full report jan. 21 2016

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED:9/8/2016FORM APPROVEDOMB NO. 0938-0391

STATEMENT OFDEFICIENCIESAND PLAN OFCORRECTION

(X1) PROVIDER / SUPPLIER/ CLIAIDENNTIFICATIONNUMBER

335742

(X2) MULTIPLE CONSTRUCTIONA. BUILDING ______B. WING _____

(X3) DATE SURVEYCOMPLETED

01/21/2016

NAME OF PROVIDER OF SUPPLIER

NIAGARA REHABILITATION AND NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

822 CEDAR AVENUENIAGARA FALLS, NY 14301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORYOR LSC IDENTIFYING INFORMATION)

F 0157

Level of harm - Minimalharm or potential for actualharm

Residents Affected - Few

Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 1/9/15.Based on interview and record review conducted during the Standard Survey completed on 1/21/16, the facility did not inform the resident's legal representative or interested family member when there is a significant change in the resident's physical,mental or psychological status;or an accident involving the resident which results in injury and has potential for requiring physician intervention. Two (Resident's #89, 56) of three residents reviewed for notification of change had issues involving abnormal laboratory test results which resulted in a change in the resident's ordered gastrostomy tube feedings and flushes (a tube inserted directly into the stomach to feed a resident and provide fluids) as well as the discontinuing of medications.The resident's responsible party was not informed of the changes (Resident #89) and the lack of physician notification regarding the resident's hypoglycemic/ hyperglycemic (low/high blood sugar levels) episodes (Resident # 56).The finding are:1. Resident #89 has [DIAGNOSES REDACTED]. As per the admission assessment dated [DATE], the resident is non ambulatory,has weakness of all extremities, and requires the total assistance of two persons with a lift machine to transfer from bed to chair. The resident is alert to person but cannot speak words due to the placement of a [MEDICAL CONDITION].Review of the facility Resident Notes revealed the following:- 11/23/15 the resident is noted to cough up yellow sputum. The resident was suctioned with improvement.- 11/24/15 the resident is noted to have a medium amount of yellow secretions from the [MEDICAL CONDITION] site.- 11/24/15 the resident is noted to have critical labs called from the laboratory including a sodium (Na - the level of salt in the blood, an indicator of hydration) of 161 (normal Na levels are 133- 147) and a blood urea nitrogen (BUN- blood test to determine kidney function and hydration status) of 112 (Normal BUN levels are 5-27). The Physician was called with new orders to increase the water flushes around the clock and with medications, discontinue two medications and repeat the laboratory tests in the AM.- 11/25/15 the laboratory called with critical laboratory results including a BUN of 126 and Na 156. The Nurse Practitioner was called with no new orders.- 11/25/15 at 5:15 PM the resident is noted to have an altered mental status with no response to staff, temperature elevation of 100.9 degrees Fahrenheit, and oxygen level 84% (low- should be greater than 90) . The Physician was called and ordered the resident to be transferred to the hospital emergency room for an evaluation. The responsible party was informed and agreed with the transfer to the hospital.Interview with the Registered Professional Nurse (RN) Unit Coordinator on 1/19/16 at approximately 11:45 AM revealed the RN did not call the resident's responsible party on 11/24/15 after receiving new orders regarding the critical lab results.The RN was unable to recall any specific events for the resident on 11/25/15 and did not call the responsible party on that date.Interview with the RN Director of Nursing (DON) on 1/19/16 at approximately 3:05 PM revealed the RN DON received the call from the laboratory regarding the critical labs (labwork results that are very abnormal and need follow up with a Physician) on 11/25/15 and she did not call the responsible party. The RN DON stated that the resident's responsible party is to be informed of all changed in medications, treatment regime and health status. The RN DON reviewed the Resident's Notes for 11/24/15 through day shift 11/25/15 and stated the responsible party was not informed in changes in the resident.Interview with the Medical Director on 1/20/15 at approximately 11:25 AM revealed the Physician expects the staff to notify the responsible parties when there is a change in status and treatment of [REDACTED].Review of the facility policy and procedure entitled Notifying MD/ Responsible Party of Resident's change in condition dated 1/2016 revealed a change in condition may include an order for [REDACTED].2. Resident # 56 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated11/6/15 revealed that the resident has moderate cognitive impairment, understands and is understood. In addition the MDS revealed documented that the resident is frequently incontinent of bowel and bladder.Review of Admission Physician orders dated 9/23/15 revealed orders for [MEDICATION NAME] XL 10 milligram (mg) daily, [MEDICATION NAME] 50 mg one tablet daily, [MEDICATION NAME] (insulin) 35 units every morning.(Diabetic medication).In addition the Physician's Orders of 9/23/15 revealed Humulog Insulin Rainbow Coverage at 7:30 AM, 11:30 AM, 5:30 AM and HS as follows:70-130 = 0 UNITS131-180 = 2 UNITS181-240 = 4 UNITS241-300 = 6 UNITS301-350 = 8UNITS351-400 = 10 UNITSOver 400 12 UNITS AND CALL MDReview of a Nurse Practitioner (NP) Acute Visit Progress Note revealed the resident was evaluated for pneumonia and diabetes mellitus with plans to continue the resident on antibiotic treatment for [REDACTED].Review of the Medication Administration Record [REDACTED]. The 9/25/15 7:30 AM glucose was 95.Review of Nurses' Notes dated 9/24/15 by Licensed Practical Nurses (LPN's) at 7:00 AM and 3:00 PM to 11:00 PM revealed no Physician notification for the low or high glucose levels documented in the MAR.Review of a Registered Nurse (RN) Nurses' Note dated 9/25/15 10:55 AM revealed the resident exhibited [MEDICAL CONDITION] activity in rehabilitation , 911 (emergency number) was called and the resident was transferred to the emergency department (ED).Interview with the NP on 1/20/16 at approximately 1:20 PM revealed that the NP was not aware that the resident had the episode of low or high blood glucose levels and she would expect the staff to call for values 60 or below and above 400. Additionally, the NP stated on 9/24/15 she probably evaluated the resident prior to those values were obtained.Review of the facility's policy and procedures and confirmed by the Acting DON and Administrator, the facility does not have a policy for glucose monitoring.415.13(e)(2)(ii)b

