Houghton Rehabilitation & Nursing Center
September 21, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

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

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview during the Standard survey completed on 9/21/18, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included shower plumbing devices that did not have vacuum breakers installed, to prevent backflow in two (200 and 300 Units) of four shower rooms. The findings are: 1. a) Observation on the 200 Unit, on 9/17/18 at 6:59 PM revealed the shower plumbing and shower wand, in the shower room located near Resident room [ROOM NUMBER], did not have a vacuum breaker installed to prevent backflow. The shower plumbing had a shower wand attached to it by a hose that allowed the wand to lie flush with the shower floor. The length of the hose would allow the shower wand to be submerged in the water on the shower floor, in the event the shower did not drain properly. b) Observation on the 300 Unit on 9/17/18 at 7:25 PM revealed the shower plumbing and shower wand, in the shower room located near Resident room [ROOM NUMBER], did not have a vacuum breaker installed to prevent backflow. The shower plumbing had a shower wand attached to it by a hose that allowed the wand to lie flush with the shower floor. The length of the hose would allow the shower wand to be submerged in the water on the shower floor, in the event the shower did not drain properly. During an interview on 9/18/18 at 9:50 PM, the Director of Environmental Service stated the shower wands and the showers' plumbing did not have a vacuum breaker installed. 415.29(d)(f)(4)

Plan of Correction: ApprovedOctober 15, 2018

1. Vacuum breakers were installed on the shower plumbing devices/shower wands for units 200 and 300.
2. 100% audit was completed on all shower plumbing devices/shower wands to ensure vacuum breakers were installed. Any concerns identified were addressed.
3. All full time and part time maintenance staff will be in-serviced by the Administrator on the importance of maintaining all resident care equipment in safe operating condition, which includes the shower plumbing devices/shower wands.
5. The Maintenance Director will report the finding to the QA Committee for the next quarter or until compliance is met.
6. The Director of Maintenance will be responsible for the implementation of this plan of correction.

FF11 483.25:QUALITY OF CARE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 21, 2018
Corrected date: November 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview statements conducted during the standard survey completed on 9/21/18, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, one (Resident #71) of one resident reviewed for [MEDICAL CONDITION] had an issue with the lack of appropriate application of compression bandages for chronic [MEDICAL CONDITION] (swelling and localized fluid retention) and the lack of obtaining TED stockings ([MEDICAL CONDITION] deterrent stockings, elastic stockings used to prevent blood clots) as planned. The finding is: 1. Resident #71 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/22/18 revealed the resident was cognitively intact, understands and was usually understood. The resident required extensive staff assistance for personal hygiene. Review of the facility's procedure for a compression bandage documented starting the compression wrap at the back of the ankle, with a figure 8 and continue to wrap in a spiral fashion with 50% (percent) overlap up to the popliteal (knee) space with neutral tension. This instruction was to prevent tight bands, each turn of the bandage should overlap the preceding by half the width to provide an even pressure gradient, the layers should accommodate the contour of the leg and should be [MEDICATION NAME] down. Patient education included having the resident call if the dressing slips down significantly. Review of the Comprehensive Care plan completed on 8/18/18, identified as current documented on 11/15/17 the resident care focus had vascular wounds on the right lower extremity related to the [DIAGNOSES REDACTED]. On 4/11/18 a revision was made to the care plan which included the use of ACE (compression bandage) wraps to the lower extremities per MD (medical doctor) order. Review of an Order Audit Report (physician's orders [REDACTED]. The order remained active from 1/26/18 to 9/21/18. Review of a physician progress notes [REDACTED]. The physical examination documented massive [MEDICAL CONDITION] of the lower legs which was noticeably improved since the last evaluation and the right lower leg ulcer had good scar formation. Review of a physician's orders [REDACTED]. Review of the Wound Consultant Note dated 4/24/18 revealed the right lower leg wound was healed and the facility was obtaining TED stockings. The note was cosigned by an unknown provider on 5/8/18. The Treatment Administration Record (TAR) from 4/24/18 to 9/20/18 documented the facility continued with Ace wraps; there is no evidence that TED stockings were ordered/ used for treatment of [REDACTED]. Review of a Nurse Practitioner (NP) Progress Note for an interval visit, documented on physical examination the resident had significant [MEDICAL CONDITION] of the bilateral lower extremities. Both legs were wrapped and the pedal pulses (top of foot) were difficult to palpate (feel) due to obesity and [MEDICAL CONDITION]. The treatment for [REDACTED]. The treatment for [REDACTED]. During an observation on 9/19/18 at 6:34 AM, the resident was sitting across from the nurse's station in a chair wearing shorts and white elastic bandages (ACE wraps) were visible on the lower legs. The bilateral leg wraps were not smooth and were bunched up along her lowers legs with a moderate amount of skin visible on the resident's right calf. On 9/19/18 at 8:29 AM, the resident was eating in the main dining room and the bandages were in the same condition. At 10:09 AM the resident was in the Unit 2 Dining/ Activity Room sitting in a chair and the bandages were in the same condition. At 1:32 PM, the resident was ambulating down the service corridor from the Main Dining Room with the bandages in the same condition. During an observation on 9/20/18 at 6:30 AM, the resident was sitting across from the nurse's station in a chair wearing shorts and the white elastic bandages were visible on the lower legs. The wraps were not smooth and were bunched up along her lowers legs with skin visible on the resident's right calf. During an interview on 9/20/18 at 7:36 AM, Licensed Practical Nurse (LPN #3) stated she had done the leg wraps for the resident on 9/19/18 and 9/20/18 at 6:00 AM. During an observation on 9/20/18 at 8:30 AM, the supply room contained a supply of elastic bandages with self-closure REF MDS 4 white moderate compression 4 in. x 5 yds. stretched. The Registered Nurse (RN #1) Resident Care Coordinator (RCC), who was present during the observation, stated those were the bandages the resident was wearing. During an observation on 9/20/18 at 9:54 AM, the resident was sitting in chair and the white compression bandage on the left leg (in addition to the right) had migrated downward and the left calf was exposed and red/purplish skin color to the calf was noted. During an interview on 9/20/18 at 12:45 PM, the Medical doctor (MD) stated the resident was currently on an antibiotic for a recurrence of [MEDICAL CONDITION] on her leg which started last Friday (9/7/18), the resident reported that her leg was becoming painful, which is the resident's presentation for a recurrence of infection. The MD stated that plan was for compression for the bilateral leg [MEDICAL CONDITION] and stated that TED stockings work better; however, for someone that size ACE wraps may be a better option, the difficulty is that the ACE wraps may need constant readjustment, and need proper application and readjustment when necessary. The MD had no recollection of a recommendation for the wound consultant for TED stockings and stated when the wound doctor passes a recommendation along to him, he institutes the order. The treatment would be inappropriate if the ACE wraps were not applied appropriately. During an interview on 9/20/18 at 1:48 PM, the NP stated that she believed the compression bandage wraps were working and the goal was to apply consistent moderate pressure of the legs. If they are not applied consistently that wound be a reason for concern. During an interview on 9/20/18 at 10:29 AM, the Director of Nursing (DON) stated that she had measured the resident last week for TEDs during routine rounds with the physician; however, she had not placed the measurements in the resident's medical record. The note paper indicated plans for mild compression 15-25 with measurements of the Right Leg 72 Calf 35 ankle, and Left Leg 66 calf 32 ankle. The DON stated their pharmacy stated that the size was not available for compression stockings. The DON also stated the ACE wraps were applied to resident incorrectly. During a telephone interview on 9/20/18 at 10:33 AM, the pharmacist stated they told the DON they did not have JOBST stockings available in that size and told the DON to call the company directly. During a telephone interview on 9/20/18 at 10:47 AM, with the compression stocking manufacturer, the representative stated the company could have the stockings custom made for the resident. 415.12

