Rutland Nursing Home, Inc.
February 27, 2017 Certification Survey

Standard Health Citations

FF10 483.20(b)(1):COMPREHENSIVE ASSESSMENTS

REGULATION: (b) Comprehensive Assessments (1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident?s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2017
Corrected date: April 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility did not ensure that a comprehensive assessment of a resident's needs, strengths, goals for ROM was completed. Specifically for a resident that has a contracture.(Resident # 1) This was evident for 1 out of 31 Residents reviewed for accuracy of assessments. The findings are: Resident #1 is a [AGE] year old. The MDS annual assessment dated [DATE] documented the resident with [DIAGNOSES REDACTED]. Dressing and personal hygiene extensive assist of one. Functional Limitation in Range of Motion impairment on one side for upper and lower extremity. There is no mention of Range of Motion Services or splint devices on the annual assessment. Observed resident on 2/24/17 at 10:30 AM in her room. Observed resident with right hand, arm, and shoulder contracture. The Resident did not have any splint devices in place. Resident stated she gets herself washed and dressed in the morning. Resident showed surveyor her splint for wrist and shoulder. Resident stated that she could tolerate the wrist splint, but the shoulder splint bothers her because she can't bend her elbow. She stated that the staff performs ROM ( Range of Motion) with her. Reviewed Physician Monthly Orders on 1/31/17; there was no documented order for ROM and Hand and shoulder Splints. Review of medical records reveal there is no documented evidence that there is a physician order [REDACTED]. Nursing Rehabilitation Program notes documented the following: (R) RHS (resting hand splint) ECO ( Elbow corrective orthosis) ROM PROM/AROM (Passive Range of Motion/Active Range of Motion) Ambulation Narrow Base Quad Cane An interview with the CNA (certified Nursing Assistant) was conducted on 2/24/17 at 11:30 AM. The CNA stated the resident is able to clean herself and dress herself. The CNA stated that at times resident would need assistance with toileting. The Rehab CNA would walk resident and would assist her with putting on splint. Resident would walk the hallway and the length of the unit. Resident likes to get tout of bed early. An interview with the CNA assigned to perform Nursing Rehabilitiation was conducted on 2/24/17 at 11:45 AM. The Rehab CNA stated that she performs rehab with Resident #1 5 days a week. She stated that the resident will wear splints or walk depending on her mood. Immediately after the interview on 2/24/17 the State Agency Surveyor observed the rehab CNA performing ROM services, and walking with resident with narrow base quad cane and w/c besides rehab CNA. An interview with the RN supervisor on 2/24/17 at 12:00 PM was conducted. The State Surveyor asked the RN supervisor who is accountable for physician orders [REDACTED]. The RN supervisor stated that the night LPN writes the non physician monthly orders. The surveyor asked who is responsible to check monthly orders are accurate. The RN supervisor replied it is the RN manager's responsibility. The RN supervisor stated that she does not check monthly orders but if she gets around to it she would check annual orders. An interview with the Director of Rehabilitation was conducted on 2/27/17 at 10:30 AM. The Rehab Director stated that this resident is receiving Nursing Rehab services, she is not receiving physical therapy or occupational therapy. The Physical Therapist (PT) and Occupational Therapist (OT) are not doing the annual comprehensive or quarterly assessment or screens for residents that are not receiving services for physical or occupational therapy. The staff is supposed to follow the MDS schedule but the staff have not been doing it. The only residents the rehab department assesses or screen are the residents currently receiving PT/OT services from rehab. If there is any change in resident's condition or splint the nurse is suppose to refer the resident with The Rehab Referral form. The director stated the last assessment for the resident was in 2012. An interview with the MDS (Minimum Data Set) coordinator RN was conducted on 2/27/17 at 11:45 AM. A resident who has a splint usually receives it from the Rehab. The nurses on the unit write the order and the Rehab CNA does the ROM and the CNA who has the resident puts the splint on the resident. The MDS assessor does the assessment for ROM and splint devices in place. It should have been indicated on the MDS that Range of Motion (passive), (active) and splint or brace assistance. The physician and rehab suppose to assess the resident for splint and ROM and the MDS assessor would document in Section O in the MDS. The RN MDS assessor was again interviewed on 2/27/17 at 12:17 PM. The MDS coordinator stated that resident is not on a restorative nursing program where the RN assess periodically and documents progress. 415.11(a)(2)

Plan of Correction: ApprovedMarch 23, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
Resident #1 sustained no adverse reaction. The Director of Rehabilitation, Physical Therapist and Occupational Therapist performed an assessment on the resident. It was determined that secondary to the resident?s contractures the resident would benefit from continued use of hand and shoulder splints. The shoulder splint was adjusted and the resident is able to tolerate wearing the splint. Physician orders [REDACTED].
The rehabilitation certified nurse assistant on the unit was re-educated by the nursing supervisor that the nurse is to be informed whenever the resident is refusing to wear the splint because of pain.
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by this practice.
To prevent and correct these issues, all residents with splinting devices were identified and reassessed by rehabilitation for appropriateness of splint, and the need to continue or discontinue use of the splint. In addition, all residents were checked to ensure that monthly orders include splints and range of motion. All residents with splints and range of motion will be reevaluated quarterly by rehabilitation. Nursing staff will be re-educated on the need to inform Rehab Team to re-evaluate a resident with any concerns pertaining to splint.
APRIL 27, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Director of rehabilitation in collaboration with the Director of Nursing reviewed the policy on splints. Revisions to the policy were made to ensure that all residents with splints and/or range of motion have physician orders.
Nursing supervisors/Nursing Designee will monitor compliance with the above protocols during routine care. Immediate corrective action, including staff re-education, will be implemented, as needed.
April 27, (YEAR)

IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility has developed an audit tool to monitor compliance with protocols related to splints and range of motion. Nurse supervisors/Nursing Designee will audit 20% of residents with splints and range of motion to ensure that the resident is wearing their splints and have monthly orders. Audits will be completed monthly.
Audit findings will be reported to the Director of Nursing/Designee. The Director of Nursing will report the audit findings to the Administrator and Medical Director monthly or sooner as warranted. The Director Of Nursing will report results as per the audit findings to the Quality Assurance Committee on a quarterly basis for committee guidance, direction and follow-up actions as may be appropriate for one year.
Responsibility: Director of Nursing
APRIL 27, (YEAR)

