Hempstead Park Nursing Home
December 22, 2016 Certification Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

Based on observation and staff interview during the Recertification Survey, the facility did not ensure that the resident environment remained as free from accident hazards as is possible on 1 of 6 nursing units. Specifically, on the 4 North unit the Weight Room door, which has a key-lock door handle, a paper towel was jammed into the latch hole preventing the door from locking. Inside the Weight Room were six circuit breaker lighting panels with unlocked panel doors that were open. The finding is: On 12/15/2016 at 9:36 AM during the initial tour of unit 4 North the Weight Room door, which has a key-lock door handle, had a paper towel jammed into the latch hole thereby preventing the door from locking. Inside the Weight Room were six circuit breaker lighting panels with unlocked panel doors that were open. The fourth floor unit is for more independent residents and there were residents observed ambulating independently on the unit. On 12/15/2016 at 9:40 AM the Director of Maintenance and Housekeeping observed the 4 North weight room door and she pulled out the paper towel that was jammed into the latch hole. She stated that the door is supposed to be locked at all times. She stated that all of the lights on the unit are controlled from the lighting panels inside the weight room. 415.12(h)(1)

Plan of Correction: ApprovedJanuary 17, 2017

F 323
I. Immediate Correction
1. Paper towel jammed in latch hole on Four North weight room was immediately removed, door checked for safety and intended locking mechanism was in working order.
2. Director of Building Service and Maintenance Staff received educational counseling on ensuring that Resident Areas are free of accident hazards and doors checked for safety according to facility procedure.
II Identification of other Residents
1. Facility respectfully states that the there was a potential for risk for all residents.
2. The Director of Building Services and Lead Maintenance Staff member checked all safety doors on all units and resident areas to ensure that no other door latch holes had paper jams that prevented doors from closing and locking properly. Doors were all checked for safety and intended locking mechanism was in working order. No other doors were identified.
III Systemic Changes
1. Policy and procedure was reviewed and found compliant.
2. In-Service will be provided to all staff regarding policy and procedure for safety locked doors to prevent accident hazards and monitoring scheduled door checks. Focus on:
a) Staff will understand that facility must remain free from accident hazards.
b) Building service will do daily checks to ensure that all safety doors are working properly and that there are no paper jams or any other type of issues that prevent doors from shutting and locking safely.
c) When checking doors all staff will be required to turn handle and attempt to open the door. If a door opens without the key, building service staff are immediately inform Director of Building Service, Maintenance or Nursing Supervisor immediately.
d) Door is to be assessed, repaired and any issues corrected immediately.
e) Upon entering a safety locked door, if staff can open door without key, staff are responsible to notify building services/designee immediately for assessment and repair.
3. Attendance record and lesson plan will be on file for validation.
.
VI QA Monitoring
a) The Building Service Director and Administration developed an audit tool to monitor compliance with procedure and schedules related to ensuring that environment remains free from accidents hazards.
b) Building Service Director will conduct 20 door audits weekly for first month. 20 door audits monthly for the first quarter. Then 20 door audits quarterly thereafter.
c) Any negative findings will be corrected immediately
d) All findings will be presented to Quality Assurance Committee monthly for first month quarter for evaluation, quarterly thereafter, and follow up as indicated.
V Person Responsible
a. Director of Building Service

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

Based on observation and staff interview conducted during the Recertification Survey, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, four (4N, 4S, 3S, 2N) of six resident units observed for housekeeping and maintenance services had furniture/walls/doors in disrepair and had dirty radiators. The findings include but are not limited to: Observations during the initial tour of the facility on 12/16/16 between 9:30 AM and 10:20 AM revealed the following: Room 430-flooring damaged and loose by the bathroom entrance, the radiator was observed dirty with a rust-like substance present. Room 425-A rust-like substance was observed on the walls by the sink, the walls were dirty by the sink, there was cracked/peeling paint by windows. Room 405- there was damaged/worn out furniture, the radiator was dirty, the walls were dirty by the radiator. Room 404--there was chipped/cracked paint by the radiator. Room 415--the floor was damaged near the sink, a 4 inch diameter hole was observed in the tile by the sink, the dressers were damaged. Room 334--A hole was observed in the wall by the electrical outlet adjacent to the bed near the window, the radiator was dirty. Room 326--the sink piping was rusted, the radiator was dirty. Room 203--the furniture had damage to the finish, the radiator was dirty, there was a chipped bathroom door. On 12/22/2016 between 11:45 AM and 12:00 PM, the units were toured with the Director of Maintenance and Housekeeping who stated room checks are done two times per week and work slips should be filled out by staff and placed on a clip board for the maintenance staff to address. She said there is nothing she can do about the furniture that is damaged, until it is replaced through renovation. The other items can be repaired. She was not aware of the items that were identified during the tour. 415.5(h)(2)