Plan of Correction: ApprovedOctober 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. For resident #71
- Ace wraps bandages were discontinued per the MD order
- Compression bandages were ordered per the MD order
- LPN was in-serviced on the importance of applying compression bandages in the appropriate manner.
- Wound specialist was in-serviced that any plan of care changes or other treatment recommendations need to be communicated verbally during wound rounds with the RN
2. All resident?s who wear compression stockings have the potential to be affected by the same deficient practice.
- An audit was completed on all resident?s who wear compression stockings to ensure that resident?s receive treatment and care in accordance with professional standards of practice which includes the appropriate application of compression stockings.
- Wound consult recommendations for the past 3 months for resident?s that are being treated for [REDACTED].
Any concerns identified were addressed.
3. All full time and part time licensed nursing staff will be in-serviced by the Director of Nursing/RN Manager on the following:
- The importance of appropriate application of compression bandages.
- The importance of thoroughly reviewing the wound consult recommendations to ensure all recommendations have been reviewed with the attending physician.
The wound specialist was educated to inform RN during rounds verbally of any changes to plan of care or treatment recommendations. The recommendations will be also in writing on the consult form.
4. All residents with compression stockings will be audited by the Director of Nursing/RN Manager weekly times four weeks and monthly times two months to ensure that compression stockings were applied appropriately and if the resident is seen by the wound specialist all recommendations will be reviewed to ensure that any recommendation are reviewed with the attending physician.
5. The Director of Nursing will report the findings of the audits to the QA committee for the next quarter or until compliance is met.
6. The Director of nursing will be responsible for the implementation of this plan of correction.

