Suffolk Center for Rehabilitation and Nursing
December 21, 2018 Certification Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

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 the resident's Minimum Data Set (MDS) assessment accurately reflected the resident's status. This was evident for 1 (Resident #44) of 4 residents reviewed for medication administration. Specifically, Resident #44 had a physician's orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment revealed that [MEDICAL CONDITION] Disorder was not included as an active diagnosis. The finding is: Resident #44 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was admitted to the hospital on [DATE] for Subdural hematoma following a fall incident. The resident was re-admitted to the facility on [DATE]. The Hospital Transfer Summary dated 9/20/18 documented that the patient/resident was started on Intravenous (IV) [MEDICATION NAME] for [MEDICAL CONDITION] after seen by Neurosurgery for [REDACTED]. The physician's orders [REDACTED]. The Quarterly MDS assessment dated [DATE] did not include [MEDICAL CONDITION] as an active diagnoses. Review of the medical record revealed that the MDS Coordinator documented medical [DIAGNOSES REDACTED]. There was no documented evidence of [MEDICAL CONDITION] [DIAGNOSES REDACTED]. An interview with the Registered Nurse (RN) MDS Coordinator was conducted on 12/20/18 at 2:40 PM. The MDS Coordinator stated that the [MEDICAL CONDITION] documentation on 7/19/18 was an error since the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The MDS Coordinator stated the Quarterly MDS dated [DATE] should have included [MEDICAL CONDITION] as an active diagnosis, since [MEDICAL CONDITION] was a [DIAGNOSES REDACTED]. 415.11(b)

Plan of Correction: ApprovedJanuary 17, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) MDS now has the active [DIAGNOSES REDACTED].# 44.
2) All residents readmitted in the last 90 days with a new MDS have the potential to be affected. All re-admissions in the last 90 days will therefore have their physicians orders and the hospital transfer summaries compared to the MDS for accuracy. Any discrepancies will be corrected.
3) Going forward all re-admissions and new [DIAGNOSES REDACTED].
4) Results of the above audits comparing hospital diagnosis, physician orders, and MDS will be reported to QAA at scheduled meetings utilizing MDS Accuracy Log.
5) Sandra Dwyer RN MDS Coordinator/Designee.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

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 develop a baseline comprehensive person-centered care plan within 48 hours of a resident's admission. This was evident for 1 (Resident #44) of 31 residents reviewed for care planning. Specifically, Resident #44 was re-admitted to the facility on [DATE] with a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] (a [MEDICAL CONDITION] Medication). There was no baseline Comprehensive Care Plan (CCP) developed for [MEDICAL CONDITION] initiated within 48 hours of the resident's admission. The finding is: Resident #44 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Hospital Transfer Summary dated 9/20/18 documented that the patient/resident was started on Intravenous (IV) [MEDICATION NAME] for [MEDICAL CONDITION] after seen by Neurosurgery for [REDACTED]. The physician's orders [REDACTED]. An interview with the Licensed Practical Nurse (LPN) Unit Charge Nurse was conducted on 12/21/18 at 11:30 AM. The LPN stated that she could not locate the CCP for [MEDICAL CONDITION]. The LPN also stated that the CCP for [MEDICAL CONDITION] should have been developed within 48 hours of admission. 415.11

