Livingston Hills Nursing and Rehabilitation Center
April 5, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observations, record review, and interviews during a recertification survey and an abbreviated survey (Case #NY 905), the facility did not ensure that the assessment accurately reflected the resident's status for four (Resident #'s 1, 52, 63, and #311) of six residents on two of three units reviewed for nutrition. Specifically, the facility did not ensure that nutritional comprehensive assessments assessed whether the following residents' intake was adequate to meet their nutritional needs: for Resident #1, who had a weight loss and was on an altered consistency diet; for Resident #52, who was a diabetic with a large traumatic wound to his left foot; for Resident #63, who had a foley catheter and received diuretic medications; and for Resident #311 who had poor intakes and a history of urinary tract infections. This is evidenced by: Nutritional Assessments documentation: Resident #1 - dated 10/10/18, did not include an observation of the resident at meal time, the average percent (%) of meal taken, and the average amount of fluid taken. Resident #52 - dated 11/13/18, documented To Be Determined (TBD) under the average percent (%) of meal taken, and the average amount of fluid taken. Resident #63 - dated 8/17/18, did not include an observation of the resident at meal time and documented TBD under the average percent (%) of meal taken, and the average amount of fluid taken. Resident #311 - dated 10/17/18, did not include an observation of the resident at meal time and documented TBD under the average percent (%) of meal taken, and the average amount of fluid taken. During an interview on 4/05/19 at 9:37 AM, the Registered Dietitian stated that when someone came in, she always wrote TBD on their assessment. She usually re-assessed residents within a week of her initial assessment. The re-assessments she did were informal and she did not document them. A follow up assessment would be done based on the resident's needs, acuity, and nutritional situation. 10NYCRR 514.11

Plan of Correction: ApprovedMay 8, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident #1 a comprehensive nutritional assessment was completed on 4/24/2019 by the Registered Dietitian.
For resident #63 a comprehensive nutritional assessment was completed on 4/24/2019 by the Registered Dietitian.
Resident # 52 he was discharged on [DATE].
Resident #311 he was discharged on [DATE].
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All resident have the potential to be affected by the same deficient practice as all residents are seen and assessed by the Registered Dietitian on admission, quarterly and with any change in status/condition warranting a dietary consult.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Upon admission, readmission, quarterly assessment and with change in status/condition warranting a dietary consult, the Registered Dietitian will document any assessment completed in the medical record. All assessments will be documented as formal and either on the Nutritional assessment form or in the form of a Nutritional Progress Note.
Education provided to Registered Dietitian regarding importance of documenting assessments as progress notes or on Nutritional Assessment Forms to ensure follow-up assessments are documented in medical record.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Random audits of 10 charts per unit will be completed weekly for 4 weeks, then monthly for 3 months by the ADON to ensure that nutritional assessments are documented on residents. Results of the audit will be reported to the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The Registered Dietitian will be responsible to ensure correction by 6/4/2019.

FF11 483.70:ADMINISTRATION

REGULATION: §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observation, record review and interviews during the recertification survey the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, facility Administration did not ensure the facility was free from accident hazards as was possible and that each resident received adequate supervision to prevent accidents when there was an incident of a resident smoking in their room and other incidents regarding cigarette smoke odors in other residents rooms. This was evidenced by: Refer to F Tag 689: Free of Accidents Hazards/Supervision During an interview on 3/31/19, the Administrator (ADM) stated that this was a non-smoking facility and there were no smokers. During an interview on 4/03/19 at 9:35 AM, the ADM stated the resident only smoked off facility property with her Mom and had no smoking supplies in her room. They put a battery- operated smoke detector in her room. The ADM stated that the resident had been caught once smoking in her room. During an observation of the resident's room and bathroom on 4/4/19 at 9:48 AM, there was no battery-operated smoke detector noted. During an interview on 4/04/19 at 9:58 AM, the ADM stated there were no investigations initiated in the past for residents who smoked in their rooms. He stated that there should have been documentation regarding the smoking incidents. During an interview on 4/5/19 at 12:05 PM, the ADM stated they had suspicions 2 - 2 1/2 months ago that a resident was smoking in his room and was aware of a cigarette smoke smell from another resident's room approximately 5-6 months ago. There were no other interventions put in place to prevent residents from smokimg in the facility. 10NYCRR415.26

Plan of Correction: ApprovedMay 9, 2019

F835 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Resident?s identified during survey who were still at the facility were searched for smoking materials, with none found, and were re-educated on the facilities non-smoking policy with understanding being communicated.
IDENTIFY OTHER POTENTIAL RESIDENTS
- A whole house education for staff and residents will be performed to assure all are aware that the facility is non-smoking.
SYSTEMIC CHANGES
- If there is any suspicion of smoking, a full investigation will be performed, which includes but is not limited too, searching residents room and belongings for any smoking materials, and taking any and all necessary action to assure resident and facility safety. Education provided to staff about reporting smoking, and appropriate actions to happen if a report of smoking is made.
QUALITY ASSURANCE
- The Administrator (or designee) will audit daily with review of all reports along with IDt, the accident and incidents to assure that proper investigations were done for any suspected incidents of smoking and that proper action took place based on the findings. This will be reported to the QA committee monthly and any negative findings will be immediately corrected.
PERSON RESPONSIBLE
- Administrator by 6/4/2019

FF11 483.21(a)(1)-(3):BASELINE CARE PLAN

REGULATION: §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on record review and interviews during the recertification survey, the facility did not ensure residents and their representatives were informed of the initial plan for delivery of care and services. Specifically, the medical records did not contain evidence that a written summary of the baseline care plans were given to the residents and resident representatives, if applicable. The findings are: The Policy and Procedure (P&P) titled Care Plans - Baseline dated 4/18, documented the baseline care plan is to be developed within 48 hours of admission and a summary provided to the resident and representative. The policy does not state that a written summary will be provided or that it will be documented in the medical record. During an interview on 04/01/19 at 3:09 PM, Case Manager #4 stated the baseline care plan is generated in the electronic medical record upon a resident's admission. She stated residents and/or families receive a written copy of the care plans only if they request it. During an interview on 04/02/19 9:15 AM, the Assistant Director of Nursing reported, the 48-hour Care Plans were completed on admission with the initial Care Plans and they are printed. If a resident was is able, we would review it with them, if not we would review with responsible party. We did not provide copies or documented evidence. 10NYCRR 415.11

Plan of Correction: ApprovedMay 8, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
No residents had baseline care plans in place.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Any resident who is admitted or readmitted to the facility will have the potential to be affected by the same deficient practice. Policy revisions and education will be done to ensure deficient practice does not recur.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Facility's policy and procedure titled Care Plans - Baseline, dated 4/2018 was reviewed and revised, dated 4/23/2019. The revisions include:
1. A written summary is to be provided to the resident or responsible party within 48 hours of admission.
2. A copy of the signed written summary will be scanned into the electronic health record.
3. Baseline care plans will be started by the Registered Professional Nurse (RN) completing the admission process and will be completed by the Interdisciplinary Team (IDT). There will be a written summary provided to the resident/responsible party within 48 hours of admission.
Education will be provided to all nursing staff on the implementation and process surrounding baseline care plans.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
The Assistant Director of Nursing (ADON) will audit all new admission and ensure baseline care plans are completed within the 48 hour time-frame. Each unit manager will be responsible to audit and ensure residents or their responsible party are given the written summary and that a signed copy is scanned into the electronic health record. These audits, by both the ADON and the unit managers will be done daily for 90 days on all new admissions or readmissions to the facility. Audits will be reviewed with the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The Assistant Director of Nursing Services will be responsible to ensure correction by 6/4/2019.

FF11 483.25(e)(1)-(3):BOWEL/BLADDER INCONTINENCE, CATHETER, UTI

REGULATION: §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure catheter care was consistent with professional standards for 1 (Resident #63) of 1 resident reviewed for catheter care. Specifically, for Resident #63, the facility did not ensure the resident was provided with indwelling catheter and peri care was to maintain an acceptable standard for personal hygiene and did not ensure the resident was assessed for the removal of an indwelling foley catheter as soon as possible. This is evidenced by: Resident #63: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could usually understand others, and could make self understood. Finding #1: The facility did not ensure the resident received peri and indwelling foley catheter care to maintain acceptable personal hygiene. The Policy and Procedure (P&P) titled Catheter Care, Urinary, last updated 9/2014 documented to change catheter based on clinical indications and clean the peri area with routine hygiene during bathing and showering. Steps in the cleaning process included, washing the genitalia and perineum thoroughly with soap and water, rinsing and towel drying the area; cleansing around the urethral meatus (opening to the bladder) and use of a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. A Comprehensive Care Plan (CCP) for Indwelling Catheter last updated 1/26/19, documented interventions to change the Foley catheter monthly and check tubing for kinks each shift. The CCP did not include peri care. During observations on 3/31/19 at 4:00 PM, 04/01/19 at 07:53 AM, and 04/05/19 at 11:50 AM, a foul-smelling odor of urine was noted upon entering the unit, and the odor became stronger when approaching this resident's room. During an observation on 04/01/19 at 8:25 AM, a strong, foul smelling odor of urine was noted on the resident. During an interview on 4/01/19 at 8:55 AM, the resident stated the smell of urine bothers her, and she used to have a deodorizer, but no longer has it. During an interview on 4/02/19 at 9:37 AM, Certified Nursing Aide (CNA) #6 stated the resident's urine is always strong smelling. During an interview on 4/03/19 at 2:18 PM, CNA #6 stated the resident will ask about the smell, if she smells, and if she smells like that all the time. The CNA stated there are no deodorizers available for use. During an interview on 4/03/19 at 2:42 PM, the Assistant Director of Nursing (ADON) stated routine peri-care should be done a minimum every shift. He stated the care of the catheter was not documented on care card, and that was a problem. He stated he would not expect odor routinely. During an interview on 4/03/19 at 3:19 PM, LPN #8 stated the CNAs should provide peri-care every time the resident is toileted and document care in the medical record. She stated as an LPN, she initials the Medication Administration Record [REDACTED]. During an interview on 4/05/19 at 9:42 AM, the resident stated staff did not clean her peri-area. During an interview on 4/05/19 at 9:58 AM, LPN #6 stated the resident's urine always had a foul odor. Finding #2: The facility did not ensure did not ensure the resident was assessed for removal of the indwelling foley catheter as soon as possible. The P&P titled Urinary and Renal Conditions last updated 9/2010 documented staff and physician will seek treatable causes and consider intermittent catherization before placing an indwelling catheter in residents with persistent or recurrent [MEDICAL CONDITION]. Additionally, the physician will document why other alternatives are not feasible in situations in which an indwelling catheter is indicated. A review of progress notes from 8/18/18 - 8/24/18 documented the resident did not have an indwelling catheter and did not have difficulty voiding. A progress note on 8/25/19 documented the resident could not void, and a catheter was placed and returned 600 cc of amber urine. A review of the physician notes dated 8/21/18, 1/17/19, and 3/26/19 did not include documentation of an indwelling catheter. During an interview on 4/05/19 at 9:55 AM, LPN #5 stated the resident has not been seen by urology. She stated when she came back from the hospital (8/18/18), she did not have the indwelling catheter, but then could not void so it was put back in. During an interview on 4/05/19 at 12:28 PM, the Director of Nursing (DON) stated the resident should have been sent to urology based on the [DIAGNOSES REDACTED]. During an interview 4/05/19 at 4:58 PM, the Medical Director stated he would expect a trial void, bladder training, and follow up with urology before placing an indwelling catheter. He stated there are other methods to address [MEDICAL CONDITION] (i.e. clamping and releasing the catheter, medication trial), and we have to try those first. 10 NYCRR 415.12(d)(1)

Plan of Correction: ApprovedApril 26, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident # 63, the MD was contacted and order was received to attempt voiding trial and remove foley catheter on 4/8/2019. Resident was advised of new order and plan to remove foley catheter for voiding trial and resident refused. MD was updated on resident refusal and order was received to send resident to Urology for consultation. Care plan was reviewed and revised to ensure interventions in place to minimize risk of UTI and to ensure appropriate care provided to resident with indwelling urinary catheter.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Any resident with an indwelling urinary catheter has the potential to be affected by the same deficient practice. Those residents with indwelling urinary catheters had their care plans reviewed to ensure appropriate catheter care interventions in place, orders reviewed to ensure voiding trials ordered or provider documentation noted contraindication to voiding trials. Policy review and revision will be done and staff education will be completed to ensure deficient practice does not recur.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Facility policy on Indwelling Urinary Catheter was reviewed and revised, dated 4/24/2019. Staff education will be completed. Documentation review will be completed and reminder to staff will include that by signing the EMAR (nurses) and P(NAME) (CNA's) they are indicating that they have provided the care they are signing for. The Medical Director will be responsible for reviewing with his Physicians appropriate interventions and steps to take prior to placing an indwelling urinary catheter. All education of staff and physicians will have signatures documented.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
The nurse manager will perform audits of any resident with an indwelling urinary catheter to ensure appropriate catheter care is being provided. The nurse manager will also the medical records to ensure the provider orders/documentation is in place regarding voiding trials/containdication to voiding trials. If documentation is not found, the MD will be notified to correct documentation, and if no correction is made, the Medical Director will be notified for assistance. These audits will be completed daily for 30 days then weekly for 4 weeks then monthly for 3 months. Results of the audits will be discussed with the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The ADON will be responsible to ensure correction by 6/4/2019

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure the care plan was evaluated for effectiveness and revised to include the changing goals and needs for 2 (Resident #'s 36 and 46) of 2 residents reviewed for care plans. Specifically; for Resident #46, the facility did not ensure the the Occupational Therapy (OT) discharge plan for the use of a left hand palmer for out of bed positioning was communicated to nursing and provided to the resident; and for Resident #36, the resident's activities of daily living care plan was not revised to include an increased level of assistance needed at meals. This is evidenced by: Resident #36: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, could understand others and could make himself understood. A Comprehensive Care Plan (CCP) for activities of daily living, last updated 4/3/19, documented the resident could feed self after set-up. A progress note dated 2/6/19, documented that staff noted the resident had increased difficulty self-feeding, and that the resident would eat if fed by staff. It documented that a physicial therapy screen was requested. During an interview on 4/05/19 at 10:40 AM, the Director of Therapy stated that the nurse had notified physical therapy that the resident needed more help with feeding. The Director stated that the resident should have been seen by an occupational therapist, however the request had been overlooked. There is no documentation of a therapy assessment for the resident's decline in feeding. Resident #46: The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, usually makes herself understood and usually understands others. A physician's orders [REDACTED]. Review of the OT Progress and Discharge Summary dated 2/1/19, documented the use of left hand palmer for out of bed positioning. The CCP dated 1/23/19 for Activities of Daily Living did not include documentation of positioning with left hand palmer and pillows as tolorated. The Kardex (undated) did not include the directive for positioning with use of a left hand palmer in place. During an interview on 04/02/19 01:44 PM, Certified Nursing Assistant (CNA) #5 stated they were not aware of the directive for use of a left hand palmer for positioning while out of bed. They put the residents hands up on pillows. CNA #5 stated the physical therapy/occupational therapy recommendations for care of the resident should be documented on the Kardex. During an interview on 04/02/19 at 01:00 PM, OT #7 reviewed the resident's medical record with the surveyor and did not find documentation of positioning with left hand roll and pillows on the care plan/kardex. OT #7 stated they use a form titled ADL Care Communication sheet to review the OT plan of care with nursing and nursing updates the care plan/Kardex after this form is reviewed. OT #7 stated they did not complete an ADL Care Communication Sheet for 2/2019 and stated the plan of care was not communicated to the nursing staff.

Plan of Correction: ApprovedApril 26, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident #36 a new therapy screen was placed and he is currently on therapy services.
For resident #46 her plan of care was updated to reflect the left hand plamer for out of bed positioning.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the same deficient practice as they could be screened to therapy. Education will be done with the therapy staff on ensuring screens are followed up on and with nursing staff on the importance of timely follow-up if a therapy screen is sent and no follow-up is done by therapy.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Screens for therapy services (PT, OT and SLP) will be submitted within 24 hours of a noted change in resident functional condition that warrants a need for therapy services. Submitted screens will be reviewed at clinical meeting the following morning to ensure screens submitted by nursing are received by therapy staff.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
The Director of Rehab, or designee will track all submitted screens by date and record the date the screen was completed. This tracker will be completed each morning in clinical meeting and will be reviewed by the IDT to ensure no rehab screens are overlooked.
The date for correction and the title of the person responsible for correction:
The Director of Rehab will be responsible to ensure correction by 6/4/2019.

FF11 483.35(a)(3)(4)(c):COMPETENT NURSING STAFF

REGULATION: §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey and an abbreviated survey (Case #NY 905), the facility did not ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care; providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. Specifically, for Resident #'s 36, 46, 47, 52, 63, 64, 70, 72, 79, 96, and #311, the facility did not ensure a competent staff member was creating and revising comprehensive care plans and goals for residents. This is evidenced by: The clarification of section 6209 of article 139 of the Education Law states: Licensed Practical Nurses in New York State do not have assessment privileges; they may not interpret patient clinical data or act independently on such data; they may not triage; they may not create, initiate, or alter nursing care goals or establish nursing care plans. Resident #47: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The Comprehensive Care Plans (CCPs) for advanced directives, social work, age, alteration of mood, and discharge, last updated 4/1/2019, were created and revised by Care Manager/Coordinator #4. The Care Manager/Coordinator #4 is a Licensed Practical Nurse (LPN). Resident #57: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Miminum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, undestands others and could make self understood. The Comprehensive Care Plans (CCPs) for communication, verbal and physical aggression, and safety, discharge, last updated 2/25/19, were created and revised by Care Manager/Coordinator #4. The Care Manager/Coordinator #4 is a LPN. Resident #311: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition, could sometimes understand others and could sometimes make self understood. The Comprehensive Care Plans (CCPs) for elopement and refusal of care (including eating, taking medications, weights, and vitals), last updated 10/24/18, were created and revised by LPN #5. Interviews: During an interview on 4/03/19 at 2:45 PM, the ADON stated he was not aware an LPN could not initiate goals on a comprehensive care plan in New York State. During an interview on 4/5/19 at 8:15 AM, the Assistant Director of Nursing (ADON) stated he is now aware that a Licensed Practical Nurse is not allowed to develop and update CCPs. He stated he was not aware prior to the survey. 10NYCRR415.13(a)(l)(i-iii)

Plan of Correction: ApprovedApril 26, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #47 care plans will be revised by the RN responsible for his care or the MSW on staff of the facility.
Resident # 57's care plans will be revised by the RN responsible for her care or the MSW on staff of the facility.
Resident # 311 was discharged prior to survey.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents residing in the facility have the potential to be affected by the deficient practice as all residents have comprehensive care plans in place. Regulation review and staff education will be completed to ensure the deficient practice does not recur.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Facility policy titled Interdisciplinary Team Comprehensive Care Plan was reviewed and revised, dated 4/24/2019. Policy revisions include:
1. Assessments of residents are on-going and care plans are revised as information about residents and resident conditions change.
2. The IDT must review and update Comprehensive care plans with a significant change in resident's condition; when a desired outcome is not met; when a resident is readmitted to the facility from a hospital stay; and at least quarterly in conjunction with the required MDS assessment.
3. Comprehensive Care Plans will be updated by the Registered Professional Nurse (RN) for care related updates or the MSW for Social Service related updates.
4. Education will be provided to all nursing staff that LPN's are not to implement or revise the care plan for residents in their care. All changes are to be made the RN or MSW responsible for the residents care.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
10 random care plans will be audited by the Director of Nursing per unit per week to ensure that care plans are being initiated or revised by the RN or MSW. The audits will be done weekly for 4 weeks and then monthly for 3 months. The audit results will be reviewed and discussed by the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The Director of Nursing will be responsible to ensure correction by 6/4/2019.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based an observation, record review and interview during the recertification survey and an abbreviated survey (Case #NY 888), the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for 8 (Residents #'s 1, 40, 50, 52, 58, 64, 79, and #310) of 24 residents reviewed for comprehensive care plans (CCPs). Specifically; the facility did not ensure that CCPs were implemented for Resident #1's altered consistency diet and Resident #40's unit ambulation; The facility did not ensure a CCP was developed for Resident #50's [MEDICAL CONDITION], for Resident #52's self-administration of medications, for Resident #58's pressure sore, for Resident #64's urinary tract infection, for Resident #310's bladder incontinence and for Resident #79, the facility did not ensure the resident was transferred according to the care plan (2 assist with a sit-stand lift). This is evidenced by: Resident #52: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make himself understood. A Medication Self-Administration Safety Screen dated 11/14/18, documented the resident was alert and oriented and had administered his own insulin at home. The resident was able to state the use, need and storage requirements for insulin. The assessment documented that the resident would document on a paper Medication Administration Record [REDACTED]. It documennted that nursing staff would review the paper MAR indicated [REDACTED]. Review of the resident's medical record on 04/01/19 at 8:00 AM, did not reveal doucmentation of a comprehensive care plan that addressed the resident's self administration of insulin for diabetes. During an interview on 04/03/19 at 3:08 PM, the Assistant Director of Nursing (ADON) stated the self administration of medication should be part of the comprehensive care plan. The ADON stated self administration of medications should be addressed within the diabetic care plan or in a separate care plan specific to self administration. The ADON stated it should be addressed somewhere within the comprehensive care plan. Resident #64: The resident was last admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was severly impaired cognitively, was able to understand others and make self understood. Review of the nursing notes dated 3/29/19 at 10:53 AM, documented that report was recieved from the hospital to start Keflex 500mg bid (twice daily) for the [DIAGNOSES REDACTED]. Review of the nursing notes dated 3/29/19 at 6:20 PM, documented the resident returned to the facility at 1:42 PM and was to receive Keflex (antibiotic) for a UTI. A Physician order [REDACTED]. Review of the medical record did not include a care plan for a Urinary Tract Infection [MEDICAL CONDITION]. During an interview on 04/03/19 04:14 PM, the ADON stated there should be a care plan for an acute infection. Resident #310: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident did not have a cognitive impairment, could understand others and could make self understood. The MDS documented the resident was frequently incontinent of bladder. Review of the resident's medical record on 04/01/19 at 01:04 PM, did not include a care plan to address bladder incontinence. During an interview on 04/03/19 at 03:08 PM, the ADON stated if a resident was incontinent of bladder, he would expect that a care plan would be developed to address the resident's bladder incontinence. 10 NYCRR 514.11(c)(1)