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIERREPRESENTATIVE'S SIGNATURE

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that othersafeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following thedate of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the datethese documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)Previous Versions Obsolete

Event ID: YL1O11 Facility ID: 335742 If continuation sheet of 16





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F 0157



(continued... from page 1)

F 0225



1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on interview and record review conducted during a Complaint investigation (Complaint #NY 114) conducted during the Standard survey completed on 1/21/16, the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, are thoroughly investigated. One (Resident #112) of five residents reviewed for the investigation of medication omissions of an anticonvulsant had issues with reporting the occurrence immediately to other officials in accordance with State law through established procedures in a timely manner (including to the State survey and certification agency).The finding is:1. Resident #112 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated11/11/15 revealed the resident was severely impaired for decision making.Review of an Incident Investigation received by the New York State Department of Health (NYSDOH) called in by the Administrator of record on 12/10/15 revealed the facility identified an occurrence of potentially five to seven doses of [MEDICATION NAME] 500 milligram (mg)(an anti-[MEDICAL CONDITION] medication) that were not documented as given onthe Medication Administration Record [REDACTED]Interview with the Acting Director of Nursing (DON) on 1/19/16 at approximately 9:45 AM revealed the resident had a fall on 11/25/15. The medical record was reviewed after the incident and the medication omissions were discovered. Two Licensed Practical Nurses (LPNs) provided written statements that they gave [MEDICATION NAME] 500 mg but did not sign it out or signed in the wrong box on the MAR. Review of photo copies of the Blister packs revealed there were no medications left over. Written warnings were issued and in-servicing provided to the all nurses. The ADON stated that the Administrator notified the NYSDOH on 12/10/15 and signed off on the investigation on 1/14/16.Interview with the Acting DON on 1/19/16 at approximately 11:00 AM revealed they conducted additional chart audits and there were no other resident issues related to medication omissions.Interview with the Administrator on 1/20/16 at 11:40 AM revealed after the resident's fall the medical record was reviewed. The empty boxes on the MAR for the [MEDICATION NAME] 500 mg was discovered and an investigation was initiated. The Administrator stated he knew the incident should have been reported to the NYSDOH within 24 hours of discovering the issue.415.4(b)(1)(ii)

F 0226



Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property.

Based on interview and record review conducted during the Standard survey completed on 1/21/16, the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. One of five employee files lacked verification with the New York State Nurse Aide Registry prior to employment.The finding is:1. Review of the Employee File for Employee #5, a member of the maintenance staff, on 1/15/16, revealed the employee was hired on 11/9/15 and the file contain documentation that a Nurse Aide Registry Verification Report had been conducted for the employee on 11/13/15.Review of a Provisional Employee Supervision Log for Employee #5 on 1/15/16 revealed the employee had worked at the facility on 11/9/15, 11/10/15, and 11/12/15.Interview with the Human Resources Director (Authorized Person) on 1/15/16 at approximately 9:41 AM revealed he was not the authorized person who had conducted the Nurse Aide Registry Verification report for Employee #5. Further interview with the Human Resources Director at this time revealed the authorized person that had conducted the Nurse Aide Registry Verification report for Employee #5 was no longer working at the facility and he was not sure why it was not conducted before the employee was hired.415.4(b)

F 0241



Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation,interview and record review conducted during the Standard survey completed on 1/21/16, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Three (Resident's #36, 75, 145) of six residents observed for dignity had issues involving staff standing while feeding residents (Residents #36, 75) and a urinary collection bag that was visible from the hallway (Resident #145).The findings are:1. Resident #36 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated11/4/15 revealed the resident requires extensive assistance of one person with eating.During an observation on 1/19/16 at 9:14 to 9:17 AM, CNA (certified nurse aide) #1 was observed standing at the bedside while assisting the resident to eat breakfast in the resident's room.2. Resident #75 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment and needs supervision, encouragement and cueing for eating.An observation on 1/19/16 from 9:11 AM to 9:16 AM revealed CNA #2 entered the resident's room, retrieved an over bed table, set up the meal tray, and started assisting the resident with her breakfast. The CNA was observed standing at the bedside while assisting the resident to eat.During an interview on 1/19/16 at 9:19 AM the RN (Registered nurse) Unit Manager stated that the CNAs should be sitting while feeding a resident.During an interview on 1/20/16 at 12:45 PM CNA #2 stated that she would usually sit down while feeding someone but there wasn't a chair in the room.3. Resident #145 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment and has an indwelling catheter.Observation revealed:-1/15/16 at 8:36 AM the urine collection bag is attached to the bedframe on the right side of the bed, facing the doorway. Yellow urine is observed in the bag.-1/19/16 at 9:15 AM the urinary collection bag is attached to the bedframe on right side of bed facing the doorway. Yellow urine was observed in the bag.During an interview on 1/19/16 at 9:17 AM the RN Unit Manager stated that they just got bag covers in and she's in there right now covering it (the urinary collection bag). The RN further stated they ran out of them and they were ordered last week.During an interview on 1/20/16 at 1:42 PM the acting DON (Director of Nursing) stated it's not written into their policy to cover the (urinary) collection bags.415.5(a)