Plan of Correction: ApprovedJanuary 17, 2019

1) Resident #44 currently has a Comprehensive Care Plan in place.
2) All residents in facility for less than 48 hours have potential to be affected. All residents in facility >48 hours will be audited for the presence of a Baseline Care Plan, and any missing Baseline Care Plans will be implemented.
3) Night RN Supervisor will be tasked every night with auditing all new admissions in the last 48 hours for baseline Care Plan and implementing BCP for any residents not having one.
4) At M-F AM Meeting Unit Managers will report on Base Line Care Plans and results will be entered in Base Line Care Plan Audit Tool. Results of this audit will be reported at regularly scheduled QAA meetings.
5) DNS/Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and staff interviews during the recertification survey, the facility did not ensure that a resident who was incontinent of bladder receives appropriate treatment and services to restore continence to the extent possible. This was identified for one (Resident #46) of one resident reviewed for Bladder incontinence. Specifically, Resident #46 had a decline in bladder function from occasionally incontinent of urine to always incontinent of urine. There was no documented evidence that the effectiveness of interventions were assessed or a bladder assessment was completed to address the decline and to determine the cause for the decline. The finding is: Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score as 15, which indicated intact cognition. The resident had no behavior problems and required limited assist of one staff member for toileting. The resident was not on a toileting program and was occasionally incontinent of urine. A Quarterly MDS assessment dated [DATE] documented no change in the resident's BIMS Score of 15. The resident required supervision with set-up help for toileting. The resident was now assessed as always incontinent of urine but was not on a toileting program. A Nursing Admission assessment dated [DATE] documented the resident was occasionally incontinent of bladder and was fully ambulatory. A Comprehensive Care Plan (CCP) dated 7/17/18 for Bladder incontinence documented the resident was incontinent of urine related to cognitive impairment and pain. The goal was for the resident to have decreased frequency of urinary incontinence through the target the date of 11/15/18. The interventions included to apply incontinence devices as identified as appropriate for the resident and to monitor/document/report to the Physician as needed (PRN) any changes in incontinence. During an initial tour conducted on 12/17/18 at 8:45 AM a strong urine odor was noted in the resident's room. A urine-soaked diaper was observed on the floor behind the garbage pail. A Second observation was conducted on 12/19/18 at 1:00 PM. There was a strong urine odor in the resident's room and the resident's bed was unmade. A Review of the resident's Urinary continence record dated 7/18/18 to 7/24/18 documented the resident had seven episodes of urinary incontinence during the seven days look back period which indicated the resident was occasionally incontinent of urine. The Urinary continence record dated 10/12/18 to 10/18/18 documented the resident has daily episodes of urinary incontinence on all shifts during the seven days look back period. A review of the progress notes dated 9/3/18 to 12/20/18 lacked documented evidence that the resident's decline in bladder function was addressed. There was no documented evidence that the decline was discussed with the resident or that a bladder assessment was completed to determine the cause of the decline. During an interview conducted on 12/19/18 at 1:00 PM with the Licensed Practical Nurse (LPN) medication nurse, she stated that the resident was a heavy wetter. The LPN stated the resident was ambulatory but was not on a toileting program. The LPN stated the resident was not able to control her bladder, the resident's mattress was usually soaked with urine, and that the resident would sometimes sit in the urine. The LPN further stated after the resident is assisted out of bed her mattress is washed and left un-made to be air dried. During an interview conducted on 12/19/18 at 1:45 PM with the resident's Certified Nursing Assistant (CNA), she stated the resident had a problem with urinary incontinence during her shift. The CNA stated frequently in the morning during breakfast the resident has episodes of urinary incontinence. The CNA further stated that she changes the resident three to four times during her shift. During an interview conducted on 12/20/18 at 12:00 PM with the Registered Nurse (RN #3) MDS Coordinator, she stated that she had completed the admission MDS assessment and the resident was assessed as occasionally incontinent of urine. The RN stated she determines the resident's incontinence status through review of the Urinary Continence Record. The RN stated according to the MDS Manual seven or less episodes of incontinence during the seven days look back period codes the resident as occasionally incontinent. The RN further stated that the RN completing the MDS assessment was responsible for updating the CCP and notifying the Physician regarding the decline in the resident's bladder function. Additionally, the RN stated the Physician would be responsible for conducting a bladder assessment when there is a decline. During an interview conducted on 12/20/18 at 12:25 PM with MDS RN #4 she stated she completed the Quarterly MDS assessment dated [DATE] and that she obtained her information from the CNA documentation in the Urinary Continence Record and that the record showed the resident was always incontinent during the seven days look back period. The RN stated that she was responsible for notifying the Physician of the resident's decline in bladder function. She stated that she might have verbally told the physician. The RN further stated that she should have written a note regarding the resident's decline in bladder function. During an interview conducted on 12/20/18 at 1:53 PM with the Physician, he stated he was reviewing his notes and there was no indication that he was notified of the resident's decline in bladder function. The Physician stated that he sees the resident frequently and would have put a plan in place, such as medication, or follow up to see if the resident had another episode of Urinary Tract Infection [MEDICAL CONDITION], and to assess the nature of the incontinence the resident was experiencing. The Physician stated that an outside consult, if warranted, would have been ordered to address the resident's decline. The Physician further stated that he is sometimes bombarded with nurses coming up to him giving him verbal notification and that he has always stated that was not an effective way of communicating changes in resident's condition. During an interview conducted on 12/20/18 at 2:43 PM with the Director of Nursing Services (DNS), she stated that when a decline in the resident's bladder function is identified the MDS RN completing the assessment is to notify the Physician. The DNS stated the Physician would document his assessment either as a free-standing note or as part of his monthly evaluation. During an interview conducted on 12/20/18 at 3:26 PM with evening shift CNA, she stated that the resident was incontinent of bladder and bowel and that every two hours she offers to toilet the resident. The CNA stated that when the resident is resting or is in bed asleep she would refuse and does not want to be bothered. The CNA further stated that the resident asks for double diapers when she goes out and when she goes to bed. 415.12(d)(2)

Plan of Correction: ApprovedJanuary 17, 2019

1) Affected resident #46 has been put on a toileting program to address her decline in continence and hopefully improve continence.
2) Incontinent residents have the potential to be affected. All incontinent residents will be reviewed for the potential of a toileting program. Residents with potential will be put on same if not already on toileting program. Traceable communication system will be implemented to assure receipt of messages by MD's.
3) All nursing staff will be in-serviced in detecting decline in continence and reporting same for inclusion in a program addressing the decline. Bowel and Bladder Programs Screener in EMR will be implemented
4) Facility will generate a list of continent residents from a prior period and incontinent residents for current period monthly, and check whether corrective program was implemented (if appropriate). Results will be reported to QAA at regularly scheduled meetings.
5) DNS/Designee 2/18/19