FF10 483.60(d)(3):FOOD IN FORM TO MEET INDIVIDUAL NEEDS

REGULATION: (3) Food prepared in a form designed to meet individual needs;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2017
Corrected date: April 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that a resident received the appropriate diet consistency to meet their indvidual needs. Specifically, a resident was observed on more than one occasion by more than one member of nursing staff being fed regular consistency instead of puree. This was evident for 1 of 31 residents sampled (Resident #108). The findings are: Resident #108 is a [AGE] year-old admitted to the facility with medical [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had severely impaired cognition. The MDS further documented the resident required the total assistance of one person for eating, and the resident received tube feeding and a mechanically altered diet. On 2/24/17 at 12:06 PM, the resident was observed in the dining room sitting in a recliner during meal time. The staff was observed feeding lunch to the resident. The lunch tray contained regular consistency macaroni & cheese and baked chicken (which had been removed from the bone). The staff was observed trying to cut the macaroni and cheese into small pieces with a spoon. The resident's eyes were closed while being fed, but she opened her mouth when the spoon was brought to her lips. At one point during the feeding, the resident opened her mouth and the CNA checked her mouth for food. The meal ticket on the tray documented Puree TF (Tube Feeding) On 2/27/17 at 12:07 PM, the resident's lunch tray was observed to include chopped fish, mashed potaoes and spinach. The Registered Dietician (RD) and Chief Clinical Registered Dietician (CCRD) were present in the dining room. The Comprehensive Care Plan (CCP) for Theraputic Diet dated 12/2016 documented the resident receives tube feeding and oral feeding. It further documented the resident was on a mechanically altered diet for dysphagia secondary to [MEDICAL CONDITION] Disorder, Depression, and [MEDICAL CONDITION]. The CCP goal was for the resident to tolerate the therapeutic/mechanically altered diet. The Speech Language Pathology (SLP) Progress Note dated 7/19/16 documented that resident was seen for a speech/swallow screen. The note documented the resident's [DIAGNOSES REDACTED]. The note further documented: this service consulted to conduct routine screening for speech/swallow. As per Nsg (Nursing) staff, current diet tolerated (without) difficulty .As per previous documentation Rt (Resident) with poor gains & engagement in sp (speech) tx (treatment). therefore, full speech-language evaluation/swallow evaluation is not warranted at this time. The last Speech Therapy Evaluation note in the medical record was dated 7/31/09. It was a discharge summary for treatment related to cognitive-linguistic skills. There was no documented evidence in the medical record that the resident received a swallow study. The 2nd Quarterly Nutrition assessment dated [DATE] documented the resident had Tube Feeding and a PO (by mouth) Pureed diet with Aspiration Precautions (full tray). The physician's orders [REDACTED]. The Certified Nursing Assistant Accountability Records (CNAARs) dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) documented the resident required spoon-feeding and a puree diet. The records also documented the resident received tube feeding. On 2/24/17 at 1:33 PM, the Certified Nursing Assistant #1(CNA #1) was interviewed and stated the resident ate 50% of breakfast which consisted of cream of wheat, eggs mashed, applesauce, tea, and orange juice. CNA #1 further stated the resident had no problems swallowing and no indication of coughing while eating. The CNA stated that when the resident begins keeping food in her mouth, it means she is full. On 2/24/17 at 1:44 PM, CNA #2 was interviewed and stated that sometimes the resident is given puree food. The CNA further stated the resident is tube fed because she could not eat previously. She stated the Dietician gives the resident pureed food, but the resident does not like pureed food and prefers the regular consistency. CNA #2 stated she did not report that the resident preferred regular food to anyone. She stated the resident is on aspiration precautions because of her breathing, but she has not observed any problems and the nurse has never had to use the suction machine. She stated she always gives the resident a small portion of food. CNA #2 stated that they give residents tube feeding when they lose weight, especially when they start to lose their appetite. On 2/27/17 at 12:17 PM, The Registered Dietitian(RD) was interviewed immediately following the lunch meal. The Resident lunch tray included chopped fish, mashed potatoes, and a vegetable. The RD stated that the resident is on puree consistency food due to Dysphagia, and the resident also receives tube feeding as the primary source of nutrition. The RD defined dysphagia as having swallowing difficulty, and she stated the aspiration precautions means the resident should sit up at a 90 degree angle during feeding. She further stated in-services regarding food consistency is provided to CNAs and Dietary Aides on a daily basis, but there is not documentation of sign-in sheets or curriculum available. The RD stated meal observations are done three times per week. On 2/24/17 at 2:16 PM, the Registered Nurse(RN) Unit Manager was interviewed and stated the Speech Therapist (ST) will schedule a [MEDICATION NAME] swallow study as needed based on observations of staff. Observations of the resident not swallowing or coughing during eating, would indicate a swallow study is needed. The RN Unit Manager stated that the staff follow the diet recommendations given by Speech Therapy and the swallow study results. She further stated there is no standard follow-up procedure for speech evaluations to be done. She stated speech evaluations are recommended if concerns are observed and when residents are admitted or readmitted . The policy and procedure for Mechanically Altered Diets , revised 3/2015, contained an attached Diet Reference Sheet which documented: Pureed - Entree, starch & vegetable are all pureed into a pudding like consistency. Thickeners may be used. Scrambled egg is non-compliant with the pureed diet. 415.14.3(d)

Plan of Correction: ApprovedMarch 23, 2017

I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
Resident #108: The Resident was evaluated by the Chief clinical Director of Nutrition and the Director of Speech Pathology. A dysphasia evaluation was performed and it was determined that the resident could tolerate meals of a regular consistency.
The two certified Nursing Assistants (CNA?s) were re-educated and counseled by the nursing supervisor:
? For not following the food consistency found on the meal ticket.
The dietary food server was re-educated and counseled by the Chief Clinical Director of Nutrition:
? For not following the food consistency found on the meal ticket.
All nursing staff on the unit were re-educated by the nursing supervisor that the resident?s food consistency must be followed.
March 21, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by the same practice.
To prevent any future occurrences, all nursing staff will be re-educated on the procedure for meal tickets. Dietary servers will be re-educated by the Chief Clinical Director of Nutrition on the importance of serving the food consistency found on the meal tickets.
APRIL 27, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Chief Clinical Director of Nutrition in collaboration with Director of Nursing reviewed the policy on food consistency, and revisions to the policy were made to ensure that all residents receive their ordered food consistency. The Director of Nursing and the Director of Nutrition will monitor compliance with the above protocols. Immediate corrective action, including staff re-education, will be implemented, as needed. (MONTH) 27, (YEAR)
IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility has developed an audit tool to monitor compliance with protocols related to meal tickets. Nursing Supervisors and dietitians will audit 20% of residents during meal time. Audits will be completed monthly for one year. Audit findings will be reported to the Director of Nursing (DON). The DON will report the audit findings to the Administrator monthly or sooner as warranted. The DON will report results as per the audit findings to the Quality Assurance Committee
on a quarterly basis for committee guidance, direction and follow ?up actions as may be appropriate, for one year.
Responsibility: Director of Nursing
APRIL 27, (YEAR)