FORM CMS-2567(02-99) Event ID: YL1O11 Facility ID: 335742 If continuation sheet

Previous Versions Obsolete Page 2 of 16





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F 0241




F 0242



Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on interview and record review during the Standard Survey completed on 1/21/16, it was determined that the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care. Two (Resident's #213, 154) of three residents reviewed for choices were unable to choose the frequency of showers each week.The findings are:1. Resident #213 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated11/25/15 revealed the resident usually is understood and usually understands and is severely impaired cognitively.During an interview on 1/14/16 at 10:14 AM the resident's guardian stated My aunt used to take showers every day at home. I did not know she could take more than one. I would like her to get at least three showers a week.Review of the resident's Care Guide dated 1/13/16 under bathing, revealed the resident receives a shower one day a week on Mondays during the 3:00 PM to 11:00 PM shift.Review of Activity Admission assessment dated [DATE] revealed it is very important to choose between a tub bath, shower, bed bath and sponge bath with bath and shower circled.During an interview on 1/19/16 at 2:25 PM certified nursing aide (CNA #3) stated The resident gets a shower once a week. The family or the resident has never mentioned to me that they would like more. I am not sure if they may have mentioned it to the nurse.During an interview on 1/19/16 at 2:29 PM Registered Nurse (RN #2), Unit Manager stated I think preferences are obtained either prior to or upon admission. I think the preferences comes from the screener. I really do not know as it is different all over.During an interview on 1/19/16 at 2:32 PM Ward Clerk #1 stated The residents' are typically scheduled to only get one shower a week. But if the resident wants more, the resident would have to ask for more than one.During an interview on 1/20/16 at 7:37 AM the Activities Director (AD) stated We start the choices care plan. We usually add what the residents prefer a shower, tub bath or bed bath. Nursing would ask preferences for shower times and frequencies.2. Resident #154 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated10/14/15 revealed the resident is understood and understands and is cognitively intact.During an interview on 1/14/16 at 8:45 AM the resident stated I only receive one shower a week. They say they will give me one shower a week, but I sometimes do not even get that. I used to take a shower every day at home. I would like a shower everyday here, but would settle for at least three a week.Review of the resident's Care Guide dated 1/14/16 under bathing, revealed the resident receives a shower one day a week on Fridays during the 7:00 AM to 3:00 PM shift.Review of Activity Admission assessment dated [DATE] reveals nothing marked for how important it is to choose between a tub bath, shower, bed bath and sponge bath.During an interview on 1/20/16 at 9:04 AM CNA #2 stated I believe she gets one shower a week. Everyone gets at least one shower a week. She has never asked me for more than one. If she did I would give her one.During an interview on 1/19/16 at 2:29 PM Registered Nurse (RN #2), Unit Manager stated I think preferences are obtained either prior to or upon admission. I think the preferences comes from the screener. I really do not know as it is different all over.During an interview on 1/19/16 at 2:32 PM Ward Clerk #1 stated The residents' are typically scheduled to only get one shower a week. But if the residents wants more, the resident would have to ask for more than one.During an interview on 1/20/16 at 7:37 AM the Activities Director (AD) stated We start the choices care plan. We usually add what the residents prefer a shower, tub bath or bed bath. Nursing would ask preferences for shower times and frequencies.415.5(b)(1)(3)

F 0250



Provide medically-related social services to help each resident achieve the highest possible quality of life.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on interview and record review conducted during the Standard survey completed on 1/21/16, the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. One (Residents #213) of one resident reviewed for social services had issues involving the lack of Social Work (SW) intervention for notification of care planning.The finding is:1. Resident #213 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated11/25/15 revealed the resident is severely impaired cognitively, usually is understood and usually understands.During an interview on 1/14/16 at 10:38 AM the resident's guardian stated, No one from the facility has ever contacted me about attending a care plan meeting. I did not even know they had them.Review of the resident's entire chart revealed no documentation of the guardian being invited to the care plan meetings.During an interview on 1/20/16 at 8:50 AM the Director of Social Work stated, The resident's responsible party lives out of state. She calls me and I meet with her separately when she is in town. Her guardian is aware of the care plan meeting as I called her. I initially met with her on 11/24/15 and the again on 12/23/15. During our meeting I updated her on the resident's status. After reviewing the chart the SW stated, I guess I did not document that she was invited to the care plan meeting. Maybe I did not invite her because she lives out of town. The resident's initial care plan meeting was 12/8/15. Usually I talk to the resident and if they are alert I invite them. If the resident is not alert, when I see the family I will invite them. Many of the residents here do not have family members that visit. The families that I do not see I call them and invite them. Before I worked here they used to send letters out, but it was stopped. Since I have been here we have not been sending letters.During an interview on 1/20/16 at 9:30 AM the SW stated, I have the policy in regards to care plan meetings. It does state that SW sends out an invitation. I have been here five months and I have never sent out letters. I did not know we were supposed to. I do not have time to send letters. I did speak to the Administrator about this and he promised SW would be getting more help.Review of the facility policy entitled Resident Team Care dated June 2014 revealed it is the policy of facility to educate residents, families and staff about the resident's current health status on at least quarterly basis based on MDS assessment and care plan development. Under Procedures #4, the Social Work Department sends an invitation to a resident's responsible party and informs an alert resident of the upcoming care plan meeting and #5 invitations are sent out within three weeks of the meeting date, sometimes sooner if the MDS assessment dates are added at a later date.415.5(g)(1)(i-xv)

F 0253


Residents Affected - Some

Provide housekeeping and maintenance services.