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and staff interviews during the recertification survey, the facility did not ensure that each resident's care plan was reviewed and revised by the interdisciplinary team (IDT) to address the resident's current needs. This was identified for one (Resident #69) of two residents reviewed for Respiratory Care. Specifically, Resident #69 had a continuous Oxygen (O2) via nasal cannula (n/c) physician's orders [REDACTED]. The CCP developed for O2 therapy was not revised to reflect the resident's current physician order [REDACTED]. The finding is: Resident #69 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was severely impaired in cognition. The MDS also documented the resident was on Oxygen therapy within the last 14 days of the review period. The Comprehensive Care Plan (CCP) developed for oxygen therapy related to disease process, Shortness of Breath (SOB), and [MEDICATION NAME] dated 11/26/18 documented to administer Oxygen settings between 2-3 liters per minute (LPM) via nasal cannula (n/c), continuous for SOB, to monitor O2 saturation (spO2) every (q) shift, and to keep spO2 above 92%. The physician's orders [REDACTED]. On 12/17/18 at 9:00 AM and at 10:42 AM, the resident was observed in bed with the n/c applied. Although the O2 n/c was applied, the O2 concentrator monitor was on 0 LPM. The O2 concentrator power was not on. An interview with the Registered Nurse (RN) Supervisor was conducted on 12/17/18 at 10:45 AM. The RN stated that the resident had an order for [REDACTED]. A Physician order [REDACTED]. The new O2 order was initiated by the Director of Nursing Services (DNS). The CCP for continuous O2 was not revised to reflect the new PRN oxygen physician's orders [REDACTED]. An interview with the Director of Nursing Services (DNS) was conducted on 12/21/18 at 1:00 PM. The DNS stated that she should have revised the CCP after the O2 order was changed to PRN. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedJanuary 17, 2019

1) Resident # 69 currently has a Care Plan in place for oxygen as needed as per MD orders.
2) All residents with orders for oxygen and or Care Plans for oxygen have the potential to be affected. All residents with orders for oxygen and or Care Plans for oxygen will be reviewed to ensure that MD orders and Care Plans are synchronized.
3) All RN?s will be in-serviced on implementing appropriate Care Plans upon receipt of an MD order.
4) A list of all MD orders for oxygen will be generated weekly and compared to all Care Plans. Compliance results will be reported to QAA at scheduled meetings, and corrective measures will be implemented if needed.
5) DNS/Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

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 a comprehensive person-centered care plan for each resident was implemented. This was evident for 1 (Resident #44) of 7 residents reviewed for unnecessary medication and medication regimen review and 1 (Resident #69) of 2 residents reviewed for respiratory care. Specifically, 1) Resident #44 had laboratory orders that were not completed as per the physician's orders [REDACTED]. The gauze padding not applied on inspection. The finding is: 1) Resident #44 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission MDS assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was cognitively intact for decision making. The physician's orders [REDACTED]. The medical record revealed no documented evidence of the laboratory results were completed as ordered. The Interdisciplinary Notes reviewed from 7/19/18 through 7/22/18 documented no evidence that the resident refused laboratory blood work. The Physician's Re-admission Order dated 9/20/18 documented to administer [MEDICATION NAME] 500 milligram (mg) tablet by mouth (PO) twice a day (BID) for [MEDICAL CONDITION]. The physician's orders [REDACTED]. The Interdisciplinary Notes reviewed from 9/21/18 through 9/22/18 documented no evidence that the resident refused laboratory blood work. The Pharmacy Medication Regimen Review dated 11/11/18 documented to Please consider ordering CBC, CMP, HgbA1c, and [MEDICATION NAME] level. There were none on file since admission. There was no documented response from the Physician. The physician's orders [REDACTED]. The Interdisciplinary Notes reviewed from 12/13/18 through 12/17/18 documented no evidence that the resident refused laboratory blood work. Review of medical record revealed that there was no CBC, CMP, HgbA1C and [MEDICATION NAME] level completed. An interview with the Director of Nursing Services (DNS) was conducted on 12/21/18 at 8:12 AM. The DNS stated that the resident refused to have her blood drawn by the laboratory phlebotomist on 7/19/18. The DNS stated that the refusal was not documented. The DNS also stated that non-STAT laboratory orders are done within a week's time. The DNS was not able to provide a copy of the laboratory request ordered by the physician. An interview with with Laboratory Provider was conducted on 12/21/18 at 9:20 AM. The Laboratory Provider stated that non-STAT laboratory orders are done within the same day as soon as the Laboratory Provider receives the request, not within a week. The 7/19/18 and 12/13/18 laboratory orders were not done as per the Laboratory Provider's record requests. The laboratory provider stated there were no order sheets received by the laboratory. The laboratory provider stated that they should have the white sheet copy provided by the facility in order for the laboratory request to be acted upon. If there was a problem, the facility could have called the laboratory provider and could have inquired if the laboratory provider had received any laboratory orders/requests. The Laboratory Provider also stated, after reviewing their computer and documentation files, that there was no baseline [MEDICATION NAME] level order received by the laboratory provider since admission. 2) Resident #69 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was severely impaired in cognition. The MDS also documented the resident was on oxygen (O2) therapy within the last 14 days of the review period. The physician's orders [REDACTED]. On 12/17/18 at 9:05 AM and 10:32 AM, Resident #69 was observed lying in bed with an O2 nasal cannula applied to her nostrils. There were no 4 x 4 gauze pads applied behind both ears to protect the skin from nasal cannula injury. An interview with the Licensed Practical Nurse (LPN) Unit Charge Nurse was conducted on 12/17/18 at 10:33 AM. The LPN stated that the 4 x 4 gauze should have been applied to protect the skin integrity behind both ears. An interview with the assigned Certified Nursing Assistant (CNA) #2 was conducted on 12/17/18 at 10:34 AM. CNA #2 stated that she must have forgotten to apply the 4 x 4 gauze after completing morning care. An interview with the Director of Nursing Services (DNS) was conducted on 12/21/18 at 1:00 PM. The DNS stated that the Certified Nursing Assistant (CNA) should have applied the 4 x 4 gauze padding to bilateral ears. An interview with the Attending Physician was conducted on 12/21/18 at 1:19 PM. The Physician stated that the 4 x 4 gauze padding order should have been followed. 415.11(c)(1)