FF10 483.10(c)(1)(2)(iii)(4)(5):INFORMED OF HEALTH STATUS, CARE, & TREATMENTS

REGULATION: (c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: (c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. (c)(iii) The right to be informed, in advance, of changes to the plan of care. (c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. (c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2017
Corrected date: April 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, record reviews and interviews, the facility did not ensure that resident's family was notified of changes in the resident's plan of care. Specifically, a resident's family was not informed when a new medication was ordered and administered to the resident. This was evident for 1 of 31 residents sampled in Stage 2 (Resident #76). The findings are: Resident #76 is an [AGE] year-old with [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had severely impaired cognition. The MDS further documented the resident displayed mood symtoms of sleeping too much and feeling depressed 2 to 6 days. The resident had no noted behaviors and weighed 94 lbs (pounds). The MDS also documented the resident was receiving antidepressant medication 7 days a week. The Resident was observed on 2/24/17 at 1:30 PM in her room eating her lunch. She engaged with this Surveyor and stated that she feels like she had more energy on this day. The resident was observed again on 2/27/17 at 9:58 AM, the resident was observed sleeping in her wheelchair. She woke up and stated to the State Surveyor that she says she states she is tired all of the time. An Interim physician's orders [REDACTED]. On 2/27/2017 at 10:37 AM an interview was conducted with the resident's daughter. She stated that she visits her mother on most weekends. She stated that staff never informed her about her mother's plan of care, the only phone calls she has ever received if her mother had a fall. On 2/8/2017 she came to the facility and came to question the RN and the MD why is her mother so tired and asked for a printed list of her medications. It was at that point she saw the medication and insisted that she be taken off that medication right away. She said when she visits her mother she appears is drowsy and she has been a [MEDICAL TREATMENT] patient since 2001, so I know it is not from the [MEDICAL TREATMENT]. The resident's daughter is listed as the person to be contacted as the next of kin in the medical record. This information is documented on the face sheet (admission record). There was no documented evidence in the medical record that the resident's designated representative was informed about the plan to start the resident on [MEDICATION NAME], nor were the risks and benefits discussed. The resident's medical record documents that on 2/24/2017, the psychiatrist documented that resident has no psych history, resident has some cognitive impairments and to discontinue the [MEDICATION NAME]. An interview with the Medical Director (MD), on 2/27/2017 at 11:08 AM stated the resident was not eating well so they started the medication to help stimulate her appetite. The MD stated that the attending MD can start the resident on the medication and then needs to have psych follow the resident afterwards. He further stated that the family is notified by the nursing staff and also encourages both the psychiatrist and the attending MD to inform the family. Also, during the care planning meetings we inform the family whether in person or over the phone. On 2/27/2017 at 12:15 PM. The MD was re-interviewed, he confirmed that the resident was placed on the medication back in (MONTH) on the 7th floor as the attending thought she would benefit from the medication. There are no documentation that the family and/or resident was ever informed. The only encounter that occurred was on 2/8/2017, when the daughter insisted that her mother be taken off the medication. An interview with the Social Work (SW), on 2/27/2017 at 12:10 PM she stated that she took over the resident when she transferred to the 8th floor on 12/2/17. There was a progress note on 11/2//2016 that there was an initial care planning meeting and the daughter could not attend, but the facility will make another appointment date. There is no other documentation from social services noted. She further stated that she is responsible for the care plans which include cognition, mood, behavior, and discharge planning, but there were none completed. 415.3(e)(1)(i)

Plan of Correction: ApprovedMarch 23, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
Resident #76: The physician evaluated the resident and [MEDICATION NAME] ([MEDICATION NAME]) 15 mg was discontinued. The resident?s daughter was informed.
The social worker was re-educated and counseled by the Director of Social Services:
? For not including the resident and the residents daughter in the care plan meeting.
? Care plans for cognition, mood, behavior and D/C were completed and family has been scheduled for a care plan meeting.
All of the nursing staff, social worker and physician on the Resident #76 unit were re-educated by their manager/supervisor that the resident and/family/ resident representative has the right to be informed of changes in medication regimen, specifically psycho active medications. (MONTH) 27, (YEAR).
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by the same practice.
To prevent any future occurrences, all physicians, nurses and social workers will be re-educated that the resident and/or family or designated person has the right to be informed of changes in medication including psychoactives. All residents on psychoactive medications were identified and checked that they were informed of the risks and benefits of the use of medication.
April 27, (YEAR).
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Director of Nursing in collaboration with Director of Social Services and the Medical Director reviewed and revised the policy on care planning in regard to the use of psychoactive medications. This policy includes that the resident/family/designated representative has the right to be informed of changes in medication regimen, and be included in care planning meetings. The Director of Nursing will monitor compliance with the above protocols. Immediate corrective action, including staff re-education, will be implemented, as needed. (MONTH) 27, (YEAR).

lV. The facility has developed an audit tool to monitor compliance with protocols related to care planning and psychoactive medications. The Director of Nursing/Designee will audit 20% of charts. Audits will be completed monthly for one year. The Director of Nursing will report the audit findings to the Administrator monthly or sooner as warranted. The Director of Nursing Services will report results as per the audit findings to the Quality Assurance Committee on a quarterly basis for committee guidance, directions and follow-up actions as may be appropriate for one year.
Responsibility: Director of Nursing/Designee.
April 27, (YEAR).