Based on observation, interview and record review conducted during a Standard survey completed on 1/21/16, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Three (Units 2, 3, 4) of three units had issues with unlabeled used urinals and fracture bed pans left in shared bathrooms, used urine collection hat left behind a toilet, resident wheelchair pedals left next to the toilet, urine soiled clothing not properly contained in a resident's closet, soiled tube feeding equipment including poles and pumps, foam positioning wedge with holes and exposed foam, a bed headboard with missing veneer and particleboard, soiled floor mats, dirty room floors, and a torn up mattress.The findings are:


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F 0253



(continued... from page 3)1. Observations on 1/13/16 between 10:00 AM and 1:00 PM revealed the following:- Room #417 - an unlabeled, used urinal on top of the toilet tank in a shared bathroom.- Room #423 - resident wheel chair pedals left next to the toilet, a used urinal measuring collection hat left behind the toilet, a floor mat covered in gray debris/ dust covering approximately four feet.- Room #414 - a used urinal not labeled on the bathroom side rail.- Room #418 - a used urinal not labeled in shared bathroom, floor mats with various amounts of gray/ white debris covering length of four foot floor mat, and a brown stain on pillow case approximately eight inches in diameter.- Room #304 - an unlabeled bedpan in a shared bathroom.Observations on 1/14/16 between 8:00 AM to 12:00 PM revealed the following:- Room #417 - an unlabeled, used urinal on top of the toilet tank in a shared bathroom.- Room #423 - resident wheel chair pedals left next to the toilet, a used urinal measuring collection hat left behind the toilet, a floor mat covered in gray debris/ dust covering approximately four feet.- Room #418 - a used urinal not labeled in shared bathroom, floor mats with various amounts of gray/ white debris covering length of four foot floor mat, and a brown stain on pillow case approximately eight inches in diameter.- Room #323 - IV pole has dried feed on it and the bag to hold the feed is dirty.- Room #332 - IV pole has dried feed on it and there is a seven inch by three inch dried feed spill on the floor.- Room #419 - a bed headboard missing the veneer and the particleboard underneath was gouged out.- Room #315 - food debris, brown liquid stains, and debris behind the room door.- Room #213 - floors are stained.During an interview with a family member on 1/14/16 at approximately 10:33 AM revealed that there is a strong odor in the resident's room (Room #222).Observations on 1/20/16 between 10:00 AM and 1:00 PM revealed the following:Room #213 - floor has brown/ black debris, used tissues on floor, and white debris under the resident's bed.- Room #222 - a strong smell of urine on the window side of the room.- Room #304 - a used, unlabeled fracture bedpan on the floor of a shared bathroom.- Room #315 - used Styrofoam cup on the floor, a used washcloth on the resident's television, and a foam wedge with torn and frayed corners with the foam exposed.- Room #323 - IV pole with dried feed on it.- Room #332 - IV pole with approximately 40 drops of dried feed on the base of it, the feed pump with dried feed on it, and the feed tube stopper with dried feed placed on top of the pole.- Room #414 - an unlabeled fracture pan in a shared bathroom.- Room #419 - a bed headboard with the veneer and particleboard missing approximately six inches by three inches in one top corner and approximately three inches by two inches in the other top corner.During an interview with a Housekeeping Aide on 1/20/16 at approximately 10:45 AM, the Housekeeping Aide stated that the CNAs (certified nurse aides) are supposed to clean the IV poles of feed spills and it is not the responsibility of housekeeping.During an interview with Registered Nurse (RN) #2 on 1/20/16 at approximately 12:00 PM, when discussing strong urine odors in Room #222, revealed that the resident's pants that were visibly wet and had a strong urine smell were left on the bottom of the resident's closet and not placed in a plastic bag or hamper. RN #2 stated that clothes that are soiled with urine or other debris should be placed in a plastic bag and put in their closet. She also stated that resident floors should be cleaned at least every day.During an interview with RN #1 on 1/20/16 at approximately 12:15 PM, RN #1 stated that she expects her staff to report to her when resident's room floors are dirty or if their equipment is in disrepair. RN #1 stated having unlabeled equipment in shared bathrooms is an infection control issue. RN #1 also stated that she did not know who is responsible for cleaning the IV poles, pumps, or feed bags in the resident's rooms.During an interview with RN #3 on 1/20/16 at approximately 12:30 PM, RN #3 revealed that she expects her housekeeping staff to clean floor mats, and for fracture bed pans and urinals to be labeled, used urine hats to be thrown out, and her staff to report that resident equipment is in disrepair stating anyone can report that a headboard needs to be repaired to maintenance.An interview with the Director of Environmental Services on 1/20/16 at approximately 1:00 PM revealed that nursing should be cleaning the IV poles and feed equipment but if it is heavily soiled that maintenance will power wash the poles. She also stated that nursing needs to report these issues to maintenance so they can follow up on any maintenance issues or resident equipment issues. The Director of Environmental Services also stated that maintenance will follow up with maintenance requests within 24 hours.Review of an undated facility policy entitled Enteral Feeding Pump and Pole Cleaning revealed under Procedure #1 the 11-7 nurse will wipe down the feeding pump, IV pole, and the IV pole base daily using the house disinfectant/ cleaning agent and in Procedure 2 the housekeeping staff will pressure clean the IV pole and base weekly, at time when the enteral feeding is not being administered.Review of facility policy entitled Cleaning and Housekeeping dated 5/1/13 revealed in Procedure #4 that every resident room will have the floor dry mopped and then wet mopped every day, water and mop head to be changed every three rooms and as needed.2. Observation of Room #411 on 1/13/16 at 12:23 PM revealed the bed by the door was unmade and the mattress was exposed. The mattress had three to four slits in the top and appeared ripped and tattered. The areas were approximately one foot in length.Second observation of the mattress on 1/19/16 at 9:45 AM with the LPN present revealed the mattress remained ripped. The LPN stated that she was not aware the mattress was ripped and she would get a new one. The LPN further stated she does not know if there are routine checks of mattresses.Review of the policy entitled Bed Sanitizing, last revised 10/2012, revealed the Housekeeping Supervisor will make a monthly schedule for bed washing, the schedule will follow residents shower schedule as close as possible.415.5(h)(2)