Plan of Correction: ApprovedJanuary 17, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) (a) For Resident #44 all ordered labs have been obtained: [MEDICATION NAME] Level, CBC, BMP, HgbA1C and [MEDICATION NAME] level.
(b) For Resident # 69 4 x4 gauze pads were placed behind bilateral ears as ordered.
2) (a) Residents who have MD orders for lab work have the potential to be affected. All currently effective orders for lab work will be reviewed and cross checked to confirm that lab test was performed.
(b) Residents with behind ear treatments will be audited to confirm that treatment is being applied as per order and corrections will be implemented if necessary.
3) (a) 11-7 LPN will ensure that all ordered labs have been completed in the last 24 hours. Refusals will be documented and physician notified. Oncoming nurse will repeat lab next lab day unless countermanded by MD.
(b) Behind ear treatments will now require signature of CNA in EMR for presence of treatment. Unit Manager/Supervisor/Designee will check for missing signatures per shift.
4) 25% of all lab orders and ordered behind ear treatments will be audited weekly X 4 and monthly thereafter for compliance and results reported to QAA at regularly scheduled meetings.
5) DNS/Designee

FF11 483.45(f)(1):FREE OF MEDICATION ERROR RTS 5 PRCNT OR MORE

REGULATION: §483.45(f) Medication Errors. The facility must ensure that its- §483.45(f)(1) Medication error rates are not 5 percent or greater;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that the medication error rate was below five percent. Specifically, during medication pass observation 2 errors out of 27 opportunities were observed resulting in an error rate of 7.4 %. (Resident #112). The finding is: The facility's undated policy on administering medications documented non-crushable medications should not be crushed. Resident #112 has [DIAGNOSES REDACTED]. A Physicians Order Form dated 11/1/18 included medications: [REDACTED]. The Physician orders [REDACTED]. During medication pass observation on 12/18/18 at 9:35 AM the first floor Licensed Practical Nurse (LPN) was observed to have administered [MEDICATION NAME] one tablet 800 mg and [MEDICATION NAME] one tablet 1000 mg. She then proceeded to crush the two tablets and mixed them with applesauce. The resident complained about the taste of the medications. After the Medications were administered, the blister packs were observed. Both medication blister packets documented Do Not Crush. The Licensed Practical Nurse (LPN) was interviewed at 10:00 AM and stated that the she did not read the instructions on the blister packs advising not to crush. The consultant pharmacist was interviewed on 12/19/18 11:34 AM. The consultant pharmacist stated that [MEDICATION NAME], if crushed causes a bitter taste that may cause the resident not to take the medication and may cause diarrhea. [MEDICATION NAME], if crushed would be more difficult to swallow. Both medications are vital for the resident to have. If crushed, the resident may not be able to take the medications. The Physician was interviewed on 12/19/18 at 11:59 AM and stated he would expect the nurse to follow the physician orders [REDACTED]. 415.12(m)(l)