Plan of Correction: ApprovedJanuary 17, 2017

F253 Housekeeping and Maintenance
I. Immediate Corrective Action
1. Room 430, flooring lose and damaged was replaced and repaired. Radiator with rust like substance was cleaned and repainted. Comprehensive evaluation of each room completed and all issues addressed.
2. Room 425A, rust like substance on walls by the sink was cleaned and repainted. Walls by sink were cleaned and repainted. Cracked /peeling paint by windows were repaired and repainted. Comprehensive evaluation of each room completed and all issues addressed.
3. Room 405, damaged furniture was removed and replaced with intact undamaged furniture. Radiator and walls by radiator was cleaned and repainted. Comprehensive evaluation of each room completed and all issues addressed.
4. Room 404, Walls that were chipped and cracked were repaired and painted. Comprehensive evaluation of each room completed and all issues addressed.
5. Room 415, damaged floor by sink was replaced. 4 inch diameter hole in tile near sink was replaced. Damaged dressers were removed and replaced with intact undamaged furniture. Comprehensive evaluation of each room completed and all issues addressed.
6. Room 334, hole in wall by electrical outlet adjacent to bed was repaired. Radiator was cleaned and repainted. Comprehensive evaluation of each room completed and all issues addressed.
7. Room 326, rusted sink pipe was changed to a clean pipe. Dirty radiator was cleaned and repainted. Comprehensive evaluation of each room completed and all issues addressed.
8. Room 203, damaged furniture was removed and replaced with intact undamaged furniture. Dirty Radiator was cleaned and repainted. Chipped bathroom door was repaired. Comprehensive evaluation of each room completed and all issues addressed.
9. Director of Building Services received an educational counseling for failure to ensure that housekeeping and maintenance completed scheduled maintenance and cleaning schedules to maintain sanitary, orderly and comfortable interior of the facility.
10. A copy of the education counseling was filed for validation.
II. Identification of Other Residents
1. Facility respectively states that all resident units were potentially at risk.
2. The Director of Building Services/Administration conducted a comprehensive inspection of interior building services to identify interior rooms and all areas that are not maintained in a sanitary, orderly and comfortable. All issues were corrected immediately.
III. Systematic Changes
1. The Director of Building Services and the Administrator reviewed the policy and procedure for cleaning and maintaining interior of facility and found same to be compliant.
2. All housekeeping and maintenance staff will be re in-services on current policy and procedure on cleaning and maintaining interior according to current guidelines by the by the Director of Building Service and Corporate In-service The lesson plan will focus on
? Housekeeping/Maintenance staff will understand the importance of ensuring that housekeeping and maintenance are responsible to maintain a sanitary, orderly and comfortable interior.
? All resident rooms and interior areas of the facility will be cleaned according to current schedule, and as needed. All staff are required to submit and complete work orders for any rust stains, peeling paint or any other environmental issues
? All resident rooms and interior areas will be maintained and preventative maintenance schedules followed and as needed. All staff are required to submit and complete work orders for any rust stains, peeling paint or any other environmental issues
? All interiors will be cleaned appropriately according to cleaning guidelines and maintenance to complete all repair work timely.
? Director of Building Services will maintain daily, weekly and monthly planned cleaning schedules and any areas that require cleaning will be cleaned immediately.
? Director of Building Service will monitor all work order logs daily and as they are submitted and ensure that repairs and replacements are completed immediately in order to maintain residents comfort and safety.
3. A copy of the Lesson Plan and attendance will be filed for reference and validation.
IV. Quality Monitoring
1. The Director of Building Services and Administration developed an audit tool to monitor compliance with systems and schedules related to providing a sanitary, orderly and comfortable interior.
2. Weekly Audits of 20 residents? areas will be conducted weekly by the Director of Building Services for the first month, then 20 residents monthly for the first quarter, then 20 residents quarterly thereafter.
3. Any negative findings will be corrected immediately.
4. Audit findings will be presented to the QA committee monthly for the first quarter, and then quarterly for evaluation and follow up as indicated.
V. Person Responsible for this Tag
Director of Building Services/Administration

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 1 of 30 sampled residents (Residents #176), the facility did not establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection. Specifically, the laundry of Resident #176, who is incontinent of urine, was not properly contained to prevent the spread and transmission of infections. The finding is: Resident # 176 had [DIAGNOSES REDACTED]. An observation on 12/19/16 at 12:30 PM of the resident's room revealed a strong urine odor near the laundry basket of the resident's room. The laundry basket lid was partially uncovered. The basket did not contain a plastic bag. The soiled clothing in the basket had a strong urine odor. The charge Registered Nurse was immediately made aware on 12/19/16 at 12:30 PM and stated that urine soaked clothes should be placed in a plastic bag and tied and placed in the laundry basket. The resident has a current Comprehensive Care Plan (CCP) for the resident's incontinence. Interventions included check and change protocol as needed, inspect skin every shift for any signs of skin breakdown and report to Wound Care Nurse / MD, instruct resident to call for assistance and report need to use bathroom, provide appropriate assistance with toileting needs, provide incontinent care every 3-4 hours and as needed, keep skin clean and dry at all times, and provide protective / preventative skin care as needed and incontinent care as needed. During an interview with the Director of Nursing (DON) on 12/22/2016 at 3:00 PM she stated soiled laundry should be contained in a plastic bag to prevent odors and transmission of potential infections. The DON stated that she is the acting infection control practitioner. 415.19(a)(1-3)

Plan of Correction: ApprovedJanuary 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 441 ? INFECTION CONTROL
I Immediate Corrective Action:
1. Resident #176. Strong odor in room coming from hamper where hamper lid was not placed securely and did not have a plastic bag. Hamper was changed and plastic bag placed in hamper with secure lid. Soiled clothing was placed in individual plastic bag, tied and placed in hamper with cover secure.
2. C.N.A.?s assigned to the resident on 12/19/16 were issued Educational Counseling for failure to report strong odors in room [ROOM NUMBER] and not properly placing laundry in hamper with lid secure. Education included facility?s policy on Infection Control, maintaining odor free, sanitary environment and prevent spread of infection.
II Identification of Other Residents:
1. Facility respectfully states that all residents had potential for harm.
2. Building Service Director audited all hampers for compliance and all issues were corrected at that time.
III Systemic Changes:
1. DNS, Building Service Director, Administration reviewed and revised the facility?s Infection Control Policy on Infection Prevention.
2. In-service to focus on:
a. Assigned housekeeper will pick up laundry as scheduled from each hamper. Housekeeper will remove plastic bag with dirty/soiled clothing and close lid lightly. Housekeeping staff will report any broken hampers and/or lids to Director of Building Services immediately for replacement.
b. C.N.A. - All clothing soiled with body waste will be placed in an separate plastic bag, tied and placed in the hamper. Nursing Staff will replace lid on hamper securely. C.N.A. staff will report any broken hampers/and or lids to Director of Building Service/RN Supervisor immediately for replacement.
c. Staff are responsible to report if lid or hamper is damaged or broken. Hamper and/or lid will be changed.
d. Staff will understand the facility is responsible to prevent infection and provide an environment free from odor and maintain sanitary environment at all items.
e. Staff will understand that if there is any odors in a resident?s room or environment, staff to identify where the odor is coming from and report this information to their immediate Charge Nurse/RN supervisor.
f. In-service records will be filed for validation.
IV Quality Assurance:
1. The Director of Nursing, Building Service Director and Administrator/ will develop an audit tool to monitor compliance on preventing spread of infection, odors and maintaining safe, sanitary, environment.
a) Weekly Audits of 20 residents? areas will be conducted weekly by the Director of Building Services for the first month, then 20 residents monthly for the first quarter, then 20 residents quarterly thereafter.
b) Any negative findings will be corrected immediately.
c) Audit findings will be presented to the QA committee monthly for the first quarter, and then quarterly for evaluation and follow up as indicated.
V. Person Responsible for this Tag
Director of Nursing
Director of Building Services