Plan of Correction: ApprovedMay 8, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident #1, her care plan was updated to include her altered consistency diet.
For resident #40, her ADL care plan was updated to include her unit ambulation.
For resident #50, a care plan was added for her [MEDICAL CONDITION].
For resident #52, he was discharged on [DATE] (the final day of survey)
For resident #58, her care plan was updated to include additional interventions for her pressure ulcer.
For resident #64, she completed her UTI treatment on 4/5/19 (the final day of survey), but a care plan was added for chronic UTI's with notation of her most recent treatment being started on 3/29/19 for 7 days. Goals and Interventions in place with her care plan.
For resident #310, he was discharged before survey, on 12/17/2018.
For resident #79, his ADL care plan was reviewed, no changes were made and a facility investigation was completed upon notification of the care plan violation to the ADON by the survey team leader and surveyor. The CNA responsible was suspended pending investigation. There was no physical or psychological harm to the resident noted as a result of the care plan violation.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the same deficient practice as all residents have comprehensive care plans. Policy review and revisions will be completed and nursing education will be completed to prevent the deficient practice from recurring.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Facility policy titled Interdisciplinary Team Comprehensive Care Plan was reviewed and revised, dated 4/24/2019. Policy revisions include:
1. Assessments of residents are on-going and care plans are revised as information about residents and resident conditions change.
2. The IDT must review and update Comprehensive care plans with a significant change in resident's condition; when a desired outcome is not met; when a resident is readmitted to the facility from a hospital stay; and at least quarterly in conjunction with the required MDS assessment.
Education will be completed with RN staff regarding care planning and the importance of ensuring development and implementation by the RN or MSW responsible for the resident's care, which include measurable goals and interventions. Additional education will be completed with all nursing staff regarding the importance of providing care according to the prescribed plan of care, regardless of staffing levels. Failure to follow the plan of care can be considered neglect and appropriate disciplinary action will be taken.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Comprehensive care plans will be reviewed each morning at clinical meeting and will be updated in real time with any changes in condition, acute infections, ADL changes, etc. to ensure timely and accurate revisions. Random audits will be completed on 10 residents by the unit manager of each unit to ensure comprehensive care plans are up-to-date and accurate. These audits will be completed weekly for 4 weeks, then monthly for 2 months. Audit reports will be reported to the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The Assistant Director of Nursing Services will be responsible to ensure correction by 6/4/2019.

FF11 483.25(l):DIALYSIS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #47) of one resident reviewed for [MEDICAL TREATMENT]. Specifically: the facility did not ensure the resident's vital signs were taken upon return from [MEDICAL TREATMENT] and that staff were assessing the [MEDICAL TREATMENT] access catheter for complications, and that the resident did not receive foods that were contraindicated for a renal diet. This is evidenced by: Resident #47: The resident was admitted to the nursing home on 1/10/19 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. As of the last day of survey 4/5/19, the facility had not produced a Policy for residents receiving [MEDICAL TREATMENT]. A Comprehensive Care Plan for: [MEDICAL TREATMENT] dated 11/2/18, documented to monitor, document, and report any sign and symptoms of infection to the access site: redness, swelling, warmth or drainage. Nutritional problem dated 10/31/19, documented the resident was on a Renal diet with no concentrated sweets. Finding #1: The facility did not ensure that vital signs were being monitored after [MEDICAL TREATMENT], A review of the twelve [MEDICAL TREATMENT] Intercommunication Forms dated from 3/2/19 - 4/2/19 documented vital signs on four of those occasions in the area designated as: Resident Returning to nursing home: To be completed by the nurse upon return to the nursing home. Progress notes for the twelve [MEDICAL TREATMENT] treatments received between 3/1/19 - 4/2/19 included documentation of vital signs for one of those treatments. During an interview on 3/31/19 at 12:49 PM, the resident stated he goes to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays and has a book that goes back and forth with him. During an interview on 4/5/19 at 12:28 pm, the Director of Nursing (DON) stated that when the resident came back from [MEDICAL TREATMENT], nurses were supposed to take the vital signs and document them in the [MEDICAL TREATMENT] communication book; that was why the papers were in the communication book. He was not aware that it was not being done. Finding #2: The facility did not ensure that the resident was receiving a renal diet as order by the physician. MD orders dated 3/1/19, documented Renal Diet. During an interview on 3/31/19 at 12:49 PM, the resident stated he was given a banana on his tray at breakfast and that he ate it. During an interview on 04/5/19 9:41 AM, the Registered Dietitian (RD) stated part of her role was to ensure the accuracy on the menu and the resident should not have had a banana on his tray because a renal diet was low potassium. The banana bypassed their check points and it was a learning experience. During an interview on 4/01/19 at 4:09 PM, the Food Service Director stated there was three people on tray line; the last person was a supervisor and would weed through the tickets to ensure that everything is on there. She did not know if the resident should have had bananas and was under the impression the computer would put what he could have based on what was served that day. There was a hiccup when they list fresh fruit as the option on the ticket the computer would not know what it was to remove it. Finding #3: The facility did not ensure the resident's vital signs were taken upon return from [MEDICAL TREATMENT] and that staff were assessing the [MEDICAL TREATMENT] access catheter for complications. During an interview on 3/31/19 at 12:49 PM, the resident stated staff don't look at his chest port or do anything with it; [MEDICAL TREATMENT] takes care of it. During an interview on 4/02/19 at 2:46 PM, LPN #4 stated she did not get vitals on him yet because she does her vital signs at end of shift and by delaying she could miss a complication with the resident. Additionally, she stated there was no place on the treatment record to sign that the catheter access port was checked. During an interview on 4/5/19 at 12:28 pm, the Director of Nursing (DON) stated that when the resident came back from [MEDICAL TREATMENT], nurses were supposed to take the vital signs and document them in the [MEDICAL TREATMENT] communication book; that was why the papers were in the communication book. He was not aware that it was not being done. Additionally, the DON stated that he would not expect staff to monitor and document the condition of the [MEDICAL TREATMENT] catheter site. When the surveyor showed the DON the care plan he implemented that documented to monitor, document, and report any sign and symptoms of infection to the access site: redness, swelling, warmth or drainage, he stated that if it was on the care plan then it should be done. During an interview on 4/5/19 3:39 PM, the Medical Director stated this resident was very complex, with a lot of co-morbidities, a poor cardiac status, and had been hospitalized multiple times. He would expect that vital signs would be taken by nursing staff as soon as the resident returned from [MEDICAL TREATMENT], that the condition of the [MEDICAL TREATMENT] would be checked and documented. By not doing these things they are putting the resident at risk. 10NYCRR 415.12

Plan of Correction: ApprovedApril 26, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident #47 vital signs will be documented upon return from [MEDICAL TREATMENT] within 15 minutes of return to the unit and an RN assessment of his HD access site will be completed. Dietary staff was educated on importance of following therapeutic diets.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
There are only 2 residents in the facility that require [MEDICAL TREATMENT] at this time. These are the only residents who have the potential to be affected by the deficient practice. Policy revision will be done and education of staff will be done to ensure the deficient practice does not recur.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
As noted in the SOD, a policy for monitoring of [MEDICAL TREATMENT] residents was unable to be located during survey so a new policy titled Monitoring of [MEDICAL TREATMENT] Residents was written and dated 4/19/2019. This new policy includes protocol for monitoring of vital signs upon return from [MEDICAL TREATMENT], documentation of vital signs and RN assessment of [MEDICAL TREATMENT] upon return from [MEDICAL TREATMENT]. Education will be completed with nursing staff regarding policy changes and importance of timely monitoring of vital signs, access site and diet.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
The nurse manager of the unit the [MEDICAL TREATMENT] residents reside on will audit the [MEDICAL TREATMENT] books to ensure that vital signs are being done upon return to the facility within 15 minutes. These audits will be completed every day that the resident leaves the building to go to [MEDICAL TREATMENT] for 90 days. The results of the audits will be brought to the QAPI committee monthly for review.
The date for correction and the title of the person responsible for correction:
The ADON will be responsible to ensure correction by 6/4/2019

FF11 483.60(i)(4):DISPOSE GARBAGE AND REFUSE PROPERLY

REGULATION: §483.60(i)(4)- Dispose of garbage and refuse properly.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash dumpsters were not kept covered and were leaking waste. This is evidenced as follows. The dumpsters were inspected on 03/31/2019 at 10:35 AM. Three dumpsters were partially filled with waste and were not covered, black and greasy liquid was found on the ground below the front and middle dumpster, cigarette butts littered the ground between the dumpsters and employee entrance, and the side of the middle dumpster was soiled with a black build-up. The Director of Maintenance stated in an interview conducted on 03/31/2019 at 2:43 PM, that staff might not be closing the dumpsters, and he had spoken with the dumpster vendor about replacing the leaking dumpsters. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedApril 26, 2019

F814 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Area?s identified during survey were cleaned to assure compliance. Waste disposal contacted to assure that dumpsters are in proper working order.
IDENTIFY OTHER POTENTIAL RESIDENTS
- Additional signage will be added to inform all about non-smoking on the facility grounds. Education will be given to appropriate staff about assuring dumpster lids are closed and to assure no littering is taking place on grounds.
SYSTEMIC CHANGES
- Waste disposal company to inspect dumpsters for proper working order, with the potential to switch to a trash compactor which would eliminate the dumpsters in their entirety. A monthly outdoor physical rounds form has been fabricated to assure the exterior of the facility is neat and tidy.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will perform weekly checks of these areas for one month, and then monthly for three months if there are no negative findings in the first month. This will be communicated to the Quality Assurance committee, and any negative findings will be reported immediately to Administration for corrective action.
PERSON RESPONSIBLE
- Director of Maintenance by 6/4/2019

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process. This is evidenced by: An undated policy from Long Term Solutions Pharmaceutical Consultants titled: Drug Regimen Review, did not document timeframes for when the facility staff and physicians would complete the steps in the MRR process. During an interview on 04/03/19 at 9:51 AM, the Assistant Director of Nursing (ADON), reviewed policy and reported it does not have time frames for all the steps in the process. Although the policy is not dated, the ADON reported they got this policy from the pharmacy this year. NYCRR10

Plan of Correction: ApprovedMay 9, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Policy titled Drug regimen review will be updated to include timeframes for MRR process.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the same deficient practice as they undergo the drug regimen review process. The Policy will be revised to ensure the deficient practice does not recur.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Policy titled Drug Regimen Review was reviewed and revised dated 4/24/2019 to include timeframes for the Medication review process. These timeframes will be as follows:
According to facility policy time frame of expectation for consultant pharmacist to send DRR's to facility will be within 24 hours of completion.
For Clinically Significant DRR's the response time from the physician/designee will be within 24 hours.
For Non Clinically Significant DRR's, the response time from the physician/designee will be within 5 business days.
Education will be provided to all nursing staff to ensure updated timeframes are followed.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
All Drug Regimen Reviews will continue to be brought to the ADON for review, filing and storage once the physician/provider had completed them and nursing has picked up the orders. The ADON will ensure that the timeframe as specified in the revised policy is adhered to.
The date for correction and the title of the person responsible for correction:
The ADON will be responsible to ensure correction by 6/4/2019.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Toxic materials are to be prominently labeled, and equipment and surfaces in the preparation areas to be kept clean, and handwashing facilities are to include paper towels. Specifically, cleaning chemical spray bottles were not labeled, food contact and kitchen equipment and floors required cleaning, and paper towels were not provided at the handwashing sink. This is evidenced as follows. The kitchen and unit kitchenettes were inspected on 03/31/2019 at 10:15 AM. A spray bottle found under the main preparation table, the contents of which foamed when the bottle was shook, was not labeled. The floor mixer, can opener, slicer, walk-in refrigerator door, plate warmer, plate pallet warmer, walk-in freezer floor, bulk food containers, prep sink, shelving, handwashing sink, drawers, waste receptacles, door to dining room, food service dollies, and fire extinguisher were soiled with food particles, food spills, or dried food. The floor was soiled with a black build-up in the dishwashing area and in corners next to walls in the main kitchen. The paper towel dispenser by the handwashing sink was empty. The microwave ovens, cupboards, cabinets, and/or floors and doors on the unit kitchenettes were soiled and required cleaning. The Food Service Director stated in an interview conducted on 03/31/2019 at 11:30 AM, that the spray bottle should have been labeled, she will ensure all areas found are cleaned, and she will refill the paper towel dispenser. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.60, 14-1.110, 14-1.112,14-1.170

Plan of Correction: ApprovedMay 9, 2019

F812 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Area?s identified during survey were deep cleaned during the survey to assure compliance. The bottle identified was disposed of to assure it did not get back into rotation.
IDENTIFY OTHER POTENTIAL RESIDENTS
- The entirety of the kitchen was deep cleaned after hours during survey to assure compliance. All other bottles in the area were checked to assure they were labeled appropriately, with no issues being found.
SYSTEMIC CHANGES
- Kitchen to have a monthly physical environment audit to be documented and given to Administration for potential follow up as needed. A deep cleaning rotating schedule has been made for high traffic areas, and staff will be educated on the expectations and proper procedure to keep those areas clean, that all needed supplies such as paper towels are readily available, and that staff report any needs such as deep cleaning or restocking of items to the department head.
QUALITY ASSURANCE
- The Director of Food Service (or designee) will report their findings to the QA committee for 6 months to assure ongoing compliance. Any negative findings will be communicated to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Food Service by 6/4/2019

