME], and did not consistently document the effect of the medication. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. He rejected care and wandered, and received antipsychotic and anti-anxiety medications. On 7/14/2016 at 11:00 AM, licensed practical nurse (LPN) #13 stated in a telephone interview that resident behaviors were documented in notes in the electronic medical record, and also in the kiosk where there was a specific tab that covered many types of behaviors. She stated the resident had a short fuse and was aggressive at times. She stated she did not recall giving the resident [MEDICATION NAME] on 4/28/2016 and she was not aware if she was supposed to document interventions attempted prior to medication administration. She stated she should have documented the medications effect in the notes. On 7/14/2016 at 12:30 PM, registered nurse (RN) Manager #4 was interviewed and stated she expected nurses to attempt non-pharmacological interventions prior to as needed behavior medications. She stated the interventions should be documented as well as the medication effects. On 7/14/2016 at 12:55 PM, LPN #14 stated in a telephone interview that he normally documented behaviors in the log on the computer. The resident had physical behavior; he screamed and wandered into others' rooms. He stated he normally offered snacks/food, redirected the resident during behaviors, or determine if the resident had pain before giving an as needed behavior medication. He stated he would normally try to give [MEDICATION NAME] first for behavior, because it was less invasive. He stated he was supposed to document the type of behavior, the prior interventions tried, and the medication's effectiveness. He stated the resident was not acting himself on 4/30/2016, and thought perhaps he gave the [MEDICATION NAME] first because the resident slapped water from his hands and believed he would not take oral [MEDICATION NAME]. Antibiotics: The physician orders [REDACTED].#7 to the emergency room (ER) related to [MEDICAL CONDITION] and increased temperature, and to rule out [MEDICAL CONDITION] (infection). The 7/2/2016 ER report documented the resident had a urinary tract infection [MEDICAL CONDITION]. A urine culture and sensitivity (C&S - identifies bacteria and determines correct antibiotic usage) was obtained and [MEDICATION NAME] and [MEDICATION NAME] (both antibiotics) were ordered. The physician orders [REDACTED]. The urine C&S report was faxed to the facility on [DATE] at 3:33 PM and documented the resident's urine grew Providencia stuartii (bacteria), and the bacteria was resistant to [MEDICATION NAME]. Nursing progress notes for the resident did not document the physician was notified of the results of the urine C&S report on 7/5/2016. The 7/6/2016 attending physician's note documented the resident was recently seen in the ER for a UTI, and his urine culture grew Providencia stuartii and it was resistant to [MEDICATION NAME]. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The resident's record did not document a rationale for the continued use of [MEDICATION NAME] after the urine C&S report documented resistance to the resident's bacteria. On 7/12/2016 at 12:00 PM, LPN #15 was interviewed and stated that she normally initialed laboratory reports after she reviewed them. If she called the physician, she also wrote a progress note and documented what the physician wanted done. RN Manager #4 was present during the interview and stated that laboratory reports were faxed directly to their unit. She stated the nurse who reviewed the abnormal findings should have called the physician and documented the call. On 7/12/2016 at 2:00 PM, RN Manager #4 provided the surveyor with a written statement from the resident's attending physician. The written statement documented it was the physician's intention to discontinue the [MEDICATION NAME] on 7/6/2016 and it appeared he had not. 2) Resident #12 had [DIAGNOSES REDACTED]. [MEDICAL CONDITION] medications: [REDACTED] The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #12's cognition was severely impaired, and she required extensive assistance with all activities of daily living (ADLs). The resident was on antipsychotic and antidepressant medications; she was not on an anti-anxiety medication. The nursing progress note dated 2/4/2016 at 2:49 PM documented the family took the resident to the hospital to visit her husband. The nursing progress note dated 2/9/2016 at 2:27 PM documented the resident went to her husband's funeral. The nurse practitioner (NP) note dated 3/10/2016 documented the nursing staff reported the resident was increasingly anxious and yelled out for approximately 4 hours between 4:00 PM and 8:00 PM daily since her husband's death. The note documented redirecting the resident did not change the behavior and [MEDICATION NAME] would be trialed. The NP order dated 3/10/2016 at 3:30 PM for the resident documented to administer [MEDICATION NAME] 0.25 milligrams (mg) at 2:00 PM daily for anxiety. The nursing progress note dated 3/11/2016 at 2:53 PM documented the resident had her initial dose of [MEDICATION NAME]. The nursing progress note dated 3/11/2016 at 10:17 PM documented the resident had a good evening, she was happy, not yelling out, and ate better. The nursing progress note dated 3/15/2016 at 3:14 PM documented the resident was yelling, assistance was offered, and the resident was unaware of her needs. The mood and behavior record documented on 3/22/2016 at 7:14 PM, the resident's behaviors included yelling, temper tantrum, repetitive verbalizations, and repetitive anxious complaints. The record did not document behaviors for any other days in (MONTH) (YEAR). The NP progress note dated 3/31/2016 documented staff reported the [MEDICATION NAME] worked for 3-4 days, and yelling behavior and anxiety resumed. The note also documented the resident had these behaviors prior to her husband's death and he would distract her. Her behavior worsened after her husband's death. She was seen in the hallway repeatedly asking, Where do I go? and staff were unable to distract her. The plan was to increase the resident's [MEDICATION NAME]. The NP order dated 3/31/2016 at 5:15 PM documented the resident's [MEDICATION NAME] was increased from 0.25 mg to 0.5 mg, and to give an extra dose of [MEDICATION NAME] 0.25 mg now. The nursing progress note dated 3/31/2016 at 11:04 PM documented the NP was in and the [MEDICATION NAME] was changed from 0.25 mg daily at 2:00 PM, to 0.5 mg daily at 2:00 PM. An extra dose of [MEDICATION NAME] 0.25 was ordered to be given one time at 5:30 PM. The comprehensive care plan (CCP) revised 4/7/2016, documented the resident took antipsychotic medication (it did not include anti-anxiety medication). Interventions included: - monitoring behaviors daily; - monitoring for side effects of medication; and - exploring reasons for the anxiety including environmental or psychosocial stressors and treatable medical conditions. The mood and behavior record for the resident documented behavioral observations for 3 days in (MONTH) (YEAR), including 4/14, 4/17, and 4/18/2016. The hospitality aide recorded the observations, which included cursing, hitting, pinching, grabbing, shaking fist at others, attention seeking behavior, insulting others, teasing, threatening others, verbal and physical aggression, yelling, temper tantrum, negative statements, persistent anger, repetitive health complaints, and unpleasant mood in the morning. (The nursing notes did not document any behaviors or interventions for behavior during this time.) The MDS assessment dated [DATE] documented the resident's cognition was severely impaired. She required extensive assistance with all activities of daily living (ADLs) and took antipsychotic, anti-anxiety, and antidepressant medications. The nursing progress note dated 6/1/2016 at 6:55 AM documented the resident was yelling out from 4:30 AM to 5:30 AM. She was turned and positioned, and settled back to sleep. The resident's care card (care instructions) dated (MONTH) (YEAR) documented the resident was alert, confused, and hard of hearing. It did not document the resident had a behavior plan. On 7/11/2016 the resident was observed: - from 12:57 PM to 1:15 PM, seated in her wheelchair in the dining room and eating lunch; - at 4:40 PM, at a table in the dining room; at 4:45 PM an activities aide came to the table and conducted a word phrase activity, and the resident was attentive; - at 5:55 PM, continuously attempting to leave the table while supper trays were being served and was redirected by the nurse manager; and - from 6:07 PM to 6:25 PM, she was alert and engaged in a conversation with the nurse manager as she ate dinner. On 7/12/2016 the resident was observed: - at 7:58 AM, quietly eating breakfast at the dining room table; and - at 11:10 AM, in her room in a recliner calling out. The registered nurse (RN) Manager went in the room and came out to get assistance for the resident to use the bathroom. The resident's record was reviewed on 7/12/2016, and there was no documentation found regarding the behaviors the resident had prior to or after starting the [MEDICATION NAME], and no documentation on its effectiveness after the dosage was increased. There was also no documented evidence non-pharmacological interventions were attempted prior to the start of [MEDICATION NAME]. When interviewed on 7/14/2016 at 9:20 AM, licensed practical nurse (LPN) #20 stated the resident's behaviors varied. The resident was recently started on [MEDICATION NAME] due to excessive yelling that started around 2:30 PM. She stated other interventions included taking the resident to the dining room where activities staff worked with her. She stated the resident's husband passed away approximately 6 months ago, and the resident did not have any change in behavior. She stated she did not know if other interventions were documented prior to starting [MEDICATION NAME], and the behaviors were documented in the behavior log. 10NYCRR 415.12 (l)(1)

Plan of Correction: ApprovedAugust 5, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Incident involving Resident #7 has been fully investigated and the Resident has had no complications from Administration of [MEDICATION NAME], and the timing of physician notification and assessment. The unit nurses were re-educated regarding monitoring, reporting, and prompt follow-up of laboratory results. Residents #7 and #12 medications and care plan were reviewed and no changes were made. Unit nurses were re-educated regarding the use of non-pharmacological interventions prior to initiating an anxiolytic, or administration of an as needed dose of an antipsychotic medication. Resident #12 medication regime will be reviewed by the consultant pharmacists and physician to determine if a dose reduction is recommended at this time.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
The Director of Nursing evaluated all Residents with a positive culture result for the past 6 months, and no other Residents were affected by the same deficient practice.
A report was generated in the electronic medication record to evaluate if documentation of non-pharmacological interventions was present prior to administration and/or initiation of anxiolytic and antipsychotic medications. As a result, mandatory education will be performed for all licensed nurses who administer anxiolytic and antipsychotic medications to ensure non-pharmacological interventions are provided and documented prior to administration of medication. The specific non-pharmacological strategies utilized prior to dosing will be documented in the electronic medication record. The effectiveness of the medication will be documented within 1 hour of administration of an as needed dose.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The medication administration policy was reviewed and no changes were made. Nursing staff will receive mandatory education regarding the Medication Administration Policy. This education will emphasize the use of non-pharmacological measures prior to medication use, implementation, and to evaluate the effectiveness of the medication.
The physician and nursing will ensure there is appropriate documentation that anxiolytic and antipsychotic medications are medically necessary, and non-pharmacological interventions are trialed before they are prescribed and or increased.
Nursing will review the sensitivity of all cultures obtained and notify physician if any organisms identified are resistive to the antibiotic that is ordered. Orders will be obtained for any changes needed at that time.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing or designee will audit a random sample of 20 Residents per month to ensure documentation of non-pharmacological interventions have been utilized prior to administration or initiation of an anxiolytic and/or antipsychotic medication.
The consultant pharmacist will conduct a drug regimen review of each Resident monthly and provide recommendations to the physician and nursing. Nursing will ensure the physician is notified of the consultant?s recommendations for appropriate follow-up.
The Director of Nursing or designee will audit all culture reports to ensure the organisms present are sensitive to the antibiotic ordered. These audits will be conducted monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible

FF09 483.35(h):FEEDING ASST - TRAINING/SUPERVISION/RESIDENT

REGULATION: A facility may use a paid feeding assistant, as defined in §488.301 of this chapter, if the feeding assistant has successfully completed a State-approved training course that meets the requirements of §483.160 before feeding residents; and the use of feeding assistants is consistent with State law. A feeding assistant must work under the supervision of a registered nurse (RN) or licensed practical nurse (LPN). In an emergency, a feeding assistant must call a supervisory nurse for help on the resident call system. A facility must ensure that a feeding assistant feeds only residents who have no complicated feeding problems. Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings. The facility must base resident selection on the charge nurse's assessment and the resident's latest assessment and plan of care. NOTE: One of the specific features of the regulatory requirement for this tag is that paid feeding assistants must complete a training program with the following minimum content as specified at §483.160: o A State-approved training course for paid feeding assistants must include, at a minimum, 8 hours of training in the following: Feeding techniques. Assistance with feeding and hydration. Communication and interpersonal skills. Appropriate responses to resident behavior. Safety and emergency procedures, including the Heimlich maneuver. Infection control. Resident rights. Recognizing changes in residents that are inconsistent with their normal behavior and the importance of reporting those changes to the supervisory nurse. A facility must maintain a record of all individuals used by the facility as feeding assistants, who have successfully completed the training course for paid feeding assistants.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, the facility did not ensure a paid feeding assistant fed only residents who had no complicated feeding problems, including difficulty swallowing, for 1 of 3 residents (Resident #19) reviewed for swallowing. Specifically, Resident #19 was ordered a pureed diet with honey thick liquids due to dysphagia (difficulty swallowing) and the resident was observed being fed by a paid feeding assistant. Findings include: Resident #19 had [DIAGNOSES REDACTED]. The speech-language pathologist (SLP) note dated 10/2/2015 documented the resident had moderate-severe dysphagia and was observed hyperextending his neck (tilting head backwards). The note documented the resident required total assistance with meals, and not to feed him when his head was tilted backwards. The swallow evaluation dated 1/26/2016 documented recommendations for the resident including: - a pureed diet with honey thick liquids; - total assistance with meals; and - not to feed the resident when his head had fallen back. The physician progress notes [REDACTED]. The physician orders [REDACTED]. The registered dietitian (RD) note dated 6/7/2016 documented the resident had a history of [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, required extensive assistance with meals, had dysphagia, and received a mechanically altered diet. The physician progress notes [REDACTED]. The 7/6/2016 resident care card (care instructions) documented the resident required total assistance with meals. The activity of daily living (ADL) record dated 7/2016 documented the resident was totally dependent on staff for eating. On 7/12/2016 at 8:10 AM, the resident was observed sitting in a chair in the 8th floor dining room. Paid feeding assistant (PFA) #30 was seated next to the resident attempting to feed him and was unable to arouse him. The resident started sliding from his chair and 2 staff members transferred him into a wheel chair. The resident sat in the wheel chair with his neck hyperextended (head tilted all the way back) as the PFA fed him and poured his liquids into his mouth. On 7/14/2016 at 8:30 AM, the resident was observed in the 8th floor dining room leaning back in his chair with his neck hyperextended. The PFA fed the resident and poured water into his mouth in this position prior to asking him to sit up. The resident straightened up and tilted his head forward when prompted. When interviewed on 7/14/2016 at 11:30 AM, PFA #30 stated she had been in the position for [AGE] years. Her duties included helping in the dining room and feeding residents that required assistance. She stated she fed anyone in the dining room that required assistance, including Resident #19. When interviewed on 7/14/2016 at 11:45 AM, the registered nurse (RN) Manager #4 stated PFAs helped with tray setup and fed residents in the dining room. She stated they could not feed residents at risk for aspiration (inhaling material into the lungs). When interviewed on 7/14/2016 at 12:45 PM, the Director of Nursing (DON) described the PFA program and their qualifications and certifications. She stated the PFA was not allowed to feed residents that the nurses or SLP had concerns with. When interviewed on 7/14/2016 at 12:55 PM, the RN Educator described the training course for PFAs. She stated it was a 16 hour (2 day) course with overview of meal consistencies and proper positioning of residents while feeding them. She further stated PFAs were not allowed to feed residents who had orders for thickened liquids or were at high risk for aspiration. She stated if a resident was being fed and their neck was hyperextended, the staff should immediately stop feeding the resident. While interviewed on 7/14/2016 at 1:30 PM, the SLP stated the proper position for eating was sitting up upright with feet flat on floor and not leaning to either side. She also said the head should be level or slightly flexed (chin tilted down). The SLP stated it was never okay to feed a resident with their neck hyperextended. 10NYCRR 415.13