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that Accident/Incident (A/I) Reports were thoroughly investigated, complete and accurate. This was evident for 1 of 2 residents reviewed for hospitalization out of a total of 30 Stage 2 sampled residents. Specifically, Resident #132 had two fall incidents. Review of the A/I Reports revealed that the Reports did not have documented attachments, did not fully investigate potential causes of the falls, and erroneously documented alarms that had sounded that were not yet implemented. The finding is: Resident #132 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 7, indicating moderately impaired cognition. Section E0100 of the MDS documented that there were no potential indicators of [MEDICAL CONDITION]. Section E0200 documented that there was no presence of behavioral symptoms. The MDS also documented that the resident was not on antipsychotic, antianxiety, or antidepressant medications. The A/I Report dated 10/20/16 at 3:45 AM documented that the resident was found sitting on the floor next to the bed. The resident was unable to account as to what happened. The A/I documented that no neurological check was done. The A/I documented that there was no investigation to determine if the call bell was functional or operational. In the Registered Nurse Supervisor (RNS) Occurrence Investigation Summary Form dated 10/20/16, the RNS documented that the bed alarm sounded and the bed alarm was identified as one of the new interventions to be implemented. The RNS also documented that the Comprehensive Care Plan (CCP) and CNA Accountability Record (CNAAR) were updated and copies were attached to the A/I. The updated CCP and CNAAR were not attached to the A/I Report. The Nurse's Note dated 10/21/16 at 11:01 PM documented that the resident was very agitated and that an emergency/immediate STAT [MEDICATION NAME] 2 milligram (mg) Intramuscular (IM) x 1 dose was administered with good effect. The Medication Administration Record [REDACTED]. The A/I Report dated 10/22/16 at 6:20 AM documented that the resident was found sitting on the floor at the foot of the bed. The A/I documented that no neurological check was done. The A/I also revealed that there was no investigation to determine if the call bell was functional or operational. The Certified Nursing Assistant (CNA) Occurrence Statement Form dated 10/22/16 documented a clip on type of alarm system. There was no documentation about bed and chair alarms, which were part of the intervention for resident safety. In the RNS Occurrence Investigation Summary Form, the RNS revealed no documented evidence that the resident received [MEDICATION NAME] injection (an antipsychotic medication) a few hours prior to the fall incident. The RNS also documented that the CCP and CNAAR were updated and copies were attached to the A/I. The updated CCP and CNAAR were not attached to the A/I Report. An interview with the Assistant Director of Nursing Services (ADNS), who is responsible for the A/I Reports, was conducted on 12/22/16 at 12:00 PM. The ADNS stated that RNS should have accurately documented and completed the resident's A/I Reports. The ADNS also stated that she would expect that a neurological check should have been done since the investigation did not reveal as to how the resident fell . The ADNS stated that the Reports should have specified which alarm sounded. The ADNS also stated that the report was inaccurate in that the RNS documented bed alarm sounded; however, the bed alarm was not yet in place as an intervention. The ADNS stated that if the resident received [MEDICATION NAME] injection prior to the fall incident, then it must be documented and considered if [MEDICATION NAME] had contributed to the fall. An interview with the Night Shift RNS, who worked on 10/20/16 and 10/22/16, was conducted on 12/22/16 at 12:15 PM. The RNS reviewed the Occurrence Report that documented bed alarm sounded and acknowledged that was what she had written in her report. The RNS also stated that she is responsible for updating the CCP and might not have updated it and did not attach the CCP to the A/I. The RNS stated that she did not believe that a neurological check was needed. The facility's policy and procedure dated 12/2014 titled Occurrence Investigation and Reporting documented . A thorough investigation will be conducted to identify occurrences of abuse, neglect, mistreatment or misappropriation . To provide a timely and thorough investigation for all occurrences reported . The RNS is responsible for completing an assessment of the resident and for completing the RNS assessment section of the form .The RNS is responsible for reviewing all staff/witness completed investigations and statements and for obtaining any clarification or additional information needed from the staff member/witness to complete the investigation .The RNS is responsible for ensuring that the new/additional preventative measures are documented on the CCP and the CNAAR . 415.4 (b)(1)(ii)