FF10 483.50(a)(2)(ii):PROMPTLY NOTIFY PHYSICIAN OF LAB RESULTS

REGULATION: (a) Laboratory Services (2) The facility must- (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician?s orders.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2017
Corrected date: April 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure ensure that the ordering physician, was notified of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's order [REDACTED].#444 had multiple orders for Laboratory services without documented evidence that they were reviewed and addressed by the physician. This was evident for 1 resident out of a sample of 31 residents. The finding is: Resident #444 is an [AGE] year old with medical [DIAGNOSES REDACTED]. Progress note from 12/17/2016-2/24/2017 was reviewed and documents intermittent notes regarding episodes of vaginal bleeding as follows:. 11/30/2016 Resident noted with large amount of vaginal bleeding Medical Doctor (MD) notified Complete Blood Count (CBC) ordered. 12/30/2016 Medical note documents Resident with hx of [MEDICAL CONDITION] has been said by nursing staff to have a large amount of vaginal bleeding CBC this am. 1/27/2016 Resident noted with small amount of blood from the vagina labs and consult ordered The Physician order [REDACTED]. 12/1 CBC 12/30 CBC 1/27/2017 CBC 2/14/2017 CBC No documented evidence of the laboratory results were found during the Recertification survey. On 2/24/2017 at approximately 1:00 PM an interview was conducted with the nurse manager who also reviewed the medical records, but was unable to locate the laboratory test results. She states that the requested laboratory results should be placed in the chart for physician review and signature. She does not know why the results are not available in the chart. Approximately 4 hours later she presented the State Surveyor with laboratory results as follows: 12/6/16 Comp Metabolic Panel (CMP), 12/30/16 CBC, 1/15/2017 CBC, 1/28/2017 CBC, 2/14/2017 CBC. The nurse manager stated that the labs were printed from the computer when the State Agency requested it and to her knowledge the labs have not been reviewed by the physician. She further states she is responsible for ensuring the labs are in the chart as ordered. An interview was conducted on 2/24/2017 at approximately 12:30 with the Physician who wrote the order dated 12/30/2016 who states that when a lab is ordered the result is available by hard copy or the computer. He states that the physician reviews the lab, a hard copy is signed and placed in the Chart. If there is an abnormal value a progress note should be written to address the concern, otherwise a signature on the lab she is indicative the results were reviewed. He states that he did not review the lab values for the order dated 12/30/2016. He further stated that the Laboratory will call and notify him of critical values. The Facility policy and procedure documents For Routine Tests the unit clerk or nurse will place the test results in the physicians communication book for review, The physician will initiate the test results and will write a progress note as to interventions implemented or not implemented. 415.20

Plan of Correction: ApprovedMarch 23, 2017

I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
Resident #444 sustained no adverse reaction. The Medical Director reviewed the resident?s laboratory results and noted that the CBC laboratory results were not critical. The responsible physician was re-educated and counseled by the Medical Director: Laboratory results must be reviewed and initialed.
The ward clerk on the unit was re-educated by the Nursing Supervisor on the policy for laboratory reports. Laboratory reports must be placed in the Physician communication book. After the Physician initials the report then it is to be filed in the resident?s medical record.
March 21, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by this practice.
To prevent and correct these issues, all nurses, ward clerks and Physicians will be re-educated on the laboratory report policy.
APRIL 27, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Medical Director and the Director of Nursing reviewed the policy on Laboratory reports. Revisions to the policy were made to ensure that the resident?s laboratory reports are reviewed and initialed by the Physician. Nursing Supervisors will monitor compliance with the above protocols during routine care. Immediate corrective action, including staff re-education, will be implemented, as needed.
April 27, (YEAR)

IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility has developed an audit tool to monitor compliance with protocols related to laboratory reports. Nurse Supervisors/Nursing Designee will audit 20% of residents with laboratory orders to ensure that reports are placed in the physician communication book and the physician has initialed the reports. Results that need to be addressed immediately will be documented in the medical report with necessary clinical interventions. Audits will be completed monthly for one year.
Audit findings will be reported to the Director of Nursing (DON). The DON will report the audit findings to the Administrator and Medical Director monthly or sooner as warranted.
The DON will report results as per the audit findings to the Quality Assurance Committee on a quarterly basis for committee guidance, direction and follow-up actions as may be appropriate for one year.
Responsibility: Director of Nursing
APRIL 27, (YEAR)

FF10 483.40(d):PROVISION OF MEDICALLY RELATED SOCIAL SERVICE

REGULATION: (d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2017
Corrected date: April 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not provide medically-realted social services to attain or maintain the highest mental and psychosocial well-being of each resident. Specifically, Resident #422 requested assistance in a transfer to another facility, no documented evidence that efforts were made to assist the residents request in a timely manner. This was evident in 1 out 31 residents reviewed for Quality of Care and Quality Life Concerns The finding is: Resident #422 is a [AGE] year old who was assessed on the most recent MDS (Mininum Data Set 3.0) assessment as having in tact cognition. An interview was conducted with the resident on 2/24/17 at approximately 12:30 PM. The resident stated that when her family visited during the Thanksgiving holiday her daughter suggested that she transfer to a nursing home in Florida to be closer to her. The resident stated she discussed this with the social worker who informed her that she would get information regarding facilities and room availablity in Florida and report back to her. The resident stated that to date the social worker did not provide her with any information regarding possible transfers or options. A Social Services Progress Report dated 1/13/2017 documented .Still upset and explained that she is tired of being in the nursing home and wants to move to another nursing home closer to her family in Florida. Social worker empathetic with residents frustration and wanting to be closer to family . Social worker took her daughter and siblings telephone numbers to discuss this matter with them. The facility has a policy regarding discharges and transfers. The policy is dated 9/10/2013 and reads: 1. Upon admission and quarterly thereafter, each residents discharge potential will be assessed and reviewed with resident/family. 3. Upon resident/family request for discharge or transfer will find out specific information related to the request and formulate a plan. 4. Makes referral(s) to appropriate community resources . The progress notes were reviewed no documented evidence of discharge planning or follow-up to the previous discharge inquiry. The resident's Comprehensive Care Plan did not include a discharge plan that identifed the resident's request for a transfer to be closer to her family in Florida, no measureable goals or time frames and no interventions in place to formulate and complete the plan for transfer. The resident's medical note did not include any notations or record of conversations with the resident's family regarding this plan for transfer/discharge. The resident's medical record did not include evidence that the social worker or any facility staff made any phone calls, or inquiries to appropriate community resources in Florida. An interview was conducted with the SW (Social Worker) on 2/27/2017 at approximately 12:00 PM. The SW who stated that during the Holidays (some time in December) the resident and her daughter requested a transfer to a facility in Florida so that she could be closer to family. She stated that she has searched the internet for nursing homes in Florida but has not called any, or reviewed them with the resident or her family. She states that she did not write a note concerning the conversation in December. 415.5(g)(l)(i-xv)