Plan of Correction: ApprovedJanuary 17, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Affected resident now on liquid [MEDICATION NAME].
2) Residents who may be receiving crushed medications with indications ?Do not Crush? have the potential to be affected. All Medication Nurses will be in-serviced on not crushing medications with instructions ?Do Not Crush?.
3) Competency will be done on all Medication Nurses to ensure that ?Do Not Crush? medications are not being crushed.
4) 10% of all medication nurses administering medications with MD order to crush will be observed weekly X 4 and 10% monthly thereafter to insure that the medications crushed are not those with ?Do Not Crush? instructions.
5) DNS/Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that the infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections was maintained. This was evident for 1 (Resident #69) of 2 residents reviewed for pressure ulcers (P/U). Specifically, Resident #69 was observed during a Stage IV Sacral P/U dressing change. During the procedure the Licensed Practical Nurse (LPN) Wound Treatment Nurse was observed using the Epi-Cleanz sanitizer wipes 6 times in a row without washing her hands in between donning her gloves. The finding is: Resident #69 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was severely impaired in cognition. The MDS also documented the resident had one unhealed Stage IV P/U. The physician's orders [REDACTED]. The Weekly Wound assessment dated [DATE] documented a Sacral Stage IV P/U that measured 3.5 centimeter (cm) x 7 cm x 1 cm. The Physician's Progress Note dated 12/17/18 documented a Sacral P/U Stage IV that measured 3.5 cm x 7 cm x 1 cm with undermining from 1 to 4 o'clock with deepest at 3 o'clock measuring 1 cm. The Treatment Wound Administration for (MONTH) (YEAR) documented to cleanse the Sacral P/U wound with Normal Saline Solution, then apply Calcium Alginate and cover with Dry Protective Dressing (DPD). During the sacral P/U dressing change observation that was conducted with the LPN Wound Treatment Nurse on 12/19/18 at 9:20 AM, the following was observed: - after irrigating the wound bed, the LPN used the Epi-Cleanz wipes to cleanse her hands and donned gloves - the LPN did not cleanse the inner right side of the wound - the LPN used the Epi-Cleanz wipes again to cleanse her hands and donned gloves - the LPN wiped the wound periphery with a dry gauze - the LPN cleansed her hands with the Epi-Cleanz wipes and then donned gloves - the LPN opened the Calcium Alginate pack and pulled gauze out of the pack -the LPN cleanse her hands with Epi-Clenz wipes and donned her gloves - the LPN opened DPD and dated the DPD - the Epi-Cleanz wipes were again used to cleanse the LPN's hands and then she donned her gloves - the LPN applied the Calcium Alginate gauze to the wound bed by folding it to fit into the size of the wound - the LPN again cleanse her hands with the Epi-Cleanz wipes and then donned gloves - the LPN picked up the DPD and applied it to cover the wound. - the LPN removed and discarded the dressing wound barrier pad. - the LPN washed her hands in the sink with soap and water. The LPN was observed 6 times using the Epi-Clenz wipes without washing her hands in between the procedure. An interview with the LPN was conducted on 12/19/18 at 9:50 AM. The LPN stated that she did not know that she used the wipes 6 times. The LPN stated that she can used the Epi-Clenz wipes up to 3 times and then she has to wash her hands before continuing the dressing change procedure. An interview with the Director of Nursing Services (DNS)/Infection Control Coordinator was conducted on 12/21/18 at 1:00 PM. The DNS stated Epi-Clenz wipes could be used up to 3 times before washing hands. 415.19(a)(1-3)

Plan of Correction: ApprovedJanuary 17, 2019

1) (a) Competency audit and in-service will be done on all nurses performing wound care on affected resident.
(b) LPN observed during dressing change on resident #69 has been in-serviced and disciplined.

2) All residents receiving wound care have the potential to be affected. All nurses performing wound care will be in-serviced and have competency on proper infection control practices.

3) All nurses will be in-serviced and have competency on infection control and hand washing.

4) Hand washing and infection control audits will be done on all nurses performing wound care, and subsequently monthly on 10% of nurses providing wound care ongoing.
5) DNS/Designee

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

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

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that residents' medical records are maintained in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident for 2 (Residents #69, and #77) of 2 residents reviewed for respiratory care. Specifically, Residents #69 and #77 has physician's orders [REDACTED]. There was no medical indication documented for the use of O2. This was also evident for 1 (Resident #44) of 4 residents reviewed for medication administration. Specifically, Resident #44 had physicians orders for laboratory blood work, which the resident refused. There was no documented evidence that the resident refused to have her blood work drawn. The findings are: 1) Resident #69 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was severely impaired in cognition. The MDS also documented the resident received O2 within the last 14 days of the review period. The physician's orders [REDACTED]. The O2 PRN order had no documented medical indication for its use. An interview with the Physician was conducted on 12/20/18 at 2:19 PM. The Physician stated the O2 order was not complete since the O2 PRN needs parameters and medical indication for its use. An interview with the Director of Nursing Services (DNS), who initiated the order, was conducted on 12/21/18 at 1:10 PM. The DNS stated that she initiated the O2 order but she did not write O2 parameters for PRN use. 2) Resident #77 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented short and long term memory problems and severe cognition impairment. The MDS also documented the resident was on O2 therapy within the last 14 days of the review period. The physician's orders [REDACTED]. The O2 PRN order had no documented medical indication for its use. An interview with the Physician was conducted on 12/20/18 at 2:19 PM. The Physician stated parameters for O2 PRN use must be documented in the order, in addition to its medical indication. An interview with the Director of Nursing Services (DNS), who initiated the order, was conducted on 12/21/18 at 1:10 PM. The DNS stated that she did not write the O2 parameters for PRN use. 3) Resident #44 has [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Interdisciplinary Notes were reviewed from 12/13/18 through 12/17/18. There was no documented evidence that the resident refused to have the blood drawn for laboratory work for the [MEDICATION NAME] blood level. Review of the medical record revealed that the [MEDICATION NAME] ordered on [DATE] was not completed. An interview with the Director of Nursing Services (DNS) was conducted on 12/21/18 at 8:12 AM. The DNS stated that the resident refused to have her blood drawn by the laboratory phlebotomist. The DNS stated that the refusal was not documented. 415.22(a)(1-4)