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

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

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

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 9/21/18, it was determined the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Three (Units 100, 200 and 400) of four units observed for the environment had issues with strong urine odors in resident rooms. Resident's A and B are involved. The findings are: Review of a policy and procedure (P&P) entitled Facility Cleaning dated 4/2018 documented it was the facility policy to keep a clean, safe, and sanitary environment for the benefit of the residents. A clean cloth with germicidal solution is to be used on exposed areas of beds, bed frames, bed rails, chairs and resident furniture. Further review of the P&P revealed the floors are to be mopped daily; dust mop then wet mop using an approved diluted cleaning agent. 1. During an observation on 9/19/18 at 9:00 AM, Resident room [ROOM NUMBER] B revealed the resident was out of the room for breakfast and there was a strong urine odor in the room. The bed was made, the garbage was empty and bathroom was clean. During an observation on 9/20/18 at 9:18 AM, Resident room [ROOM NUMBER] B revealed the resident was out of the room for breakfast, there was a strong urine odor in the room, the bed was stripped, the garbage was empty and there was a wet floor sign in front of the resident's room door. During an interview on 9/20/18 at 9:40 AM, with the Administrator and the Director of Nursing (DON), the DON stated the resident's bedding may need to be washed due to the strong urine odor in the room and that she would take it to the laundry. The DON also stated that the mattress was just replaced recently but did not know exactly when it was replaced. The Administrator also stated the mattress was replaced recently and would check to see when it was replaced. During an observation on 9/20/18 at 10:19 AM, revealed there was a housekeeper (Housekeeper #3) in Resident room [ROOM NUMBER] washing the mattress on bed B. The floor was wet and there was a strong chemical smell in the room. Housekeeper #3 was in the room cleaning for approximately one hour. During an interview at the time of the observation, Housekeeper #3 stated he was fairly new to the facility and had not worked on Unit 200 much, but he stated the room and mattress did have an odor of urine. During an observation on 9/20/18 at 12:02 PM, Resident room [ROOM NUMBER] revealed a fan was placed at the foot of bed B and the room continued to have a urine odor. During an interview on 9/20/18 at 2:55 PM, the DON stated the facility did not have documentation when the mattress in room [ROOM NUMBER] B was replaced. During an interview on 9/21/18 at 9:59 AM, the full-time housekeeper (Housekeeper #2) on Unit 200, when in Resident room [ROOM NUMBER], stated the room and mattress smelled of urine and it was like that every day. The interview further revealed she has tried to get rid of the odor, if the bed is stripped she would wash the mattress twice when cleaning the room. 2. During intermittent observations from 9/17/18 through 9/21/18 revealed the following: - 9/17/18 at 8:10 PM, the hallway between Resident Rooms #101 and 102 there was a urine odor. The door was shut to Resident room [ROOM NUMBER]. Upon entering Resident room [ROOM NUMBER] the smell disappeared. Entering Resident room [ROOM NUMBER] a very strong pungent urine odor was present. The resident was in the room sitting in a recliner chair. - 9/18/18 at 9:01 AM, as the surveyor walked by Resident room [ROOM NUMBER], the door was shut. There was a strong stale urine smell that remained outside the door. Upon opening the door to room [ROOM NUMBER] and entering the room a much stronger urine odor was present. The resident was sitting in her recliner watching television and consuming breakfast. - 9/18/18 at 10:50 AM, went in room [ROOM NUMBER]. As soon as the door was open a very strong overpowering urine odor was present. - 9/19/18 at 10:35 AM, Resident room [ROOM NUMBER]'s door was shut and there was an odor outside the room that smelled of stale urine. Upon opening the door and entering Resident room [ROOM NUMBER] there was still a very intense urine smell. - 9/20/18 at 8:49 AM, in the hallway just outside Resident room [ROOM NUMBER] the door was closed and there was still an odor of stale urine. The surveyor entered the room and there was still a strong urine odor in the room. - 9/20/18 at 11:15 AM, the pungent urine smell could be smelled in the hallway at least 20 feet away from Resident room [ROOM NUMBER] with the door closed. - 9/21/18 at 10:41 AM, the surveyor walked past Resident room [ROOM NUMBER] and door was open to the room. The surveyor went over to door way of the room and could smell a strong pungent urine odor. - 9/21/18 at 11:54 AM, the door to Resident room [ROOM NUMBER] was open and the resident was out of the room sitting by the nursing station. As the surveyor walked by the resident, they stopped and spoke with the resident. The resident did not smell of urine. During an interview on 9/20/18 at 9:19 AM, Licensed Practical Nurse (LPN #1) stated, I have only worked here for two weeks, but the smell has been here since I started. The resident in room [ROOM NUMBER] is incontinent of bladder and when she stands up it goes all over the floor. The ones in charge are aware of the problem and apparently have tried different things. Sometimes I hold my breathe when I go in that room. During an interview on 9/20/18 at 9:32 AM, the Maintenance/ Environmental Director stated, room [ROOM NUMBER] does have a strong urine odor. It has for a long time. The resident in that room has incontinence problems. We have tried to clean the room completely and re did the entire room. We ripped the tiles off the floor and put a special sealant on the concrete under it and then we replaced the tiles and put extra wax sealant on the tile. We repainted the walls. The entire room was fixed up. We did this maybe around (MONTH) or (MONTH) (YEAR) and it smells again. Everyone knows about this room and the odor. I do have housekeeping go in there all the time and they do the best they can, but the odor still remains. During an interview on 9/20/18 at 10:18 AM, Housekeeper #1 stated I have been the housekeeper on this unit for the past two weeks. room [ROOM NUMBER] does smell like urine. I do go in there twice a day and clean it and it does help a little, but the smell is still there. It may also be her chair that smells because she is sitting in it all the time and that resident has a weak bladder. During an interview on 9/20/18 at 11:04 AM, the Director of Nursing (DON) stated, room [ROOM NUMBER] has a funky odor. Sometimes the resident will not let us help her with her care or incontinent care. She sometimes goes to the bathroom herself and will be incontinent the entire way to the toilet and urine leaks on the floor. She cannot wear pull-ups or briefs as she is allergic to them. She does wear panty liners but that doesn't help. She sits in the recliner and sleeps in the recliner. She does not use her bed. The recliner may be holding the odor to it. We are looking into cloth briefs for her. It is her choice to have the door close, we do not close it because of the odor. It isn't fair to other residents, but we have tried everything to eliminate the odor. During an interview on 9/20/18 at 11:13 AM, the Administrator stated, room [ROOM NUMBER] definitely has a funky odor. We have been trying various products to take away the odor. We use a special cleaning product in that room. The resident is incontinent, and we have tried many products with her, but nothing seems to help. I have recently ordered a new product, clothe briefs. We are going to try them on her. We have worked on this room for a while and have done a lot with it, but nothing seems to help. During an interview on 9/21/18 at 10:41 AM, Resident A stated There is one area of the hallway between #101 and the room opposite from it that has a horrible odor every time I go through there. I sometimes take my air freshener spray and spray ahead of me because it smells so bad. It smells like urine. Nothing would please me more to see them do something about that horrible smell. I do not even know how staff can stand it. 3. On 9/17/18 from 6:30 PM to 10:00 PM the hallway prior to entering Resident room [ROOM NUMBER] (approximately 5-10 feet), there was a strong stale urine odor. The urine odor was also inside Resident room [ROOM NUMBER]. The resident was not in the room and the source of the odor was unknown. On 9/18/18 at 3:11 PM while standing at the threshold of the Resident room [ROOM NUMBER] outside the doorway, the hall had a strong unpleasant odor which smelled like stale urine. The resident was sitting in a fabric covered recliner in the room without an incontinence pad underneath him. The resident was wearing pants, an incontinence brief and his clothing appeared dry. On 9/20/18 at 9:19 AM during an observation with the Administrator and Director of Nursing outside the room [ROOM NUMBER], there was an unpleasant odor of stale urine. During the observation the Administrator stated, that she does routine environmental rounds with the Maintenance Director. The Administrator stated the resident had behaviors due to his dementia and was frequently incontinent while sitting in the recliner. The recliner chair was just changed three weeks ago and stated the odors were probably coming from the recliner. During an interview on 9/18/18 at 8:40 AM, the responsible party of Resident B stated the hall and the resident's room smells unpleasant like stale urine. 415.5(h)(2)

Plan of Correction: ApprovedOctober 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.For Resident room [ROOM NUMBER]B:
-The room was thoroughly sanitized by the housekeeping department.
-The plan of care was reviewed and the resident's toileting plan to take the resident to the bathroom was changed to every 2 hours and PRN.
-A new mattress will be ordered for the residents bed.
-A urine test was ordered by the physician to rule out a UTI.
-The resident was started on cranberry capsules every day per MD order.
-The resident room will be sanitized two times a day by the housekeeping department.
For Resident room [ROOM NUMBER]:
-The resident's room was thoroughly sanitized by the housekeeping department.
-A bedside commode was issued to the resident.
-The resident's plan of care was reviewed and the resident's toileting plan to take the resident to the bathroom was changed to every 2 hours and PRN.
-A urology consult was ordered by the physician.
-A urine test was ordered by the physician to rule out a UTI.
-The resident was started on cranberry capsules every day per the MD order.
-The resident's room will be sanitized two times a day by housekeeping department.
For Resident room [ROOM NUMBER]
-The residents room was thoroughly sanitized by the housekeeping department.
-The fabric-cover recliner was replaced with a vinyl recliner.
-The resident was offered a urinal.
-Cranberry juice was added to the resident's meal plan.
-The resident's room will be sanitized two times a day by the housekeeping department.
2. All residents have the potential to be affected by the same deficient practice. 100% room audits were completed by the housekeeping department to ensure that the residents are provided with a sanitary, orderly and comfortable environment. Any concerns that were identified were addressed.
3. All full time and part time housekeeping/maintenance staff will be in-serviced by the Director of Maintenance on the importance of providing the resident's with a sanitary,orderly and comfortable environment.
4. Room audits will be conducted by the Director of Maintenance weekly times four weeks and monthly times two months to ensure that the residents are provided with a sanitary, orderly and comfortable environment.