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it was free from accident hazards as was possible and that each resident received adequate supervision to prevent accidents, for nine Resident (#'s 1, 6, 52, 57, 76, 400, 401, 402, and #403) of nine reviewed for accident hazards. Specifically: For Resident #52, the facility did not ensure that the resident, had a locked space to keep his insulin supplies for the treatment of [REDACTED].#'s 6, 57, 76, 400, 401, 402, and #403, who smoked prior to their admission to the facility and who smoked or were suspected of smoking in the facility or on the facility grounds, the facility did not ensure that risks and hazards for smoking were identified, evaluated and analyzed, and did not implement interventions to reduce the risks and hazards. Additionally, the facility did not ensure that Resident #1, who was on a ground diet, did not have access to a regular consistency diet by trading food with her husband who was on a regular consistency diet. This is evidenced by: The facility policy for smoking dated 7/8/17, documented that residents who were deemed able to sign themselves out and go off property to smoke, may be allowed, pending medical approval to be able to sign themselves out. 1. This is a non-smoking facility 2. If a resident was medically cleared to sign themselves out, they will be allowed to keep their materials with them, provided they are secured in the resident's locked drawer and not used at any other time. 4. If a resident chooses to smoke in the facilit or on facility grounds, clearance to sign themselves out will be re-approached. Non-compliance will forfeit this ability. 6. Residents are not allowed to give smoking articles to other residents. 10. The facility maintains the right to confiscate smoking articles if found in violation. Finding #1: Resident #6: The facility did not ensure that risks and hazards for smoking were identified, evaluated and analyzed, and did not implement interventions to reduce the risks and hazards. The resident was admitted to the nursing home on 12/4/18 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During an observation on 4/4/19 at 9:28 AM, the resident was noted exiting his bathroom and immediately shutting the door. He had a lighter in his right hand and walked to the other side of the room. When he turned around a pack of cigarettes was noted in his left hand and the lighter was still in his right hand. There was no smoke detector noted in the room. Surveyor #1 opened the bathroom door noted a heavy aroma of fresh cigarette smoke. During an observation on 4/4/19 at 9:30 AM, Surveyor #2 and Licensed Practical Nurse (LPN) #1 entered the resident's bathroom and noted a heavy aroma of cigarette smoke. A Progress Note dated 2/10/19 at 6:06 PM, written by a Registered Nurse, documented that the resident returned from the outside patio area at 6:00 PM and was informed that the facility was a non-smoking facility. He denied smoking and acknowledged the policy. The Comprehensive Care Plan (CCP) did not include a care plan to address the residents potential or actual non-compliance with the smoking policy. During an interview on 4/4/19 at 9:28 AM, the resident stated that he smoked around back at the picnic table. He stated that the surveyor probably smelled smoke in the bathroom because he had a 1/2 of a cigarette on him; but he was not smoking. During an interview on 4/03/19 9:35 AM, the Administrator (ADM) stated to his knowledge the resident went off property to smoke, kept his smoking supplies on his person. and had a locked drawer. They did not have a care plan for smoking. During an interview on 4/4/19 at 9:57 AM, Registered Nurse Manager (RNM) #1 stated she was aware of the incident where the resident was smoking in his room. She had never done a smoking assessment on the resident and had put a care plan in place that identified him as at risk to smoke. She brought cigarettes and a lighter out of his room. She had not spoken to him previously, because it had never been an issue; he had not smoked in his room or on the property before so she never had a reason to know where his supplies were. She was not aware of a battery operated smoke detector was to be placed in the resident's room. During an interview on 4/5/19 at 12:05 PM, the ADM stated residents who kept their supplies would not be searched or monitored for their supplies unless there was a cause ie. smoking in the facility. They had suspicions 2 - 2 1/2 months ago that the resident was smoking in his room when someone reported smelling smoke from his room. Finding #2: Resident #57: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Miminum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, undestands others and could make self understood. During an observation on 4/2/19 at approximately 5:30 PM, the resident was noted smoking in the parking lot of the facility with another female. When the surveyor asked the resident if she worked there she stated no, laughed and sat on the ground between 2 parked cars. This incident was reported by the surveyor to the Case Management/ Coordinator. A Monthly Medical Evaluaton dated 12/19/19, documented that the resident had episodes of smoking cigarettes. A Facility Incident Report for Elopement dated 1/10/19 for the resident, documented that the resident knew the exit code to the employee hallway and knew the men's locker room would be available to sneak a cigarette. She too advantage of the change of shift to exit to have a smoke in the locker room. A Comprehensive Care Plan for smoking in the building was not developed until 1/11/19. The CCP documented that the resident was smoking in the facility despite conversations with her about the smoking policy and the safety of others. It documented that when they spoke to her about it, she just shrugged her shoulders and laughed. It documented that she was on every 15 minute checks and that they would discuss with the resident and family to attempt to find a solution. During an interview on 4/02/19 03:14 PM, Certified Nursing Assistant (CNA) #2 stated the facility suspected Resident #'s 57 and 400 were smoking in the building and that was one of the reasons the shower room at the end of the hall is kept locked. Resident #57 knew the code to the employee hallway, locked herself in the men's locker room and when she came out the locker room smelled like smoke. During an interview on 4/03/19 at 9:35 AM, the ADM stated the resident only smoked off facility property with her Mom and had no smoking supplies in her room. They put a battery operated smoke detector in her room. The ADM stated that the resident had been caught once smoking in her room. During an observation of the resident's room and bathroom on 4/4/19 at 9:48 AM, there was no battery operated smoke detector noted. During an interview on 4/03/19 at 3:13 PM, the LPN Care Manager/Coordinator (CM/C) stated the shower room at the end of the hall was kept locked to prevent smoking in the shower room, as they had smelled smoke in there before. During an interview on 4/03/19 at 3:13 PM, the LPN Care Manager/Coordinator (CM/C) stated Resident #57 had incident 1/10/19, and had stated that she intended to go back to drugs when she got out. During an interview on 4/4/19 at 9:57 AM, Registered Nurse (RN) #1 stated that the resident went off the property with her mom and smoked. The last she knew her mother had her supplies. She had not assessed the resident for an at risk to smoke. During an interview on 4/4/19 at 10:02 AM, LPN #2 stated she she was not aware that Resident #57 was observed smoking in the parking lot the other day and was not aware of anyone ever searching her room for smoking supplies. During an interview on 4/04/19 at 9:58 AM, the ADM stated he did not know why room searches were done, but in the past Resident #57's s room was searched, and no smoking supplies were found. Finding #4: Resident #400: Review of a Progress note dated 1/16/19 at 10:50 AM, by the Care Mananger/Coordinator documented the writer met with the resdient and explained that due to his disregard for facility policies, they would be finding him placement elsewhere. They had reviewed the policies with the resident on mulitple times yet he continued to ignore them and put others and himself at risk. During an interview on 4/02/19 03:14 PM, Certified Nursing Assistant (CNA) #2 stated she worked on the East unit on Sundays and would stand in the hall and smell smoke from room [ROOM NUMBER]. Resident #400, who resided on the North Unit, would come to the East Unit, get towels and take them into room [ROOM NUMBER] where Resident #402 (the resident could not use his arms) and 403 resided. Resident #400 would shut the door, stuff the towels under it, open the windows and smoke in the room along with Resident #403 and Resident #402. Resident #400 would hold Resident #402's cigarette for him while he smoked. The resident, who resided next door to room [ROOM NUMBER], complained multiple times that their smoke was coming in her window. It was always reported and everyone was aware that it was happening. They did speak to Resident #400 but nothing changed. During an interview on 4/04/19 at 9:58 AM, the ADM stated he did not know why the residents room was searched, but in the past Resident #400's room was searched, and no smoking supplies were found. During an interview on 4/4/19 at 10:11 am, CNA #12 stated she heard about Resident #402 smoking in his room with the help of Resident #400 from the north unit, and that it was happing every night. they all reported to the supervisors, but nothing happened that she knew of. They could not see it but could smell it. Resident #400 would get towels put them under the door and open window all the way. Both residents would smoke and the room. One of the residents in next room would report smelling the cigarette smoke. The resident on the other side of room [ROOM NUMBER], who was demented would get up looking for her cigarettes. This went on for at least a month. The shower room was locked because of the smoking. Resident #403: The resident was admitted to the facility on [DATE], and resided in room [ROOM NUMBER] with Resident #402, with [DIAGNOSES REDACTED]. The Miminum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, understands others and could make self understood. Progress notes dated: 6/20/18 - written by the Nurse Practitioner, documented she was called to see the resdient as he had been smoking multiple times in his room despite being advised not to. 6/22/18 - written by the Registered Nurse, documented that another resident reported smelling cigarette smoking; upon entering resident room, no smoke noted reminded of smoking policy. 6/27/18 - written by the RN, documented the resident was noted smoking in the back patio. He was remined that it was non-smoking facility and that he did not have Leave of Absence (LOA) orders. 7/5/18 - written by the RN documented that while performing an intravenous(IV) treatment, a foul odor was noted in the room. There was a large orange juice container with cigarette butts in water. The resident was remined of the dangers and the Medical Director was made aware. The CCP did not include a care plan to address the unsafe smoking in the faclility. During an interview on 3/31/19, the Administrator stated that this was a non-smoking facility and there were no smokers. During an interview on 4/04/19 at 9:58 AM, the ADM stated there were no investigations in the past for smoking in resident rooms that he was aware of. Additional Interviews: During an interview on 4/02/19 03:14 PM, Certified Nursing Assistant (CNA) #2 stated changed. Another time she smelled smoke coming from Resident, #401's room. She told the nurses. They did not find a cigarette but did find a lighter. They smelled smoke in her room another time and when they asked if she was smoking in her room, she replied, yes; she was told she could not do it again. They also suspected Residents' #57 and 400 were smoking in the building and that was one of the reasons the shower room at the end of the hall is kept locked becase residents were smoking in there. Resident #57 also, got the code from someone to the employee hallway, went down the hall and locked herself in the men's locker room. When she came out the room smelled like smoke. A staff member who used to work there, took residents out to smoke near the water tower at the back of the property. During an interview on 10:20 AM Clover stated res who were smoking were threating(NAME)for reporting them she was upset because she had to move but they were threatening. During an interview on 4/03/19 at 3:13 PM, the LPN CM/C stated they did smell smoke in the shower room at the end of the hall and now kept it locked to prevent smoking in the room. During an interview on 4/4/19 at 9:51 AM, House Keeper (HK) #15 stated that when she first came about a year ago she found a cigarette butt in the drawer to one of the empty resident rooms on the East Unit. She knew it was not there the day before because a complete cleaning was done on the room the day before; she did report it to the nurse at the desk. During an interview on 4/4/19 at 10:02 AM, LPN #2 stated that they smelled cigarette smoke in other roooms before. They would offer a nicotine patch and tell then they can't smoke. She did not know if there was a smoking contract that residents signed. During an interview on 4/5/19 at 12:05 PM, the ADM stated that residents who kept their supplies would not be searched or monitored for their supplies unless there was a cause ie. smoking in the facility. He was aware of a smell of smoke from Resident #76's room approximately 5-6 months ago; he was not aware of a residents family complaining about the smell. Resident # 52: The facility did not ensure that Resident #52 had access to locked space to store his diabetic medication, needles, syringes, and lancets, and did not intervene when these items were consistently left out on an overbed table near an open door where they could be accessed by anyone in the hall. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact, could understand others and could make himself understood. The resident had a Negative Pressure Wound Therapy(NPWT) (a vaccuum dressing that continuously pulled drainage from a wound when on into a collection canister) to his left foot. During observations on: 3/31/19 at 10:38 AM - the resident's insulin pen was on his over bed table 4/01/19 at 09:14 AM - the resident's bedroom door was open and there were 10 unopened syringes on the resident's nightstand. 4/02/19 at 02:49 PM - the resident's bedroom door was open and there was a box of lancets, a box of novofine needle tops, a vile of insulin, and an insulin pen on the resident's over bed table. The resident's locked drawer was ajar. 4/02/19 at 3:35 PM - the door to Resident #52's was open; needles, insulin and syringes were noted on the residents overbed table that was near the door. Resident #57 was ambulating in the hall. 4/03/19 at 11:52 AM - diabetic supplies including lancets, and needles were noted on the overbed table, that was next to the residents door which was open. 4/03/19 at 2:08 PM - a box of lancets, and a box of needles were noted on the resident's overbed table next to his open door, visible from the hall. 4/04/19 at 9:48 AM and 4/05/19 at 10:38 AM - a box of lancets, and a box of needles were on the overbed table next to the door visible from teh hall. The key to the locked drawer was in the lock. During an interview on 3/31/19 at 10:38 AM, the resident stated he kept his insulin at his bedside and administered it himself. During an interview on 4/02/19 at 2:45 PM, LPN #4 stated that residents from other units came on the East unit to use the vending machine. During an interview on 4/01/19 at 09:16 AM, RN #1 stated the resident should have his insulin and insulin supplies in a locked drawer and believed he was educated on where to keep his diabetic supplies and must have the key. During an interview on 4/01/19 at 9:18 AM, the resident stated he was never issued a key to the locked drawer in his room. During an interview on 4/01/19 at 9:25 AM, LPN #1 stated that his diabetic supplies were supposed to be in a locked drawer and she would make sure he got a key today. During an interview on 4/02/19 at 2:52 PM, RN #1 stated she spoke with him yesterday and he signed an agreement, that he would keep his supplies safe. During an observation on 4/02/19 at 3:50 PM, RN #1 was at the desk with a key taped to a piece of yellow payer and stated she had just recieved the key for the resident's locked space at 3:30 pm and she had to now give it to the resident. She realized having the needles and syringes out in the open was a resident safety issue, but stated she did not go into his room to do something about it when he was not there because he was accusatory. During an interview on 4/03/19 at 3:08 PM, the ADON, stated that the needles and diabetic supplies were a safety hazzard and should have been stored in the locked drawer in his room. Resident #1: The facility did not ensure that the resident, who was on a ground diet, was not trading food with her husband who was on a regular consistency diet. The resident was admitted to the nursing home on 10/2/19 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. It further documented that the resident required setup and supervision for meals and was on a mechanically altered diet. During an observation on 3/31/19 at 12:33 PM, the resident was in her room, eating ziti with ground meat in the sauce. The resident stated she could not chew the meat and was picking it out of her mouth, putting in on her tray. During in observation on 4/01/19 at 08:47 AM, the resident was eating breakfast (pancakes) in bed. The her meal ticket documented she was on a ground diet. The resident stated she got scrambled eggs and her husband got the pancakes but they switched because she did not like scrambled eggs. She told them she did not like scrambled eggs, but they kept sending them. MD orders dated 1/17/19, documented No Concentrated Sweets (NCS) diet ground texture with regular consistency liquids. During an interview on 4/01/19 at 9:21 AM, Unit Assistant (UA) #2 stated She passed out meal trays and just made sure the name was correct, she was not trained to check the consistency and did not do it. She was aware that the residnet and her husband frequently switched breakfast when she was served eggs. During an interview on 4/01/19 at 4:25 PM, Certified Nursing Assistant (CNA) #2 stated the resident complained about the scrambled eggs all the time, but her husband liked them so if he had something different, they would trade food. During an interview on 04/01/19 at 4:28 PM, Licensed Practical Nurse (LPN) #1 stated she was aware that the resident and her husband switch meals some times. The resident was not on an altered consistency diet she was on a regular diet with thin liquid. During an interview on 04/01/19 04:52 PM, the DON stated the resident should not have been eating the pancakes and they should have been made aware that the resident was doing this. During an interview on 4/01/19 at 3:12 PM, the Registered Dietitian (RD) stated the resident was on a ground diet, was not happy with breakfast choices because she did not like the pureed bread products. The Speech Language Pathologist (SLP) re-evaluated the resident recently and did not want her upgraded from ground food. The resident should not be eating pancakes unless they were pureed. During an interview on 4/02/19 at 2:03 PM, the SLT stated that the resident should be supervised. It is a potential choking risk for her to be eating her husband's regular consistency pancakes. 10NYCRR 415.12(h)(1)

Plan of Correction: ApprovedMay 9, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
On 4/4/2019,(NAME)Hills Nursing and Rehabilitation Center became a full non-smoking facility for all residents.
For resident #6 a smoking assessment was completed on 4/4/2019 and a comprehensive care plan was initiated on 4/4/2019 for smoking and potential for nicotine withdrawal.
For resident #57 a smoking assessment was completed on 4/4/2019 and a comprehensive care plan was initiated on 4/4/2019 for smoking and potential for nicotine withdrawal. She previously had been ordered for the nicotine patch but refused to wear it. Of late she was wearing the patch, but removed or refused to wear it when her mother would take her on LOA as she would smoke once signed out by her mother.
For resident #400 he was discharged prior to survey on 3/6/2019.
For resident #403 he left AMA prior to survey on 7/5/2018.
For resident #52 a second key to his locked drawer was provided to him to secure his medication and supplies as well as re-education was provided to him on 4/1/2019. He was subsequently discharged from the facility on 4/5/2019.
For resident #1 her care plan was changed to be out of bed for meals or supervised by staff if in bed for meals due to being on an altered consistency diet and the increased risk of choking due to the altered diet and her swapping food with her husband who is on a regular consistency diet. For resident #1, Speech Therapy is working with her in an attempt to upgrade her diet as well as the resident wishes to have a regular diet and not remain on an altered consistency diet any longer.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the same deficient practice. Staff education will be done and policy review and revision will be done to ensure the deficient practice does not recur.

What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Facility smoking policy dated 7/8/2017 was reviewed and revised, dated 4/24/2019.(NAME)Hills Nursing and Rehab Center became a fully non-smoking facility for residents residing in the facility effective at 1:00 pm on 4/4/2019. Staff education regarding the changes to the facility's smoking policy will be completed to ensure staff are aware of the changes.
Education regarding comprehensive care plans will be done with staff to ensure staff are aware of importance of following plan of care as written. This education will include, but will not be limited to dietary modification and safety interventions for those residents with modifications of their diets. Residents with an alteration in diet do not eat unsupervised in their room, or eat in the unit dining rooms. By eating in a supervised fashion, staff will observe if the resident attempts to swap food with another resident and can stop that from happening, thus ensuring a resident does not receive a food that is of an incorrect consistency.
Accident and Incident education will be completed with staff to ensure that facility staff are reporting to the supervisor on duty (i.e., nurse manager, nursing supervisor, ADON, DON, etc.) any incident that occurs so that a facility investigation can be completed. Education will include, but will not be limited to; violation of care plan and smoking in the facility.
Resident #1 will be supervised during meals as she is on an altered consistency diet and care plan to reflect this change. By staff supervising the resident while eating, they will be able to prevent the resident from eating or obtaining food that is not part of her prescribed diet.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
All staff will attend the education to ensure an understanding of what needs to have an incident report and subsequent investigation completed on it. The Director of Nursing or designee will monitor 24 hour report each morning and ensure that anything documented that should have an incident report completed in fact has one done, and that a facility investigation has been completed.
Staff will document in the medical record if during the supervision of resident #1 they observe her with food of the wrong consistency per her prescribed diet, and a facility investigation will be completed.
The date for correction and the title of the person responsible for correction:
The ADON will be responsible to ensure correction by 6/4/2019

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 15, 2019

Citation Details

Based staff interview and the Legionella Sampling and Management Plan (SMP) review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Part 4, Protection Against Legionella, Section 4-2.3 requires that environmental assessments be updated annually, and Section 4-2.4 requires that by (MONTH) 1, (YEAR) initial Legionella sampling shall be at periods not exceeding 90 days prior to annual sampling. Specifically, the facility did not maintain a current Legionella Environmental Assessment Form (EAF) and test for Legionella as required by New York State regulation. This is evidenced by the following. When requested on 04/02/2019 an Environmental Assessment of Water systems in Healthcare Settings (form DOH-5222) was not available for survey review. When requested on 04/02/2019 potable water system Legionella testing reports dated at periods not exceeding 90 days prior to annual sampling were not available for survey review. The Administrator stated in an interview conducted on 04/02/2019 at 10:45 AM, that he will complete an EAF and start Legionella water testing immediately. 415.19(a)

Plan of Correction: ApprovedMay 9, 2019

I210 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Outside consultant contacted to write new Facility Water Management Plan. Form DOH-5222 was completed and presented during survey. Legionella testing scheduled and will be performed in a frequency of less than every 90 days times four then annually.
IDENTIFY OTHER POTENTIAL RESIDENTS
- Consultant water plan to be implemented and educated to staff to assure compliance and knowledge of the new water management plan. Any other education, audits, etc. that are outlined in the Plan will be implemented as Facility Policy and Procedure.
SYSTEMIC CHANGES
- New Water Management Plan will be implemented as Facility Policy. Any necessary audits, checks, etc. will be performed as prescribed and documented for review.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit monthly for 12 months that the new Water Management Plan is being followed and all necessary items on it are being performed. They will report their findings to the Quality Assurance committee and report any negative findings to Administration for immediate follow up.
PERSON RESPONSIBLE
- Director of Maintenance by 6/4/2019

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey the facility did not ensure it developed, implemented and maintained an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible, did not ensure the IPCP was reviewed annually and updated as necessary and did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not ensure that the policy titled Infection Control Program Standard and Transmission Based Precautions included and explained how standard precautions, and when transmission-based precautions should be utilized, including but not limited to the type and duration of precautions for particular infections or organisms involved; the facility did not ensure Policies and Procedures were reviewed at least annually; the facility did not ensure three employees received the flu vaccine and that those employees who did not receive the flu vaccine masks covered their mouths and nose; for Resident #96, the facility did not ensure the care plan for [MEDICAL CONDITION] Resistant Staphylococous aureus in the right knee included an intervention for contact precautions; the facility did not ensure the residents' environment on the East unit was as free as possible from wound exudate (fluid) and blood; and the facility did not ensure the development and implementation of a Water Management Plan (WMP) in accordance with adopted regulations. This was evidenced by: Finding #1: The facility did not ensure that the policy titled Infection Control Program Standard and Transmission Based Precautions included and explained how standard precautions, and when transmission-based precautions should be utilized, including but not limited to the type and duration of precautions for particular infections or organisms involved. The facility policy titled Infection Control Program Standard and Transmission Based Precautions, with a review date of 6/2018 did not explain how standard precautions and when transmission-based precautions should be utilized, including but not limited to the type and duration of precautions for particular infections or organisms involved and that the precautions should be the least restrictive possible for the resident given the circumstances and the resident's ability to follow the precautions; and did not ensure the policy documented that staff with a communicable disease or infected [MEDICAL CONDITION] should be prohibited from direct contact with residents or their food, if direct contact will transmit the disease. During an interview on 04/05/19 at 12:49 PM, Licensed Practical Nurse (LPN) #10 stated this flu season they had someone with influenza and all the department heads were notified. When a positive test comes back the physician and department heads are notified. The physician placed the infected resident and the resident's roommate (who had a negative flu test) on [MEDICATION NAME](A medication used to treat symptoms caused by the flu virus). The resident was placed on precautions and had all the bins in her room. The resident had a nasty cough, was on contact precautions, and was confined to the floor and her room. LPN #10 was asked how she would determine what type of transmission-based precautions to put this resident on. The LPN stated you would find what type of isolation to use by the facility policy in the supervisor's office or ask the supervisor for the book. During an interview on 04/05/19 at 12:42 PM, LPN #12 stated he has not had to put anyone on transmission-based precautions and would ask the unit manager if he had to. The resident's type of isolation precautions would be on the 24- hour report and remain there until the resident was off precautions. During an interview on 04/05/19 at 01:07 PM, LPN #5 stated if a resident was symptomatic they would notify the physician, and if suspicious for infection control concerns, the physician would order the precautions. Housekeeping sets up the isolation bins and brings them to the floors. If a resident is placed on contact precautions you put the information on the office report, notify the supervisor and resident's family. The isolation type should be in the orders and should be on the care plan. If LPN #5 was suspicious of infection, she would institute precautions, based on the resident's symptoms. LPN #5 stated she hasn't read the policy in a long time, and does not know where it is kept. The LPN stated the facility provides annual mandatory trainings on infection control. During a phone interview on 4/5/19 at 2:50 PM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) in person, the ADON stated the facility's policy titled Infection Control Program Standard and Transmission Based Precautions is the only one he can find. The DON stated she had a policy on the ICP program but that it may be elsewhere, and she is currently out of the office. The DON stated staff initiate transmission-based precautions by the notifying the supervisor, who then calls he DON. If the DON is not available, there is an infection control binder in the supervisor's office that staff have access to. The DON stated it is a nursing judgement if they have a suspicion to set up precautions, and then call the physician. Transmission-based precautions would be under point click care software, under diagnosis, or listed under medical assessment, or in doctors' notes, there would be a care plan. The housekeeping department sets up the isolation carts. The facility does not have a policy that instructs housekeeping staff to set up the isolation carts. The DON stated they have a form titled Isolation Start and Stop Interdepartment Communication Sheet that is used to communication transmission-based precautions. During an interview on 04/05/19 at 04:48 PM, Certified Nursing Assistant (CNA) #12 stated they receive training on infection control annually. There are signs on the door if someone is on transmission-based precautions with the type such as droplet or contact, then they wear gloves, gown and/or mask. If you see the sign on the door, ask the nurse and get report. CNA #12 does not know if transmission-based precautions are on the care Kardex. During an interview on 04/05/19 at 04:56 PM, CNA #11 stated the nurse would tell you what type of precautions a resident is on. CNA #11 was not able when asked, to name the types of transmission-based precautions. She stated she would wear gloves and a mask, and that she receives infection prevention training every 6 months or yearly. Finding #2: The facility did not ensure that the following IPCP policies and procedures were reviewed annually: 1. Immunization Documentation for Employees - last dated 7/1/17. 2. To Communicate fully, any isolation risk, to all departments - last dated 1/27/17. 3. Infection Control Reporting and Recording Education - last dated 2/2017. 4. Infection Control of [MEDICAL CONDITION] - last dated 3/20/2018. 5. Immunization Program - last dated 8/2018. 6. Infection control (Standard Precautions, Hand Washing and Donning/Doffing or Personal Protective Equipment) - last date 4/2009. 7. Measure of antibiotic use and antibiotic stewardship activities - No date. 8. Antibiotic Stewardship and Prescribing Policy - No date. 9. Antibiotic Stewardship Program - No date. 10. Engagement of Residents and Family Members in Antibiotic Use - No date. 11. Communication of Resident Condition and Treatment with Antimicrobial Orders - No date. During a telephone interview on 4/5/19 at 2:50 PM, the DON stated their process for reviewing policies is to go through the book and update it yearly, but some are out of range. Finding #3 The facility did not ensure three employees received the flu vaccine and that those employees who did not receive the flu vaccine masks covered their mouths and nose. During an observation on 04/01/19 at 09:22 AM, Licensed Practical Nurse (LPN) #1 wore a face mask not covering her nose while working on the medication cart on the unit. During an observation on 04/01/19 at 03:35 PM, LPN #1 wore a face mask not covering her nose while working on the medication cart with a resident sitting in a wheelchair next to the medication cart. During an observation on 04/02/19 at 11:45 AM, Certified Nursing Assistant (CNA) #2's face mask was worn down under the chin exposing her mouth and nose in a patient care area. During an observation on 04/02/19 at 01:10 PM, in the physical therapy department, Certified Occupation Assistant (COT) #10 was observed pulling down the face mask to speak with the Occupational Therapist (OT) with residents in the room. During an interview on 04/02/19 at 01:10 PM, the COT stated she did not receive the flu shot and thought she could pull it down when talking to her co-workers. The OT stated she thought there was certain footage that you did not have to have your mask covering your face. During an interview on 04/01/19 at 09:25 AM, LPN #1 stated she wore a face mask because she did not get the flu shot. She stated she knew the face mask was supposed to cover her nose, as well as her mouth, when she was near residents. She thought she did not need to cover her nose if she was at the medication cart without residents near her. During an interview on 04/02/19 at 11:45 AM, CNA #2 stated she is wearing a mask because she did not get a flu shot, and the mask keeps slipping down. Finding #4: Resident #96: The facility did not ensure the care plan for [MEDICAL CONDITION] Resistant Staphylococous aureus in the resident's right knee dated 2/21/19, included an intervention for contact precautions. The resident was last admitted to the facility on [DATE], with a primary [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact, can understand others and can make herself understood. During observation on 4/5/19 at 09:00 AM, there was a sign posted to see the nurse before entering, and a 3-drawer isolation cart inside the door. LPN #4 stated the resident is on Contact Isolation because of [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) in her right knee. During review of the resident's record, the care plan (CP) initiated on 2/21/19 documented a Focus of: The resident [MEDICAL CONDITION] - colonization right knee - Right knee replacement in 2008 with chronic wound infection cycle repeating many times- increasing green drainage from right knee. Goal: The residents infection will resolve with minimal complications as evidenced by negative culture, vital signs within normal limits, and no signs/symptoms of acute infection by review date. This was initiated and revised on 2/21/19 with a target date of 5/22/19. Interventions were revised and/or initiated on 3/11/19. The CP did not document the resident's transmission-based precaution, the type and duration of the isolation and when and how isolation should be used for the resident. During an interview on 4/5/19 at 2:50 PM, with the DON and ADON, the ADON stated that residents should have care plans for transmission based precautions. Finding #5 The facility did not ensure the residents' environment on the East Unit was as free as possible from wound exudate and blood. During an observation on 03/31/19 at 12:39 PM, there was what the staff stated was dried red wound exudate and blood smeared on the floor throughout room [ROOM NUMBER], including the resident's bathroom floor. The resident was in his room and had a saturated wound dressing to his left foot that was coming into contact with the floor. He stated the floor was covered with dried blood from his foot wound. He stated blood from his wound leaked out of the dressing onto the floor all the time. During an observation on 04/03/19 at 11:52 AM, there was a large amount of what the staff stated was dried red wound exudate and blood throughout room [ROOM NUMBER], on both the bedroom floor and bathroom floor. During an observation on 04/04/19 at 9:26 AM, there was what the staff stated was dried wound exudate and blood on the floor in room [ROOM NUMBER]. There was also a trail of what the staff stated was wet and dry red wound exudate and blood coming from room [ROOM NUMBER] and going down the hallway from room [ROOM NUMBER] to room [ROOM NUMBER]. At the same time, a resident of the East Unit was independently wheeling his wheelchair through the wound exudate and blood on the hallway floor. During an observation on 04/04/19 at 9:28 AM, a staff member was assisting a resident, who was wearing gripper socks, to walk down the hallway between rooms [ROOM NUMBERS] where there was what the staff stated was wet and dry wound exudate and blood spotted and smeared on the floor. During an observation on 04/05/19 at 10:38 AM, there was what the staff stated was dried red wound exudate and blood smeared across the floor throughout room [ROOM NUMBER]. The resident's left foot dressing was saturated with bright red blood and wound exudate. During an interview on 04/05/19 at 10:39 AM, Licensed Practical Nurse #2 stated she was aware the resident unhooked his wound VAC making it non-functional which made the resident's left foot dressing become saturated with blood. She stated the resident's blood would get on the floor when the resident walked on his left foot. She stated the resident was educated daily. During an interview on 04/05/19 at 10:44 AM, Registered Nurse #1 stated wound exudate and blood on the floor in a room or hallway from an over saturated wound dressing was an infection control issue. She stated when staff saw the blood on the floor, they tried to notify housekeeping as soon as possible. 10NYCRR415.19 Finding #6 The facility did not develop and implement a Water Management Plan (WMP) in accordance with adopted regulations. When requested on 04/02/2019, a potable water WMP and a potable water system flow chart and written description were not available for survey review. The Administrator stated in an interview conducted on 04/02/2019 at 10:45AM that a comprehensive potable water WMP and a flow chart with a written description of the potable water system have not been developed. But he will contact a consultant to develop the required WMP.

