Humboldt House Rehabilitation and Nursing Center
June 21, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: (a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a complaint investigaton (Complaint #NY 144) during the Standard survey completed 6/21/17, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene. One (Resident #211) of four residents observed for grooming who are dependent on staff for ADLs had greasy, dirty hair and did not receive staff assistance with showers. 1. Resident #211 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident has severe cognitive impairment, understands and is understood. Further review of the MDS revealed there was no documentation of behavioral symptoms. The MDS documented that the resident requires the extensive assistance of one person for personal hygiene, dressing and toileting and physical assistance of one person for bathing. Review of the Comprehensive Care Plan revised 1/14/17 revealed the resident has an activity of daily living (ADL) self-care performance deficit and requires extensive assistance of one staff for bathing and showering. Review of an undated CNA (certified nurse aide) Kardex (used by staff to provide care) revealed the resident required extensive assistance of one staff for bathing/ showering. The CNA Kardex did not include a plan for the frequency or day of the resident's showers. Review of an untitled and undated Third Floor Master Shower List revealed the day and shift for residents' showers listed by each resident's room and bed assignment. Resident #211's room and bed number were included on the Master Shower List. Review of the (MONTH) (YEAR) Weekly Bath Verification Sheets revealed a CNA signed for providing Resident #211 a bath on three of four Tuesday evenings and a nurse signed that the baths were provided. Review of the (MONTH) (YEAR) Weekly Bath Verification Sheets revealed residents' names were no longer listed on the sheets. The Weekly Bath Verification Sheets only listed a room and bed number and Resident #211's room was no longer included on the sheets. Review of all available Third Floor Daily Assignment Sheets for the day and evening shifts from 6/1/17 through 6/16/16, 7:00 AM to 3:00 PM revealed that bath or shower for Resident #221 's room was not listed on the assignments. Observation of Resident #211 in the dining room while he was eating lunch on 6/14/17 at 12:26 PM revealed his hair was greasy and clumped. During an interview with the Registered Nurse (RN #2) Unit Coordinator on 6/16/17 at approximately 9:50 AM revealed that a license practical nurse (LPN) will complete the Daily Assignment Sheet at the beginning of each shift and include the residents who are scheduled for a shower on that shift in the CNA assignment. The LPN will use the Weekly Bath Verification sheet to identify the showers that are scheduled on that shift's assignment. During an interview with LPN #1 and the Third Floor Unit Secretary on 6/16/17 at approximately 10:00 AM, LPN #1 stated that the CNA is to sign the Weekly Bath Verification sheet when they provided a resident with a bath or shower. LPN #1 further stated that the CNA will occasionally include any additional showers they completed on their shift on the Daily Assignment Sheet. LPN #1 did not know why Resident #211's room was not included on the Weekly Bath Verification sheets. The Third Floor Unit Secretary stated that she recently revised the Master Shower List and must have deleted the resident's room and bed assignment when she updated the list. The Unit Secretary further stated that the Master Shower List is used to develop the Weekly Bath Verification sheets. Review of a policy and procedure entitled Shower/ Tub/ Bath dated 10/10 revealed the following information should be recorded on the resident's ADL record and/ or in the resident medical record: 1. The date and time the shower/ tub bath was performed. 2. The name and title of the individual who assisted the resident with the shower. 3. All assessment data any reddened areas, sores, etc. on the skin. 4. How the resident tolerated the bath/ shower. 5. If the resident refused and the reason why and the intervention taken. 6. The signature and title of the person recording the data. 415.12(a)(3)

Plan of Correction: ApprovedJuly 25, 2017

Resident #211
? The resident was given shower.
? The master shower sheet was updated to add resident.

To identify other residents who may be affected by this deficiency:
? All units Master Shower list have been audited by Nurse Manager to ensure every resident/room/bed is accounted for. All shower schedules verified with weekly check in EMR. Weekly shower sheet were verified in the EMR to ensure Residents are receiving showers as scheduled
Visual inspections of all Residents performed by the Team Leader to ensure cleanliness post shower.
To ensure these deficient practices do not recur, the following measures will be completed:
? The facility Policy & Procedure Showers will be reviewed and revised by the DON, ADON and Administrator.

? The DON/Designee will educate CNAs and Nurses on the new weekly LPN skin sheet, master shower sheet and revised Shower policy.
? DON/designee will audit weekly (x4) then monthly (x3) the Weekly LPN skin check sheets for shower completion documentation and a visual check/interview that confirms that resident received shower.
? DON/designee with audit Master Shower sheet monthly until 100 % accurate x 3 consecutive months ensuring all residents are included on master sheet.

How the corrective action will be monitored to ensure the deficiency does not recur:
? The DON will report monthly to the facility QAPI committee the results of the LPN skin check audits related to shower documentation and visual checks/interview that confirmed resident received shower x4 months. The QAPI committee will determine the need for continuation.
? Any identification of an ongoing issue will require immediate further education, process change and ongoing auditing as indicated.

The DON is responsible to ensure the P(NAME) is accomplished.


E3BP 402.7(a)(4):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (4) Where the criminal history information of a prospective employee reveals a charge for any felony, the Department shall hold the determination regarding a prospective employee's eligibility for employment in abeyance until the charge is finally resolved. Upon receipt of notification from the Department of the abeyance, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider before final resolution of the criminal charge.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 1, 2017

Citation Details

Based on interview and record review during the Standard survey completed on 6/21/17, the facility did not immediately remove employees from direct care or supervision of residents upon receipt of negative determination letters. This affected two (Employee #2 and Employee #3) of three employee files reviewed for Criminal History Record Check (CHRC) negative determination findings. The findings are: 1. Record review of the personnel file for Employee #3 (Dietary Aide) revealed Employee #3 received a Hold in Abeyance letter dated 9/15/16 from the New York State Department of Health Criminal History Record Check Legal Review Unit. Review of documentation from the facility's payroll records revealed Employee #3 worked 15 shifts after the Hold in Abeyance letter was issued, and his last date worked in the facility was 9/30/16. Interview with the Human Resources Assistant (Authorized Person) on 6/19/17 at approximately 10:35 AM revealed she checks the CHRC system daily when she is in the office and when she receives a negative determination letter, she immediately alerts the employee's Supervisor to have that employee taken off the schedule. Further interview revealed she was on vacation at the time of the negative determination letter for Employee #3, but she had arranged for the facility's backup Authorized Person to assume her CHRC duties while she was away. The Human Resources Assistant also stated this employee should not have worked after the date on the Hold in Abeyance letter. 2. Record review of the personnel file for Employee #2 (Certified Nurse Aide) revealed Employee #2 received a Hold in Abeyance letter dated 10/28/16 from the New York State Department of Health Criminal History Record Check Legal Review Unit. Review of documentation from the facility's payroll records revealed Employee #2 worked one shift after the Hold in Abeyance letter was issued, and her last date worked in the facility was 10/29/16. Additional review revealed Employee #2 also swiped in at the facility from 7:03 AM until 7:13 AM on 10/31/16 and from 7:02 AM until 7:08 AM on 11/2/16. Interview with the Human Resources Assistant (Authorized Person) on 6/19/17 at approximately 10:20 AM revealed she cannot explain the short work times recorded for Employee #2 on 10/31/16 and 11/2/16. Further interview revealed she cannot recall when she discovered the Hold in Abeyance letter for Employee #2. The Human Resources Assistant also stated she thinks she sent an email immediately to the Nursing Supervisor advising them that Employee #2 could no longer work, but she cannot locate the email. Review of the facility policy entitled Section 117 - Employment Criminal History Record Checks, revised 5/5/16, revealed upon receipt of a Hold in Abeyance letter, the facility will meet with the employee and determine whether to terminate the employee. The policy further states the Department of Health will afford the employee an opportunity to explain in writing within 30 calendar days from the date of notification why the employee's eligibility should not be disapproved. Interview with the Human Resources Assistant (Authorized Person) on 6/20/17 at approximately 12:20 PM revealed this policy should more clearly say that upon receipt of a Hold in Abeyance letter, the employee must be immediately removed from the schedule. 402.7(a)(4)

Plan of Correction: ApprovedJuly 24, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Employee #2 and #3 no longer works at the facility.

How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All negative CHRC checks received in the last 6 months reviewed for timeliness and follow through. Any lapse of follow though evaluated and determination of reason for lack of follow though documented.
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 for CHRC checks/ backup procedure reviewed and revised as needed. Both Facility?s Primary and Back Up CHRC Authorized Personnel educated on New York State Department of Legal Criminal Record Check Procedures and facility procedure. Departmental Supervisors educated on facility policy and importance of follow through and removal of employee immediately upon notification.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur:
ALL NEG CHRC checks will be reviewed daily. Monthly audits will be conducted for six employee charts to ensure there is no negative findings and appropriate action was taken. Administrator or designee will be notified of negative check and follow through daily.
The results of the Monthly audit will be discussed at the facility's monthly QAPI meeting for appropriate follow-up as warranted.