5. the Director of Maintenance will report the findings of the audits to the QA Committee or QAPI for the next quarter or until compliance is met.
6. The Director of Maintenance will be responsible for the implementation of this plan of correction.

FF11 483.15(c)(1)(i)(ii)(2)(i)-(iii):TRANSFER AND DISCHARGE REQUIREMENTS

REGULATION: §483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: September 21, 2018
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 9/21/18, the facility did not ensure that before a facility transfers or discharges of a resident, the physician documented in the resident's medical record the basis for the transfer or discharge. Specifically, one (Residents #85) of one resident reviewed for community discharge to home did not have documentation from the physician regarding the resident's discharge on 8/10/18. The finding is: Review of facility policy and procedure entitled Discharge Summary- Documentation dated 4/2018 revealed the Physician/ practitioners will inform the resident of anticipated discharge date and treatments that will take place while in the facility. A physician order [REDACTED]. 1. Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/2/18 revealed the resident was cognitively intact, understands and was understood. Review of a Nursing Progress Note dated 8/8/18 revealed the Physician was contacted and updated on the residents upcoming discharge and opened area to their coccyx (tailbone). Review of IDT (interdisciplinary): Discharge Instructions/ Summary of Stay dated 8/9/18 revealed a discharge date of [DATE]. Review of the entire medical record revealed there was no discharge note completed by the medical staff. During an interview on 9/20/18 at 2:50 PM, the Medical Records Director stated, I do not have a discharge summary from the physician. He had never given me one for Resident #85. During an interview on 9/20/18 at 3:35 PM, the Director of Nursing (DON) stated, I would expect the Physician to be aware of the resident being discharged . I really do not expect the Physician to write a discharge summary or note because we have the team write a note with everything on it. I do not know what the policy states. 415.3(h)(1)(ii)(a)