Plan of Correction: ApprovedMarch 23, 2017

I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
Resident #422: The Director of Social Services interviewed the resident and determined that the resident is requesting to be placed in a nursing home in Florida. The daughter was called and informed. A list of prospective nursing homes was provided to the resident and mailed to her daughter via certified mail return receipt.
The resident and daughter will decide on which nursing homes they would prefer for admission. As soon as a decision is made Rutland Nursing Home will contact the nursing homes, and send requested documentation required for placement. If accepted, Rutland Nursing Home will coordinate the transfer of the resident to Florida, with the daughter/family member.
The assigned social worker was re-educated and counseled by the Director of Social Services:
? For not adhering to the protocol of transfer/discharge and not following up with the resident and resident's daughter regarding progress to facilitate transfer/discharge.
April 27, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by the same practice. To prevent any future occurrences, all social workers will be re-educated on the importance of adhering to the resident/family members request for discharge in a timely manner.
APRIL 27, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Director of Social Services has reviewed the policy; and revisions were made to ensure that the resident rights in regard to discharge are followed. The Director of Social services will monitor compliance with the above protocols. Immediate corrective action, including staff re-education, will be implemented, as needed. APRIL 27, (YEAR)
IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility has developed an audit tool to monitor compliance with protocols related to discharge planning. The Director of Social Services/Designee will audit 20% of resident charts. Audits will be completed monthly. The Director of Social Services/designee will report the audit findings to the Administrator monthly or sooner as warranted.
The Director of Social Services will report results as per the audit findings to The Quality Assurance Committee on a quarterly basis for committee guidance, direction and follow ?up actions as may be appropriate, for one year.
Responsibility: Director of Social Services
APRIL 27, (YEAR)

FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident?s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident?s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2017
Corrected date: April 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interviews during the Recertification survey, the facility did not ensure the resident's family right to participate in care planning. Specifically, Resident # 76, Resident's family stated that they were never informed about the change in plan of care for the resident to start a new medication. This was evident for 1 of 31 residents sampled in Stage 2 (Resident #76). The findings are: Resident #76 is an [AGE] year-old woman with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had severely impaired cognition. The MDS further documented the resident displayed mood symptom's of sleeping too much and feeling depressed 2 to 6 days. The resident had no behaviors and weighed 94 lbs (pounds). The MDS also documented the resident was receiving antidepressant medication 7 days. An Interim physician's orders [REDACTED]. There was no documented evidence in the medical record that the resident's designated representative was informed about the plan to start the resident on [MEDICATION NAME], nor were the risks and benefits discussed. A care plan meeting for the resident was held on 11/02/16. There were no signatures from the resident or her representative on the sign in sheet. However, there are signatures from representatives of the Nursing department. There is a social work progress note in the resident's medical record dated 11/02/16. This note documented that the daughter could not attend the initial care planning meeting, but will call back to reschedule another meeting. No further note indicating the meeting was rescheduled, or that the resident's daughter was contacted. On 2/24/2017, the psychiatrist documented that resident has no psych history, resident has some cognitive impairments and to discontinue the [MEDICATION NAME]. An interview was conducted with the resident's daughter, on 2/27/2017 at 10:37 AM. She stated that staff never informed her about the plan of care, the only phone calls she has ever received if her mother had a fall. On 2/8/2017, she came to the facility and came to question the RN and the MD why is her mother so tired and asked for a printed list of her medications. It was at that point she saw the medication and insisted that she be taken off that medication right away. Every time, I see my mother she is drowsy and she has been a [MEDICAL TREATMENT] patient since 2001, so I know it is not from the [MEDICAL TREATMENT]. The residents' daughter asked the nurse and the attending MD to review the resident's medication, she realized she was on this new medication, and insisted to discontinue the [MEDICATION NAME] 15mg, also the daughter stated that she finds her mother to be forgetful and incoherent. At that point, a psychiatry evaluation was pending. An interview with the Medical Director (MD), on 2/27/2017 at 11:08 AM. The MD stated that the resident was not eating well so they started the medication to help stimulate her appetite. The MD stated that the attending MD can start the resident on the medication and then needs to have psychiatry follow the resident afterwards. He further stated that the family is notified by the nursing staff and also encourages both the psychiatrist and the attending MD to inform the family. He further stated that families are also informed over the telephone. On 2/27/2017 at 12:15 PM. The MD was re-interviewed, He confirmed that the resident was placed on the medication back in (MONTH) on the 7th floor as the attending thought she would benefit from the medication. There are no documentation that the family and/or resident was ever informed. The only encounter that occurred was on 2/8/2017, when the daughter insisted that her mother be taken off the medication. An interview with the Social Work (SW), on 2/27/2017 at 12:10PM, She stated that she took over the resident when she transferred to the 8th floor on 12/2/17. There was a progress note on 11/2/2016 that there was an initial care planning meeting and the daughter could not attend, but the facility will make another appointment date. The resident was admitted to the facility on [DATE] and was first invited to the meeting on 2/27/17. There was a social work progress note on 2/24/2017 that documents that the family would be invited to a care planning meeting that will be held on 2/27/2017 . 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedMarch 23, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
Resident #76: The physician evaluated the resident and [MEDICATION NAME] ([MEDICATION NAME]) 15 mg was discontinued. The resident?s daughter was informed by MD.
The social worker was re-educated and counseled by the Director of Social Services:
? For not including the resident and the residents daughter in the care plan meeting.
All of the nursing staff on the unit, social worker and physician were re-educated by their manager/supervisor that the resident and/ or family or designated person has the right to be informed of changes in medication specifically psychoactive medications. (MONTH) 21, (YEAR).
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by the same practice.
To prevent any future occurrences, all physicians, nurses and social workers will be re-educated that the resident and/ or family or designated person has the right to be informed of changes in medication specifically [MEDICAL CONDITION].
April 27, (YEAR).
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Director of Nursing in collaboration with Director of Social Services and Medical Director has written a policy on care planning in regard to [MEDICAL CONDITION] medications. This policy includes that the resident and/ or family or designated person has the right to be informed of changes in medication specifically [MEDICAL CONDITION] and the need to be included in care planning meetings. The Director of Nursing will monitor compliance with the above
protocols. Immediate corrective action, including staff re-education, will be implemented, as needed. (MONTH) 27, (YEAR).