Plan of Correction: ApprovedMay 14, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident #96 a wound culture had been ordered and collected on 4/3/2019 and results received on 4/8/2019 which showed [MEDICAL CONDITION] in the right knee. Precautions were discontinued on 4/8/2019 per physician order. Had precautions not been discontinued, her comprehensive care plan for [MEDICAL CONDITION] in her right knee would have been updated to include interventions for contact precautions.
For resident #52 he was discharged from facility on 4/5/2019.
- Outside consultant contacted to write new Facility Water Management Plan. Form DOH-5222 was completed and presented during survey. Legionella testing scheduled and to be performed per the Federal Guidelines.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
When an infection is suspected or confirmed policy will be followed to ensure that all staff are made aware of risks and proper protection needed and how that is communicated. The Policy has been revised and education will be provided to all staff to ensure communication of all changes and updates/revisions made to the policy.
All residents have the potential to be affected by the deficient practice as infection control policies and procedures apply to all residents in our care. Policy and procedure review and revisions will be done, education will be completed with all staff and audits will be completed to ensure the deficient practice does not recur. specifically audits of staff that declined the flu vaccine will be audited for compliance at random intervals throughout the season in total of 5 audits.
-- Consultant water plan to be implemented and educated to staff to assure compliance and knowledge of the new water management plan. Any other education, audits, etc. that are outlined in the Plan will be implemented as Facility Policy and Procedure.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
1. Facility policy titled ?Infection Control Program Standard and Transmission Based Precautions? was reviewed and revised, dated 4/24/2019 to include:
a. Definition of types of precautions used in the LTC setting, including standard precautions.
b. policy/procedure for initiating isolation precautions for staff.
c. Personal protective equipment (PPE) to be used for each type of precaution.
d. Ensuring care plans document interventions for Transmission Based Precautions.
e. Staff will communicable disease or infected [MEDICAL CONDITION] are prohibited from direct contact with residents or their food, if direct contact will transmit disease.
f. Instructions for the housekeeping department (or nursing when housekeeping is not in the facility) on how to set up the isolation carts.
2.New policy written titled ?Annual Review of Policies? dated 4/24/2019. All policies identified will be reviewed and updated. This new policy will ensure that every facility policy is indexed and a schedule will be created to ensure that each month policies will be reviewed, ensuring all policies are reviewed at least annually.
3.Staff members who do not receive the flu vaccine received on-the-spot verbal re-education that they chose not to receive the vaccine, and per regulation their mask must be worn at all times when they are in an area where they could come in contact with residents. How to wear the mask properly was reviewed, including covering their mouth and nose, the nose piece pinched to ensure a tight fit, and to change the mask periodically throughout the day. Staff reminded that if they are observed not wearing the mask correctly that disciplinary action will be taken as this is a resident safety concern. All facility department heads reminded that they are responsible to ensure their respective staff members who chose to wear a mask during the flu season are wearing it appropriately. Department Heads also reminded that as part of the facility leadership team, they are to hold any staff they see wearing a flu mask incorrectly accountable.
4.Staff Education will be provided to entire house staff on infection control policy changes, isolation precaution types, PPE and location of where to find isolation reference binder/Infection control policy and procedures (Nursing Supervisor?s office). Education will also include that staff will pull the revised Infection Control Program Standard and Transmission Based Precautions Policy for guidance on standard precautions and the implementation of transmission based precautions.
5.- New Water Management Plan will be implemented as Facility Policy. Any necessary audits, checks, etc. will be performed as prescribed and documented for review.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
The Infection Control Practitioner will complete audits of anyone in the facility who is on isolation precautions to ensure appropriate precautions are in place and being followed by staff, including review of comprehensive care plan. Results of the audits will be discussed with the QAPI committee monthly.
Staff with red dots on their ID badges will be monitored by all leadership staff to ensure that their flu mask is worn appropriately while in the building. If they are found to be wearing their mask inappropriately, their respective department head and the Infection Control Practitioner will be notified so disciplinary action can be taken.
- The Director of Maintenance (or designee) will audit monthly for 12 months that the new Water Management Plan including a Potable water system flow chart and written descriptions and that it is being followed and all necessary items on it are being performed. They will report their findings to the Quality Assurance committee and report any negative findings to Administration for immediate follow up.
The date for correction and the title of the person responsible for correction:
The Infection Control Practitioner and Director of Maintenance will be responsible for ensuring correction by 6/4/2019.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility had evidence that all alleged violations were thoroughly investigated, for two (Resident #'s 57 and 404) of two residents reviewed for investigations. Specifically: the facility did not ensure that a complaint by Resident #404 that alleged that Resident #57 kept coming into his room uninvited looking for physical companionship was investigated. This is evidenced by: Resident #57: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Miminum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, understands others and was able to make self understood. Resident #404: The resident was admitted to the nursing home on 6/19/18 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Finding #1: Progress notes dated 2/22/19 by the Case Manager/Coordinator (CM/C) documented that Resident #404 reported to her that he did not feel comfortable because Resident #57 came into his room whenever Resident 57 wanted, seeking physical companionship. The resident stated that he and Resident #57 had been intimate once at the facility. He stated that he did not want to be intimate with Resident #57 anymore and that Resident #57 continued to make him uncomfortable During an interview on 4/04/19 at 4:47 PM, the CM/C stated a care plan had not been put in place for Resident #404 for victimization. The CM/C asked Why would they? That was Resident #404's perception. Resident #57 denied entering Resident #404's room seeking intimacy. Both resident's were both careplanned as seeking companionship. During an interview on 4/5/19 at 12:30 PM, the Director of Nursing (DON) stated that Resident #404 should have had a victim care plan in place and the incident should have been investigated. 10NYCRR 415.4

Plan of Correction: ApprovedApril 26, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident #57, her room was changed away from resident #57's room after his voiced complaint.
For resident #404, he was discharged prior to survey.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the deficient practice as all residents have the right to physical intimacy. Staff education will be provided to monitor for signs of residents being overly attention seeking with other residents, and if it is noted to notify nurse manager or nursing supervisor. Education will also be completed on incident reporting to ensure staff is reporting appropriate information to nursing leadership so facility investigations can be completed.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Facility policy on Accidents and Incidents will be reviewed and revised (if necessary). Facility wide education will be completed to ensure staff is aware of what should be reported so a facility investigation can be completed.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Incident and Accident Reports are reviewed every morning by the IDT during clinical report after 24 hour report is reviewed to ensure there is an A&I completed for everything that should have one. The Director of Nursing will audit all A&I's daily to ensure completion of one for every significant clinical event. The Director of Nursing will report audit findings to the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The Director of Nursing will be responsible to ensure correction by 6/4/2019.

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

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, (YEAR) Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in facilities with gas operated equipment. Specifically, the facility has gas operated equipment and carbon monoxide detection is not installed. This is evidenced as follows. On 04/03/2019 at 3:40 PM, two gas operated hot water heaters were found in a small room within the Boiler Room. Carbon monoxide detection was not found in any place in the facility. The Director of Maintenance stated in an interview on 04/04/2019 at 11:15 AM that the facility does not have carbon monoxide detection. 483.70 (b); (YEAR) International Fire Code, Section 915

Plan of Correction: ApprovedApril 26, 2019

F836 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Vendor contacted during survey, vendor came in during survey to see exactly what was needed and work was scheduled for immediately after survey.
IDENTIFY OTHER POTENTIAL RESIDENTS
- A Carbon monoxide detector was installed by vendor and hard wired into our fire alarm system to alarm building wide should anything be detected. No other areas require this.
SYSTEMIC CHANGES
- Carbon Monoxide detector will be inspected during the Facilities? routine fire alarm inspection to assure proper working order.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will assure that the Carbon Monoxide detector is inspected during the Facilities routine Fire Alarm inspection. These findings will be reported to the Quality Assurance committee as part of the Fire Alarm inspection report. Any negative findings will be reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance by 6/4/2019

FF11 483.10(g)(17)(18)(i)-(v):MEDICAID/MEDICARE COVERAGE/LIABILITY NOTICE

REGULATION: §483.10(g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on interviews and record review during the recertification survey, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries. Specifically, the facility did not provide residents with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, form CMS- ) at the termination of Medicare Part A benefits. This was evidenced by: During an interview on 4/01/19 at 10:35 AM, the Minimum Data Set Coordinator (MDS) #1 stated they did not issue the ABN forms. She was not aware of these forms or any policy related to the notifications. During an interview on 4/01/19 at 10:42 AM, MDS Coordinator #2 reported he did not do an ABN, and was not aware of the form or the notification requirements. 10 NYCRR 415.3 (g)

Plan of Correction: ApprovedMay 9, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
It was identified during recertification survey that no residents had been issued the SNF Advanced Beneficiary Notice (ABN). Beginning with this Plan of Correction, any Medicare Part A resident being discharged from therapy or that has a reduction in their part A services, the resident, resident's HCP or legal guardian will be notified by the MDS Coordinator(s). Notification will be made in person or via telephone with a certified letter following telephone conversation due to signature needed on the ABN.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Any resident who is in the facility on a Medicare Part A covered stay has the potential to be affected by the same deficient practice. A facility policy and Procedure was written for ABN completion and education was completed with the MDS Coordinator and Director of Rehab. The MDS Coordinators have reviewed the Medicare Claims Processing Manual, Chapter 30.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
MDS Coordinators will be notified by the Director of Rehab when Medicare Part A residents are being discharged from therapy services. The MDS Coordinators will review the residents 100 day Medicare Part A calendar to determine days remaining, or if skilled services will continue while still in the facility. This will allow the MDS Coordinators to determine potential residents in need of ABN's to be issued. Education will be provided to the MDS coordinators on the issuance of ABN's to any resident coming off of a med A stay.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
As part of the weekly Utilization Review meeting, every potential discharge from therapy will be discussed with the IDT, as well as the resident's need(s) for continued skilled care. This discussion will allow for potential ABN dates to be determined. Potential ABN dates will be documented on a calendar which will be kept in the MDS Office. The MDS Coordinators will audit ABN's needed and those issued to residents to ensure that no ABN's are missed. This audit will be done monthly and results will be reported to the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The MDS Coordinator will be responsible to ensure correction by 6/4/2019.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 2 (Resident #'s 36 and 52) of 6 residents reviewed for nutrition. Specifically, for Resident #36, the facility did not ensure weights and reweights were obtained and the physician was notified of weight changes in a timely manner, did not ensure nutritional status, including weights and fluid status, were accurately assessed, and did not ensure the care plan addressing the residents decline in ability to self-feed was followed resulting in a significant unplanned weight change (6.3% weight loss in one month (2/7/19 - 3/14/19), 14.3% weight loss in the last six months (9/19/18 - 3/14/19). Additionally, for Resident #52, the facility did not ensure the resident's nutritional needs for diabetic management and wound healing were identified, evaluated, and addressed. This is evidenced by: Resident #36: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, could understand others and could make himself understood. Finding #1: The facility did not ensure weights and reweights were obtained and the physician notified of weight changes in a timely manner. The Policy and Procedure (P&P) titled Monthly Weight Policy dated 4/24/18, documented that monthly weights would be completed by the first week of each month, would be entered into the medical record, and any resident who weights equal to or greater than 101 lbs. (pounds) will be reweighed the next day if they have an unintended weight change of equal to or greater than 5 lbs. from the previous month. The P&P documented that a weight change notification was to be completed by the Registered Dietitian (RD) for residents with a significant weight loss, and the forms are reviewed and signed by the physician and filed in the resident chart. The P&P does not include documentation of who is responsible for obtaining the reweight. The weight record documented the following: 08/08/18 = 267 lbs. 09/19/18 = 244 lbs. There was no documented reweight for a weight loss of 23 lbs. 10/12/18 = 243 lbs. 11/12/18 = 237 lbs. There was no documented reweight for a weight loss of 6 lbs. 12/08/18 = 233 lbs. 01/11/19 = 224 lbs. There was no documented reweight for a weight loss of 9 lbs. 02/07/19 = 223 lbs. 03/14/19 = 209 lbs. There was no documented reweight for a weight loss 14 lbs. A weight change notification dated 11/21/18, documented the resident's current weight was 237 lbs. (2.47% weight loss over 30 days, and 10.9% weight loss over 6 months). The form documented the resident had a history of [REDACTED]. The weight change notification was not signed by the physician. A weight change notification dated 1/29/19, documented the resident's current weight was 224 lbs. (3.86% weight loss over 30 days, and a 17.04% weight loss over 6 months). The form documented the resident was receiving health shakes three times daily and that the resident continued to receive diuretics for [MEDICAL CONDITION] (fluid retention). The weight change notification was not signed by the physician. A weight change notification dated 3/19/19 documented the resident's current weight was 209 lbs. (6.28% weight loss over 30 days and 14.34% weight loss over 6 months). The form documented the resident was to receive Ensure Plus one can three times daily and a request for the physician to evaluate. The weight change notification was signed by the physician on 4/2/19. During an interview on 4/05/19 at 10:24 AM, Registered Dietitian (RD) #6 stated weights are obtained per the policies and protocol that are in place. The RD was not aware of issues obtaining monthly weights. The weight change form was given to Licensed Practical Nurse (LPN) #5, and the unit manager would notify the physician or place the form in the doctor's book. During an interview on 4/05/19 at 1:10 PM, Licensed Practical Nurse (LPN) #5 stated the physician did not sign the 3/19/19 weight change notification until 4/2/19, because he was not in the building. She stated she would not call him related to significant weight loss because the resident was already on supplements and had bloodwork done. Finding #2 The facility did not ensure the resident's nutritional status, including weights and fluid status, were accurately assessed. A Comprehensive Care Plan (CCP) for Nutrition last updated 1/24/19, documented a goal of maintaining adequate nutritional status by maintaining weight with no significant changes other than from fluid shifting due to [MEDICAL CONDITION]. A CCP for [MEDICAL CONDITION] last updated on 1/19/19, documented a goal of being free from [MEDICAL CONDITION] through target date of 4/19/19, and an intervention to monitor/document/report dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], and diminished appetite. A weight change notificaiton dated 12/17/18, documented the resident had a 12.73% significant weight loss over the past 6 months, and no new recommendations were made. A quarterly nutrition assessment dated [DATE], documented a significant weight loss over the past 30 days due to fluid changes, and an additional health shake was added. A weight change notification dated 1/29/19, documented the resident had a 17.04% significant weight loss over the past 6 months, and no new recommendations were made. A weight change notification dated 3/5/19, documented the resident had a 16.48% significant weight loss over the past 6 months, and no new recommendations were made. Physician notes dated 3/26/19, 2/26/19, 1/22/19, 11/6/18, and 10/2/18 documented the resident did not have [MEDICAL CONDITION]. During an interview on 4/05/19 at 10:24 AM, RD #6 stated she did not feel the weight loss was just fluid changes anymore and stated she was concerned. During an interview on 4/05/19 at 5:40 PM, the Assistant Director of Nursing (ADON) stated the resident had no changes in diuretics in the past 3 months, and the medical record did not include documentation of [MEDICAL CONDITION] monitoring in the last 3 months. During interview on 4/05/19 at 4:52 PM, Physician #15 stated weight changes in the past have been related to fluid, and he was not aware of a significant change in the resident's weight. Finding #3 The facility did not ensure the resident received the assistance needed at meals to maintain nutritional status. A CCP for Nutrition last updated 2/7/19, documented feeding assistance was required at meals. The resident care card documented the resident required feeding assistance and encouragement at meals. A progress note dated 2/6/19, documented staff noted that the resident had increased difficulty self-feeding and a physical therapy screen was sent. The note also documented the resident would eat if fed by staff. A progress note dated 2/18/19, documented the resident's wife stated foods are not always cut up prior to service, and her husband was not always encouraged significantly at meal times. A progress note dated 3/4/19, documented the resident's wife requested a diet consistency change to mechanical soft meats with gravy for ease of eating. The note documented the consistency was changed in the menu system and the Speech Language Pathologist was notified. A Speech and Language Pathology assessment dated [DATE], documented the resident was evaluated for report of increased difficultly chewing and mild pocketing (holding food in mouth). The resident's diet was changed to mechanical soft solids with extra sauce/gravy and thin liquids. A review of the certified nursing assistant's documentation of care provided dated from 2/7/19 -3/31/19 (159 total occasions) documented the resident did not receive assistance from staff on 30 occasions and received set up only with no staff oversight on 75 occasions. Additionally, it documented that the resident consumed less than 50% on 73 occasions. During an observation on 3/31/19 at 12:52 PM, the resident was sleeping. The resident's lunch tray was on the over bed table with 0% consumed. The resident was not receiving assistance from staff. During an observation on 4/02/19 at 10:00 AM, the resident's tray was on his over bed table and less than 25% had been consumed. The resident was not receiving assistance from staff. At 10:35 AM, the breakfast tray was removed by the Unit Manager with less than 25% consumed. During an interview on 4/05/19 at 10:24 AM, RD #6 stated the nurse notified her about the resident needing encouragement with meals, she updated the care plan, and she would expect to see staff providing verbal cues and feeding assistance at meals. She stated not eating could contribute to weight loss. She stated she did not do meal rounds (direct observations of residents during meal time) and she was not aware the resident had been sleeping through meals and had not been assisted at meal time. If reported, she would have had a conversation with the Unit Manager. She attends morning report, and the resident's poor intake had not been discussed. During an interview on 4/05/19 at 10:40 AM, the Director of Therapy stated the resident needed more help with feeding, the nurse notified physical therapy, and an occupational therapist should have seen him, but it was overlooked. There was no documentation of a therapy assessment for the decline in the resident's ability to feed. She felt the resident's hands were getting stiffer. He was placed on therapy this week once they realized the screen had not been done. She attends morning report, and nothing had been mentioned about the change in the resident's feeding status. During an interview on 4/05/19 at 1:10 PM, LPN #5 stated she was aware the resident was eating less than 25% and stated it should not have been on the 24-hour report as this is a QA tool, and stated the dietitian can look in the health record to see the resident's intakes. She stated the screen sent to physical therapy was related to positioning, not intake. She stated the physician did not sign the 3/19/19 weight change notification until 4/2/19 because he was not in the building. She stated she would not call him related to significant weight loss because he was already on supplements and had bloodwork done. During an interview on 4/05/19 at 5:40 PM, the ADON stated the resident had no changes in diuretics in the past 3 months and there was no documentation of [MEDICAL CONDITION] monitoring in the last 3 months. During an interview on 4/05/19 at 4:47 PM, the Medical Director stated the lack of assistance at meals could be the reason for weight loss. Resident #52 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make himself understood. The comprehensive care plan for nutrition last revised 12/12/18, documented labs and diagnostic work would be obtained and monitored as ordered, and the results would be reported to the physician and followed up on as indicated. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Clinical lab reports documented on: 11/14/18, an A1c lab value of 8.5% - High (A1c =>6.5 is consistent with diabetes) 3/27/19, an A1c lab value of 9.4% - High A nutrition assessment dated [DATE], documented (TBD) To Be Determined, under the average percent (%) of meal consumed and the average amount of fluid consumed. The nutrition assessment was not updated to include the actual percentage of food and fluid consumed by the resident. An Admission Nutrition Screen dated 11/14/18, documented, the resident was to receive increased protein for healing that included 2 hard-boiled eggs and bacon (x2) at breakfast. A review of progress notes from 12/01/18 to 03/31/19, did not include documentation of the resident's finger stick blood sugars (FSBS) and did not include documentation of the insulin administered per the sliding scale. The resident's meal tickets reviewed from 03/18/19 to 04/01/19, documented the resident was to receive a double entree. During an observation on 04/02/19 at 10:10 AM, the resident did not receive a double entrée and did not receive 2 hard-boiled eggs on his breakfast tray. During an interview on 04/02/19 at 10:16 AM, the resident stated he refused breakfast. He stated there were too many carbohydrates on his tray and he did not receive 2 hard-boiled eggs that he was supposed to have for increased protein. He stated it was quite frequent that he did not receive 2 hard-boiled eggs at breakfast and rarely received a double entrée on his meal tray. He stated his blood sugar was 300 that morning, but had not reported it to the nursing staff. He stated his blood sugar was always over 300 in the morning, because he did not administer his long acting insulin at bedtime as ordered by the physician. During an interview on 04/02/19 at 10:33 AM, the Registered Dietician (RD) stated this was the first she had heard the resident was not receiving double entrees and had not received 2 hard-boiled eggs on his tray. She stated she was not aware the resident was having high blood sugars in the morning and not administering his evening dose of long acting insulin. She stated had not reviewed the resident's FSBS since his admission, because the resident had a physician's orders [REDACTED]. She stated the resident did not document his blood sugars, but stated he was a Type 1 diabetic and was more familiar with his body and his diabetic management. During an interview on 04/02/19 at 02:52 PM, the Registered Nurse #1 (RN) stated she did not know if the resident was giving himself the correct dose of insulin or when he was administering the insulin. She stated the resident should have been keeping a log, but that the nurses should have also been monitoring and documenting in the Medication Administration Record [REDACTED]. She stated the doctor was aware of the labs, but he had not asked to review the resident's blood sugars. During an interview on 4/3/19 at 3:08 PM, the Assistant Director of Nursing (ADON) stated it was concerning that the resident's A1c had increased. The increase indicated to the ADON that the resident was not adequately managing his diabetes, and either was the facility. He stated the resident's A1c should have been drawn and reviewed 3 months from the original draw date of 11/13/18. He stated if the lab wasn't drawn, he would expect to see documentation in the chart as to why. During a subsequent interview on 04/05/19 at 09:41 AM, the RD stated she should have been monitoring the resident's blood sugars, reviewing all pertinent labs related to nutrition, including the A1c, in addition to monitoring his weight for both diabetic management and wound healing. She stated the increase in A1c lab value indicated to her that the resident was not taking enough insulin and the increase could also mean his insulin needed to be adjusted. In addition to reviewing labs, she stated she should have reviewed the resident's glucose meter or blood sugars to determine if the appropriate nutritional interventions were in place or needed to be changed. She stated the resident should have received double entrees for increased calories and protein to promote wound healing. She stated double entrees were documented on the resident's meal ticket but stated it should have been on his care plan and on the MAR indicated [REDACTED]. She stated she felt this resident's case fell through and could have been managed better. 10 NYCRR 415.12(i)(l)