Plan of Correction: ApprovedJanuary 17, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) (a) Residents # 69 and # 77 currently have medical indication for O2 use.
(b) Resident # 44 had [MEDICATION NAME] blood level done.
2) Residents on O2 and residents with lab orders have potential to be affected.
(a) All residents on O2 will be checked to ensure that there is a medical indication for the O2 use.
(b) All residents with lab orders in the last 30 days will be reviewed to assure that the lab tests were performed.
3) (a) All nurses will be in-serviced on including a [DIAGNOSES REDACTED].
(b)11-7 Nurse will run a report daily of all labs ordered for next scheduled blood draw and ensure that corresponding lab sheets exist.
(c)All nurses will be in-serviced on documenting blood draw refusals, and rescheduling for next scheduled lab day.
4) (a) All O2 orders will be audited monthly for medical indication and results reported to QAA.
(b) 10% of lab orders will be audited weekly X 4 and then monthly for lab results and/or documentation of refusal.
5) DNS/Designee

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals. This was evident for 2 (Residents #69 and #77) of 2 residents reviewed for respiratory care. Specifically, Residents #69 and #77 had Physician order [REDACTED]. Both residents were observed utilizing a nasal cannula which was connected to a O2 concentrator that was shut off. Both residents were not receiving O2 as ordered. The findings are: 1) Resident #69 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was severely impaired in cognition. The MDS also documented the resident was on O2 therapy within the last 14 days of the review period. The physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) developed for O2 therapy related to disease process, Shortness of Breath (SOB), and [MEDICATION NAME], dated 11/26/18, documented to administer O2 at 2-3 LPM via nasal cannula, continuous for SOB, and to monitor O2 saturation (spO2) every (q) shift (s) and to keep spO2 above 92%. On 12/17/18 at 9:05 AM and 10:32 AM, Resident #69 was observed lying in bed with an O2 nasal cannula applied to her nostrils. The O2 concentrator's O2 reading level was at 0 LPM. The O2 concentrator's power was off. An interview with the Licensed Practical Nurse (LPN) Unit Charge Nurse was conducted on 12/17/18 at 10:33 AM. The LPN stated that the resident should be receiving her O2 via nasal cannula and that the O2 concentrator power should not be turned off. An interview with the assigned Certified Nursing Assistant (CNA) #2 was conducted on 12/17/18 at 10:34 AM. CNA #2 stated that she did not know that the O2 concentrator was turned off. The CNA #2 stated that both the CNA and nurses are responsible for the resident's O2 concentrator. An interview with the Director of Nursing Services (DNS) was conducted on 12/21/18 at 1:00 PM. The DNS stated that Certified Nursing Assistants (CNA), who were responsible to keep the O2 concentrator on, statements per investigation revealed that the CNAs forgot to plug in the O2 concentrator or accidentally turned it off. A CNA #2 Investigation statement dated 12/21/18 documented that she accidentally turned off Resident #69's O2 concentrator when moving the O2 concentrator. An interview with the Attending Physician was conducted on 12/21/18 at 1:19 PM. The Physician stated that the O2 ordered should have been followed. 2) Resident #77 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented short and long memory problems and severely impaired cognition. The MDS also documented the resident was on O2 therapy within the last 14 days of the review period. The physician's orders [REDACTED]. The CCP developed for Alteration in Respiratory System related to [MEDICAL CONDITIONS] and Acute [MEDICAL CONDITION] dated 11/26/18 documented to provide O2 per the physician's orders [REDACTED]. On 12/17/18 at 8:51 AM and at 10:00 AM, the resident was observed being fed by a Certified Nursing Assistant (CNA) in the dining room with an O2 nasal cannula applied. The O2 concentrator's O2 reading level was at 0 LPM. The O2 concentrator's power was off. An interview with the LPN Unit Charge Nurse was conducted on 12/17/18 at 10:33 AM. The LPN stated that the resident should be receiving her O2 via nasal cannula and that the O2 concentrator power should not be turned off. An interview with the assigned Certified Nursing Assistant (CNA) #1 was conducted on 12/17/18 at 10:34 AM. CNA #1 stated that she did not know the the O2 concentrator was turned off. The CNA #1 stated that both the CNA and nurses are responsible for the resident's O2 concentrator. An interview with the Attending Physician was conducted on 12/20/18 at 2:19 PM. The Physician stated that the O2 order should have been followed. An interview with the Director of Nursing Services (DNS) was conducted on 12/21/18 at 1:00 PM. The DNS stated that CNAs, who were responsible to keep the O2 concentrator on, statements per investigation revealed that the CNA forgot to plug in the O2 concentrator. A CNA #1 Investigation statement dated 12/21/18 documented that she forgot to plug in the O2 concentrator and to put Resident #77's O2 concentrator's power on. 415.12(k)(6)

Plan of Correction: ApprovedJanuary 17, 2019

1) Residents #69 and #77 currently are receiving O2 as per current MD orders.
2) Residents on O2 have potential to be affected. All residents with MD orders for continuous O2 will have concentrators running at all times.
3) All nursing staff will be in-serviced that O2 concentrators for residents with standing orders must be on at all times.
4) Spot checks on various times, days and shifts will be done daily X 7 and 3 X a week thereafter to insure that concentrators for residents with standing orders are on. Results will be reported to QAA at regular meetings.
5) DNS/Designee 2/18/19