Plan of Correction: ApprovedJanuary 17, 2017

F225
1) Immediate Corrective Action for Resident affected:
Resident #132
1. The Resident no longer resides at the facility.
2. The Assistant Director of Nursing (ADNS) was given an educational counseling for not ensuring that a thorough investigation for the occurrences of 10/20/16 and 10/22/16 involving Resident #132 was completed.
3. The 11-7 RNS who did not conduct a thorough investigation for the occurrence of 10/20/16 and 10/22/16 is no longer employed by the facility.
2) Identification of other Resident:
1. The DNS and Corporate RN will conduct a review of all the Occurrence Reports for the past 60 days to ensure that a thorough and accurate investigation was completed. The facility respectfully states that upon completion of this review, any identified issues will be corrected.
3) Systemic Changes made so the deficiency will not reoccur:
1. The DNS and Corporate RN reviewed and updated the facility?s P&P with regard to Occurrence Investigation and Reporting and found same to be compliant.
2. The P&P will be in-serviced to all Nursing staff.
The lesson plan will focus on:
(1) How to complete the required investigation forms/statements
(2) The following components of the P&P:
? All staff members are required to report occurrences
? A thorough investigation will be conducted for each occurrence to identify any occurrences which may rise to the level of Abuse, Neglect, Mistreatment or Misappropriation
? Occurrence investigation findings will also be used to identify additional preventative measures which will be incorporated into the Resident?s Fall Prevention plan of care
? The RNS will be responsible for initiating the occurrence investigation
? The RNS will be responsible for ensuring that all required occurrence investigation forms and relevant statements are obtained in a timely manner
? The RNs will be responsible for ensuring that all sections on the required occurrence investigation forms are filled out completely
? The RNS will be responsible for reviewing the completed investigation forms and statements and obtaining any clarification and/or additional information needed for the investigation
? The RNS will be responsible to immediately notify the Administrator and the DNS when there is reasonable cause to believe that Abuse, Neglect, Mistreatment, Misappropriation or suspicion of a crime against a Resident has occurred.
? The RNS is responsible for implementing any additional preventative measures to address any related factors/probable causes for the occurrence which have been identified through the investigative process
? The RNS will be responsible for ensuring that the Falls Prevention care plan and the CNA electronic care card/CNA instruction has been updated to include the new preventative interventions
? The DNS/Designee will be responsible for reviewing the Occurrence Log daily (Monday-Friday) to identify all Occurrences that are currently under investigation and for ensuring that the investigation is completed in a timely manner
? The DNS/Designee will be responsible for reviewing the completed Occurrence Investigation and completing section II and III of the Investigation Summary within the required time frame.
4) Monitoring of the Corrective Action/Quality Assurance:
1. The DNS developed an audit tool to monitor the facilities compliance with the timely and thorough investigation of Occurrences. The audit will be completed by the DNS/Designee for each Occurrence Report weekly x 2 weeks and then 10 randomly selected Occurrence reports monthly x 3 months and quarterly thereafter. All findings will be reported to the QA Committee monthly x 3 months and quarterly thereafter for input and follow-up as needed.
5) Responsibility: Director of Nursing

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

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews during the Recertification Survey the facility did not ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for 1 of 1 residents (#91) reviewed for Pain Recognition and Management. Specifically, a Neurologist recommended [MEDICATION NAME] (a pain medication) and Physical Therapy for Resident #91 due to back pai[DIAGNOSES REDACTED] in a written consultation; however, the staff was not aware that the consultation was done. The finding is: Resident #91 has [DIAGNOSES REDACTED]. The 11/13/2016 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. There was no pain documented in the MDS. A Comprehensive Care Plan (CCP) for Pain, effective 9/16/2016, documented that the resident had back problems. The goal included that the resident would achieve the optimal level of comfort. The resident had a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. On 12/15/2016 at 11:56 AM Resident #91 was interviewed. He stated he had pain in his back, an 8 out of 10 (on a 10-point scale, with 10 being the worst pain), but was not getting much relief from his pain medication. He said he was seen by a doctor approximately three days ago and the doctor ordered another pain medication but he still had not received it. He stated that he also gets [MEDICATION NAME] and was due for it and that he would ask the nurse for it. Resident #91 was seen by a Neurologist on 12/13/2016. The consult was ordered by the Primary Physician on 11/22/2016 to evaluate for [DIAGNOSES REDACTED]. On 12/15/2016 at 12:55 PM the unit Licensed Practical Nurse (LPN) Charge Nurse/Medication Nurse was interviewed regarding the recommendations in the Neurology consult. She stated she had not seen the consult and she and a Registered Nurse (RN) supervisor had been looking for a paper consult. She was referred to the 12/13/2016 Neurology consult that was entered by the Neurologist in the computer. She stated, I did not know the consult was in the computer. She stated she would inform the primary Physician about the recommendations. On 12/15/2016 at 1:44 PM the Director of Nursing Services (DNS) was interviewed. She stated that she had spoken to the Neurologist and let him know that when he makes a recommendation he is supposed to let the supervisor know. She stated that the Primary Physician has been contacted today and the [MEDICATION NAME] and Physical Therapy services have been ordered. A physician's orders [REDACTED]. On 12/20/2016 at 2:13 PM the RN Supervisor was interviewed. She said she did not know of the Neurology consult. She stated, The Neurologist did not follow the procedure and let us know that a consult was done. The consult is supposed to be handed to us. On 12/21/2016 at 10:42 AM the Neurologist was interviewed. He stated, You assume that someone will see the consult when you enter it into the computer. The consult may not have been picked up due to the transition from paper to computer. The facility's Policy and Procedure, titled Consultation and Specialty Services, dated 12/8/2014, states .Upon completion of consultant's examination/assessment, consultant will notify charge nurse or nursing supervisor of any assistive devices provided, such as eye glasses, dentures, hearing aids, and others. On 12/22/2016 at 12:43 PM the DNS was interviewed. She stated the policy applies to all consultant recommendations, including medications. 415.12

Plan of Correction: ApprovedJanuary 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 309 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
I Immediate Corrective Action
Resident # 91
1. Resident was seen and examined by Medical director on 12/22/16 with orders to continue medications as ordered. Per MD, resident has no new complaints, vital signs within normal limits and general condition stable.
2. A pain assessment was completed by registered nurse (RN) on 12/15/16. Resident received [MEDICATION NAME] 50 mg 1 tab by oral route PRN per MD order starting on 12/15/16 in addition to [MEDICATION NAME] 10 mg 1 tab every 6 hours for chronic pain with good effect and pain scale of 0 after medication taken.
3. Resident was seen and evaluated by Physical therapist and started receiving Physical therapy program on 12/20/16.
4. An Interdisciplinary care plan meeting was held on 12/23/16. The plan of care was reviewed and updated including review of all consultation and pain management.
5. The neurologist consultant was provided education on 12/15/16 by Medical director and DNS regarding notification of licensed nurses/PMD of any recommendation at the end of consultation assessment.
6. Educational Record on file for validation.