Plan of Correction: ApprovedMay 9, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident #36 he was placed on weekly weights, a new therapy screen was placed and he was picked up on therapy services, care plan was updated, nutrition consult in place and he was already being followed by Registered Dietitian for recommendations for supplementation.
For resident #52 he was discharged from facility on 4/5/2019.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the same deficient practice. Education will be completed with nursing staff and policy review and revision of weight monitoring.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Facility policies titled Monthly Weight Policy and Weekly Weight Policy reviewed and revised, dated 4/25/2019. New weight tracking logs to be placed on all units following education of nursing staff. Education to be provided to all nursing staff on weight monitoring, lab monitoring of diabetic residents, meal ticket monitoring/review.
Care Plan was updated regarding weight loss. Education provided to all staff will include following care plan as prescribed.
In addition the front line staff CNA will specifically address feeding status and meal consumption at the care plan meetings going forward to ensure IDT maintains awareness of any changes for care plan updating. IDT and Nursing educated to this change.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Weights will continue to be monitored and discussed for changes every Thursday morning after clinical meeting with the IDT. Any weight changes of concern will be addressed by the IDT and interventions will be addressed with the physician in real time. Orders will be obtained and weights will be continued to be tracked per facility policy. Significant weight changes (>5% change in 30 days or >10% change in 180 days)will also continue to be monitored and discussed with the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The ADON and Registered Dietitian will be responsible to ensure correction by 6/4/2019.

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey, the facility did not ensure that one (Resident #52) of one resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, for Resident #52, the facility did not ensure physician orders were obtained according to the wound care center consultations to provide consistent care and treatment to the resident's left foot wound related to a traumatic injury, did not ensure licensed nursing staff received education and training on [DEVICE] (vacuum assisted closures) for Negative Pressure Wound Therapy (NPWT) to treat wounds resulting in potentially increasing the resident's risk for infection, and did not ensure weekly wound observations made by members of the interdisciplinary team documented the ongoing assessment of the resident's left foot wound and the evaluation of the wound care treatments. This is evidenced by: Resident #52: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make himself understood. The facility's policy and procedure (P&P) titled Pressure Ulcer and Wound Care documented wound care orders were to be verified or obtained as needed; assessments and interventions implemented were to be documented in the resident record; a system for weekly (or more frequent) wound assessment had been established; and comprehensive wound assessments should include at least the following: location of the wound, measurements, tunneling or undermining, appearance of wound base, type and percentage of tissue in the wound, drainage description and amount. Finding #1 The facility did not ensure physician orders were obtained according to the wound care center consultations to provide consistent care and treatment to the resident's left foot wound related to a traumatic injury. The comprehensive care plan for the left foot wound dated 11/27/18 and last revised 04/01/19 with the goal that the resident's wound would improve by the next review date, and included an intervention dated 11/27/18 to change the wound VAC dressing with black foam every Monday, Wednesday, and Friday and to observe daily. A physician order dated 02/05/19, documented to check the resident's left foot wound every shift and as needed (PRN) and to clean and reinforce the dressing as needed. The order documented to not remove the original dressing according to the wound care center consultation dated 02/04/19. The (MONTH) 2019 Treatment Administration Record (TAR) did not include documentation of the physician wound care order dated 02/05/19. A physician order dated 03/05/19, documented that the left lateral foot wound was to be cleansed with normal saline prior to applying a new dressing. The order documented to continue the wound VAC at 100 MM HG and to change it 3 times a week and PRN. The (MONTH) 2019 TAR did not include documentation of the physician wound care order dated 03/05/19. A review of the resident's TAR from 02/5/19 through 03/19/19, did not include documentation of physician orders to treat the resident's left foot wound according to the weekly wound care center consultations. The weekly Wound Care Center consultations documented the following treatment changes to the resident's left lateral foot wound. The treatment changes were not documented on the TAR and the changes dated 02/11/19, 02/18/19, 02/25/19, and 3/11/19 did not have corresponding physician orders. - On 02/04/19 - [MEDICATION NAME] (a living, bi-layered skin substitute) graft that was not to be changed by the facility. The graft was secured by a non-adherent dressing and steri strips. The consult documented the facility was not to remove the dressing that was held in place by steri strips. - On 2/11/19 - Cleanse the left lateral foot wound with normal saline prior to applying a clean dressing. It documented to continue the wound VAC therapy with 150 MM HG of continuous negative pressure with black foam and to change the dressing three times weekly. The alternate dressing for NPWT (Negative Pressure Wound Therapy) was a [MEDICATION NAME] AG (a dressing designed to absorb wound drainage) dressing to the wound. - On 2/18/19 - Cleanse the left lateral foot wound with normal saline prior to applying a clean dressing. It documented to continue wound VAC therapy with 150 MM HG of continuous negative pressure with black foam placed over the existing Endoform (a dressing made up of structural proteins to aid in wound healing) dressing. The alternate dressing for NPWT was an Endoform dressing and to cover the wound and secure. The consult instructed to avoid excessive contact of tape with skin and to change the dressing three times weekly and as needed. - On 2/25/19 - Cleanse the left lateral foot wound with normal saline prior to applying a clean dressing. It documented to continue wound VAC therapy with 100 MM HG of continuous negative pressure with black foam placed over existing [MEDICATION NAME] with steri strips and [MEDICATION NAME] One (a non-adherent, soft silicone wound contact layer that allows drainage to pass into an absorbent dressing) and to change the dressing three times a week. The alternate dressing for NPWT was an Endoform dressing and to cover the wound and secure. The consult instructed to avoid excessive contact of tape with skin and to change the dressing three times weekly and as needed. - On 3/4/19 - Cleanse the left lateral foot wound with normal saline prior to applying a clean dressing. It documented to continue wound VAC therapy with 100 MM HG of continuous negative pressure with black foam placed over the existing Endoform dressing. The alternate dressing for NPWT was an Endoform dressing and to cover the wound and secure. The consult instructed to avoid excessive contact of tape with skin and to change the dressing three times weekly and as needed. -On 3/11/19 - [MEDICATION NAME] graft that was not to be changed by the facility. The graft was secured by a non-adherent dressing and steri strips. The consult documented the facility was not to remove the dressing that was held in place by steri strips. -On 3/18/19 - cleanse the left lateral foot wound with normal saline prior to applying a clean dressing. It documented to apply an Endoform dressing saturated with normal saline and a [MEDICATION NAME] Blue Transfer (a highly absorption antibacterial dressing) dressing and to cover the wound and secure. The consult instructed to avoid excessive contact of tape with skin and to change the dressing three times weekly and as needed. During an interview on 04/05/19 at 10:41 AM, Registered Nurse (RN) #1 stated the resident goes to the wound care center weekly and that the facility doctor refers to the wound care center for wound care treatments. She stated the wound care center determined if the treatments, such as the wound VAC, were an effective treatment for [REDACTED]. During an interview on 04/5/19 at 11:38 AM, the Assistant Director of Nursing stated the resident has had the wound VAC on and off since (MONTH) (YEAR). He stated there should be wound care orders and an order for [REDACTED]. He stated someone should have picked up on that fact there were no orders on the TAR from 02/5/19 through 3/19/19 and the doctor should have also noticed there were no treatment orders. He stated he could not be certain what wound care treatment the resident had received during that time since there were no physician orders and there was no documentation of the treatment on the TARs. He stated someone should have communicated with the wound center. He stated he could not say that the resident was receiving adequate treatment for [REDACTED]. During an interview on 4/5/19 at 3:38 PM, the Medical Director stated he does not specialize in wounds and the resident was being treated at the wound care center for his left foot wound. He stated he accepted the treatment order recommendations from the wound care center to treat the resident's foot wound. He stated no one ever made him aware that there was no order in the computer for the resident's wound care treatments. He stated he did not think the resident had received quality care for his left foot wound. He stated there was a lack of oversight throughout the facility and it started at the top. Finding #2 The facility did not ensure licensed nursing staff received education and training on the use of [DEVICE] for Negative Pressure Wound Therapy to treat wounds, resulting in potentially increasing the resident's risk for infection. The facility policy and procedure for [DEVICE] was requested on 04/05/19 and was not provided by the facility. During a wound care observation on 04/02/19 at 04:04 PM, Case Manager #4 completed the wound VAC dressing change. There was a large amount of purulent serosanguineous (pale red or pink color liquid) drainage and a slight odor. The wound edges were macerated, and the wound base was 85% yellow slough (dead skin tissue). A wound VAC was reapplied for negative pressure wound therapy on the resident's left lateral foot wound. A black sponge was used to cover the wound. The vacuum tubing was fastened up along the lateral malleolus (outer ankle bone) in direct contact with the skin and fastened with the adhesive sheet. During an observation on 04/03/19 at 11:52 AM, there was a large amount of blood spots all over the resident's bedroom floor and into the bathroom. The resident was observed in the hallway with the wound VAC in place. The wound VAC could not be heard suctioning and there was no exudate (fluid) observed drawn from the wound through the tubing. There was also no drainage in canister. The resident stated the wound VAC had been off since early that morning before he got out of bed. He stated staff would change his dressing later that afternoon. The resident was observed resetting the wound VAC and the wound VAC immediately started sucking drainage from the wound. He stated when the wound was bleeding, the wound VAC needed to be reset. He stated it was not his job to tell the staff the VAC needed to be reset. During an observation on 04/05/19 at 10:38 AM, the resident was in his room and there was dried blood smeared on the floor. The resident stated the blood was from the dressing on his foot being over saturated and leaking onto the floor. The resident showed the surveyor that the wound VAC tubing was unhooked and had been disconnected earlier that morning before he had gotten out of bed. He had not reported the wound VAC was unhooked and not running to the nursing staff. During an interview on 04/02/19 at 03:46 PM, Licensed Practical Nurse (LPN) #4 stated she had never changed the wound VAC dressing and she had not been trained to do it. During an interview on 04/02/19 at 03:50 PM, RN # 1 stated she had not been trained to do wound VAC dressings. She stated she would watch the LPNs apply the dressing but was unable to teach them as she had not been trained. She stated the Assistant Director of Nursing (ADON) was a wound specialist so if there was a problem during the day she would call the ADON or the RN supervisor. During an interview on 04/02/19 at 04:35 PM, Case Manager #4 stated she had not received wound VAC training in the facility but was familiar with wound VAC from her former employer. During an interview on 04/05/19 at 10:39 AM, LPN #2 stated she knew the resident unhooked the tubing of his wound VAC to make it non-functional which made the resident's left foot dressing become saturated with blood. She stated the resident walked on his foot and he was not supposed to. She stated the resident was educated daily and the doctor was aware that the resident walked on his foot and disconnected the wound VAC because it was documented in the nursing progress notes. During a subsequent interview on 4/05/19 at 10:56 AM, LPN #2 stated she changed the resident's wound VAC dressing three times a week on Monday, Wednesday, and Friday. She stated she was trained in [DEVICE] 7 years ago at that facility but had not received any additional training. She stated she had not received training on what to do if the wound VAC had been shut off for a long period of time with the sponge in place. She stated she had never read the manual for the wound VAC. During an interview on 04/5/19 at 11:38 AM, the Assistant Director of Nursing stated no one in the facility specializes in wound care. He stated he had wound VAC training prior to being employed at that facility, but was not aware the wound VAC should not remain on the wound for an extended period of time if the wound VAC was disconnected or not functioning. He stated the wound VAC company came to the facility at the end of (YEAR) to do wound VAC training, but he could not provide records of the nursing staff who had been trained on the use of a wound VAC. During an interview on 4/5/19 at 3:38 PM, the Medical Director stated he did not specialize in wound care and the resident was being treated at the wound care center for his left foot wound. The MD stated he had received a few calls regarding the drainage from the resident's wound and directed staff to send the resident to the wound care center. He stated the ADON was the staff member who routinely followed up on wounds in the facility. He stated it was not safe to have the wound VAC sponge sitting on the wound when the wound VAC was disconnected as that could worsen the wound and could [MEDICAL CONDITION]. He stated the wound VAC sponge soaked up bacteria and it was not good to have the sponge in place on the wound without the wound VAC on and suctioning. He stated staff should be educated on that. Finding #3 The facility did not ensure weekly wound observations by members of the interdisciplinary team documented the ongoing assessment of the resident's left foot wound and the evaluation of the wound care treatments. The comprehensive care plan for the left foot wound dated 11/27/18 and last revised 04/01/19, included an intervention dated 11/27/18, for weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. A review of the medical record did not include documentation of the interdisciplinary team's weekly wound observations from 02/19/19 to present. A review of the nursing progress notes from 02/20/19 to 03/31/19 did not include documentation of the condition of the resident's wound or measurements of the wound. During an interview on 04/5/19 at 11:38 AM, the Assistant Director of Nursing stated even though the resident was being seen weekly by the wound care center, the interdisciplinary team continued to do weekly wound observations to track the progress of the resident's wound. He stated the team did not review the resident's treatment orders as part of the weekly wound observation. He stated he was not aware that the last documented wound observation was in (MONTH) 2019. He stated weekly observations were being done by the IDT and that the RN should have been documenting the weekly rounds. During an interview on 4/5/19 at 3:38 PM, the Medical Director stated there should always be an order in place to check and document on the wound every day. He would expect the staff to be documenting on the status of the wound. He stated he did not know if the nursing staff was communicating with the wound care center and would expect that the staff would contact the wound care center for any concerns. 10NYCRR415.2

Plan of Correction: ApprovedMay 8, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #52 was discharged from the facility on 4/5/2019.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Residents are screened by the admission staff in conjunction with the ADON before being admitted for wound care to ensure we can properly meet the wound care needs of the potential resident. Those new admissions, as well as any resident who develops, or has the potential to develop a pressure ulcer has the potential to be affected by the same deficient practice. Policy review and revision will be completed and education will be completed with staff regarding wound care, pressure ulcers and wound therapy/treatments.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
*Facility Policy titled Pressure Ulcer and Wound Care was retired and a new policy, dated 4/24/2019 replaced it titled Pressure Ulcer and Wound Care Plan.
*Education will be provided to all LPN and RN staff regarding wound care which will include:
1. reviewing wound consults/orders upon return from outside consult
2. Wound vac use/operation
3. Importance of communication with MD/Consulting providers if questions/concerns about orders regarding wound care.
4. Accountability of nursing to inform medical director of wound issues/treatment concerns
5. Changes made as a result of this plan of correction.
*Rep from Wound Healing Technologies will provide inservicing for staff on use of wound vac at least once per year. - (Rep coming to meet with nursing administration to schedule training on 5/9/2019)
*Weekly wound rounds will include all wounds in house. This will include, pressure, surgical, diabetic and vascular. Wounds will be tracked weekly using the Point Click Care skin and wound photographic app on weekly wound rounds or using the Wound-Weekly observation tool outside of wound rounds. Weekly wound rounds will also include review of current treatment plan to ensure wound orders are accurate and in place.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
The nurse managers will audit physician orders [REDACTED]. Weekly wound measurements and weekly wound assessments will be completed on weekly wound rounds to ensure all wounds are tracked and being monitored by the IDT and being treated appropriately. The IDT will evaluate the treatment weekly on wound rounds and make recommendations to the provider after weekly rounds. The ADON will continue to report on wounds monthly to the QAPI committee.
The date for correction and the title of the person responsible for correction:
The ADON will be responsible for ensuring correction by 6/4/2019.