The date for correction and the title of the person responsible for correction of each deficiency:

Responsible Party: Assistant Administrator


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

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 9, 2017

Citation Details

Based on observation, interview, and record review conducted during the Standard survey completed 6/21/17, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. One (Unit 3) of three dining rooms observed for dignity during dining had issues involving residents sitting at one table who were not served at the same time and staff standing while feeding a resident. Residents # 2, 16, 51, 73, 74, 100, 156, 178, 192, 199, 211, and 245 were involved. The findings are: 1. a.) Review of the Third Floor Seating Chart for meals revealed that Table 9 had four residents sitting at the table. Observation of lunch in the Unit 3 Dining Room on 6/14/17 from 12:36 PM to 1:05 PM revealed the following: - 12:36 PM - Resident #74 was served her lunch from the first meal cart. - 12:40 PM - The second resident (#156) was served her meal tray from the second meal cart. - 12:47 PM - The third resident (#73) was served her tray from the third meal cart. - 12:52 PM - The fourth resident (#51) received her meal tray from the third meal cart. Review of the Third Floor Seating Chart revealed that Table 3 had four residents sitting at that table. Observations during lunch on 6/14/17 revealed the following: - 12:34 PM -The first two residents (# 199 and 178) received their trays from the first meal cart. - 12:53 PM - The last two residents (#245 and 16) were served their meal tray form the third meal cart. During the lunch meal on 6/14/17, an observation at approximately 12:57 AM revealed that Resident #100 at Table 4 was being assisted by a Certified Nurse Aide (CNA #1). the observation revealed that CNA stood while she was feeding the resident from 12:57 PM to 1:05 PM. CNA #1 stopped feeding the resident at approximately 1:05 PM and left the Dining Room area. Observation of the lunch meal in the Unit 3 Dining Room on 6/19/17 from 12:41 PM to 1:04 PM revealed Table 9 had three residents seated at the table. The observation revealed the following: - At approximately 12:41 PM, the first resident (#74) was served her tray. - At 12:51 PM, the second resident (#2) was sitting at the table waiting for his tray and stated Where is my tray, I am hungry? Why does she have her tray and I do not? At that time, a CNA was overheard to tell the resident that his tray was on a different cart and would be coming soon. Resident #2's tray was served at approximately 1:00 PM. - 1:04 PM - The third resident (#51) at Table 9 received her meal tray. In addition, the observation revealed that Table 5/6 (the two tables were put together) had two residents seated at that table. The observation revealed the following: - 12:51 PM - The first resident (#211) was served his tray. - 12:56 PM - The second resident (#192) at the table stated Everyone has their tray except me. Where is my tray? -1:00 PM - Resident #192 received her meal tray. During an interview on 6/19/17 at approximately 12:50 PM, a Licensed Practical Nurse (LPN #4) stated Many of the residents are not up and out in the dining room today because we only have three CNAs today. We normally have 5 or 6 CNAs on. That is why meal tray passing is so slow today. During an interview on 6/19/17 at approximately 1:07 PM, the Registered Dietitian (RD #2) stated Some of the residents may have preferred to eat in their rooms today for lunch and that may be why they are not in the dining room today. I do find this an issue that residents are not being served at the same time at each table. We have identified this issue and are currently working on it. I am working with the Food Service Director to get the trays and meal carts to coordinate better. We are currently working on our seating chart to match the way the trays come out of the carts. During an interview on 6/20/17 at 10:58 AM, CNA #1 stated I was standing when feeding Resident #100 because her head was down and I was trying to get her to eat. I know I should have been sitting down. During an interview on 6/20/17 at 10:59 AM, the Assistant Director of Nursing (ADON) stated Staff should be sitting down while assisting a resident with eating. During an interview on 6/20/17 at approximately 11:13 AM, the Unit 3 Registered Nurse (RN #2) Unit Manager stated Staff should be sitting while assisting a resident with eating. They definitely should not be standing. Review of a policy and procedure (P&P) entitled Quality of Life- Dignity dated (MONTH) 2009 revealed that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Review of a P&P entitled Assistance with Meals dated (MONTH) 2013 revealed residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals. 415.5(a)

Plan of Correction: ApprovedJuly 25, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Third floor seating chart and tray order was redone to ensure residents sitting at the same table would receive their trays simultaneously- 7/9/2017
Director-of-Nursing
CNA 1 was rein-serviced on sitting down while feeding residents to support and promote resident dignity 6/14/2017
Director-of-Nursing
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents residing in the facility will be monitored daily from the date of this exit survey until the date of the submission of this plan of correction by nursing managers/supervisors to ensure residents residing at the same table receive their trays simultaneously and all staff are sitting while feeding residents.
Director-of-Nursing
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All full/part-time nursing staff was rein-serviced on resident rights and dignity to include, ensuring residents receive meal trays simultaneously when sitting at the same table. Ensuring staff are sitting when feeding residents to support and promote resident dignity 7/20/2017
Director-of-Nursing
All full/part time nursing staff was rein-serviced on the policy/procedure of Assistance with Meals 7/20/2017
Director-of-Nursing or designee
How the corrective action(s) will be monitored to ensure the deficient practice will not recur:
The IDT team will complete weekly audits x 9 weeks during all meals including weekends to ensure residents at the same table receive their trays simultaneously 10/20/17
Administrator
The IDT team will complete weekly audits x 9 weeks during all meals including weekends to ensure staff are feeding residents while sitting 10/20/17

Results of all audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The date for correction and the title of the person responsible for correction of each deficiency:
Administrator is ultimately responsible to ensure that the total P(NAME) for this tag is accomplished.

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 9, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/21/17, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date when applicable. One (Fourth Floor Team 2) of four medication carts observed for medication storage had issues involving an undated Advair Diskus (medication to control symptoms of wheezing and shortness of breath) (#60) and an undated Incruse Ellipta (inhaled medication to treat airflow obstruction) inhaler (#80). The findings are: 1. Resident #60 has [DIAGNOSES REDACTED]. Review of the Medication Review Report printed 6/20/17 revealed an order for [REDACTED]. Observation of the Fourth Floor Team 2 medication cart on 6/20/17 at 9:45 AM revealed an opened, used Advair Diskus labeled for Resident #60 with 24 doses remaining. Observation of the Advair Diskus revealed it was not labeled with an open and/or use-by date. During an interview at the time of the observation on 6/20/17 at 9:46 AM, the Licensed Practical Nurse (LPN #3) stated that she knew they (the inhalers) had to be labeled, this is not her usual floor. The LPN then proceeded to label the Advair discus and box with a date of 6/12/17. When asked if the LPN knew when the discus was opened, the LPN stated no, I'm just counting back the days by the doses left to give. When asked if the LPN knew the delivery date of the inhaler, the LPN looked on the box the inhaler was in and stated I think it's this one and pointed to the date 3/27/17. During an interview on 6/21/17 at 8:30 AM, the Pharmacy Consultant stated Advair is only good for 30 days from when it's opened and it should have been used up based on the delivery date if it was opened right away. 2. Resident #80 has [DIAGNOSES REDACTED]. Review of the Medication Review Report printed 6/20/17 revealed an order for [REDACTED]. Observation of the Fourth Floor Team 2 medication cart on 6/20/17 at 9:45 AM revealed an opened, used Incruse/ Ellipta inhaler labeled for Resident #80 with eight doses remaining. The Incruse/ Ellipta inhaler was not labeled with an open and/or use-by date. During an interview on 6/20/17 at 9:46 AM, LPN #3 stated she knew they (the inhalers) had to be labeled, this is not her usual floor. When asked about the delivery date for the Incruse/Ellipta inhaler, the LPN pointed to the date 4/29/17 located on the pharmacy label. During an interview on 6/21/17 at 8:30 AM, the Pharmacy Consultant was asked about the Incruse/ Ellipta inhaler. The Pharmacy Consultant stated that she believes it's the same amount of time as the Advair when asked if the inhaler should be labeled when opened. During an interview on 6/20/17 at 9:55 AM, the RN RCC #3 stated Yes, I don't have a steady nurse on that side when asked if the inhalers should be labeled when opened. Review of Full Prescribing Information from the manufacturer of the Incruse/ Ellipta inhaler dated (YEAR) revealed instructions to discard the inhaler 6 weeks after opening the foil tray or when the counter reads 0, whichever comes first. 415.18(d)

Plan of Correction: ApprovedJuly 24, 2017

Resident # 60
? LPN #3 was educated on dating inhalers.
? Inhaler was reordered and replaced.
Resident # 80
? LPN #3 was educated on dating inhalers.
? Inhaler was reordered and replaced.
To identify other residents who may be affected by this deficiency:
? Night Shift Supervisor/designee completes a 100% audit on all residents receiving medications to ensure labeling of drug and biologicals accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Audit from date of survey exit until P(NAME) submitted.
To insure these deficient practices do not recur, the following measures will be completed:
? DON/Designee will educate all Nurses on the requirement to date drugs and biologicals. Drugs and biological used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
? Nurse Manager/Nursing Supervisor will complete weekly (x4) then monthly (x3) audits ensuring date opened is present and it has not exceeded the recommended expiration date after opening on necessary medications.
How the corrective action will be monitored to ensure the deficiency does not recur:
? Any identification of an ongoing issue will require immediate further education, process change and ongoing auditing as indicated.
? Nurse Manager/Nursing Supervisor will complete weekly (x4) then monthly (x3) medication date audits ensuring date opened is present and it has not exceeded the recommended expiration date after opening.
The DON will report monthly to the facility QAPI committee the results of the weekly (x4) then monthly (x3) Drug and Biologicals audits. The QAPI committee will determine the need for continuation.

