Safire Rehabilitation of Northtowns, LLC
March 16, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY 132) during the Standard survey completed on 3/16/18 the facility did not ensure that each resident who is unable to carry out Activities of Daily Living (ADL) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (Residents #4, 77) of four residents observed for ADL's. Specifically, Resident #77 had long, dirty fingernails and Resident #4 had dirty clothing, greasy hair, and was not showered weekly. The findings are: 1. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 2/2/18 revealed the resident rarely understands or was understood and needs physical assistance with activities of daily living. The facility policy entitled Nail Care dated 3/1/17 documented that nail care includes daily cleaning, regular trimming and should be documented in the resident's medical record. Observations revealed the following: - On 3/8/18 at 10:00 AM, the resident's fingernails on the left hand were observed to be long and have brown debris underneath them. - On 3/13/18 at 9:45 AM, four fingernails on resident's left and right hands had brown debris under them with chipped nail polish. - On 3/14/18 at 9:45 AM, four fingernails on resident's left and right hands had brown debris under them with chipped nail polish. The Comprehensive Care Plan (CCP) dated 2/15/18 revealed the resident needed total assistance from staff with grooming. The undated Third Floor Shower Schedule, identified as current by staff revealed the resident's assigned shower day was Monday on the 6:00 AM to 2:00 PM shift. The undated Bath and Shower Sheet, identified as current by staff, revealed the skin checks were not completed. During an interview on 3/14/18 at 10:04 AM, the Activities Aide stated they do manicures with the residents, they clean and polish nails but aren't allowed to cut them. The Activities Aide stated this resident does get her nails done, and she doesn't resist or pull away, but doesn't know the last time they were done with activities. At this time the Activities Aide was ambulating with the resident, looked at her nails, and stated that she would do her nails today. During an interview on 3/14/18 at 11:07 AM, Licensed Practical Nurse (LPN #7) stated the bath and shower sheets are used to document that showers or bed baths are given. During an interview on 3/14/18 at 11:45 AM, Certified Nurse Aide (CNA #1) stated he was assigned to this resident on her shower day this week. He gave her a bed bath instead of a shower because the resident was resistant to showers. The bath and shower sheet gets filled out when the resident gets a bed bath or shower, then they sign it. When asked why the bath and shower sheet wasn't completed the CNA stated he forgot to do it. CNA #1 could not recall if the resident's fingernail were dirty. 2. Resident #4 was admitted into the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident was cognitively intact and she was usually understood and usually understands. The policy entitled Bathing/ Shower dated 3/1/17 revealed the purpose of the policy was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. A resident will be offered the choice of frequency, day(s) of the week, and location of their shower/ bath. The documentation would include the date and time the shower/ tub bath was completed. If the resident refused the shower/ tub bath, the reason(s) why and the intervention taken. Additionally, the Supervisor was to be notified if the resident refused the shower/ tub bath. During an observation on 3/8/18 at 1:09 PM, the resident's hair appeared dirty (greasy) and her clothes had stains on them. At that time the resident stated, I would like to get a shower once a week, but I am lucky if I get it twice a month. During an observation on 3/9/18 at 10:35 AM, the resident's hair still appeared greasy. At that time the resident stated she did not receive her shower last night. The CCP dated 3/1/18 documented the resident required staff assistance with upper and lower extremities. The Second Floor Shower Schedule documented the resident was to be showered weekly on Thursday during the 2:00 PM to 10:00 PM shift. The Bath & Shower Sheets dated 9/1/17 through 3/14/18 revealed the resident did not receive 20 out of 30 showers during this time frame. During an interview on 3/15/18 at 3:38 PM, CNA #10 stated, If a resident is to receive a shower on my shift the nurse will let us know. The bath & shower sheet will be left out for the CNA to fill in when completed. We will document on the bath sheet if the resident refuses or if they received the shower. During an interview on 3/15/18 at 3:40 PM, LPN #2 stated, Resident #4 is to receive her shower every Thursday on the 2:00 PM to 10:00 PM shift. The CNAs are to mark the Bath & Shower Sheet in the book if the resident received their shower or bed bath. If the sheets are not marked it means the shower was not given. If the resident refuses they are to let the nurse know. I do not know why there are blanks, apparently she did not get her showers as scheduled. 415.12(a)(3)

Plan of Correction: ApprovedApril 19, 2018

The facility will ensure that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Resident #77 ? Fingernails were cleaned and manicured by the activities aide on 3/14/18. The RN Unit Manager assigned to unit 3 on 3/15/18 trimmed resident #77?s fingernails on the 7-3 shift.
The residents CNA mini care plan and ADL comprehensive care plan was updated by the unit manager on 3/20/18, the care plan revision included that the LPN assigned to resident #77?s medication administration will check her fingernails daily on the 7-3 shift to ensure nails will be cleaned and trimmed as needed between her scheduled shower day/bath days. The medication record indicates that her nails were checked for cleanliness daily and CNA assigned to resident on the 7-3 shift will be instructed to clean/trim her nails when indicated. The care plan intervention will be documented daily on the MAR indicated [REDACTED]
Resident #4 received a shower on the 7am-3pm shift on 3/16/18. Resident #4's clothing was laundered.
The resident?s comprehensive care plan and CNA mini care plan will be reviewed and revised by the IDT to include that whenever resident #4 refuses ADL care including AM & PM care or her weekly shower, the licensed nurse assigned to the shift will be notified. All shower refusals will be documented on the behavior flow sheet and 24hour report sheet by the nurse being notified of shower/bath refusal. The IDT team will update the plan of care when indicated.
All residents who are unable to carry out their activities of daily living have the potential to be affected by this same deficient practice.
The RN unit managers will conduct ADL audits for all identified residents who are unable to provide selfcare. The residents observed will be evaluated for resident grooming, including personal care and oral hygiene. Each resident?s shower/bath sheet will be audited against ADL care plan, and CNA care plan.The nurse will observe the resident?s hair, nails, and body appearance including condition of clothing.
They will review Shower/bath sheets and bathing schedules to ensure the CNAs have notified the shift charge nurse of shower/bath refusals. Any resident who refused will be re approached. All findings will be recorded on the audit tool and forwarded to the DON for review.
The DON will analyze and trend data collection and report findings to the QAA at the next scheduled meeting.
The corporate DON reviewed the policy and procedure entitled ?Nail Care? dated 3/1/17 and ?Bath/Shower? dated 3/1/17on 4/3/18. No revision was needed.
CNA #1 who was assigned to resident #77 on the 7-3 shift will be reinserviced and counseled by DON on notifying the nurse for shower refusals and nail care.
The CNA assigned to resident #77 on all 3 shifts on 3/8/18, 3/13/18 and 3/14/18 will be counseled and reinserviced by the DON on the nail care policy and procedure.
The CNA?s who did not give resident #4 a shower on Thursdays on the 2pm-10pm shift during the week of 3/8/18 and 3/15/18 and did not report to the 3-11 shift nurse that the resident refused their showers will be counseled and reinserviced by the DON regarding shower/bathing refusal and nail care.
The DON will in-service all nursing staff on the updated bath/shower sheet and in-service the nursing staff on the procedures dated 3/1/17 entitled ?Bathing/Shower? and the ?Nail Care? policy and procedure dated 3/1/17 which includes refusal requiring supervision notification.
The unit managers will conduct a weekly shower schedule audit for all residents on assigned shifts to ensure that the residents are receiving their showers/baths/nail care as assigned. The audit will include observation of the resident, a review of the resident?s shower sheets indicating whether or not they received their shower or refused and that all refusals are properly reported and documented.
All deficient practice identified will be immediately reported to the DON to ensure employees receive progressive discipline and in-servicing.
The IDT will review and revise the ADL care plan whenever the resident is refusing care/personal hygiene with bathing and showering and update interventions to address refusals and resident shower schedule choices.
The DON/ADON will analyze and trend data collection from shower schedule audit tools. All findings will be reported to the QAA committee monthly, this will be on going.
Responsible Party: Director of Nursing

FF11 483.70:ADMINISTRATION

REGULATION: §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 3/16/18, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. There was a lack of control and accountability of controlled drugs upon delivery to the facility and when discontinued drugs were surrendered and awaiting final disposition. The Administrator was not aware that proper safeguards, regarding the secure handling of controlled drugs, were not in place in the facility. The finding is: Refer to F 755 - Pharmacy Services/Procedures/Pharmacist/Records Review of a facility policy and procedure (P&P) entitled Inventory Control of Drugs (point of entry/ exit) dated 7/17 revealed the following: - The Nursing Supervisor will log the following information into the Inventory/ Narcotic Destruction Log whenever a controlled substance is received as follows: Date and time received from pharmacy, resident name, medication order including name of drug, dose or drug, amount of medication dispensed, prescription number, name of MD/ NP prescribing the narcotic, name of dispensing pharmacy, name of courier service delivering controlled substance, and Registered Nurse (RN) Supervisor receiving narcotic from courier service. - The unit nurse surrendering the controlled substance will count off narcotics with the DON (Director of Nursing) and witnessed by the ADON (Assistant Director of Nursing) or Consultant Pharmacist. All personnel will sign the individual pharmacy control sheet and Inventory Narcotic Destruction Log verifying the count for the narcotic medications surrendered for destruction. - The DON/ ADON and Consultant Pharmacist (2 personnel) receiving the controlled substance from the unit nurse will immediately enter the narcotic into the electronic narcotic destruction DEA inventory form as outlined in controlled substance on site destruction policy. Review of a P&P entitled Medication Disposal/ Destruction dated 9/17 revealed the facility will adhere to all federal, state, and local regulations related to medication destruction/ disposal when discarding any medication and medical waste. 1. Review of the facility Inventory/ Narcotic Destruction Log, used to document incoming controlled drugs from the pharmacy and surrendered drugs intended for destruction, located in the Director of Nursing's (DON's) office on 3/12/18 revealed there were no entries written in the Log book. Observation on 3/12/18 at 8:41 AM revealed there were five locked cabinets secured to the walls in a small bathroom located in the DON's office. Upon request of the surveyor, the cabinets were opened by the ADON (Assisted Director of Nursing) and the DON and observation revealed that four of the five cabinets were completely filled with discontinued controlled drugs and the medication controlled substance count sheets (untitled) were attached to each medication with a rubber band. Observation of the controlled substance count sheets revealed the sheets were dated from (YEAR) through the 3/2018. Review of a controlled substance count sheet for [MEDICATION NAME]/APAP ([MEDICATION NAME] - Schedule 2 narcotic pain medication), obtained from the cabinet in the DON's office, revealed there were two signatures at the top of the sheet, an additional signature with an initial, and an X written through the remainder of the page. Additional review of the sheet revealed that the Received by:____ signature line and the Surrendered to:____ signature line at the bottom of the form were both blank. During an interview on 3/12/18 at 8:35 AM, after the DON reviewed the controlled substance count sheet for [MEDICATION NAME]/APAP, she stated that the two signatures at the top of the page were the signatures of the nursing supervisor and the staff nurse who originally received delivery of the medication. The other signature and the initials were her and the ADON's and that were entered onto the sheet when the medication was surrendered to them for destruction. The DON stated there is no signature for the nurse who brought the medication to her to be surrendered. The DON stated, she has not had the nurses sign the Surrender to line in the past but will be requiring that in the future. During an interview on 3/12/18 at 9:17 AM, the Administrator stated she would need to refer to the policy to know the process of surrendering and destruction of controlled substances. The Administrator stated she would expect the medications in the control cabinets waiting for destruction to have been scanned for accountability. When interviewed on 3/12/18 at 9:24 AM, the DON stated that right now there is no way of knowing what is in the cabinets because she doesn't have a tracking system. The DON stated that the previous ADON left this facility's employment a couple weeks ago and the Inventory/Narcotic Destruction Log book from (MONTH) (YEAR) up through two weeks ago has been missing since she left. During an interview on 3/12/18 at 10:25 AM, the Pharmacy Consultant stated the process for surrendering controlled drugs is for the medications to be brought down from the nursing units to the DON's office; the Control Substance Count Sheet is supposed to be scanned immediately so the information is automatically entered for tracking; and the information is to be logged into the Inventory/ Narcotic Destruction Log book. The Pharmacy Consultant stated that she completed audits which identified there were too many controlled substances on the nursing units waiting to be surrendered on multiple occasions (3/2017 to 3/2018). The Pharmacy Consultant stated she would expect the DON to have a record to know what is in the cabinets for destruction and the Inventory/ Narcotic Destruction Log book is to be completed when a control substance is delivered to the building and when it is surrendered for destruction to maintain an accountability of all control substances in the building. The Pharmacy Consultant reviewed a few copies of the surrendered control sheets from the cabinets in the DON's office and the Consultant stated that there was no signature of who surrendered the medication to the DON. The Pharmacy Consultant reviewed the Inventory/ Narcotic Destruction Log book which revealed that no entries have been made into the book. The Pharmacy Consultant stated there is no system in place that is being utilized to assure accountability of control substance medications. Interview on 3/16/18 at 12:07 PM with the Administrator revealed she would need to refer to the policy and nursing concerning the process of control substance destruction. The Administrator stated she was not aware that the controlled drugs were not being logged into the Inventory/ Narcotic Destruction Log book upon receiving or surrendering. The Administrator stated she was not aware that the Inventory/Narcotic Destruction Log book tracking medications from (MONTH) (YEAR) up to approximately 2 weeks ago was missing and she was not aware that the nurses' signatures for surrendering the controlled drugs to the DON was not complete. The Administrator stated there will be Quality Assurance processes developed to monitor for system failures. Review of Part 80.6 of the New York State Rules and Regulations on Controlled Substances for Safeguarding Controlled Substances revealed the following: - (c) The administrative head of a licensee hospital, laboratory, dispensary, nursing home and health-related facility and the supervisor of a manufacturer or distributor is responsible for the proper safeguarding and handling of controlled substances within the hospital or other facility. An administrative head or supervisor is not relieved of his responsibility to detect and correct any diversion or mishandling of controlled substances by a delegation of responsibility. 415.26

Plan of Correction: ApprovedApril 12, 2018

On 3/12/18 the Administrator immediately notified the Corporate DON of the violation. The corporate DON and Regional RN Education Nurse arrived on site. The corporate DON instructed the Regional Nurse Educator to assist the Don and acting ADON in completing a narcotic verification audit/count to ensure all narcotics were accounted for and no diversion occurred. The D/C narcotic medications were removed from the 4 double locked narcotic cabinets that were awaiting destruction. The Corporate DON advised the Regional RN Educator to ensure the Facility policies and procedure for inventory of control drugs (Point of Entry/ Exit) and the medication disposal/destruction policy dated 9/17 were followed, while conducting the narcotic count/inventory verification audit process.
The audit began immediately with the regional nurse present. The narcotics were counted by the DON/ADON, verified against pharmacy packing slip (point of entry) then marked to the narcotic blister pack label, pharmacy narcotic count down sheet, physicians order and discontinued order dates, medication orders including name or drug, dose of drug, amount dispensed, pharmacy prescription number, name of medical provider prescribing the narcotic, name of dispensing pharmacy, name of courier delivering the controlled substance indicated on packing slip, the RN receiving the narcotic from the pharmacy indicated on packing sheet.
The unit nurse surrendering the narcotic and signing for and counting the narcotic with the DON and ADON or pharmacist as a witness to the surrender process and ensuring 3 signatures was indicated on the individual count sheet when the narcotic was surrendered.
Once the narcotic medication was accounted for and there was no evidence of narcotic diversion the narcotic medications were entered into the inventory/narcotic destruction log book and the DOH-166 control substance surrender form detailing the control substances to be destroyed. The Corporate Director of Nursing completed the DOH-2340 request for approval of disposal/destruction of controlled substance from. The DOH 2340 form and DOH 166 inventory forms were completed and mailed to the Bureau of Narcotic Investigation on the same day. The BNE approved the narcotic destruction to occur on the week of 4/18/18 via ?Drug take back day?.
The Regional RN educator notified the corporate DON and Administrator of deficient practices identified throughout the audit process. The Regional RN Educator will analyze and trend data collection and policy and procedure violations and report findings to the QAA committee at the next scheduled meeting.
The DON and acting ADON were in-serviced on the policies and procedures mentioned above throughout the narcotic verification audit. This occurred on 3/12/18 through 3/14 /18.
The policies and procedures entitled ?Inventory Control Drugs point of entry/exit dated 7/17 and the policy and procedure entitled ?Medication Disposal/Destruction dated 9/17 were reviewed by corporate DON. No revisions were needed.
The facility administrator will counsel the DON for not following the facility policies and procedures and the established system for control substance, lack of control and accountability of control drugs upon delivery to the facility and when discontinued drugs are surrendered and awaiting final disposition.
The DON did not ensure the accurate acquiring and receiving including receipt and disposition of all controlled substances in sufficient detail to enable an accurate reconciliation.
The Administrator will assure the consultant pharmacist conducts audits on the control and accountability of controlled drugs and that proper safeguards are in place at the facility. The Director of Nursing, Regional RN Educator and Consultant Pharmacist will conduct audits at regular and random intervals and submit to the Administrator upon completion. All data will be submitted to the Quality Assurance committee monthly. This will be ongoing.
Responsible Party: Administrator

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: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 3/16/18, the facility did not ensure that a written summary of the baseline care plan, that included initial goals, list of current medications, dietary instructions, and services/ treatments to be administered by facility and personnel acting on behalf of the facility, was provided to the resident or the resident's representative for one (Resident #85) of 10 newly admitted residents. Specifically, there was no evidence in the medical record the summary was provided to the resident or the resident's representative by completion of the comprehensive care plan. The finding is: 1. Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 2/7/18 revealed the resident had severe cognitive impairment. The resident was discharged home on[DATE]. The Interim Care Guide dated 1/31/18 was signed by the nurse completing the form however, there was no signature of the resident or the resident representative. The care guide did not include goals or a list of medications. The Comprehensive Care Plan (CCP) dated 2/14/18 revealed there was no evidence the care plan was reviewed and provided to the resident or the resident's representative. Nurse's Progress Notes dated 1/31/18 through 2/20/18 revealed there was no documentation that the care plan was reviewed and that a copy was provided to the resident or the resident's representative. Social Services Progress Notes dated 2/1/18 through 2/2/18 revealed there was no documentation the baseline care plan summary was reviewed and that a copy was provided to the resident or the resident's representative. The next Social Work (SW) note entry dated 2/20/18 revealed a family meeting took place with the resident, his daughter and granddaughter present. There was no documentation that a written summary of the baseline care plan or the CCP was provided to the resident or the resident's representative. During an interview on 3/15/18 at 9:00 AM, the Social Worker stated, they have care plan meetings probably two to three weeks after admission. Residents and families are invited. A lot of times she doesn't hear from family, so she calls them the day before the meeting, ask if they got their meeting notice and give them an option of a phone conference. When asked if they provide a written summary of the care plan the Social Worker stated, not really no, we go over it with them but had never heard anyone say they wanted a copy, I wasn't aware of the requirement (for baseline care plans). During an interview on 3/15/18 at 10:15 AM, the Director of Nursing (DON) stated on admission we do an interim care plan includes ADLs (Activities of Daily Living) like transfer/ eating/ basic essential things needed on admission. The comprehensive (Care Plan) is completed later, the MDS nurse knows the exact timeframes. The DON stated she was not familiar with the baseline care plan summary requirement. During an interview on 3/15/18 at 10:18 AM, the MDS coordinator stated the care plan is done by day 21. The meetings are completed on or before day 21. When asked if a baseline summary is completed and provided to the family, the MDS coordinator stated, no, I don't think we do. If families come in on admission, I don't think they get a copy of anything unless they request it. The MDS coordinator stated that unless a resident is alert and oriented they go over everything upon admission with the family if they are present. The MDS coordinator stated she was not familiar with the baseline care plan summary requirement. 415.11

Plan of Correction: ApprovedApril 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A baseline careplan will be given on admission to all residents admitted or readmitted to the facility by the supervisor starting 4/12/2018. Additionally, residents will partake and help staff complete their baseline careplan on admission.
Resident number 85 no longer resides at the facility. This resident was discharged on [DATE] in stable condition.
All residents who have been admitted to the facility in the last 30 days have the potential to be affected by this same deficient practice. The interdisciplinary team will conduct a 100% record review for all residents identified above. A 100% will be conducted to ensure the baseline care plan was developed within 48 hours of admission, reviewed by the interdisciplinary team, and reviewed with the resident and the resident?s representative who has been provided the baseline careplan within 48 hours of admission per saffire cares baseline careplan form/policy and procedures dated 11/22/17 whenever deficient practice is identified will be corrected within 48 hours.
The social worker will ensure the resident and the residents representative is invited to the comprehensive careplan meeting.