FF11 483.60(d)(4)(5):RESIDENT ALLERGIES, PREFERENCES, SUBSTITUTES

REGULATION: §483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that each resident received and the facility provided food that accommodated resident allergies [REDACTED].#1 of seven reviewed for nutrition. Specifically, the facility did not ensure that Resident #1 who was on an altered diet, was given foods per her preferences. This is evidenced by: Resident #1: The resident was admitted to the nursing home on 10/2/19 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. It further documented that the resident required setup and supervision for meals and was on a mechanically altered diet. During in observation on 4/01/19 at 08:47 AM, the resident was eating breakfast in bed consisting of pancakes that were over 3/4 of the way completed. The ticket documented ground diet. The resident stated she got scrambled eggs and her husband got the pancakes but they switched because she did not like scrambled eggs. She told them she did not like scrambled eggs but they kept sending them. MD orders dated 1/17/19, documented No Concentrated Sweets (NCS) diet ground texture with regular consistency liquids. During an interview on 4/01/19 at 4:25 PM, Certified Nursing Assistant (CNA) #2 stated the resident complained about the scrambled eggs all the time, but her husband liked them so if he had something different, they would trade food. During an interview on 04/01/19 at 4:28 PM, Licensed Practical Nurse (LPN) #1 stated she was aware that the resident did not like eggs and they sent a recommendation to tell the kitchen about the scrambled eggs. During an interview on 4/01/19 at 3:12 PM, the Registered Dietitian (RD) stated the resident was a ground diet, was not happy with breakfast choices because she did not like the pureed bread products. She talked to the resident about not wanting scrambled eggs but, after the food preferences sheet was already done. During an interview on 4/01/19 at 4:04 PM, the Food Service Director stated she was aware that the resident did not like scrambled eggs and requested not to get them but because her diet was limited they sent them anyway to ensure that she got enough protein on her tray. 10NYCRR 415.14(d)(4)

Plan of Correction: ApprovedApril 26, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Alternative high protein choices will be sent for resident #1 for breakfast and eggs will not be sent. Eggs had previously been removed from her food preferences in meal tracker. Resident care plan was updated to include being out of bed for meals or supervised by staff in room if resident wishes to stay in bed due to altered consistency.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the deficient practice as all residents meal preferences are entered into meal tracker. Education with staff to ensure meal tickets are checked for diet consistency will be done.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Education will be provided to nursing staff that residents with altered consistency diets are to be out of bed for meals and supervised while eating. If resident wishes to stay in bed for meals, then residents are to be supervised while eating by staff. Education to include staff must alert nurse manager/nursing supervisor if residents witnessed not following prescribed plan of care. Education provided to resident # 1 that she cannot switch food with her spouse due to consistency alteration.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Meals will be observed by licensed staff either in dining rooms or in resident rooms and food will be checked for consistency and food preferences before serving to resident.
The date for correction and the title of the person responsible for correction:
The Food Service Director and ADON will be responsible to ensure correction by 6/4/2019.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey the facility did not ensure that in accordance with accepted professional standards and practices, it maintained medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized, for five Residents (#'s 1, 52, and 63, 404) of twenty-four reviwed. Specifically: For Resident #52, the facility did not ensure the medical record, of a resident who self-administered diabetic medication, included documentation of the resident's blood sugars and insulin administration; for Resident #63, that physician notes included documentation of the residents indwelling catheter and discoloration of urine in the Foley bag; for Resident #400, that documentation of what occurred that precipitated that the resident would be issued a 48 hour discharge (given for imminent danger) notice; and for Resident #1 that identified incidences of the resident eating food that put her at risk for choking were documented. This is evidenced by: Resident #52: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make himself understood. A Medication Self-Administration Safety Screen dated 11/14/18, documented the resident may self administer medications unsupervised. The assessment also documented the resident would document on a paper Medication Admission Record (MAR) the dose of insulin given, the location of subcutaneous injection and the time of injection. Nursing staff would review the resident's paper Medication Administration Record [REDACTED]. The (MAR) for (MONTH) 2019 and (MONTH) 2019 documented U-SA (unknown- self administered) every day from 02/13/19 to 03/31/19 for the administration of the Basaglar and [MEDICATION NAME]. A review of the medical record from 02/13/19 to 03/31/19 did not include documentation of the resident's blood sugars or the insulin administered during that time period. During an interview on 04/02/19 at 09:27 AM, Licensed Practical Nurse (LPN) #2 stated the resident was supposed to be documenting his blood sugars and the amount of insulin he administers. She stated she did not document the blood sugars or insulin units in the Electronic Medication Administration Record [REDACTED]. During an interview on 04/02/19 at 02:52 PM, Registered Nurse #1 stated the resident should have been keeping a log of his blood sugars and the nurses should have monitored and documented in the MAR. During an interview on 04/03/19 at 03:08 PM, the Assistant Director of Nursing (ADON) stated when a resident self-administered medication, the eMar did not give the nurses the option to document in the eMAR. He stated he would not expect to see documentation in the eMAR by the nursing staff, but he would expect the staff to document in the progress notes that they had checked the resident's documentation to ensure the resident was testing and administering his insulin the way he should be and according the physician's orders [REDACTED]. Resident #63: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could usually understand others, and could make herself understood. A review of the physician notes dated 8/21/18, 1/17/19, 3/26/19 did not include documentation of an indwelling catheter or dicoloration of urine in the Foley bag. During an interview on 4/5/19 at 12:28 PM, the Director of Nursing (DON) stated if the physician was aware of the Foley and the discoloration of the urine, it would be documented in his notes. During an interview 4/05/19 at 4:58 PM, the Medical Director stated there should be documentation that the urine was discolored (purple). Resident #404: The resident was admitted to the nursing home on 6/19/18 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Progress notes dated 3/5/19 by the CM/C, who documented she spoke to the resident about an incident that had occurred over the weekend (3/2/19-3/3/19). She reviewed the facility policy again and documented that he was told he would be given 48 hr discharge if the incident occured again. During an interview on 4/04/19 at 4:47 PM, the CM/C stated she recalled there was an incident but did not recall what it was. She would not have documented the incident that occurred when she spoke to him about it because she was not there at the time, she was just following up. During an interview on 4/05/19 at 8:15 AM, the Assistant Director of Nursing (ADON) stated there was no investigation into the incident that led the CM/C to tell the resident he would be given a 48 hour discharge notice on 3/3/19. He not aware of the incident and it should have been investigated and documented. 10NYCRR 415.3(d)(1)

Plan of Correction: ApprovedApril 26, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #52 was discharged on [DATE], but prior to discharge on 4/1/2019 was given a paper Medication Administration Record [REDACTED]. However, the resident documented on the blank back of the paper his FSBS and dose of insulin and what he had eaten.
Resident # 63 the Physician was asked to document on the resident's indwelling urinary catheter and appearance of urine, as well as any changes or treatments he would like ordered. Voiding trial was ordered, which resident refused and urology consult was ordered.
Resident # 404 was discharged prior to survey
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All resident have the potential to be affected by the same deficient practice as we use the same electronic health record for all resident. Policy and Procedure review and revision (as applicable) will be completed and education will be provided to staff and providers on thorough and accurate documentation to ensure the deficient practice does not recur.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
1.Facility policy titled Medication self administration revised to include monitoring accountability for nursing staff when resident(s) are determined to be safe to self-administer unsupervised by the IDT.
2. Education for nursing staff on documentation expectations.
3. Education for Physician/Providers on thorough and accurate documentation.
4. Incident and Accident (I&A) Education to be provided to all staff to ensure any incident that occurs has the appropriate report completed and a facility investigation is completed.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Each morning in clinical meeting, the DON or designee will review the electronic clinical record as 24 hour report is reviewed for any significant clinical issues. This will ensure that documentation is accurate and thorough and will highlight any documentation that needs to be improved or still needs to be completed. I&A's are already reviewed daily at clinical meeting and that process will continue to ensure any clinical event that should have a facility investigation completed has one.
The date for correction and the title of the person responsible for correction:
The ADON will be responsible to ensure correction by 6/4/2019.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure good personal hygeine was provided to 2 (Resident #'s 79 and 89) of 2 residents reviewed for activities of daily living. Specifically; for Resident #79, the facility did not ensure staff responded in a timely manner to the resident's request for assistance to the bathroom, for Resident #89, the facility did not ensure staff changed the resident soiled clothing after a meal. This is evidenced by: Resident #79: The resident was admitted to the facility on [DATE], with urinary incontinence, right renal cell [MEDICAL CONDITION] s/p nephrectomy (kidney removal [MEDICAL CONDITION]), and [MEDICAL CONDITION] (TBI). A Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, could usually understand others and could sometimes make self understood. The Comprehensive Care Plan (CCP) for Activities of Daily Living, last updated 2/20/19, documented the resident required extensive assist for toileting, with use of a sit to stand lift by two staff. The CCP for Falls, last updated 2/20/19, documented the resident is at moderate risk for falls and needs a prompt response for all requests for assistance. During observations on 3/31/19, from 10:20 AM - 11:31 AM (1 hour and 11 minutes), the resident's call light was on at 10:20 AM. The surveyor asked the resident if he needed to go to the bathroom and the resident shook his head yes in response. At 11:31 AM, the resident was toileted by one CNA, without the use of the lift or another CNA. During observations on 04/02/19 from 9:50 AM - 11:07 AM (1 hour and 17 minutes), the resident was observed in the hallway outside of his room communicating his need to use the bathroom to an LPN at 9:50 AM, the resident shook his head yes when the surveyor asked if he needed to use the bathroom, and the resident was toileted at 11:07 AM with the lift and 2 staff members. During an interview on 04/03/19 at 2:00 PM, the resident shook his head yes when the surveyor asked if it bothered the resident to have to wait to be toileted. During an interview on 4/03/19 at 2:10 PM, CNA #6 stated the resident is transferred to the toilet with a sit to stand lift and 2 people. She stated it is difficult to toilet him in a timely manner when there are only two aides on the unit assignment. During an interview on 4/03/19 at 02:25 PM, LPN #5 stated the resident is transferred to the toilet with a sit to stand lift and 2 people. She stated when we have 2 aides scheduled on the unit assignment it is impossible to toilet him in a timely manner. Resident #89: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment, was sometimes able to make himself understood and usually able to understand others. During an observation on 3/31/19 from 11:05 AM until 3:30 PM on the South unit, Resident #89 was observed wandering about the unit. The front of the resident's pants was soiled with food that resembled dried eggs. During an interview on 03/31/19 at 04:01 PM, the ADON stated the resident should have been changed after the meal. He should not still have the food soiled clothing on. During an interview on 4/3/19 at 11:30 AM, CNA #10 stated that working weekends was scary with only 1-2 CNAs on a unit. The CNAs do not have time to do everything that needs to be done for the residents. The things that do not get done when there are 1-2 CNAs are turning & positioning, showers, changing incontinent residents, or changing soiled clothing after meals. 10NYCRR415.3(c)(1)

Plan of Correction: ApprovedMay 9, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident 79 the CNA responsible for transferring the him without following his plan of care was suspended during the investigation to ensure resident safety. Re-education was completed prior to the CNA returning to work regarding the need to follow the prescribed plan of care.
For resident 89, upon notification by the survey team leader to the ADON, the resident's clothing was changed.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Any resident who requires assistance in performing ADL's or transfers above a supervision level has the potential to be affected by the deficient practice. Education will be provided to all nursing staff on resident rights and dignity.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
CNA staff will be re-educated that care is to be provided per the care card. Failure to follow the care card may constitute neglect and appropriate follow-up (including disciplinary action) will be taken. Education will include that care is to be provided timely and regardless of staffing. If additional resources are needed a call is to be placed to the unit manager or nursing supervisor and additional resources will be delegated to help provide care to residents.
Education will include that any resident observed with dirty clothing will be returned to their room and have their clothing changed timely to maintain their dignity.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Each unit manager will be responsible for ensuring resident in their care are provided timely and safe care per their designated plan of care. Any issues will be reported for follow-up by nursing administration. A facility investigation will be completed, including Incident and Accident report. Any staff found to be violating a resident's plan of care will be suspended pending investigation. If no injury to the resident as a result of the violation AND no prior history of plan of care violations, the staff may return to work at the facility's discretion. If the staff has a history of plan of care violations OR there is an injury to the resident, termination of employment will occur and a report will be made to the NYS Department of Health according to the NYS Incident Reporting Manual guidelines.
Audits will be completed by social services and nurse management staff of the residents to ensure that no residents are observed with dignity concerns. These audits will be done weekly and results will be reported to the QAPI committee weekly.
The date for correction and the title of the person responsible for correction:
The Assistant Director of Nursing will have responsibility to ensure correction of this deficiency by 6/4/2019.

FF11 483.10(c)(7):RESIDENT SELF-ADMIN MEDS-CLINICALLY APPROP

REGULATION: §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a certification survey, the facility did not ensure the interdisciplinary team (IDT) appropriately assessed a resident to self-administer medications for one of one (Resident #52) resident reviewed for self-administration of medication. Specifically, for Resident #52, the facility did not ensure there was a process to demonstrate the resident had self-administered his diabetic medication, that the resident was securely storing the diabetic medication and supplies, and that the resident's ability to self-administer medication was periodically assessed by the IDT. This is evidenced by: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make self-understood. The facility's policy and procedure titled Self-administration of a Medication last revised on 09/12/18, documented when a resident expressed a desire to self-administer medication an assessment would be completed in the electronic medical record (EMR); the unit manager would discuss with the IDT; the physician would be made aware and an order to self-administer would be obtained; the medications would be secured and made accessible to the resident only; the nurse would continue to monitor and document medication administration; and self-administration of medication would be care planned for and re-evaluated at quarterly reviews for continued success. The comprehensive care plan did not include a care plan that addressed self-administration of medication. Physician orders [REDACTED]. -Basaglar KwikPen Solution Pen-injector 100unit/ml; inject 30 units subcutaneously in the morning for diabetes unsupervised self-administration. -Basaglar KwikPen Solution Pen-injector 100unit/ml; inject 3 units subcutaneously every evening for diabetes unsupervised self-administration. -[MEDICATION NAME] Solution Pen-injector 100unit/ml; inject 5 units subcutaneously before meals and at bedtime for diabetes unsupervised self-administration. -[MEDICATION NAME] Solution Pen-injector 100unit/ml; inject as per sliding scale: if 151-200 2 units; 201-250 4 units; 251-300 6 units; subcutaneously before meals and at bedtime for diabetes unsupervised self-administration. A Medication Self-Administration Safety Screen dated 11/14/18, documented the resident may self-administer medications unsupervised. The assessment also documented the resident would document on a paper Medication Admission Record (MAR) dose of insulin given, location of subcutaneous injection and time of injection. Nursing staff would review the resident's paper MAR indicated [REDACTED]. The medical record did not include a quarterly Medication Self-Administration Safety Screen as documented in the facility policy. A Medication Self-Administration Safety Screen dated 04/01/19, documented the resident may self-administer medications unsupervised. The assessment also documented the resident would document on a paper MAR, FSBS (Finger Stick Blood Sugar), dose of insulin given, location of subcutaneous insulin given and time. Nursing would review paper MAR indicated [REDACTED]. During an observation on 03/31/19 at 10:38 AM, the resident's insulin pen was on his over bed table. During an observation on 04/01/19 at 09:14 AM, the resident's bedroom door was open and there were 10 unopened syringes on the resident's nightstand. During an observation on 04/02/19 at 02:49 PM, the resident's bedroom door was open and there was a box of lancets, a box of novofine needle tops, a vile of insulin and an insulin pen on the resident's over bed table. The resident's locked drawer was ajar. During an interview on 04/01/19 at 09:18 AM, Resident #52 stated he was never issued a key to the locked drawer in his room to store his diabetic supplies. He stated he was never issued a log to record his blood sugars until that morning, 04/01/19. He stated the nurse told him that there was documentation in the computer stating he agreed to complete a log to keep track of his blood sugars and insulin but stated that agreement was never made with him. During an interview on 04/02/19 at 09:27 AM, Licensed Practical Nurse (LPN) #2 stated she would not know if the resident was taking his insulin or checking his blood sugars as ordered unless the resident told her otherwise. She stated she did not document the resident's blood sugars or amount of insulin he had self-administered in the (MAR) because the resident was supposed to be completing his own documentation. She also stated that the doctor would have no way of knowing the resident's blood sugars and would not know if the resident's insulin needed to be adjusted since the resident had not kept a log and no other monitoring was being done by staff. During an interview on 04/02/19 at 10:33 AM, the Registered Dietician (RD) stated she had not reviewed the resident's blood sugars since his admission because the resident had a physician's orders [REDACTED]. She stated the resident did not document his blood sugars, but she stated he was a Type 1 diabetic and was more familiar with his body and his diabetic management. During an interview on 04/02/19 at 02:52 PM, the Registered Nurse #1 stated she met with the resident on 04/01/19 about secure storage of diabetic supplies and the resident agreed to keep his insulin and needles locked in his drawer. She stated maintenance provided the resident with a key to his drawer that afternoon. She stated she did not know if the resident was giving himself the correct dose of insulin and did know how if he was checking his blood sugars. She stated the resident should have been keeping a log of his blood sugars and the nurses should have monitored and documented in the MAR. During an observation on 4/02/19 at 3:50 PM, RN #1 was at the desk with a key taped to a piece of yellow payer and stated she had just received the key for the resident's locked space at 3:30 pm and she had to now give it to the resident. She realized having the needles and syringes out in the open was a resident safety issue but stated she did not go into his room to do something about it when he was not there because he was accusatory. During an interview on 04/03/19 at 2:10 PM, RN # 1 stated she thought the self-administration assessments were supposed to be completed quarterly and had not completed an assessment for the self-administration of medication until 04/01/19. The assessment documented the resident could continue to self-administer his diabetic medications. She stated based on what she had recently found out, she did not believe the resident should be self-administering his diabetic medications even though he still was. During an interview on 04/03/19 at 3:08 PM, the Assistant Director of Nursing (ADON) stated the resident should be re-assessed every quarter for his ability to self-administer medication with his care plan review. He stated the comprehensive care plan should address the self-administration of medication. He also stated that the resident should have been provided with a paper MAR indicated [REDACTED]. He stated the resident was to document, but the staff should have been monitoring every shift as well. He stated since the resident was not documenting and monitoring his blood sugars, the medication administration should have transitioned back to nursing. During an interview on 4/5/19 at 03:38 PM, the Medical Director (MD) stated the resident self-administered his diabetic medication, but he would expect the nurses to also monitor and inform him if there were any concerns. He stated since there was no monitoring being done, he did not know if the resident was self-administering his medication appropriately.

Plan of Correction: ApprovedMay 8, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
A medication self assessment safety screen was completed on 4/1/2019 as none had been completed on resident # 52 since the initial medication self assessment safety screen dated 11/14/2018.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Any resident(s) who voices a desire to self-administer medication(s) have the potential to be affected by the same deficient practice. Currently there are no other residents in the building who wish to self administer any medications. Policy review and revision is being completed and staff education will be completed to prevent this deficient practice from occurring again.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Previous facility policy titled Self administration of a medication dated 9/12/2018 was reviewed and revised, dated 4/24/2019. Revisions include:
1. Documentation by resident on a paper Medication Administration Record [REDACTED].
2. Nursing's role and responsibility to check the resident's documentation, including process if resident is not documenting or not taking medications as ordered.
3. All medications/supplies for those resident who will self0adminiter unsupervised will be stored in the resident's locked drawer in their bedside nightstand. This will ensure no other resident(s) have access to medication belonging to a resident who is self-administering.
4. Comprehensive Care Plan will be initiated upon IDT decision that resident is safe to self-administer by the Registered Professional Nurse (RN) responsible for the resident's care. The care plan will include identifiable goals and interventions to ensure resident safety and monitoring of medication administration.
5. Medication Self Administration Safety Screen Assessment will be completed upon initial request from resident to self-administer medication(s) and quarterly thereafter to re-evaluate resident's ability and safety in continuing to self-administer his/her own medication(s).
Staff education will be provided to all LPN's and RN's employed in the facility on the policy changes and responsibility of nursing.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
The nurse manager of the unit the resident resides on will be responsible to ensure any resident who wishes to self-administer medications is screened and discussed with the IDT. The nurse manager will ensure the RN responsible for the resident's care completes the medication self-administration safety screen assessment initially and then quarterly. The nurse manager is also responsible to ensure medications/supplies are secured in the resident's locked drawer in their nightstand. The nurse manager will be responsible to audit any resident's chart who self-administers medication to ensure that medications are stored in a locked drawer to ensure no other resident can access the medication, resident documentation reviewed each shift, any discrepancies noted and if so, reported to phsycian and IDT, and Comprehensive Care Plans includes care plan for self administration. These audits will be done weekly for 4 weeks and then monthly for 3 months.These audit results will be reported on monthly to the QAPI committee.
The date for correction and the title of the person responsible for correction:
The Assistant Director of Nursing Services will be responsible to ensure correction is completed by 6/4/2019.