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #19 diet consistency and need for feeding assistance remains appropriate. The Resident care plan and Resident Care Record have been updated to document the Resident may not be fed by a paid feeding assistant, and should be assisted by licensed or certified staff.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
All Residents who receive thickened liquids or modified consistency foods were evaluated to ensure they were not fed by a paid feeding assistance during meal rounds. The meal round audit was completed on all nursing units for breakfast, lunch, and dinner. No other Residents were identified as being affected by the same deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Paid Feeding Assistant policy was reviewed. Clarifications were made regarding the definition of a modified diet, and a licensed nurse must evaluate and determine who is appropriate for a feeding assistant to feed. The policy stipulates the licensed nurse must document in the plan of care and the Resident Care Record who may or may not be fed by a paid feeding assistant. The Resident Care Record form was updated with a check box identifying who may or may not feed each Resident. Mandatory education will be provided for all staff that feed, assist, and supervise Residents during meal time. This education will emphasize the importance of safety while feeding, proper positioning, when a paid feeding assistant is appropriate to feed, and documentation on the Resident Care Record for feeding.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit each nursing unit monthly, at varying meal times, until 100% compliance has been achieved for 3 consecutive months. The audit will include verification of proper documentation on the Resident Care Record for staff assignment during feeding. The auditor will then verify, during the meal, if the Resident(s) are being fed by the appropriate staff. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency

FF09 483.35(d)(3):FOOD IN FORM TO MEET INDIVIDUAL NEEDS

REGULATION: Each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined for 1 of 14 residents (Resident #13) reviewed for activities of daily living (ADLs), the facility did not provide food prepared in a form designed to meet individual needs. Specifically, Resident #13 had a plan for finger foods to eat as she wandered, and finger foods were not provided during survey. Findings include: Resident #13 had [DIAGNOSES REDACTED]. The speech-language pathologist (SLP) dysphagia evaluation dated 8/25/2016 recommended the resident remained on a level 2 (mechanically altered) solid food and regular thin liquids diet. The physician order [REDACTED]. The comprehensive care plan (CCP) updated 6/25/2016 documented the resident had inadequate food and fluid intake, needed verbal cues and assistance, was to receive half portions to prevent being overwhelmed, was to be provided with a half of a sandwich to promote self feeding, did well with finger foods, and required a divided dish for meals. The CCP documented the resident was not able to be stationary for long periods and took meals with her on her Lap Buddy (inflatable device to prevent falls). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required supervision with moving about the unit and eating, had an altered diet, and had a physical restraint. The physician order [REDACTED]. The physician order [REDACTED]. The 7/2016 certified nurse aide (CNA) resident care record (care instructions) documented the resident was confused, used a Lap Buddy (inflatable device to prevent falls), was a set-up assist for meals, and was to receive finger foods to eat while self propelling on unit. The registered dietitian (RD) progress note dated 7/7/2016 documented the resident continued on a level 2 mechanically altered diet with thin liquids per SLP recommendations on 8/25/2015. The note documented the resident received half portions at all meals, used a divided plate, and was not to have plastic lids or paper products related to placing them in her mouth. Her average meal intake for 7 days was 48%, she was independent at meal time, and the past 7 day fluid consumption averaged 747 ml per day. The note documented the resident did not like to eat in the dining room, took all food/fluids with her on the go, and nursing was aware of her fluid intake and goal. On 7/11/2016 at 5:45 PM, registered nurse (RN) Manager #5 approached the surveyor and stated the resident wandered around the unit in the wheelchair when she ate. The resident used her Lap Buddy (restraint) as a tray, and had been eating in this manner for quite some time. The resident was provided with finger foods to help her eat more easily, and this was included in her care plan. On 7/11/2016 at 5:55 PM, the resident was observed wandering the unit in her wheelchair with a divided plate resting on top of her Lap Buddy, a juice cup in her right hand, and a regular fork in her left hand. The resident did not receive finger foods and instead had an altered consistency salad, mashed potatoes and a slice of bread with the crust removed. At 6:28 PM, the resident was observed to have spilled most of her dinner on the floor and into her chair. An unidentified safety aide removed the plate from the resident's Lap Buddy. The resident was observed through 6:55 PM, and she was not offered or provided with alternative food or fluids. On 7/12/2016 from 9:08 AM - 9:30 AM, the resident was observed in her wheelchair, with a full plate of breakfast which included scrambled eggs, oatmeal, and mandarin oranges. She did not have a drink and was not observed to be assisted or encouraged during this time. On 7/12/2016 at 2:03 PM, the resident was observed in the hall in her wheelchair, with most of her lunch on her plate (fruit jello, green beans, rice, chicken), a plastic two-handled cup, a straw in her hand, and she did not have a sandwich. On 7/13/2016 at 9:18 AM, the resident's breakfast tray was observed on the tray table at the foot of the resident's bed. The breakfast meal included cut up pancakes, ground meat (on a regular dish), oatmeal, a whole banana (with the peel on), a whole donut (wrapped in plastic wrap), and a cup with apple juice in it. The tray table was out of the resident's reach when she was in bed, the resident was asleep, and the food was uncovered. On 7/13/2016 at 2:36 PM, the resident was observed in her wheelchair with a divided plate, regular fork, full serving of spaghetti with sauce, 1/2 serving of mashed potatoes, 1/2 serving of vegetables, and no drink. The resident was observed to attempt to take several bites of her food with the fork, the food dropped onto her Lap Buddy and into the side of the chair, and she continued to attempt to bring the empty fork to her mouth while wheeling herself in the chair. At 2:40 PM, CNAs #16 and 19 took the resident to her room, removed her plate, did not offer alternative food, and assisted the resident back to bed. An occupational therapy (OT) feeding evaluation dated 7/13/2016 documented the resident needed reinforcement to eat 50-75% of the time, and 25% of her food remained on the floor or on her lap. She spilled food from utensils, and needed some assistance to prevent spills. During an interview with CNA #16 on 7/14/2016 at 10:30 AM, she stated that the resident required total assistance in dressing, hygiene, and toileting. She stated the resident often spilled her food and drinks and was unable to access her own drinks or food if left on the tray table. On 7/14/2016 at 11:50 AM, RN Manager #5 stated in an interview, the resident was served a salad a few nights prior and she told staff to make her a sandwich instead. She stated if the resident dropped her meal, staff could offer a sandwich as a finger food. She stated the resident was not routinely served finger foods as she ate her regular meals well. On 7/14/2016 at 12:30 PM, RDs #11 and 12 were interviewed and stated: - There was not a regular RD assigned to the nursing facility, as they were all covering when needed. - Neither RD #11 or 12 were aware the resident ate meals while traveling and neither had seen her eat recently. - After reviewing the resident's medical record, RD #12 stated that in the past, the resident was provided with foods she could eat on the go, and she did not know if she received foods on the go presently. RD #12 further stated the resident's CCP documented she did well with sandwiches or foods she could hold, but she did not know if the resident received those foods. - RDs #11 and 12 both stated that if the resident's meal ticket listed a sandwich, then someone should make a sandwich and provide it to the resident. - RD #12 stated she was not aware the resident received an entree salad on 7/11/2016 and she would have addressed it had she known. - RDs #11 and 12 stated they did not know if spaghetti would be an appropriate meal for the resident and would have to ask OT. - RDs #11 and 12 stated they were not aware whether the resident had an OT feeding evaluation recently. 10NYCRR 415.14(d)(3)

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #13 care plan and resident care record were updated. The Resident will remain in her wheelchair for meals, but will be seated at a staff table to provide supervision and prompting to ensure maximum intake of food. If the Resident is able to tolerated only short durations of dining in this environment, her food will be replaced or heated (as applicable), and she will be re-approached to take meals in the dining room. The Resident was evaluated by the dietician and Occupational Therapist. The plan for finger foods remains appropriate for Resident #13. Her meal ticket was reviewed and correctly states the service of finger foods. The Resident will also be offered the entrée per her tolerance and preference. Service and nursing staff received education to ensure finger foods were provided to promote independence with feeding.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
The Mealtime observation was completed on all nursing units to monitor for appropriate assistance being offered, correct meal tickets, food form, adequate consumption of food, meal service delivery, seating selection, and staff assistance during meals. All concerns were corrected at the time of observations, and continued monitoring during meals service will be provided to ensure the Resident?s needs are met.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
A policy for mealtime considerations was developed. This policy addresses food form, assistance during meals, proper feeding techniques, positioning, modified consistency, and monitoring to ensure the Resident?s needs are being met during the dining experience.
Mandatory education will be provided for all staff that feed, assist, and supervise Residents during meal time. This education will emphasize the importance of ensuring the meal ticket reflects the food delivered for the resident, providing foods of choice, supervision, assistance, seating selection, meal service delivery to promote maximum oral intake, dignity and independence.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit each nursing unit monthly, at varying meal times, until 100% compliance has been achieved for 3 consecutive months. This audit will be conducted by the multi-disciplinary team. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not ensure food was prepared and stored under sanitary conditions in the main kitchen. Specifically, one-half pound of deli meat was not held under refrigeration during storage, a food preparation sink lacked an indirect drain, and dishes were not air dried properly after washing. Findings include: 1) Cold Holding On 7/11/2016 between 11:15 AM and 11:45 AM, the cafeteria deli cooler was observed by a surveyor. Containers of sliced deli meat (turkey and ham) were observed in a cold well on top of ice. The temperature of the 1/4 pound of turkey was recorded by the facility to be 55 degrees Fahrenheit (F). The temperature of the 1/4 pound of ham was recorded by the facility to be between 45-49 degrees F. In an interview with the Food Service Site Manager on 7/11/2016 between 11:15 AM and 11:45 AM, she stated usually the ice surrounding the deli containers is to the top of the rim. She was unsure why more ice was not present and would immediately discard the deli meat. 2) Indirect Drain On 7/11/2016 between 11:15 AM and 11:45 AM, the main kitchen food preparation sink was observed by a surveyor. The 2-bay food preparation sink was observed to contain a hard piped waste line. No air gap was observed. In an interview with the Food Service Site Manager on 7/11/2016 between 11:15 AM and 11:45 AM, she stated she was unaware the food preparation sink did not contain an indirect drain. 3) Air Drying On 7/11/2016 between 11:15 AM and 11:45 AM, the main kitchen dishwasher area was observed by a surveyor. The clean side of the dishwasher room contained multiple shelves and carts for clean dishware and utensils. The following was observed: - a cart contained over 100 small bowls that were interstacked with the concave side up. When a surveyor observed the multiple interstacked bowls, the bowls contained water puddled in the bottom of the bowl; and - a bus pan contained greater than 50 interstacked plastic cups stored on their sides. The cups contained visible water inside each cup and were not properly air dried. In an interview with the Food Service Site Manager on 7/11/2016 between 11:15 AM and 11:45 AM, she stated she was unaware the dishware was not fully dry. She stated the facility had just begun using the cart to store bowls and would instruct staff on proper air drying techniques. 10NYCRR 415.14(h), 14.1.40(a), 14-1.141, 14-1.116

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
The affected deli meet was immediately discarded. The cold well system was assessed, and the process was modified. The products are kept in a stainless steel pan and are submersed down into the ice. The temperatures have been maintain throughout service and are consistent with acceptable temperature range. The Director of Facilities examined the main kitchen food preparation sink, and identified an indirect drain below the floor level. No additional replacement or installation was required. Additional drying racks were obtained. Adding additional racks allows for all cups and glasses ample time for thorough drying and longer drying times.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
The Food Service Director has audited the cold food storage stainless containers for proper temperature, and all temperatures remained within acceptable ranges. The Director of Facilities assessed all preparation areas and no other lack of indirect drains was identified. The Food Service Director audited dishware for adequate drying, and found the new process was effective in ensuring dishes were dried thoroughly.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The food service staff received education regarding cold storage of food, monitoring temperatures, proper drying technique. There are no other food preparation sinks without indirect drains. All dishes have been thoroughly dried utilizing the new racks.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Food service Director has developed an audit to monitor cold food temperatures, and proper drying of dishware. The Director and/or designee will audit weekly, until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Food Service Director and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Food Service Director will be responsible for this deficiency

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not ensure the resident environment was maintained as free of accident hazards as possible. Specifically, for Resident #10 and for 11 of 17 resident rooms sampled for siderails (rooms 324, 501, 503, 504, 507, 526, 724, 808, 811, 812, and 814), the rooms contained mattresses that were improperly restricted to prevent movement during siderail use, in order to reduce the risks of entanglement or entrapment. Findings include: On 7/11/2016 at 11:50 AM during the initial tour, a surveyor observed room 324. The bed contained a 1/2 siderail that was up, and the other side of the bed was against the wall dresser. When the surveyor tested the space between the siderail and the mattress, the mattress was observed to move and created an approximately 5-6 inch gap between the mattress and the siderail. When the surveyor observed the bed frame, it did not contain a mechanism to hold the mattress in place to restrict the movement of the mattress to maintain mattress spacing that would reduce the risk of entanglement and/or entrapment. On 7/11/2016 between 12:00 PM and 4:40 PM, beds in the following rooms with siderails observed in the raised position were tested by a surveyor: - room 507 contained 1/2 siderails up on each side of the bed; the mattress was able to slide freely from side to side and created large gaps between the mattress at the head and foot of the bed, and between the siderails and the mattress; - room 503 contained a bed with 1/2 siderails on each side of the mattress. The resident stated the siderails were up when he was in bed. The bed contained an alternating air mattress that freely moved when pressure was placed on the mattress. The alternating air chambers also were observed to create pressure on the surveyor's hand when placed between the siderail and the mattress when the air chamber inflated; and - rooms 501, 526, 814, and 504 contained beds with siderails up and did not contain a mechanism to prevent the movement of the mattress. On 7/12/2016 between 10:50 AM and 11:10 AM, and on 7/14/2016 between 10:50 AM and 11:00 AM, beds in the following rooms with siderails observed in the raised position were tested by a surveyor: - room 724 contained a bed with the left side rail up, and the bed did not contain a device to prevent the movement of the mattress; - Resident #10's bed contained loose siderails and did not contain a mechanism to prevent the movement of the mattress; - room 811 contained a bed against the wall with a perimeter mattress that was able to move freely, and the mattress created a space between the wall and the mattress when pushed; and - room 812 contained a loose mattress that had a 5 inch space between the mattress and the foot of the bed. In an interview with the Director of Facilities on 7/12/2016 between 10:50 AM and 2:00 PM, he stated the facility has two different styles of beds and is in the process of replacing all beds. He stated the newer style of bed allows the bed to go lower to the floor and the older style bed was purchased in the mid-1990's. He stated the facility is currently purchasing approximately 10 new beds each year. He stated the facility has a work order system, and if nursing has a problem with a bed, nursing submits a work order for repair. On 7/14/2016 at 10:30 AM, room 808 was observed with the Administrator, Director of Facilities, Director of Nursing, and the Clinical Director of Nursing. The bed was observed to have both 1/2 siderails up. When the mattress was pushed from the side, the mattress freely moved and created an approximately 6 inch space between the siderail and the mattress. The bed did not contain a mechanism to prevent the movement of the mattress. In an interview with the Administrator at the time of the observation, she stated she was unaware of the space created by the mattress and that the bed did not have a mechanism to prevent the movement of the mattress. She stated the facility will immediately begin to review the beds and develop a solution to reduce the risks associated with the older style beds. The Director of Facilities stated there were approximately 200 older style beds remaining in the facility. Resident #10 had [DIAGNOSES REDACTED]. The resident restrictive device assessment dated [DATE] did not document the resident had siderails on her bed or if the side rails were assessed as a restraint. The comprehensive care plan (CCP) dated 6/3/2016 did not document the resident had side rails on her bed. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She required extensive assistance to total dependence in all activities of daily living (ADLs) with the exception of eating requiring set up and supervision. The resident's care card (care instructions) dated 7/2016 did not document the resident used siderails as a positioning aid. When observed and interviewed on 7/11/2016 at 4:55 PM, the resident was in bed and 2 half side rails were in the up position. The side rail on the resident's right side was loose and shaky. The resident stated she used the side rails to hold onto when the staff assisted her in positioning. When interviewed on 7/14/2016 at 9:35 AM, the registered nurse (RN) Manager #19 stated the policy of the facility was no siderails. She stated if the resident wanted siderails, an assessment was done. She stated the resident wanted the rails and the resident's care card should document the siderails were at the resident's request for positioning. At 10:20 AM, RN Manager #19 and the surveyor went to the resident's room and observed the siderails. RN Manager #19 stated the rail was very loose and it would need to be fixed.