The Director of Nursing will analyze and trend the data in report findings to the quality assurance meeting.

The corporate Director of Nursing reviewed the policy and procedure titled careplan/baseline within 48 hours of admission/ readmitted d 11/22/17 no revision was needed.
The corporate Director of Nursing will in-service the administrator and Director of Nursing on baseline careplan policy and procedures during the week of 4/16/18. The administrator will ensure the baseline careplan policy and procedures and the baseline care plan form.
The Director of Nursing will in service the interdisciplinary team and licensed nursing staff on the baseline careplan policy and procedure.
The Registered Nurse supervisor will be required to conduct baseline careplan audit for all resident admission and readmissions every night. The Registered Nurse supervisor will forward the audit findings to the Director of Nursing every morning. If the 11-7 Registered Nurse supervisor identifies a deficient practice they will complete the baseline careplan. This will be ongoing.
The Director of Nursing will ensure that the interdisciplinary team meets after the morning meeting and updates the baseline careplans completed by the 11-7 Registered Nurse supervisor. The social worker will be responsible for reviewing the baseline careplan with the resident/resident representative with 48 hours of admission and providing the each of copy of the careplan.
The Director of Nursing will analyze and trend the data collection obtained from the 11-7 shift audits weekly and forward the findings to the facility administrator, regional quality assurance nurse and the corporate Director of Nursing. The baseline care plan audit findings will be presented by the Director of Nursing to the quality committee monthly. This will be ongoing.

Responsible Party: Director of Nursing

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 minimal harm
Citation date: March 16, 2018
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on [DATE], the facility did not ensure that Comprehensive Care Plans (CCP) was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessments. Two (Residents #16, 73) of 35 residents reviewed for Care Plans had issues involving the lack of Care Plan revisions for a resident on [MEDICAL CONDITION] medications (Resident #16) and a resident with advanced directive changes (Resident #73). The findings are: Review of the facility policy titled Care Plans - Comprehensive dated [DATE] revealed that the facility is to have ongoing assessments of the CCP and revise them when the resident's condition and information changes. 1. Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident has severe cognitive impairment, did not have any unwanted behaviors, and receives antidepressant, antianxiety, and antipsychotic medication on a routine basis. Review of the CCP dated [DATE] under the Behaviors revealed medications Trazadone (antidepressant), [MEDICATION NAME] (antianxiety), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (antipsychotic) 0.5 milligrams (mg) BID (twice a day) PRN (as needed) x three days (started [DATE]). Review of the Consultant Pharmacist Record dated [DATE] revealed [MEDICATION NAME] was discontinued on [DATE] and replaced with [MEDICATION NAME] 0.5 mg once a day. On [DATE] the Pharmacist noted that the [MEDICATION NAME] was discontinued on [DATE]. Review of the Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 Unit Manager (UM) on [DATE] at 11:33 AM revealed the resident is no longer on Trazadone and [MEDICATION NAME] and that the CCP should have been updated to reflect the change. Interview with the Director of Nursing (DON) on [DATE] at 11:42 AM revealed that she expects her staff to update the resident's CCP within 24 hours when there is a change in a resident's medications. 2. Resident #73 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is sometimes understood and usually understands. Review of the Daily Orders Report dated [DATE] through [DATE] revealed a Physician's Order under Advanced Directives Do Not Resuscitate (DNR-to withhold CPR (cardiopulmonary resuscitation) and emergency life saving measures in the event of the absence of a heartbeat and/or respiration) dated [DATE]. Review of the Medical Orders for Life Sustaining Treatment form (MOLST) dated [DATE] revealed resident has a DNR, is on comfort measures only and do not send to the hospital. Review of the CCP dated [DATE] revealed under Advanced Directives the resident is a Full Code. Interview with the Social Worker (SW) on [DATE] at 1:00 PM revealed any CCP change should be done immediately regarding Advanced Directives. During an interview on [DATE] at 1:36 PM, after reviewing Resident #73's CCP, LPN #2 UM stated that the SW is responsible for updating the CCP regarding Advanced Directives and the update should be done immediately. Follow up interview with the SW on [DATE] at 11:02 AM revealed she was responsible for updating Resident #73's CCP when he changed from a Full Code to a DNR and comfort care. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedApril 12, 2018

A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message.

E3BP 402.6(a):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. (a) The provider shall ensure the submission of a request for a criminal history record check for each prospective employee. If a permanent record does not exist for the prospective employee, the Department shall be authorized to request and receive criminal history information from the Division concerning the prospective employee in accordance with the provisions of section 845-b of the Executive Law. Access to and the use of such information shall be governed by the provisions of such section of the Executive Law. The Division is authorized to submit fingerprints to the FBI for a national criminal history record check.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during the Standard survey completed on 3/16/18, a Criminal History Record Check (CHRC) was not performed for one (Certified Nurse Aide) of eight employee files reviewed for compliance with CHRC regulations. The finding is: 1. Record review of personnel files on 3/13/18 revealed one (Certified Nurse Aide) of eight employees reviewed did not have a background check preformed through the CHRC program. Further review revealed a CHRC 102 Form - Acknowledgement and Consent Form for Fingerprinting and Disclosure of Criminal History Record Information - was signed by the employee on 1/4/18. Continued review of this employee's automated time card record revealed this employee worked 117.6 hours in this facility between 1/11/18 and 2/27/18 without being submitted to CHRC. Interview with the Administrator on 3/13/18 at 3:30 PM revealed as a general practice, CHRC 102 Forms are filled out by the applicant on-site and then faxed to a related facility where the paperwork is processed and submitted to CHRC. Additional interview with the Administrator on 3/14/18 at 11:05 AM revealed she first discovered this employee's paperwork was never submitted to CHRC when this Surveyor requested the file for review, and she discussed it with the CHRC Authorized Person, who is stationed at the related facility where the paperwork is processed, and neither are sure why the paperwork was not submitted to CHRC. Review of the facility's policy called, Criminal Conviction Record Requests, revised 11/10/16, revealed the Human Resources Generalist will conduct a search of the Criminal History Record Check section of the HPN (Health Provider Network) website to determine employment eligibility of all applicants to whom the facility wishes to extend an offer of employment. 402.6(a)

Plan of Correction: ApprovedApril 12, 2018

The CHRC check for the employee was performed on 3/12/2018 . The staffing coordinator responsible for this violation was terminated from the facility on (MONTH) 16th, (YEAR).
All residents have the potential to be affected by this violation.
The interim scheduler will perform an audit confirming that all Criminal History Record checks have been performed on current employees.
The Administrator is now performing all of the Criminal History Record Checks. This is being done prior to an employee being approved for hire at the facility.

The Administrator will review the source documents of all potential employees to verify the Criminal History Record Check has been performed, and an employee is hire able, prior to an employee being approved to start employment.
The Human Resource Coordinator will randomly audit new employee records for compliance with Criminal History Record checks monthly for three months and than quarterly. Results will be submitted to the Quality Assurance Committee.

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during the Standard survey completed on 3/16/18, the facility did not immediately remove an employee from direct care of residents upon receiving a Criminal History Record Check (CHRC) negative determination letter for the employee. This affected one (Certified Nurse Aide) of three employee files reviewed for CHRC negative determinations since the last standard survey. The finding is: 1. Record review of personnel files on 3/13/18 revealed a Pending Denial letter from the New York State Department of Health Criminal History Record Check Legal Review Unit was issued for an employee (Certified Nurse Aide) on 1/19/18. Review of this employee's automated time card record revealed this employee worked 87.9 hours beyond 1/19/18 and this employee's last day of employment was 2/11/18. Interview with the Administrator on 3/14/18 at 11:20 AM revealed the CHRC Authorized Person is stationed in a related facility and the Authorized Person completed the CHRC 105 Form - Termination Form - on 1/19/18 for this employee, but there must have been a missed communication which allowed this employee to continue working beyond the Pending Denial Letter and the CHRC 105 Form. Review of the facility's policy called, Criminal Conviction Record Requests, revised 11/10/16, revealed if the facility receives criminal history information about an employee at any time during the provisional employment period that reveals a listed offense, the employee will be immediately disqualified for employment. 402.7(a)(2)(i)

Plan of Correction: ApprovedApril 12, 2018

The CNA was terminated from employment on 2/11/2018. The staffing coordinator responsible for this violation was terminated from the facility on (MONTH) 16th, (YEAR).
All residents have the potential to be affected by this violation.
The Administrator confirmed with Human Resources that there were no outstanding Criminal History Record Checks with a pending denial requiring employee termination.
The Administrator is now performing all of Criminal History Record Checks and receiving all results directly and any pending denial results will be acted on immediately.

The Human Resource Coordinator will randomly audit employee records for timely termination of those employees whom have a pending denial monthly for three months and than quarterly. Results will be submitted to the Quality Assurance Committee.
Responsible Party: Administrator

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Standard survey completed on 3/16/18, the facility did not develop and implement a comprehensive person-centered Care Plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Four (Residents #14, 19, 43, 60) of 35 residents reviewed for Care Plan development had issues. Specifically, no care plan was developed for a resident with a history of urinary tract infections [MEDICAL CONDITION] (Resident #60); a resident with an arteriovenous (AV) fistula for [MEDICAL TREATMENT] (Resident #19); and residents who had resident to resident altercations (Residents #43 and #14). The findings are but not limited to: Review of a facility the policy titled Care Plans - Comprehensive dated 2/1/17 revealed that the facility is to develop a Comprehensive Care Plan (CCP) that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. The facility is to have ongoing assessments of the CCP and revise them when the resident's condition and information changes. 1. Resident #19 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS - a resident assessment tool) dated 12/19/17 revealed the resident has severe cognitive impairment and receives [MEDICAL TREATMENT]. The Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed that the resident attends [MEDICAL TREATMENT] three times a week and nursing staff must monitor the AV fistula (a connection between an artery and a vein used for [MEDICAL TREATMENT] patients for their treatments) for signs and symptoms of bleeding, infection, and check for bruit and thrill (sounds that the fistula makes when heard through a stethoscope). Review of the current CCP dated 12/21/17 revealed, under the [MEDICAL TREATMENT] section of the CCP, the resident is non-compliant with fluid and diet restrictions. The CCP revealed no documentation regarding monitoring the AV fistula. During an interview on 3/15/18 at 10:42 AM, Licensed Practical Nurse (LPN) #2 Unit Manager stated, It would be a good idea to put something on the CCP about the resident's AV fistula; I'll update the Care Plan. During an interview on 3/15/18 at 10:52 AM, the Director of Nursing (DON) revealed the expectation is for staff to document on the CCP a resident with an AV fistula and to monitor that fistula. 2. Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident is cognitively intact and is understood and understands. During an interview on 3/8/18 at 11:28 AM, Resident #14 stated, Two days ago the man in the orange shirt, while pointing to Resident #60, (a male resident seated in the dining area), walked over to me and started reaching for my lunch. I told him to stop and he took his walker and jammed it into my walker. Review of an Accident/ Incident report dated 3/6/18 revealed Resident #14 and #60 were sitting next to each other in the dining room and Resident #60 tried to eat food from Resident #14's tray. Resident #14 became upset and both started arguing. Resident #60 grabbed Resident #14's left wrist. Resident #14's left wrist was assessed and slight redness was observed. Review of Resident #14's Resident Care Records (Nurse's Progress Notes) dated 3/6/18 at 2:30 PM revealed Resident #14 was sitting in dining room with her food tray. Another resident eating next to her tried to get her food and Resident #14 got upset and both started arguing. The other resident got agitated and physically responded, he grabbed Resident #14's left wrist and found slight redness on her wrist. Review of Resident #14's CCP dated 1/4/18 revealed the resident is independent with mobility and eating; is alert and oriented times three and has independent decision-making. The CCP lacked development and interventions for a resident to resident altercation for 3/6/18. Review of the Mini Care Plan (care guide used by Certified Nurse Aides (CNA) to provide care) dated 3/9/18 revealed a lack of interventions for a resident to resident altercation. Interview with the Social Worker (SW) on 3/14/18 at 12:43 PM revealed the SW was not aware of this incident and that there is no CCP development related to the resident to resident interaction. The SW stated the resident to resident altercation including interventions will be added to Resident #14's Care Plans. 3. Resident #43 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident is cognitively intact, is understood and understands and requires two persons assist for transfers. During an interview on 3/8/18 at 10:18 AM, Resident #43 stated, A long time ago me and another resident who was my roommate at that time got into an altercation so my roommate was moved to another room. While pointing to a male resident in an orange shirt near the Nurse's Station (Resident #60) Resident #43 stated, He walks in my room and I don't like it because he goes through my belongings, so the staff put up a door guard to prevent him from coming in my room. I'm not sure when it was put into place or if it works, but the man hasn't come into my room again. Review of an Accident/ Incident report dated 2/11/18 revealed a CNA heard yelling from Resident's #43 & #60 room. Resident #43 admitted he punched Resident #60 in the face because he was wandering around his bed grabbing him. Resident #60 sustained a 2-centimeter (cm) x 0.5 cm laceration beneath his left eye and was sent to emergency room for evaluation. Resident #60 was provided a room change. Review of the CCP dated 3/1/18 revealed Resident #43 requires extensive assistance for bed mobility, requires two assist with a mechanical lift for transfers, and is alert and oriented times three. Review of the behavior section revised 2/12/18 revealed physically aggressive to others with interventions to monitor behaviors as needed, redirect to a safe environment and physically part resident from others whom he is agitated with. Further review revealed the CCP lacked the intervention for the door guard. Review of the Mini Care Plan dated 3/9/18 revealed it lacked the intervention for the door guard. During an interview on 3/14/18 at 10:22 AM, when asked what the purpose of Resident #43's door guard was, Registered Nurse (RN) #1 responded, I'm assuming the stop sign is to prevent anyone from wandering into rooms. Resident #60 wanders into rooms. During an interview on 3/14/18 at 2:15 PM the SW revealed Resident #43 has a door guard on his room to keep any wandering residents out of his room. Observation of Resident #43 seated in his room on 3/15/18 at 7:43 AM and at 8:31 AM revealed the door guard was not attached across the doorway, and no staff were in the room. During interviews on 3/15/18 at approximately 9:00 AM, CNA's #1 & #4 revealed they were aware that a door guard is to prevent wanderers from entering rooms. Both stated Resident #43 had one applied by maintenance approximately one month ago but they were not certain when or why it is being used. During an Interview on 3/15/18 at 2:15 PM, the SW stated she does not know when Resident #43's door guard was initiated because nursing initiates door guards. The door guard should be up at all times unless a staff member is in the room to prevent Resident #60 from going into Resident #43's room. The SW stated she would be updating the Care Plans. 4. Resident # 60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severely impaired cognition. Review of the Daily Orders Report dated between 1/19/18 through 3/15/18 revealed a physician's orders [REDACTED]. Review of a Bacteriology laboratory result dated 2/13/18 revealed a urine culture was positive for bacteria. Review of the emergency room Discharge Summary dated 3/6/18 revealed the resident was transferred back to the Nursing Facility on antibiotics for a UTI. Review of the CCP revised 1/24/18 revealed a focus area Urinary Incontinence/ Bladder resident is frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). The CCP was not developed to reflect UTI's. During interview on 3/14/18 at 12:21 PM, RN #5 Unit Manager stated, I typically revise the CCP's when a problem area is identified. During interview on 3/14/18 at 2:01 PM, the DON stated the expectation is that the Unit Managers develop Care Plan's based on each resident's individual needs. 415.11(c)(1)

Plan of Correction: ApprovedApril 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #19 was evaluated by the Medical Provider 4/2/18 no new orders.Resident #19 Care plan for [MEDICAL TREATMENT] Care was review and revised by the Unit 2 Nurse Manager on 3/15/18. Resident #19 remains at the Facility in stable condition.
Resident #14 was evaluated by physician on 4/12/18. Resident #14?s Care plan and CNA mini care plan was reviewed and revised by the Interdiciplinary Team on 3/14/18 and 3/17/18. The Care Plan and mini care plan were updated/developed as a result of the resident to resident altercation that occurred on 3/6/18. The care plan intervention was updated to include keeping the two residents separated. Resident #14 still resides at the facility and is in stable condition.
Resident #43 was seen by the medical provider on 4/12/18, no new orders were given at the time of the visit. Resident #43 care plan and CNA mini care plan were updated by the Social worker on 3/14/18 to include a door guard intervention to prevent other residents from entering his room. Resident #43 remains at the facility in s table condition.
Resident #60 no longer resides at the facility. He was transferred to the hospital on [DATE] for Dysphagia, then discharged from the hospital to another SNF and will not be returning to the facility.
All residents have the potential to be affected by this same deficient practice.
The IDT will conduct a 100% record review for all current residents at the facility to ensure the comprehensive care plans are completed timely, accurately and are person-centered including measurable goals/objectives and timeframes to meet the resident?s medical, nursing and mental psychosocial needs identified in the comprehensive assessment. Each resident?s comprehensive care plan will be updated at that time. Any deficient practice will be reported to the DON for immediate action and follow up.