The Director-of-Nursing will be responsible for ensuring the corrective action is implemented.

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 1, 2017

Citation Details

Based on observation, interview, and record review during the Standard survey completed on 6/21/17, the facility did not properly store, prepare, distribute and serve food under sanitary conditions. One of one Main Kitchen, one (Second Floor) of three Kitchenettes, and one of one Dish Washing Room had issues including unlabeled, undated food containers; food contact surfaces that were not maintained in a clean condition or in good repair; and wall fans and ceiling not maintained in a clean condition. The findings are: 1. a.) Observation of the Main Kitchen on 6/14/17 from approximately 8:30 AM to 8:55 AM revealed the following refrigerated food items were outdated or undated: - Approximately one pound of seasoned ground beef in a clear plastic bin was labeled 6/8 - Three plastic pitchers of milkshakes, each three to six cups had no date - Approximately six cups of spaghetti sauce in a clear plastic bin had no date - Approximately one-half pound of deli turkey in clear plastic wrap had no date - Seven individual poured cups of milk had no date Interview with the Food Service Director at the time of the observation revealed the seasoned ground beef was just made yesterday, but the label was not changed; the milkshakes were made today, but her staff forgot to label them; and the spaghetti sauce was made yesterday. Review of a facility policy entitled Food Storage Policy dated 9/06 revealed opened/ cooked products in refrigerated storage must be labeled and dated and discarded after three days of refrigeration. b.) Additional observation of the Main Kitchen on 6/14/17 from approximately 8:30 AM to 8:55 AM revealed: - A blue plastic ice scoop holder was soiled on the interior with a gray substance and was being used to store a clean ice scoop - a bench style can opener blade was soiled with food debris and the area behind the blade was filled with metal shavings - A drawer containing clean ladles was soiled on the interior with food debris - Six of seven in-use bright green, plastic food container lids located in the two-door cooler were cracked and broken 2. Observations of the Second Floor Kitchenette refrigerator on 6/14/17 at approximately 8:45 AM and 6/19/17 at approximately 3:37 PM revealed a half-eaten pickle was wrapped in clear plastic wrap with no label or date. Interview with a Licensed Practical Nurse (LPN) at the time of the second observation revealed the pickle must belong to a resident because staff are not allowed to keep their food in this cooler. Additional interview revealed all food items should be labeled with a resident name and date. 3. Observation of the Dish Washing Room on 6/14/17 at approximately 9:00 AM revealed two of two in-use wall fans were dust laden and two of two sprinkler head cages were dust laden. Additional observation revealed the ceiling tile grid work had several areas of dust accumulation and food or liquid splatter. 483.35(i)(2), 415.14(h) 14-1.90, 14-1.110(e), 14-1.171

Plan of Correction: ApprovedJuly 24, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:

The seasoned ground beef was discarded- 6/14/2017
Dietary Director
The three plastic pitchers of milkshakes were discarded 6/14/2017
Dietary Director
The six cups of spaghetti sauce was discarded 6/14/2017
Dietary Director
The one-half pound of deli-turkey was discarded 6/14/2017
Dietary Director
The seven individual poured cups of milk were discarded 6/14/2017
Dietary Director
The blue ice scoop holder was immediately cleaned 6/14/2017
Dietary Director
The bench style can opener was cleaned and the metal shavings removed 6/14/2017
Dietary Director
The drawer containing the clean ladles was cleaned of all food debris 6/14/2017.
Dietary Director
The bright green, plastic food container lids were replaced 6/14/2017.
Dietary Director
The pickle was discarded on 6/19/2017.
Nurse Manager
The two in-use wall fans were immediately cleaned and dust removed 6/14/2017
Maintenance Director
The two sprinkler heads were cleaned and dust removed 6/14/2017
Maintenance Director
The ceiling tile grid work was cleaned and dust removed 6/14/2017.
Maintenance Director
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
100 percent audit was conducted in the main kitchen to ensure all refrigerated items were properly labeled and dated 6/14/2017
Dietary Director
100 percent audit was conducted in the main kitchen and dish-room to ensure all items, equipment and utensils were clean and free from debris and dust 6/14/2017
100 percent audit was conducted in all kitchenette areas with a refrigerator to ensure all food items were labeled and dated 6/19/2017
Dietary Director

What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
The Dietary Director was rein-serviced on the Food Storage Policy 6/16/2017
Administrator
All full and part-time dietary staff will be rein-serviced on the Food Storage Policy 7/20/2017
All full and part-time dietary staff will be rein-serviced on the departmental cleaning schedule to include the main kitchen and dish-room 7/20/2017
Dietary Director
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
The Dietary Director was rein-serviced on the Food Storage Policy 6/16/2017
Administrator
All full and part-time dietary staff will be rein-serviced on the Food Storage Policy 7/20/2017
All full and part-time dietary staff will be rein-serviced on the departmental cleaning schedule to include the main kitchen and dish-room 7/20/2017
Dietary Director
How the corrective action(s) will be monitored to ensure the deficient practice will not recur:
Weekly audits will be conducted in the main kitchen x 8 weeks to ensure all refrigerated items are properly labeled and dated 8/1/2017
Administrator
Weekly audits will be conducted in the main kitchen x 8 weeks to ensure all equipment are clean and in good repair 08/1/2017
Administrator
Weekly audits will be conducted in the dish-room to ensure all equipment is clean and free of dust 08/1/2017
Administrator or designee
Weekly audits will be conducted x 8 weeks in all the kitchenette areas to ensure all refrigerated items are labeled and dated correctly. 09/20/2017
Administrator
Results of the audits will be forward to the facility monthly QAPI committee all concerns will have appropriate follow-up and further action as indicated.
Administrator
The date for correction and the title of the person responsible for correction of each deficiency:
The Administrator will ensure that the total P(NAME) for this tag is accomplished

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 9, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/21/17, the facility did not ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #164) of five residents reviewed for accidents had issues that involved a certified nurse aide (CNA) leaving the resident's bed in high position while leaving the room to obtain supplies. The finding is: 1. Resident #164 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 4/19/17 revealed the resident has severe cognitive impairment. Review of Progress Notes dated 1/14/17 through 6/20/17 revealed the resident was found on the floor on 2/3/17 and 2/8/17. Interventions put into place after the incidents were a floor mat next to the bed and a scoop mattress Review of the CNA Kardex (used by staff to provide care) dated 6/16/17 revealed approaches for the resident to have a floor mat on the left side of the bed, staff to check every 1.5 hours and as required for incontinence, keep call bell in reach, and respond to call light promptly. Review of the Comprehensive Care Plan (CCP) last revised 6/16/17 and Progress Notes dated 1/14/17 to 6/16/17 revealed the resident was found on the floor on his room on 1/14/17, 2/3/17, 2/6/17, 5/3/17, 5/29/17, and 6/16/17. CCP interventions include obtaining a physical therapy consult, early get up in the AM, a floor mat in the left side of the bed, and offer toileting on last rounds on the 11:00 PM to 7:00 AM shift. On 6/16/17 at 7:35 AM, the resident was observed to be on his knees on the floor mat next to his bed with his upper body and arms on the mattress. A Licensed Practical Nurse (LPN) and the Registered Nurse (RN #3) Resident Care Coordinator (RCC) were observed to go into the resident's room at 7:36 AM. During an observation of morning care on 6/16/17 at 7:49 AM, the resident was lying in bed with his eyes closed. CNA #2 was observed to elevate the bed and the top of the mattress was approximately 3 1/2 feet from the floor. The CNA stated she had to go and get soap and left the room at 7:50 AM. The CNA did not lower the bed before she left the room. At 7:54 AM, the CNA returned to the room with the RN (#3) RCC to complete morning care. During an interview on 6/16/17 at 8:22 AM, CNA #2 stated I normally put the bed in the low position when I leave the room but I was nervous. When asked if the CNA knew that the resident was found kneeling at side of bed this morning, the CNA stated I didn't know about that. During an interview on 6/16/17 at 10:23 AM, the RN (#3) RCC stated she left the bed up in high position and it should have been lower. The RN RCC stated that for falls, the resident has a scoop mattress, they check on him every hour and a half, he is care planned as an early morning get up but some days he wants to sleep. So today I updated the Care Plan so the resident is seen last on the 11:00 PM to 7:00 AM shift rounds for toileting. 415.12(h)(1)(2)

Plan of Correction: ApprovedJuly 25, 2017

Resident # 164
? The CNA and LPN were educated on resident safety while in bed specifically keeping bed in a low position when leaving the room.

To identify other residents who may be affected by this deficiency:
? DON/Designee will have 6 CNAs/ 6 lpn's from various units (to include each shift) complete a short questionnaire on resident safety while in bed specifically keeping bed in a low position when leaving the room to evaluate staff level of education needed.

To ensure these deficient practices do not recur, the following measures will be completed:
? DON will review the CNA/LPN questionnaires in preparation of education agenda.
? DON/Designee will educate all CNAs on resident safety while in bed specifically keeping bed in a low position when leaving the room.
? Nurse Manager/Nursing Supervisor will complete random weekly (x4) then monthly (x3) bed safety audits on all shifts during resident care on 5 residents per unit.