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice?
Of the 12 beds identified: 303, 324,501,503,504,507,526,724,808,811,812,814 in the sample, 8 have been replaced with newer beds that are compliant with the requirements and the remaining 4 have the mechanism ordered from the manufacturer to restrict the movement of the mattress. They will be installed immediately upon delivery.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An inventory of all beds in the facility was completed on (MONTH) 18, 19, (YEAR). All 272 beds plus the 5 spare beds did not have the mechanism to restrict mattress movement from side to side. Mechanisms for all 272 beds plus the 8 replacement beds were ordered on (MONTH) 2, (YEAR). All beds will either be replaced or have the restrictive mechanism added by (MONTH) 1st, (YEAR).
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.
A bed replacement plan has been developed to buy 15 new beds per year going forward until all are current. DAL NH 15-05: Entrapment Risk with Bed Systems and Components , Guidance for Industry and FDA Staff; Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, and Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, LTC facilities and Home Care settings have all been reviewed by Administrator, DON and Manager of Facilities.
4. How the corrective actions(s) will be monitored to ensure the deficient practice will not recur, ie, what quality assurance program will be put into practice.
Mattress positioning and safety will be added to the Environmental Rounds checklist to randomly audit beds going forward for compliance. The sample will consist of 25 beds, will be completed monthly, each month until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Facilities and will be reported to the Quality Improvement Council.
5. The date for correction and the title for the person responsible for each deficiency.
The Director of Facilities is responsible.

FF09 483.15(h)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the interior environment was maintained in a sanitary, orderly, and comfortable manner in 6 of 7 resident units (Units 3, 4, 5, 6, 7, and 8). Specifically, there were scraped door jambs, floor surfaces were soiled/sticky and had a buildup present, floors surfaces were patched with duct tape, a door contained scrape marks and cracked laminate, a geri chair had a large tear in the vinyl covering, and there was excessive storage in resident lounges and bathing areas. Findings include: On 7/11/2016 between 11:45 AM and 1:40 PM, the following was observed on unit 7 by a surveyor: - resident room 324, sink drain was leaking on the floor and the floor was unclean with buildup in the corners and in the toilet room; - resident room 811, metal base was off the heating/air conditioning unit; - unit 5 dining room floor was unclean and sticky; - unit 5, a geri chair had torn vinyl covering; - unit 7 dining room, floor was unclean; and - unit 7 shower room (near room 710) floor was unclean with fecal material and fecal material was in the drain. On 7/11/2016 between 4:20 PM and 5:15 PM, the following was observed on unit 7 by a surveyor: - black duct tape was worn, and not smooth and cleanable, between the cross corridor doors on the floor near the elevator lobby; - shower room (near room 710) floor was unclean, and fecal material was in the entrance and in the drain; and - resident room 717, door had worn and tattered brown duct tape covering areas where the laminate was in disrepair. In an interview with the Director of Facilities on 7/11/2016 between 4:20 PM and 5:15 PM, he stated housekeepers clean the shower rooms once daily and the fecal material may be from after they cleaned. He stated he would have it cleaned immediately. On 7/12/2016 between 10:00 AM and 2:30 PM, the following was observed by a surveyor: - resident rooms 525 and 526, door had worn brown duct tape that was not smooth and cleanable; - resident room 610, door and door jamb contained scrape marks, and the door laminate contained crack marks; - resident room 613, door contained scrape marks; - resident room 717, door had worn duct tape; - resident room 727, door contained scrape marks and worn duct tape at the base; and - resident room 819, nightstand was missing an approximately 1 inch by 18 inch strip. On 7/13/2016 between 1:45 PM and 3:30 PM, the following was observed by a surveyor: - unit 4 elevator lobby threshold contained worn black duct tape that was not smooth and cleanable; - unit 4 resident/family lounge area floor was sticky, contained rust marks on the floor, door frame was scraped, and area was used for excessive storage of equipment, resident belongings, and lifts; - resident room 416, door contained scrape marks and worn duct tape, door contained cracked laminate that produced a very sharp edge; - resident room 413, door contained scrape marks, left overbed top light did not work and the resident requested additional light; - unit 4 shower room had excessive storage of 4 wheelchairs, 1 walker, and 1 fall mat; - corridor floor between room 407 and 410 contained duct tape used to patch the floor; - resident room 403, 404, and 406, door contained worn and peeling duct tape; - resident room 421, threshold contained worn duct tape; - corridor floor near room 420 contained a 6 inch by 12 inch floor area patched with worn duct tape; - unit 3 shower bed contained rusty side rails, and the tub room contained peeling paint on the ceiling; - corridor floor near room 309 contained peeling worn duct tape; - unit 3 medication room, floor was unclean and contained dust and wrapper pieces; and - resident room 302, floor was extremely sticky. In an interview with the Director of Facilities on 7/13/2016 between 1:45 PM and 3:30 PM, he stated the floors may become sticky depending on what product the housekeepers use. He stated he was unaware the floor was sticky in multiple areas of the facility. He stated the facility has been replacing doors that have laminate in disrepair, and they are trying to replace the remaining doors as quickly as possible. He stated the duct tape was used to repair cracks in the door laminate. 10NYCRR 415.5(h)(2)

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Room 324 sink drain has been repaired and the floors have been stripped and waxed in that room. Room 811 heating/air conditioning metal base plate has been replaced. Unit 5 and 7 dining room floors, 4th floor lounge, and 7th shower room floor haven been stripped and waxed. The unit 3 medication room and Resident room 302 have been stripped, waxed, and all debris removed from the floor. The geri-chair located on unit 5 with a torn vinyl covering has been repaired. On the 7th floor the duct tape was removed, and the tile repaired between the cross corridor doors. The doors to the 4th floor lounge, rooms 403, 404, 406, 413, 525, 526, 610, 613, 717, and 727 have been ordered, and will be replaced by 9/30/2016. The over bed top light in room 413 has been repaired. The nightstand in room 819 has been replaced. The duct tape on the 4th floor elevator threshold, between rooms 407-410, room 421 threshold, corridor near rooms 420 and 309 has been removed, and replaced with new tile. The unit 3 shower room ceiling has been painted, and the shower bed side rails cleaned. The excessive storage of equipment, belongings, and lifts from the 4th floor lounge, and shower room has been cleaned and uncluttered.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
A systematic audit of all floors was conducted to determine areas in need of repair and/or stripping and waxing. All sticky, damaged, or soiled floors have been repaired, stripped and waxed. An evaluation of all doors within the facility was conducted. A total of 53 doors (including those in sample) were identified as being in need of repair and/or replacement. The doors have been ordered, the arrival of the new doors is estimated by (MONTH) 15, (YEAR), and completion of work will be accomplished by 9/30/2016. During environmental rounds, all other nightstands will be evaluated for cracked and peeling laminate. The nightstands will be replaced and/or repaired. All geri-chairs utilized within the facility were inspected for rips and/or tears and repairs have been completed. All over bed lights have been inspected, and light bulbs replaced. Each unit lounge and shower room was evaluated for storage of equipment and personal items, rusted rails, and cracked paint. All equipment and personal items have been removed and stored appropriately. Shower beds have been cleaned, and work orders will be generated during environmental rounds for any painting/repair needs.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Environmental rounds checklist has been updated. The checklist will include inspection of flooring, cleanliness of all surfaces/flooring, condition of equipment, proper working order of Resident lighting, storage areas, and peeling/cracked surfaces. Environmental rounds will be conducted monthly, and will include participation of the interdisciplinary team. All identified areas will be corrected, and tracked by the Director of Facilities.
Mandatory education will be provided for all staff regarding cleanliness in the environment. This education will include prompt reporting and work order completion for equipment/drains in need of repair, replacement of broken furniture, peeling paint, rusting or soiled equipment, avoiding storage of equipment, belongings and lifts in lounges and shower rooms.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Facilities, with the Administrator or designee will conduct an audit of the environment monthly. This audit will include all Resident units, medication rooms, lounges, dining rooms and shower facilities. Monitoring for compliance is the responsibility of the Director of Facilities and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Facilities will be responsible.

FF09 483.65:INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) 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. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 2 of 4 residents (Residents #5 and 25) observed for wound care, and for 3 of 7 nursing units observed for meals (Units 2, 6, and 8), the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, a nurse did not wash her hands after completing a wound treatment for [REDACTED].#25. On Units 2, 6, and 8, the dietary servers were observed handling multiple surfaces with their gloved hands and then having direct contact with food with those same gloved hands. Findings include: 1) Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive to total assistance with activities of daily living (ADLs), had a urinary catheter, and was frequently incontinent of stool. He was at risk for developing pressure ulcers, did not have one, and had pressure reducing devices in place. The nursing progress note dated 7/5/2016 documented the resident had a Stage II (partial thickness skin loss) pressure ulcer on his left buttock that was not present on admission. The physician order [REDACTED]. The comprehensive care plan (CCP) dated 7/11/2016 documented the resident had an open area on his left buttock. Interventions included to cleanse the open area with normal saline, pat area dry and cover with [MEDICATION NAME], and change the dressing every 3 days and as needed. Resident #25 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and required total assistance with most activities of daily living (ADLs). She was at risk for developing a pressure ulcer, did not have one, and had pressure reducing devices in place. The nursing progress note dated 7/5/2016 documented the resident had an unstageable pressure ulcer on the bony prominence of the outer aspect of her left foot that was not present on admission. The 7/8/2016 physician order [REDACTED]. The comprehensive care plan (CCP) dated 7/11/2016 documented the resident had an unstageable pressure area on the outer aspect of her left foot. Interventions included to complete dressings as ordered. During a wound dressing change observation on 7/13/2016 at 9:25 AM, licensed practical nurse (LPN) #2 knocked and entered Resident #5's room, used Purell (hand sanitizer) on her hands, donned gloves, and performed the ordered wound care using Purell between glove changes. LPN #2 then gathered used supplies, placed the used supplies in a red biohazard bag, departed the room, and took the biohazard bag to the soiled utility room for disposal. She pushed the Purell dispenser in the soiled utility room and stated it was out of Purell prior to exiting the room. LPN #2 did not wash her hands with soap and water prior to or after leaving the resident's room, and after leaving the soiled utility room. During a wound dressing change observation on 7/13/2016 at 9:35 PM, LPN #2 exited the soiled utility room after performing a dressing change for Resident #5, proceeded to Resident #25's room, knocked on the door, used Purell as she entered the room, and performed the ordered wound care using Purell between glove changes. LPN #2 then gathered the used supplies, placed them in a red biohazard bag, and took the biohazard bag to the soiled utility room for disposal. She entered a common bathroom near the utility room and washed her hands with soap and water. When interviewed on 7/13/2016 at 9:40 AM, LPN #2 stated staff were to wash hands before touching the resident and when leaving the room. She stated it was acceptable to use Purell between glove changes as long as the hands were not visibly soiled. She stated she thought she washed her hands after leaving Resident #5's room. When interviewed on 7/14/2016 at 10:05 AM, registered nurse (RN) Manager #1 stated he expected the nurse to wash her hands before and after completing resident care. He stated the nurse was to use soap and water for 15 seconds. He stated Purell could be used during glove changes as long as the hands were not visibly soiled and were dry prior to putting on new gloves. When interviewed on 7/14/2016 at 1:15 PM, the Director of Nursing (DON) stated she expected staff to wash hands prior to donning gloves, after removing the old dressing, and when leaving the room. She stated Purell may be used in place of soap and water. She stated staff were to use soap and water during the treatment if hands were visibly soiled or sticky from Purell use. 2) In the Unit 6 dining room on 7/11/2016, dietary server #8 was observed preparing residents' meals. During the meal service, dietary server #8 was observed touching multiple surfaces and items with gloved hands and then handling food items without changing gloves or employing hand washing, including: - Beginning at 1:00 PM, dietary server #8, with her hands gloved, scooped pudding into a bowl, went into the back room refrigerator and obtained ice cream, opened the refrigerator, and handled packaged cookies. Then with the same gloved hands, she held a bun and made a sandwich for a resident. - After making the sandwich, dietary server #8, with the same gloved hands, scooped pudding into a bowl, ladled soup into a bowl, and then obtained a plate. With the same gloved hands, dietary server #8, held two pieces of bread and made a tuna fish sandwich. - Dietary server #8 repeated this practice multiple times during the meal service and was not observed changing gloves or employing hand washing during meal service. In the Unit 6 dining room on 7/11/2016, dietary server #9 was observed preparing residents' meals. During the meal, dietary server #9 was observed touching multiple surfaces and items with gloved hands and then handling food items without changing gloves, including: - Beginning at 5:30 PM, dietary server #9 opened the refrigerator with her gloved hands, went into the back room refrigerator to obtain ice cream, and then obtained a Styrofoam plate form the cupboard. With the same gloved hands, dietary server #9 prepared a veggie burger on a bun for a resident and handled the bun with gloved hands. - Dietary server #9 repeated this practice several times during the meal and was not observed changing gloves or washing hands during the meal service. In the Unit 6 dining room on 7/13/2016, dietary server #8 was observed preparing residents' meals. During the meal, dietary server #8 was observed touching multiple surfaces and items with gloved hands and then handling food items without changing gloves, including: - At 12:45 PM, dietary server #8 went into the back room refrigerator to obtain ice cream, used the scoops to serve multiple food items, and then used the same gloved hands to hold bread and remove the crust from a slice of bread. - At 1:15 PM, dietary server #8 wore gloves and held a pack of crackers, then scooped spaghetti and zucchini. With the same gloved hands, the server held two piece of bread and removed the crusts. - Dietary server #8 repeated this practice several times during the meal and was not observed changing gloves or hand washing during the meal service. On 7/13/2016 at 1:40 PM, dietary server #8 stated in an interview she wore gloves during the entire meal service and only changed her gloves when they were really dirty. 3) In the Unit 2 dining room on 7/11/2016, dietary server #27 was observed preparing residents' meals between 5:32 PM and 6:03 PM. During the meal, dietary server #27 was observed touching multiple surfaces and items with gloved hands and then handling food items without changing gloves, including: - Using a gloved hand to open the refrigerator and using the same gloved hand to scoop croutons, lettuce, bread, and touching plate and bowl surfaces prior to serving the residents; - Using the wireless phone several times, placing it on her shoulder with her gloved hand, removing the phone from her shoulder and setting it on the counter surface, and then reaching for items with the same gloved hands, including bread rolls, bread slices, eggs, croutons, and lettuce. - Dietary server #27 repeated this practice several times during the meal and was not observed changing gloves or hand washing during the meal service. Dietary server #27 was contacted by telephone on 7/14/2016 at 12:49 PM, and was unavailable to interview prior to the exit of the recertification survey. 10NYCRR 415.19(a)(1-2)(b)(3-4)