F 0279



Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**THIS IS A REPEAT DEFICIENCY FROM THE PARTIAL EXTENDED SURVEY COMPLETED ON 8/13/15.Based on interview and record review completed during the Standard survey completed on 1/21/16, the facility did not develop a Comprehensive Care Plan (CCP) for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and psychosocial needs. One (Resident #221) of five residents reviewed for unnecessary medications lacked development of a care plan to address an antipsychotic medication ([MEDICATION NAME]).The findings are:1. Resident #221 has [DIAGNOSES REDACTED]. Review of the face sheet revealed the resident was admitted on [DATE].Review of a Physician's Order dated 1/1/16 through 1/31/16 revealed an order for [REDACTED].Review of the Care Plan identified as current on 1/19/16 revealed a lack of Care Plan development for depression and the use of an antipsychotic medication for treatment.Interview with the Registered Nurse (RN) Charge Nurse #2 on 1/19/16 at approximately 2:30 PM revealed she is new to the facility but would think there should be a Care Plan for antipsychotics and depression.Review of the facility policy entitled Care Plans dated 2/15 revealed upon admission, each discipline is responsible to begin developing an individualized Care Plan for each resident.415.11(c)(1)

F 0280



Allow the resident the right to participate in the planning or revision of the resident's






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(continued... from page 4) care plan.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON [DATE] & [DATE].Based on interview and record review conducted during the Standard survey completed on [DATE], the facility did not periodically review and revise the Comprehensive Care Plan (CCP). Five (Resident's #36, 102, 166, 174, 213) of 31 residents reviewed for Care Plans had issues involving the lack of a Care Plan revisions to address changes in code status (Resident's #36, 166), revisions to address low [MEDICATION NAME] levels, pressure sore development, changes in fluid consistency (Resident's #102, 174), and a lack of inviting a residents guardian to participate in care planning (Resident #213).The findings include but are not limited to:1. Resident #213 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated[DATE] revealed the resident usually is understood and usually understands and is severely impaired cognitively.During an interview on [DATE] at 10:38 AM the resident's guardian stated, No one from the facility has ever contacted me about attending a Care Plan meeting. I did not even know they had them.During an interview on [DATE] at 8:50 AM the Director of Social Work (SW) stated, The resident's responsible party/guardian lives out of state. She calls me and I meet with her separately when she is in town. Her guardian is aware of the Care Plan meeting as I called her. I initially met with her on [DATE] and the again on [DATE]. During our meeting I updated her on the resident's status. After looking through the chart the SW stated, I guess I did not document that she was invited to the Care Plan meeting. MaybeI did not invite her because she lives out of town. The resident's initial Care Plan meeting was [DATE]. Usually I talk to the resident and if they are alert I invite them. If the resident is not alert, when I see the family I will invite them. Many of these residents here do not have family members that visit.The families that I do not see I call them and invite them. Before I worked here they used to send letters out, but it was stopped. Since I have been here we have not been sending letters.During an interview on [DATE] at 9:30 AM the Director of Social Work (SW ) stated, I have the policy for you in regards to Care Plan meetings. It does state that the Social Worker sends out an invitation. I have been here 5 months and I have never sent out letters. I did not know we were supposed to. I do not have time to send letters. I did speak to the Administrator about this and he promised Social Work would be getting more help.Review of the resident's entire chart revealed there was no documentation noted of the guardian being invited to the Care Plan meetings.Review of the policy titled Resident Team Care dated [DATE] revealed it is the policy of the facility to educate residents, families and staff about the resident's current health status on an at least quarterly basis based on MDS assessment and Care Plan development. Under Procedure #4 the Social Work Department sends an invitation to a resident's responsible party and informs an alert resident of the upcoming Care Plan meeting and #5 invitations are sent out within three weeks of the meeting date, sometimes sooner if the MDS assessment dates are added at a later date.2. Resident #102 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the residentwas admitted [DATE] and is independent in decision making.Review of a Nutrition Note dated [DATE] and the undated Fixed Care Plan revealed the resident was receiving a carbohydrate consistent diet, liberal renal regular diet with 1200 cc( cubic centimeters) fluid restriction and had no pressure sores.Review of Routine Chemistry results dated [DATE] revealed an [MEDICATION NAME] level (measure of protein in the blood) of 2.3 below normal values of 3XXX,[DATE].8. Review of the New/ Readmission Assessment initiated [DATE] revealed a notation completed by the Registered Nurse (RN) dated [DATE] that the resident has a stage 2 pressure ulcer on the right Buttock. Review of a Physician order [REDACTED].Review of the undated Fixed Care Plan lacked revisions to include the low [MEDICATION NAME] levels, Stage 2 pressure sore, and diet changes to reflect altered texture, thickened liquids, and a change in the therapeutic diet.Interview with Registered Dietitian (RD) #1 on [DATE] at approximately 10:00 AM revealed Care Plans should be updated when a problem arises and stated that is how RD #1 does it but isn't sure how the other RD's update the Care Plans.3. Resident #166 has [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS- a resident assessment tool) dated [DATE] revealed that the resident is cognitively intact, understands, and is understood.A review of the facility new admission form dated [DATE] revealed that the resident is a full code for cardiopulmonary resuscitation (CPR).A review of the Care Plan dated [DATE] revealed that the resident wants to be a full code for CPR.A review of the physician's orders [REDACTED].A handwritten note on a Physician's Visit Note dated [DATE] revealed that resident was seen by the Physician that day and the resident requested to no longer be a full code. Additionally, the note revealed wants no CPR, artificial feeds or hydration. Spoke with family. Signed MOLST.A review of the Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] revealed that the resident did not want to be resuscitated with limited medical interventions, not to be intubated (breathing by artificial means), do not send to the hospital, no feeding tube, no intravenous fluids, limited use of antibiotics, and no [MEDICAL TREATMENT]. This form was signed by the resident and the Director of Social Work. Further review revealed the form was then signed by the Physician on [DATE].A review of the Care Plan revealed that there are no notations of the resident's updated do not resuscitate status.An interview with the Director of Social Work (SW) on [DATE] at approximately 11:52 AM revealed that the Care Plan should be updated right away or at least within 24 hours with the resident's new do not resuscitate status.An interview with the Director of Nursing (DON) on [DATE] at approximately 12:34 PM revealed that Social Worker (SW) is responsible for updating the Care Plan when it concerns the Advance Directives of the resident. The DON also stated that the Care Plan should be updated right away or at least within 24 hours.415.11(c)(2)(i-iii)