Plan of Correction: ApprovedOctober 15, 2018

QAPI has been initiated

FF11 483.40(b)(3):TREATMENT/SERVICE FOR DEMENTIA

REGULATION: §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

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

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview statements conducted during the standard survey completed on 9/21/18, the facility did not ensure that a resident who displays or is diagnosed with [REDACTED]. Specifically, one (Resident #23) of 10 residents reviewed for dementia had an issue with lack of medical intervention from the interdisciplinary team (Nursing, Pharmacist, and Medical Doctor) to address the resident's prolonged refusals of planned oral medications, including but not limited to antihypertensive medication. The finding is: 1. Resident #23 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 7/11/18 revealed the resident had severe cognitive impairment, understands and was understood. Review of a History & Physical dated 10/11/16 revealed the resident lacked capacity to make medical decisions, had malignant hypertension and had a history of [REDACTED]. Review of the Comprehensive Care Plan completed on 7/18/18 and identified as current documented the resident was dependent on staff for meeting emotional, physical and social needs related to cognitive deficits (started 10/18/16), and has an altered cardiovascular status related to [DIAGNOSES REDACTED]. Interventions initiated on 10/11/16 included monitoring the resident's vital signs, with a revision on 3/30/17 to monitor and report any signs and symptoms of malignant hypertension, headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, [MEDICAL CONDITION] activity, difficulty breathing (dyspnea). On 12/12/17 a revision documented the resident has verbal and physical aggressive behaviors and a history of choosing not to take his medications and all routine oral medications were discontinued. Review of the physician's orders [REDACTED]. Review of physician's orders [REDACTED]. 12/12/17, and [MEDICATION NAME] (antihypertensive medication) 30 mg daily for high blood pressure started 10/12/16 and discontinued 12/12/17. Review of the Medication Administration Records (MAR) dated (MONTH) (YEAR) through (MONTH) (YEAR) documented the following medication refusals: - (MONTH) (YEAR) - the resident refused medication 25 out of 30 days (25/30) - (MONTH) (YEAR) - 27/30 days - (MONTH) (YEAR) - 15/31/ days - (MONTH) (YEAR) - 19/30 days - (MONTH) (YEAR) - 30/31/days - (MONTH) (YEAR) - 30/30 days - (MONTH) (YEAR) - 12/12 days, medications discontinue on 12/12/18. Review of the pharmacy consultant reviews from (MONTH) (YEAR) to (MONTH) (YEAR) noted the resident's refusals of medications; however, no recommendations were made to administer medications, including but not limited to antihypertensive medication in an alternative form. Review of the 11/10/17 Annual History & Physical documented the resident lacked capacity for making medical decisions, had a history of [REDACTED]. Review of a Plan of Care progress note by the Social Worker documented the Behavioral Health Committee met on 12/12/17 to review the resident's care. The team discussed the resident's current medication regimen which noted that the resident had taken medications a total of 4 times since 11/1/17. The Interdisciplinary Team with the Medical Doctor (MD) present, recommended discontinuing all oral medications due to persistent refusals despite patient education. The resident and the family were previously educated on several occasions and the responsible party was aware of the discontinuation of the medications and was in agreement with plans to monitor for signs and symptoms (of what not defined) and report as necessary. Review of the Blood Pressure Summary report documented from 3/26/18 to 4/15/18 blood pressures between 152-184 systolic and 74-100 diastolic (normal range blood pressures less than 120/ 80 per the American Heart Association (AHA)). Review of an incident progress report dated 3/28/18 documented that the resident became agitated in the main dining room and targeted a certified nurse aide (CNA). The resident called her names, was swearing, and threatened to kill her. Per consultation with the Administrator, Social worker and MD, the resident was transferred to the hospital behavioral health unit for evaluation. Review of Hospital Patient Visit Information for an Emergency Department (ED) visit dated 3/28/18 documented the resident was seen for dementia and hypertension. Patient instructions were reviewed (unknown with whom) about understanding dementia and high blood pressure, out of control; no specific blood pressures were documented in the hospital record. However, instructions included to follow up with-in the next two weeks for a blood pressure re-check. Review of physician order [REDACTED]. Review of the Blood Pressure Summary report revealed: - 4/16/18 a blood pressure of 220/148 at 11:51 AM - 4/17/18 a blood pressure of 218/130 at 11:32 AM - 4/18/18 a blood pressure of 224/142 (blood pressures over 180/120 may be hypertensive crisis per AHA) at 11:32 AM. Review of a Provider note dated 4/16/18 at 13:50 (1:50 PM) completed by the Registered Nurse (RN) Supervisor revealed the MD was notified regarding a blood pressure of 200/128. The MD, family, and nursing were well aware of blood pressure and the fact that the resident refuses all medications. Further review of the notes revealed there were no physician notifications documented for the elevated blood pressures on 4/17/18 and 4/18/18. Review of the Physician Progress Report for a 60-day follow-up dated 4/20/18 documented the resident lacked capacity to make medical decisions. The assessment documented a [DIAGNOSES REDACTED]. The note did not document vital signs and/ or that a vital sign review was completed. The physician spoke to the resident about the medication refusal, who stated he does not care about his blood pressure and he will continue to refuse all medication. There was no indication the MD spoke to the responsible party. Review of an acute visit Nurse Practitioner (NP) note dated 5/1/18 documented the resident was evaluated for refusing all his medications and his blood pressure had been very high secondary to his medication refusal. The NP assessment documented essential hypertension elevated secondary to medication refusals; if the blood pressure remains elevated consider using an antihypertensive patch instead of oral medication. A follow up by the NP on 5/8/18 documented after discussion and encouragement last week, the resident was agreeable to take medications. Per the nursing staff, the resident was still non-compliant with medications, thus a [MEDICATION NAME] (antihypertensive medication) patch was ordered. There was no documentation/consideration about administering other previously planned medications in a form other than oral for the resident. Review of physician orders [REDACTED]. weekly for hypertension. On 5/29/18 the [MEDICATION NAME] dosage was changed to 0.2 mg/ 24 hr. weekly. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. However, the resident received no pharmacologic treatment for [REDACTED]. During an interview on 9/20/18 at 1:57 PM, the Nurse Practitioner stated that she first started working at the facility around (MONTH) (YEAR). During her initial evaluation she noted the resident's medication refusals and started him on a [MEDICATION NAME]; it worked out well for him. During an interview on 9/20/18 at 1:58 PM, the Pharmacy Consultant stated during her monthly medication reviews she looked at the medications the resident was receiving. The Pharmacy consultant stated the medication refusals are for the physician to figure out, and she did not see that she had any responsibility to make any recommendations and medication refusal was a resident's right. During an interview on 9/20/18 at 4:17 PM, the Physician stated that he could not recall if he was notified about the resident's elevated blood pressure on (MONTH) 16, 17 & 18. During the interview the MD read the nursing progress notes and noted that he was notified of a BP of 200/128. The MD reviewed the BP summary report screen and stated the higher BP of 220/148 in the BP summary document was not reported to him and could have been an error. The MD stated that based on the information in the medical record he did not believe that he was notified of the continued elevated blood pressure on 4/17 and 4/18. The physician also stated when the diastolic blood pressure is at 150 he would consider it emergent and send the resident to the ED; as far as he knew no medical intervention was done from 4/16/18 to 4/18/18. The physician could provide a rationale as to why the alternative route for the blood pressure medication was not tried prior to 5/8/18 for this resident with known behaviors. During an interview on 9/20/18 at 4:39 PM, the Director of Nursing (DON) stated she recalled some discussion in morning report about the resident's blood pressure medication and recalled that getting him to take the patch took some convincing. The RN DON stated that the former RN RCC no longer worked at the facility and she had no information about why there was no medical intervention from 4/16/18 to 4/18/18 or why it took so long to place the resident on an alternative to oral hypertensive medication. The DON stated the lack of administration of the antihypertensive medication placed him at risk for a cardiovascular event. During an interview on 9/18/18 at 12:07 PM, the responsible party stated the facility does not contact her much regarding the resident's medication changes; she knows the resident has behaviors, confrontations with other residents and refuses medications. The responsible party stated the resident had a history of [REDACTED]. 415.12