II Identification of Other Resident.
1. The facility respectfully states that all residents were potentially affected by the deficient practices to ensure that care/services are provided for resident?s highest well-being in accordance with the comprehensive assessment and plan of care.
2. The DNS made a list of all the current Residents who have neurology consultation consultations completed the last 60 days to ensure follow-up with recommendations.
3. The DNS and medical director also made a list of all current resident on pain management. List will be utilized by DNS and medical director for auditing to ensure that all residents on pain management are assessed and receiving appropriate pain management plan of care.
4. Any issues will be immediately corrected.

III Systemic Changes
1. The DNS and Corporate RN reviewed and revised the facility?s P&P for Consultation.
2. The DNS and Corporate RN also reviewed and revised the facility?s P&P for pain management.
3. The DNS/designee will in-service all Licensed Nurses with regard to the P&P. The focus will address:
? Upon completion of the consultant?s evaluation/examination, the consultant will hand over the completed consult form to the RN supervisor.
? RN supervisor who received consultant?s completed form will review recommendation, notify primary physician (PMD) and obtain orders as needed.
? Resident on pain management will continue to be assessed for pain before pain medication administration and reassessed response thereafter.
? If pain is not relieved, PMD will be notified for further evaluation and management.
? Plan of care will be reviewed and revised according to resident?s needs.
4. In service records will be kept on file for validation.
IV Quality Assurance
1. The Director of Nursing will develop an audit tool to monitor the facility?s compliance with the P&P.
2. DNS/Designee will complete four audits weekly times four weeks, then four audits monthly times three months and quarterly thereafter.
3. Any negative findings will be corrected immediately. All findings will be presented to QA Committee monthly for the first quarter, then quarterly thereafter for evaluation and follow-up as indicated.
V Responsible for this F Tag
1. Director of Nursing

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

REGULATION: (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident?s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician?s, nurse?s, and other licensed professional?s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, the facility did not ensure that medical records on each resident were accurately maintained and complete. This was evident in 1 of 2 residents reviewed for hospitalization in a total of 30 Stage 2 sampled residents. Specifically, Resident #132 was transferred to the hospital. The facility could not locate the Transfer Record containing the pertinent vital signs and documentation prior to the transfer. The finding is: Resident #132 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Nurse's Note dated 10/25/16 at 11:40 PM documented that the resident had bizarre behavior and that the family member wanted the resident to be sent to the hospital. The Physician offered to administer [MEDICATION NAME] injection to the resident, but the family member refused and insisted that the resident be sent to the hospital. The facility could not locate the Transfer Record containing the pertinent vital signs and documentation prior to the transfer. An interview with the Assistant Director of Nursing Services (ADNS) and DNS was conducted on 12/22/16 at 2:30 PM. Both stated that they could not locate any transfer form documentation in the medical record. 415.22(a)(1-4)

Plan of Correction: ApprovedJanuary 17, 2017

F 514: Resident Records-Complete/Accurate/Accessible

I Immediate Corrective Action
Resident # 132:
1. The resident no longer resides in the facility; therefore no corrective action can be implemented.
2. The RN supervisor and charge nurse who failed to secure a copy of the transfer form on 10/25/16 received educational counselling.
3. The Medical record clerk received educational counselling for failure to ensure that resident?s medical record document are in place.
4. Educational Record on file for validation.


II Identification of Other Resident.
1. Facility states that all residents were potentially affected for failure to maintain complete and accessible documentation in clinical record.
2. Director of Nursing compiled a list of all residents who were transferred out to the hospital the last 60 days.
3. List will be utilized by DNS to perform a review of all residents who were transferred out to hospital to ensure that a copy of the completed transfer forms with vital signs records are in place.
4. Any issues will be immediately corrected.

III Systemic Changes
1. The DNS and Corporate RN reviewed and revised the facility?s P&P for medical record keeping and maintaining completed transfer form copy accessible in resident?s medical record.
2. The DNS/designee will in-service all Licensed Nurses with regard to the P&P. The focus will address:
a. Staff will follow set guidelines for ensuring all documentation in the clinical record is accurately and completely documented and accessible.
b. All services or tasks provided by nursing staff must be documented, including completion of the transfer form, and a copy must be secured in resident medical record.
c. Staff are accountable for completing assignment, documenting accurately, timely and that services were rendered according to plan of care and that records are accessible.
d. Medical record clerk will check the resident?s medical record post hospital transfer or discharge, to ensure that all document for medical record keeping are in place.
3. In service records will be kept on file for validation.
IV Quality Assurance
1. The Director of Nursing and Corporate nurse develop an audit tool to monitor completion of transfer forms and to ensure that a copy is secured and accessible in the resident?s medical records.
2. DNS/Designee will complete four audits weekly time four weeks, then four audits monthly times three months and quarterly thereafter.
3. Any negative findings will be corrected immediately. All findings will be presented to QA Committee monthly for the first quarter, then quarterly thereafter for evaluation and follow-up as needed.
V Responsible for this F Tag
1. Director of Nursing