How the corrective action will be monitored to ensure the deficiency does not recur:
? The DON will report monthly to the facility QAPI committee the results of the bed safety x4 months. The QAPI committee will determine the need for continuation.
? Any identification of an ongoing issue will require immediate further education, process change and ongoing auditing as indicated.
The DON will ensure that the P(NAME) is accomplished.

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: (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- (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; (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: June 21, 2017
Corrected date: August 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation (Complaint #NY 274) during the Standard survey completed on 6/21/17, the facility did not ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. One (Resident #111) of three residents reviewed for nutrition had issues including the lack of timely nutritional interventions to address significant weight loss and a lack of complete documentation of the resident's actual meal consumption. The finding is: 1. Resident #111 was admitted on [DATE] for subacute rehabilitation with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/26/17 revealed the resident has severe cognitive impairment. a.) Review of an admission Nutritional Screening/ assessment dated [DATE] revealed the resident was independent with self-feeding and received a Carbohydrate Consistent Diet. The Assessment documented that the resident's usual body weight was 165 to 170 pounds (#), current weight pending, nutritional needs were based on the hospital discharge weight of 168#, and no pedal (involving the feet)/lower extremity [MEDICAL CONDITION] (swelling caused by fluid accumulation) was noted. Review of the resident's Weight Summary Sheet revealed the next weight was documented on 12/15/16 and reflected a significant weight decline to 156.6#. Review of a Quarterly Nutritional Progress Note dated 12/29/16 revealed the resident's current weight was 156.6# (12/15/16) and no other weights to compare any changes. Additional review of the Quarterly Nutritional Progress Noted revealed there was no documented evidence that meal plan changes were made following the weight loss until 2/10/17. Review of a Dietary Progress Note dated 2/10/17 revealed the resident's spouse voiced concerns that the resident was not getting enough food at meals. The Dietary Progress Note recommended that the meal plan be changed to include double entree portions and mashed potatoes with gravy three times a week. Additional review of the resident's Weight Summary sheet revealed the next documented weight of 152.3# was obtained on 2/21/17. Interview with the Registered Dietitian (RD #1) on 6/15/17 at 11:05 AM revealed that 6/15/17 was her second day working at the facility. The RD stated she would expect weights to be done monthly. Interview with RD #2 on 6/15 at 11:10 AM revealed she has been working at the facility for two months and to her knowledge those are the only weights available for Resident #111. RD #2 stated Technically the resident should be weighed a minimum of monthly. The scales have been working fine. Review of a facility policy and procedure entitled Weights dated 7/11 revealed all residents are weighed upon admission, re-admission, and monthly thereafter to establish weight pattern and monitor for changes. b.) Review of the Meal/ Fluid Logs dated 1/29/17 to 2/22/17 revealed there was a lack of documentation of meal consumption for 24 of 75 meals. Interview with the Registered Nurse (RN #1) Resident Care Coordinator (RCC) on 6/20/17 at 12:30 PM revealed the nurses are responsible to assure the meal consumption sheets are completed. The RN RCC stated It's been a problem, we are working on it. 415.12(i)(1)

Plan of Correction: ApprovedJuly 25, 2017

The facility will ensure that residents will maintain acceptable parameters of nutritional status and will ensure therapeutic diets when needed and ordered.
Resident # 111- no longer resides in the facility. The closed chart was reviewed by the DON and RD to identify issues involving nutritional status, interventions and lack of documentation.


To identify other residents who may be affected by this deficiency:
-The weight records of all residents residing in the facility at the time of the survey exit until this P(NAME) submission will be reviewed by the RD staff to determine if any other residents may have been affected. Any issues involving lack of weights being completed, weight loss requiring nutritional intervention will be addressed immediately by the dietitian.
- the meal consumption sheets of all residents residing in the facility at the time of survey exit and submission of this P(NAME) will be reviewed by DON and designees along with clinical nutrition to evaluate any residents requiring further intervention.
To insure these deficient practices do not recur, the following measures will be completed:
-The dietitians will be in serviced by the Administrator of the need to notify the DON and administrator if the nursing staff does not complete weights timely.
-The facility Policy & Procedure for weight loss, nutritional interventions for weight loss, meal consumption, and completion of weights, will be reviewed by the, DON, Dietitian and Administrator.
-A Quality Assurance team member will provide education to the facility Dieticians to include review of facility policies and procedures regarding timely nutritional intervention for weight loss, and the mechanism for reporting to administration any weights that have not been obtained.
-Facility Dietician will provide mandatory inservice to the Nursing staff with regard to the timeliness of weights and documentation of meal consumption.
- The unit managers will be educated by DON on their responsibility in reviewing the meal consumptions sheets on a daily basis. The meal consumptions will be brought to the facility am meeting daily (Mon-Fri) for the next 3 months to ensure completion. The DON or designee will be responsible to ensure completion and ongoing follow up to the staff members who do not complete per the facility policy.
-The facility has established a nutrition/hydration QAPI subcommittee that will meet weekly, residents with Identified weight loss and the nutritional intervention implemented will be reviewed.
How the corrective action will be monitored to ensure the deficiency does not recur:
-The minutes of the weekly skin/hydration committee meeting will be presented to the QAPI committee by the RD monthly x 6 months; the QAPI committee will make further recommendations for further process change as indicated. RD is responsible
- The RD will report monthly to the facility QAPI committee all identified weight losses and the timely implementation of nutritional interventions
- The RD will complete monthly audits of the meal consumption sheets and report those finding to the QAPI committee monthly x 3 months. Any identification of an ongoing issue will require immediate further education, process change and ongoing auditing as indicated.
The Director-of-Nursing will ensure corrective action is implemented for P(NAME).

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 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, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 9, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/21/17, the facility did not provide the necessary care and services to attain and maintain the resident's highest practicable well-being. Specifically, one (Resident #221) of one resident reviewed for non pressure related skin conditions did not have a comprehensive initial and ongoing nursing assessments of an open area on the right lower leg by a registered professional nurse. In addition, there was no evidence of physician's orders [REDACTED]. The finding is: 1. Resident #211 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimal Data Set (MDS - a resident assessment tool) dated 4/21/17 revealed the resident has severe cognitive impairment, understands and is understood. The resident did not have any identified skin problems including skin tears. During an observation of the resident's shower on 6/16/17 at 10:41 AM, the resident was sitting in a shower chair as the Licensed Practical Nurse (LPN #6) dried the resident's body using a towel. The observation revealed there was an open area on the mid anterior area of the right lower leg that was approximately 1.5 centimeter (cm) wide by 3.0 cm long and less than 1.0 millimeter in depth. The open area was red in color with a small amount of brown crusting around the edges. LPN #6 stated she was not aware of the open area on the resident's right leg and would inform LPN #1 who was the assigned medication/ treatment nurse. Review of the Clinical physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of the current Comprehensive Care Plan (CCP) revealed the resident was identified with potential for impairment to skin integrity related to decreased mobility (8/5/16). The CCP goal, revised 1/14/17, documented that the resident will maintain clean and intact skin. There was no identification of an affected area of skin integrity or of an intervention for a wound care treatment for [REDACTED]. Review of the Progress Notes, revealed an Incident Note written by a Registered Nurse (RN #4) dated 2/4/17 documented that the resident scratched his right shin causing it to bleed. The RN documented that the area was cleansed with normal saline solution, TAO (triple antibiotic ointment) was applied, the area was covered with a dry dressing and the Physician was informed. There was no measurement or description of the affected area. Further review of the Progress Notes revealed the following skin/ wound notes: - 4/19/17 at 11:30 PM - An LPN documented Resident right shin area - no drainage, starting to scab, area pink, no s/s (signs/symptoms) infection, area healing. - 6/12/17 1:38 AM - LPN #7 documented cleanse left shin area with NS, apply house ABT ointment and DCD, every evening shift for re-opened scab until closed. Review of the TAR's from 3/1/17 through 6/15/17 revealed documentation that a left shin area was cleansed with NS, house ABT ointment was applied and the area was covered with a DCD each evening, except for 15 evenings where there was no documentation that the treatment was completed. Further review of the TAR's revealed instructions for weekly skin monitoring to be completed Wednesday mornings for skin integrity with instructions for the nurse to document in the Assessment tab. A nurse signed off for completion of the task for 12 of 16 weeks from 3/1/17 through 6/15/17. Review of the Weekly LPN Skin Check documented in the Assessment Section of the medical record revealed two documented skin checks were completed on 1/10/17 and 3/21/17. LPNs #8 and 3 documented no new skin issues identified on both skin checks. During an interview on 6/16/17 at 11:53 AM, the RN Assistant Director of Nursing (ADON) stated she was not aware that the resident had an open area on the right lower leg. The ADON further stated that the resident picks at his skin and nursing staff will put TAO on areas of the skin that the resident has picked at. During further interview on 6/16/17 at 12:01 PM, the ADON stated that an RN assessment of the open area should be completed weekly by herself or the wound care team that includes the ADON and a Nurse Practitioner. The ADON stated that weekly RN assessments of the resident's wound were not completed. The ADON further stated that the LPN should report any open areas to Unit Manager for an initial assessment, the ADON will follow up on weekly wound rounds, and this was not done for Resident #211. During an interview on 6/16/17 at 12:25 PM, LPN #1 stated that Resident #211 has an open area on the right shin. LPN #1 stated that she thought that only pressure ulcers needed to be measured and she was not aware that all open areas on the skin require an RN assessment and measurement of the area. In addition, LPN #1 stated that when the LPN signs off for the weekly skin check on the TAR, the nurse should be completing the Weekly LPN Skin Check in the Assessment Section of the medical record. Review of a facility policy and procedure entitled Wound Care dated 10/10 revealed the following information should be recorded in the resident's medical record: All assessment data (i.e. (that means) wound bed color, size, drainage, etc) obtained when inspecting the wound. 415.12