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Make sure services provided by the nursing facility meet professional standards of quality.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on interview and record review conducted during a Complaint Investigation (Complaint #NY 061) and during the Standard survey completed on 1/21/16, the facility did not ensure that services were provided or arranged by the facility met professional standards of care. Five (Resident #51, 56, 134, 154, 174) of 31 residents reviewed for professional standards had an issue involving a lack of nutritional assessments completed within 14 days.The findings include but are not limited to:1. Resident #174 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated12/22/15 revealed the resident was admitted on [DATE] and is independent in decision making.Review of physician's orders [REDACTED].Review of Nutritional Progress Notes dated 12/16/15 revealed the resident is receiving a CCD, NAS Regular consistency diet. The resident's admission weight is 363# (pounds). A Nutritional assessment will follow.Review of routine laboratory (lab) Chemistry Results dated 12/24/15 revealed an [MEDICATION NAME] level of 3.1 (normal values 3.5 - 5.0) and a glucose level of 58 (normal levels 60 - 100).Review of routine Chemistry Results dated 12/31/15 revealed a further decline in [MEDICATION NAME] level to 2.8 and a decline in total protein to 5.9 (normal levels 6.0 - 8.0).Review of the Medical Record on 1/15/16 revealed a lack of a nutritional assessment or any further nutrition documentation regarding nutritional needs or abnormal nutrition related labs.Review of a facility policy entitled Nutritional Screening/ Assessment dated 5/2015 revealed all residents will receive a complete nutritional assessment in their Medical Record on admission, annually and when there is a significant change in







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(continued... from page 5) the resident's condition.Interview with Registered Dietitian (RD) #1 on 1/19/16 at 11:30 AM revealed nutritional assessments should be completed within 14 days of admission. In a later interview on 1/20/16 at approximately 10:00 AM revealed if a resident has a low [MEDICATION NAME] level a worksheet should be completed reassessing the resident's nutritional needs for increased protein.During an interview with RD #2 on 1/20/16 at 9:43 AM, RD #2 stated In a perfect world nutrition assessments are done within 14 days after admission.2. Resident #134 has [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS revealed the resident understands, is understood and has an impaired decision making ability.Review of the resident's Comprehensive Care Plan (CCP) dated 11/3/15 revealed the resident has [MEDICAL CONDITION] (low blood count), is at risk for dehydration due to attending [MEDICAL TREATMENT] three times a week and is at risk for an impairment in nutrition due to [MEDICAL CONDITION].Review of the resident's admission physician's orders [REDACTED].Review of the Physician's History and Physical dated 6/17/15 revealed the resident has [MEDICAL CONDITION] and attends [MEDICAL TREATMENT] three times a week, has [MEDICAL CONDITION] and hypertension.Review of the Nutritional Progress Note dated 6/17/15 revealed the resident was admitted to the facility with a NAS renal diet and a fluid restriction of 1200 cc daily. The resident's weight data is pending and the dietary department will follow the resident per protocol.Review of the Nutritional Progress Note dated 7/23/15 revealed the resident is noted to refuse meals at times. The food service supervisor is providing the resident with menu substitutions.Review of the Nutritional Progress Note dated 9/2/15 revealed the resident has a noted weight loss of unknown origin.Review of the Nutritional Progress Note dated 9/25/15 revealed the RD reviewed the chart for fluid requirements. The resident is receiving a NAS renal diet with a 1200 cc per day fluid restriction per the physician's orders [REDACTED].Review of the Nutritional Screening Assessment dated 10/20/15 revealed the resident was admitted to the facility on [DATE] on a NAS renal diet with a 1200 cc per day fluid restriction.Review of the resident's CCP dated 11/3/15 revealed the resident has a potential for an alteration in nutritional status and a risk for dehydration. Approaches include to provide a NAS renal diet with a 1200 cc per day fluid restriction total from medications, meals and snacks.Interview with the RD on 1/19/16 at approximately 1:35 PM revealed that all residents admitted to the facility are to have a nutritional assessment completed within 10 days of admission. The RD reviewed the resident's record and stated the resident was admitted to the facility on [DATE] and the Nutritional Screening Assessment was not completed until 10/20/15.4. Resident #154 admitted on [DATE] has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understood and understands. The resident has a Body Mass Index (BMI) of less than 22 and is not receiving nutritional supplements.Review of physician's orders [REDACTED].>Review of Nutritional Progress Notes dated 11/6/15 revealed the resident was admitted on [DATE]. Diet: Regular. Assessment to follow.Review of Nutritional Screening/ Assessment revealed the completion date of the assessment was on 12/21/15; 10 weeks and 6 days after admission.During an interview with RD #1 on 1/19/16 at 3:07 PM, RD #1 stated I knew there was going to be an issue with the assessments and them not being written in time. Initial assessments should be written within 14 days of admission, then every quarter and annually. When she was due I had just started and I did not have that unit assigned to me.During an interview with RD #2 on 1/20/16 at 9:43 AM, RD #2 stated In a perfect world the assessments are to be done within 14 days of admission. After that quarterly assessment and after three quarterly notes they would get an Annual Assessment. I did not do the assessment. I have no excuse. I do not know if I was notified. I really do not know. I was the only RD here at the time and I only work part-time two days a week covering all three floors.5. Resident #51 readmitted on [DATE] has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is severely cognitively impaired, is understood and understands.Review of Nursing Progress Notes revealed the resident had loose stools on 11/22/15 and 11/23/15.Review of physician's orders [REDACTED].Review of physician's orders [REDACTED].Review of the last Annual Assessment revealed it was completed on 10/14/14, followed by Quarterly Assessments on 1/2/15, 4/10/15 and 7/8/15.Review of a Nutritional Progress note written on 11/24/15 revealed loose stools continue. Receiving Hy-fiber BID (twice per day) for bowel management. Stool sample taken for [MEDICAL CONDITION]. Will add 120 cc fluids to each meal to ensure proper hydration and [MEDICATION NAME] lost fluids through stools.Review of the Meal Acceptance Sheets dated 11/22/15 through 11/27/15 revealed 11 out of 18 meals for food and fluid were left blank.During an interview with RD #1 on 1/19/16 at 3:07 PM, RD #1 stated I knew there was going to be an issue with the assessments and them not being written in time. Initial assessments should be written within 14 days of admission, then every quarter and annually. When she (Resident #51) was due I had just started and I did not have that unit assigned to me. I only went up there and wrote a note because I had heard something about the resident having loose stools.During an interview with RD #2 on 1/20/16 at 9:43 AM, RD #2 stated In a perfect world the assessments are to be done within 14 days of admission. After that quarterly assessment and after three quarterly notes they would get an Annual Assessment. I did not do the assessment. I have no excuse. I do not know if I was notified. I really do not know. I was the only RD here at the time and I only work part-time two days a week covering all three floors.415.11(c)(3)(i)