FF11 483.30(a)(1)(2):RESIDENT'S CARE SUPERVISED BY A PHYSICIAN

REGULATION: §483.30 Physician Services A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. §483.30(a) Physician Supervision. The facility must ensure that- §483.30(a)(1) The medical care of each resident is supervised by a physician; §483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure the medical care of each resident is supervised by a physician for 1 (Resident #36) of 6 residents reviewed for nutrition. Specifically, the facility did not ensure a the physician was notified in a timely manner of the resident's unintended, significant weight loss. This is evidenced by: Resident #36: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, could understand others and could make himself understood. The weight record documented the following: 02/07/19 = 223 lbs. (pounds) 03/14/19 = 209 lbs. There was no documented reweight for a weight loss 14 lbs. A weight change notification dated 3/19/19 documented the resident's current weight was 209 lbs (6.28% weight loss over 30 days and 14.34% weight loss over 6 months). The form documented the resident was to receive Ensure plus one can three times daily and requested physician to evaluate. The weight change notification was signed by the physician on 4/2/19. During an interview on 4/05/19 at 10:24 AM, Registered Dietitian (RD) #6 stated the weight change form was given to Licensed Practical Nurse (LPN) #5, and the unit manager would notify the physician or place the form in the doctor's book. During an interview on 4/05/19 at 1:10 PM, Licensed Practical Nurse (LPN) #5 stated the physician did not sign the 3/19/19 weight change notification until 4/2/19 because he was not in the building. She stated she would not call him related to significant weight loss because he was already on supplements and had bloodwork done. During a phone interview on 4/05/19 at 4:52 PM, Physician #15 stated he was not aware of a significant weight change for the resident, and in the past weight changes have been related to fluid status. He stated he is in the facility once a week, and staff will call with anything alarming. 10NYCRR415.15(b)(1)(i)(ii)

Plan of Correction: ApprovedApril 26, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident #36 he was placed on weekly weights to monitor for continued weight loss. Any weight loss will be communicated to the physician of record and Registered Dietitian for review and recommendation.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the same deficient practice as they could be at risk for weight loss. Education with staff will be completed and policy review and revision (if appropriate) will be completed to ensure deficient practice does not recur.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Policy titled Monthly Weight Policy was reviewed. Communication of weight loss will be made to the physician per facility policy, and staff will also notify physician of weekly weight loss after weights are obtained. If there is no response from the physician after two attempts, the Medical Director will be notified for intervention to ensure appropriate interventions are in place. Education of LPN's and RN's will be done to ensure this change in notification is communicated
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Weights will continue to be discussed weekly on Thursdays after clinical meeting by the IDT. Any difficulties in contacting the physician or in having the physicians order supplementation/acknowledge weight loss will be discussed at this weekly meeting. Weights will continue to be monitored and discussed at the monthly QAPI meetings for any significant weight changes (greater than 5% in 30 days or greater than 10% in 180 days). A new weekly/monthly weight sheet will be implemented with the education for this plan of correction on each nursing unit to ensure adequate tracking of weights.
The date for correction and the title of the person responsible for correction:
The ADON and Registered Dietitian will be responsible to ensure correction by 6/4/2019

FF11 483.10(g)(6)-(9):RIGHT TO FORMS OF COMMUNICATION W/ PRIVACY

REGULATION: §483.10(g)(6) The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. This includes the right to retain and use a cellular phone at the resident's own expense. §483.10(g)(7) The facility must protect and facilitate that resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to: (i) A telephone, including TTY and TDD services; (ii) The internet, to the extent available to the facility; and (iii) Stationery, postage, writing implements and the ability to send mail. §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident's own expense. §483.10(g)(9) The resident has the right to have reasonable access to and privacy in their use of electronic communications such as email and video communications and for internet research. (i) If the access is available to the facility (ii) At the resident's expense, if any additional expense is incurred by the facility to provide such access to the resident. (iii) Such use must comply with State and Federal law.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on interviews conducted during the recertification survey, the facility did not ensure the resident's right to send and promptly receive unopened mail and packages delivered to the facility for the resident. Specifically, the facility did not ensure postal services were provided to residents on Saturdays. This was evidenced by: During a group interview conducted on 04/01/19 at 10:43 AM, four residents reported they do not receive mail on Saturdays. During an interview on 4/01/19 at 1:46 PM, the Social Worker reported that mail is not delivered on Saturday, because the facility has a post office box and the staff that picks up mail from the post office do not work on Saturday. During an interview on 04/03/19 at 03:37 PM, the Activities Director reported, the Human Resources Director picks up mail from the post office during the week and the activities department brings mail to the residents. On Saturdays, the mail is not picked up from the post office. 10NYCRR 415.3 (d)(2)(i)

Plan of Correction: ApprovedApril 26, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Mail will be received from the Town of(NAME)post office on Saturday mornings and be delivered to the residents in the facility on Saturdays.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents residing at(NAME)Hills Nursing and Rehabilitation Center have the potential to be affected by the deficient practice as they can have mail delivered to the facility.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
The receptionist on Saturday morning will go to the Town of(NAME)post office at 11:00 am and retrieve any mail that is in the facility's Post Office (PO) Box. This timeframe was given to the facility staff by the Postmaster at the post office, as they mail is not placed into the PO Box until just before 11 am. Once the mail is returned to the facility, the receptionist delivers the mail to the activity department staff who will deliver the mail to the residents in the facility.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Resident's will be asked at each of the upcoming monthly resident council meetings to ensure delivery is occurring on Saturdays. Resident responses will be documented in the resident council meeting minutes, which are signed by the resident council president.
The date for correction and the title of the person responsible for correction:
The Director of Activities and the Director of Human Resources will be responsible to ensure correction by 6/4/2019.

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

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

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. The facility must provide for a sanitary, orderly, and comfortable interior. Specifically, floors were not clean on 3 of 3 resident units. This is evidenced as follows. The resident unit corridor floors were inspected on 04/03/2019 at 2:00 PM. The corridor floors on the North Unit, East Unit, and South Unit were soiled with dirt and old wax build-up next to walls and in corners. The Director of Housekeeping stated in an interview on 04/03/2019 at 3:55 PM, that all floors on the resident units need cleaning, and the floor stripping and cleaning will begin next week. 483.10(i)(2)

Plan of Correction: ApprovedApril 26, 2019

F584 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Area?s identified during survey were stripped and waxed per protocol.
IDENTIFY OTHER POTENTIAL RESIDENTS
- All others checked and corrective cleaning and/or waxing performed as needed.
SYSTEMIC CHANGES
- A quarterly strip and wax schedule has been produced to assure all common areas are done at a minimum, with higher traffic areas getting additional times to be strip and waxed.
QUALITY ASSURANCE
- The Director of Housekeeping (or designee) will audit this schedule and the areas done to assure compliance and report their findings to the Quality Assurance committee monthly for three months. Any negative findings will be reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Housekeeping by 6/4/2019

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not store soiled linens in accordance with adopted regulations. Ventilating systems must be maintained and operated in such manner that air shall not be circulated from soiled utility rooms to other parts of the facility. Specifically, soiled linen rooms were not provided with mechanical ventilation. This is evidenced as follows. Observations on 04/05/2019 at 4:30 PM, revealed that the main soiled linen room in lacked mechanical ventilation. The Administrator stated in an interview 04/05/2019 at 4:30 PM, that the mechanical ventilation duct in the main soiled linen room is covered to prevent water pipes from freezing in the winter. 10 NYCRR 415.29 (h), (j)(6)(ii); 10 NYCRR 70-2.2(g)(2)

Plan of Correction: ApprovedApril 26, 2019

I560 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- The temporary cover was removed during survey and shown during survey.
IDENTIFY OTHER POTENTIAL RESIDENTS
- All other soiled linen areas checked for proper ventilation, with no negative findings.
SYSTEMIC CHANGES
- The pipes in the room in question were wrapped to ensure no freezing would occur. Education given to Maintenance staff to assure that ventilation system is never covered and that if an issue such as the pipes in that area being chilled occurs, to bring to Administration attention before taking action to assure an issue like this does not occur again.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit monthly for 3 months the soiled linen areas to assure proper ventilation. They will report their findings to the Quality Assurance committee and report any negative findings to Administration for immediate follow up.
PERSON RESPONSIBLE
- Director of Maintenance by 6/4/2019

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey the facility did not ensure sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident on 2 (North, South) of three units. Specifically, the facility did not ensure that there was enough staff to ensure: Resident #89 had his soiled clothing changed after a meal, and Resident #79's request for assistance to the bathroom was responded to in a timely manner. This is evidenced by: South Unit: The Daily Shift Assignment Sheet for 7:00 AM to 3:00 PM shift on the South Unit documented staffing as follows: 3/31/19 - 1 Licensed Practical Nurse (LPN) and 2 Certified Nurse Aides (CNA). 4/1/19 - 1 LPN and 3 CNAs. 4/2/19 - 2 LPNs and 3 CNAs. Resident #89: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severe cognitive impairment and was sometimes able to make himself understood and usually able to understand others. During an observation on 3/31/19 from 11:05 AM until 3:30 PM, on the South unit, Resident #89 was observed wandering about the unit with the front of his pants soiled with food. During an interview on 4/1/19, CNA #8 stated when there are only 2 CNAs on a unit showers do not get done. Once residents receive their morning care there is no time to go back to a resident to change, or put them back to bed. The last rounds at 2:00 PM will not get done completely, at 3:00 PM the shift ends and the day shift must leave. During an interview on 4/3/19, CNA #10 stated that working weekends was scary with only 1-2 CNAs on a unit. The CNAs do not have time to do everything that needs to be done for the residents. The things that do not get done when there is 1-2 CNAs was turn & positioning, showers, changing incontinent residents, or changing soiled clothing after meals. North Unit: The Daily Shift Assignment Sheet for 7:00 AM to 3:00 PM shift on the South Unit documented staffing as follows: 3/31/19 - 1 LPN and 2 CNAs. 4/2/19 - 2 LPNs and 2 CNAs. Resident #79: The resident was admitted to the facility on [DATE], with urinary incontinence, right renal cell [MEDICAL CONDITION] s/p nephrectomy (kidney removal [MEDICAL CONDITION]), and [MEDICAL CONDITION] (TBI). A Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, could usually understand others and could sometimes make self understood. The Comprehensive Care Plan (CCP) for Activities of Daily Living, last updated 2/20/19, documented the resident required extensive assist for toileting, with use of a sit to stand lift by two staff. The CCP for falls, last updated 2/20/19, documented the resident is at moderate risk for falls and needs a prompt response for all requests for assistance. During observations on 3/31/19, from 10:20 AM - 11:31 AM (1 hour and 11 minutes), the resident's call light was on at 10:20 AM. The resident shook his head yes when the surveyor asked if he needed to use the bathroom. The resident was toileted at 11:31 AM without the lift and without another CNA. During observations on 04/02/19, from 9:50 AM - 11:07 AM (1 hour and 17 minutes), the resident was observed in the hallway outside of his room at 9:50 AM. The resident shook his head yes when the surveyor asked if he needed to use the bathroom. The resident was toileted at 11:07 AM with the lift and 2 staff members. During an interview on 04/03/19 at 2:00 PM, the resident shook his head yes when the surveyor asked if it bothered the resident to have to wait to be toileted. During an interview on 4/03/19 at 2:10 PM, CNA #6 stated the resident is transferred to the toilet with a sit to stand lift and 2 people. She stated it is difficult to toilet him in a timely manner when there are only two aides on the unit assignment. During an interview on 4/03/19 at 02:25 PM, LPN #5 stated the resident is transferred to the toilet with a sit to stand lift and 2 people. She stated when we have 2 aides scheduled on the unit assignment it is impossible to toilet him in a timely manner. During an interview on 4/03/19 at 2:36 PM, the Assistant Director of Nursing (ADON) stated that it is not acceptable for a resident to wait for over an hour to be toileted. 10NYCRR415.13(a)(1)(i-iii)

Plan of Correction: ApprovedApril 26, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
For resident #89 upon the surveyor discussing the concern with the ADON, the resident's clothing was immediately changed.
For resident # 79 upon the surveyor and team leader disclosing the observation from 3/31/2019 to the ADON on 4/2/19, the CNA was immediately suspended pending investigation for violation of care plan.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents in our care have the potential to be affected by the same deficient practice. Staffing is being constantly addressed due to the nationwide shortage of CNA's and nurses. This facility has a mandation protocol in place, a per-diem pool and is constantly recruiting new staff in an attempt to ensure sufficient staffing to provide the highest quality care and prevent the deficient practice from recurring.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
*In an attempt to increase our staffing numbers, we have increased our sign-on bonus for CNA's to $7,500 and for LPN's to $3,000. We have increased our referral bonuses for current employees who refer new employees as well. We have increased our no frill rate of pay to $17/hour for CNA's and to $24/hour for LPN's. No-frill refers to employees who are hired and opt to not receive the health benefits offered by the union.
*Education will be provided to all staff regarding resident rights and dignity, and that care has to be provided timely and safely, per the plan of care. Should additional help be needed, a call is to be made to the nursing supervisor on duty and additional help will be made available. Staff can be made available by floating of staff from other units to assist in providing care on units where staffing may be lower due to acuity, census, etc.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
Staffing is continually monitored by facility administration (Administrator, DON, ADON) and facility ownership. Care being provided to residents in discussed constantly by nursing leadership team and concerns are raised typically in the form of grievances or resident/family complaints or staff concerns. As stated by this ADON during interview during survey, staff has not reported that care is routinely not being completed due to staffing concerns. As a result of this Plan of Correction, the Social Services department will conduct random audits looking for dignity and care concerns on 5 residents on each unit. These audits will be completed daily for 4 weeks, then weekly for 4 weeks, then monthly for 2 months. The audit results will be reviewed with the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The Social Service Supervisor in conjunction with the ADON will have responsibility to ensure correction by 6/4/2019.

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey the facility did not ensure that care and services were provided that were consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #58) of one rersidents reviewed for pressure ulcers. Specifically, for Resident #58, the facility did not ensure the care plan for the resident's pressure area on coccyx included interventions to prevent or to promote healing of a pressure ulcer. This is evidenced by: The Policy & Procedure (P&P) titled Pressure Ulcer and Wound Care undated documented any resident with a wound received treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and preventing infection. Resident #58: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderately impaired cognition, was able to make herself understood and could usually understand others. The Nurse Progress Note dated 3/3/19 documented the resident had an open area to the coccyx measuring 3.5 centimeters (cm). The Nurse Progress Note dated 3/9/19 documented, the resident continues with daily dressing to the coccyx. The resident was admitted to the hospital with [REDACTED]. The comprehensive care plan (CCP) titled, At risk for pressure ulcer dated 7/19/18, documented an update to the problem dated 3/3/19 and documented, pressure ulcer coccyx. There were no interventions added, and there were no previous interventions to prevent the development of pressure ulcers. The CCP titled ADL Self-care Performance Deficit dated 7/20/18 documented, extensive assist x 2 for bed mobility. There were no documented instructions for turning & positioning. The readmission assessment dated [DATE] at 3:32 PM, documented resident was readmitted from the hospital. Skin integrity documented, a coccyx area pressure ulcer with measurements of 9 centimeters (cm) x 8 cm x 2 cm. Necrotic (dead) tissue noted around base of wound with two small ulcers to the right of the wound. Skin raw and red. Santyl and dry protective dressing every shift. The weekly wound observation tool documented an increase in the size of the pressure ulcer from 3/13/19, when it measured (in centimeters) 7x8x0, to 4/2/19, when it measured 9x8.5x4 and had necrotic tissue that was foul smelling. A physician's orders [REDACTED]. A review of the Comprehensive Care Plans revealed no care plan for the necrotic wound and/or the wound infection. During an observation on 04/02/19 at 11:00 AM, the coccyx was noted to have a large area of necrotic tissue with the lower portion of necrotic tissue unattached from the sides of the wound and falling into the wound crater, giving access to pack the wound. There was a foul odor from the wound. The resident was observed lying in bed on her back on 3 observations between 10:48 AM to 1:15 PM on 3/31/19, on two observations between 8:48 AM to 10:05 AM on 4/1/19, and on 2 observations between 9:15 AM to 10:45 AM on 4/2/19. The resident was observed sitting in reclining chair, positioned on her back on 2 observations between 11:20 Am to 1:45 PM on 4/1/19 and on 4 observations between 11:30 AM to 4:30 PM on 4/2/19. During an interview on 4/3/19 at 9:35 AM, the Assistant Director of Nursing (ADON) stated he was the Wound Nurse for the facility and was in charge of the care plans for the unit. The Risk for Pressure Ulcer CCP should not have been updated on 3/3/19 for the pressure sore, there should have been a new one developed. He also should have developed a CCP for the pressure sore on readmission and should have included interventions for changing position and an out of bed schedule to promote healing. The resident should not have sat in the chair yesterday for 5 hours, and she should be turned and positioned throughout the day. During an interview on 4/5/19 at 12:28 PM, the ADON stated that prior to the development of this pressure sore there were no interventions in place to prevent the development and there should have been. She was placed on an air mattress when she returned from the hospital on [DATE], no other interventions were put into place. During an interview on 4/5/19 at 3:39 PM, the Medical Director stated he was not aware that there were no wound care orders to promote healing of the pressure sore. There should have been positioning of the resident every two hours and monitoring of the wound and any drainage. Whatever is causing the wound, it needed to be kept from getting worse with offloading, nutrition and dressings. She received a substandard of care. During an interview on 04/05/19 at 10:52 AM, the Licensed Practical Nurse Manager) (LPNM) #10 stated the resident was placed on an air mattress the day after her readmission, she was not placed on any special positioning program. The resident should not have been in her chair yesterday all day, did not know what time they put her back to bed, we will start an out of bed program. The Physician was in and saw the wound yesterday and ordered to have the wound debrided by the Wound Center. An appointment was made for Monday (4/8/19). 10NYCRR415.12(c)(1)

Plan of Correction: ApprovedApril 26, 2019

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Comprehensive Care Plan for resident #58 was updated on 4/5/2018 to include interventions to promote healing of existing unstageable pressure ulcer. These included, but were not limited to, turn and position schedule every 2 hours, limiting time out of bed to geri-chair to 2 hours, avoiding positioning resident on back to reduce pressure on her coccyx.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have a braden assessment done on admission/readmission, weekly for 4 weeks then quarterly or with any new area of skin breakdown. All residents who score a moderate or high risk on the braden assessment have the potential to be affected by the deficient practice as they could be at risk for pressure ulcer development. Policy revision and education will be completed to ensure the deficient practice does not recur.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Policy titled Pressure Ulcer and Wound Care was retired and a new policy titled Pressure Ulcer and Wound Care Plan dated 4/24/2019 replaced it. Revisions include:
1. Pressure ulcer prevention/treatment intervention added
2. Definitions added to better assist staff
3. Comprehensive Care Plan to be developed to include treatment interventions to promote healing.
4. Review of Comprehensive Care Plan and treatments/interventions to be done on weekly wound rounds.
Education to all nursing staff (RN, LPN, CNA's) will be completed to ensure staff is aware of the new policy and the changes in it.
How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice:
The ADON will audit all charts weekly for residents who have pressure injuries/ulcers to ensure interventions are in place on the comprehensive care plan. The unit managers will be responsible to ensure the interventions are being followed as directed by the care plan. The ADON will review the audit results with the QAPI committee monthly.
The date for correction and the title of the person responsible for correction:
The ADON will be responsible for ensuring correction by 6/4/2019.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 17, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and employee interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.3.6 permits the use of Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL -1 to power patient care-related electrical equipment and Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment. NFPA 70 National Electrical Code 2011 Edition Articles 400.8, 400.7, and 368.56(B) require that relocatable power taps (power strips) be secured to the wall, and Article 590 section 590.3 (D) prohibits the use of mulit-plug adapters. Specifically, non-compliant power strips were used to power both patient care-related equipment and non-patient care electrical devices in patient care areas, power strips were not secured, and multi-plug adaptors were used. This is evidenced as follows. A selection of resident rooms was spot checked on 04/03/2019 at 2:00 PM. A non-compliant power strip was used to power personal electronics and a hospital bed in resident room [ROOM NUMBER]; this power strip was dangling loosely in the air hanging from an electrical outlet. A non-compliant power strip was used to power electronics in the Physical Therapy room, and a multi-plug adaptor was used to power personal electronics in resident room [ROOM NUMBER]. The Director of Maintenance stated in an interview conducted on 04/03/2019 at 3:30 PM that power strips should not be dangling in the air, multi-plug adaptors should not be used, and he does not know if the power strips are compliant. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.3.6; 2011 NFPA 70 400.8, 400.7, 368.56(B) 590.3(D); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3; 1999 NFPA 70