Plan of Correction: ApprovedJuly 25, 2017

The facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental and psycho-social well being consistent with resident?s comprehensive assessment and plan of care.
Resident # 221
-The resident?s medical record was reviewed by the DON and a comprehensive skin assessment has been completed by an RN. Resident #221 care-plan was updated to reflect current skin issue.
-The resident remains in the facility and skin is intact
To identify other residents who may be affected by this deficiency:
-RN comprehensive skin assessment of residents residing in the facility from the date of his survey exit until the date of the submission of this plan of correction will be completed. Any residents identified with skin issues the residents medical record will be reviewed to ensure there is an appropriate MD order, treatment is in place, the treatments are being completed per order, and that there is an updated measurement by an RN.
-The care plans and TARS of all residents with wounds will be updated as indicated.
To ensure these deficient practices do not recur, the following measures will be completed:
-the facility wound care Policy & Procedures (this covers all wound types) will be reviewed and revised if indicated.
-Licensed Nurses involved in failing to complete assessments of wounds, obtain MD orders and complete the treatments and weekly skin check will be in serviced and counseled.
-A mandatory in-service will be presented by a facility RN QA team member to all Licensed nurses. This in-service will review Wound Care Policies & Procedure, including the documentation required on the RN assessment , measurement and documentation, maintaining the residents comprehensive care plan and the LPN weekly skin check. Also in serviced will be the required daily dashboard review of the EMAR by all licensed nurses to ensure completion of all treatments, and weekly skin checks.
- the DON or designee will run the EMR report daily that provides review of all orders written in 24 hours, all orders written will be verified by the DON or RN designee that the orders are on the TAR.
- The DON will ensure the EMR Dashboard indicating any skin checks not competed is reviewed daily by her or designee, along with the EMR report for treatments omitted will be reviewed daily.
- The DON or designee will audit all records of residents with any new or ongoing skin issues weekly to ensure that there is an RN assessment completed initially and on a weekly basis.
How the corrective action will be monitored to ensure the deficiency does not recur:
-weekly audits of 6 medical records 2 from each unit will be completed for residents with wounds, ensuring current orders are in place, wound sites are identified accurately, treatment sheets are correct, treatments are being completed, weekly RN notes are present, and that the weekly LPN skin check is completed. These audits will be complete by the DON or designee for nine months and then as directed by the QAPI committee.
-The DON will review the audits and report her analysis at the monthly QAPI meeting for the next 9 months to demonstrate the success of the plan or the need to provide additional education if needed.
-Remedial education will be given immediately if audit results demonstrate ongoing problems.
The Director-of-Nursing will ensure all corrective action is implemented.

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (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 (5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident?s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician?s, nurse?s, and other licensed professional?s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: June 21, 2017
Corrected date: August 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation (Complaint #NY 804) during the Standard survey completed 6/21/17, the facility did not maintain clinical records on each resident that were complete, accurately documented, and readily accessible. One (Residents #103) of 28 residents reviewed for accurate medical records had an issue involving incomplete documentation of the acceptance or refusal of meals and supplements for a resident with a significant weight change. The finding is: 1. Resident #103 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/19/17 revealed the resident is cognitively intact. Review of an Admission Nutritional Screening assessment dated [DATE] revealed the resident received a regular diet with pureed texture, regular consistency and received 8 ounces (oz) of milkshake (high calorie high protein supplement) at all meals. Review of a Quarterly Nutrition Progress Note dated 4/17/17 revealed the resident had a significant weight loss of 16.6# (pounds) in 60 days possibly related to poor intake. The plan was to provide 8 ounces (oz) of Glucerna (diabetic high protein supplement) at all meals and bedtime (HS) with recommendations for Gelatein 20 (high protein gelatin) at lunch and dinner. Review of the Meal/Fluid Intake Logs dated 1/29/17 through 4/27/17 revealed a lack of documentation of: meal consumption for 79 of 223 meals and supplement consumption for 202 of 223 meals. Interview with the Registered Dietitian (RD #1) on 6/15/17 at 11:05 AM revealed 6/15/17 was her second day working at the facility and she wasn't here during Resident #103's admission. The RD stated she would expect the consumption sheets to be filled out completely. Interview with RD #2 on 6/15 at 11:10 AM revealed she has only been working at the facility for two months. RD #2 stated it is the responsibility of nursing to fill out the consumption sheets. Interview with the Registered Nurse (RN #1) Resident Care Coordinator (RCC) on 6/20/17 at 12:30 PM revealed the nurses are responsible to ensure that the meal consumption sheets are completed. The RN RCC stated It's been a problem. We are working on it. Review of a facility policy and procedure entitled Meal/ Fluid Intake dated 9/2010 revealed nursing assistants will complete documentation of the Meal/ Fluid Intake log. The charge nurse will ensure its completion at the meal. 415.22(a)(1,2)

Plan of Correction: ApprovedJuly 25, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #103
Resident no longer resides at the facility. The resident's closed chart was reviewed by the DON and RD to identify issues concerning incomplete documentation, accessibility of records, documentation of meals and supplements.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Unit Managers, RD, reviewed all residents intake sheets from date of survey to ensure logs were completed .Any residents with significant weight loss and multiple, greater than 5 meals not documented in meal intake sheets had complete evaluation by RD with appropriate interventions implemented.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
The Meal/Fluid intake policy was reviewed.
All FT/PT Nursing staff was re-in serviced per policy.
All Nursing staff educated regarding importance of completing intake sheets after meals.
RN Unit Managers/Supervisors educated to check intake sheets prior to the end of meal service to ensure accuracy.
Expectation of meal consumption logs to be completed with each meal.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur:
Audit of all facility meal logs will be conducted every week x 8 weeks. Results of the audits will be presented to QAPI every month to ensure ongoing compliance. Further revisions will be implemented as indicated to ensure compliance.

The date for correction and the title of the person responsible for correction of each deficiency.
Responsible Party: Director-of-Nursing