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Provide care by qualified persons according to each resident's written plan of care.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 1/9/15.Based on observation, interview and record review conducted during a Standard survey completed on 1/21/16, the facility did not ensure that services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care. Three (Resident's # 36,37,145) of 31 residents reviewed for care planning did not receive care and services per the plan of care. Specifically, Resident #37 did not have Dycem (a non-slip material that prevents residents from slipping out of their chairs) on the Geri chair cushion, rolled washcloths in both hands and incontinent care every two hours; Resident #36 suprapubic catheter was not secured with tape; and Resident #145's Foley (tube inserted into the bladder to drain urine) catheter was not secured with a leg strap.The findings are:1. Resident #37 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - a resident assessment tool)dated 9/30/15 revealed that the resident is cognitively intact, understands and is understood. The resident is incontinent of bowel and bladder, and is totally dependent on staff for bathing, toileting, and dressing.Review of the Care Plan dated 11/24/15 revealed that the resident is care planned to have incontinent care every two hours or as needed, bilaterally wash cloths to be worn daily and removed as needed and during hygiene and cleaning, and to have Dycem on top of their cushion.During an observation on 1/15/16 at approximately 8:00 AM revealed no Dycem on the top of the cushion on the resident's chair. Continued observation at approximately 8:30 AM, after the Certified Nurse Aide (CNA) #6 provided the resident morning care, CNA #6 did not apply the hand rolled up wash cloths in his hands.Multiple observations on 1/15/16 between approximately 8:40 AM through 1:00 PM revealed the resident sitting in the unit dining room to eat breakfast and lunch. He remained in the same position at the same table. In addition, the resident did not to have rolled wash cloths in his hands.During an interview with CNA #6 on 1/15/16 at approximately 1:00 PM, CNA #6 stated The last time I did incontinent care (for Resident #37) was this morning during morning care (approximately 8:15 AM). CNA #6 stated, I'll be doing incontinent care again when he goes to bed after lunch. When asked if she had provided incontinent care between 8:15 AM through 1:00 PM, she stated that no.







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(continued... from page 6)During an observation of the resident seated in his chair on 1/15/16 at approximately 2:00 PM revealed no Dycem on the top cushion.During an interview with Registered Nurse (RN) #3 on 2/15/16 at approximately 2:15 PM, RN #3 revealed that she expects her staff to report to her that the resident does not have Dycem on his chair and if the resident refused or was not wearing the wash cloths in both hands. RN #3 stated she expects her staff to perform incontinent care on the resident every two hours per his care plan.2. Resident #36 has [DIAGNOSES REDACTED]. The resident had no behaviors directed towards others, and no rejection of care. The resident requires total staff assistance for bed mobility, transfer, dressing, toilet use and personal hygiene.Review of the certified nurse aide (CNA) Care Guide dated 1/19/16 revealed the resident has a Foley and the nurse is to secure the suprapubic tubing to the resident's abdomen with tape.Observation on 1/19/16 from approximately 8:30 AM to 8:45 AM revealed two CNA's (#4 and #8) provided personal care for the resident. The suprapubic tube was not secured to the resident's abdomen with tape. After care was provided the tube remained unsecured.The RN Unit Coordinator stated during an interview on 1/20/16 at approximately 12:00 PM that the suprapubic tube is required to be anchored with tape in accordance with the resident's Care Plan.3. Resident #145 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has severe cognitive impairment, usually understands and is sometimes understood. The resident requires extensive staff assistance for bed mobility, dressing, toilet use, and personal hygiene.Review of the Care Guide dated 12/30/15 revealed the resident has a Foley and requires a leg strap to secure the tubing.Observation of personal care on 1/19/16 and on 1/20/16 revealed the Foley tubing was not secured with a leg strap in accordance with the plan of care.The RN Unit Coordinator stated during an interview on 1/20/16 at approximately 12:00 PM that the suprapubic tube should be secured with a leg strap in accordance with the plan of care.415.11(c)(3)(ii)