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Incident involving Resident #5 and 25 has been fully investigated and the Residents have had no complications related to the lack of hand washing during the dressing change. The nurse who did not wash her hands between dressing changes for Resident #5 and 2 was re-educated on proper hand washing technique and infection control. The nurse was observed during a subsequent dressing change by an RN and demonstrated proper hand washing technique post education.
Incident involving dietary aides providing service on units 2, 6, and 8 has been fully investigated and no Residents were identified as experiencing complications related to the lack of hand washing or changing of gloves while preparing food and touching multiple surfaces. The dietary aides involved were re-educated on proper hand washing technique and the importance of changing gloves when handling food after touching surfaces. The dietary workers were observed during subsequent meals by the Dietary Supervisor and each demonstrated proper hand washing technique and changes gloves as necessary while preparing food and touching other surfaces.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
A random sample of licensed practical nurses (LPN) was selected to observe during a dressing change to ensure proper hand washing technique and practice was being utilized. Five (5) LPNs were observed by an RN and all demonstrated proper technique. There were no other Residents identified who we affected by the same deficient practice.
A random sample of dietary aides was selected to observe during meal preparation at varying meals and times to ensure proper hand washing technique and glove usage was being utilized. Five (5) dietary aides were observed by the dietary supervisor and all demonstrated proper technique. There were no other Residents identified who we affected by the same deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The dressing change policy was reviewed with no changes made. All nurses who complete dressing changes will receive mandatory education regarding hand washing and infection control. The training will emphasize the importance of proper hand washing, cross contamination, the risk for infection, and proper dressing change technique. A procedure reference book, Taylor?s Clinical Nursing Skills 4th Ed, which includes information regarding dressing changes, and proper technique for hand washing is readily available on each unit for staff member use.
All staff who provides assistance with Resident meals, with an emphasis on those who prepare and serve foods, will receive mandatory education regarding proper infection control practices. This education will include proper use of gloves, hand washing, and potential contamination of foods when touching surfaces and then food products.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing or designee will audit 10 nurses during dressing changes to ensure the procedure was completed correctly, hand washing was performed, and infection control practices maintained. This audit will be conducted monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
The Food Service Director or designee will audit 7 dietary aides during meal service. These audits will be conducted during varying times and meals to ensure proper hand washing and glove usage technique is being utilized during meal preparation.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible

FF09 483.25(i):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure 2 of 6 residents reviewed for weight loss (Residents #3 and 27) maintained acceptable parameters of nutritional status. Specifically, Resident #3 had documented weight loss and was not encouraged or assisted at meals as planned. Resident #27 had documented weight changes, re-weights were not completed, and timely changes were not made to her nutritional plan of care. Findings include: 1) Resident #3 had [DIAGNOSES REDACTED]. The registered dietitian (RD) progress note dated 3/20/2016 documented the resident's usual body weight (UBW) was 110 pounds. A weight of 90 pounds was documented on 3/16/2016. The nursing progress note dated 6/2/2016 at 9:34 AM documented the resident needed much encouragement to eat and drink. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition, frequent poor appetite, and required supervision with meals. The comprehensive care plan (CCP) dated 6/3/2016 documented for staff to provide assistance if meal consumption was at or below 50%. The speech-language pathologist (SLP) evaluation dated 6/7/2016 documented the resident had moderate dysphagia, and to assist with meals if consumption was at or below 50% of meals. The physician progress notes [REDACTED]. The RD progress note dated 6/17/2016 documented a nutrition [DIAGNOSES REDACTED]. The resident received 120 cc (cubic centimeters) of Ensure [MEDICATION NAME] (nutritional supplement) twice daily (bid) at medication pass for 350 calories, and 200 cc Ensure Clear (nutritional supplement) at all meals for 365 calories daily. The occupational therapy (OT) note dated 6/21/2016 documented recommendations including: - offer the resident 1 food item and 1 beverage item at a time; - provide visual prompts to encourage self-feeding; - staff to sit with the resident; and - if the resident refused a meal in the dining room, offer the meal in the resident's room. The CCP updated 6/21/2016 documented for staff to sit with the resident at meals and provide visual prompts to encourage continual self-feeding, as well as offer a meal in the bedroom if she refused the meal in the dining room. The nursing progress note dated 6/25/2016 at 1:50 PM documented the resident was very resistive to taking her nutritional supplement and needed much encouragement. The SLP note dated 6/28/2016 documented the resident tolerated pureed solids with thin liquids. Staff were to assist with meals as needed (PRN). The Medication Administration Record [REDACTED]. The resident care record (care instructions) dated 7/6/2016 documented the resident required set-up and assistance with meals. The resident was observed on 7/12/2016 at 8:00 AM sitting in the dining room while breakfast was served. The resident placed her eggs on top of her coffee cup, and her pureed oranges were untouched. Staff did not sit with the resident, encourage meal intake, or provided visual cues to the resident. On 7/13/2016, the weight record documented the resident weighted 81 pounds. (The resident weighed 91 pounds on admission, on 3/9/2016.) On 7/13/2016 at 12:55 PM, the resident was observed sitting at the table in the dining room with a clothing protector folded on the table and she was not eating. Staff did not sit with the resident, encourage meal intake, or provided visual cues to the resident. On 7/13/2016 at 1:20 PM, the resident was observed eating another resident's food. A certified nurse aide (CNA) took the food away from the resident. The resident then began mixing her food between bowls that were in front of her. The CNA took the food and said, I think you're done. The meal consumption record from 7/11/2016 - 7/14/2016 documented the resident ate 50% or greater, at 0 of 12 meals. On 7/14/2016 at 8:10 AM the resident was seated at the dining table with a bowl of eggs and was not eating. The resident remained seated and not eating through 9:00 AM, without encouragement or cueing offered by staff. At 9:00 AM, a hospitality aide removed the resident's clothing protector and moved away from the dining table. At 9:15 AM, the resident's meal tray was taking from the table and the resident remained seated in the dining room. During an interview with CNA #29 on 7/14/2016 at 11:15 AM, she stated staff walked around dining area during meals to see if residents required assistance. She stated the resident was resistive to assistance in the past, So I don't try with her. During an interview with registered nurse (RN) Manager #4 on 7/14/2016 at 11:45 AM, she stated most residents on the unit were stable, with the exception of Resident #3. She stated the resident had a failure to thrive [DIAGNOSES REDACTED]. She stated, Maybe we can seat her somewhere else. 2) Resident #27 had [DIAGNOSES REDACTED]. The weight record documented the resident weighed 150.8 pounds on 1/28/2016, and 153.4 pounds on 1/29/2016. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately cognitively impaired. She required supervision with eating and extensive assistance for most other activities of daily living (ADLs). She was on a mechanically altered diet. She did not have a weight loss or weight gain, and having snacks between meals was very important to her. The weight record documented the resident weighed 150 pounds on 2/4/2016 (3.4 pound/2.22% loss from 1/29/2016). The 3/7/2016 Resident Care Record (care instructions) documented the resident required assistance with eating. The weight record documented the resident weighed 151.1 pounds on 3/9/2016 (1.1 pound/0.73% gain in 30 days). A registered dietitian (RD) progress note dated 3/22/2016 documented the resident participated in dysphagia therapy from 2/4/2016 - 3/4/2016. The resident's average meal intake was 69% which was a decline from last review. The resident had 1% loss in 30 days and was at risk for suboptimal intake related to consistency modifications resulting in unintentional weight loss, dehydration, and skin breakdown. The resident's nutritional plan of care would remain the same. The 3/2016 meal intake record documented the resident accepted between 0 - 33% of her snacks daily. The weight record documented the resident weighed: - 150 pounds on 3/24/2016; - 147 pounds on 3/30 and 4/1/2016 (6.4 pound/4.17% loss in 60 days); - 139 pounds on 4/13/2016 (14.4 pounds/9.39% significant loss from 1/29/2016); and - 141.2 pounds on 4/20/2016 (12.2 pounds/7.95% significant loss from 1/29/2016). There were no documented re-weights from 3/24/2016 - 4/20/2016. A nursing progress note dated 4/22/2016 documented the physician was made aware of weight loss with orders for Ensure [MEDICATION NAME]. A physician telephone order dated 4/22/2016 documented Ensure [MEDICATION NAME] (nutritional supplement) 120 milliliters (ml) by mouth (po) twice daily (BID) for weight loss. There was no documentation that nutritional services was notified or assessed the resident following the weight loss or addition of Ensure. The weight record documented the resident weighed 150.5 pounds on 4/28/2016 (9.3 pound/6.18% significant gain in 1 week). The MDS assessment dated [DATE] documented the resident was cognitively intact. She ate with supervision with one person physical assist, did not have a significant loss or gain in weight, and was on a mechanically altered diet. She was at risk for skin breakdown and was to have nutrition or hydration intervention to manage skin problems. The weight record documented the resident weighed 151.1 pounds on 5/4/2016 (9.9 pounds/6.55% significant gain in 2 weeks). An RD progress note dated 5/5/2016 documented the resident's meal intake averaged 74%. The note documented the resident's weights on 4/13 and 4/20/2016 appeared to be in error. The resident continued to be at risk for suboptimal intake and no changes were made at that time. There was no documentation of the resident's Ensure in the RD progress note. The weight record documented the resident weighed 145.2 pounds on 5/11/2016 (5.9 pounds/3.9% loss in 1 week). There was no documentation a re-weight was completed. The comprehensive care plan (CCP) dated 5/15/2016 documented the resident was at risk for suboptimal intake resulting in unintentional weight loss, dehydration, and skin breakdown. The resident would be on weekly weights, be provided Ensure [MEDICATION NAME] 120 twice daily at medication pass, and have adaptive equipment at meals. The weight record documented the resident weighed: - 151.2 pounds on 5/18/2016 (6 pound/3.9% gain in 1 week); - 150.8 pounds on 6/1/2016; and - 145.5 pounds on 6/15/2016 (7.9 pounds/5.2% loss in 5 months and 5.3 pounds/3.5% in 2 weeks). There was no documentation a re-weight was completed for 6/15/2016. An RD progress note dated 6/27/2016 documented the resident's current plan of care remained appropriate. The CCP was updated on 6/28/2016 and documented the resident was receiving 90 ml of Ensure [MEDICATION NAME] twice daily at medication pass. The resident was observed on 7/11/2016: - between 12:55 PM and 1:05 PM, not eating her pureed entree. At 1:05 PM and 1:10 PM, the resident was attempting to scoop her pureed carrots with a knife and consumed a teaspoonful amount. The resident remained seated, occasionally attempting to eat with her knife through 1:18 PM. - At 5:43 PM, she was seated with family members at the dinner table. The family requested an alternate dish at that time. The resident's family member continued to encourage the resident who had increased difficulty, shaking, taking small amounts of food to her mouth, and had difficulty using a fork. At 6:05 PM, the resident's family left. Through 6:28 PM, the resident was unable to manipulate her silverware, consumed less than a teaspoonful of food at a time after multiple attempts, and placed her straw in her pureed vegetables. The resident received her alternate dish at 6:28 PM. The resident made multiple attempts to eat her pureed entree and vegetable. The resident did not receive assistance through 6:33 PM when the surveyor left the dining area. The resident was observed on 7/13/2016 at 9:35 AM and 9:57 AM with her head down, not eating at the dining table. From 5:32 PM - 6:00 PM, the resident was seated at the dining table and had difficulty picking up noodles from her macaroni salad onto her silverware. After multiple attempts, the resident would bring a noodle to her mouth, suck on the dressing, and spit the noodle back out. The resident continued to have difficulty with her noodles and pureed cauliflower during that time period. During an interview with RD #26 on 7/14/2016 at 11:41 AM, she stated the resident's weight fluctuated. She stated she did not make any changes to the resident's plan of care when weights were lower than normal, as she did not feel the weights were accurate. She stated when weights were abnormal for a resident, re-weights were completed and should have been done for this resident. During an interview with certified nurse aide (CNA) #24 on 7/14/2016 at 12:36 PM, she stated the resident had increased difficulty with eating during the past week. She stated normally it took 5-10 minutes to receive an alternate meal. She stated the resident used to eat better. During an interview with CNA #25 on 7/14/2016 at 1:02 PM, she stated the resident had increased difficulty with eating. She did better with her fluids than her solids, and her weight fluctuated. She stated weekly weights were done on Wednesdays. If a weight was 3 pounds or more different from the previous week, a nurse was notified, and a re-weight was done to ensure accuracy. 10NYCRR415.12(i)(1)

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #3 care plan, level of assistance/cueing required to complete a meal was reviewed and remains appropriate. The Registered Nurse evaluated the Resident during subsequent meals, and trialed the Resident at a table she was previously seated at. This seating assignment will increase her socialization, proximity to peers, and provide increased staff interaction and supervision. The unit staff who feed and supervise Residents during meals received education regarding strategies to promote intake, re-approaching Residents who do not actively participate in feeding or who are distracted easily, and dignity. Resident #27 was assessed by the clinical Dietician. At this time, the Resident?s weights have remained stable. Resident #27 was also evaluated by the speech pathologist on 7/13/2016, and her diet order was changed to puree with nectar thick fluid. On 7/14/2016 the occupational therapist evaluated the Resident and recommended a blue inner lip plate, scoop bowl, and light weight built up slight angle spoon to promote self-feeding. The care plan and resident care card were revised to reflect these recommendations, and staff was re-educated. The Resident is seated at a staff table, and will receive assistance as needed to complete her meals.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
The Mealtime observation was completed on all nursing units to monitor for appropriate assistance being offered, cueing, meal service, use of adaptive equipment, and the seating assignment to facilitate staff assistance during meals. All concerns were corrected at the time of observations, and continued monitoring during meals service will be provided to ensure the Resident?s needs are met. The clinical dietician evaluated all Resident who have experienced weight loss to ensure proper weights and re-weights have been documented. No other Residents were identified with the same deficient practice as it pertains to accurate weight monitoring.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Nutrition Assessment and Reassessment policy was revised to include timely assessment of weight loss by the dietician within 3 business days. Nursing will perform an automatic reweigh (within 24 hours) of a weight loss/gain of 3 pounds in one week or 5 pounds in one month.
The dietician will monitor and assess all Residents who have experienced a weight loss of 3 pounds in one week, 5 pounds in a 30 day period, or demonstrating a weight loss trend, document recommendations, and update the care plan accordingly. The Clinical Dietician will meet weekly with nursing to review each Resident who has experienced a weight loss/gain of 3 pounds in one week, or 5 pounds in a 30 day period. During this meeting the care plan will be reviewed, strategies to promote intake, advanced directives (as applicable), and pharmacological interventions.
A policy for mealtime considerations was developed. This policy addresses care and services to maximize Resident participation, intake, and assistance during meals, proper feeding techniques, positioning, documentation, and monitoring to ensure the Resident?s needs are being met during the dining experience.
Mandatory education will be provided for all staff that feed, assist, and supervise Residents during meal time. This education will emphasize the importance of promoting independence during meals, proper seating and socialization to promote intake, cueing and assistance as required completing the meal, strategies to redirect Residents who are easily distracted, to obtain reweighs for anyone who has experienced a weight loss/gain of 3 pounds in one week and 5 pounds in 30 days, and notification of dietary, therapy with changes in eating patterns and ability.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Chief Clinical Dietician and/or designees will audit each nursing unit monthly, at varying meal times, until 100% compliance has been achieved for 3 consecutive months. This audit will be conducted by the multi-disciplinary team. Monitoring for compliance is the responsibility of the Chief Clinical Dietician, and will be reported to the Quality Improvement Council. The Chief Clinical Dietician will audit all Resident with weight loss on a weekly basis to ensure assessments are completed in a timely manner, appropriate measures are in place, and care plans are updated. The audit will be completed until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Chief Clinical Dietician and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Chief Clinical Dietician will be responsible for this deficiency