Plan of Correction: ApprovedMay 2, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K920 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- The non-compliant power strip found in room [ROOM NUMBER] was removed.
- The non-compliant power strip found in the therapy room was removed.
-The multi-plug adapter found in room [ROOM NUMBER] was removed.
Residents and staff using items were educated about the importance of bringing in only approved items and having them inspected by maintenance prior to usage.
IDENTIFY OTHER POTENTIAL RESIDENTS
- Remainder of the Facility was checked with no other items being found out of compliance.
SYSTEMIC CHANGES
- Education will be provided to all staff and residents/representatives about assuring that no electrical items are brought in and put into service prior to be inspected and cleared by the Maintenance department to assure no non-approved items are put into service. Staff education will include that only approved power strips, according to NFPA 70 National Electrical Code 2011 are allowed to be used in resident care area. This will be put into the Mandatory and New Hire Education as well as New Admission Packet Information.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit 25% of rooms to assure that no non-inspected and no non-approved items are in use monthly for 3 months. Findings will be reported to the QA committee for follow up with any negative findings reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 6, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that PCREE is maintained with consideration of the owner's manual, and section 10.5 requires that a record shall be maintained of required tests. Specifically, PCREE was not tested prior to being placed in service, PCREE was not maintained as prescribed in the owner's manual, and a log was not kept of all testing. This is evidenced as follows. The Director of Maintenance stated in an interview on 04/03/2019 at 1:45 PM that inspections and testing of the IV machines, electric beds, pressure relieving mattresses, and C-pap machines in use in this facility were not recorded. Observations 04/03/2019 at 2:00 PM revealed that oxygen concentrators 14HF 9, E 37, 8, N 52, and 03C 6 were in use in resident rooms and situated directly next to walls, curtains, or furniture. Review of the oxygen concentrator owner's manual safety instructions on 04/03/2019 revealed that while in use, the concentrator is to be situated at least 12-inches from walls or other obstructions. Observations on 04/03/2019 at 2:00 PM revealed that the nebulizers in resident rooms [ROOM NUMBER] were plugged into electrical outlets and were not in use. Review of the nebulizer owner's manual safety instructions on 04/03/2019 revealed that the units are always to be unplugged immediately after use. Observations on 04/03/2019 at 2:00 PM revealed that the suction machines 849, 155, and AJQ205RP0052, on the crash carts in the North Unit, South Unit, and East Unit dining rooms did not have bacterial filters in place or available for installation between the pump and collection canister. Registered Nurse #1 stated in an interview on 04/03/2019 at 2:00 PM that the suction machines on the dining room crash carts are ready for immediate use. Review of the suction machines' owner's manuals safety and operating instructions on 04/03/2019 revealed that bacteria filters are to be installed between the pump and collection canister prior to using. The Assistant Director of Nursing stated in an interview 04/05/2019 at 7:00 PM that staff have not been provided education on the safe use of PCREE as outlined in the owner's manuals. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3, 10.5; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedApril 26, 2019

K921 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Items found during survey were immediately corrected per policy, owners manual, et. Al.
IDENTIFY OTHER POTENTIAL RESIDENTS
- Remainder of the Facility was checked for these issues, with any negative findings being immediately corrected at the time of finding.
SYSTEMIC CHANGES
- Education will be provided to appropriate staff about the proper way to maintain the PCREE per owners manual, policy, et. Al. A log has been created to encompass all currently in use and future PCREE to assure that they are maintained and inspected per Owners Manual and policy. This education will be made part of Mandatory Education and New Hire Education.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit 25% of the items on the new PCREE log to assure that no non-inspected and no non-approved items are in use monthly for 3 months, and then quarterly thereafter for 12 months. Findings will be reported to the QA committee for follow up with any negative findings reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not maintain the emergency generator as required by adopted regulations. NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.1 requires that the continuing reliability and integrity of the emergency generator, such as with a reliable fuel reserve, be maintained. Section 8.4.9 requires that emergency power standby systems (emergency generator), including all appurtenant components, shall be under load once every 36 months for 4 continuous hours. Specifically, fuel quality did not meet the minimum standards, and the emergency generator was not exercised under load conditions for 4 continuous hours within the past 36 months. This is evidenced as follows. The emergency generator inspection and maintenance records were reviewed on 04/03/2019. The inspection report dated 01/19/2019 documents that the fuel quality test performed on the emergency generator fuel reserve did not meet the minimum standards. When requested, a report documenting that the emergency generator was tested under load for 4 continuous hours within the past 36 months was not provided. The Director of Plant Operations stated in an interview conducted on 04/03/2019 at 1:45 PM that the generator was not exercised under load of 4 continuous hours within the last 36 months, and the reserve fuel was not treated because he did not have access to the test report to know to make a correction. 42 CFR 483.70 (a) (1); 2010 NFPA 110 8.1, 8.4.9

Plan of Correction: ApprovedMay 3, 2019

K918 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Fuel test completed during survey and recommendations completed per report by vendor. The generator has been run for four hours under load conditions with no break with no issues. Prior, it had been run for 3 hours and 55 minutes with no issues within the past 36 months.
IDENTIFY OTHER POTENTIAL RESIDENTS
- Generator log reviewed with no other issues being found.
SYSTEMIC CHANGES
- A yearly test and documentation will be performed on the Generator fuel container and fuel and all recommendations followed up on at that time annually. Future 4 hour run time tests will be scheduled as part of our routine generator checks, not to be greater than 36 months apart per guidelines.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit the Generator Log monthly for 3 months, then quarterly for 9 months. All findings will be communicated to the QA committee with any negative findings being communicated to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance

K307 NFPA 101:ELECTRICAL SYSTEMS - MAINTENANCE AND TESTING

REGULATION: Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 14, 2019

Citation Details

Based on observation and employee interview during the recertification survey, the facility did not inspect electrical equipment in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition Sections 6.3.3.2 and 6.3.4.1 require that receptacles not listed as hospital-grade, at patient bed locations shall be tested at intervals not exceeding 12 months; the testing shall include: the physical integrity shall be confirmed by visual inspection; the continuity of the grounding circuit shall be verified; correct polarity of the hot and neutral connections shall be confirmed; the retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). Specifically, the facility did not ensure receptacles not listed as hospital-grade, at patient bed locations, were tested as required. This is evidenced as follows. Observations on 04/03/2019 at 2:00 PM revealed receptacles not listed as hospital-grade in patient bed locations were found in resident rooms 202, 209, 214, 215, 216, 220, 221, 306, 307, 310, 318, 319, 320, 327, 328, 403, 404, 407, 414, 415, 417, 419, 420, and 421. The Director of Maintenance stated in an interview conducted on 04/03/2019 at 3:30 PM that he did think resident rooms had outlets not listed as hospital-grade, and the outlets not listed as hospital-grade have not been tested . 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.3.3.2, 6.3.4.1

Plan of Correction: ApprovedApril 26, 2019

K914 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Outlets identified were tested and replaced if necessary to assure compliance and proper working order.
IDENTIFY OTHER POTENTIAL RESIDENTS
- All other resident room outlets were tested , documented, and corrective action taken as necessary to assure compliance and proper working order.
SYSTEMIC CHANGES
- A yearly test and documentation will be performed on all facility outlets to assure compliance and proper working order. Any necessary non-hospital grade outlets in resident rooms will be transitioned to hospital grade.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit 10% of outlets monthly for 3 months. All findings will be reported to the QA committee, with any negative findings reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance

EP TRAINING PROGRAM

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not include documentation of the method used for demonstrating knowledge of the training program. This is evidenced as follows. A review of the Emergency Plan, Training Program on 04/01/2019 revealed that the program did not include a documented method by which staff must demonstrate knowledge of the Emergency Plan, such as a written quiz or a question and answer session. The Administrator stated in an interview conducted on 04/01/2019 at 2:30 PM that he is in the process of developing a method by which staff can demonstrate knowledge of their roles in Emergency response. 42 CFR: 483.73(d)(1)(ii)

Plan of Correction: ApprovedApril 26, 2019

E037 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- A written test was made and given to current staff members to see their level of understanding of the Emergency Plan, with any necessary education given based on scores.
IDENTIFY OTHER POTENTIAL RESIDENTS
- This test was made part of the Emergency Plan, and part of the mandatory and new hire educations. All staff will be assured to have taken this test.
SYSTEMIC CHANGES
- To assure understandability, a new course of educations is being made, to cover a different part of the Emergency Plan in greater depth than a general over view education. Tests and/or question sessions will be given to assure staff understand the Emergency Plan.
QUALITY ASSURANCE
- The Administrator (or designee) will audit 10% of current staff charts for the written test and on going educations monthly for 3 months. Findings will be communicated to the QA committee for follow up, with any negative findings being immediately corrected.
PERSON RESPONSIBLE
- Administrator

K307 NFPA 101:FIRE DRILLS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 19, 2019

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not conduct fire drills as required by adopted regulations. NFPA 101 Life Safety Code 2012 edition section 19.7.1 requires that fire drills (drills) shall be scheduled under varied conditions. Specifically, drills conducted during the 11 PM to 7 AM shift were scheduled under the conditions encountered within the same 2-hour period. This is evidenced as follows. The fire drill evaluations were reviewed on 04/05/2019. These documents reveal that between (MONTH) (YEAR) and (MONTH) 2019 the 11 PM to 7 AM shift drills were scheduled between 4:15 AM and 6:00 AM. The Administrator stated in an interview conducted on 04/05/2019 at 4:00 PM that he will ensure the 11 PM to 7 AM shift fire drills are scheduled at random times. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.1.2

Plan of Correction: ApprovedApril 26, 2019

K712 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- An extra 11-7 shift fire drill at a distinct and unique time was performed to assure that one happened this quarter at a different time with positive results.
IDENTIFY OTHER POTENTIAL RESIDENTS
- All other shifts fire drill times were checked for the past year to assure compliance with no issues found.
SYSTEMIC CHANGES
- This times for the 11-7 shift fire drills will be chosen quarterly in advance in conjunction with Administration to assure a rotating time during that shift, with education provided to the Maintenance staff who run the drills. The fire drill results will be a part of our routine QA.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit these drills monthly for 6 months. All findings will be reported to the QA committee, with any negative findings reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance

K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

REGULATION: Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 21, 2019

Citation Details

Based on staff interview and record review during the recertification survey, the facility did manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, the facility did not provide continuing education associated with the handling of medical oxygen cylinders. This is evidenced as follows. When requested on 04/01/2019 records were not provided documenting that the facility provided training on the risks and use of oxygen cylinders. The Administrator stated in an interview conducted on 04/05/2019 at 6:00 PM that he believes the facility provided the training on the risks and use of oxygen cylinders but has not record of the training. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedApril 26, 2019

K926 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Education and proper documentation of that education provided and created to assure that all in house staff that handle Oxygen tanks were educated in their proper handling, and documented to show it.
IDENTIFY OTHER POTENTIAL RESIDENTS
- Facility will assure that all current in house, Agency, etc. staff will have this education prior to handling Oxygen tanks.
SYSTEMIC CHANGES
- Education on handling Oxygen tanks will be made part of the Mandatory Yearly education as well as part of the New Hire Orientation Education.
QUALITY ASSURANCE
- The Administrator (or designee) will audit these education monthly for 3 months to assure all in house and new staff have received the proper education prior to handling oxygen tanks. All findings will be reported to the QA committee with all negative findings being immediately reported to Administration and the QA team for immediate correction.
PERSON RESPONSIBLE
- Administration

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 21, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the hazardous areas were not protected in accordance with adopted regulations. NFPA 101, Life Safety Code 2012 edition section 19.3.2.1.3 requires that doors to hazardous areas be self-closing or automatic-closing. Specifically, the door to the main soiled linen room, a hazardous area, did not self-close. This is evidenced as follows. The door to the main soiled linen room was inspected on 04/05/2019 at 4:00 PM. When tested , the door did not self-close. The Administrator stated in an interview conducted on 04/05/2019 at 4:30 PM that the door to the main soiled linen room used to be self-closing and he will re-install the closing device. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.2.1.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.3.2, 7.2.1.8.2

Plan of Correction: ApprovedApril 26, 2019

K321 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Self-closing door device was re-attached to the door identified.
IDENTIFY OTHER POTENTIAL RESIDENTS
- All other doors for hazardous areas checked for Self-closing door devices checked for function with no negative findings.
SYSTEMIC CHANGES
- Education to be done with staff who routinely use these doors about the importance of the devices, what to look for if they are in disrepair, and the proper way to report it they are found to not be working.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit these doors monthly for 3 months. All findings will be reported to the QA committee, with any negative findings reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, communication plan did not include sharing emergency preparedness policies and procedures with residents and their families or representatives. This is evidenced as follows. A review of the Emergency Plan on 04/01/2019 revealed the communication plan did not include sharing relevant portions of the emergency preparedness plans and policies with family members and resident representatives. The Administrator stated in an interview conducted on 04/02/2019 at 2:30 PM that relevant portions of the Emergency Plan have not yet but will be communicated to residents' families or their representatives. 42 CFR: 483.73(c)(8)

Plan of Correction: ApprovedApril 26, 2019

E035 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- An educational handout was produced during survey, and sent to all residents and/or resident representatives.
IDENTIFY OTHER POTENTIAL RESIDENTS
- The Educational handout was given to all current residents and/or resident representatives, and will be a part of the Admissions Packet for new Admissions going forward to assure all are educated. Any changes will be reflected in the handout and communicated.
SYSTEMIC CHANGES
- The educational handout on the Emergency Plan will be made a part of the Admissions Packet to assure all relevant parties receive the information as required. Any changes to the plan will be reflected in the hand out, and a new copy distributed.
QUALITY ASSURANCE
- The Administrator (or designee) will audit to assure that Current Residents/Representatives received the educational brochure. After this, 25% of new admission packets will be audited to assure the educational brochure is handed out and understood. Audits will be communicated to the QA team and any negative findings will be reported to the QA committee for correction.
PERSON RESPONSIBLE
- Administrator

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.15.1 requires automatic sprinkler protection in concealed spaces, such as above suspended ceilings, of exposed combustible construction. Specifically, automatic sprinkler protection was not provided in areas of combustible construction above suspended ceilings. This is evidenced as follows. An assessment of the sprinkler system was conducted on 04/05/2019 at 10:45 AM. Combustible construction, 4-foot by 3½-inch wood studs for privacy curtain tracts, was found above the suspended ceilings in resident rooms 311, 312, 324, and 325. Sprinkler protection was not found in these areas. The Director of Maintenance stated in an interview on 04/05/2019 at 11:30 AM that he will remove the wood above the suspended ceilings as it is not fire retardant-treated wood. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.15.1

Plan of Correction: ApprovedApril 26, 2019

K351 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Wooden supports in areas identified removed and replaced with appropriate metal studs.
IDENTIFY OTHER POTENTIAL RESIDENTS
- All other areas with hanging privacy curtain tracks were checked and replaced as needed to assure no other areas remained with wooden supports tracks.
SYSTEMIC CHANGES
- Education to be done with Maintenance staff to assure no other non-approved materials are used, or remain in place in the Facility.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit these areas monthly for 3 months. All findings will be reported to the QA committee, with any negative findings reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 27, 2019

Citation Details

Based on observation, record review, and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 Edition Section 8.3.5.6.3 restricts the installation of metal electrical boxes in smoke barrier walls when the required fire resistance of the smoke barrier wall is reduced. Section 8.5.2.2 requires that smoke barriers shall maintain a minimum fire-resistance rating and shall be continuous from floor to the underside of the roof and through all concealed spaces. Specifically, in 1 of 1 smoke barriers observed, metal boxes were not fire protected with approved fire-stopping materials, the wall was not continuous, and the fire-resistance rating was not maintained. This is evidenced as follows. The East Unit north smoke barrier wall (wall) was inspected on 04/05/2019 at 10:45 AM. In resident room 325 an 8-foot by ¼ inch length where the wall meets the underside of the roof was not fire-sealed and in resident room 312 one ½-inch unsealed hole were found. In resident rooms 324 and 325 six metal electrical boxes installed in the wall were found opposite within 2-feet of each other. A red substance was found pasted inside one of the metal boxes. The Director of Maintenance stated in an interview conducted on 04/05/2019 at 11:30 AM that he will fire-seal the penetration and space between the roof and wall; and the red substance found in the one electrical box, was used in all metal electrical boxes in smoke barrier walls, and is the same fire caulk used to seal penetrations. The specification data sheet for the fire caulk used in the metal electrical boxes was reviewed on 04/05/2019. The information on the sheet does not document fire-protecting metal electrical boxes as an approved use of the fire caulking. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5.6.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedMay 5, 2019

K372 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Penetrations identified were sealed immediately following survey. The metal electric boxes identified are being replaced with fire protected metal electrical boxes. These fire protected metal boxes will have a UL approved fire stopping applied correctly per the installation instructions.
IDENTIFY OTHER POTENTIAL RESIDENTS
- All other smoke barrier walls were observed, with any penetration sealing being performed as needed, and any electrical boxes identified as not meeting standard being scheduled to be converted.
SYSTEMIC CHANGES
- Education to be done with Maintenance staff to assure no other non-approved materials are used, or remain in place in the Facility, and to communicate with outside vendors to inform the Maintenance department if they make any penetrations in a fire wall so that Maintenance staff may properly fill them.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit these areas monthly for 3 months. All findings will be reported to the QA committee, with any negative findings reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

REGULATION: Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 25, 2019

Citation Details

Based on observation, record review, and staff interview during the recertification survey, the facility did not maintain equipment using gas or related gas piping in accordance with adopted regulations. NFPA 54, National Fuel Gas Code 2012 Edition Section 9.3 requires that gas operated equipment air for combustion (make-up air) shall be provided in accordance with the appliance manufacturer's instructions. Specifically, adequate make-up air was not provided for gas hot water heaters. This is evidenced as follows. The gas operated hot water heaters and the room in which they were located, were inspected on 04/03/2019 at 3:40 PM. These hot water heaters were in a room measured at 8-feet by 8½-feet by 12 feet, an area of 816 cubic feet. The information data plate on the side of each hot water heater lists the devices as producing 520,000 British Thermal Units (btu) per hour (hr), a total of 1,040,000 btu/hr total between the two devices. One permanent vertical duct communicating directly to the outdoors provided outdoor air for combustion. The vertical duct opening was 16-inches by 8-inches (128 square inches total) and the bottom of the opening measured at 16-inches from the floor. The room is enclosed with a door and has no other provisions for air for combustion. The hot water heater Instruction Manual was reviewed on 04/04/2019. The manual requires that for hot water heaters producing a total of 1,040,000 btu/hr in a space less than 16,640 cubic feet in size, requires two permanent vertical ducts communicating directly to the outdoors, the openings of which are 260-square inches. The opening of one vertical duct is to be within 12-inches from the floor, and the opening of the other vertical duct is to be within 12-inches from the top (ceiling) of the room. The Director of Maintenance stated in an interview conducted on 04/04/2019 at 2:15 PM that he will seek a vendor to assess and address the requirements for makeup air for the hot water heaters. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.1, 9.1.2; 2012 NFPA 54 9.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 54

Plan of Correction: ApprovedMay 16, 2019

K511 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- Outside HVAC vendor contacted, arrived during survey to see work to be done. Work scheduled to be completed 5/20/19 at 8:00 am.
IDENTIFY OTHER POTENTIAL RESIDENTS
- All other mechanical rooms were checked to assure proper ventilation, with no negative findings.
SYSTEMIC CHANGES
- This area will be audited Quarterly to assure that proper ventilation and programming of the heaters is in place and correct, and will be placed on the preventative maintenance schedule with the outside vendor.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit these areas monthly for 3 months. All findings will be reported to the QA committee, with any negative findings reported to Administration for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition Section 8.3.3.1 and Table 8.3.4.2 requires that the doors to stairwells with a 1-hour fire resistance rating have doors with a 1-hour fire resistance rating. Section 7.2.1 requires that stairwell doors be self-closing and have a latch or other fastening device. Sections 8.6.1 and 8.5 require that rated ceiling assemblies shall be continuous. Specifically, stairwell doors did not have labels indicating a 1-hour fire resistance rating, did not self-close, and did not have a latch. And rated ceiling assemblies were not continuous. This is evidenced as follows. The basement level stairwell doors were inspected on 04/03/2019 at 12:00 PM. The doors were not labeled fire door assemblies, the inactive leaf doors did not self-close and seat to the door frame and did not have a latch or other fastening device. The Director of Maintenance stated in an interview conducted on 04/03/2019 at 12:00 PM that he does not know why the stairwell doors did not have the labels indicating the fire rating, will adjust the self-closing mechanisms, and will contact a vendor to install latching. The rated ceiling assembly was inspected on 04/05/2019 at 4:45 PM. One large 4-foot by 4-foot penetration, open between the basement storage area and the main floor was observed. The Administrator stated in an interview on 04/05/2019 at 4:45 PM that the service elevator is not used and will be removed; the opening in the rated ceiling will be sealed as per the rating of the ceiling assembly. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1.1, 8.3.3.1, Table 8.3.4.1, 7.2.1, 8.6.1, 8.6.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.

Plan of Correction: ApprovedApril 26, 2019

K311 Plan of Correction
CORRECTIVE ACTION FOR AFFECTED RESIDENTS:
- The door are to be inspected and labeled by an outside service vendor that has the ability to determine and label such doors. A self closing and latching apparatus was added to the door and tested to assure proper working function. The penetration and area are to be sealed according to the standards and guidelines set forth in the NFPA guidelines, will all materials and methods being approved materials and methods prior to sealing.
IDENTIFY OTHER POTENTIAL RESIDENTS
- All other areas of the Facilities single vertical opening were checked with no negative items found.
SYSTEMIC CHANGES
- Auditing fire doors for self closing and latching and condition of label will be made a part of the routine Monthly Maintenance Checks to assure proper condition. Any negative findings will be brought to Administration for immediate correction.
QUALITY ASSURANCE
- The Director of Maintenance (or designee) will audit these areas and doors monthly for 3 months to assure all are in proper working order and have the proper labeling. All findings will be reported to the QA committee with all negative findings being immediately reported to Administration and the QA team for immediate correction.
PERSON RESPONSIBLE
- Director of Maintenance