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: December 22, 2016
Corrected date: February 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that each resident's Comprehensive Care Plan (CCP) was reviewed and revised after a significant assessment. This was evident for 1 of 3 residents reviewed for hospitalization in a total of 30 Stage 2 sampled residents. Specifically, Resident #132 had two fall incidents dated 10/20/16 and 10/22/16. The CCP developed for Falls revealed that there were no updates completed after each fall. The finding is: Resident #132 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The A/I Report dated 10/20/16 at 3:45 AM documented that the resident was found sitting on the floor next to the bed. The resident was unable to account as to what happened. No pain or injury was documented. The A/I Report dated 10/22/16 at 6:20 AM documented that the resident was found sitting on the floor at the foot of the bed. No pain or injury was documented. The CCP developed for Falls dated 10/12/16 did not have documented evidence that it was reviewed and revised to address the 10/20/16 and 10/22/16 fall incidents and did not identify the new interventions to be implemented. An interview with the Assistant Director of Nursing Services (ADNS), who is responsible for the review of all A/I Reports, was conducted on 12/22/16 at 1:00 PM. The ADNS stated that the Night Shift RN Supervisor, who was involved in documenting the fall incidents, is responsible for updating the CCP for Falls after a fall has occurred. The facility's policy and procedure dated 12/2014 titled Occurrence Investigation and Reporting documented .The RNS is responsible for ensuring that the new/additional preventative measures are documented on the CCP and the CNAAR . 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedJanuary 17, 2017

F280
1) Immediate Corrective Action for Resident affected:
Resident #132
1. The Resident no longer resides at the facility.
2. The 11-7 RNS who did not ensure that the Fall Prevention care plan was reviewed and revised is no longer employed by the facility.

2) Identification of other Resident:
1. The DNS/Designee will conduct a review of all the Occurrence Reports for the past 60 days and the related Fall Prevention Care Plans to identify any revisions that should have been added. The facility respectfully states that upon completion of this review all Fall Prevention Care Plan will be current.

3) Systemic Changes made so the deficiency will not reoccur:
1. The DNS and Corporate Nurse reviewed the facility?s P&P with regard to Occurrence Investigation and found same to be compliant.
2. The P&P will be in-serviced to all RNS and the IDT team. The lesson plan will focus on:
? The RNS will be responsible for implementing any additional preventative measures to address any related factors/probable causes with regard to the Occurrence
? The RNS will be responsible for ensuring that the fall prevention care plan has been updated to include the new preventative interventions/revisions.
? The IDT team members will be responsible for ensuring that any additional preventative measures that have been recommended from the AM/Morning Meeting members have been added to the Fall Prevention care plan.

4) Monitoring of the Corrective Action/Quality Assurance:
1. The DNS developed an audit tool to monitor the facility?s compliance with reviewing and revising Fall Prevention care plans after an occurrence. The audit will be completed by the DNS/Designee for each Occurrence Report x 2 weeks, 10 randomly selected Occurrence Reports monthly x 3 months and quarterly thereafter. All findings will be reported to the QA Committee monthly x 3 months and quarterly thereafter for input and follow-up as needed.
5) Responsibility: Director of Nursing

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the Recertification Survey, the facility did not ensure that the Comprehensive Care Plan was followed for one of three Stage 2 residents reviewed for Activities of Daily Living (ADLs) in a total sample of 30 residents. Specifically, Resident #166 was being transferred with one Certified Nurse Assistant (CNA) while the Physician orders [REDACTED]. The finding is: Resident #166 has [DIAGNOSES REDACTED]. Observation of Resident #166 on 12/22/16 at 10:00 AM revealed that the resident was alert and seated in a wheelchair in her bed room. A quarterly Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Score (BIMS) of 9 indicating that the resident's cognition is moderately impaired. A Physical Therapy Progress noted dated 11/2/16 documented that the resident had a significant change in mobility, balance and ambulation status due to complaints of bilateral knee pain and decreased standing tolerance. The Comprehensive Care Plan (CCP), dated 11/2/16 and updated 11/16/16, documented that the resident required extensive physical assistance from two persons for transfers. The current Physician orders, dated 11/3/16 and updated 12/6/16, documented that the resident was a maximum assist of two persons for transfers. The (MONTH) and (MONTH) (YEAR) CNA Accountability Record documented the resident required one person for transferring. The current CNA electronic resident care card, which provides direction to the CNA regarding resident care needs, was reviewed. The transfer information documented in the electronic system was noted as follows: Self Performance = 1 indicating Supervision; for Support = 0 indicating no set up or physical help was needed from staff. There was no documented evidence that CNA direction for transferring status was changed when the physician's orders [REDACTED]. An interview was conducted with the Director of Rehabilitation on 12/22/2016 at 10:50 AM. She explained that for safety purposes, the resident should have been transferring with two staff persons. The Director further explained that the resident's knees could buckle. An interview was conducted with the medication Registered Nurse (RN) who explained that it was the night nurse who cosigned the physician's orders [REDACTED]. An interview with the 7 AM to 3 PM CNA was conducted on 12/22/2016 at 11 AM. She stated that the resident is very non-complaint with care. When the resident is non-compliant with care, the resident is transferred with two staff members. The CNA further stated that this morning, the resident was transferred out of bed with one staff member. The CNA further explained that the resident needs vary. The CNA was not aware that the physician had ordered the resident be transferred with 2 assists. 415.11(c)(3)(ii)

Plan of Correction: ApprovedJanuary 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I
Immediate Corrective Action for Resident affected: 
 
Resident #166 
1) The Physical Therapist completed a transfer assistance assessment to determine the Resident?s current transfer assistance need.
 
2) The CNA electronic care card has been updated to include the resident?s current transfer assistance needs.
 
3) The Unit Nurse who transcribed the 11/3/16 Physician?s order received an educational counseling for not ensuring that all orders were transcribed properly. 
4) The Unit Nurse who transcribed the 12/6/16 Physician?s order received an educational counseling for not ensuring that all orders were transcribed properly. 

 
II
Identification of other Resident: 
 
1) The DNS/Designees will conduct an audit for all current residents with regard to the CNA electronic care card including the current transfer assistance need of the Resident.  The facility respectfully states that any identified issues have been corrected. 
 