FF09 483.25(m)(2):RESIDENTS FREE OF SIGNIFICANT MED ERRORS

REGULATION: The facility must ensure that residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 7 residents (Resident #7) observed during a medication administration observation was free from significant medication errors. Specifically, Resident #7 was administered insulin into the deltoid muscle during an observation. Findings include: Resident #7 had [DIAGNOSES REDACTED]. The comprehensive care plan dated 2/29/2016 documented the resident had diabetes and was to receive medications as ordered. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, required limited assistance with most activities of daily living, and received insulin injections. The physician orders [REDACTED]. During a medication administration observation on 7/12/2016 at 8:30 AM, licensed practical nurse (LPN) #3 prepared to give the resident his insulin injection in his room. She asked the resident if she could give him his insulin, he stated yes, and she proceeded to roll up his left sleeve exposing his upper arm. She pulled the skin on the upper arm taut, inserted the needle at a 90 degree angle (intramuscularly) into the deltoid (large triangular muscle covering the shoulder), and injected the insulin. She disposed of the syringe into the sharps container and exited the room. The Insulin Administration Policy was revised on 9/2014 and documented that after the medication was prepared: - a skin fold should be formed between the thumb and index finger, at least 3 inches apart by the non-dominant hand; then - the needle was to be inserted into the subcutaneous tissue at a 45 degree angle. LPN #3 was interviewed on 7/14/2016 at 9:10 AM and stated it was her understanding that insulin was to be given in the deltoids, the thighs, or the abdomen. She stated she believed she attended an inservice regarding insulin injections in the last couple of years. Registered nurse (RN) Manager #4 was interviewed on 7/14/2016 at 9:25 AM and stated that insulin could be given in varied sites such as the abdomen and in the backs of the arms. She stated that giving an insulin injection into the deltoid muscle was not the appropriate route of administration for that medication. 10NYCRR 415.12 (m)(2)

Plan of Correction: ApprovedAugust 5, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Incident involving Resident #7 has been fully investigated and the Resident has had no complications of hyper/[DIAGNOSES REDACTED] from insulin administered in the deltoid muscle. The nurse who administered the insulin to Resident #7 was re-educated on proper insulin administration sites, and was observed during administration of insulin utilizing proper technique after completing the education.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
A random sample of licensed practical nurses (LPN) was selected to observe during the insulin administration process to ensure the correct site and technique was utilized. Five (5) LPNs were observed by an RN and all demonstrated proper technique. There were no other Residents identified who we affected by the same deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The medication administration policy was reviewed with no changes made. All nurses who administer medications will receive mandatory education regarding insulin administration. The training will emphasize the importance of using the correct site and technique for all sub cutaneous medications. Annual medication competency evaluations for nurses who administer medications were updated to include verbalization or demonstration of the appropriate site used during the administration of insulin. A procedure reference book, Taylor?s Clinical Nursing Skills 4th Ed, which includes information regarding the appropriate insulin injection sites and proper technique for insulin administration is readily available on each unit for staff member use.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing or designee will audit 10 nurses during insulin administration to ensure the correct site was utilized. This audit will be conducted monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible

FF09 483.13(a):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure 1 of 5 residents (Resident #11) reviewed for restraints was free from physical restraints not required to treat medical symptoms. Specifically, for Resident #11, there was no documented evidence the use of a seat belt was assessed to determine if it was the least restrictive device; there was not a physician order [REDACTED]. Findings include: Resident #11 had [DIAGNOSES REDACTED]. The facility's policy for restraint usage, effective 9/14/1999 and reviewed 11/2014, documented: - restraint decisions were made by the collaborative efforts of the resident, family, physician, and interdisciplinary team members; - physical restraints were ordered and used to treat specific medical symptoms assisting the resident to reach his/her highest level of physical/psychological well/being and protecting his/her health and safety; - physical restraints and safety devices were to be ordered by a qualified medical professional and the order was to contain: the appropriate need or continued need based on medical symptom, the type of device, the specified period of time, the release schedule, and ordered for 30 days; and - each resident had an individualized care plan involving restraint usage, and restraints were assessed quarterly. The resident's care card (care instructions) dated (MONTH) (YEAR) documented the resident had a self releasing seat belt and it was to be released every 2 hours. The restrictive device assessment dated [DATE] did not document the resident had a restraint. The comprehensive care plan (CCP) updated 1/14/2016 documented the resident's daily decision making was impaired. She had a history of [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. She required extensive assistance to total dependence on staff for activities of daily living, did not walk, was incontinent, and had no falls since the last assessment. The MDS documented restraints were not used. The physical therapist (PT) note dated 3/28/2016 documented the resident was evaluated for physical therapy related to falls. The resident had a fall and fractured her lower left leg in January. She had a brace on the leg causing pressure on the ankle. The resident had 2 falls in the past week, one from the bed and one from the geri chair. PT recommended elevation of the leg and the resident should be brought out of the room for closer monitoring. The note did not document the resident used a seat belt. The PT notes dated 4/4/2016 and 4/22/2016 documented the resident was seen for positioning follow-up. She was in good position in a Broda chair (type of geri chair). The PT notes did not document the resident used a seat belt. The CCP updated 4/4/2016 documented the resident had a history of [REDACTED]. The nursing progress note dated 5/25/2016 at 10:28 AM documented the resident was alert and taking her seat belt off. She was placed at the nursing station for monitoring. The nursing progress note dated 6/10/2016 documented the resident's daughter asked the nurse if the resident could have a wheelchair with a seat belt to go outside. The physician order [REDACTED]. The OT note dated 6/13/2016 documented the resident was seen for OT evaluation for positioning in wheelchair and seat belt with special instructions for daughter to take outside. The note documented the resident was seated in a Broda chair, in good position, and was last seen for wheelchair positioning on 4/22/2016 by PT. During the evaluation, the therapist maneuvered the Broda chair without it catching or swaying. The therapist placed a call to the daughter and left a message. The plan was for the therapist to reassess the resident after a call back from the daughter to determine if the resident would benefit from modifications or a different chair. The note did not document the resident was using a seat belt. The restrictive device assessment dated [DATE] did not document the resident had a restraint. The nursing progress note dated 6/23/2016 at 10:58 AM documented the resident kept taking her seat belt off and tried to get up unassisted. The MDS assessment dated [DATE] documented the resident's cognition was severely impaired. She required extensive assistance to total dependence on staff for activities of daily living, did not walk, was incontinent, and had 2 or more falls since the last assessment. The MDS documented restraints were not used. The resident's care card dated (MONTH) (YEAR) documented the resident had a self release seat belt and it was to be released every 2 hours. When interviewed on 7/11/2016 at 11:30 AM, the registered nurse (RN) Manager #19 stated the resident had a restraint and it was an alarming seat belt. When observed on 7/11/2016 at 4:40 PM, the resident was in the dining room asleep in her Broda chair with the seat belt fastened. When observed on 7/12/2016 at 10:10 AM, the resident was in the dining room seated in her Broda chair with the seat belt fastened and having a snack. When observed on 7/13/2016 at 8:45 AM, the resident was at the nursing station in her Broda chair with an overbed table, reading a magazine. The resident was alert and talkative. When observed on 7/13/2016 from 12:55 PM to 2:10 PM, the resident was in the dining room in a regular wheelchair with a seat belt fastened the entire time. The resident finished her lunch at 1:52 PM. At 2:10 PM, the certified nurse aide (CNA) took the resident to her room for a nap. When interviewed on 7/13/2016 at 2:13 PM, CNA #28 stated the seat belt was used to keep the resident from crawling out of the chair. She stated the resident had the seat belt for a few months and sometimes unbuckled it herself. She stated she was not aware of any instructions to release the seat belt, and the seat belt was not released at meals. When interviewed on 7/14/2016 at 9:20 AM, licensed practical nurse (LPN) #20 stated the resident had a seat belt to keep her from falling out of the chair. She stated the seat belt was initiated after the resident fell out of the chair and broke her leg. When interviewed on 7/14/2016 at 9:35 AM, RN Manager #19 stated the decision to initiate a restraint was made by the interdisciplinary team and the physician. She stated documentation would include: family notification and education regarding risks and benefits, a physician order, and an assessment to determine the least restrictive device. She stated the resident had an order for [REDACTED]. The PT stated she saw the resident on 7/13/2016, and she was very alert, was able to release the seatbelt on command, and the seat belt was not a restraint. She stated for the seat belt not to be considered a restraint, the resident has to be able to release it on command every time and she was able to do that yesterday. She stated PT was not involved in the initial decision to use the seat belt, and she did not know if the resident was able to release the seat belt by herself prior to 7/13/2016. On 7/14/2016 at 11:30 AM, the resident was observed sitting in her wheelchair in the dining room with the seat belt fastened. The surveyor pointed to the seat belt and asked the resident what it was for and if she could take it off. The resident stared at the surveyor and did not seem to understand. The PT came over and put the resident's hand on the seat belt and prompted her to release it. The resident was able to release the seat belt with prompting. The RN who completed the restrictive device assessment dated [DATE] was unavailable for interview. When interviewed on 7/14/2016 at 12:45 PM, the Director of Nursing (DON) stated residents were assessed by an RN for restraint usage, and PT was involved. The need for a restraint would then be discussed with the physician, and an order was obtained. She stated if a resident was able to self release a seat belt, it would be documented on the assessment form, and would be on the CCP as a reminder. The DON looked at the resident's restrictive device assessment dated [DATE] and stated the resident did not have any restraint, including a seatbelt. She stated Resident #11 had lucid periods, and at other times was out of it, and her ability to self release a seat belt would depend on her cognition. She stated in her opinion, a seat belt could be detrimental for the resident and increased her chance of tipping over forward with the wheelchair. 10NYCRR 415.4(a)(2)

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #11 was assessed by physical therapy and nursing. Based on observation and assessment, the alarming seatbelt has been discontinued. During periods of lethargy, the Resident will utilize a reclining posture chair for comfort and proper positioning. When alert the Resident will utilize a standard wheelchair to maximize her independence and maintain her highest practical physical function. The Resident?s care plan, restrictive device assessment, and Resident care record have been completed and updated accordingly.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An audit was conducted by the nurse Managers for all Residents who utilize ?quick release? seat belts and/or restraints to ensure there is a current active order, restraint usage evaluation, consent for physical restraint, accurate restrictive device assessment, an individualized care plan for restraint use, and the Resident care record reflect Resident specific interventions related to the restraint. No other Residents were identified with the same deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Restraint Usage Policy was reviewed and no changes were required. Mandatory full house education regarding the Restraint Usage policy, identification of restraints, use of the least restrictive measures, implementation of restraints, on-going evaluation, documentation, and care planning when restraints are utilized.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing or designee will audit all Residents who have restraints to ensure the Resident Restrictive Device Assessment is complete and accurate, the MD order is current, the Restraint Usage Evaluation is complete, each month until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency

FF09 483.20(k)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: The services provided or arranged by the facility must meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 5 of 9 residents observed during a medication administration observation (Residents #7, 31, 32, 33, and 34), the facility did not provide services that met professional standards of quality. Specifically, for Residents #7, 31, 32, 33, and 34, the nurse pre-prepared [MEDICATION NAME] (laxative) for future administration to the residents. Findings include: Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #7 had severely impaired cognition, was always continent of bowels, and required limited assistance with toileting. The physician orders [REDACTED].#7 documented polyethylene [MEDICATION NAME] powder ([MEDICATION NAME], laxative) 17 grams by mouth daily. Resident #33 had [DIAGNOSES REDACTED]. The physician orders [REDACTED].#33 documented polyethylene [MEDICATION NAME] powder 17 grams by mouth daily. The MDS assessment dated [DATE] documented Resident #33 had severely impaired cognition, was always incontinent of bowels, and required extensive assistance with toileting. On 7/12/2016, licensed practical nurse (LPN) #3 was observed during medication administration: - at 7:40 AM, she prepared 5 cups of a substance at the medication cart. She stated it was [MEDICATION NAME], and she was preparing it ahead of time because the residents did not like it gritty. She showed the surveyor the residents' names documented on the cup lids and placed the cups back into the medication cart; - at 7:45 AM, LPN #3 entered an unidentified resident's room with a vitamin and a nutritional supplement. The resident was sleeping and the medication was wasted; - at 8:00 AM, she administered medications to Resident #33 that included the pre-prepared [MEDICATION NAME]; and - at 8:15 AM, she entered Resident #7's room with his medications. The resident was administered medications including the pre-prepared [MEDICATION NAME] at 8:30 AM. LPN #3 was interviewed on 7/14/2016 at 9:10 AM and stated she administered pre-prepared [MEDICATION NAME] to Residents #31, 32 and 34 after the medication observation was completed with the surveyor on 7/12/2016. She stated she was not aware of a facility policy for pre-preparing medications and she only did so because the residents liked the [MEDICATION NAME] prepared that way. Registered nurse (RN) Manager #4 was interviewed on 7/14/2016 at 9:25 AM and stated that medications were to be prepared one resident at a time and then administered. 10NYCRR 415.11(c)(3)(i)

Plan of Correction: ApprovedAugust 5, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Incident involving Resident(s) # 7, 31, 32,33, and 34 has been fully investigated and none of the Residents have experienced complications from the administered [MEDICATION NAME]. The nurse who prepared and administered the [MEDICATION NAME] to Resident(s) # 7, 31, 32, 33, and 34 was re-educated on proper medication preparation and administration to include preparing medications for only one Resident at a time and was observed during preparation and administration of [MEDICATION NAME] utilizing proper technique after receiving education.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
A random sample of licensed practical nurses (LPN) who administer medications was selected to be observed during the [MEDICATION NAME] preparation and administration procedure to ensure that the correct process was being utilized. The sample consisted of five (5) LPNs who were observed by an RN; there were no variances noted during the medication observation. No other Residents were identified as being affected by the same deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The medication administration policy was reviewed with no changes required. All nurses who administer medications will receive mandatory education regarding [MEDICATION NAME] preparation and administration. The training will emphasize the importance of proper [MEDICATION NAME] preparation and administration to include preparing medications for only one Resident at a time. Annual medication competency for nurses who administer medications was updated to include appropriate preparation during the administration of powdered medications.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing or designee will audit 10 nurses during [MEDICATION NAME] administration to ensure the nurses are only preparing medications for one Resident at a time. The audit will be utilized each month until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

Physical Plant Violation - State Only 10NYCRR 713-2.21 (e)(2)(iii): Backflow preventers (vacuum breakers) shall be installed on hose bibbs, janitor's sinks, bed pan flushing attachments and on all other fixtures to which hoses or tubings can be attached. Based on observation and interview, it was determined that the facility did not ensure that hose bibb connections with hoses attached in the main kitchen dishwasher room and in the Unit 3 kitchenette were provided with backflow preventers (vacuum breakers) for 2 of 5 floors (Floors 1 and 3) observed. Findings include: On 7/11/2016 between 11:15 AM and 11:45 AM, a surveyor observed the following: - the dishwasher room in the 1st floor main kitchen had a garden hose with sprayer. The hose bibb connection lacked a backflow preventer (vacuum breaker); and - the unit 3 kitchenette on the 3rd floor had a garden hose with sprayer on the side of a cabinet. The hose bibb connection lacked a backflow preventer. In an interview with the Director of Facilities on 7/13/2016 between 2:45 PM and 3:30 PM, he stated he was unaware the hose bibb connections lacked backflow devices, and would have them installed immediately. NYCRR 713-2.21 (e)(2)(iii)