The DON will analyze and trend data collection and report findings to the QAA committee at the next scheduled meeting.
The current comprehensive care plan, baseline care plan and interim care plan policies and procedures and process was reviewed by the Corporate DON on 4/3/18. No policy and procedure revision was needed.
The Regional RN Educator will in-service the Unit Managers, DON, ADON, and Interdisciplinary team on the current facility policies and procedures:
. Care plan assessments
. Care plan IDT process
. Care plan preliminary goals and objectives
. Problem list identified
. Resident assessment instrument
. Resident/family participation assessment/care plan
. Using the care plan
. Baseline care plan
The DON/ADON will in-service all licensed nurses, new hires when applicable including agency employees.
The LPN unit 2 manager who did not include resident #19?s AV Fistula monitoring on the [MEDICAL TREATMENT] CCP will be counseled and in-serviced by the DON on completing the [MEDICAL TREATMENT] care plan specific to the resident and facility EMAR clinical protocols.
The RN Unit Manager who did not develop a UTI care plan for resident #60 will be counseled by the DON and in-serviced on policies and procedures related to the episodic/Interim care plan process and timely completion.
The Social Worker will be counseled by the Administrator and in serviced by the Regional RN on updating the careplan.
The CNA assigned to resident #43 on the 6-2 shift on 3/15/18 will be counseled by the DON and re-in serviced by the DON on informing the Nurse when a mini CNA care plan in not correct, and assuring the placement of door guards.
The ADON or designee will conduct 40 random comprehensive care plan audits each month for three months and than quarterly to ensure that interventions are in place and that they are effective. All residents? charts and comprehensive care plans will be reviewed at least quarterly. Any deficient practice
will be reported to the DON for immediate follow up and action.
The DON/ADON will analyze and trend data collection and report findings to the QAA committee monthly. This will be ongoing.
Responsible Party: Director of Nursing

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 3/16/18, the facility did not ensure that each resident's drug regimen is free from unnecessary [MEDICAL CONDITION] drugs. One (Resident #85) of three residents reviewed for unnecessary [MEDICAL CONDITION] medications had issues involving the lack of indications for the use of an antipsychotic medication ([MEDICATION NAME]) and the lack of non-pharmacological behavioral interventions prior to the initiation of the medication. The finding is: 1. Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 2/7/18 revealed the resident has severe cognitive impairment and no physical or verbal behavioral disturbances. the MDS documented that medications received included antipsychotics and the resident was discharged home on[DATE]. Review of a Daily Orders Report dated 1/31/18 to 2/25/18 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. A Nurse's Admission Note dated 1/31/18 documented that no behavior issues were noted; the resident was pleasant, cooperative, confused, and easily redirected; and that the resident had a history of [REDACTED]. There was no documented evidence of a Nurse's Note for 2/1/18. Review of an Admission H&P (History and Physical), completed by the physician, dated 1/31/18 revealed there was no documentation of physical or verbal behavioral disturbances directed towards others or himself. Medical problems include but are not limited to dementia of Alzheimer's type and [MEDICAL CONDITION] (post-traumatic stress disorder) and supportive care was the plan. Review of a Transfer Summary, completed by the Physician's Assistant (PA), dated 2/8/18 revealed there was no documentation that the resident directed physical or verbal behaviors towards himself or other. The PA documented that the resident is prone to falls for attempting to get out of his wheelchair by himself. Review of a Nursing Progress Note dated 2/2/18 at 6:30 PM revealed the resident was found on the floor, sitting on his buttocks at 3:25 PM. No injury noted, therapy informed and a dycem (non-slip mat) was placed in his wheelchair. The Director of Nursing (DON) and Physician Assistant (PA) were notified of the fall, no new orders were given at that time. At 6:00 PM, the PA gave an order for [REDACTED]. Review of Nursing Progress Notes dated 2/3/18 to 2/11/18 revealed there was no documentation of agitated behaviors. Review of the Daily Unit Report dated 2/2/18 revealed no documentation of any behavior issues. During an interview on 3/14/18 at 12:06 PM, the PA stated she started the resident on [MEDICATION NAME] because he was having some issues with [MEDICAL CONDITION], he was agitated and falling. When asked what the resident's specific behaviors were, the PA stated he kept trying to get out of his wheelchair and every time he tried it was unsuccessful and he would fall. When asked if that was an appropriate indication for ordering an antipsychotic medication, the PA stated I know it's used for delusions with dementia but I just wanted to use it short term to get him to adjust and settle. When asked if she knew if staff were trying any non-pharmacological interventions, the PA stated I sat for long hours with him in the dining room. I think I documented that, it was in the first couple weeks that he came in. When asked if the PA did a medical workup on the resident, check for UTI (urinary tract infection) etc., the PA stated he came from the hospital like that. He had a whole workup there and I think they used [MEDICATION NAME] on him in the hospital. The PA stated I don't know why they didn't document it (his behaviors), he was annoying other patients because his agitation was severe and I recommended it (the medication) because he was having mental status changes. During an interview on 3/14/18, the Registered Nurse (RN #2) who wrote the 2/2/18 Nursing Progress Note stated that the resident could get non-compliant and stand up all the time. We'd tell him not to and he'd stand up anywhere, we had to constantly watch him and keep him near the Nurses' Station. The RN stated she didn't remember the resident being combative or anything. Non- pharmacological interventions they would try included talking to him or having him watch TV. The RN stated if someone is combative, she documents it on the MAR indicated [REDACTED]. During an interview on 3/15/18 at 8:58 AM, the Social Worker (SW) stated I wondered why he was started on [MEDICATION NAME]. I never saw any bad behavior from him and I didn't mention the [MEDICATION NAME] in my notes because I didn't know why he was on it. During an interview on 3/15/18 at 10:15 AM, the DON stated this resident did have behaviors and staff would try to distract him, offer him snacks but he would get mad, say 'leave me the hell alone' and get upset. We use a behavior flowsheet in the computer to document behaviors. The DON was able to have the Assistant Director of Nursing (ADON) show a behavior flowsheet for a different resident but was unable to access a behavior flowsheet for Resident #85. During further interview at 12:38 PM, the DON stated they can't get behavior flowsheet access when people are discharged from their system, so I have no behavior documentation for this resident. When told there was no behavior documentation in the Nursing Progress Notes or the 24-Hour Reports, the DON stated they were probably relying on the flowsheet for documentation. Review of a facility policy and procedure entitled Antipsychotic Medication Use dated 11/1/17 revealed residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective, and nursing staff will document in detail the individual's target symptoms 415.12(l)(1)(2)(i)(a)

Plan of Correction: ApprovedApril 12, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #85 no longer resides at the facility and was discharged home on[DATE] in stable condition.
All residents who currently reside at Safire Rehabilitation of Northtowns and are prescribed [MEDICAL CONDITION] drugs such as an antipsychotic, anti-depressant, anti-anxiety and hypnotic medication have the potential to be affected by this same deficient practice.
The consultant pharmacist will conduct a 100% record review/audit for all identified residents who are prescribed antipsychotic medications. The [MEDICAL CONDITION] drug audit will include the drug dose, adverse effects and ensure medication is prescribed for appropriate indications for use necessary to treat a specific condition as diagnosed and documented in the clinical records by the prescribing practitioner. The clinical record review will include a review of the physician, nursing and social work progress notes, psychology, psychiatry consultations physicians monthly telephone orders behavior flow sheets, 24 hours shift to shift reports specific to initiations of interventions and routine behaviors prior to PRN medications used and the ongoing need for [MEDICAL CONDITION] medications, laboratory reports, behavior and antipsychotic care plans and BMarc documentation. All deficient practices identified will be reported to the Medical provider, Medical Director and DON for immediate action and follow-up. The Consultant Pharmacist will analyze and trend data collection and report findings to the QAA committee at the next scheduled meeting.
The IDT will review and revise as needed the Resident Comprehensive Care Plans for [MEDICAL CONDITION] drug use and behavior management interventions for those residents who have been prescribed [MEDICAL CONDITION] medications.
The Corporate DON reviewed the current policy and procedure entitled ?Antipsychotic Medication Use? dated 11/1/17, on 3/30/28 no revision was needed.
The Pharmacy Consultant will in-service/educate the Medical Director on the revised 11/18 [MEDICAL CONDITION] drug use Regulations, indication for use when necessary to treat a specific condition as diagnosed and documented in the clinical record. This will include gradual dose reduction, behavior interventions and PRN orders for anti-psychotic drug orders renewals and resident evaluation every 14 days the training will also include the facility policy & procedure for antipsychotic, medications use and behavioral interventions, flow sheets/ Nurses notes documentation.
The Medical Director will in-service/educate all other facility medical providers on revised Prescriber Regulations for antipsychotic use and PRN use and required Resident evaluations and Behavior Documentations and Facility Policy and Procedures pertaining to antipsychotic medications and behavioral interventions.
The RN Regional Educator will in-service the Administrator, DON, Social Workers, IDT and Licensed Nursing staff on the policy & Procedure for antipsychotic drug use, required reporting and documentation procedures for facility behavior management program.
The Licensed Nursing staff will also be educated on the behavior flowsheet documentation in the Emar software program.
The PA who prescribed resident #85 [MEDICATION NAME] 1mg BID without reviewing the nurses progress notes prior to prescribing a psychotic medication will be counseled and in-serviced by the medical director.
Any licensed Nurse who administered the [MEDICATION NAME] 1 mg doses from 2/2/18 to 2/12/18 and did not complete the behavior flow sheets and or nurses notes, notification to supervisor that Emar did not have attached flow sheet will receive progressive disciplinary action and reeducation.
The DON will complete medication errors counseling as needed.
The regional RN educator will provide remedial education. The DON will conduct a daily audit for all resident?s prescribed [MEDICAL CONDITION] medication to ensure that behaviors and behaviors interventions have been recorded on the computerized behavior flow sheet.
The DON will notify the Medical Director of all findings related to antipsychotic medications being prescribed without appropriate indication for use when identified to ensure immediate action and follow-up occurs. The DON will analyze and trend data collection and report findings to the QAA Committee monthly.
The Regional Nurse Educator will conduct a weekly audit for same criteria listed above to ensure the proper oversight occurs and facility policies and procedures for [MEDICAL CONDITION] drug use and behavior management occurs.The RN Regional Educator will report findings and a written report to the DON, Administrator and Corporate DON weekly.

The DON will report findings to the QAA Committee monthly.
Responsible Party: Administrator

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review completed during a complaint investigation (Complaint #NY 970) conducted during the the Standard survey completed on 3/16/18, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #47) of seven residents reviewed for accidents lacked evidence that safety interventions were revised and implemented to prevent further falls. The finding is: 1. Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 1/22/18 revealed the resident has severe cognitive impairment and is rarelynever understood or understands. The MDS documented that the resident requires the assistance of two people for bed mobility, transfer by mechanical lift, dressing, toilet use and personal hygiene. Review of the Comprehensive Care Plan (CCP) dated 8/24/17 to 2/8/18 revealed the resident was identified at risk for falls due to a history of falls. CCP approaches included the use of a wing mattress, floor mats on the left and right side of the bed and monitor the resident's position in bed during rounds. An audio monitor was added 1/15/18. The CCP documented that approaches for the use of a bed and chair alarm were discontinued 11/15/17. Review of Resident/Visitor Accident & Incident Reports (A&I's) from 11/1/17 to 3/11/18 revealed Resident #47 had 22 falls while in the facility. Additional review of the A&I's revealed the following: - 11/25/17 at 2:30 PM - The resident was found on the floor in his room next to his bed. The planned intervention was to continue the current Care Plan. - 12/9/17 at 2:00 PM - The resident was found on the floor in his room next to his bed with a 14 centimeter (cm) by 6 cm skin tear on his left arm. The planned intervention room was to check for sharp edges in his room and the resident was sent to the hospital. - 1/3/18 at 5:45 AM - The resident was found on the floor in the dining room. The planned intervention was to continue the current Care Plan and Hospice was notified. There were no revisions made to the CCP to ensure the resident's safety. - 1/11/18 at 11:10 PM - The resident was found on the floor in his room next to his bed. The planned intervention was to continue the current Care Plan. There were no revisions made to the CCP to ensure the resident's safety. - 2/17/18 at 8:25 PM - The resident was found on the floor in his room, next to his bed with a skin tear on his left forearm. There were no revisions made to the CCP to ensure the resident's safety. - 2/17/18 at 11:48 PM - The resident had a witnessed fall in the dining room on the second floor. The intervention was to send the resident to the hospital after this second fall, however there were no revisions made to the CCP to address the repeated falls and to ensure the resident's safety. - 2/19/18 at 1:00 PM - The resident was found half on the floor and half on the bed in her room. The planned intervention was to monitor the resident for anxiety. There were no revisions made to the CCP to ensure the resident's safety. - 3/8/18 at 8:30 AM documented the resident was found on the floor in his room next to his bed. The planned intervention documented that Hospice was notified; the resident was seen by the Physician and an X-ray of his right arm was ordered. There were no revisions made to the CCP to ensure the resident's safety. Fall Risk Assessment Tools dated 1/15/18, 2/17/18, 2/19/18, 3/9/18 and 3/10/18 documented that the resident had a score of 24. A score of 11 or above indicates high risk for falling. Additional review of the CCP, last dated 3/2/18, revealed a chair alarm was initiated on 3/5/18 and discontinued on 3/6/18. During an observation on 3/8/18 at 9:15 AM, Resident #47 was lying in bed with a tee shirt and brief on, no shoes or socks, and the resident's right eye was ecchymotic (bruised). The resident had multiple scabbed areas on both of his lower extremities and he was attempting to sit up in bed. There were floor mats in place on both sides of the bed. There was no audio monitor in the resident's room or at the Nurses' Station. An interview with a family member on 3/8/18 at 10:13 AM revealed that Resident #47 has had at least 25 falls since he was admitted in (MONTH) of (YEAR). He just fell Friday, Saturday and Sunday and now again this morning, they're doing an X-ray of his arm because it hurts when you touch it. They told me they were going to put an alarm back on him but they are all broken. Observation on 3/9/18 at 7:40 AM revealed that Resident #47 was sleeping in a low bed with his feet on the floor. There were mats on both sides of the bed. The untitiled Care Guide, used by certified nurse aides (CNAs) to provide care, dated 3/12/18 documented instructions for floor mats on the left and right side of the bed; bed in low position when unattended; walk the resident when he is restless and bring him to the dining room after his family leaves. During an observation on 3/12/18 at 9:24 AM, Resident #47 was sitting up in his w/c in the dining room and his foot rests were elevated 45 degrees. The leg rest of the w/c was covered with a calf board and his feet were positioned behind the calf board on the floor. The resident made multiple attempts to stand and he was very unsteady. A chair alarm was not in use. Observation on 3/13/18 at 4:59 AM, Resident #47 was in bed sleeping with just a brief on. His feet were on the floor, his nonskid socks were on the floor at the side of the bed and the floor mat on the door side of the bed was pushed away from the bed. During an interview with the Licensed Practical Nurse (LPN #2) Unit Manager (UM) on 3/15/18 at 1:21 PM revealed she applied a chair alarm to Resident #47 after his fall on 3/3/18. The LPN UM stated the chair alarm broke the next day, they didn't have any more in the building and they had to order one but it hasn't come in yet. When asked if any other intervention was put into place to prevent further falls until the alarm came in, LPN UM #2 stated No. During an interview on 3/16/18 at 12:12 PM, the DON stated the Intradisciplinary Team reviews A&I's in the morning meetings and during the Quality Assurance meetings. It's a team approach to cover fall prevention. She further went on to say the facility was educating the staff regarding not using MD visits or hospital visits as interventions to prevent falls. When asked if the alarm was on order for Resident #47, the DON stated yes but it hasn't come in yet. When asked if any other intervention was put into place to prevent further falls until the alarm came in, she stated No. 415.12(h)(2)

Plan of Correction: ApprovedApril 20, 2018

Resident #47 no longer resides at the facility. He was discharged in stable condition on 3/27/18. Resident #47's plan of care was reviewed and updated to include additional fall prevention interventions.
All residents who are at risk for falls have the potential to be affected by this deficient practice.

A 100% medical record and care plan record review will be conducted by the IDT for all residents who trigger at risk for falls. The IDT will evaluate the residents current falls care plan interventions and effectiveness at reducing falls. The IDT in conjunction with the medical provider and consultant pharmacist will evaluate the resident medication regime to evaluate if the medications are placing resident at a higher falls risk. The IDT will review all previous falls history for each resident and evaluate external and environmental risk factors such as floor mats, positioning devices, poor lighting, activity programs, furniture placement and foot wear etc.
The Director of Nursing will analyze and trend the data collection obtained from this comprehensive medical chart / care plan audit and report finding to the QAA committee at the next scheduled meeting.
The shift RN supervisors working 11/25/18, 1/3/18, 1/11/18, 2/17/18, 2/19/18, 3/6/18, 3/8/18, 3/12/18 will be counseled by the DON and re-in serviced by the Regional RN educator on immediate implementation Falls prevention Care Plan interventions.
The CNA?s assigned to resident #47 on 3/8/18, 6am-2pmshift, and on 3/12/18 6am-2pm shift, will be counseled by the DON and re-in serviced on the importance of following the care plan interventions and reporting to the nurse when falls prevention devices are missing.
The DON will be counseled by the Administrator and will be rein-serviced by the Corporate DON on all falls prevention policies and procedures.
The facility will re-introduce bed and chair alarm use as a falls care plan intervention when applicable, including a risk-benefit analysis and monitoring. The DON will in-service facility staff on the alarm policy and on the fall prevention policy and procedure revisions.
The nursing staff including licensed nurses and CNA?s will be educated on all resident?s falls care plan updates when initiated via the 24 hours report, am meetings, and shift to shift reports.
The Corporate DON will revise the accident/incident investigation forms to include falls interventions including residents? internal/external risk factors, medications, locations, types of falls, review of environmental factors, furniture placement, reviews of current care plan interventions and new care plan intervention initiated immediately post fall to prevent re-occurrence. The RN completing the report will be required to complete a falls investigative worksheet at the time of each fall and include findings and immediate action taken for new falls care plan interventions which will be attached to the accident incident report.
The Corporate DON will in-service the Administrator and Don, and Regional RN educator. The Regional RN Education Nurse will in-service the Facility staff on the incident/accident policy and procedure revision.
The ADON/RN supervisor on each shift will be required to complete an incident accident check list and attach updated care plans and CNA mini care plan as evidence that new care plan interventions were initiated. The ADON/Rn shift supervisor will also complete an accident incident investigation audit immediately post fall/incident accident. This audit will be attached to the A &I and reviewed by the DON and IDT at the AM meetings. The IDT will then review and revise the comprehensive care plan as necessary at that time.
Each month, the DON will be responsible for analyzing the all falls/incident accident reports and investigation audits conducted by the RN supervisor/ ADON. All data will be trended and a comprehensive audit summary will be reported to the Quality Assurance committee monthly. This will be on going.
Responsible Party: Director of Nursing

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during a Standard survey completed on 3/16/18, the facility did not 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. Issues include the facility did not activate their Legionella water sampling plan. This affected three (First, Second, and Third) of three resident use floors. The finding is: 1. Record review of the facility policy called, Identify and/ or Prevent Nosocomial Legionnaires Disease, dated 9/16/16, revealed the facility will conduct surveillance on the potable water system by sampling for Legionella quarterly for the year of (YEAR), then annually and as needed thereafter. Interview with the Regional Chief Engineer on 3/9/18 at 2:00 PM revealed the facility's Legionella water sampling has not yet begun. According to the New York State Department of Health's Health Advisory called, Regulation for the Protection Against Legionella dated 8/12/16, Part 4 of the New York State Sanitary Code Protection Against Legionella, became effective on (MONTH) 6, (YEAR). Subpart 4-2 of the regulations require all general hospitals and residential health care facilities to adopt and implement a Legionella culture sampling and management plan for their potable water systems by (MONTH) 1, (YEAR). It further states the plan shall include a schedule to conduct routine Legionella culture sampling and analysis at intervals not to exceed 90 days in the first year and annually thereafter. 415.19(a)(1) 10 NYCRR Subpart 4-2.4

Plan of Correction: ApprovedApril 12, 2018

The facility will conduct quarterly water testing for one year and then annually and as needed thereafter.
All residents have the potential to be affected by this violation.
The Maintenance Director will be educated on the requirement of Legionella water sampling. Legionella water sampling will be added to the maintenance schedule and conducted by the Maintenance Director quarterly (April (YEAR), (MONTH) (YEAR),October (YEAR), (MONTH) 2019) for 1 year and then annually and as needed thereafter.
The Infection Control Nurse will audit compliance with the water testing quarterly for 1 year and than annually. Results will be submitted to the Quality Assurance Committee.
Responsible Party: Infection Control Nurse