lV. The facility has developed an audit tool to monitor compliance with protocols related to care planning and psychoactive medications. Nursing supervisors/Nursing Designee and the Director of Social Services will audit 20% of residents. Audit will be completed on a monthly basis. Audit findings will be reported to the Director of Nursing. The Director of Nursing will report the audit findings to the Administrator monthly or sooner as warranted. The Director of Nursing Services will report results as per the audit findings to the Quality Assurance Committee on a quarterly basis for committee guidance, directions and follow-up actions as may be appropriate for one year.
Responsibility: Director of Nursing.
April 27, (YEAR)

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2017
Corrected date: April 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review and interview of staff the facility did not provide services in accordance with the resident's written plan of care. Specifically, 2 CNAs (Certified Nurse's Assistants) was observed on two occasions, however nursing staff admitted to regularly feeding a resident with an order for [REDACTED]. This was evident for 1 out of 31 residents reviewed for Resident Assessments The findings is: Resident #108 is a [AGE] year old with medical [DIAGNOSES REDACTED]., [MEDICAL CONDITION] Disorder. The Minimum Data Set 3.0 assessment dated on 6/14/2016 documented resident's Cognitive status is severely impaired. The MDS further documented that resident is nonverbal, rarely/never makes herself understood and rarely never understands others and has impaired vision. The Resident requires total dependence with one person physical assist in Activities of Daily Living including eating. Resident is bed bound, ambulates by wheelchair, unable to make needs known. Swallowing / Nutritional status: no swallowing disorder. Feeding tube -nasogastric or abdominal (PEG) / Mechanical altered diet. The Comprehensive Care Plan titled Therapeutic Diet dated 12/2016 documents Resident is on Tube Feeding (TF) and By mouth (PO). It further documented Mechanically altered diet with dysphasia secondary to [MEDICAL CONDITION] disorder . The Goal is that resident will tolerate therapeutic/mechanically altered diet. Interventions include achieve and maintain nutritionally related labs within normal limits, stabilize nutritional problems thru dietary interventions. On 02/24/2017 at 12:06:28 PM the resident was observed in the dining room, during meal time. The staff was observed feeding a lunch tray to Resident which included - macaroni and cheese and baked chicken with the meat removed from the bone. The staff was observed trying to mash the macaroni and cheese with the spoon. The residents eyes were closed while being fed, she opened her mouth when disposable spoon with food is introduced. At one point during the feeding, the resident opened her mouth and CNA checked her mouth. The meal ticket was immediately reviewed and documented Puree TF'. 02/24/2017 1:33:11 PM Certified Nursing Assistant (CNA #1) was first interviewed after the meal observation. Since CNA #1 fed the Resident at breakfast, she was asked to recall what and how much did the Resident had at breakfast. She said the resident had 50% hot cereal, cream of wheat, eggs mashed, tea/orange juice, applesauce. CNA #1 said the Resident had no problems swallowing, no indication of coughing when she eats. CNA #1 also stated that when Resident starts keeping food in her mouth, it means she is full. On 02/24/2017 at 1:44 PM immediately following interviewing CNA #1 right after the meal observation an interview was conducted with the Certified Nursing Assistant (CNA #2) who stated they sometimes give her Pureed. Today, she likes the macaroni and cheese, chicken and a vegetable. She doesn't like ice cream, likes apple juice; loves strawberry yogurt. She further stated that she could not previously eat that's why she is tube fed. She further stated the Dietitian gives her Pureed but she doesn't like the Pureed and preferred what she has today. She did not report that the resident did not prefer puree or wanted regular consistency. She stated the resident is on aspiration precaution because of her breathing; but she does not see that she has a problem - that's why the machine (suction machine) is in there but never saw the nurse use it. She states she always give her a small portion of food. CNA #2 further stated that when the patient start to lose wt, they decided to give tube feeding especially when they start to lose their appetite. CNA#2 stated that there are several in-service training once a month. The CNAs check how much the resident eat daily every month. On 02/24/2017 at about 12:07:20 PM lunch time, the resident tray was observed to include chopped fish, mashed potatoes and spinach. The RD and CHIEF RD were in the dining room. On 02/27/2017 at 12:17 PM The Registered Dietitian (RD) was interviewed immediately following the that day's lunch meal. The Resident lunch tray included Chopped Fish, Mashed Potatoes and a vegetable. The RD stated that Resident is on Pureed food consistency for PO feedings (by mouth with a full tray due to dysphasia. She is on recreational feeding and on tube feeding([MEDICATION NAME], 1.2, 1 liter @90mL given at 6pm(to allow Resident to eat at daytime since PO feeding is not adequate, so tube feeding is a major source of nutrition). She mentioned that the last 3 day food record done was in [DATE]-20, 2013 due to inadequate intake. The RD defined dysphasia as having swallowing difficulty. The RD stated that aspiration precaution means is to sit in 90 degree angle, to sit up straight in the chair when they're feeding. The RD stated that in-service training regarding the food consistency to CNAs and Dietary Aides are done on a daily basis (no documentation of sign in-sheets were made available). Information is deseminated when Speech Therapist initiate a thickened liquid, Nursing will pick up recommendation and then, send to Dietary. RD stated that Meal observations are done 3x a week. On 2/24/2017 at 2:16 PM the Registered Nurse(RN) Unit Manager was interviewed. The Unit Manager Registered Nurse (RN) was interviewed regarding Policy and Procedure regarding swallow evaluation and dysphasia diet. She stated that a swallow evaluation is done to determine if Resident can be on by mouth (PO feedings). Upon the recommendation of the Doctor or the Nurse, they will do a swallow evaluation or [MEDICATION NAME] swallow down here by the X-ray Department. Speech will schedule it if necessary. The evaluation will be done if the Resident is not swallowing, and there's signs like coughing. The Staff will follow the recommendation based on the results of the evaluation. No standard follow-up procedure for swallowing evaluation are done, like every 3 months but I'm assuming it's once a year. She verified with DNS and there is no policy to have speech evaluation. Speech evaluation is based on observation and they will be evaluated when they come back from the hospital. The Physician order [REDACTED]. The 2nd Quarterly Nutrition assessment dated 12.9.2016 documented: Diet Prescription / Oral Supplements: Tube Feeding (TF), By mouth (PO) Pureed diet(Aspiration precaution) - Full tray The Certified Nursing Assistant (CNA) Accountability Record dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) documented: Feeding/eating: total dependence, Tube Feed (checked), Diet Type: [MEDICATION NAME], 1.2 Calories, Consistency : Pureed, spoon-fed Speech Language Pathology on the Progress Note of 7/19/2016 documented that Resident is currently on GT for primary means of nutrition/hydration/meds and puree, thin liquid diet with poor oral intake. Resident previously received speech treatment on 7/30/09 and discontinued on 7/31/09 secondary to reaching maximal potential. This service was consulted to conduct routine screening for speech/swallow. As per Nursing Staff, current diet tolerated with no difficulty. Nursing Home Administrative / Resident Care Policies and Procedures with effective Date: 11/2000 with a Revised Date of 3/2015 documents : Mechanically Altered and Therapeutic Diets: Diet Reference Sheet . defines Puree as Entree, starch and vegetable are all pureed into a PUDDING like consistency. Thickeners may be used. Scrambled egg is non-compliant with the pureed diet. 415.11(c)(3)(ii)