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
The dishwasher room hose bibb connection, and unit 3 kitchenette on 3rd floor hose bibb connection have been repaired and now have a backflow device.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
All sinks with a hose bibb connection will be evaluated by the Director of Maintenance. If needed, back flow devices will be installed. This work will be completed by 8/12/2016
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
As part of the preventative maintenance schedule, hose connections, and back flow devices will be evaluated by the Director of Facilities to ensure the proper mechanisms have been installed and maintained to prevent back flow of water.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Facilities and/or designee will audit each hose connection in the dishwasher room and nursing units monthly, until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Facilities and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Facilities will be responsible for this deficiency

FF09 483.25(j):SUFFICIENT FLUID TO MAINTAIN HYDRATION

REGULATION: The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined for 4 of 14 residents (Residents #10, 13, 16, and 27) reviewed for hydration, the facility did not ensure each resident was provided with sufficient fluid intake to maintain proper hydration and health. Specifically: - Resident #10 was admitted to the facility with an order for [REDACTED]. - Resident #13 consumed fluids poorly and there was no documented evidence of a clinical nutrition reassessment or that changes to the plan of care were attempted; - Resident #16 had a decline in fluid intake without changes being attempted in the plan of care. The resident later required IV (intravenous) hydration and there was no documented evidence changes were made to the plan of care until the resident received her second course of IV hydration; and - Resident #27 was treated for [REDACTED]. There was no documented evidence the resident's fluid needs were reassessed when she had UTIs, and no documented evidence changes were made to the plan of care to optimize fluid intake timely. Findings include: 1) Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) initiated on 2/14/2016 documented the resident was at risk for suboptimal intake, which could result in weight loss, dehydration, and skin breakdown. The goals included no signs or symptoms of dehydration. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and fed herself after meal set-up. The registered dietitian (RD) progress note dated 2/24/2016 documented the resident consumed an average 1590 millimeters (ml) of fluid per day, which included a supplement drink of Ensure or [MEDICATION NAME] (nutritional supplements) twice daily. The RD noted the resident fed herself. The nutrition counselor progress note dated 3/31/2016 documented the resident consumed an average of 1275 ml per day, which was 85% of her assessed fluid needs. The resident continued to receive Ensure or [MEDICATION NAME] twice a day, fed herself, and her daughter completed her menus. No changes were made to the plan of care at that time. The RD progress note dated 5/10/2016 documented the resident's fluid intake averaged 1015 ml per day, she continued to receive the Ensure or [MEDICATION NAME] twice a day, and her intake had declined. The RD made no changes to the plan of care at that time. The laboratory (lab) report dated 5/12/2016 documented the resident's blood urea nitrogen (BUN, measure of hydration status) was high at 80 milligrams per deciliter (mg/dl) (normal=7-18 mg/dl), creatinine (measure of kidney function and hydration) was high at 2.17 mg/dl (normal = 0.55-1.02 mg/dl), and sodium (measure of hydration status) was high at 146 milliequivalents per liter (mEq/L) (normal=136-145 mEq/L). The 5/12/2016 physician order [REDACTED]. The RD progress note dated 5/13/2016 documented the resident's intake had declined to 1015 ml per day when she was seen by the RD on 5/10/2016 and IV fluids were initiated. The RD noted the resident's current meal plan provided 600 ml of fluids at breakfast, 480 ml at lunch and dinner, and 240 ml between meals. There was no documentation of changes being made to the plan of care at that time. The physician progress notes [REDACTED]. The physician orders [REDACTED]. The MDS assessment dated [DATE] documented the resident had moderately impaired cognition, needed total assistance at meals, received an antibiotic, had a fever, and was dehydrated during the assessment period. The RD progress note dated 5/25/2016 documented the resident's fluid intake was 875 ml per day and the resident was fed by staff at 8 meals during the past week. Pudding was initiated twice a day. The resident was being treated for [REDACTED]. Physician orders [REDACTED]. - on 6/13/2016, provide meal assistance to the resident at meals if she took in less than 25%; - on 6/17/2016, initiate IV fluids; and - on 6/19/2016, discontinue IV fluids. The RD progress note dated 6/20/2016 documented the resident's fluid intake was suboptimal and she required IV hydration. The RD also noted the resident received extensive assistance at 10 meals in the past week. There was no documentation of changes made to the resident's plan of care. The 6/30/2016 updated care card (care instructions) documented to assist the resident at meals. On 7/11/2016 between 11:45 AM and 12:05 PM, registered nurse (RN) Manager #5 stated in an interview that the resident was dehydrated recently. In order to increase her intake, the resident was moved to a table with residents who needed to be fed, as she was now fed at meals. On 7/11/2016, the resident was observed at the supper meal including; - at 6:10 PM, the resident was seated in her wheelchair in the dining room with her meal in front of her. She received a pureed BLT salad, pureed tomatoes, pureed pears, lemon yogurt, pureed bread, [MEDICATION NAME] (lactose free milk), and tea. Certified nurse aide (CNA) #10 was sitting at the resident's table feeding two other residents and did not encourage or assist the resident; - at 6:33 PM, the resident had taken a few spoonfuls of yogurt and sips of [MEDICATION NAME] and then spilled about 1/2 of the yogurt cup on herself. From 6:33 PM to 6:42 PM, the resident used her spoon to scoop the yogurt off of her clothing protector and back into the yogurt container; and - at 6:51 PM, CNA #10 picked up the resident's meal ticket and documented her intake. When he did this, he did not encourage or assist the resident. The resident ate a few bites of the yogurt and took a few sips of [MEDICATION NAME]. The consumption record dated 7/11/2016 documented the resident ate 25% at the supper meal. The 7/11/2016 intake and output daily average with detail report did not document fluids consumed at supper on 7/11/2016. On 7/13/2016 at 9:00 AM, the resident was observed at a table with the breakfast meal and drinks in front of her along with her 9 AM Ensure supplement. The resident was drinking the Ensure on her own. The CNA collecting the meal tickets stated in an interview at that time that the resident was offered 600 ml with breakfast and accepted 360 ml that day. On 7/13/2016 at 3:22 PM, CNA #10 stated in an interview, the resident should be encouraged and assisted at meals. CNA #10 stated the resident had trouble with her hand so needed help with a spoon sometimes. On 7/13/2016 at 3:25 PM, the resident was observed seated in dining room with a cup in front of her with clear liquid in it. Inside the cup was an upside down and empty pudding container. On 7/14/2016, RN Manager #5 stated in an interview that after the resident was dehydrated the second time, she was moved to a table where residents were assisted at meals. She stated she expected the resident to be assisted at meals, although she was not a good drinker. The RN Manager stated the resident's order to be be assisted at meals if intake was less than 25% meant that staff should document the resident's intake on her ticket, and then keep track of her intake so that her average intake was over 25%. She stated when the resident's average intake was less than 25%, she would be fed, and this did not have to be implemented at each individual meal. On 7/14/2016 at 12:30 PM, RDs #11 and 12 were interviewed and stated: - there was not an RD assigned to the nursing facility; all of the RDs covered when needed; - the nutrition counselor who saw the resident on 3/31/2016 was no longer employed by the facility and was not available for interview; - RD #11 saw the resident on 5/10/2016, and RD #12 saw the resident on 6/20/2016, and neither could remember the resident; - RD #11 stated she did not make changes to the resident's plan of care when her intake was 1015 ml per day because she did not know if that was a decline in the resident's usual intake. She stated even though it was not documented, it was her usual routine to speak with nursing and ask if any meal changes were warranted when she reviewed a resident; - RD #12 stated any RD who was at the facility could attend morning report and they would have become aware of the resident needing IV fluids at morning report; - RD #12 stated they did not print out any reports from the electronic medical record, including reports that documented residents who consumed fluids poorly or residents who had a decline in intake; - RD #11 stated pudding was added to the resident's meal plan on 5/25/2016, and pudding would provide some fluid to the resident; and - RDs #11 and 12 both stated they were not involved in determining the level of care the resident needed at meals, as that would be determined by therapy. They stated if they saw a problem, they would ask therapy to get involved. Nether RD recalled observing the resident at meal rounds. 2) Resident #10 had [DIAGNOSES REDACTED]. The hospital discharge summary dated 6/2/2016 documented the resident was treated for [REDACTED]. The resident was also treated for [REDACTED]. The physician admission orders [REDACTED]. The dietitian admission note dated 6/3/2016 documented the resident was treated for [REDACTED]. The resident's meal intake was 25 to 50% during that time. The admission history and physical written by the physician on 6/3/2016 documented the resident was admitted to the facility for rehabilitative and wound care services. She had [MEDICAL CONDITION] and was experiencing generalized pain and weakness. The resident's lung sounds were clear, her oxygen saturation was 96% on room air (normal), and she had no [MEDICAL CONDITION] (swelling). The note did not document the resident was on a fluid restriction. The comprehensive care plan (CCP) dated 6/3/2016 documented the resident had [MEDICAL CONDITION] and the goal was to be free from complications. Interventions included assessing heart rate, blood pressure, and respirations each shift, a 1500 cc fluid restriction, monitor for [MEDICAL CONDITION] and elevate, monitor for signs and symptoms of complications, rest periods, and weekly weights. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She required extensive assistance to total dependence in all activities of daily living (ADLs) with the exception of eating, which required set up and supervision. The physician progress notes [REDACTED]. The resident's lungs were clear and she had no [MEDICAL CONDITION]. The resident's care card (care instructions) dated 7/2016 documented the resident had a 1500 cc fluid restriction. The resident's intake records from 7/3/2016 to 7/10/2016 documented her fluid intake ranged from 1065 cc/day to 1545 cc/day. The resident was observed on 7/11/2016 at 5:40 PM in bed eating supper. She had 2 drinks with her dinner and her meal ticket documented a 1500 cc fluid restriction. The physician progress notes [REDACTED]. There was no documentation pertaining to the fluid restriction. When interviewed on 7/12/2016 at 3:00 PM, the resident stated she was not on a fluid restriction prior to admission. When interviewed on 7/14/2016 at 9:35 AM, the registered nurse (RN) Manager #19 stated the resident was on a fluid restriction for [MEDICAL CONDITION]. She stated the resident was admitted with generalized weakness and had a lot of [MEDICAL CONDITION]. She stated not all residents with [MEDICAL CONDITION] were on fluid restrictions, and it depended on the resident's symptoms. She stated that Resident #10 had no signs of [MEDICAL CONDITION] since admission. She did not know the resident's history, and did not know if the resident was on a fluid restriction prior to admission. When interviewed on 7/14/2016 at 1:50 PM, the physician stated fluid restrictions were usually initiated by a cardiologist for [MEDICAL CONDITION] and residents came from the hospital with the restriction in place. He stated he worried about residents on fluid restrictions not getting enough fluids and depended on the dietitian to look at the fluid balance to determine if the restriction was reasonable. He stated Resident #10 was fairly new to the facility, and he assumed the fluid restriction was due to [MEDICAL CONDITION] and he would have to re-evaluate it. He stated the resident had no signs or symptoms of [MEDICAL CONDITION] since admission, and was unaware if the resident was on a fluid restriction before her recent hospitalization . 3) Resident #27 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 1/27/2016 documented the resident had decreased mobility related to recent UTIs and dehydration with a hospitalization . A registered dietitian (RD) progress note dated 1/29/2016 documented resident's assessed daily fluid needs were 2070 - 2415 milliliters (ml). The resident was on an antibiotic for a UTI, and was at risk for suboptimal intake related to consistency modifications resulting in unintentional weight loss, dehydration, and skin breakdown. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately cognitively impaired, required supervision with 1 person physical assist for eating. She was frequently incontinent and had a recent UTI. An RD progress note dated 2/5/2016 documented the resident's assessed daily fluid needs remained 2070-2415 ml. The resident's daily fluid intake ranged from 1290-1560 ml, with a 1427 ml average for 7 days. No changes were made to the resident's nutritional plan of care. The CCP updated on 2/8/2016 documented the resident had insufficient fluids and did not consume all liquids in 3 days. The resident had a history of [REDACTED]. Staff were to encourage increased fluid intake as tolerated, monitor for symptoms of dehydration, monitor intake and output, administer antibiotics as ordered, and provided added fluid during this infection. Nursing progress notes documented on 3/4, 3/5, 3/6, and 3/7/2016 that the resident continued on an antibiotic for a UTI. A 3/10/2016 nursing progress note documented the resident was no longer on the antibiotic. Nursing progress notes documented on 3/12, 3/21, and 3/24/2016 that the resident was [MEDICATION NAME](antibiotic) twice daily (BID) on the weekends for [MEDICATION NAME] treatment for [REDACTED]. An RD progress note dated 3/22/2016 documented the resident's assessed fluid needs remained 2070-2415 ml/day. The resident had a slight increase in her BUN (blood urea nitrogen, measure of hydration status). Her fluid intake ranged from [PHONE NUMBER] ml/day, with a 1092 average for 7 days. No changes were made to the resident's nutritional plan of care. A physician progress notes [REDACTED].=7-18 mg/dl, deciliter), with creatinine at 0.77 (measure of kidney function and hydration, normal = 0.55-1.02 mg/dl). Her BUN was 21 a month ago, and her creatinine was 0.95 last week. The 3/2016 fluid intake report documented the resident did not meet her fluid goal 27 of 31 days; she consumed 1200 ml or less on 15 of those 27 days. Physician orders [REDACTED]. - on 4/6/2016, obtain a U/A C&S (urinalysis with culture and sensitivity); - on 4/7/2016, the resident'[MEDICATION NAME] dosage was discontinued; and - on 4/9/2016, the resident was started on [MEDICATION NAME] (antibiotic) for 7 days. A nursing progress note dated 4/7/2016 documented the resident's urine was tannish in color via straight cath (catheterization), and her vaginal area was dry and painful. A nursing progress note dated 4/9/2016 documented the resident received the initial dose of [MEDICATION NAME], fluids were encouraged, and the resident continued to complain of painful urination. The MDS assessment dated [DATE] documented the resident was cognitively intact. She required supervision with 1 person physical assist for eating, and required nutrition or hydration intervention to manage skin problems. She was frequently incontinent and had a UTI in the last 30 days. The 4/2016 fluid intake report documented the resident did not meet her fluid goal 30 of 30 days; the resident consumed 1200 ml or less 12 of those 30 days. A physician progress notes [REDACTED]. An RD progress note dated 5/5/2016 documented the resident's fluid intake averaged 1328 cc for 7 days. The resident's supplement intake average was 219 in 7 days. The resident's BUN was 22 and creatinine was 0.92. The resident's fluid preferences remained decaf coffee, tea, juice, and milk only with her cereal. No changes were made to the resident's nutritional plan of care. The CCP was updated on 5/15/2016 and documented the resident was at risk for suboptimal intake resulting in unintentional weight loss, dehydration and skin breakdown. The resident received a fluid plan that included 360 ml/240 ml/240 ml at meals, and 240-480 ml in between meals. The resident received Ensure 120 ml twice daily at medication pass. The physician order [REDACTED]. The 5/2016 fluid intake report documented the resident did not meet her fluid goal 28 of 31 days; the resident consumed 1200 ml or less 8 of those 28 days. The physician orders [REDACTED]. Nursing progress notes dated 6/10 and 6/12/2016 documented the resident continued on an antibiotic for a UTI. A physician progress notes [REDACTED]. An RD progress note dated 6/27/2016 documented the resident's assessed fluids needs were 2040-2380 ml/day. The resident averaged 1622 ml for a 7 day period. The CCP updated on 6/28/2016 documented the resident's Ensure [MEDICATION NAME] was changed to 90 ml twice daily at medication pass. The 6/2016 fluid intake report documented the resident did not meet her fluid goal 24 of 30 days. The physician orders [REDACTED]. The physician orders [REDACTED]. The CCP updated on 7/8/2016 documented the resident had a UTI and was at risk for discomfort, incontinence, and fever. The resident would be provided with added fluids during the infection. The resident was observed seated in the dining room on 7/11/2016 from 1:05 PM - 1:18 PM, not drinking, and without encouragement offered by staff. At 5:43 PM, the resident had 2 drinks with lids/straws, a red juice, and chocolate milk. Family sat with the resident through 6:05 PM. After family left, the resident took one sip of her red juice and 1 sip of the chocolate milk through 6:31 PM. At 6:31 PM, the resident attempted to reach for her red juice and was unable to, as a food bowl was in the way, and another resident assisted her to reach her drinks. The resident took a sip of chocolate milk at 6:32 PM. No staff offered assistance to the resident during that time. The resident was observed on 7/13/2016 at 9:35 AM and 9:57 AM with 3 drinks with straws, and one hot beverage cup with a straw. The resident had her head down and was not drinking, and was not offered encouragement. From 5:32 PM - 5:51 PM, she drank 4 ounces of her 8 ounce milk, and 8 ounces of water and juice remained. The resident remained seated at the table not drinking, without encouragement offered by staff through 6:00 PM. During an interview with certified nurse aide (CNA) #23 on 7/14/2016 at 10:55 AM, she stated the resident was a slow eater and was to get the first tray during meal pass. She stated the resident did well with her solids and did not do as good with her fluids. During an interview with RD #26 on 7/14/2016 at 11:41 AM, she stated during the resident's last nutritional assessment on 6/27/2016 the resident was receiving an average daily fluid intake of 1662 cc. She was getting a supplement, Ensure 120 ml BID, and was averaging 231 of supplement intake. She stated the resident's assessed needs were 2040 ml/day, and she had noticed improvement over time. She stated the resident had UTIs on 2/29, 4/6, 6/1, and 7/6/2016. She stated she would be notified someone had a UTI during the facility's morning report. She stated if someone was diagnosed with [REDACTED]. She stated early in 5/2016, the resident's average intake was 1328 ml and she was not meeting her assessed needs. She reviewed the resident's fluid intake before the 4/6/2016 [DIAGNOSES REDACTED]. She did not recall if she was notified of the resident's low fluid intake. Upon review of the resident's record/progress notes, the RD did not have any additional notes for the resident. During an interview with CNA #24 on 7/14/2016 at 12:36 PM, she stated the resident did not consume her fluids well at meals. She stated she would accept fluids outside of meal time. She stated the resident had increased difficulty at meal time. She stated staff generally took an hour to pass trays and were not always assisting residents during that time frame. 10NYCRR415.12(j)