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review conducted during the Standard Survey completed on 3/16/18, the facility did not 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. Specifically, the facility did not implement water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water systems. This affected three (First, Second, and Third) of three resident use floors. The finding is: 1. Record review of the facility policy entitled, Identify and/ or Prevent Nosocomial Legionnaires Disease, dated 9/16/16 revealed the facility would conduct surveillance on the potable water system by sampling for Legionella quarterly for the year of (YEAR), then annually and as needed thereafter. Interview with the Regional Chief Engineer on 3/9/18 at 2:00 PM revealed the facility's Legionella water sampling had not yet begun. Review of the Centers for Medicare & Medicaid Services Survey and Certification Letter S&C 17-30 subject: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 6/2/17 revised 6/9/17 with an effective date of immediately revealed: Healthcare Facilities must have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water systems. 415.19(a)(1)

Plan of Correction: ApprovedApril 12, 2018

The facility will conduct quarterly water testing for one year and then annually and as needed thereafter.
All residents have the potential to be affected by this violation.
The Maintenance Director will be educated on the requirement of Legionella water sampling. Legionella water sampling will be added to the maintenance schedule and conducted by the Maintenance Director quarterly (April (YEAR), (MONTH) (YEAR),October (YEAR), (MONTH) 2019) for 1 year and then annually and as needed thereafter.
The Administrator will audit compliance with the water testing quarterly for 1 year and than annually. Results will be submitted to the Quality Assurance Committee.
Responsible Party: Maintenance Director

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard Survey completed on 3/16/18, the facility did not have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated. Two (Residents #58, 60) of seven residents reviewed for investigation of accidents/incidents had issues involving the lack of a complete investigation of falls (Resident #58) and lack of an investigation and/or a thorough investigation of a resident with wandering behaviors who consumed inappropriate food items and grabbed and inappropriately touched other residents (Resident #60). The findings are: Review of a facility policy and procedure entitled Abuse, Neglect, Mistreatment, Exploitation, Injury of Unknown Sources, or Misappropriation of Resident Property Prevention/ Prohibition Program dated 11/20/17 revealed the facility shall conduct a thorough investigation of all alleged violation/ sexual abuse involving mistreatment, neglect or abuse, including injuries of unknown an unknown source and prevent further potential abuse while the investigation is in progress. 1. Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS -resident assessment tool) dated 1/26/18 revealed the resident has severe cognitive impairment. Review of Nurses Notes revealed the following: - 2/16/18 at 8:10 AM - the resident was found on the floor next to her bed, bleeding from her upper lip. The resident was screaming in pain. An RN (registered nurse) assessment was done, family and Physician were called, and the resident was sent to the hospital due to currently receiving a blood thinner. - 3/11/18 at 7:00 PM - the resident was found on floor in room next to her bed, rubbing her forehead like she was trying to verbalize she bumped it. The supervisor called onto unit, daughter notified. No visible injuries noted, neuro (neurological) checks all within normal limits. Review of Resident/Visitor Accident & Incident Reports dated 2/16/18 and 3/11/18 revealed there were no witness/ staff statements attached, no documentation of contributing factors to the falls, and no summary of the investigation to determine if the resident's care plan was followed. During an observation on 3/15/18 at 8:29 AM, the resident was sitting on the edge of the bed and appeared to be trying to get out of bed. Fall mats were in place on each side of the bed on the floor. At 8:30 AM, a certified nurse aide (CNA) was observed to go into the room to assist the resident to get out of bed. During an interview on 3/15/18 at 10:42 AM, the Director of Nursing (DON) stated she knows there were statements attached to the incident reports and the RN Nurse Manager said she was coming in today to look for them. The DON stated she has done education with staff that they can't leave without providing a statement, it's a new process for the CNAs to make sure they do statements before they leave. Further interview at 3:10 PM, the DON stated the RN Manager never came in to look for statements, but she knows there were statements with the Accident & Incident Reports when the RN submitted them. I gave them (the reports) back to her to add more items, when they came back to me the statements weren't there. The DON stated that the RN Manager can't remember where she put the statements and we searched for them. The DON further stated that yes there should be staff member statements when accidents/ incidents occur. 2. Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/27/18 revealed the resident has severe cognitive impairment. Review of the Comprehensive Care Plan (CCP) dated 1/24/18 revealed the resident ambulates independently with a rollator (rolling walker) in his room and requires supervision for directional cues. The CCP documented that communication is rarely/never understood, the resident rarely/never understands (1/24/18) and has severe cognitive deficits (1/24/18). Additionally, the CCP identified that the resident is at risk for wandering related to dementia, wandering, rummaging, and agitation (2/11/18). The CCP for swallowing (1/18/18) documented that the resident is to receive nectar thick liquids. Resident Care Record Notes documented the following: -1/25/18 at 7:45 AM - Resident #60 was wandering in other resident's rooms during the night, eating their food and drinking regular liquids even though the resident is on nectar thick liquids. - 1/26/18 at 7:27 AM - The resident had regular liquids/ a peanut butter and jelly sandwich and coughed. The food and liquids were removed from his room. The Nursing Supervisor was notified and an assessment was completed. - 1/28/18 at 11:15 PM - The resident was upsetting other residents by going into their rooms, sitting on their beds, and grabbing residents. - 2/2/18 at 12:30PM - The resident was spitting on tables, the floor, and in his hands. He was touching other residents, wandering into other resident's rooms and removing food items from other resident's meal trays. - 2/3/18 at 9:10 AM - A CNA found the resident inappropriately touching another female resident. Following the incident, the resident was found on the floor after returning to his room. - 2/19/18 at 6:00 AM - The resident wandered into room where two female residents were unclothed. The two female residents started screaming and the resident was combative when redirected. Review of a Resident/ Visitor Accident & Incident Report dated 2/3/18 revealed Resident #60 was found inappropriately touching another Resident #33. When redirected back to his room, he immediately got up out of bed and fell . Resident #60 was sent to the emergency room for evaluation and a room change occurred. No witness/ staff statements were included with the Accident & Incident Report; there was no documentation of contributing factors to fall; and there was no summary of the investigation to determine if the care plan was followed. No other Resident/ Visitor Accident/ Incident reports were provided. Observation on 3/13/18 at 7:23 AM revealed that Resident #60 got out of his bed and ambulated to the doorway of his room wearing only a t-shirt and a brief. CNA #3 offered toileting and a snack and redirected him back to bed. During an interview on 3/14/18 at 10:02 AM, a Licensed Practical Nurse (LPN) #5 stated she typically reports all incidents to the Nursing Supervisor and documents on the 24-Hour Report as well as the Nurses Notes. The LPN stated that the Nursing Supervisor completes the Resident/ Visitor Accident & Incident Reports. During a telephone interview on 3/14/18 at 8:42 PM, the 3:00 PM to 11:00 PM shift Registered Nurse (RN #4) Nursing Supervisor stated that she typically reviews 24-Hour Reports at the change of shift and passes pertinent information on to the next Nursing Supervisor. RN #4 stated she did not recall any incidents with Resident #60, Most incidents with him occur on the other shifts. Further during the telephone interview, RN #4 stated she always notifies the DON of any Accidents & Incidents and she never really thought about completing an Accident & Incident Report if someone consumed the incorrect diet. I never came across the issue before. During an interview on 3/16/18 at 8:57 AM, RN #3 (the 11:00 PM to 7:00 AM shift Nursing Supervisor) stated she was unable to recall the incident involving the resident drinking regular liquids, but would expect the staff to notify her of all incidents, resident to resident altercations, falls, and she would consider a resident consuming the wrong diet an accident. RN #3 stated a report should have been completed; she typically starts the Accident & Incident Report and the Assistant Director of Nursing (ADON) or DON follows up. During an interview on 3/16/18 at 9:20 AM, the DON stated she was unaware that Resident #60 was drinking regular liquids and she would expect a phone call from the RN Supervisor on the off shifts. The DON then stated yes there should have been Accident & Incident reports completed for 1/25/18,1/26/18, 1/28/18, 2/2/18, 2/3/18 and 2/19/18. The DON further stated she has done education with staff and they know they can't leave without providing statements, It's our new process. She stated she was unaware of what the nurses were documenting, and she expects inappropriate behaviors to be on the 24-Hour Report and discussed in morning report. They know I expect a call when an accident/ incident occurs. 415.4(b)(3)

Plan of Correction: ApprovedApril 30, 2018

Resident # 58 was seen by the medical provider on 3/26/2018 post the 3/16/2018 incident. No new orders were written when the provider evaluated. The Accident Incident Investigations that were initiated on 2/16/18 and 3/11/18 have now been thoroughly completed including employee/witness statements, documentation of contributing factors to the falls and summary of the investigation to determine if the residents care plan was followed.
The comprehensive care plan was reviewed and revised to include Falls prevention interventions specific to each fall. The CNA mini plan and comprehensive care plans were both updated with the new interventions.
Resident # 58?s accident incidents that occurred on 2/16/18 and 3/11/18, did not require DOH notification as there were no care plan violations or evidence of abuse/neglect, or mistreatment.
Resident # 60 no longer resides at the facility. *Resident #60's record was reviewed to ensure all applicable Accidents/Incidents involving this resident have been thoroughly investigated*
All residents who currently reside at the facility have the potential to be affected by the same deficient practice.
The regional QA RN and the Administrator will conduct a 100% Accident/Incident audit review with a 1 month look back for all residents who currently reside or were discharged from the facility. The paperwork review will include all Accident/Incident reports to ensure there is no evidence of Abuse/neglect/mistreatment or exploitation or injuries of unknown origin that were not fully investigated and ensure that all areas of the A/I reports were filled out including employee/witness statements, documentation of contributing factors to the falls and summary of the investigation to determine if the residents care plan was followed.
All negative findings will be reported to the medical director and Corporate DON to ensure immediate action occurs. The regional QA RN will analyze and trend data collected and report findings to the QAA committee at the next scheduled meeting.
The corporate DON and regional administrator will receive a copy of the QA report.
On 4/3/18 the corporate DON reviewed the policies and procedures entitled ?Abuse, neglect mistreatment, exploitation, injuries, of unknown source or misappropriation of resident property, prevention/prohibition program? dated 11/20/17, and accident incident investigating and reporting. No revisions were needed.
The DON who failed to assure the facility policies and procedures mentioned above and ensure incident/accident reports were completed per facility policy and procedure and thoroughly investigated will be counseled by the Administrator.
The RN 7-3 shift supervisor who assessed resident # 58 on 2/16/18 post fall and did not complete a thorough investigation and obtain statements from employees, assure care plan interventions and document contributing factors of the fall to prevent re-occurring falls will be counseled by the DON and Inservice by the RN Regional Educator on same policies and procedures DON were in serviced on including falls prevention program policies/ procedures completing a thorough investigation implementing resident care plans interventions immediately after incident to prevent re occurrence and ensure resident safety.
The RN 3-11 shift supervisor who assessed resident # 58 on 3/11/18 post fall and did not complete thorough investigation and obtain statements from employees, care plan a new intervention and document contributing factors of the injury of unknown source will be counseled by the DON and in serviced by the RN Regional Educator on same policies and procedures DON were in serviced on including falls prevention program policies/ procedures completing a thorough investigation implementing resident care plans interventions immediately after incident to prevent re occurrence and ensure resident safety.
The RN 7-3 shift unit manager who did not ensure resident A&I report was completed on 1/25/18 when found wandering in other rooms: eating + drinking regular liquids and did not complete an investigation and put immediate care plan intervention in place to prevent re-occurring incidents will be counseled by the DON and In serviced by the RN Regional Educator on same policies and procedures DON were in serviced on including falls prevention program policies/ procedures completing an incident/accident report initiating immediate interventions and conducting a thorough investigation and keeping residents safe.
The RN 7-3 shift unit manager who assessed resident # 60 on 1/26/18 post incident and did not complete an incident report or thorough investigation ,obtain statements from employees, keep resident safe and care plan a new intervention will be counseled by the DON and In serviced by the RN Regional Educator on same policies and procedures DON were in serviced on including completing an incident/accident report and conducting a thorough investigation, initiating immediate care plan interventions to prevent re occurrence and ensure resident safety.
The RN 11-7 shift supervisor who did not complete a A&I report, ensure immediate care plan interventions were initiated for resident # 60 for the resident to resident incident or wandering into other rooms and grabbing a resident on 1/28/18, care plan a new intervention to prevent reoccurring incident will be counseled by the DON and in serviced by the RN Regional Educator on same policies and procedures DON were in serviced on including completing an incident/accident report and conducting a thorough investigation, initiating immediate care plan interventions to prevent re occurrence and ensure resident safety.

The RN 7-3 shift unit manager who assessed resident # 60 on 2/2/18 at 12:30pm but did not complete an A&I report for the resident touching other residents and their trays, spitting and wandering in other resident?s rooms, did not complete an investigation, did not protect other residents and did not initiate care plan intervention for resident # 60 and other residents involved will be counseled by the DON and in serviced by the RN Regional Educator on same policies and procedures DON were in serviced on including completing an incident/accident report and conducting a thorough investigation, initiating immediate care plan interventions to prevent re occurrence and ensure resident safety.
The RN 11-7 shift RN supervisor who did not fully complete an A&I report on 2/3/18 for resident # 60 who sustained a fall following a resident to resident incident will be in serviced by the RN Regional Educator on same policies and procedures DON were in serviced on including completing an incident/accident report and conducting a thorough investigation, initiating immediate care plan interventions to prevent re occurrence and ensure resident safety.
All staff involved in investigations will be in serviced on completing a thorough investigation.
The Regional quality assurance RN will audit all 24-hour reports and A&I reports weekly to ensure compliance with completion of A&I?s. The QA RN will analyze and trend data collected weekly and meet with facility Administration to report all findings in writing. The QA RN will forward reports to the Regional Administrator and Corporate DON for review. The QA RN will report all findings to the QAA committee and corporate management monthly. This will be ongoing.
The DON will analyze and trend resident A&I data collection findings monthly to the QAA committee. This will be ongoing.
Responsible Party: Director of Nursing

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 3/16/18, the facility did not store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. Two (Units 2, 3) of two units observed for safe medication storage were not secure. Specifically, Unit 2's locked medication room door could be opened without the key and Unit 3's medication room keys were handed to another nurse without reconciling the medications. The findings are: 1. During an observation on 3/15/18 at 11:50 AM, the Regional Purchasing Manager requested Licensed Practical Nurse (LPN) #2 let him in Unit 2's medication room to look for a piece of equipment. LPN #2 responded that he would have to wait until the nurse who had the keys returned from lunch. He asked LPN #2 two more times to open the door because he was in a hurry. LPN #2 again responded he would have to wait. He then stated, I have a key and can get in the room myself. LPN #2 stated he was not allowed to be in that room without the nurse and to not go in there. He then placed his body in front of the door handle so the handle was not visible and opened the door and stated, See I told you I could get in there. LPN #2 instructed him to exit the medication and close the door. He disregarded LPN #2's direction and proceeded to walk in the medication room. During an interview on 3/15/18 at 11:50 AM, upon asking how he could open the medication room door without a key, the Regional Purchasing Manager responded, I just jiggled the handle and it opened. When asked if he was allowed in the medication room without a nurse present, he did not answer and abruptly left the unit. During an observation with two surveyors present on 3/15/18 at 12:00 PM, LPN #2 Unit Manager wiggled Unit 2's medication room door handle and was unable to open the door. A name badge was then slid down the 1/4 gap between the door and the door jamb down to the latch and the door was able to be opened without a key. During an interview on 3/15/18 at 12:25 PM, the DON (Director of Nursing) stated, I didn't know Unit 2's medication room door was able to be opened without the key. I'm completely appalled over this situation. He (Regional Purchasing Manager) shouldn't have gone in there without a nurse and he should know better. I spoke with him on the phone and he told me he has a master key to the door, but apparently, he doesn't. I asked him to write a statement about what happened and I am waiting for this. During an interview on 3/15/18 at 12:44 PM, the Corporate DON stated, This is totally unacceptable. He (Regional Purchasing Manager) should not have opened that door or have gone in the medication room without a nurse. I questioned him on phone in the presence of the surveyor and it was stated that he does not have a master key to the room. The door had a big gap between it and the jamb and he was able to shove something in it to open it. Review of an undated written statement by the Regional Purchasing Manager received on 3/15/18 reveals, I then took a key and moved the fab on the door handle and it opened. Review of the policy titled, Storage of Medications dated 2/1/17 reveals the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Only persons authorized to prepare and administer medications shall have access to medication room, including any keys. 2. Observation of Unit 3 on 3/12/18 at 7:40 AM, revealed the DON received the medication cart keys from LPN #6 in the hallway next to the medication cart. No reconciliation or counting of medication was observed. During an interview on 3/12/18 at 7:42 AM, the DON stated she had the medication keys from both carts on Unit 3 and that LPN #6 had taken the keys to the control substance cabinets with her on break. Upon return from break at 8:15 AM, LPN #6 stated she did not have the keys to the control medication cabinets; the DON had them with the cart keys because they are on the same ring. At 8:16 AM the DON stated, she did not know she had the keys to the control cabinets. She believed the control cabinet keys to be on a separate key ring. During an interview on 3/12/18 at 8:17 AM, the DON and LPN #6 revealed that a count/ reconciliation of the control substances should have been completed prior to exchanging the keys. Further they revealed they had not counted the control medications at 7:40 AM when the keys were passed from LPN #6 to the DON. Review of Controlled Substance Inventory Record dated 3/11/18 through 3/17/18 for Unit 3 East revealed 17 controlled substance medications and Unit 3 West revealed 15 controlled substance medications to be counted. The medications listed are: [MEDICATION NAME], [MEDICATION NAME], Klonopin, Onfi, [MEDICATION NAME], and [MEDICATION NAME]. During an interview on 3/12/18 at 8:39 AM, the DON stated, she is aware a count of control medications should be completed each time prior to another nurse taking the keys and will be educating staff. Review of the policy titled, Controlled Substances - Unit and ER (emergency) Narcotic Box dated 2/1/17 revealed (line #6) the narcotic keys will not be given to another nurse unless a full narcotic count of all unit narcotics occurs. 415.18(e)(1-4)

Plan of Correction: ApprovedApril 12, 2018

On 3/15/18, the regional engineer installed a steel plate over the inch gap between the door and door jamb down to the latch to prevent access to the 2nd floor medication room without the medication room key. The Chief Engineer conducted a 100% audit and evaluated all medication room door closer/ locks and door jambs to ensure the medication rooms were secure and no access to medication storage area could be obtained without the medication room key.Although no further deficient practice was identified, the Chief Engineer installed a steel plate over the door jamb down to the latch on both unit # 1 and unit # 3 medication room doors to ensure the medication room storage area was secured and no access could be obtained without the medication room key.
The regional purchasing manager was immediately counseled and also re-educated by the corporate purchasing director on 3/12/18 that he is not to enter a medication room/narcotic storage area without a licensed nurse present.
The corporate D.O.N reviewed all the Storage of medications policy dated 2/1/17 and the Control substance unit and ER narcotic box dated 2/1/17. No revision was needed.
The maintenance director will audit weekly and ensure medication room storage area doors are secure/ locked and no access can occur with the medication room key. The facility maintenance director will be responsible for presenting all findings and corrective actions to the Quality Assurance Committee monthly.