FF10 483.10(j)(2)-(4):RIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES

REGULATION: (j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. (j)(3) The facility must make information on how to file a grievance or complaint available to the resident. (j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents? rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident?s grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident?s concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents? rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents? rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation (Complaint #NY 622) during the Standard survey completed on 6/21/17, the facility did not ensure that prompt efforts were made by the facility to resolve grievances that a resident or a resident's representative may have. Specifically, one (Resident #232) of two residents reviewed for grievances lacked documented evidence that allegations were thoroughly investigated, acted upon, and resolved. The finding is: 1. Resident #232 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/3/17 revealed the resident is cognitively intact, understands and is understood. Review of a Visual/ Bedside Kardex (guide used by staff to provide care) with a print date of 6/20/17 revealed that staff are to toilet and perform incontinent care Q2-3 H (every two to three hours) and PRN (as needed), and the resident requires limited assistance of one staff member for toileting. Additional review of the Kardex revealed the resident requires the extensive assistance of one staff member with showering and bed bathing as necessary and the resident prefers showers in the morning. Review of the current Comprehensive Care Plan (CCP) dated 3/24/17 revealed the resident requires extensive assistance of one staff member with showering and bed bathing as necessary. The CCP documented that the resident is incontinent of bowel and bladder at times and requires one extensive assist with care. a.) Review of an undated weekly Shower Schedule (identified as current by the Registered Nurse (RN #1) Resident Care Coordinator (RCC)) revealed the resident is scheduled to have a shower on Wednesdays during the day shift and Sundays during the evening shift. During interviews on 6/16/16 at 10:17 AM and on 6/21/17 at approximately 10:32 AM, the resident's primary contact (friend) stated that she and Resident #232 have reported multiple care related complaints to the facility. The primary contact stated that she received a letter that the issues would be investigated and that she would receive a report of the findings but she never did. The primary contact also stated that some of the concerns remain a problem; like Resident #232 getting a shower; assistance with toileting needs, and that some of the staff are rude. During an interview on 6/21/17 at approximately 4:35 PM, Resident #232 stated that she does not get showered as often as she would like and that she has to wait a long time for the staff to come after she rings the bell to help her to the bathroom. The resident also stated that some of the staff members are good and some are rude. The resident stated that she has complained about these things in the past and nothing ever seems to happen. Review of the Bath Verification Sheets revealed the following: - (MONTH) (YEAR) - The documentation revealed that the resident received one shower and two bed baths. - (MONTH) (YEAR) - Documentation revealed that the resident received three showers - (MONTH) (YEAR)- There was no documented evidence that any showers or bed baths were provided. During an interview on 6/20/17 at 3:41 PM, RN #1 stated that the resident is scheduled to have one shower a week on Wednesdays, and that she has never requested more. The RN stated that the CNAs document the showers that are given, are on the Bath Verification Sheets. The RN stated there were no additional Bath Verification Sheets. During an interview on 6/20/17 at approximately 3:42 PM, the Unit Clerk stated there were no additional Bath Verification Sheets. b.) Review of a Resident Complaint/ Grievances Form, completed by the Social Worker (SW), dated 4/4/17 revealed resident and friend very upset stating the certified nurse aide (CNA) did not provide personal care prior to taking Resident #232 to therapy. Resident requesting shower 2x (two times) per week. Administrative review revealed, final written warning to CNA, Resident to be showered 2X/ week, CNA not to care for resident. Additional review of the Resident Complaint/ Grievances Form revealed the signature lines indicating verbal and written notifications to the complainant were blank. Review of a Resident Complaint/ Grievances Form, completed by the Social Worker, dated 5/8/17 revealed the resident's friend (complainant) was very upset and verbalized multiple care concerns that included the following: - resident has not gotten a shower since 1st week of admission - call lights are not answered timely and CNAs refuse to toilet resident and tell her to just go in your brief - CNAs do not wear name tags and are rude and disrespectful Additional review of the Resident Complaint/ Grievances Form dated 5/8/17 revealed the resolution written by RN #1 documented that she spoke with the friend (complainant) on 5/10/17 and addressed every concern and changed care areas where applicable. The friend was satisfied with the corrections made regarding Resident #232's care. There was no documented Administrative review and the signature line indicating written notification was blank. Review of a Resident Complaint/ Grievances Form, completed by the Social Worker (SW), dated 6/6/17 revealed the resident and friend reported that on (MONTH) 27th on the 3:00 PM to 11:00 PM shift, the CNA dropped the residents cell phone three times and broke it. A description of the CNA was provided, and they reported that the CNA is always rude. Additionally, the issue was reported to the Nursing Supervisor but did not complete a report. The friend requested that she be reimbursed for the phone replacement fee. The Resident Complaint/ Grievances Form documented that a copy of the report was forwarded to the Administrator. Additional review of the Form revealed that on 6/20/17, the SW re-approached the friend to bring in the receipt for the replacement phone. There were no other documented actions taken. The verbal signature line was blank and there was no documented Administrative review. Review of Grievance/ Complaint/ Missing Property Monthly tracking logs revealed the following: - 4/3/17 - Complaint logged by the SW, lack of care; Outcome/ Resolution - provided number of Nursing Supervisor, there was no documented follow-up. - 4/4/17 - Complaint logged by SW, lack of care, putting on soiled clothing; Outcome/ Resolution - shower 2X week, there was no documented follow-up. - (MONTH) (YEAR) - revealed there were no complaints logged for Resident #232. - 6/7/17 - Complaint logged damaged cell phone and rude CNA, there was no documented outcome/ resolution, there was no documented follow-up. - 6/8/17 - Complaint logged phone disappeared, there was no documented outcome/ resolutions, and there was no documented follow-up. During an interview on 6/21/17 at approximately 8:25 AM, RN #1 stated that she was not aware of the complaint from 4/4/17 and that the resident was to have two showers a week. The RN stated that she thought that all the issues from the 5/8/17 complaint were resolved. The RN further stated that she knows who the CNA is from the 6/8/17 complaint and has written her up on multiple occasions. During an interview on 6/21/17 at 8:40 AM, the Administrator stated that that the SW is the Grievance Officer. The Administrator stated that he was aware of the phone being broken and they were working to get the phone reimbursed. However, he was not aware of the complaint in regards to the rude CNA. The Administrator stated that he did not have any additional investigations related to Resident #232. During an interview on 6/21/17 at approximately 8:44 AM, the SW stated that she initiates the majority of the complaint forms for the facility, and tries to at least get back verbally to the complainant. The SW stated the complaint dated 4/4/17 was reported to the nursing department but she could not recall who she spoke with. The SW added that she was not sure if there was a manager on the floor at that time. In regards to the 6/6/17 complaint, the SW stated the complainant could not identify the CNA by name. The SW stated we felt that we had addressed all the issues in the team meeting. The SW then stated, allow me to plead my case; we have had such a transition and we have not had any continuity in Administration. I feel that we have done our very best with the volume of complaints that we have been dealing with. The SW stated that she did not have any further investigations or information regarding Resident #232. During an interview on 6/21/17 at 9:15 AM, the Director of Strategic Planning and Development stated that she oversees the Administrators and that she even acted as the Administrator here for a short while. The expectation is that if a complaint is reported, there must be an investigation into all components of the complaint. The process is: that if a complaint comes in, a report of the complaint is documented on the grievance form, the complaint gets put into the log book to track, the complaint form is brought to the morning meeting and discussed, decisions are made as to what departments are involved and an investigation is to be started. The Director stated We try to come to an appropriate resolution, we document our investigation findings, and resolutions. We are to follow up with the complainant and document. Additionally, there needs to be an Administrative review. The Director of Strategic Planning and Development stated that the complaints for Resident #232 were not thoroughly investigated and acted on. We have a process but we did not maintain our process. In addition, there was no further information or investigations in regards to Resident #232. Review of an undated policy entitled Recommendation/ Complaint Guidelines revealed that all complaints will receive prompt attention from the Administrator and or the appropriate staff member. 415.3(c)(1)(i)

Plan of Correction: ApprovedJuly 25, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #232 was interviewed by the Social worker to obtain updated preferences to include showers. Resident currently receives 2 showers per week 7/12/2017
Director-of-Social Work
Resident interviewed regarding the incident on 4/3/2017 lack of care resident currently has no concerns regarding lack of care. Follow-up to be documented on grievance form.
Resident interviewed regarding the incident on 4/4/2017. Resident has no concerns regarding lack of care and receives showers twice per week. Follow-up documentation to be completed on grievance form.
CNA was verbally educated regarding incident on 6/7/2017. Phone was reimbursed by facility after receipt received. Follow-up documentation to be completed on grievance form.
Resident's primary contact was communicated with on 7/12/17, 7/17/2017 to review previous and outstanding grievances and plan. Primary contact in agreement with plan.
Phone was taken by resident's responsible party on 6/8/2017 due to damage. Follow-up documentation to be completed on grievance form.
Resident #232 was interviewed by Social Worker /Administrator regarding any outstanding grievances. The resident has no current concerns. 7/11/2017
Director of Social Work.

How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
100 percent audit will be conducted on monthly logs for the previous 60 days to ensure completion and appropriate follow-up.
5% of the resident's population will receive a weekly random audit to ensure resident complaints/grievances have been properly addressed, and documented with appropriate follow up.
All outstanding grievances from the date of survey exit until submission of this P(NAME) will be audited by the Administrator and the Director-of-Social Work to ensure completion and appropriate follow-up was conducted. 7/20/2017
Director of Social Work/Administrator
Facility grievance policy and procedure reviewed by Administrator revised as indicated
7/21/2017
100% review of unit shower schedules and all current residents to ensure each resident has a shower scheduled and receiving
8/1/2017
Administrator or designee and Social Work will attend approved resident council meetings to review grievance policy x three months 8/1/2017
All residents and/or responsible parties will receive a copy of the facility's complaint and grievance policy.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All full/part-time nursing staff were rein-serviced on completing and documenting resident?s showers per care-plan 7/20/2017
All full/part-time nursing staff were rein-serviced on residents rights and dignity to include appropriate interaction, statements, and conduct while providing care 7/20/2017
All social workers were rein-serviced on complaint/grievances policy to include completion of form, appropriate follow-up, investigatory process, missing property, and completion of monthly tracking log 7/11/2017
Administrator
All full/part-time nursing staff were rein-serviced on answering call-lights in a timely manner 7/20/2017.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur:
IDT members on all three shifts will conduct weekly audits x 3 months to ensure call lights are answered appropriately 10/20/17

Nursing admin will conduct weekly audits x 2 months to ensure residents are receiving showers according to care-plan/policy.
09/20/2017
Administrator
All complaints/grievances will be brought to the facility new QA sub committee by SW and will be reviewed on a daily basis until completely resolved by the Administrator.
Social Work will present to monthly QA committee the complete grievance logs for review and follow-up- ongoing
Director-of-Social Work
The date for correction and the title of the person responsible for correction of each deficiency:
Administrator