Plan of Correction: ApprovedAugust 5, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #10 was assessed by the clinical dietician and the physician. The fluid restriction remains medically appropriate. Staff was educated regarding accurate documentation of fluid intake, and ongoing nursing assessment to monitor for signs and symptoms of [MEDICAL CONDITION] or dehydration. Resident #13 was assessed by the clinical dietician; care plan and resident care record were updated. The Resident will remain in her wheelchair for meals, but will be seated at a staff table to provide supervision and prompting to ensure maximum fluid intake. Service and nursing staff received education to ensure fluids were provided and she receives cueing and encouragement to promote maximum intake. Since implementing this new feeding plan, the Resident?s intake has improved. Resident #16 care plan for assistance with intake remains appropriate, and she will be seated at a staff table to ensure proper supervision and assistance. Unit staff that provide assistance to Resident who are not able to independently complete a meal or require cueing was completed. Resident #16 was assessed by the clinical dietician, nursing, and physician. The family was consulted, advanced directive reviewed, and MOLST updated to reflect no artificial hydration due to the progressive nature of her disease process. Resident #27 was assessed by the clinical dietician for fluid needs, potential for recurrent urinary tract infections, and her care plan was updated with strategies to increase her fluid intake. The Resident will receive an additional 6 ounces of water with each medication pass as tolerated.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
Five other Residents within the facility have a fluid restriction and a [DIAGNOSES REDACTED]. None of these Residents have been affected by the same deficient practice, and have documentation of the medical need for a fluid restriction. The Mealtime observation was completed on all nursing units to monitor for appropriate assistance being offered, cueing, meal service, and the seating assignment to facilitate staff assistance during meals. All concerns were corrected at the time of observations, and continued monitoring during meals service will be provided to ensure the Resident?s needs are met. Any Resident who has a progressive medical decline without their wishes regarding artificial hydration addressed within their advanced directives could be potentially affected by the same deficient practice. All Residents who have an active infection, and are not meeting their fluid needs could be potentially affected by the same deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Nutrition Assessment and Reassessment policy was revised to include any Resident who has an infection will receive an additional 6 ounces of water with each medication pass. The Clinical Dietician will review each Resident in the facility who is not meeting their fluid needs on a weekly basis. These Resident will be discussed at a weekly Hydration meeting that includes nursing and clinical dietary. The interdisciplinary team will update the plan of care, review medical status, advanced directives, and update the physician as needed.
A mealtime consideration policy was developed. The policy addresses strategies for staff to utilize during the dining experience to encourage Residents to meet their fluid needs, positioning, and appropriate follow-up with Resident requests, nursing/clinical supervision, reporting poor intake, and posture.
Mandatory education will be provided for all staff regarding hydration. The education will emphasize the importance of accurate documentation, assistance, fluid pass, prompt reporting of changes in condition, and infections to the clinical Dietician.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Chief Clinical Dietician and/or designees will audit Residents who are not meeting their fluids needs or who have an infection to ensure they have an updated fluid needs assessment, accurate care plan, and strategies to prevent dehydration unless unavoidable. In addition, meal rounds will be conducted on each nursing unit monthly, at varying meal times, until 100% compliance has been achieved for 3 consecutive months. This audit will be conducted by the multi-disciplinary team. Monitoring for compliance is the responsibility of the Chief Clinical Dietician and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Chief Clinical Dietician will be responsible for this deficiency

FF09 483.25(a)(2):TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS

REGULATION: A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 5 of 14 residents (Residents #11, 12, 13, 14, and 27) reviewed for activities of daily living (ADLs), the facility did not ensure residents were given appropriate treatment and services to maintain or improve their ADL abilities. Specifically: - Resident #11 was not encouraged to eat independently in order to maintain ADL abilities; - Resident #12 was not provided with the proper adaptive feeding equipment to facilitate self-feeding and was not placed in the restorative nursing program as recommended for ambulation; - Resident #13 was not encouraged or assisted at meals, did not receive care planned finger foods, and did not receive the planned adaptive feeding equipment at meals; - Resident #14 was not cued or assisted at meals and her tray was not fully set-up to facilitate self-feeding; and - Resident #27 was not cued or assisted at meals as planned. Findings include: 1) Resident #12 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. She required extensive assistance with all ADLs and did not ambulate. The comprehensive care plan (CCP) revised 3/2/2016 documented to ambulate resident to the bathroom with a rolling walker and contact guard assistance with a gait belt and a wheelchair to follow. The CCP documented the resident had difficulty feeding herself and used a right angled teaspoon utensil for all meals, and staff were to assist as needed. The physical therapy (PT) note dated 3/4/2016 documented the resident's goals were met and she was discharged from PT. The resident transferred with minimal assistance of one and walked up to 75 feet with a rolling walker and contact guard assistance. The plan was for staff to ambulate the resident to the bathroom and to start the restorative nursing program when an opening was available. The MDS assessment dated [DATE] documented the resident's cognition was severely impaired. She required extensive assistance with all ADLs and ambulated once or twice in her room during the assessment period with a two person assist. The speech-language pathologist (SLP) note dated 6/1/2016 documented the resident received swallowing therapy from 5/12/2016 to 6/1/2016. The note documented the resident was on a pureed diet; she desired to feed herself, was happy with the current diet, and needed some assistance at times. The resident's care card (care instructions) dated (MONTH) (YEAR) documented the resident was non ambulatory and needed assistance with eating. The care card did not document adaptive equipment for eating. The ADL records dated 7/1/2016 - 7/13/2016, documented the resident walked: - on 7/8/2016 in her room with extensive 2 person assist; - on 7/9/2016 at 11:04 AM, in her room, independent with no set up or staff help; - on 7/9/2016 at 8:17 PM, in her room with extensive 2 person assist; and - on 7/10/2016 at 12:03 PM, in her room with extensive 2 person assist. When observed on 7/11/2016 at 12:57 PM, the resident was served her lunch tray. She had her food in bowls, adaptive utensil that pointed towards her held in her right hand, and cups with lids and straws. The certified nurse aide (CNA) sat next to her and encouraged her to eat. At 1:06 PM, the resident was feeding herself. When observed during the supper meal on 7/11/2016 from 6:00 PM to 6:25 PM, the resident was given her meal and a CNA placed an adaptive utensil in the resident's left hand. The resident was alert and did not eat. The registered nurse (RN) Manager #19 sat down with the resident and moved the spoon from her left hand to her right. The spoon angled away from the resident and the resident was unable to get food to her mouth. RN #19 took the spoon from the resident and fed her the meal. She did not encourage the resident to feed herself and did not notice the resident was given a utensil for a left handed person. When observed during breakfast on 7/12/2016 at 7:58 AM, the resident had a spoon in her right hand angled towards her and ate independently. When observed on 7/12/2016 at 11:10 AM, the resident was in her room, in a recliner chair trying to get up. RN Manager #19 went into the room and the resident told her she need to use the bathroom. RN Manager #19 got assistance and a mechanical lift to take the resident to the bathroom. When interviewed on 7/14/2016 at 9:20 AM, licensed practical nurse (LPN) #20 stated the resident did not walk anymore. She stated on a good day, the resident could stand and pivot to transfer, and on other days a mechanical lift was used. When interviewed on 7/14/2016 at 10:02 AM, the Rehabilitation Director stated the resident was discharged from PT on 3/4/2016 and referred to the restorative nursing program. She stated the resident currently walked in the room with staff on the unit. She stated the resident was walking 75 feet with a contact guard when discharged from PT. She did not know if the resident was ever in the restorative nursing program or if any follow-up was done. When interviewed on 7/14/2016 at 10:15 AM, RN Manager #19 stated she fed the resident on 7/11/2016 when she saw the resident was unable to get the food to her mouth. She stated the food was ending up on her lap and she fed her. She stated she was unaware the resident had the wrong utensil, and stated the resident would probably done better with the correct utensil. When interviewed on 7/14/2016 at 10:35 AM, RN #21 stated she coordinated the restorative nursing program and was unaware the resident was referred to it. She state when there was not room in the program for a resident, she would look at the current caseload and if there was someone no longer benefiting, she would discharge that person to make room. RN #21 checked her correspondence and stated she did not get a referral for the resident. 2) Resident #13 had [DIAGNOSES REDACTED]. The speech-language pathologist (SLP) dysphagia (difficulty swallowing) evaluation dated 8/25/2015 recommended the resident remain on a level 2 solid food and regular thin liquids diet. The physician order [REDACTED]. The 6/25/2016 updated comprehensive care plan (CCP) documented the resident had inadequate food and fluid intake, needed verbal cues and assistance, was to receive half portions to prevent being overwhelmed, was to be provided with a half of a sandwich to promote self feeding, and required a divided dish for meals. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required supervision with eating and had an altered diet. The physician order [REDACTED]. The 7/2016 care card (care instructions) documented the resident was confused, used a Lap Buddy (inflatable device to prevent falls), was a set-up assist for meals, and was to receive finger foods to eat while propelling self on unit. The dietitian progress note dated 7/7/2016 documented the resident continued on a level 2 mechanically altered diet with thin liquids, had half portions at all meals and used a divided plate, and was to have no plastic lids or paper products due to placing them in her mouth. The note documented the resident's average meal intake for 7 days was 48 percent and fluid intake averaged 747 milliliters (ml) per day. The resident did not like to eat in the dining room, she took all food/fluids with her on the go, and nursing was aware of her fluid intake and goal. On 7/11/2016 at 5:45 PM, registered nurse (RN) Manager #5 approached the surveyor and stated the resident wandered around the unit in the wheelchair when she ate and used her Lap Buddy (restraint) as a tray. She stated the resident had been eating in this manner for quite some time, she was provided with finger foods to help her eat more easily, and this was included in the resident's care plan. On 7/11/2016, the resident was observed: - at 5:55 PM, wandering the unit in her wheelchair with a divided plate resting on top of her Lap Buddy, a juice cup in her right hand, and a regular fork in her left hand. The resident did not receive finger foods and instead received an altered consistency salad, mashed potatoes and a slice of bread with the crust removed; - at 6:03 PM, in another resident's room with 1/2 of her food on the floor. Food was noted in the right side of her wheelchair and on top of her Lap Buddy, and 3/4 of her mashed potatoes remained in the dish; - at 6:28 PM, still in the same room with most of her dinner on the floor. An unidentified staff member removed the plate and assisted the resident back into the hall. She was not offered cueing or assistance from 5:55 PM-6:28 PM; and - from 6:30 PM to 6:55 PM, not offered or provided with alternative food or fluids. On 7/12/2016 from 9:08 AM to 9:30 AM, the resident was observed in her wheelchair, with a full plate of breakfast that included scrambled eggs, oatmeal, and mandarin oranges. She had no drink and was not observed to be assisted or encouraged during this time. On 7/12/2016 at 2:03 PM, the resident was observed in the hall seated in her wheelchair with most of her lunch on her plate. She had a plastic two-handled cup, a straw in her hand, and was not offered any assistance or cueing. On 7/13/2016 at 9:10 AM, an unidentified certified nurse aide (CNA) was observed bringing a tray into the resident's room and immediately exiting the room. At 9:18 AM, the resident was observed lying in bed covered up with her eyes closed. At the end of the bed, against the footboard, was a tray table with a breakfast meal on top of it. The breakfast meal included cut-up pancakes, ground meat (on a regular dish), oatmeal, a whole banana (with the peel on), a whole donut (wrapped in plastic wrap), and a cup of apple juice. The tray table was out of the resident's reach when she was in bed, the resident was asleep, and the food was uncovered. On 7/13/2016 at 12:50 PM, an unidentified therapy staff member picked up the resident's tray from the serving line and asked a licensed practical nurse (LPN) where the resident sat. The LPN said the resident roamed when she ate and the therapist would have to follow her if she wanted to see her at a meal. The therapist attempted to have the resident drink from a two-handled cup with a straw in it. The resident was not able to suck through the straw and a CNA approached and encouraged her. The resident blew through the straw and liquid came out of the cup and onto the CNA's face and neck. At 1:10 PM, the resident was observed wandering in her wheelchair while the therapist held the cup and gave her sips of the drink. The straw was removed from the cup at that time. On 7/13/2016 at 2:36 PM, the resident was observed in her wheelchair with a divided plate, regular fork, full serving of spaghetti with sauce, 1/2 serving of mashed potatoes, 1/2 serving of vegetables, and no drink. The resident attempted to take several bites of her food with the fork, the food dropped onto her Lap Buddy and into the side of the chair, and she continued to attempt to bring the empty fork to her mouth while wheeling herself in the chair. At 2:40 PM, CNAs #16 and 19 took the resident to her room, removed her plate, did not offer alternative food, and assisted the resident back to bed. The Occupational Therapy (OT) feeding evaluation dated 7/13/2016 documented the resident needed reinforcement to eat 50-75% of the time, 25% of food remained on the floor or lap, she spilled food from utensils, and she needed some assistance to prevent spills. The consumption record documented the resident's average meal intake: - on 7/11/2016 was 25%; - on 7/12/2016 was 50%; and - on 7/13/2016 was 33%. On 7/14/2016 at 10:30 AM, CNA #16 stated in an interview that the resident often spilled her food and drinks and was unable to access her own drinks or food if left on the tray table. On 7/14/2016 at 11:50 AM, RN Manager #5 stated in an interview, if the resident was asleep during breakfast she was not sure if the staff woke the resident up and tried to feed her. She stated the resident has had OT evaluations for feeding and spilled a lot of her food. She stated the staff could gauge her intake based on how much she spilled as she usually spilled her food on herself and not on the floor. She stated the resident was served a salad a few nights ago and she told staff to make her a sandwich instead. She stated if the resident dropped her meal, staff could offer a sandwich as a finger food. She stated the resident was not routinely served finger foods as she ate her regular meals well. On 7/14/2016 at 12:35 PM, registered dietician (RD) #11 stated in an interview that the resident was last seen in 3/2016. The resident had a poor appetite, ate her food on the go, and did well with finger foods. She was care planned to receive 1/2 sandwich, and the sandwich should be included with her meals. She stated that she was not made aware of any difficulty the resident was having with her eating. 3) Resident #14 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented resident's cognition was severely impaired and she needed limited assistance for eating. The comprehensive care plan (CCP) updated on 5/7/2016 documented the resident had a history of [REDACTED]. The goals included the resident would consume adequate food and fluids. Approaches included Ensure (supplement) with meals, honoring food preferences, and providing 1/2 portions at lunch and supper as to not overwhelm the resident. The CCP did not document the level of assistance the resident needed with meals. The dietary progress note dated 5/10/2016 documented the resident was independent at meals and consumed 37% of foods provided. The resident received supplements at and between meals. The 6/30/2016 updated care card (care instructions) documented the resident needed set-up assistance at meals. On 7/11/2016 at 1:05 PM, the resident was observed seated in the unit dining room. She received 1/2 sandwich, wax beans, juice, a hot beverage, and ice cream. From 1:05 PM to 1:33 PM, the resident made no attempt to eat and no staff approached her. At 1:35 PM, the resident left the dining room on her own. She did not eat or drink and was not encouraged by staff during the meal. The lunch meal consumption record dated 7/11/2016 documented the resident ate 25% of her meal. On 7/11/2016 at 6:05 PM, the resident was observed seated in the unit dining room. She received wheat bread without crust, an entree salad, fruit, broccoli, potatoes, coffee, and 2 glasses of juice. The resident was using her fork and poking it at her napkin when observed. From 6:05 PM to 6:34 PM, no staff approached the resident. At 6:34 PM, the resident had not eaten and the straw wrappers remained on the tops of straws that were in her two glasses of juice. At 6:51 PM, a certified nurse aide (CNA) asked the resident if she was going to eat and encouraged her to eat broccoli or potatoes. At that time, the CNA removed the straw wrappers from the resident's straws and asked her to drink. The dinner meal consumption record dated 7/11/2016 documented the resident ate 0% of her meal. The resident was observed in the dining room on 7/12/2016 at 2:03 PM with her lunch meal in front of her. She had not consumed any of the lunch meal, had only eaten the dessert (jello), and drank 2 glasses of juice. The CNA did not address her or offer encouragement when she picked up and removed her tray. The lunch meal consumption record dated 7/12/2016 documented the resident ate 25% of her meal. On 7/13/2016 from 8:40 AM to 9:42 AM, the resident was observed in the unit dining room. She had pancakes, oatmeal, sausage, a banana, a whole donut, juice, and coffee. There was no encouragement or cueing observed. There were several large pieces of food (pancake pieces and sausage) on the floor under the resident. The resident had consumed a cup of juice and a few bites of the donut. The breakfast meal consumption record dated 7/13/2016 documented the resident ate 25% of her meal. On 7/14/2016 at 10:45 AM, CNA #17 stated in an interview that the resident was able to feed herself, liked company when she ate, required set up assistance and some encouragement. The CNA stated the resident did not usually have good intake, and when provided company and encouragement, she would eat more. On 7/14/2016 at 11:50 AM, registered nurse (RN) Manager #5 stated in an interview that staff were expected to assist and encourage residents who did not eat well. 10NYCRR 415.12(a)(2)


Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #11 care plan and resident care record were reviewed and remain appropriate. The Resident is seated at a staff table, and should be prompted to self-feed before initiating feeding by staff. The Certified Nurse Aide received education regarding prompting the Resident before attempting to feed her. Resident #12 care plan remains appropriate to meet her needs and promote independence during feeding. The adaptive utensil is no labeled to promote proper usage, added to the meal ticket to ensure delivery to the table, and the Registered Nurse received education regarding proper use of equipment. Resident #12 is non-ambulatory at this time; a physical therapy evaluation was completed. The Resident declined participation in therapy, is not a candidate for a restorative nursing program, and her care plan remains appropriate. Resident #13 care plan and resident care record were updated. The Resident will remain in her wheelchair for meals, but will be seated at a staff table to provide supervision and prompting to ensure maximum intake of food. If the Resident is able to tolerated only short durations of dining in this environment, her food will be replaced or heated (as applicable), and she will be re-approached to take meals in the dining room. The plan for finger foods remains appropriate for Resident #13 per her choice and/or acceptance. Service and nursing staff received education to ensure finger foods were provided to promote independence with feeding. Resident #14 care plan was reviewed and remains appropriate for intermittent cueing to promote self-feeding. The Resident was relocated to a staff table. If the Resident is not demonstrating efforts to feed herself, staff was re-educated to provide the appropriate cueing to complete the meal. Resident #27 was evaluated by the speech pathologist on 7/13/2016, and her diet order was changed to puree with nectar thick fluid. On 7/14/2016 the occupational therapist evaluated the Resident and recommended a blue inner lip plate, scoop bowl, and light weight built up slight angle spoon to promote self-feeding. Resident #27 care plan and resident care card were revised to reflect these recommendations, and staff was re-educated. The Resident is seated at a staff table, and will receive assistance as needed to complete her meals.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
The Mealtime observation was completed on all nursing units to monitor for appropriate assistance being offered, cueing, meal service, use of adaptive equipment, and the seating assignment to facilitate staff assistance during meals. All concerns were corrected at the time of observations, and continued monitoring during meals service will be provided to ensure the Resident?s needs are met. All Residents who have been discharged from physical therapy, and had recommendations for restorative nursing were audited to ensure proper follow-up and services were rendered. No other Resident was identified as being affected by the same deficient practice.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
A policy for mealtime considerations was developed. This policy addresses the use of adaptive equipment, assistance during meals, proper feeding techniques, positioning, modified consistency, and monitoring to ensure the Resident?s needs are being met during the dining experience.
Mandatory education will be provided for all staff that feed, assist, and supervise Residents during meal time. This education will emphasize the importance of promoting independence during meals, providing the correct food form for ease of self-feeding, proper seating and posture to promote intake, cueing and assistance as required completing the meal. The restorative nursing policy was reviewed and no revisions were made. Education will be provided for nursing staff regarding the process of notification, assessment, care planning, and implementation of the restorative nursing program.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit each nursing unit monthly, at varying meal times, until 100% compliance has been achieved for 3 consecutive months. This audit will be conducted by the multi-disciplinary team. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council. The Director of Nursing and/or designee will audit all Residents who are discharged from therapy with recommendations for restorative nursing to ensure the necessary services are being provided and documented appropriately. The audit will be completed monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency

FF09 483.25(f)(1):TX/SVC FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES

REGULATION: Based on the comprehensive assessment of a resident, the facility must ensure that a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 14, 2016
Corrected date: September 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 1 of 7 residents (Resident #12) reviewed for behaviors, the facility did not ensure a resident who displayed mental or psychosocial adjustment difficulty received the appropriate treatment and services to correct the assessed problem. Specifically, Resident #12's spouse died and there was no documentation a plan was implemented to assist the resident with the grieving process. Findings include: Resident #12 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired, and she required extensive assistance with all activities of daily living (ADLs). The MDS assessment documented the resident had no behaviors. The nursing progress note dated [DATE] at 2:49 PM documented the family took the resident to the hospital to visit her husband. The comprehensive care plan (CCP) dated [DATE] documented the resident's husband died . The goal was for the resident to accept the loss within 30 days with a goal date of [DATE]. Interventions included encouraging family visits to provide support to the resident, staff awareness, and for social services to visit the resident on an individual basis to allow her time to vent her feelings. The nursing progress note dated [DATE] at 2:27 PM documented the resident went to her husband's funeral. The activities progress note dated [DATE] at 3:27 PM documented the resident received visits from staff to offer emotional support related to the death of her husband. The note documented the resident was going to the dining room for meals and socialization. The social service progress note dated [DATE] at 1:25 PM documented the resident was care planned for her husband's death, she was weepy at times, and staff were providing emotional support as needed. The note documented the resident had adjusted to having a new roommate, and the social worker would continue to visit and remain available to the family. The nurse practitioner (NP) note dated [DATE] documented the nursing staff reported the resident was increasingly anxious and yelled out for approximately 4 hours between 4:00 PM and 8:00 PM daily since her husband's death. The note documented redirecting the resident did not change the behavior and [MEDICATION NAME] (anti-anxiety medication) would be trialed. The NP order dated [DATE] at 3:30 PM for the resident documented to administer [MEDICATION NAME] 0.25 milligrams (mg) at 2:00 PM daily for anxiety. The nursing progress note dated [DATE] at 3:14 PM documented the resident was yelling, assistance was offered, and the resident was unaware of her needs. The NP progress note dated [DATE] documented staff reported the [MEDICATION NAME] worked for ,[DATE] days, and the resident's yelling behavior and anxiety resumed. The note documented the resident had these behaviors prior to her husband's death and he would distract her. Her behavior worsened after her husband's death, she was seen in the hallway repeatedly asking, Where do I go?, and staff were unable to distract her. The plan was to increase the resident's [MEDICATION NAME]. The NP order dated [DATE] at 5:15 PM documented the resident's [MEDICATION NAME] was changed from 0.25 mg to 0.5 mg daily and to give an extra dose of [MEDICATION NAME] 0.25 now. The MDS assessment dated [DATE] documented the resident's cognition was severely impaired. She required extensive assistance with all ADLs. She took antipsychotic, anti-anxiety, and anti-depressant medications. The MDS documented the resident had no behavioral symptoms. The social service progress note dated [DATE] at 12:12 PM documented the resident was an alert woman with noted confusion related to Alzheimer's dementia. She preferred to rest in her room and got along well with staff and other residents. The note also documented the resident was accepting of her husband's death and remained stable over the past 3 months. The resident's care card (care instructions) dated ,[DATE] documented the resident was alert, confused, and hard of hearing. It did not document the resident had a behavior plan. On [DATE] the resident was observed: - from 12:57 PM to 1:15 PM, seated in her wheel chair in the dining room eating lunch; - at 4:40 PM, at a table in the dining room, and at 4:45 PM an activities aide came to the table and conducted a word phrase activity, and the resident was attentive; - at 5:55 PM, continuously attempting to leave the table while supper trays were being served and was redirected by the nurse manager; and - from 6:07 PM to 6:25 PM, she was alert and engaged in a conversation with the nurse manager as she ate dinner. On [DATE] the resident was observed: - at 7:58 AM, quietly eating breakfast at the dining room table; and - at 11:10 AM, in her room in a recliner calling out, and the registered nurse (RN) Manager went in to the room and came out to get assistance for the resident to use the bathroom. The resident's record was reviewed on [DATE] and there was no documented evidence the resident was seen by the social worker between [DATE] and [DATE]. There was no documented evidence the resident was offered grief counseling, or if other interventions to address the resident's grief, loss, or change in mood were attempted prior to starting [MEDICATION NAME]. When interviewed on [DATE] at 9:20 AM, licensed practical nurse (LPN) #20 stated the resident's behaviors varied. The resident was recently started on [MEDICATION NAME] related to excessive yelling that started around 2:30 PM. She stated other interventions included taking the resident to the dining room where activities staff worked with her. She stated the resident's husband passed away approximately 6 months ago and she did not have any change in behavior. She stated the resident at times would yell for her husband and would have to be redirected. She did not know of any interventions put in place for grieving and was unaware if the social worker visited the resident. When interviewed on [DATE] at 10:15 AM, RN Manager #19 stated there were no specific interventions put in place for the resident after her husband died . She state the resident had a very attentive family and the staff offered support. She stated social services should have offered grief counseling. When interviewed on [DATE] at 11:55 AM, the social worker stated when a resident's relative died , she would visit the resident, update the care plan, and alert staff. Care planning would include informing and involving staff, social services providing room visits, providing emotional support, and offering the opportunity to talk to a pastor. She stated when the resident's husband died , she provided room visits, talked to staff, and the resident did well and was accepting of his death. She stated she did not always document her visits with the resident or conversations with the staff. She stated she did not know if the resident was on any psychoactive medications or had any changes in medications since her husband's death. 10NYCRR 415.12 (f)(1)

Plan of Correction: ApprovedAugust 5, 2016

1. What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #12 was evaluated by the Social Worker for history of loss/grief related to her husband?s death, and anxiety. The care plan for Resident #12 was reviewed; the goal for effective grieving to occur within 30 days was discontinued. The Resident?s medication regime will be reviewed by the consultant pharmacists and physician to determine if a dose reduction is recommended at this time. The plan of care was reviewed/revised to include activities of her choosing, attempt redirection/conversation during meals, and monthly follow-up by the social worker to ensure she is not experiencing difficulty related to her loss.
2. How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An audit was conducted by the Director of Social Services who reviewed all current residents who experienced the loss of a loved one during the past six months. There were three (3) other Residents who experienced loss and/or grief. Two of three sampled Residents required revision to their plan of care, and had not received follow-up visits from a social worker to assess their grief and coping needs. The care plans and documentation for one Resident, was appropriate, no revisions required, and none have experienced further complications related to their loss.
3. What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Support for Residents Experiencing Loss of a Loved One policy has been updated. Upon notification of the death of a friend, pet or family member, the Social Worker will visit resident within 2 business days; the CP and any necessary supportive interventions will be initiated at that time. The Social Worker will then follow up with a 1:1 visit in one week and again in one month. An individualized care plan will be established for a minimum of 30 days. Nursing will update the Social Worker with any increased anxiety and/or behaviors prior to initiating medication. Mandatory education will be provided for all staff to ensure grief concerns are communicated to the social worker, and an appropriate plan is developed in a timely manner.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Social Services, or designee, will audit all residents who experienced the loss of a loved one. The date of loss, relationship, care plan completion, and social services follow-up will be monitored through this process.
The audit will be conducted monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Social Services and will be reported to the Quality Improvement Council.
5. The date for correction and the title of the person responsible for each deficiency.
The Director of Social Services will be responsible for this deficiency