The facility D.O.N who failed to conduct a reconciliation of narcotics on 3/12/18 prior to obtaining the medication cart/narcotic cabinet keys will be counseled by the Administrator and reinserviced by the Regional Nurse Educator on policies and procedures related to narcotic/medication storage/inventory accountability, reconciliation of narcotics shift to shift count including access to medication rooms, narcotic storage including any keys. The policies and procedures to be reviewed are as follows:
Accepting + delivery of medications
Storage of medications dated 2/1/17
Schedule II control substance medication
Inventory control/narcotic drugs point of entry/exit
Control substance unit and ER (emergency) narcotic box dated 2/1/17
Administering medication
LPN # 6 will be counseled by the D.O.N and reinserviced by the regional RN educator on the same policies and procedures related to narcotic/medication storage/ inventory, accountability, shift to shift narcotic counts/ reconciliation including access to medication rooms, narcotic storage including keys.
The RN regional educator will Inservice all licensed nursing staff on above mentioned policies and procedures related to narcotic/medication storage/ inventory+ accountability reconciliation of narcotics, shift to shift counts, including access to medication rooms narcotic by
The D.O.N will conduct unannounced shift to shift narcotic counts on all units and shifts weekly,to ensure narcotic counts are being conducted between shifts and scheduled breaks. The facility narcotic count audit tool will be completed for data collection.
The regional RN educator will conduct random unannounced shift to shift narcotic counts weekly for three months. All findings will be forwarded to the D.O.N and Administrator. The D.O.N will analyze and trend the data collection from all audits conducted and submitted to the Quality Assurance committee monthly.
Responsible Party: Director of Nursing

FF11 483.12(a)(3)(4):NOT EMPLOY/ENGAGE STAFF W/ ADVERSE ACTIONS

REGULATION: §483.12(a) The facility must- §483.12(a)(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. §483.12(a)(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.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the Standard survey completed on 3/16/18, the facility did not implement written policies and procedures that prohibit abuse, neglect, exploitation, mistreatment of [REDACTED]. One (CNA - Certified Nurse Aide) of eight employee files reviewed for state registry checks lacked verification with the New York State Nurse Aide Registry prior to employment. The finding is: 1. Record review on 3/13/18 revealed one (CNA) of eight employee files reviewed did not contain a Nurse Aide Registry Verification Report. Further review of this employee's automated time card record revealed this employee worked 150.4 hours at this facility between 12/27/17 and 2/11/18. Additional review of this employee's file revealed the New York State Criminal History Record Check Legal Review Unit issued a Pending Denial letter for this employee dated 1/19/18. Interview with the Administrator on 3/13/18 at 3:45 PM revealed this employee was terminated from employment on 2/11/18 because of the result of the New York State Criminal History Record Check. Additional interview with the Administrator on 3/14/18 at 11:15 AM revealed the Nurse Aide Registry Verification Report cannot be located for this employee. Review of the undated document called, Compliance Policy and Procedures, revealed before hiring or retaining any individual, the facility will appropriately query available websites, including, but not limited to, New York Nurse Aide Registry. 415.4(b)(1)(ii)(a)(b)

Plan of Correction: ApprovedApril 12, 2018

The CNA was terminated from employment on 2/11/2018. The staffing coordinator responsible for this violation was terminated from the facility on (MONTH) 16th, (YEAR).
All residents have the potential to be affected by this violation.
The interim scheduler will perform an audit that all Nurse aide registry checks and criminal history record checks have been performed on current employees.
The interim scheduler will perform nurse aide registry checks on all employees prior to their start date. The Administrator is now performing all of Criminal History Record Checks. This is being done prior to an employee being approved for hire at the facility.

The Administrator will review the source documents of all potential employees to verify the Nurse Aide Registry check and Criminal History Record Check has been performed, prior to an employee being approved to start employment.
The Human Resource Coordinator will randomly audit new employee records for compliance with Nurse Aide Registry checks and Criminal History Record checks monthly for three months and than quarterly. Results will be submitted to the Quality Assurance Committee.
Responsible Party: Administrator

FF11 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 3/16/18, the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; determine that drug records are in order; and that an account of all controlled drugs is maintained and periodically reconciled. There was a lack of control and accountability of controlled drugs upon delivery to the facility and when discontinued drugs were surrendered and awaiting final disposition. The findings are: Review of a facility policy and procedure (P&P) entitled Inventory Control of Drugs (point of entry/ exit) dated 7/17 revealed the following: - The Nursing Supervisor will log the following information into the Inventory/ Narcotic Destruction Log whenever a controlled substance is received as follows: Date and time received from pharmacy, resident name, medication order including name of drug, dose or drug, amount of medication dispensed, prescription number, name of MD/ NP prescribing the narcotic, name of dispensing pharmacy, name of courier service delivering controlled substance, and Registered Nurse (RN) Supervisor receiving narcotic from courier service. - The unit nurse surrendering the controlled substance will count off narcotics with the DON (Director of Nursing) and witnessed by the ADON (Assistant Director of Nursing) or Consultant Pharmacist. All personnel will sign the individual pharmacy control sheet and Inventory Narcotic Destruction Log verifying the count for the narcotic medications surrendered for destruction. - The DON/ ADON and Consultant Pharmacist (2 personnel) receiving the controlled substance from the unit nurse will immediately enter the narcotic into the electronic narcotic destruction DEA inventory form as outlined in controlled substance on site destruction policy. Review of a P&P entitled Medication Disposal/ Destruction dated 9/17 revealed the facility will adhere to all federal, state, and local regulations related to medication destruction/ disposal when discarding any medication and medical waste. 1. Review of the facility Inventory/ Narcotic Destruction Log, used to document incoming controlled drugs from the pharmacy and surrendered drugs intended for destruction, located in the Director of Nursing's (DON's) office on 3/12/18 revealed there were no entries written in the Log book. Observation on 3/12/18 at 8:41 AM revealed there were five locked cabinets secured to the walls in a small bathroom located in the DON's office. Upon request of the surveyor, the cabinets were opened by the ADON (Assisted Director of Nursing) and the DON and observation revealed that four of the five cabinets were completely filled with discontinued controlled drugs and the medication controlled substance count sheets (untitled) were attached to each medication with a rubber band. Observation of the controlled substance count sheets revealed the sheets were dated from (YEAR) through the 3/2018. Interview with the DON and ADON on 3/12/18 at 8:41 AM revealed there was no written record of the discontinued medications in the cabinets. The DON stated that she knew the medications in the cabinet were for destruction because the forms attached to the drugs documented surrendered. The DON stated that she knew what was in the cabinets by looking in the cabinets. The DON also stated that the last scheduled drug destruction pick-up was scheduled in (MONTH) (YEAR), but it was cancelled. During an interview on 3/12/18 at 8:53 AM, the DON stated when discontinued controlled drugs are brought to her office for destruction, each medication label is supposed to be scanned to the pharmacy for tracking, but none of these (pointing to the cabinets) were scanned because she has not had time. The DON stated that several medication blister packs were removed from the nursing units for destruction a couple weeks ago and placed in the cabinets (in her office), but the medications have not been scanned or logged onto a tracking record. The DON stated that she and the ADON are present in her office when the Unit Manager brings the discontinued medications and the corresponding control substance count sheets to the office for surrendering. The DON stated she did not believe that the staff nurse and the Nurse Managers reconcile the discontinued controlled drugs prior to bringing the medications to her office. Review of a controlled substance count sheet for [MEDICATION NAME]/APAP ([MEDICATION NAME] - Schedule 2 narcotic pain medication), obtained from the cabinet in the DON's office, revealed there were two signatures at the top of the sheet, an additional signature with an initial, and an X written through the remainder of the page. Additional review of the sheet revealed that the Received by:____ signature line and the Surrendered to:____ signature line at the bottom of the form were both blank. During an interview on 3/12/18 at 8:35 AM, after the DON reviewed the controlled substance count sheet for [MEDICATION NAME]/APAP, she stated that the two signatures at the top of the page were the signatures of the nursing supervisor and the staff nurse who originally received delivery of the medication. The other signature and the initials were her and the ADON's and that were entered onto the sheet when the medication was surrendered to them for destruction. The DON stated there is no signature for the nurse who brought the medication to her to be surrendered. The DON stated, she has not had the nurses sign the Surrender to line in the past but will be requiring that in the future. During an interview on 3/12/18 at 9:17 AM, the Administrator stated she would need to refer to the policy to know the process of surrendering and destruction of controlled substances. The Administrator stated she would expect the medications in the control cabinets waiting for destruction to have been scanned for accountability. When interviewed on 3/12/18 at 9:24 AM, the DON stated that right now there is no way of knowing what is in the cabinets because she doesn't have a tracking system. The DON stated that the previous ADON left this facility's employment a couple weeks ago and the Inventory/Narcotic Destruction Log book from (MONTH) (YEAR) up through two weeks ago has been missing since she left. During an interview on 3/12/18 at 10:25 AM, the Pharmacy Consultant stated the process for surrendering controlled drugs is for the medications to be brought down from the nursing units to the DON's office; the Control Substance Count Sheet is supposed to be scanned immediately so the information is automatically entered for tracking; and the information is to be logged into the Inventory/ Narcotic Destruction Log book. The Pharmacy Consultant stated that she completed audits which identified there were too many controlled substances on the nursing units waiting to be surrendered on multiple occasions (3/2017 to 3/2018). The Pharmacy Consultant stated she would expect the DON to have a record to know what is in the cabinets for destruction and the Inventory/ Narcotic Destruction Log book is to be completed when a control substance is delivered to the building and when it is surrendered for destruction to maintain an accountability of all control substances in the building. The Pharmacy Consultant reviewed a few copies of the surrendered control sheets from the cabinets in the DON's office and the Consultant stated that there was no signature of who surrendered the medication to the DON. The Pharmacy Consultant reviewed the Inventory/ Narcotic Destruction Log book and which revealed that no entries had been made into the book. The Pharmacy Consultant stated there is no system in place that is being utilized to assure accountability of control substance medications. During an interview on 3/12/18 at 10:42 AM, the DON stated that when the previous ADON resigned, she took the keys for the inside door of the narcotic cabinets in the DON's office, which were retrieved immediately because she was no longer employed here and she was not returning. The DON stated she had not notified the Bureau of Narcotics Enforcement Agency that the previous ADON took the keys home and the Inventory/ Narcotic Destruction Book was missing. The DON stated there is no system in place at this time to ensure accountability of the controlled drugs waiting for destruction. When interviewed on 3/12/18 at 10:53 AM, Pharmacy Consultant stated This is a disaster, it's a huge liability and the DON should have notified her or the Administrator that the Inventory/Narcotic Destruction Log book was missing. The Pharmacy Consultant stated that all the control substances being received into the building and any medications being surrendered for destruction should be entered into the Inventory/Narcotic Destruction Log book. When interviewed on 3/12/18 at 10:58 AM, the DON stated she believed that the Inventory/ Narcotic Destruction Log book is only for the controlled drugs that are surrendered for destruction. The DON stated when controlled drugs are delivered from pharmacy, the packing slip and the substance control count sheet is copied and placed into a binder. The DON stated she did not know that the Inventory/Narcotic Destruction Log book was to be completed when the medications are delivered to the facility by the pharmacy. During further interview on 3/12/18 at 11:36 AM, the Pharmacy Consultant stated the purpose of the Inventory/ Narcotic Destruction Log book is for tracking all the controls (controlled drugs) received and surrendered, for accountability and for quick reference to ensure the status of a medication. Interview with the Dispensing Pharmacist on 3/12/18 at 12:20 PM revealed the scanning system is a program that the DON or ADON uses for surrendering controlled drugs. The scanned information is populated and added to the DOH 166 Form (New York State Department of Health, Bureau of Narcotic Enforcement - Controlled Substance Inventory Form) as an easy tracking system and ready for submission for destruction. The Pharmacist stated the pharmacy doesn't audit or review the information scanned, that it is a separate program for their (the DON and ADON) use. Interview on 3/16/18 at 12:07 PM with the Administrator revealed she would need to refer to the facility policy and nursing concerning the process of control substance destruction. The Administrator stated she was not aware that the controlled drugs were not being logged into the Inventory/ Narcotic Destruction Log book upon receiving or surrendering. The Administrator stated she was not aware that the Inventory/Narcotic Destruction Log book tracking medications from (MONTH) (YEAR) up to approximately 2 weeks ago was missing and she was not aware that the nurses' signatures for surrendering the controlled drugs to the DON was not complete. The Administrator stated there will be Quality Assurance processes developed to monitor for system failures. 415.18(a)

Plan of Correction: ApprovedApril 30, 2018

On 3/12/18 the Administrator immediately notified the Corporate DON of the violation. The corporate DON and Regional RN Education Nurse arrived on site. The corporate DON instructed the Regional Nurse Educator to assist the Don and acting ADON in completing a narcotic verification audit/count to ensure all narcotics were accounted for and no diversion occurred. The D/C narcotic medications were removed from the 5 double locked narcotic cabinets that were awaiting destruction. The Corporate DON advised the Regional RN Educator to ensure the Facility policies and procedure for inventory of control drugs (Point of Entry/ Exit) and the medication disposal/destruction policy dated 9/17 were followed, while conducting the narcotic count/inventory verification audit process.
The audit began immediately with the regional nurse present. The narcotics were counted by the DON/ADON, verified against pharmacy packing slip (point of entry) then marked to the narcotic blister pack label, pharmacy narcotic count down sheet, physicians order and discontinued order dates, medication orders including name or drug, dose of drug, amount dispensed, pharmacy prescription number, name of medical provider prescribing the narcotic, name of dispensing pharmacy, name of courier delivering the controlled substance indicated on packing slip, the RN receiving the narcotic from the pharmacy indicated on packing sheet.
The unit nurse surrendering the narcotic and signing for and counting the narcotic with the DON and ADON or pharmacist as a witness to the surrender process and ensuring 3 signatures was indicated on the individual count sheet when the narcotic was surrendered.
Once the narcotic medication was accounted for and there was no evidence of narcotic diversion the narcotic medications were entered into the inventory/narcotic destruction log book and the DOH-166 control substance surrender form detailing the control substances to be destroyed. The Corporate Director of Nursing completed the DOH-2340 request for approval of disposal/destruction of controlled substance from. The DOH 2340 form and DOH 166 inventory forms were completed and mailed to the Bureau of Narcotic Investigation on the same day. The BNE approved the narcotic destruction to occur on the week of 4/18/18 via ?Drug take back day?.
The Regional RN educator notified the corporate DON and Administrator of deficient practices identified throughout the audit process. The Regional RN Educator will analyze and trend data collection and policy and procedure violations and report findings to the QAA committee at the next scheduled meeting.
The DON and acting ADON were in-serviced on the policies and procedures mentioned above throughout the narcotic verification audit. This occurred on 3/12/18 through 3/14 /18.
The policies and procedures entitled ?Inventory Control Drugs point of entry/exit dated 7/17 and the policy and procedure entitled ?Medication Disposal/Destruction dated 9/17 were reviewed by corporate DON. No revisions were needed.
The facility administrator will assure the pharmacy Consultant audits for accurate acquiring and receiving including receipt and disposition of all controlled substances in sufficient detail to enable an accurate reconciliation. The pharmacy Consultant will audit this system at random, at least one time per month and report any deficiencies immediately to the Director of Nursing and Administrator. The Pharmacy Consultant will submit all findings to the Quality Assurance Committee. This will be ongoing.
Responsible Party: Administrator

FF11 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDER

REGULATION: §483.30(b) Physician Visits The physician must- §483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 3/16/18 the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments. Specifically, the facility did not ensure the Physician or non-Physician providers signed all orders for two (Residents #31, 85) of six residents reviewed for Physician's visits. The findings are: Review of the facility policy entitled Physician Medication Orders dated 2/1/17 revealed verbal orders must be signed by the prescriber at his or her next visit. 1. Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 2/7/18 revealed the resident had severe cognitive impairment. The resident was discharged home on[DATE]. Review of the Daily Orders Report dated 1/31/18 to 3/15/18 revealed drug orders and non-drug orders with start dates of 1/31/18 and 2/25/18 were not signed by the Physician or non-Physician provider until 3/14/18. Review of the medical record revealed Physician visits were completed on 1/31/18 and 2/26/18. Physician Assistant (PA) visits were completed on 2/8/18, 2/9/18, and 2/18/18. 2. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact. Review of the Daily Orders Report dated 1/9/18 to 3/15/18 revealed drug orders and non-drug orders with start dates of 1/9/18 and 2/7/18 that were not signed by the Physician or non-Physician provider until 3/12/18. Review of the medical record revealed Physician's visits were completed on 2/7/19 and PA visits were completed on 1/9/18 (with Physician present), 1/22/18, and 2/5/18. During an interview on 3/14/18 at 12:10 PM, the PA stated I just got privileges to do that (sign orders), there was a little bit of a system thing and I'm still learning. There are multiple ways to sign the orders as I know now, the system didn't prompt me. If I put in an order, I would sign it right away but I learned there's another screen that I have to go to (to sign verbal orders). But the action button on the screen didn't work for me on this screen so I thought I didn't have to sign anything. The system is newer for the staff, they've been using it since (MONTH) and I got here in September. During an interview on 3/15/18 at 10:05 AM, the Director of Nurses (DON) stated she was not aware that orders not being signed. She knew there have been glitches with the computer system. When asked when the orders are supposed to be signed, the DON stated within 24 hours for verbal orders, the providers have the policies and they know when they are supposed to sign them. The DON further stated she was not aware the providers were not signing the orders and she should have been aware, so she could have called their software provid65er. During interview on 3/15/18 at approximately 2:00 PM, the Register Nurse (RN #1) WCC (Wound Care Certified) stated they get notifications if an order needs a provider's signature. The RN showed the surveyor on the computer screen a drop down that they can use to select a unit, then it would show which residents had orders needing to be signed. The RN went to a different screen (for Resident #31) and it showed medications by rows and columns and the column labeled PH and RN (Physician and Registered Nurse) respectively, with green boxes. The RN stated this means that all the orders are signed by a physician and nurse, the boxes would be red if they weren't signed. When asked if she knew when they were signed, the RN stated she didn't know. Review of the Omissions Report for All Units printed on 3/15/18 for Resident's #31 and 85 revealed the orders were complete however there was no date of when the provider signed the orders. During further interview at 3:12 PM the DON stated, there is no way for us to get a history report for provider signatures in this system, the software people are in all day training today and tomorrow and they would be the ones who could come up with a way to see all provider signatures. 415.15(b)(2)(v)

Plan of Correction: ApprovedApril 30, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #85 no longer resides at the facility and was discharged home in stable condition on 3/6/18. The chart and electronic medical record were reviewed to ensure all orders were signed accordingly.
Resident #31 was seen by her medical provider on 4/12/18 who evaluated the resident and signed the physicians orders and completed a medical progress note. The chart and electronic medical record were reviewed to ensure all orders were signed accordingly.
.
The facility PA was immediately in serviced on 3/15/18 via telephone and web-based training by Reliable Software support staff. The PA was in-serviced how to run the physician signature report for verification of physician?s orders, telephone orders and monthly orders needing to be signed. She was also in serviced on how to efficiently pull reports and identify orders needing a practitioner?s signature. Any new providers will be educated on how to ensure provider signature.
All residents who have the potential to be affected by this same deficient practice.
A 100% electronic medical record audit was immediately conducted on 3/15/18 by the PA, after additional training was received. The PA conducted a review of all residents? electronic medical records for medication order entry for both telephone and monthly orders. Theelectronic report was also run to validate all physicians? orders had been signed by the PA and MD. All deficient practices identified were reported to the MD and DON for immediate follow up and action.
The PA will analyze and trend the data that was collected and report all findings to the Medical Director and QAA committee at the next scheduled meeting.
On 4/3/18 the Corporate DON reviewed the policy and procedure entitled ?Physicians medication orders?, no revision was needed.
The PA who did not sign the physicians order at the next scheduled visit for resident #131 and #85 from 1/9/18 through 3/14/18, per facility policy and procedure entitled ?Physicians medication orders? dated 2/1/17 will be counseled by the Medical Director and in serviced by the Regional RN Educator on above stated policy.
The residents? comprehensive care plans will be reviewed and revised by the IDT as necessary.
The medical staff, Licensed nursing staff, consultant pharmacist, Regional RN educator, Regional QA nurse and facility Administrator will be re-inserviced on the EMAR by the reliable support staff via web training and the policy and procedure entitled Physicians medication orders dated 2/1/17. The EMAR training will include how to run the various reports to ensure the physicians telephone orders are signed within 48 hours and monthly orders have been signed on or before due date, and how to review physicians order for current and discharged residents.
The medical provider will run a physician order [REDACTED]. This will be ongoing. The DON, ADON will be responsible for running the same report Monday ? Friday and notifying the medical providers whenever deficient practice is identified. The medical director will be notified. The validation reports will be forwarded to the Administrator daily and the Medical Director weekly. The Medical Director will include this data collection in the monthly physician order [REDACTED].
The medical Director will be responsible for auditing the physician order [REDACTED]. The medical Director will analyze and trend all data collection and report findings to the QAA Committee monthly. This will be ongoing.
The medical records manager will audit the physician order [REDACTED]. This will be ongoing.
Responsible Party: Medical Director