Plan of Correction: ApprovedMarch 23, 2017

I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
Resident #108: The Resident was evaluated by the Chief Clinical Director of Nutrition and the Director of Speech Pathology. A dysphasia evaluation was performed and it was determined that the resident could tolerate recreational meals of a regular consistency. Diet orders were obtained from the MD.
The two certified Nursing Assistants (CNA?s) were re-educated and counseled by the nursing supervisor:
? For not following the food consistency on the meal ticket.
The dietary food server was re-educated and counseled by the Chief Clinical Director of Nutrition:
? For not following the food consistency on the meal ticket.
All nursing staff on the unit were re-educated by the nursing supervisor that the resident?s food consistency order must be followed.
March 21, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by the same practice.
To prevent any future occurrences, all nursing staff will be re-educated on the procedure for following food consistency on meal tickets. Dietary servers will be re-educated by the Chief Clinical Director of Nutrition on the importance of serving the food consistency found on the meal ticket.
April 27, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Chief Clinical Director of Nutrition in collaboration with Director of Nursing reviewed the policy on food consistency and revisions to the policy were made to ensure that all residents receives the ordered food consistency. The Director of Nursing and the Director of Nutrition will monitor compliance with the above protocols. Immediate corrective action, including staff re-education, will be implemented, as needed. (MONTH) 27, (YEAR)
IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility has developed an audit tool to monitor compliance with protocols related to food consistency. Nursing Supervisors/Nursing Designee and dietitians will audit 20% of residents during meal time. Audits will be completed on a monthly basis. Audit findings will be reported to the Director of Nursing(DON)and Director of Nutrition. The DON will report the audit findings to the Administrator monthly or sooner as warranted. The DON will report results as per the audit findings to the Quality Assurance Committee
on a quarterly basis for committee guidance, direction and follow ?up actions as may be appropriate, for one year.
Responsibility: Director of Nursing
APRIL 27, (YEAR)

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: February 27, 2017
Corrected date: April 27, 2017

Citation Details

2012 NFPA 101 19.3.6.3 Corridor Doors 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. 19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled. Based on observation and staff interview, it was determined that the facility did not ensure that doors protecting the corridor were held open with approved hold-open devices as evidenced by doors to resident room #s 1000 and 1016 that did not properly close in that the doors sagged and scraped against the floor when tested , the door to 10th floor (Fl) Social Worker office that was equipped with a hold open hook and the door to room # 1933 that was blocked open by a wastebasket. This was noted on 2 of 10 floors of the facility. The findings are: On 02/22/17 and 02/23/17 during the life safety recertification survey between 9:00 am to 3:30 pm, it was observed that doors protecting the corridor were held open with unapproved hold open devices and did not properly close when tested . Examples include but are not limited to: - Resident room #s 1000 and 1016 that did not properly close in that the doors sagged and scraped against the floor when tested , - The 10th Fl Social Worker office that was held open with a hook installed at the bottom of the door - Resident room # 1932 that was blocked open by a wastebasket. In an interview on 02/23/17 at approximately 2:00 pm with the Director of Safety (DS), he stated that the observed unapproved hold open devices had been removed and all resident room doors will be checked to ensure proper closing. 2012 NFPA 101- 19.3.6.3 711.2(a) (1)

Plan of Correction: ApprovedApril 25, 2017

1. Three resident rooms were identified in this Statement of Deficiency. For resident rooms 1000 and 1016 the doors were repaired and no longer scrap against the floor. The third resident room the waste-basket was removed at the same time it was identified during the survey.
The hook used to hold open the Social Work office on the 10th floor was removed by facilities staff also on the same day it was identified.
2. All residents have the potential to be affected by this Statement of Deficiency. The Director of Facilities/Designee has in-serviced staff on NFPA 101 Corridor Doors, on how to identify doors which do not close properly, blocked with items or held open with unapproved devices. All resident room doors and office doors have been checked to ensure that they close properly and are not blocked with items i.e. waste baskets or held open with a device.
3. The Director of Facilities/Designee will ensure that preventive maintenance rounds are conducted quarterly by the facilities staff to ensure that the doors meet NFPA101 Corridor-Doors requirement. Any door identified during the PM checks will be systematically repaired/addressed.
4. The Director of Facilities/Designee will conduct quarterly Environment of Care rounds with the multidisciplinary team and audit the doors on each floor to ensure that they are in appropriate working condition. Findings will be presented at the quarterly QAPI committee meeting for one year for committee guidance, direction and follow-up actions as may be appropriate.
Responsibility:
Director of Facilities