Plan of Correction: ApprovedOctober 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 744
1. For resident 23
-The resident is currently receiving a [MEDICATION NAME] Patch for hypertension and an [MEDICATION NAME] Patch for Alzheimer?s Dementia.
- The Pharmacy consultant was in-serviced by the administrator on the importance of notifying the physician when completing her medication reviews of residents that are refusing medications and any recommendations that she may have to address the residents medical needs.
- The Medical Director was in-serviced by the administrator on the following. 1) The importance of re-evaluating the residents medication regime when the resident is refusing medications to address the resident?s medical needs. 2) The importance of addressing prolong resident refusal of medications or treatments with the responsible party.3) The importance of documenting the resident?s refusals of medication or treatments in the resident?s medical record.
- The licensed nursing staff will be in-serviced on the importance of addressing the prolonged refusal of medication or treatments with the physician to address the resident?s medical needs.
- The licensed nursing staff will be in-serviced on the importance of notifying the physician for abnormal vital signs values.
- Resident #23 was evaluated for depression by the nurse practitioner.
2. All residents have the potential to be affected by the same deficient practice.
A 100% resident audit will be completed on all medication and treatment records to ensure all prolonged refusal of medications or treatments by the resident have been addressed with the physician .
Any concerns identified were addressed.
3. The Medical director, attending physician, nurse practitioner and Pharmacy Consultant were in-serviced by the Administrator on the following:
-The Medical Director was in-serviced on the following
- The importance of re-evaluating the resident?s medication regime when the resident is refusing medications to address the resident?s medical needs
-The importance of addressing prolong refusal of medications or treatments by the resident with the responsible party.
-The importance of documenting the resident?s refusal of medications or treatments in the resident?s medical record.
The Pharmacy consultant was in-serviced on the importance of notifying the physician when completing her medication reviews of residents that are refusing medications or treatments and any recommendations that she may have to address the resident?s medical needs.
The licensed staff will be in-serviced by the Director of Nursing on the following: 1. The importance of notifying the physician of abnormal vital sign values.2. The importance of notifying the physician of prolong resident refusal of medications or treatments so the resident?s medical needs can be addressed.
4. 10 residents medication and treatment records will be audited per week for 4 weeks and monthly for 2 months by the Director of Nursing/RN Manager to ensure any residents with prolong refusal of medications or treatments have been addressed by the physician and documented in the resident?s medical record and the responsible party were notified of the refusals.
10 resident?s vital sign assessments will be audited per week for 4 weeks and monthly for 2 months by the Director of Nursing/RN Manager to ensure any Abnormal vital signs were addressed with the physician.
5. The Director of Nursing will report the findings of the audits to the QA committee for the next quarter or until compliance is met.
6. The Director of Nursing will be responsible for the implementation of this plan of correction.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 21, 2018
Corrected date: November 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during the Standard survey completed on 9/21/18, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #51) of two residents reviewed for pressure ulcers. Specifically, treatment was not provided as ordered by the physician for a resident with a Stage 3 coccyx (tail bone) pressure and the resident was not provided with a pressure relieving mattress (air mattress) as recommended by the wound consultant. The finding is: Review of the facility policy entitled Pressure Injury (Ulcer) Prevention and Treatment Protocol dated 5/1/17 revealed that any resident having a pressure injury receive necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Interventions included residents identified at high risk for breakdown shall be monitored for any changes in condition. They will also have resident specific preventative measures put into place which may include but no limited to: Use pressure relieving devices such as but not limited to foam pads, air or gel cushions, pressure relieving mattresses. 1. Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 8/1/18 documented the resident had severe cognitive impairments, understands and was understood. The MDS documented the resident required extensive staff assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. It documented zero unhealed pressure ulcers. Furthermore, the MDS documented pressure reducing device for chair and pressure reducing device for bed. Review of the Comprehensive Care Plan dated 7/20/18 revealed the resident had limited mobility related to muscle weakness and [MEDICAL CONDITION]. Interventions included ROHO (pressure relieving device) cushion in high back wheelchair with left lateral support, calf board, bilateral foot pedals, heel floats, and pillow between knees. Further review revealed a focus area of impairment to skin integrity and for pressure injury related to limited mobility and bladder and bowel incontinence. Interventions included, but not limited to: educate resident/family/ caregivers of causative factors and measure to prevent skin injury, keep skin clean and dry, mat to be placed on wall next to bed for safety, turn and reposition every two to three hours due to Stage 3 pressure ulcer of coccyx. There were no indications for the use of a pressure relieving mattress on bed. Review of the Annual History and Physical dated 8/18/18 revealed the Medical Doctor (MD) documented the resident had a sacral decubitus ulcer and was being seen by a wound care service. Review of the most recent wound consult assessment dated [DATE], revealed the resident had a Stage 3 pressure ulcer of the coccyx measuring 4 centimeter (cm) in length, x 2 cm in width and 0.3 cm in depth with moderate amount of exudate (drainage). The consult notes dated 5/22/18 revealed the coccyx ulcer was healed on 3/14/18 but had reopened on 5/22/18 and measured 1.5 cm in length x 0.6 cm in width and 0 cm in depth. The wound consultant notes dated 9/20/18, also documented a second Stage 3 pressure ulcer of the coccyx measuring 3 cm length x 2 cm width and 0.2 cm depth with moderate amount of exudate. Preventative wound recommendations noted on the weekly wound consults dated 8/2/18 through 9/20/18, recommended an air mattress, gel chair cushion and continue use of wedge to offload coccyx area. a.) Review of the Order Summary Report revealed an order dated 9/9/18 for Santyl (sterile ointment to remove dead skin tissue) ointment to coccyx topically, cleanse wound with normal saline (NS) (a mixture of sodium chloride in water used to clean wounds), pat dry, apply Santyl to wound bed, cover with moist gauze and dry clean dressing (DCD) every day shift and PRN (as needed). Review of the Medication Administration Record [REDACTED]. The PRN treatment was not signed off as completed for that day (9/19/18). During an interview on 9/19/18 at 8:00 AM, the Licensed Practical Nurse (LPN #3) stated that she had completed the resident's sacral wound treatment early this AM. During a care observation on 9/19/18 at 11:49 AM, with the Registered Nurse (RN #1) RCC (Resident Care Coordinator) present, Certified Nurse Aide (CNA) #1 and CNA #2 provided incontinence care for the resident. The resident's brief was heavily saturated with urine. The resident had two large open, beefy red pressure ulcers noted on the coccyx with a moderate amount of serosanguineous (blood and serum) exudate and white colored exudate. The pressure ulcers had no dressing or bandages covering the ulcers and there were no dressings observed in the soiled brief. During an interview 9/19/18 at 2:47 PM, the RN RCC #1 stated that she was in the room while the CNA's provided incontinent care and that she did not see the wound or the dressing. During an interview on 9/19/18 at 3:04 PM, LPN #2 she stated she was not aware the resident's dressing were off as LPN #3 had reported to her that she had completed the scheduled wound care early that morning. During an interview on 9/19/18 at 3:22 PM the Director of Nursing (DON) she stated the she wasn't aware that the resident didn't have a dressing on her coccyx wound. She stated that she had been informed that the resident refused her last incontinent care on the day shift, but had she known there was no dressing in place she would have taken care of that at that time. She stated the resident was going to be medicated for pain, wait 30 minutes, then provided with incontinent and wound care. During a care observation on 9/19/18 at 3:56 PM, CNA #4 and the DON rolled the resident onto her side and removed a heavily urine saturated brief. CNA #4 provided incontinence care and then RN RCC #1 completed the resident's treatments as ordered by the physician. During an interview on 9/20/18 at 11:32 AM, CNA #1 stated that she gave the resident a shower on 9/19/18 at 6:30 AM and then put the resident back to bed so that LPN #3 could complete the resident's treatment. Later that day when we were doing her incontinent care prior to lunch the resident did not have a dressing on but sometimes it does come off and get bunched up in the brief. CNA #1 stated that she told LPN #3 the resident would need a new bandage because she didn't have one on. During an interview on 9/20/18 at 11:36 AM, LPN #3 stated that she did the resident's wound care dressing at 6:20 AM on 9/19/18. LPN #3 stated that she was not aware the dressing had come off and that it needed to be replaced. She stated had she been made aware she would have done it right away because the resident does have a PRN order. Additionally, she would expect the aides let her know if a treatment needed to be replaced. b.) During intermittent observations, from 9/18/18 at 3:13 PM to 9/20/18 at 4:06 PM revealed there was no air mattress on the resident's bed. During an interview on 9/19/18 at 3:06 PM, the RN evening Supervisor #3 she stated the RCC reviews consultant recommendations and implements the recommendations. The RCC obtains an order for [REDACTED]. During an interview on 9/20/18 at 3:04 PM, the RN RCC #1 stated that she didn't recall about the air mattress when doing rounds with the wound consultant Nurse Practitioner. She stated it's the responsibility of the RCC or RN Supervisor to review consultant notes and implement the recommendations. She stated that they follow the recommendations of the wound consultant, talk about it in the morning meeting and leave them in the drawer for the MD to review. If there was something that needed to be done right away they would call the MD and document that on the consult sheet. The RN also stated that an order was not needed for an air mattress as was a nursing judgement. In addition, to have an air mattress placed on a resident's bed, a notice could be put into the computer system for maintenance, a note on the Daily Supervisor Sheets or on the 24-hour report sheets. Review of the Supervisor Information Sheets and 24-hour Summary reports dated 8/2/18 through 8/7/18 revealed there were no notations regarding wound consultants recommendations regarding and air mattress for the resident. During an interview on 9/20/18 at 3:22 PM, the Director of Maintenance stated staff used to put the request into the computer system if a resident needed an air mattress. He stated they no longer use that system but if an air mattress was needed they would just come and tell him. Additionally, he did not recall a request for an air mattress and he had not put one on the resident's bed. 415.12 (c)(2)