FF11 483.12(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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. §483.12(c)(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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 3/16/18, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than two 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. Five (Residents #14, 43, 58, 60, 78) of six residents reviewed for reporting of alleged violations of abuse were involved in resident to resident altercations and/or incidents that were not reported to the New York State Department of Health (NYSDOH) as required. The findings are: Review of a facility policy and procedure (P&P) entitled Abuse, Neglect, Mistreatment, Exploitation, Injury of Unknown Sources, or Misappropriation of Resident Property Prevention/ Prohibition Program dated 11/20/17 revealed the facility shall conduct a thorough investigation of all alleged violation/ sexual abuse involving mistreatment, neglect or abuse, including injuries of an unknown source and prevent further potential abuse while the investigation is in progress. All alleged violations and results of all investigations shall be reported immediately to the Administrator of the facility and to other officials in accordance with New York State Department of Health (NYSDOH) and CMS Federal regulations. The results of all investigations must be completed and reported to the facility Administrator and the NYSDOH, if requested, within five working days of the incident. All information obtained from the investigation must be maintained in the investigative file in the facility. 1. Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/27/18 revealed the resident has severe cognitive impairment. Review of the Comprehensive Care Plan (CCP) dated 1/24/18 revealed the resident ambulates independently with a rollator (rolling walker) in his room and requires supervision for directional cues. The CCP documented that communication is rarely/never understood, the resident rarely/never understands (1/24/18) and has severe cognitive deficits (1/24/18). Additionally, the CCP identified that the resident is at risk for wandering related to dementia, wandering, rummaging, and agitation (2/11/18). a.) Review of a Nurses Note dated 2/10/18 at 3:20 PM revealed the Assistant Director of Nursing (ADON) was called to Resident #60 and Resident #43's shared room to find Resident #43 stating he punched Resident #60 in the nose because Resident #60 was grabbing at Resident #43's belongings. The two residents were separated. Resident #60 was transferred to the emergency room for evaluation. The resident's (#60) daughter, the DON (Director of Nursing), and the MD (medical doctor) were made aware. Review of a Resident/Visitor Accident & Incident Report for Resident #43 dated 2/11/18 at 3:30 PM revealed a CNA heard Residents #43 and 60 yelling in their shared room and Resident #43 admitted he punched Resident #60 in the face because he was wandering around his bed grabbing him. A Resident/Visitor Accident/Incident Report for Resident #60 documented that Resident #60 sustained a bruise with a laceration beneath his left eye measuring 2 centimeters (cm) x 0.5 cm and a 0.5 cm by 0.2 cm laceration to his nose. Resident #60 was sent to the emergency room for evaluation of his injuries and a room change was made. Additional review of the Accident & Incident Reports revealed no documented evidence that the incident was reported to the State Survey Agency. During an interview on 3/12/18 at 3:05 PM, the DON stated this incident involving Residents #42 and 60 took place on 2/11/18. b.) Review of a Nurses Note dated 3/6/18 at 2:30 PM (identified as a late entry) revealed a verbal and physical altercation between Residents #14 and 60 occurred while the residents were in the dining room. Resident #60 attempted to eat food from Resident #14's meal tray. The DON and PA (Physician Assistant) were made aware. The DON's directive was to send Resident #60 to the emergency room for a psychiatric evaluation. The daughter was notified of the incident and the transfer. Review of Resident/Visitor Accident & Incident Report for Resident #60 dated 3/6/18 at 2:00 PM revealed Residents #14 and #60 were sitting next to each other in the dining room and Resident #60 tried to eat food from Resident #14's tray. Resident #14 got upset, both residents started arguing and Resident #60 grabbed Resident #14's left wrist. A Resident/Visitor Accident & Incident Report for Resident #14 dated 3/6/18 at 2:00 PM documented that Resident #14's left wrist was assessed and slight redness was observed. The Accident & Incident report revealed no documented evidence that the incident was reported to the State Survey Agency. During an interview on 3/8/18 at 11:28 AM, Resident #14 stated that two days ago the man in the orange shirt, while pointing to Resident #60, (a male resident seated in the dining area), walked over to me and started reaching for my lunch. I told him to stop and he took his walker and jammed it into my walker. During an interview on 3/14/18 at 2:01 PM, the DON stated she reported the incidents involving Resident #60 to the State Agency over the phone. Review of Accidents/Incidents reported to the NYS DOH Centralized Complaint Intake Program for the facility revealed there were no incidents reported involving Resident #60. Review of the NYS DOH Nursing Home Reporting Manual dated (MONTH) (YEAR) revealed inappropriate physical contact resulting in injury or likely to harm a resident and touching intimate body parts or the clothing covering intimate body parts are reportable incidents. 2. Resident #78 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is understood, understands and is cognitively intact. Further review of the MDS revealed Resident #78 is independent with transfers and ambulation. Review of a Room Transfer Slip dated 3/7/18 revealed Resident #78 was moved from the second floor to the third floor and the resident, family, and nurse were notified. Review of a Resident Care Record Note dated 3/7/18 revealed staff were notified that Resident #78 had an altercation with her roommate (Resident #58) at 2:00 PM. The roommate was playing with her television, she went to stop her roommate and the roommate slapped her on the right cheek. The DON and PA were notified and a voicemail was left for the responsible party. Review of the Daily Unit Reports dated 3/7/18 and 3/8/18 revealed a plan to monitor Resident #78 for delayed bruising of the right cheek. Interview with Resident #78 on 3/8/18 at 11:23 AM revealed she was slapped in the face by another resident (#58) yesterday. I was trying to hold her hands and she slapped me in the face. The Social Worker said they were going to move my room. They moved me to this room about 3:30 PM yesterday. Observation of the resident at the time of the interview revealed there was no visible redness on her face. Interview with the DON on 3/14/18 at 11:27 AM revealed an Accident & Incident Report for Resident #78 was found on the Third Floor at the Nurses' Station. The Resident/Visitor Accident & Incident Report was dated 3/7/18 at 2:00 PM and documented that the resident was slapped by her roommate on the right cheek and the care plan change was to move the resident to another floor. The Accident & Incident report revealed no documented evidence that the incident was reported to the State Survey Agency. During an interview on 3/14/18 at 3:05 PM, the DON stated I just found out about this today, it wasn't reported. I'm going to report it today. 415.4(b)(4)

Plan of Correction: ApprovedApril 19, 2018

All of the non-reported incidents involving resident numbers 14,60, 43,78, and 58 were reported to the Department of Health by the Director of Nursing via the Health Commerce System on 3/17/2018.
All Residents have the ability to be affected by this violation.
The Administrator will counsel the Director of Nursing and the Director of Nursing will be reeducated by the Administrator on the reporting requirements.
The Administrator will review all Accident and Incident Reports for the last 90 days to confirm that all incidents identified as reportable have been reported according to the reporting requirements.
The Administrator will review all Accident and Incident Reports daily to assure compliance with reporting. The Administrator will confirm, via the Health Commerce System log, all reports that the Director of Nursing files.
The Administrator will conduct an audit monthly of all Accident and Incident Report from the month to assure all reportable incidents have been reported and timely to the Department of Health. This audit will be conducted monthly for three months and than quarterly. Results of the audit will be submitted to the QA committee.
Responsible Party: Administrator

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 3/16/18, the facility did not ensure each resident medical record was maintained in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized. Three (Residents #60, 85, 337) of 35 medical records reviewed had issues. Specifically, documentation of Accident/Incident Reports were delayed, inaccurate or unavailable (Resident #60), lacked accessible behavior documentation (Resident #85), and a resident received [MEDICATION NAME] (narcotic pain medication) without a Physician's Order (Resident #337). The findings are: 1. Resident #60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - resident assessment tool) dated 1/27/18 revealed the resident has severely impaired cognition. Review of Comprehensive Care Plan (CCP) dated 1/24/18 revealed the resident ambulates independently with a rollator walker in room and supervision for directional cues. Communication is rarely/ never understood and rarely/ never understands (1/24/18) and has severe cognitive deficits (1/24/18). The resident is at risk for wandering related to dementia, rummaging, and agitation (2/11/18). Review of the Nurse's Notes revealed the following: -1/25/18 at 7:45 AM resident was wandering in peer's rooms during the night eating their food and drinking regular liquids even though nectar thick liquids are ordered. -1/26/18 at 7:27 AM resident had regular liquids/ a peanut butter and jelly sandwich, coughed, food and liquids removed from his room. Nursing Supervisor was notified and RN (Registered Nurse) assessment completed. -1/28/18 at 11:15 PM resident was upsetting other residents by going into their rooms, sitting on their beds, noted grabbing at residents.1:1 behavior teaching, redirection, fluids and snack offered. - 2/2/18 at 12:30 PM resident was spitting on tables, floor, in his hands, touching other residents, wandering into other resident's rooms and removing food items from other resident's meal trays. -2/3/18 at time resident was found by CNA (Certified Nurse Aide) inappropriately touching another female resident. Then the resident was then found on the floor after returning to his room. -2/19/18 at 6:00 AM resident wandered into room with two in exposed female residents. The two females started screaming, the resident was combative when redirected. Review of Accident & Incident Reports provided for Resident #60 included 1/18/18, 2/3/18 (incomplete investigation), 2/11/18, 2/13/18/, and 3/6/18. No other Resident/ Visitor Accident/ Incident reports were provided. During interview on 3/15/18 at 9:20 AM, the Director of Nurses (DON) stated she found the Accident/ Incident Report dated 2/3/18 in the Supervisor's box, and stated, It's incomplete, the Supervisor initiated the report, never completing it and she's been sick for 2 weeks. The DON stated she forgot it was in the box. 2. Resident #85 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had severe cognitive impairment, no physical or verbal behavioral disturbances, and medications received included antipsychotics. The resident was discharged home on[DATE]. Review of the Daily Orders Report dated 1/31/18 through 2/25/18 revealed a Physician's Order for [MEDICATION NAME] ([MEDICATION NAME]-antipsychotic) 1 mg (milligram) twice daily for altered mental status; started on 2/2/18 and ended on 2/12/18. The 2/2018 Medication Administration Record (MAR) revealed the resident received [MEDICATION NAME] 1 mg twice daily starting 2/2/18 at 6:00 PM until 2/11/18 at 6:00 PM. During an interview on 3/14/18 RN #2 stated, the resident could be non-compliant, and stand up all the time. We'd tell him not to and he'd stand up anyway, we had to constantly watch him and keep him near Nurse's Station. I don't remember him being combative or anything. We'd try talking to him, watching TV etc. If a resident is combative RN #2 documents in the computer on the MAR and behavior flowsheet. During an interview on 3/15/18 at 10:15 AM, the DON stated, Resident #85 did have behaviors and staff would try to distract him, offer him snacks but he'd get mad and say leave me the hell alone and get upset. We use a behavior flowsheet in the computer to document behaviors. The DON was unable to access a behavior flowsheet for Resident #85. During further interview at 12:38 PM, the DON stated, We can't get behavior flowsheet access from their system when people are discharged , so I have no behavior documentation for this resident. When told there is no behavior documentation in Nurse's Notes or on 24 Hour reports, the DON responded, They were probably relying on the flowsheet for documentation. 3. Resident #337 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, requires extensive assist of two for bed mobility, transfers and toilet use. Review of the policy titled Medication Orders dated 4/10/17 revealed PRN (as needed) Medication Orders - When recording PRN medication orders, specify: The type, route, dosage, frequency, strength and the reason for administration. Review of the policy titled Administering Medications dated 2/1/17 revealed; medications must be administered in accordance with the orders, including any required time frame and state regulations and the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of the policy titled Medication Error dated 2/3/12 revealed a medication error is defined as a failure to give medications according to physician's order, accepted professional standards or manufacture's specifications. Review of the Daily Orders Report dated 2/24/18 through 3/15/18 revealed a Physician's Order for [MEDICATION NAME]-[MEDICATION NAME] (Tylenol) 5-325 mg one tablet by mouth every ______ hours PRN for pain with a start date of 2/24/18 and end date of 3/7/18. The order does not indicate the frequency of hours between doses. Further review of the Daily Order Report revealed an order for [REDACTED]. Review of the MARs dated 2/1/18 through 2/28/18 and 3/1/18 through 3/14/18 revealed no entry that [MEDICATION NAME] -[MEDICATION NAME] 5-325 mg was administered. Review of Resident #337's unnamed [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg medication descending count record dated 2/26/17 revealed the resident received 16 doses between 2/27/18 and 3/11/18. Review of the Specialty RX (prescription) count sheet for Resident #337 revealed [MEDICATION NAME] -[MEDICATION NAME] 5-325 mg was signed out as follows: Three doses on 2/27/18, one dose on 2/28/18, 3/1/18, two doses on 3/2/18, one dose on 3/5/18, two doses on 3/6/18, one dose on 3/7/18, two doses 3/8/18, one dose on 3/10/18 and two doses on 3/11/18. Observation on 3/13/18 at 8:43 AM of Resident #337's EMR (electronic medical record) revealed no Physician's Order for [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg in the system. During an interview on 3/13/18 at 8:43 AM, Licensed Practical Nurse (LPN) #4 stated the [MEDICATION NAME] - [MEDICATION NAME] order used to be in the computer but it would not allow her to enter the information. The Nurse Manager (NM) knew about the problem but couldn't fix it. LPN #4 was not sure if anyone else knew about the computer problem and she continued to give the medication knowing it was not being entered on the MAR. During an interview on 3/13/18 at 1:44 PM, RN #1 reviewed the (MONTH) (YEAR) MARs and did not know the order was not appearing on the MAR but was being signed out on the control record as being given. During an interview on 3/13/18 at 2:40 PM, the Physician Assistant (PA) stated she discontinued the [MEDICATION NAME] - [MEDICATION NAME] 5- 325 mg order on 3/8/18 because she did not think the resident was taking it because there were no entries on the MAR indicating he was receiving it. The PA was informed today he had been taking the [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg, therefore after she reviewed the EMR, she believed there was a discrepancy in the order that caused the problem with the computer entry prior to (MONTH) 8, (YEAR). The PA discontinued the order on (MONTH) 8, (YEAR) and is now aware the resident received the medication on (MONTH) 10th and 11th (YEAR) without an order, therefore an order was written. The PA stated the nurse should have alerted the provider if the EMR was not allowing them to sign the medication out in order and fix the problem. During an interview on 3/13/18 at 2:55 PM, the Assistant Director of Nursing (ADON)stated she was not aware there was a computer problem with an order. The nurse should have verified the [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg order was current and not give the medication until there was an appropriate order and ability to enter the information in the EMR. During an interview on 3/13/18 at 3:00 PM, the DON stated she was not aware of a computer problem with an [MEDICATION NAME] -[MEDICATION NAME] order. The nurses should inform her of any issues with the computer and not give a medication without an appropriate order. During an interview on 3/16/18 at 12:07 PM, the Administrator stated she was not aware there was a computer problem for a control substance which prevented a nurse from entering the information in the EMR after it was given. The Administrator stated she was aware a medication error occurred, because the [MEDICATION NAME] - [MEDICATION NAME] was given without an appropriate order. 415.22(a,b,c)

Plan of Correction: ApprovedApril 30, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #60 was no longer resides at our facility. He was transferred to the hospital on [DATE] for then discharged from the hospital to another LTC and will not be returning to Safire Rehabilitation of Northtowns. The Director of Nursing and Physician Assistant reviewed the residents record.
Resident #85 no longer resides at our facility and was transferred home on 3/6/18 in stable condition. The Director of Nursing reviewed the residents record.
Resident #337 no longer resides at our facility and was discharged home in stable condition on 3/22/18. The Physician Assistant reviewed the residents record.
All residents have the potential to be affected by the same deficient practice. The facility will ensure each resident?s clinical records are in accordance with accepted professional standards and practice that are complete and accurately documented, readily accessible and systematically organized.
The nursing management team will conduct a 100% record review with a 90 day look back for all residents to ensure the current physicians order in the electronic medical record are accurate and include the complete medication/treatment order specifying the type, route, dosage, frequency/time, strength, and reason for administer. The Medication Administration Record, [REDACTED]. The Speciality RX narcotic count sheet and narcotic descending count record will be referenced against the medication narcotic orders and MARS.
The computerized behavior flow sheet will be referenced with all residents, [MEDICAL CONDITION] drug orders to ensure behavior flow sheets are in place and completed accurately and are accessible in EMAR system.
The nurse?s notes, and physicians progress notes will be reviewed for resident incident/accidents to ensure the A&I reports have been completed timely and accurately and are systematically organized and accessible. The A&I reports will be filed in Accident/Incident Binders and entered into the A&I tracking log located in the DON?s office.
All deficient practices identified will be reported to the Medical Director, DON and Administrator to ensure appropriate follow-up action occurs. The DON will analyze and trend the data collection and report findings to the Quality Assurance Committee.
The Director of Nursing will randomly audit 10 resident charts for accuracy and completion including applicable behavior documentation and physicians orders for pain medications, monthly for 3 months and then quarterly.