 
III
 
Systemic Changes made so the deficiency will not reoccur: 
 
1) The DNS reviewed and updated the Transcription of Physician?s Orders P&P to include the EMR process.  The P&P will be in-serviced to all licensed nursing staff.  The lesson plan will focus on: 
- The Transcribing Nurse will be responsible for the accurate transcription of the Physician?s orders 
- Accurate transcription includes completion of consultation forms, lab requisitions, Therapy requisitions, Dietary notifications, Medication Administration Record(MAR), Treatment Administration Record (TAR), CNA electronic resident care card 
- The Transcribing Nurse will alert the on-coming shifts that there are new Physician?s orders which require review 
- The two shifts following the transcription of Physician?s orders will be responsible for reviewing the orders to ensure that they have been transcribed accurately 
-Any identified transcription error/omission will be brought to the attention of the RNS for follow-up/intervention as indicated.
 
 
IV 
Monitoring of the Corrective Action/Quality Assurance: 
 
1)The DNS developed an audit tool to monitor the facility?s compliance with the accurate transcription of Physician?s orders.  The audits will be conducted by the assigned RNS for 5 randomly selected Physician orders [REDACTED].  All audit findings will be reported to the QA Committee quarterly for input and follow-up as needed. 
 
 
V
5) Responsibility: Director of Nursing 
 

FF10 483.25(a)(1)(2):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: (a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- (1) In making appointments, and (2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews during the Recertification Survey the facility did not ensure that residents received proper treatment to maintain vision abilities for 1 of 1 resident reviewed for Vision out of a total Stage 2 sample of 30 residents. Specifically, Resident #91 had a recommendation from an Optometrist for [MEDICATION NAME] (a nutritional supplement) to slow the progression of Age Related [MEDICATION NAME] Degeneration (ARMD); however, the supplement was not ordered. The finding is: Resident #91 has [DIAGNOSES REDACTED]. The 11/13/2016 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The vision was documented as adequate and there were no corrective lenses. A Comprehensive Care Plan (CCP) for Visual Function, dated 8/25/2016, documented an intervention to monitor for visual changes and report to the Medical Doctor (MD) as necessary. On 12/20/2016 at 10:36 AM Resident #91 was interviewed. He said he needed glasses because he could not see small print and that his eyes bothered him a bit. The resident was seen by an Optometrist on 10/28/2016. The consult documented the [DIAGNOSES REDACTED]. Eye glasses were not prescribed; however, the optometrist recommended to start [MEDICATION NAME], 1 tablet twice daily. On 12/20/2016 at 10:40 AM the 10/28/2016 Optometry consult with the [MEDICATION NAME] recommendation was brought to the attention of the Licensed Practical Nurse (LPN) Charge Nurse. She stated she was not aware of it. On 12/20/2016 the resident was seen by the Optometrist. The [MEDICATION NAME] was re-recommended and was ordered. On 12/21/2016 at 8:20 AM the LPN Charge Nurse was interviewed. She stated that the Optometrist was in to see Resident #91 yesterday (12/20/2016). She stated that the [MEDICATION NAME] has now been ordered. She stated that Resident #91 was previously on the third floor and was transferred to the fourth floor on 10/27/2016. The resident was seen by the Optometrist on 10/28/2016, but then the consult was sent back down to the third floor and was not followed up. On 12/21/2016 at 9:29 AM the Optometrist was interviewed. She stated that when she saw the resident on 10/28/2016 the resident was not prescribed eye glasses because he refused. She stated that [MEDICATION NAME] is a supplement for the eyes and she recommended it because it slows down the progression of [MEDICATION NAME] Degeneration. On 12/21/2016 at 12:44 PM the Director of Nursing Services (DNS) was interviewed. She stated that the consult may have been misplaced when the resident moved to the fourth floor. 415.12 (3)(b)

Plan of Correction: ApprovedJanuary 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 313: Treatment/Devices to Maintain Hearing/vision
I Immediate Corrective Action
Resident # 91
1. Resident was seen and examined by Medical director on 12/22/16 with orders to continue [MEDICATION NAME] medication as ordered. Per MD, resident has no new complaints, vital signs within normal limits, visual function same with no eye infection symptom and general condition stable.
2. Optometrist examined resident on 12/20/16 and provided resident with reading glasses on 12/21/16.
3. RN assessed resident and notify PMD of optometrist recommendation on 12/20/16 and orders obtain to start resident on [MEDICATION NAME] tab. Resident received medication with no complaints made.
4. An Interdisciplinary care plan meeting was held on 12/23/16. The plan of care was reviewed and updated to maintain current visual function with vitamin supplement and eyeglasses use.
5. Licensed nurse and RN supervisor assigned to resident #91 on 10/28/16 received Educational Counseling for failure to obtain clarification and follow-up of consultant?s recommendation in a timely manner.
6. Educational Record on file for validation.


II Identification of Other Resident.
1. The facility respectfully states that all residents were potentially affected by the deficient practices to ensure that residents receive proper treatment and assistive devices to maintain visual abilities.
2. The DNS made a list of all the current Residents who have unit changes and optometry consultations completed the last 60 days,
to ensure follow-up with recommendations.
3. Any issues will be immediately corrected.