FF10 483.25(b)(2)(f)(g)(5)(h)(i)(j):TREATMENT/CARE FOR SPECIAL NEEDS

REGULATION: (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident?s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident?s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to ? prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident?s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents? goals and preferences, and 483.65 of this subpart. (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents? goals and preferences, to wear and be able to use the prosthetic device.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during complaint Investigations (Complaints # NY 622 and #NY 804) during the Standard survey completed on 6/21/17, the facility staff did not ensure that the residents receive proper treatment and care for respiratory and foot care. Two (Residents #5, 103) of two residents reviewed for specialized care had issues involving the lack of proper foot care and the lack of a physician's order for oxygen therapy. The findings are: 1. Resident #232 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/3/17 revealed the resident is cognitively intact, understands and is understood. Review of a Visual/ Bedside Kardex (guide used by staff to provide care) with a print date of 6/20/17 revealed the resident is ambulatory and requires the extensive assistance of one staff member for dressing. Further review of the Kardex revealed the resident required extensive assist of one staff member with showering and bed bathing as necessary. The Kardex documented that the resident prefers showers in the morning and skin should be monitored with daily care and weekly skin checks; report any changes to the Charge Nurse. Review of the current Comprehensive Care Plan (CCP) dated 3/24/17 revealed the resident requires extensive assist of one staff member with showering and bed bathing as necessary. In addition, the CCP documented that the resident has impaired circulation (revised on 6/11/17) with approaches to encourage proper fitting footwear and inspect feet daily for areas of rubbing or injury. Review of an Order Summary Report dated (MONTH) 21, (YEAR) revealed active orders to check capillary refill, toe mobility, color and temperature of the right foot every shift, apply TED stockings ([MEDICAL CONDITION] deterrent stockings - elastic stockings used to prevent blood clots) every morning and at bed time for [MEDICAL CONDITION] on in am and off at HS (hour of sleep), and obtain Podiatry consults as needed. Review of the Treatment Administration Records (TAR) dated 3/24/17 through 6/21/17 revealed the nurses initialed that skin checks and circulation checks were completed. Additional review of the TAR dated 6/1/17 through 6/21/17 revealed documentation that the TED stockings were being applied. Review of an undated weekly Shower Schedule (identified as current by the Registered Nurse (RN #1) Resident Care Coordinator (RCC)) revealed the resident is scheduled to have a shower on Wednesdays during the day shift and Sundays during the evening shift. During an interview on 6/21/17 at approximately 10:32 AM, the resident's primary contact (friend) stated Resident #232 had complained that her toes hurt and that her toe nails are long and need attention. The friend stated staff keep telling me that there is a podiatrist who comes into the facility, but the resident has not been seen. During an observation and interview on 6/21/17 at approximately 8:12 AM, the resident independently removed her slippers and socks. The resident's toe nails on both feet were observed to be thick. Some of the toe nails were cracked, three of the toe nails were long and curled over the top of her toes. The resident stated that her toe nails bother her. She went on to say, some of the nails get caught on her socks and bed covers. The resident stated that staff have not attempted to cut her toe nails and she has not been seen by a podiatrist. During a second observation of the resident on 6/21/17 at 8:16 AM, in the presence of the Registered Nurse (RN #1) Resident Care Coordinator, RN #1 stated there is a podiatrist that comes into the facility on a regular basis. RN #1 stated the resident has not seen by a podiatrist since she was admitted to the facility. RN #1 further stated, the resident's toe nails are long, curled, mycotic (thick) and she needs to be seen by the podiatrist. RN #1 stated that she would make sure that she is put on his list for the next time he comes in. RN #1 stated that she often will do the weekly skin assessments for the nurses because they are busy. The RN stated that she has not paid much attention to resident's toe nails while doing skin checks and probably should have. RN #1 stated the computerized skin sheet does not include to check the resident's finger nails and toe nails like the old paper system did. Review of the computerized nursing Weekly Skin Check LPN (Licensed Practical Nurse) (shower check) forms dated 4/12/17 through 6/21/17 revealed the resident had no new skin issues identified and there were no documented comments related to the resident's toe nails. Review of the interdisciplinary Progress Notes dated 3/24/17 through 6/21/17 revealed no documented evidence that toe nail care was provided. During an interview on 6/21/17 at approximately 10:05 AM, LPN #5 stated that on shower days the resident's nails usually get checked. If the resident's toe nails need to be cut, the nurse would do them or the resident would be put on the list to be seen by the podiatrist. During an interview on 6/21/17 at approximately 10:10 AM, a Certified Nurse Aide (CNA#2) stated that the CNAs should let the nurse know if a resident's toe nails are long, but a CNA would not cut them, because a resident might be a diabetic. Review of a policy and procedure entitled Care of Fingernails/ Toenails dated (MONTH) 2010 revealed nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Stop and report to the nurse supervisor if there is evidence of ingrown toenails, infection, pain or if nails are too hard or too thick to cut with ease. Nail care should be recorded in the resident's Medical Record. 2. Resident #103 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/19/17 revealed the resident is cognitively intact. Review of a Nursing Admission Screen dated 1/18/17 revealed the resident was using oxygen (O2) at 3 Liters (L) via nasal cannula (NC - plastic tubing to deliver oxygen into the nose). Review of the Comprehensive Care Plan (CCP) dated 2/7/17 revealed the resident received oxygen therapy at 2L NC related to ineffective gas exchange. Review of Progress Notes revealed the following: - 1/21/17 - O2 on per order - 1/23/17 - O2 on and no SOB (shortness of breath) noted. - 2/1/17 - A certified occupational therapy assistant (COTA) documented that the resident was on 3L of O2 upon entering room. Pulse oximetry (measurement of oxygen level in the blood) was 97% (normal 90 to 100 %) and nursing notified. Nursing states there is no order for O2 in the computer at this time. Await nursing response. 2/11/17 - Low pitch wheezing in right upper lobe. Resident currently on O2 at 2L NC. 2/9/17 - Complained of SOB with a persistent cough. Pulse ox (oximetry - measurement of oxygen level in the blood) 87% at rest. 2/18/17 - O2 continuous continued. Review of a Nursing Home to Hospital Transfer Form dated 4/27/17 revealed the resident's O2 saturation was 68% (low) and treatments included O2 at 8L new today. The Transfer Form documented that the Reason for transfer was an abnormal pulse oximetry (low oxygen saturation). Review of Physician's Orders dated 1/18/17 through the resident's discharge on 4/27/17 revealed there was no documented evidence of an order for [REDACTED]. Interview with the Registered Nurse (RN #1) Resident Care Coordinator (RCC) on 6/20 at 2:30 AM revealed the resident was receiving oxygen. The RN RCC stated there was periodic documentation in the Progress Notes that she was on oxygen. The RN RCC stated there was no order for the oxygen and that it wasn't documented on the Treatment Administration Record (TAR) that she was receiving it. The RN RCC stated There should have been an order for [REDACTED]. Interview with the Physician on 6/20/17 at 3:15 PM revealed the resident was on oxygen and of course there should be an order for [REDACTED]. Review of a facility policy and procedure entitled Oxygen Administration dated 10/10 revealed guidelines for safe oxygen administration includes the following: - Verify that there is a physician's order for this procedure. - Review the physician's order or facility protocol for oxygen administration. - Review the resident's care plan to assess for any special needs of the resident. 415.12(k)(6)(7)

Plan of Correction: ApprovedJuly 24, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 232
? Residents toe nail were cleaned by nurse.
? Resident was later seen by the podiatrist and nails trimmed on 7/11/17.
Resident Care Plan was updated and Podiatry visit will be scheduled regularly.

Resident # 103
? Medical record reviewed by Facility RN an order was not found for O2 therapy
an order for [REDACTED].
To identify all residents who may be affected by this deficiency from date of survey until P(NAME) submitted:
? Nurse Mangers/designee completes a 100% audit of documentation and visual inspection on all residents toe nails and cleaned, trimmed, and/or added to podiatry list as needed.
? Nurse Mangers/designee completes a 100% audit on all resident receiving O2 therapy to ensure an MD order is present.
?
To ensure these deficient practices do not recur, the following measures will be completed:
? DON, Nurse Managers and QA nurse reviewed and revised the weekly LPN skin check sheet to include toe nail care and or podiatry need documentation.
? The DON/Designee will educate Nurses on the new weekly LPN skin sheet documentation requirements specifically related to toe nails.

? DON/Designee will educate all Nurses on the requirement to have an MD order for resident receiving O2 therapy.
How the corrective action will be monitored to ensure the deficiency does not recur:
? The DON will report monthly to the facility QAPI committee the results of the weekly (x4) then monthly (x3) LPN skin check sheets for toe nail care and podiatry need audits. The QAPI committee will determine the need for continuation.
? The DON will report monthly to the facility QAPI committee the results of the weekly (x4) then monthly (x3) O2 therapy audits. The QAPI committee will determine the need for continuation.
? Any identification of an ongoing issue will require immediate further education, process change and ongoing auditing as indicated.
? ADON/Nursing Supervisor will complete weekly (x4) then monthly (x3) O2 therapy audits ensuring there are MD orders present. Outcome will be reported at monthly QAPI.
? ADON/Nursing Supervisor will complete weekly (x4) then monthly (x3) O2 therapy audits ensuring there are MD orders present. Outcome will be reported at monthly QAPI.
The DON will be responsible to ensure the P(NAME) is accomplished.