The Administrator will randomly audit 10 accident/incident reports monthly for timely documentation, including applicable staff/witness statements, monthly for three months and than quarterly.
Responsible Party: Director of Nursing

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on observation, interview, and record review conducted during the Standard survey completed on 3/16/18 the facility did not ensure residents had a right to a dignified existence in an environment that promotes maintenance or enhancement of their quality of life. Three (Unit 1, 2 and 3) of three units observed for dining the residents received their cold beverages either in disposable plastic cups and/ or paper cartons. The finding is: The policy entitled Quality of Life-Dignity dated 2/1/17 revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. During meal observations on all three units for the following meals and dates reveal the following: - 3/8/18 during the lunch meal, residents received disposable plastic cups and paper cartons for their cold beverages. - 3/9/18 during the breakfast meal, residents received disposable plastic cups and paper cartons for their cold beverages. - 3/12/18 during a lunch tray line observation, residents received disposable plastic cups and paper cartons for their cold beverages. - 3/15/18 during the lunch meal, residents received disposable plastic cups and paper cartons for their cold beverages. - 3/16/18 during the lunch meal, residents received disposable plastic cups and paper cartons for their cold beverages. During an interview on 3/12/18 at 12:21 PM, the Food Service Director (FSD) stated, I have had cups on order since 11/3/17. It is like pulling teeth to get anything around here. I know the drinks should be in regular cups, but my supply has been slowly depleting. I do not have many left, so I must use the disposable ones. I have e-mails that I have sent several times regarding ordering new cups, but I still have not received any. Review of e-mails regarding the purchase and ordering of new cups revealed an order was placed on 1/11/18. E-mails were sent on 2/6/18 questioning the order status of the cups and again on 2/7/18 with approval that six cases may be placed for next week, but to be advised that the quantity may be lowered to stick within budget. 415.3(c)(1)(i)

Plan of Correction: ApprovedApril 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility received it's shipment of plastic cups on 4/10/2018 and they have been placed in circulation. The facility is no longer using disposable cups. Plastic cups are being provided for usage with paper cartons.
All residents have the potential to be affected by this violation. There are no residents currently NPO.
The Food Service Director has created a par level for plastic cups and will order necessary [MEDICATION NAME] to maintain the determined par level of cups, assuring residents do not get served drinks in disposable cups.
The Food Service Director will educate the dietary staff on the usage of disposable products for emergency only and the par level of plastic cups.
The Food Service Director will audit ten trays on each shift for dignity and the usage of disposable items randomly each month for three months and submit the results to the Quality Assurance Committee.
Responsible Party: Food Service Director

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Complaint investigation (Complaint #NY 699) during the Standard survey completed on 3/16/18, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Two (Residents #68 & 490) of five residents observed for pressure ulcers had issues. Specifically, for a resident with a lack of weekly pressure ulcer assessments from (MONTH) (YEAR) through Sept (YEAR) (Resident #68), and lack of bilateral heel booties usage for a Stage II pressure ulcer (Resident #490). The findings are: Review of the Policy titled Weekly Decubitus Assessment Forms dated 2/1/17 revealed on going pressure ulcer review will be documented weekly by the Wound Care RN (Registered Nurse). The Wound Care RN, Wound Care MD (Medical Doctor) and Unit Charge Nurse will perform weekly rounds. Review of the Policy titled Pressure Ulcer/ Skin Breakdown-Clinical Protocol dated 2/1/17 revealed skin/ wound protocol for Stage II partial thickness skin loss and skin tears: Positioning devices- therapeutic chair cushion, therapeutic mattress, heel booties or heel lift boots, bed cradle, etc., Provide pressure relief: reposition immobilized patients every two hours and prn (as needed); Use positioning devices to relieve pressure to heels and prevent direct contact with another surface. 1. Resident #68 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 2/2/18 revealed the resident is cognitively intact, understands, is understood, and has a Stage III and Stage IV pressure ulcer. Review of the Weekly Dermal Lesion/ Pressure Ulcer Assessment Forms dated (MONTH) 11, (YEAR) through (MONTH) 22, (YEAR) revealed an assessment of the left lateral foot unstageable pressure ulcer measuring 0.7 cm (centimeters) x 1.2 cm with a wound bed description of eschar (black or brown dead tissue) with a black hard intact tissue dated 6/22/17. No further assessments were documented in the medical record. Review of the Weekly Dermal Lesion/ Pressure Ulcer Assessment Forms dated (MONTH) 1, (YEAR) through (MONTH) 15, (YEAR) revealed an assessment of the left lateral heel Stage IV pressure ulcer measuring 1 cm x 1.5 cm with a wound bed description of 25% slough (soft, moist, dead tissue may be white, yellow, tan or green) and a treatment of [REDACTED]. No further assessments were documented in the medical record. Review of the Weekly Dermal Lesion/ Pressure Ulcer Assessment Forms dated (MONTH) 30, (YEAR) through (MONTH) 22, (YEAR) revealed an assessment of the left heel Stage IV pressure ulcer measuring 3 cm x 3 cm with a wound bed description of 50% slough with a treatment of [REDACTED]. No further assessments were documented in the medical record between (MONTH) (YEAR) through (MONTH) 7, (YEAR). Review of the Weekly Dermal Lesion/ Pressure Ulcer Assessment Forms dated (MONTH) 28, (YEAR) through (MONTH) (YEAR) revealed an assessment of the right heel Stage II pressure ulcer measuring 1.5 cm x 2.1 cm with a wound bed described as scabbed and a treatment of [REDACTED]. The next assessment dated (MONTH) 7, (YEAR) revealed right heel Stage II pressure ulcer measuring 1 cm x 1 cm with a depth of <0.1 cm with scant amount of serous (pale, yellow, transparent body fluid). No further assessments were documented in the medical record between (MONTH) (YEAR) through (MONTH) 7, (YEAR). Review of the Weekly Dermal Lesion/ Pressure Ulcer Assessment Forms dated (MONTH) 17, (YEAR) revealed an assessment of the right lateral foot Stage II pressure ulcer measuring 1.5 cm x 0.6 cm with a wound bed description of dry skin. Additional review revealed an illegible and incomplete date in (MONTH) of a Stage II pressure ulcer measuring 1.8 cm x 1.6 cm with a wound bed description of dry. No further assessments were documented in the medical record between (MONTH) (YEAR) through (MONTH) 7, (YEAR). During an interview on 3/14/18 at 10:50 AM, the Registered Nurse (RN) #1 Wound Care Certified (WCC), stated she was hired as the wound nurse and identified there was a lack of documentation which the Director of Nursing (DON) was aware. RN #1 stated she was unable to locate any documentation of the left lateral foot and left lateral heel after (MONTH) 15, (YEAR), and documentation of the right heel and right lateral foot between dates of (MONTH) (YEAR) through (MONTH) 7, (YEAR) when she completed her first entries. During an observation of the left heel pressure ulcer treatment on 3/16/18 at 8:36 AM revealed a stage IV pressure ulcer. During an interview on 3/16/18 at 9:34 AM, the DON stated upon starting in (MONTH) (YEAR) there was no tracking of wounds; she was the second RN in the building and she did the best she could to assess the residents. The DON stated she realized the problem was beyond her capabilities of being able to be the DON and manage the wounds so a WCC was hired. 2. Resident #490 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment, requires extensive staff assistance for bed mobility and is at a risk of developing pressure ulcers. Review of the comprehensive Care Plan (CCP) dated 3/2/18 revealed Skin Integrity as an area of concern related to: Braden Scale (tool used to assess a patient's risk of developing a pressure ulcer) low risk and planned interventions for incontinent care per policy; Turn and Position (T&P); Treatments as ordered; Braden scale per policy. In addition, Stage II pressure ulcer to the left heel related to immobility with the planned interventions: right and left heel pads worn in and out of bed. Review of the Daily Orders Report revealed a Physician Order's dated 3/2/18 for pads to bilateral heels at all times. On heels (every shift). Review of the 3/2017 Treatment Administration Record (TAR) revealed bilateral heel pads to bilateral heels at all times, every shift. The heel pads were signed with a check mark indicating the treatment was complete. Review of the Weekly Skin Tracker/ Quality Assurance Report dated 3/2/18 revealed a Stage II pressure ulcer to the left heel measuring 6.3 cm x 5 cm with Skin Prep (topical application that toughens skin and enhances adherence of dressing) while blister is intact, heel booties and T&P q (every) 2 hours and prn. Review of the On Going Evaluation Week #1 form dated 3/2/18 revealed heel booties to be on at all times. Review of the Mini Care Plan (care guide used by Certified Nurse Aide (CNA) to provide care) dated 3/14/18 revealed heel booties was not documented as an intervention. Review of the Weekly Skin Tracker/ Quality Assurance Report dated 3/9/18 revealed a Stage II pressure ulcer to the left heel measuring 5.8 cm x 4.2 cm with a new treatment of [REDACTED]. Review of the On Going Evaluation Week #2 form dated 3/9/18 revealed the resident's daughter only wants a thin profile dressing due to resident shoe preference, despite education. Treatment was changed to large border gauze dressing daily. Observation of the resident on 3/12/18 at 10:12 AM revealed CNA #7 & 10 entered the room to perform morning care. CNA #7 uncovered the resident's feet, the resident's heels were positioned flat against the mattress, wearing a pair of socks. The blue heel booties were located on the dresser next to the T.V. During an interview on 3/12/18 at 11:00 AM, CNA #7 stated she was unaware the resident had heel booties because, heel booties are listed on the care guide. Further observation on 3/12/18 at 1:40 PM revealed the Licensed Practical Nurse (LPN) #8 uncovered the resident's feet in bed to remove a soiled dressing. Prior to treatment change the resident had heels flat on the mattress without booties, the dressing to the left heel was intact. During an interview on 3/12/18 at 2:30 PM, LPN #8 stated she was unsure if the resident had heel booties because she normally does not work on this unit. Additional observation on 3/13/18 at 4:38 AM revealed the resident was in bed with a rolled blanket under the heels and no heel booties. During interview on 3/13/18 at 4:43 AM, RN #2 stated heel booties are the same as heel pads, a resident will usually require wearing them if their heels are mushy, boggy or any pressure areas. RN #2 free floated the resident's heels with a rolled blanket because she was unable to locate heel booties and would pass the information to the on-coming nurse. RN #2 signed the TAR as completing the treatment stating, I considered it the same as heel booties. During interview on 3/14/18 at 9:17 AM, CNA #11 stated the heel booties were implemented last week when the resident developed a pressure area to her heel. I'll be honest, they aren't on when I come in to do care. They're usually on the dresser or the T.V. I put them on when she (Resident #490) goes to bed but what happens after that I don't know. During interview on 3/15/18 at 9:01 AM, RN #1 WCC revealed heel pads and heel booties are the same thing. Recommendations are given to the Unit Manager that will make changes to the Care Plan. If the Unit Manger is unavailable then the RN Supervisor is expected to update the Care Plan. During interview on 3/16/18 at approximately 9:15 AM the DON stated, typically heel booties are on the care guide (Mini Care Plan), CCP, and the TAR. The DON stated that her expectation is that nurses signing for heel booties are to ensure the booties are on and if unable to locate them they are to call laundry for an additional pair. 415.12 (c)(2)

Plan of Correction: ApprovedApril 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #68 was seen by the medical provider on 04/12/18. The weekly pressure ulcer assessments of the left heel were conducted by the RN wound care nurse on 3/13/18, 3/20/18, 3/27/18, 4/4/18 and 4/11/18. The 4/11/18 treatment orders for the stage IV pressure ulcer to left heel are [MEDICATION NAME] Patch ROD & DCD/[MEDICATION NAME]. The 4/11/18 pressure ulcer assessment measuring L 3.8 cm x W 3.6cm x D 0.2 cm with wound bed description 30% moist yellow slough, granulated surrounding tissue.Current pressure relief devices include heel lift prevlon booties. Resident #68 comprehensive care plan and CNA mini care plan was reviewed on 4/12/18, no revisions to the plan of care was needed. Resident #68 remains at the facility in stable condition.
Resident #490 was seen by the medical provider on 4/12/18. The weekly pressure ulcer assessments to the left heel were conducted by the RN wound care nurse on 3/9/18, 3/16/18, 3/21/18, 3/30/18, 4/3/18 and 4/9/18. The 4/9/18 treatment orders for the stage II pressure ulcer to the left heel are Exuderm low profile. The 4/9/18 pressure ulcer measuring L 0.8 cm x W 0.7cm x D 0 cm with wound bed description 100% granulated. Current pressure relief devices include heel pads to LBR foot while in bed.
Resident #490?s care plan was reviewed and revised by the IDT on 4/12/18. Bilateral Heel Booties have not been added to the CCP and CNA mini care plan and treatment record per family request. The wound care RN discussed the risk and benefits for using pressure relief ?Heel Booties? with the resident?s daughter on 3/9/18 and resident?s daughter did not agree to the care plan intervention. Resident #490 remains at the facility in stable condition.
All residents who have an existing pressure sore (ulcer) or who are at risk of developing a pressure ulcer have the potential be affected by the same deficient practice.
A 100% medical record and care plan review will be conducted for residents who currently have pressure ulcers, or who are at risk for developing pressure ulcers. The Comprehensive Care Plan will be reviewed and revised by the interdisciplinary team to ensure they are receiving the necessary treatment and services to promote wound healing, prevent infection and pressure ulcers from developing. The Medical Record Review will include review of the physician?s orders to ensure orders are transcribed and pressure-relieving interventions are in place to prevent pressure ulcers from developing. The interdisciplinary team will compare the physician?s orders and progress notes to the treatment and medication record, wound consultation records, laboratory records, and weekly wound data collection records. The Comprehensive Care plan and CNA mini care plan will be reviewed and revised by the interdisciplinary team when needed.The DON and wound care nurse will be immediately notified of deficient practice identified to ensure appropriate measures and MD follow up action occurs.
Medication error reports will be completed when treatment errors are identified.
The wound care nurse will analyze and trend data collection and report findings to the QAA committee at the next scheduled meeting. The Regional QA RN will receive this QA report weekly.
The corporate DON reviewed the policies and procedures entitled ?Weekly Decubitus assessment form date 2/1/17 and ?Pressure Ulcer/Skins Breakdown Clinical Protocol? dated 2/17/17. No revision to the Policy and Procedure were needed.
The Regional RN Educator will in-service the DON, ADON, Unit Managers, Wound Care RN, IDT, Medical Providers and Licensed Nursing staff on the policies and procedures mention above. The Regional RN Educator will in-service all CNA staff on the above-mentioned policy and procedures specific to their skill set and CNA mini care plan interventions.
The CNA #7 assigned to resident #490 on 7-3 shift on 3/12/18 who did not follow the CNA care guide and ensure heel booties were placed on the resident will be counseled and re-educated by the DON on following the care plan and the importance of pressure relief devices.
The LPN #8 who changed resident #490?s dressing on the 7-3 shift on 3/12/18 and did not notify the Unit Manager or Wound Care Nurse for clarification of the plan of care, and did not apply heel booties will be counseled and in-serviced by the DON.
The RN#2 who changed resident #490?s dressing or 3/13/18 the 11-7 shift and did not apply bilateral booties but signed the TAR as completed will be counseled and educated by the DON.
The RN #1 wound who did not know the difference between heel pads, and heel booties will be re-in-serviced on the differences by the Regional RN Educator.
The DON who did not ensure weekly pressure ulcer assessments were conducted from (MONTH) 6, (YEAR) through (MONTH) 23, (YEAR) no longer works at the facility, and was terminated from employment on (MONTH) 23, (YEAR).
The current DON who did not ensure weekly pressure ulcer assessments were conducted from (MONTH) 23, (YEAR) through (MONTH) (YEAR), will be counseled by the Administrator and Re-in-serviced by the Regional RN Educator including a review of the DOH regulation for weekly pressure ulcer assessment requirements and facility policy and procedures related to pressure ulcer prevent and treatment mentioned above.
The DON will no longer conduct the weekly QA Skin/Pressure Ulcer Audit Tool. This will now be completed by the wound care RN to ensure audit tool is accurate. The wound Care RN will ensure that the pressure ulcer assessment and care plan interventions have been initiated, there is evidence that physicians? orders have been implemented and the CCP and CNA mini care plan is updated and interventions are implemented and in place. The wound care RN will also be responsible for conducting a weekly observation for resident?s care plans and ensure that pressure relief devices are in place for those residents at risk for or have an actual pressure ulcer to ensure the CNA mini care plan is correct and being followed. The wound care RN will ensure D/C pressure relief devices have been removed from the resident?s room.

All deficient practice identified will be immediately reported to the DON to ensure the medical provider was notified and immediate action occurred. The wound care RN will forward copies of the audit weekly to the medical providers, DON, ADON, Administrator, QA Regional RN and IDT clinical team members. The wound care nurse will analyze and trend the data collection and report findings to the QAA committee monthly, this will be ongoing.
The DON will continue to conduct the weekly wound care meetings including the review of the weekly QA audit tool conducted by the wound care RN.
The Corporate DON will implement and in-service the DON on the monthly IPRO pressure ulcer tracking audit tool. The DON will update this audit weekly and analyze and trend data collection monthly to ensure pressure ulcer assessment and care plan interventions have been initiated and there is evidence that physician?s orders have been carried out for the residents who have pressure ulcers. The IPRO pressure ulcer audit review will include wound staging, measurement, wound description, healing status, treatment order intervention, documentation that wound cleansing and treatment occurred, pain management, pain management pressure relief interventions are in place and available, and the care plan has been reviewed and revised.
The DON will analyze and trend data collection and report findings to the QAA Committee monthly. The cooperate DON and Regional QA Nurse will receive a copy of this report monthly, this will be ongoing.

Responsible Party: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: June 11, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 3/16/18, structural components of the facility were not properly protected from fire. Issues include, structural steel beams and steel web trusses, located above the non-fire rated ceiling assembly in corridors, rooms, and attic spaces were not protected to meet minimum fire rated building construction type II (111). This affected three (First, Second, and Third) of three resident use floors and one of one attic and one of one basement. The finding is: 1. According to the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, the minimum acceptable construction type for this three-story building is type II (111). This construction type requires the building to be completely sprinklered and that structural components are non-combustible and protected with at least a one-hour fire resistive rating. Type II (111) construction type requires that structural components are protected with at least a one-hour fire resistive rating either by some type of physical one-hour fire rated protective covering on structural components or by maintaining a one-hour fire rated ceiling assembly. Intermittent observations on 3/8/18 between the hours of 8:30 AM and 1:00 PM revealed that this three-story building, with basement, was fully protected by an automatic sprinkler system. Observations on 3/13/18 between the hours of 8:15 AM and 10:00 AM revealed there were unprotected steel beams and steel web roof trusses above the lay-in ceiling tiles on the First, Second and Third Floors. The observation also revealed there were unprotected steel beams and steel web roof trusses in the attic. Interview with the Regional Chief Engineer on 3/13/18 at 8:30 AM revealed the facility has not made any changes to the unprotected lay-in ceiling tile assemblies or the unprotected steel trusses and beams throughout the facility since the last survey and the facility does not have a current FSES with a passing score. Interview with the Administrator on 3/15/18 at 12:35 PM revealed the facility applied for a Time Limited Waiver with the New York State Department of Health after the last Life Safety Code survey. Continued interview revealed she participated in a conference call with members of the New York State Department of Health Bureau of Architectural & Engineering Review most recently on 2/1/18 and the status of the Time Limited Waiver at that time was under review. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.1.6 2012 NFPA 220: 4.1.1

Plan of Correction: ApprovedApril 20, 2018

The Administrator submitted a time limited waiver request (#171W030) to the department of health on (MONTH) 19th, (YEAR) and it is currently under review. The Administrator will be responsible to communicate with BAER to facilitate approval at the state and federal (CMS) levels.
The facility has not made any changes to the unprotected lay-in ceiling tile assemblies or the unprotected steel trusses and beams throughout the facility since the last survey.
The facility will proceed with protecting the steel beams and trusses according to the limited waiver request once approved by the department of health. The facility is fully protected by an automatic sprinkler system.
The deficiency, time limited waiver request and physical correction plan will be discussed at the next QA committee meeting

Responsible Party: Regional Chief Engineer

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during the Life Safety Code Survey completed on 3/16/18, the kitchen hood extinguishment system was not tested at least every six months. This affected the hood extinguishment system in one of one main kitchen. The finding is: 1. Record review of kitchen hood extinguishment system reports on 3/8/18 revealed the main kitchen hood extinguishment system was inspected on 10/26/16 and then it was not inspected again until 8/15/17, approximately ten months later. Interview with the Regional Chief Engineer on 3/8/18 at 2:10 PM revealed he performed an audit in (MONTH) (YEAR) and discovered that the kitchen extinguishment system had not been inspected since (MONTH) (YEAR). Further interview revealed at the time of the audit he immediately scheduled the inspection with an outside contractor and created a new policy called, Fire Systems Inspections. Per the 2011 edition National Fire Protection Association (NFPA) 96 ? Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, listed hoods containing mechanical or fire-actuated dampers, internal washing components, or other mechanically operated devices shall be inspected and tested by properly trained, qualified, and certified persons every six months or at frequencies recommended by the manufacturer in accordance with their listings. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2.5.1, 9.2.3, 2011 NFPA 96: 11.5