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2017
Corrected date: April 27, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that doors protecting hazardous areas were made self-closing and positively latched as evidenced by: the doors to the 5th floor (Fl) resident chart room and nurse manager office observed with combustible storage lacked self-closing devices, the basement's linen chute discharge room door to the corridor was warped and did not positively latch and the door to the Dietary staff locker room, that was used to store plastic containers, did not positively latch when tested . This was noted on 2 out of 10 floors. The findings are: On 02/22/17 and 02/23/17 during the life safety recertification survey between 9:00 am to 3:30 pm, it was observed that doors protecting hazardous areas were not made self-closing, did not positively latch or did not fully close when tested . Examples include but are not limited to: - The 5th Fl resident chart room and nurse manager office. The rooms were more than 50 sq ft and were observed with storage of cardboard boxes. The doors to the corridor lacked self-closing devices - The door to the basement's linen chute discharge room did not positively latch when tested . In addition, the door was noted to have the bottom part warped and did not close properly. This issue may compromise the smoke resistance of the door. - The basement's staff locker room was observed with stored plastic containers and the door did not positively latch when tested In an interview on 02/23/17 at approximately 9:05 am with the Director of Safety (DS), he stated that the items stored on the 5th floor offices will be removed. In an interview at approximately 12:30 pm with the Director of Engineering, he stated that the defective doors observed in the basement area will be fixed or replaced if needed. 2012 NFPA 101- 19.3.2.1 711.2(a) (1)

Plan of Correction: ApprovedApril 25, 2017

1. No residents were identified as being affected in this Statement of Deficiency. The 5th floor chart room, Nurse managers' office and Dietary locker room was cleared of all combustible storage and the plastic containers. The basement linen chute doors have been replaced and latches positively. The Dietary staff locker room lock has been replaced and repairs made to the door. The self-closure mechanisms were installed.
2. All residents have the potential to be affected by this practice. Facilities staff has identified all doors protecting hazardous areas to ensure that the self-closing mechanisms are functioning and the doors latch positively.
3. The Director of Nursing/Designee has in-serviced Nursing staff, Social Work, Recreation, Rehab., and Housekeeping staff on NFPA 101 Hazardous Areas-Enclosure 2012 Existing- that storage cannot be stored in non-storage areas.
The Director of Dietary in-serviced Dietary staff on NFPA 101 Hazardous Areas-Enclosure 2012 Existing - that storage cannot be stored in non-storage areas.
The Director of Facilities in-serviced Facilities staff on NFPA 101 Hazardous Areas - Enclosing 2012 Existing - that storage cannot be stored in non-storage areas.
The Director of Facilities/Designee in-serviced facilities staff on the identification, repair, and replacement of doors requiring self closing mechanisms, as well as doors that do not positively latch. The Director of Facilities/Designee will conduct preventive maintenance rounds on a quarterly basis to ensure that doors that require self closing devices are in place and positively latches.
4. The Director of Facilities/Designee will conduct quarterly Environment of Care rounds with the multidisciplinary team and audit doors on each unit with self closure mechanisms to ensure that doors are not warped and closing properly.
Responsibility:
Director of Facilities

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: February 27, 2017
Corrected date: April 27, 2017

Citation Details

2012 NFPA 101 19.2.2.2 Doors. 19.2.2.2.1 Doors complying with 7.2.1 shall be permitted 7.2.1.5 Locks, Latches, and Alarm Devices. 7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied. Based on observation and staff interview, it was determined that the facility did not ensure that egress doors were arranged to be readily opened from the egress side as evidenced by the kitchen's walk-in refrigerators and freezers that had a hasp and padlock on the non-egress side of the doors. This was noted on 1 out of 10 floors. The findings are: The facility's kitchen area was equipped with 3 walk-in refrigerators and 4 walk-in freezers. It was also noted that the doors to the walk-in freezers and refrigerators had hasps and padlocks on the non-egress side of the doors. In an interview on 02/23/17 at approximately 11:10 am with the Director of Dietary of the facility (DD), he stated that the walk-in freezers and refrigerators were locked only at night time when the kitchen was closed. In a subsequent interview with the Director of Dietary, he stated that the hasps and padlocks will be removed. 2012 NFPA 101 19.2.2.2, 7.2.1.5.1 711.2(a)(1)

Plan of Correction: ApprovedApril 25, 2017

1. No residents were identified in this Statement of Deficiency. The Director of Facilities had the hasps and pad locks removed from the three identified freezers and refrigerators on 2/23/2017
2. No residents have the potential to be affected by this practice. The Director of Dietary and the Director of Facilities checked all walk-in freezers and refrigerators in the kitchen, and no additional hasps or padlocks were found.
3. The Dietary Director has in-serviced all dietary personnel that hasps or padlocks are not permitted on any walk-in refrigerators or freezers found in NFPA 101 Means of Egress General.
4. The Director of Dietary/Designee will conduct monthly environment of Care rounds with the multi-disciplinary team and audit all walk-in refrigerators/freezers located in the kitchen to ensure compliance. Findings will be presented at the quarterly QAPI committee meeting for one year, for committee guidance, direction and follow-up action as may be appropriate.
Responsibility:
Director of Dietary and Director of Facilities

K307 NFPA 101:PORTABLE SPACE HEATERS

REGULATION: Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2017
Corrected date: April 27, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not ensure that portable space heaters that were found in an employee area were tested for safe operating temperatures. This was noted in the basement. The findings include: During the Life Safety Code survey of the basement on 02/23/17, at approximately 12:00pm, it was noted that three portable space heaters were found underneath the work desks in the Dietary Department Office space in the basement. The portable space heaters were not being used at the time of the observation. In an interview at this time, both the Assistant Director of Facility and the Assistant Director of Engineering stated that they were not aware that the portable space heaters were in the building, and that they were not tested for safe operating temperatures. They immediately removed them, and stated that they are not allowed in the building. 2012NFPA101: 19.7.8 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedApril 25, 2017

1. No residents were identified as being affected by this practice. The heaters were promptly removed.
2. All residents have the potential to be affected by this Statement of Deficiency. Facilities staff have conducted rounds in the building to remove personal heaters.
3. The Director of Facilities/Designee has written a policy based on NFPA 101 Portable Space Heaters. Effective 4/24/17 a policy is in place that prohibits the use of Portable Space Heaters in the Facility. All staff have been in-serviced that portable heaters cannot be used in the Nursing Home.
4. The Director of Facilities/Designee will conduct quarterly Environment of Care rounds with the multidisciplinary team to ensure that space heaters are not in the Nursing Home. The findings will be presented at the Quarterly QAPI committee meeting for one year for committee guidance, direction and follow-up as may be appropriate.
Responsibility:
Director of Facilities