Plan of Correction: ApprovedOctober 15, 2018

F 686.
For resident # 51
- The RN RCC completed the resident?s treatment as ordered by the MD.
- Air mattress was applied to the resident?s bed.
- New treatment order was implemented by the physician - Santyl to the Stage3 pressure injury wound bed and cover with a moist gauze and cover with a transparent dressing
- The LPN was in-serviced by the Director of Nursing on the importance of ensuring that all dressings are securely intact when completing treatments that require a dressing.
- The CNA'S were in-serviced by the Director of Nursing on the importance of notifying the charge nurse immediately when providing care to a resident and a open wound is noted with no dressing is covering the wound.
- The RN RCC will be in-serviced by the Director of Nursing on the importance of reviewing wound consultation recommendations to ensure new recommendations are implemented by the nursing department or the physician.
2. All residents with pressure ulcers have the potential to be affected by the same deficient practice.
- An audit will be completed by the Director of Nursing/RN Manger on all residents with pressure injuries to ensure that all wound dressings are securely intact as ordered by the physician.
- An audit will be completed by Director of Nursing/RN Manager on all residents with pressure injuries for the past 3 months to ensure that recommendations that were made by the wound specialist were reviewed by the physician or nursing staff and implemented. This included pressure relieving devices.
3. All full time and part time nursing staff will be in-serviced by the Director of Nursing/RN Manager on the following
- CNA's will be in-serviced on the importance of notifying the charge nurse immediately when providing care to a resident and a open wound is noted with no dressing covering the wound.
- All licensed staff will be in-serviced on the importance of ensuring that all dressings are securely intact when completing treatments that require a dressing.
- All RCCS and supervisors will be in-serviced on the importance of reviewing wound consultation recommendations to ensure new recommendations are implemented by the nursing department or by the physician.
4. 3 residents with pressure injuries will be audited per week for four weeks and monthly for 2 months by the Director of Nursing/RN Manager to ensure dressings were applied correctly as ordered by the physician and wound consultation recommendations were reviewed for the implementation of new recommendations.
5. The Director of Nursing will report the findings of the audits to the QA Committee for the next quarter or until compliance is met.
6 The Director of Nursing will be responsible for the implementation of this plan of correction.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

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

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 9/21/18, corridor doors were not properly maintained. Issues included corridor doors were obstructed from closing and would not latch into their door frames. This affected three (200, 400, Main Street Unit) of five resident use units. The findings are: 1. a) Observation on the 400 Unit, on 9/17/18 at 7:10 PM, revealed the corridor door to the Nursing Coordinator's office was obstructed from closing by a four-foot tall by two-foot wide computer cart. Further observation revealed the power cord for the cart was run under the door and was plugged into a duplex outlet in the office. b) Observations on the Main Street Unit, on 9/17/18 at 7:45 PM and on 9/21/18 at 8:35 AM, revealed the corridor door to the Main Kitchen was obstructed from closing by a three-foot tall by three-foot long by two-foot wide dietary cart. Observation on 9/21/18 at 9:32 AM revealed the corridor door to the Main Kitchen was obstructed from closing by a steam table. c) Observation on the Main Street Unit, on 9/17/18 at 8:25 PM, revealed one of the two corridor doors to the Main dining room was obstructed from closing by a three-foot tall by three-foot long by two-foot wide dietary cart. Continued observation revealed it was the corridor door located closest to the therapy room that was obstructed form closing. d) Observation on the 200 Unit, on 9/19/18 at 12:44 PM, revealed the corridor door to Resident Room #209 was obstructed from closing by a walker. Further observation at this time revealed no residents were in the room. During this observation, the Director of Environmental Services stated the staff knew not to obstruct corridor doors. 2. a) Observation on the 200 Unit, on 9/19/18 at 12:37 PM, revealed the corridor door to Resident Room #209 would not latch into its frame. b) Observation on the 200 Unit, on 9/19/18 at 12:45 PM, revealed the corridor door to Resident Room #211 would not latch into its frame. During this observation, the Director of Environmental Services stated he had no documentation for audits of the building's corridor doors. c) Observation on the 200 Unit, on 9/19/18 at 12:57 PM, revealed the corridor door to Resident Room #221 would not latch into its frame. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.6.3.5, 19.3.6.3.10