Plan of Correction: ApprovedApril 12, 2018

The facility created and implemented the policy ?Fire System Inspections?. The kitchen hood extinguishment system was inspected on 8/15/17 and again in 2/22/18.
All residents have the potential to be affected by the violation.
The facility will coordinate inspections at least every 6 months. The maintenance Director will be educated on this requirement. The monthly maintenance schedule will be modified to include having the maintenance supervisor schedule the hood inspection for every (MONTH) and August.
The Administrator will audit the maintenance schedule each month for compliance and submit results to the Quality Assurance Committee.
Responsible Party: Maintenance Director

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a Life Safety Code survey completed on 3/16/18, the facility did not keep a written record of maintenance and testing of all patient care-related electrical equipment. This affected equipment (electric beds, lifts, and oxygen concentrators) used on three (First, Second, and Third) of three resident use floors. The findings are: 1. Record review of the service manual for an in-house brand of electric bed on 3/13/18 revealed the bed is to be visually inspected on a monthly basis. Review of the document called, 2018 Facility Bed Inspection Log revealed the most recent visual inspection of each bed was performed in (MONTH) (YEAR) by the Maintenance Assistant. Interview with the Regional Chief Engineer on 3/13/18 at 12:55 PM revealed the (YEAR) Safire Bed Inspection Log was the only documentation he could locate on the visual inspection of beds, and he could not locate any documentation of visual inspection of beds from (YEAR). Interview with the Maintenance Assistant on 3/14/18 at 2:00 PM revealed he looks at residents' beds daily due to various maintenance requests about beds. Continued interview revealed he visually inspects residents' beds during room checks when a room becomes vacant, but he cannot provide any documents to support this. 2. Record review of the user manual for an in-house brand of lift on 3/13/18 revealed there is a checklist of items to inspect/ adjust monthly, including, but not limited to, the caster base, the shifter handle, the mast, the boom, the manual/ hydraulic pump/ electric [MEDICATION NAME] assembly, and the control valve. Review of a service ticket from an outside contractor revealed nine lifts were inspected at this facility on 9/1/17. Review of in-house inspection records revealed eight lifts were inspected by maintenance personnel in (MONTH) (YEAR) and (MONTH) (YEAR). Interview with the Regional Chief Engineer on 3/14/18 at 1:50 PM revealed all of the facility's nine lifts were inspected by an outside contractor on 9/1/17 and eight of the nine lifts were inspected by maintenance personnel in (MONTH) and (MONTH) (YEAR), but he cannot locate any documentation of the inspection of the nine lifts during (YEAR). Interview with the Maintenance Assistant on 3/14/18 at 2:10 PM revealed he checked all of the facility's lifts on a monthly basis during (YEAR), but no records were kept. 3. Record review of the instruction guide for an in-house brand of oxygen concentrator on 3/13/18 revealed preventative maintenance may be performed at intervals decided by the provider. Interview with the Regional Chief Engineer on 3/13/18 at 1:20 PM revealed he decided the appropriate interval would be quarterly for oxygen concentrator preventative maintenance in this facility. Record review of the in-house preventative maintenance log for oxygen concentrators on 3/13/18 revealed the most recent preventative maintenance occurred in (MONTH) (YEAR). Interview with the Regional Chief Engineer on 3/13/18 at 1:25 PM revealed he cannot locate any documentation of the inspection of the facility's oxygen concentrators prior to (MONTH) (YEAR). Interview with the Maintenance Assistant on 3/14/18 at 2:05 PM revealed he performed preventative maintenance on all of the facility's oxygen concentrators on a monthly basis during (YEAR), but no records were kept. The 2012 edition of the National Fire Protection Association (NFPA) 99 - Health Care Facilities Code states a record shall be maintained of the tests required and associated repairs or modifications. At a minimum, the record shall contain all of the following: (1) Date (2) Unique identification of the equipment tested (3) Indication of which items have met or have failed to meet performance requirements 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.5.6, 10.5.6.2, 10.5.6.2.1, 10.5.6.2.2, 10.5.6.3

Plan of Correction: ApprovedApril 17, 2018

The facility conducted a preventive maintenance audit on all beds, lifts and oxygen concentrator?s on 4/11/2018 and 4/12/2018. All other PCREE equipment will be reviewed.
All residents have the potential to be affected by this violation.
A PCREE preventative maintenance schedule, based on PCREE manufacturer instructions and service manuals, has been created. It includes the unique identification of all PCREE equipment to be tested , the frequency that the equipment should be tested , the date of testing and the indication of which items have met or failed to meet performance requirements.The facility will provide preventative maintenance of all equipment according to the PCREE maintenance schedule and document accordingly.
The maintenance staff will be in-serviced on the new PCREE PM schedule.
The maintenance director will audit compliance of the PCREE preventative maintenance program monthly for three months and then quarterly for 6 months. Results will be submitted to the quality assurance committee.
Responsible Party: Maintenance Director

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 3/16/18, the emergency generator was not properly maintained. Issues include the facility did not consistently conduct weekly inspections of the emergency generator and the emergency generator was not run under load for at least 30 minutes, 12 times a year in 20 to 40-day intervals. This affected one of one emergency generator, that provided emergency backup power to three (First, Second, and Third) of three resident use floors. The findings are: 1. Record review of the facility's generator logs on 3/8/18 revealed the facility did not have documentation of weekly inspections for the emergency generator between 5/12/17 and 7/11/17. 2. Record review of the facility's generator logs on 3/8/18 revealed the facility did not have documentation of monthly load tests for the emergency generator between 4/28/17 and 7/11/17. 3. Record review of the facility's generator logs on 3/8/18 revealed more than 40 days had passed between the monthly load tests for the emergency generator between 8/3/17 and 9/28/17 (56 days) and between 1/10/18 and 2/26/18 (47 days). Interview with the Regional Chief Engineer on 3/8/18 at 2:20 PM revealed he performed an audit in (MONTH) (YEAR) and discovered that the generator weekly checks and monthly load tests were not being performed consistently. Further interview revealed at the time of the audit he immediately performed a visual check and load test on the generator and created a new policy called, Weekly Visual Inspection and Monthly Load Testing of Generator. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.3.2.2.10, 6.3.2.2.10.2, 6.4.4, 6.4.4.1, 6.4.4.1.1.3, 6.4.4.1.1.4(A), 6.5.4, 6.5.4.1.1.2 2010 NFPA 110: 8.3.4, 8.3.4.1, 8.4, 8.4.1

Plan of Correction: ApprovedApril 17, 2018

The facility preformed a visual and load test of the generator on 7/11/2017.
The facility conducted all visual checks at least weekly thereafter. The facility conducted the each monthly generator test and the most recent monthly generator test was held on 3/22/18,within the 40 day timeframe.
The facility created a new policy called ?Weekly Visual Inspection and Monthly Load Testing of Generator?. The maintenance personnel will be in-serviced on the contents of the new policy.
All residents have the potential to be affected by this violation.
The monthly load test will be conducted by the Maintenance Director/designee between the 1st and 10th of every month to assure there is no more than 40 days between testing. The weekly visual inspection will be completed by the Maintenance Director/designee on Tuesdays.
The monthly load test documentation will be audited for compliance by the Administrator monthly for three months and than quarterly for 6 months. Results will be submitted to the Quality Assurance Committee.
Responsible Party: Maintenance Director

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 3/16/18, fire drills were not conducted on each shift during the fourth quarter of (YEAR) and the second quarter of (YEAR). This affected three (First, Second, and Third) of three resident use floors. The findings are: 1. Record review of fire drill reports on 3/8/18 revealed a second shift fire drill was not conducted in the fourth quarter (October, November, December) of (YEAR). Further review of the fire drill reports revealed the fourth quarter fire drills were held as follows: 10/11/16 at 6:20 AM (third shift) 10/28/16 at 10:30 AM (first shift) 11/28/16 at 6:20 AM (third shift) 12/30/16 at 8:18 AM (first shift) 2. Record review of fire drill reports on 3/8/18 revealed second and third shift fire drills were not conducted in the second quarter (April, May, June) of (YEAR). Further review of the fire drill reports revealed the second quarter fire drills were held as follows: 5/12/17 at 8:04 AM (first shift) Interview with the Regional Chief Engineer on 3/8/18 at 2:00 PM revealed he performed an audit in (MONTH) (YEAR) and discovered that the fire drill minimum was not met. Further interview revealed at the time of the audit he immediately instituted a new fire drill scheduling log and updated the facility's existing policy on fire drills. Interview with the Administrator on 3/15/18 at 4:10 PM revealed the facility's Quality Assurance Committee notes show that three fire drills were performed in (MONTH) (YEAR), but the written reports for these fire drills were unable to be located. 10NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.7, 19.7.1, 19.7.1.6

Plan of Correction: ApprovedApril 20, 2018

The Maintenance Supervisor responsible at the time is no longer employed at the facility. The current maintenance supervisor has been educated on the requirement to conduct fire drills on each shift each quarter at various times. The facility has conducted fire drills per shift per quarter since (MONTH) (YEAR).
All residents have the ability to be affected by this violation.
The facility conducted a Quality Assurance meeting on 4/12/18 to examine the deficiencies cited under Federal K0712.The regional chief engineer updated the facility's existing policy on fire drills on 7/17/2017. The facility will update the policy again to identify the hours that indicate 1st shift, 2nd shift and 3rd shift. It will also be updated to require the maintenance director to submit a copy of the actual fire drill records to the Quality Assurance Committee Monthly. The maintenance director will be educated on these updates.
A fire drill will be held on each shift each month for 6 months and than at least each shift per quarter thereafter.
The Administrator will audit the fire drills monthly to assure they are being conducted according to the requirement. Results will be submitted to the Quality Assurance Committee monthly for three months and than quarterly.
Responsible Party: Maintenance Supervisor

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

REGULATION: Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 3/16/18, the facility did not ensure that a formal and documented risk assessment for the building system categories was conducted in accordance with National Fire Protection Association (NFPA) 99 ? Health Care Facilities Code. This affected three (First, Second, and Third) of three resident use floors. The finding is: 1. Record review of the facility's preventative maintenance and emergency preparedness documents on 3/8/18 through 3/15/18 revealed no formal and documented risk assessment for the building system categories in accordance with the 2012 edition of NFPA 99 ? Health Care Facilities Code. Interview with the Regional Chief Engineer on 3/14/18 at 9:10 AM revealed the facility does not have a completed NFPA 99 Risk Assessment. Per the 2012 edition of NFPA 99, building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code and the categories shall be determined by following and documenting a defined risk assessment procedure. 10NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 4.1, 4.2, 4.3

Plan of Correction: ApprovedApril 17, 2018

The regional chief engineer will conduct a NFPA 99 risk assessment.
All residents have the potential to be affected by this violation.
The annual maintenance schedule will be revised to include completing a new risk assessment annually.
The risk assessment will be reviewed, at least annually and after any major changes to the building by the Regional Chief Engineer and submitted to the quality assurance committee.
Responsible Party: Regional Chief Engineer

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 3/16/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not have a method to share information from their Emergency Preparedness Plan with residents and their families or representatives. The finding is: 1. Record review on 3/14/18 and 3/15/18 of the facility's Emergency Preparedness Plan, dated 2/26/18 revealed the facility did not have a method to share information from their Emergency Preparedness Plan with residents and their families or representatives. Interview with the Administrator on 3/15/18 at 3:55 PM revealed there is currently no form of communication of emergency preparedness information with residents and their family members. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(c)(8)

Plan of Correction: ApprovedApril 12, 2018

The facility emergency preparedness plan will be updated to include a provision for sharing information about the emergency preparedness plan with residents and their families or representatives.
All residents had the potential to be affected by this violation.
A sign will be posted at the front desk sign-in table indicating the location and availability of the emergency preparedness plan.
The administrator will attend the resident council meeting scheduled for (MONTH) 24th,2018 and provide information about the emergency preparedness plan. All residents and their responsible party will receive a letter detailing information regarding the emergency preparedness plan. The resident admission packet will be updated to include information about the facility emergency preparedness plan.
Responsible Party: Administrator

PRIMARY/ALTERNATE MEANS FOR COMMUNICATION

REGULATION: [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 3/16/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Preparedness Plan did not contain current information about the facility's primary and alternate means of communication during an emergency. The finding is: 1. Record review on 3/14/18 and 3/15/18 of the facility's Emergency Preparedness Plan, dated 2/26/18, revealed a policy called, Loss of Telephone Service and Internal Communication stated the facility's primary means of communication during an emergency would be landline telephone and alternate means of communication would be cellular telephones and two-way radios. Additionally, a policy called, Failure of Communication System, was dated 7/28/05 and located in the facility's previous disaster manual. Further review of this policy revealed it stated beepers could be used for communication during an emergency. Interview with the Regional Chief Engineer on 3/15/18 at 9:15 AM revealed both of these policies must be updated. Further interview revealed the facility no longer maintains two-way radios or beepers and in the event of an emergency, internet would be used for communication, but neither policy mentions the use of the internet for communication. 42 CFR 483.73-Emergency Preparedness 42 CFR 483.73(c)(3)

Plan of Correction: ApprovedApril 12, 2018

The emergency preparedness plan, ?Loss of Telephone Service and Internal Communication? will be updated, removing the use of two-way radios and beepers and including the usage of internet for communication. The previous disaster manual policy ?Failure of Communication System? will be removed from operation.
All residents have the potential to be affected by this violation.
All polices in the emergency preparedness plan will be reviewed by the Regional Chief Engineer, Administrator, and Director of Nursing and updated if needed.
The ?Loss of Telephone Service and Internal Communication? policy will be reviewed at least annually by the Regional Chief engineer, Administrator and Director of Nursing and submitted to the quality assurance committee.
Responsible Party: Administrator

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 3/16/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Preparedness Plan did not address the facility's role under a waiver declared by the Secretary in accordance with section 1135 of the Act. The finding is: 1. The Emergency Preparedness Rule, developed by the Centers for Medicare and Medicaid Services, requires that some providers have policies and procedures, which address the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. This may include policies and procedures on what a facility would do if they had to provide care at an approved alternate site as well as processes on how would they let the community know they are operating at a different care site and any reporting they may need to do if they were under an approved 1135 Waiver. Record review on 3/14/18 and 3/15/18 of the facility's Emergency Preparedness Plan, dated 2/26/18, revealed the facility's role under a waiver declared by the Secretary in accordance with section 1135 of the Act was not addressed. Interview with the Regional Chief Engineer on 3/15/18 at 9:11 AM revealed the 1135 Waiver is not addressed in their current Emergency Preparedness Plan. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedApril 12, 2018

The emergency preparedness plan will be amended to include the 1135 wavier during an emergency.
All residents had the potential to be affected by this violation.
The entire emergency preparedness plan will be reviewed by the regional chief engineer, administrator and director of nursing and updated as necessary. Education will be provided to the facility management team on the 1135 waiver.
The emergency preparedness plan will be reviewed annually by the regional chief engineer, administrator and director of nursing and submitted to the quality assurance committee.
Responsible Party: Administrator

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 3/16/18, sprinkler heads from the automatic sprinkler system were obstructed by solid curtains in Bathing Rooms. This affected of three (First, Second, and Third) of three resident use floors. The findings are: 1. Observation on the First Floor on 3/8/18 at 8:45 AM revealed a solid shower curtain was hung in front of a shower stall in the Bathing Room which measured approximately four and a half feet wide by five feet deep. Further observation at this time revealed the shower curtain would obstruct the spray pattern of the closest sprinkler head, which was a pendant head whose deflector was located approximately eleven inches above and approximately thirty horizontal inches away from the shower curtain. 2. Observation on the Second Floor on 3/8/18 at 9:30 AM revealed a solid shower curtain was hung in front of a shower stall in the Bathing Room which measured approximately three and a half feet wide by four feet deep. Further observation at this time revealed the shower curtain would obstruct the spray pattern of the closest sprinkler head, which was a sidewall head whose deflector was located approximately four inches above and approximately 144 horizontal inches away from the shower curtain. Additional observation revealed there was another solid shower curtain located between the shower stall and the sidewall sprinkler head, and this shower curtain was located approximately eight inches below the sidewall sprinkler head. 3. Observation on the Third Floor on 3/8/18 at 10:25 AM revealed a solid shower curtain was hung in front of a tub alcove in the Bathing Room which measured approximately seven and a half feet wide by six feet deep. Further observation at this time revealed the shower curtain would obstruct the spray pattern of the closest sprinkler head, which was a sidewall head whose deflector was located approximately seven inches above and approximately sixteen horizontal inches away from the shower curtain. 4. Observation on the Third Floor on 3/8/18 at 10:25 AM revealed a solid shower curtain was hung in front of a shower stall in the Bathing Room which measured approximately four and a half feet wide by five feet deep. Further observation at this time revealed the shower curtain would obstruct the spray pattern of the closest sprinkler head, which was an upright head whose deflector was located approximately six inches above and approximately forty-two horizontal inches away from the shower curtain. 5. Observation on the Third Floor on 3/8/18 at 10:25 AM revealed a solid shower curtain was hung in front of a shower stall in the Bathing Room which measured approximately three and a half feet wide by four feet deep. Further observation at this time revealed the shower curtain would obstruct the spray pattern of the closest sprinkler head, which was a pendant head whose deflector was located approximately five inches above and approximately fifteen horizontal inches away from the shower curtain. Interview with the Housekeeping and Laundry Supervisor on 3/14/18 at 3:00 PM revealed the solid shower curtains are not new, they are more than one year old. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5.1, 9.7, 9.7.1. 9.7.1.1 2010 NFPA 13: 8.6.5, 8.6.5.2.2, 8.7.5, 8.7.5.2.2

Plan of Correction: ApprovedApril 12, 2018

The facility ordered shower curtains with a mesh panel at the top so that the automatic sprinkler system would no longer be obstructed. The shower curtains will be installed in the 1st floor, 2nd floor and 3rd floor shower rooms.
All residents had the potential to be affected by this violation.
All shower areas were audited to assure the curtains did not obstruct the automatic sprinkler system. The housekeeping/ laundry supervisor was educated on this requirement.
The laundry/ housekeeping supervisor will audit all shower areas monthly for 3 months and then quarterly for 6 months to assure compliance. Results will be submitted to the QA committee.
Responsible Party: Housekeeping/Laundry Supervisor

SUBSISTENCE NEEDS FOR STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 16, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 3/16/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Preparedness Plan did not address the provision of subsistence needs, including medical and pharmaceutical supplies, during an emergency. The finding is: 1. Record review on 3/14/18 and 3/15/18 of the facility's Emergency Preparedness Plan, dated 2/26/18, revealed the provision of subsistence needs, including medical and pharmaceutical supplies, during an emergency were not addressed. Interview with the Regional Chief Engineer on 3/15/18 at 8:43 AM revealed the facility does not have a contract with an emergency Pharmacy because it has an in-house secure pharmaceutical storage unit, but this is not discussed in the Emergency Preparedness Plan. Continued interview revealed the Emergency Preparedness Plan does list some supply vendors, but does not contain a plan for obtaining supplies during an emergency. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(b)(1)(ii)

Plan of Correction: ApprovedApril 12, 2018

The emergency preparedness plan will be amended to include the provision of emergency pharmaceutical supplies and detailing a plan for obtaining supplies during an emergency.
All residents had the potential to be affected by this violation.
The entire emergency preparedness plan will be reviewed by the director of nursing, administrator and regional chief engineer and updated as necessary.
The emergency preparedness plan will be reviewed at least annually by the Administrator, Director of Nursing and Regional Chief Engineer and submitted to the Quality Assurance Committee.
Responsible Party: Administrator