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure the residents equipment was maintained in good condition. This was evident for one (2nd Floor) of two nursing floor units observed during tour. Specifically, the wheelchairs/recliners of Residents #14, #74, #72, #50, and #69 had either one or bilateral torn arm rests. 2) During a pressure ulcer (P/U) dressing change observation on 12/20/18, Resident #69's Oxygen (O2) concentrator was very noisy. The findings include but are not limited to: During an observation tour of the 2nd Floor Nursing Unit conducted on 12/17/18 between 9:03 AM to 10:15 AM, the following was observed: 1) Resident #14 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 10 indicating moderately impaired cognitive skills for daily decision making. The MDS documented the resident required supervision of one person for locomotion on and off the unit, had functional limitation in range of motion (ROM) due to impaired bilateral upper and lower extremities, and utilized a wheelchair for mobility. The resident's wheelchair with torn bilateral arm rests. An interview with the assigned 7:00 AM- 3:00 PM shift Certified Nursing Assistant (CNA) #1 was conducted on 12/17/18 at 9:10 AM. The CNA stated that she was not aware of the condition of the resident's wheelchair arm rests. She stated that if she had seen the torn arm rests, she would have reported it to the Unit Charge Nurse. 2) Resident #74 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Annual MDS assessment dated [DATE] documented severely impaired cognition with short and long- term memory problems. The MDS documented the resident required total assistance of one person for locomotion on and off the unit, had functional limitation in range of motion (ROM) due to impaired bilateral upper and lower extremities, and utilized a wheelchair for mobility. The resident was observed sitting in a designated recliner with torn bilateral arm rests. An interview with the assigned 7:00 AM- 3:00 PM shift Certified Nursing Assistant (CNA) #2 was conducted on 12/17/18 at 9:10 AM. The CNA stated that she did not know that the resident's recliner arm rests were torn and that if she had known the arm rests were torn, she would have reported it to the Unit Charge Nurse. An interview with the Registered Nurse (RN) Supervisor was conducted on 12/20/18 at 10:40 AM. The RN stated that she would have the wheelchair and recliner checked by the Maintenance department. The Unit's Maintenance Log was reviewed from (MONTH) 1, (YEAR) to (MONTH) 19, (YEAR). There was no request for the designated wheelchair and/or recliner for repair. 3) Resident #69 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident had short and long-term memory problems and had severely impaired cognitive skills. The MDS also documented the resident received oxygen therapy within the last 14 days of the review period. The physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) developed for oxygen therapy related to disease process, Shortness of Breath (SOB), and [MEDICATION NAME] dated 11/26/18 documented oxygen settings at 2-3 LPM via nasal cannula, continuous for SOB. The O2 Concentrator form for Concentrator Serial #94D dated 11/1/18 revealed that the concentrator was checked for filter, flow rate, alarms operation and oxygen flow. There were no additional comments on the form. During a pressure ulcer (P/U) dressing change observation on 12/19/18 at 9:20 AM, Resident #69's Oxygen (O2) concentrator was very noisy. An interview with the Licensed Practical Nurse (LPN)/Wound Treatment Nurse was conducted on 12/20/18 at 10:30 AM. The LPN stated that she was not aware that the O2 concentrator was noisy and loud. The LPN also stated that she would report it to the Maintenance Department. An interview with the assigned 7:00 AM- 3:00 PM shift CNA #3 was conducted on 12/20/18 at 10:35 AM. The CNA stated that the O2 concentrator was a little noisy, but she thought that was alright. An interview with the Maintenance Department Director was conducted on 12/20/18 at 10:50 AM. The Director stated that he will have the O2 Concentrator supplier check and replace the O2 concentrator. 415.5(h)(2)

Plan of Correction: ApprovedJanuary 17, 2019

1. (a) All armrests of affected residents have been replaced by intact armrests.
(b) Oxygen concentrator has been replaced with quiet O2 concentrator
2.(a) All resident utilizing chairs with armrest have the potential to be affected. All armrests have been checked for integrity and any defective armrests have been replaced.
(b) All O2 concentrators have been checked for noise level and all were found to be quiet.

3.(a) Maintenance will inspect every wheelchair armrest monthly ongoing for integrity and replace/repair as needed. Nursing Staff will be in-serviced to report any defects of armrests immediately to Maintenance utilizing Maintenance Communication mechanism.
(b) Maintenance every O2 concentrator for noise level monthly X 3 and quarterly thereafter as part of regular maintenance protocol. Nursing Staff will be in-serviced to report any unusual noise emanating from concentrators and report same to Maintenance utilizing Maintenance Communication mechanism.
4. Director of Environmental Services (DES) will report to QAA at scheduled meetings on checks for armrest integrity and O2 concentrator noise.
5. Director of Environmental Services/Designee