Plan of Correction: ApprovedOctober 15, 2018

K363
1. - The computer cart was removed from the Nursing Coordinators office.
- The dietary cart and steam table were removed from the corridor door to the main kitchen.
- The dietary cart was was removed from the corridor doors to the main dining room
- The walker was removed from the corridor door to resident room # 209
- The doors for room # 209, # 211 and # 221 were repaired to ensure that the doors latch properly into the door frames.
2. 100%audit was completed by the maintenance director on all doors in the facility to ensure that the doors latch into the door frame.
100% audit was completed by the maintenance director to ensure that there was no obstruction that would cause the doors in the facility not to close properly.
Any issues identified were addressed.
3. The maintenance director will be in-serviced by the administrator on the importance of ensuring that the doors in the facility latch properly into the door frame.
- All full time and part time staff will be in-serviced by the Director of Nursing to ensure that all doors are free from obstruction at all times.
4. Monthly audits will be completed by the maintenance department to ensure that all doors in the facility latch properly into the door frames and doors are free from obstruction .
5. The Maintenance Director will report findings of the audits to the QA committee for the next quarter or until compliance is met.
6. The Director of Maintenance will be responsible for the implementation of this plan of correction.

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

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

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on interview and record review during a Life Safety Code survey completed on 9/21/18, electrical equipment was not properly maintained. Issues included, power strips were plugged together (daisy chained) to other power strips, electrical adapters were in use and were not approved to be used with medical devices, and an extension cord was being used to supply power to an electric device. This affected three (200, 300, and Main Street Units) of five resident use units. The findings are: 1. a) Observation on the Main Street Unit, on 9/17/18 at 8:42 PM, revealed a power strip was plugged into to a six-outlet electrical adapter. This power strip was supplying power to a computer, computer router, a computer monitor, and a printer in the dietary office located in the Main Kitchen. During the observation, the Director of Environmental Services stated he was not aware the power strip was plugged into the adapter or that the adapter was being used in this office. b) Observation on the 200 Unit, on 9/19/18 at 12:37 PM, revealed an oxygen concentrator, a nebulizer, an electric recliner-style chair, and a night light were plugged into a six-outlet electrical adapter that was plugged into a duplex electrical outlet located in Resident room [ROOM NUMBER]. Further observation at this time revealed the adapter was not approved to be used with medical devices. During this observation, the Director of Environmental Services stated, the adapter was not rated to be used with medical devices and the facility did not have any power strips that were rated to be used with medical devices. The Director of Environmental Services further stated he was not aware the adapter was being used in this resident's room. 2) Observation on the Main Street Unit, on 9/17/18 at 9:00 PM, revealed a power strip, that was attached to a Computer On Wheels (COW), was daisy chained to a second power strip that was supplying power to the COW located in the Therapy room. 3) Observation on the 300 Unit, on 9/17/18 at 9:47 PM, revealed an extension cord was being used to supply power to an aroma therapy diffuser located in the 300 Unit lounge. During the observation, the Maintenance Director stated he was not aware the extension cord was being used in the lounge. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 2.1, 2.2, 10.2.3.6(5), 10.2.4, 10.2.4.2, 10.2.4.2.1 2011 NFPA 70: 110.3(A)(1), 110.3(A)(7), 110.3(A)(8), 400.3, 400.8(1), 590.3(B)

Plan of Correction: ApprovedOctober 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 920
1. - The 2 power strips in the Main Street Unit were removed.
- The six outlet electrical adapter was removed from room [ROOM NUMBER] and the Main Street Unit.
- The extension cord on the 300 unit lounge was removed.
2. 100% facility audit was completed by the maintenance department to ensure all electrical equipment is properly maintained.
Any issues identified were addressed.
3. All full time and part time staff will be in-serviced by the Director of Nursing/Administrator on the importance of notifying the maintenance department before any power strips, electrical adapters or extension cords are utilized in the facility.
4. Monthly audits will be completed by the maintenance dept to ensure all electrical equipment is properly maintained.
5. The Director of Maintenance will report the findings to the QA Committee for the next quarter or until compliance is met.
6. The Maintenance Director will be responsible for the implementation of this plan of correction.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

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

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 9/21/18, the building's fire alarm system was not properly maintained. Issues included, smoke detectors failed their sensitivity testing and were not replaced and retested . This affected four (100, 200, 300, and Main Street Unit) of five resident units. The findings are: 1. On 9/18/18, a review of a Sensitivity Testing report for the building's smoke detectors dated 12/6/17, revealed six smoke detectors located on the 100, 200, 300, and Main Street Units had sensitivity readings above the manufacture's acceptable ranges. Further review of this report, on 9/18/18, revealed the report stated all smoke detectors had passed their sensitivity testing. Approximately nine months had passed since these smoke detectors had failed their sensitivity testing. During an interview on 9/19/18 at 8:42 AM, the Director of Environmental Services stated he had spoken to a representative from the outside contractor that inspected and tested the building's fire alarm system and the representative told him the contractor missed the failed smoke heads on the report and they could come out to the facility before the week's end to replace the smoke detectors that failed their sensitivity testing. On 9/19/18, a review of a letter from the outside contractor that inspected and tested the building's fire alarm system dated 9/18/18, revealed the outside contractor had provided the facility with an estimate for the replacement of six smoke detectors that failed their sensitivity testing. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.4, 19.3.4.1, 9.6, 9.6.1.3 2010 NFPA 72: 14.2, 14.2.1.1.1, 14.2.1.1.2, 14.2.1.2, 14.2.1.2.2, 14.4.5.3, 14.4.5.3.1

Plan of Correction: ApprovedOctober 15, 2018

1. The six smoke detectors located on the 100,200 and 300 units were replaced by the outside contractor.
2. Upon replacement of the six smoke detectors all current smoke detectors met testing requirements and sensitivity readings were within acceptable range.
3. All maintenance staff will be in-serviced to review all written reports from outside contractor smoke detector testing and to sign off on bottom of report to confirm accuracy of vendor report.
4. Audits will be completed by the maintenance dept upon receipt of report to ensure smoke detector sensitivity testing is accurately documented to show all smoke detectors pass their sensitivity testing.
5. Any issues identified by outside contractor report will be addressed by administration and Maintenance Director upon receipt of the report.
6. The Maintenance Director will be responsible for the implementation of this plan of correction.