III Systemic Changes
1. The DNS and Corporate RN reviewed and revised the facility?s P&P for Consultation.
2. The DNS/designee will in-service all Licensed Nurses with regard to the P&P. The focus will address:
? Upon completion of the optometry consultant?s evaluation/examination, the consultant will hand over the completed consult form to the RN supervisor.
? The RN who received consultant?s completed form will review recommendation, notify primary physician (PMD) and obtain orders as needed.
? Visual Plan of care to be reviewed and revised according to resident?s needs.
3. In service records will be kept on file for validation.
IV Quality Assurance
1. The Director of Nursing will develop an audit tool to monitor the facility?s compliance with the P&P.
2. DNS/Designee will complete four audits weekly times four weeks, then four audits monthly times three months and quarterly thereafter.
3. Any negative findings will be corrected immediately. All findings will be presented to QA Committee monthly for the first quarter, then quarterly thereafter for evaluation and follow-up as needed.
V Responsible for this F Tag
1. Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:NUMBER OF EXITS - CORRIDORS

REGULATION: Number of Exits - Corridors Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies. 18.2.5.4, 19.2.5.4

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued. K-252 S/S=B At least two acceptable exits are not provided form the 4416 square foot basement general store room. One of the two required exits is an emergency escape hatch, which is not in accordance with 7.5. 483.70(a), 711.2(a)(1), 10NYCRR 415.29, 2012NFPA 101: 7.5, 19.2.4.1, 19.2.4

Plan of Correction: ApprovedJanuary 23, 2017

Facility respectfully requests a continuation of waivers.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

2010 NFPA 13: 8.6.3.4 Minimum Distances Between Sprinklers. 2010 NFPA 13: 8.6.3.4.1 Unless the requirements of 8.6.3.4.2, 8.6.3.4.3, or 8.6.3.4.4 are met, sprinklers shall be spaced not less than 6 ft (1.8 m) on center. Based on observation and staff interview, the facility did not ensure that sprinklers shall be spaced not less than 6 feet apart in the kitchen. This was noted in the basement. The findings are: On 12/16/16 at approximately 10:16am during the recertification survey, three pendent type sprinkler heads spaced less than 6 feet apart were observed over the three compartment sink within the kitchen in the basement. In an interview on 12/16/16 at approximately 10:16am, the Administrator stated that they will have one capped. 2010 NFPA 13: 8.6.3.4, 8.6.3.4.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedFebruary 9, 2017

I Immediate
1. Sprinkler Company contacted and are scheduled to cap one of the sprinklers located above the three compartment sink located in the kitchen. In order to ensure that minimum distance between sprinklers is spaced not less than six feet apart. Scheduled 2/17/2017
2. Building Service Director was educated on 2010 NPFA 13. 8.6.3.4, Minimum Distance between sprinklers.
3. Educational counseling will be filed for validation

II Identification
1. The facility respectfully states that all sprinklers could be affected
2. Building Service Director and Lead Maintenance Member audited all sprinklers to ensure that sprinklers are spaced not less than six feet apart. No issues identified.

III Systemic Changes
1. The Administrator and Building Service Director reviewed the Life Safety Code 2010 2010 NFPA 13: 8.6.3.4.
2. All maintenance staff will be in-serviced. Focus on:
- Staff will understand that requirement 2010 NFPA 13:8.6.4.3 for sprinklers shall be spaced not less than six feet.
- Staff will understand that Sprinklers not meeting standards will not trigger appropriate activation of water spray due to heat pattern.
- Staff will understand that if not appropriately placed, the water spray from each sprinkler will interfere with spray of other sprinkler and will not extinguish and protect against fire hazard.
- Any new sprinklers systems added or removed due to construction, etc. will be reviewed by building service director and administration before making any changes and verify that sprinklers comply with Minimum Distance between Sprinklers.
- Lesson Plan and attendance on file for validation.

IV Quality Assurance
1. Administrator/Director of Building Services will develop an audit tool to ensure that sprinkler systems are spaced not less than six feet apart and maintained according to Life Safety Code Standard.
2. Any negative findings will be corrected immediately.
3. Findings will be presented at QA Meeting monthly for first three months, and quarterly thereafter as needed.

V Responsible for Tag
1. Building Service Director and Administration

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 22, 2016
Corrected date: February 17, 2017

Citation Details

2011 NFPA 25: 13.4.2 Check Valves. 2011 NFPA 25: 13.4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition. Based on observation, staff interview and documentation review, the facility did not maintain the automatic sprinkler system in reliable operating condition in that there was no documentation provided regarding a check valve inspection completed within the last five years. The findings are: On 12/19/16 between 10:30am- 2:00pm during the recertification survey, there was no documentation provided regarding a check valve inspection completed within the last five years. In an interview on 12/19/16 at approximately 2:15pm, the Director of Environmental Services stated that they will call the company and provide the documentation by the exit date. Documentation provided to the team by the exit date indicated that only a hydrostatic test was completed within the last 5 years but not a check valve inspection. 2011 NFPA 25: 13.4.2, 13.4.2.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedFebruary 9, 2017

I Immediate
1. Sprinkler Company contacted to set up testing date according to NFPA 25 to complete five year inspection on Valve Inspection. Date set to do testing is (MONTH) 17, (YEAR).
2. Building Service Director received an educational counseling for not following set guidelines and have the Maintenance and Testing of Automatic Sprinkler and Standpipe Systems, inspected and tested and maintained. Education counseling will be filed for validation.

II Identification
1. The facility respectfully states facility could be affected

III Systemic Changes
1. The Administrator and Building Service Director reviewed the Life Safety Code N2010 NFPA 13: 8.6.3.4.1, 10 NYCRR 711.2(a) (1).
- Staff will understand the importance of compliance with Maintenance and Testing of Automatic Sprinkler and Standpipe Systems.
- Staff will understand the importance of complying with Standards for the Inspection, Testing and Maintaining Water Based Fire Systems in order to verify that all components operate correctly, move freely and are in good condition.
- Staff will understand that documentation for testing must be filed for validation and produce document as needed.
- Lesson Plan and attendance on file for validation.

IV Quality Assurance
4. Administrator/Director of Building Services will develop an audit tool to ensure that Automatic Sprinkler system are inspected, tested and maintained according to set schedule.
5. Any negative findings will be corrected immediately.
6. Findings will be presented at QA Meeting monthly for first three months, and quarterly thereafter as needed.


V Responsible for Tag
1. Building Service Director and Administration