FF11 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the recertification survey, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. Specifically, during a medication pass observation, a Licensed Practical Nurse (LPN) was observed crushing medications to give to Resident # 112. The Medication's Blister packs, dispensed by pharmacy, documented Do Not Crush. The finding is: The facility's undated policy on administering medications documented non-crushable medications should not be crushed. Resident #112 has [DIAGNOSES REDACTED]. A Physicians Order Form dated 11/1/18 included medications: [REDACTED]. The Physician orders [REDACTED]. During medication pass observation on 12/18/18 at 9:35 AM, the first floor Licensed Practical Nurse (LPN) was observed to have administered [MEDICATION NAME] one tablet 800 mg and [MEDICATION NAME] one tablet 1000 mg. She then proceeded to crush the two tablets and mixed them with applesauce. The resident complained about the taste of the medications. After the Medications were administered, the blister packs were observed. Both medication blister packets documented Do Not Crush. The Licensed Practical Nurse (LPN) was interviewed on 12/18/18 at 10:00 AM and stated that she did not read the instructions on the blister packs advising not to crush. The consultant pharmacist was interviewed on 12/19/18 at 11:34 AM. The consultant pharmacist stated that [MEDICATION NAME], if crushed causes a bitter taste that may cause the resident not to take the medication and may cause diarrhea. [MEDICATION NAME], if crushed would be more difficult to swallow. Both medications are vital for the resident to have. If crushed, the resident may not be able to take the medications. The Physician was interviewed on 12/19/18 at 11:59 AM and stated he would expect the nurse to follow the physician orders [REDACTED]. 415.11(c)(3)(i)

Plan of Correction: ApprovedJanuary 17, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Resident # 112 is now on liquid [MEDICATION NAME] as per MD order and is no longer receiving [MEDICATION NAME] medication in a pill form.
2) All residents with swallowing difficulties receiving medications in pill form have the potential to be affected. Medication form for these residents will be reviewed by clinical staff for suitability, and changes made if necessary.

3) All licensed nursing staff will be in-serviced in following manufacturer?s dispensing instructions for medications and MD orders for medication dispensing.
4) In-servicing and competencies will be done on all licensed nursing staff. Subsequently 10% of licensed nursing staff per month on a rotating basis will have competencies done. Results of all competencies will be reported to QAA at scheduled meetings.

5) DNS/Designee 2/18/19

Standard Life Safety Code Citations

K307 NFPA 101:HVAC

REGULATION: HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 21, 2018
Corrected date: February 18, 2019

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-521 Vertical Ventilation ducts that passed through floors were not protected in accordance with the requirements of NFPA 90A, Standard for the Installation of Air-conditioning and Ventilating Systems. NFPA [PHONE NUMBER]: 19.5.2.1, 9.2, NFPA 90A-2012, NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedJanuary 8, 2019

Facility respectfully requests continuation of the waivers.

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: December 21, 2018
Corrected date: February 18, 2019

Citation Details

2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 19.2.2.2.1 Doors complying with 7.2.1 shall be permitted. 2012 NFPA 101: 7.2.1.7.1 Where a door assembly is required to be equipped with panic or fire exit hardware, such hardware shall meet all of the following criteria: (1) It shall consist of a cross bar or a push pad, the actuating portion of which extends across not less than one-half of the width of the door leaf. (2) It shall be mounted as follows: (a) New installations shall be not less than 34 in. (865 mm), and not more than 48 in. (1220 mm), above the floor. (b) Existing installations shall be not less than 30 in. (760 mm), and not more than 48 in. (1220 mm), above the floor. (3) It shall be constructed so that a horizontal force not to exceed 15 lbf (66 N) actuates the cross bar or push pad and latches. 2012 NFPA 101: 7.2.1.9.1* General. Where means of egress door leaves are operated by power upon the approach of a person or are provided with power-assisted manual operation, the design shall be such that, in the event of power failure, the leaves open manually to allow egress travel or close when necessary to safeguard the means of egress. Based on observation and staff interview, the panic hardware required to manually open power sliding doors in the event of power failure, was not in accordance with Chapter 7. This was noted at the main entrance and the emergency exit in the vicinity of the beauty parlor on the lower level. The findings are: On 12/19/18 between 10:00am- 12:00pm during the recertification survey, power sliding doors were observed at the main entrance and at the emergency exit in the vicinity of the beauty parlor on the lower level. The panic hardware, required to manually open the doors in the event of power failure, was not in accordance with Chapter 7 in that the provided push pads extended across less than one-half the width of the door leaf. In an interview on 12/19/18 at approximately 2:15pm, the Director of Environmental Services stated that he would call the company to address the issue. 2012 NFPA 101: 19.2.1, 19.2.2.2.1, 7.2.1.7.1, 7.2.1.9.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJanuary 8, 2019

Element #1
The facility Maintenance Director had Nabco door company come in to remove door paddles and make doors compliant with 2012 NFPA 101:7.2.1.7.1. Nabco doors will have job completed by 2/15/2019
Element #2
All residents were potentially affected by this deficiency. The facility Maintenance Director or (designee)will conduct quarterly inspections of doors to make sure they work properly.
Element #3.
The facility Maintenance Director or (designee) will conduct quarterly environmental rounds to assure code compliance on existing infrastructure and address any new issues.
Element#4
The facility Maintenance Director will incorporate these tours into the existing quarterly building inspection and will report the findings to the Quality Assurance Committee on a quarterly basis.
Element #5
The facility Maintenance Director will be responsible for ensuring the plan of correction is implemented.