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: September 1, 2017

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 6/21/17, structural components of the building were not properly protected from fire. Issues included unprotected structural steel beams located above a non-fire rated ceiling assembly that was not protected to meet the minimum fire rating of building construction type II (222). This affected one (First Floor) of four resident use floors. The finding is: 1. Intermittent observations on 6/14/17 from approximately 9:30 AM until 3:15 PM revealed that the facility was located in a fully sprinklered four-story building and each of the floors had ceilings that were comprised of lay-in style ceiling assemblies. Observations on 6/16/17 from approximately 8:00 AM until 10:15 AM revealed unprotected steel beams were observed above the lay-in style ceiling tiles in the First Floor front lobby and corridor. The observations revealed that the ceiling tiles were not labeled with a fire resistance rating, the ceiling tiles were not clipped in place, and the grid work for the ceiling tiles and the metal wiring that the grid work was hung from lacked any labeling of their fire resistance ratings. Interview with the Director of Environmental Services on 6/16/17 at approximately 9:00 AM revealed the facility had not made any changes to the lay-in style ceiling assemblies on the First, Second, Third, and Fourth Floors nor the unprotected steel beams located above the lay-in style ceiling assembly on the First Floor. The minimum acceptable construction type for this four-story building is type II (222) per the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. This construction type requires that structural components are protected with at least a two-hour fire resistive rating, either by a physical two-hour fire rated protective covering on the structural components or by maintaining a two-hour fire rated ceiling assembly. The Centers for Medicare & Medicaid Services recognizes the 2013 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety, (also known as the Fire Safety Evaluation System or FSES). This standard provides alternative approaches to life safety based on equivalent safety concepts. A facility that achieves a passing score on the 2013 edition of the FSES will be considered to meet the fire safety requirements for certification and recertification with the Medicare and Medicaid programs. Record review revealed an FSES was conducted at the facility on 2/3/14 using the 2000 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 8.2, 8.2.1, 8.2.1.1, 8.2.1.2, 19.1.6, 19.1.6.1, 19.3.5, 19.3.5.1 2012 NFPA 220 Standard on Types of Building Construction: 4.1, 4.1.1 Centers for Medicare & Medicaid Services Survey and Certification letter, Ref: S&C: 17-15-LSC dated (MONTH) 16, (YEAR): Fire Safety Requirements

Plan of Correction: ApprovedJuly 24, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
The facility is fully sprinkled. Russell(NAME)and Associates have been secured to conduct the FSES. on 7.17.2017.
The results of the FSES will be forward to the NYSDOH.
The facility will make physical correction if necessary
The facility will apply for a Time Limited Waiver for a minimum of three years.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
A one-hundred percent audit was completed to identify steel beams and steel web truss that are not protected to meet minimum acceptable fire rated building construction classification
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All maintenance staff have been rein-serviced on the policy that steel web truss systems must be protected to meet minimum acceptable fire rated building construction classification.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur:
The FSES report will be reviewed at the facility?s monthly QA meeting. This process will continue for a period of six months
The date for correction and the title of the person responsible for correction of each deficiency:
Administrator

K307 NFPA 101:GAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG

REGULATION: Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99) 11.6.2 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 6/21/17, an oxygen cylinder was not properly restrained. This affected one (Third Floor) of four resident use floors. The finding is: 1. Observation on the Third Floor on 6/15/17 at approximately 11:07 AM revealed one D sized oxygen cylinder was stored free standing and unsecured on the floor in Resident room [ROOM NUMBER]. Interview with the Director of Environmental Services, at the time of the observation, revealed the oxygen cylinder should not be stored unrestrained on the floor. Interview with a Registered Nurse (RN) #2 Unit Coordinator, at the time of the observation, revealed she did not know the oxygen cylinder was stored in Resident room [ROOM NUMBER] and at this time, RN #2 took the oxygen cylinder from the Director of Environmental Services and placed it horizontally and unsecured on an office chair, approximately two and a half feet above the floor. Additional interview with the Director of Environmental Services revealed the oxygen cylinder should not be stored unrestrained on a chair and he will take it to the oxygen storage shed and place it in a metal rack. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.3.2.4 2012 NFPA 99: 11.6.2, 11.6.2.3, 11.6.2.3(1), 11.6.2.3(11)

Plan of Correction: ApprovedJuly 24, 2017

Resident # 317
? Nurse Manager was educated on proper O2 handling and storage.
To identify other residents who may be affected by this deficiency:
? Nurse Managers complete a 100% audit on all rooms of residents receiving O2 ensuring no O2 cylinders are unrestrained in the room.
To ensure these deficient practices do not recur, the following measures will be completed:
? Maintenance Director /Designee will educate all nursing staff including Nurse Managers on proper handling and storage or O2 cylinders.

How the corrective action will be monitored to ensure the deficiency does not recur:
? Maintenance Director will complete weekly (x4) then monthly (x3) O2 storage audits ensuring on proper handling and storage of O2 cylinders
? The Maintenance Director will report monthly to the facility QAPI committee the results of the weekly (x4) then monthly (x3) O2 storage audits. The QAPI committee will determine the need for continuation.
? Any identification of an ongoing issue will require immediate further education, process change and ongoing auditing as indicated.
Director-of-Nursing will ensure all corrective action is implemented.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 1, 2017

Citation Details

Based on observation, interview and record review during a Life Safety Code survey completed on 6/21/17, it was determined that an exit door was not available for full instant use in case of an emergency. This affected one of one Boiler Room. The finding is: 1. Observation on the First Floor on 6/14/17 at approximately 1:30 PM revealed the metal exit door in the Boiler Room was not readily available for full instant use. At this time, the Director of Environmental Services and this surveyor each made an unsuccessful attempt to open the door on the left by pushing with body weight and kicking the bottom. Continued observation revealed the door on the right was equipped with an engaged slide lock at the top of the door frame. After attempting to open the door on the left directly, the Director of Environmental Services opened the slide lock on the right side door and both doors were able to be pushed open simultaneously. An illuminated exit sign was present at this location. Interview with the Director of Environmental Services at the time of the observation revealed in addition to Maintenance Staff, the Housekeeping staff also regularly use the Boiler Room because it is used as a staging area for their carts. Interview with the Maintenance Director on 6/20/17 at approximately1:47 PM revealed a piece of metal and rubber stripping was attached to the outside bottom of the left side door and it was bent and overlapped into the right side door. Review of the document called Environmental Door and Exit Audit on 6/20/17 at approximately 1:55 PM revealed the Boiler Exit door was checked on 5/14/17 by a member of the Maintenance staff and the result was listed as good. Interview with the Maintenance Director at the time of the record review revealed the procedure to check a door includes turning off the alarm and making sure the door opens and closes properly. 10 NYCRR 415.29(a)(2), 711.2(a)(1), 2012 NFPA 101: 19.2.1, 7.1.10, 7.1.10.1

Plan of Correction: ApprovedJuly 16, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
The metal exit door in the boiler room was immediately repaired allowing the door to open fully for full instant use 6/14/2017
Environmental Director
The metal and rubber stripping on the boiler door was immediately repaired 6/20/17
Environmental Director
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
100 percent audit was conducted on all exit doors to ensure doors fully open and are readily available for full instant use 6/20/2017
100 percent audit was conducted on all exit doors to ensure any metal and rubber stripping is in good repair 6/20/2017
Environmental Director.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Full and part-time maintenance/ house-keeping staff will be re-inserviced on Means of Egress to include ensuring exit doors fully open and are ready available 7/22/2017
Environmental Director
How the corrective action(s) will be monitored to ensure the deficient practice will not recur:
Weekly audits will be conducted x 8 weeks to ensure all exit doors fully open and are readily available for full instant use 9/20/2017
Environmental director
Weekly audits will be conducted x 8 weeks to ensure all exit doors with any metal and rubber stripping are in good repair 9/20/2017
Environmental Director
All results of audits will be forward to the Administrator and discussed at the facility?s monthly QA
Administrator
The date for correction and the title of the person responsible for correction of each deficiency:
Responsible Party: Director of Environmental Services

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2017
Corrected date: August 1, 2017

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 6/21/17, the required internal pipe exam for the automatic sprinkler system was not performed. This affected four (First, Second, Third, and Fourth Floors) of four resident use floors. The finding is: 1. Review of the facility's sprinkler system inspection records dated 8/9/16, 12/28/16, 3/2/17, and 6/7/17 revealed the remark, Perform obstruction investigation on system was noted on all inspection records. Interview with the Maintenance Director on 6/20/17 at approximately 9:00 AM revealed he could not locate documentation regarding the installation date of the sprinkler system, but his best guess was that the building had a partial sprinkler system installed in 2011 and became fully sprinklered in 2013. Further interview revealed an estimate to conduct an internal pipe exam was obtained from an outside contractor during (MONTH) (YEAR), but the work was not scheduled to be done until questioned by this surveyor. The inspection was to be conducted on 6/20/17. According to the 2011 edition of National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, an internal obstruction exam shall be conducted every five years. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25: Table 5.1.1.2, 5.1.3, 14.2

Plan of Correction: ApprovedJuly 24, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
The internal pipe exam for the automatic sprinkler system was completed on 6/20/2017 there were no findings
Director-of-Maintenance

How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
A 100% audit will be conducted on all equipment associated with NFPA Sprinkler System- Maintenance Testing to ensure all required exams are current ant discrepancies will be immediately addressed
7/21/2017
Administrator
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.
The maintenance director was rein-serviced on ensuring required exams are current for NFPA Sprinkler System- Maintenance Testing
7/21/2017
Administrator
The Facility log for the NFPA Sprinkler System- Maintenance Testing will be reviewed quarterly to ensure all required exams are current.
8/4/2017
Administrator
How the corrective action(s) will be monitored to ensure the deficient practice will not recur:
The results of the quarterly audits will be reviewed at the Facility?s monthly QA meeting for discussion and action as warranted
Administrator
The date for correction and the title of the person responsible for correction of each deficiency:
Administrator