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Level of harm - Actualharm


Provide necessary care and services to maintain the highest well being of each resident**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**THIS IS A REPEAT DEFICIENCY FROM THE PARTIAL EXTENDED SURVEY COMPLETED ON [DATE] AND THEABBREVIATED SURVEY COMPLETED [DATE].Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not provide the necessary care and services to maintain a resident's highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Three (Residents #36, 37, 56) of thirty-one residents reviewed for quality of care had issues. Specifically, Resident #36 had a change in condition and there was a lack of a timely, comprehensive assessment by a registered nurse (RN), lack of timely physician notification, and lack of ongoing monitoring of the resident's condition. The resident expired in the facility prior to obtaining physician ordered bloodwork and a diagnostic test. This resulted in actual harm that is not immediate jeopardy for Resident #36.In addition, Resident #56 did not have a renal consult as ordered by the physician and did not receive a recommended follow-up [MEDICATION NAME] appointment after a colonoscopy. Resident #37 had an order for [REDACTED].The findings are:1. Resident #36 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated[DATE] revealed the resident is cognitively intact, understands, is understood, had no behaviors directed towards others, and no rejection of care. The resident requires total staff assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident did not receive scheduled or as needed (PRN) pain medication and had no pain per resident interview.Review of the current comprehensive Care Plan (CCP) revealed that the resident has a [MEDICAL CONDITION] (artificial connection of the bowel to the surface of the skin)/[MEDICAL CONDITION] (surgical creation of opening in the small intestine) with planned approaches for an ongoing assessment for abdominal distention and stool character. The CCP for Nutrition documented that the resident has the potential for altered BM (bowel movement) function with a goal to maintain normal ostomy (surgically created opening between an internal organ and the body surface) function.Additional review of the CCP revealed the problem area for Choices documented that the resident prefers the call bell to be clipped to his chest for easy accessibility.Review of the certified nurse aide (CNA) Care Guide dated [DATE] revealed the resident is to have the call bell placed on his blanket at chest level at all times for independent use.Review of an RN Assessment Documentation form dated [DATE] revealed the resident's abdomen was soft, non-tender and bowel sounds were active.A Nursing Home Follow-up Note, written by the physician, dated [DATE] documented that the resident had a [MEDICALCONDITION] and had normoactive bowel sounds in all quadrants, soft, non-distended.Review of Nurses' Notes revealed the following:- [DATE] for the 11:00 PM to 7:00 AM shift - At 2:00 AM, a Licensed Practical Nurse (LPN #5) documented that the resident complained of abdominal pain and the right upper quadrant of the abdomen had some distention. Tylenol 650 milligrams (mg) was administered and will monitor. The LPN documented that the resident complained of nausea with no emesis (vomit). There is no documented evidence that the RN Supervisor was contacted at 2:00 AM.- [DATE] at 4:40 AM - RN #6 assessed the resident and documented that the resident had a distended, tympanic (drum like sound) abdomen, tender with palpation, right upper quadrant bowel sounds somewhat present but hypoactive, [MEDICAL CONDITION] patent with brown loose stool, bowel large and protruding through abdomen. Will monitor for continuation of signs and symptoms for possible new order from MD (medical doctor).Additional review of the Nurses' Notes dated [DATE] from 2:00 AM through 4:40 AM revealed no documented evidence that the resident's vital signs (temperature, blood pressure, pulse, respiratory rate) were assessed or that the physician was notified.Review of the Medication Administration Record [REDACTED]little relief. Additional review of the MAR indicated [REDACTED].Review of the 24 Hour Report Summary Data dated [DATE] for the 11:00 PM to 7:00 AM shift ([DATE]) revealed at 2:00 AM, the resident complained of abdominal pain with some distention, Tylenol given, complains of nausea, no emesis. At 4:40 AM, abdomen very distended, hypoactive bowel sounds, stoma is enlarged, BM in bag. At 5:30 AM still complains of pain, Tylenol repeated. Temperature 98 (normal 98.6 degrees). No other vital signs were documented and there was no documentation that the physician was notified.Review of the facility investigation entitled Phone Conversation Notes, documented by the Acting Director of Nursing (DON) dated [DATE] revealed the RN Supervisor assessed that the resident was probably constipated and directed [MEDICATION NAME] (stool softener) to be given. The RN Supervisor told the Acting DON that at 5:30 AM, the resident's temperature was 96.4 degrees Fahrenheit (normal 98.6), pulse 100 (average 80), respirations 22 (normal 12 to 20), and no blood pressure (BP) could be taken due to the resident's shaking from [MEDICAL CONDITION].Review of the medical record, including Nurses' Notes, the 24 Hour Report Summary Data or any other facility document provided to the survey team, revealed no documented BP reading from 2:00 AM when the resident's change of condition occurred to 7:00 AMObservation of morning activities on Unit 4 on [DATE] at 6:30 AM revealed the resident was lying in bed on his back, repeatedly calling out I need help. The observation revealed that the resident resided on the door side of the semi-private room. The resident's call light was not on, however the door was open. Continued observation for 10 minutes revealed two CNAs (#4 and #9) walked up and down the hallway arranging linens and checking rooms. During the 10 minutes, the resident intermittently called out Help, help, help or I need help for prolonged intervals, particularly when staff walked by the resident's room. Continued observation at approximately 6:40 AM revealed the resident's call light was located at the end of the bed and not within the resident's reach. The resident continued to call out I need help here, as CNA #4 passed the resident's room. CNA #4 went into other residents' rooms to wake them up and CNA #9 walked down the hall passing Resident #36's room. At 6:43 AM, CNA's #4 and #9 were two resident rooms down the hall and the resident was calling Help, I need my






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(continued... from page 7) nurse. CNA #4 walked past the resident's room again as he was mumbling Help and CNA #4 walked down the hall and attended to another resident. The resident began to yell loudly Please help, several times. At approximately 6:46 AM, CNA #9 walked down the hall and passed the resident's room as he was calling out Help, I need help.At approximately 6:55 AM, the surveyor entered Resident #36's room and asked the resident what he needed assistance with and the resident stated his stomach was hurting and motioned towards his left lower abdomen.Interview with CNA #10 on [DATE] at approximately 6:56 AM revealed she was finishing the night shift and she was not assigned to the resident. CNA #10 stated she attended to the resident several times during the night because he was complaining of abdominal pain which was unusual for the resident. CNA #10 stated the resident usually sleeps through the night and is fairly cooperative.During an interview with the 11:00 PM to 7:00 AM shift LPN (#5) on [DATE] at approximately 6:57 AM, the surveyor informed LPN #5 of the resident's left lower abdominal pain. LPN #5 stated that the resident started complaining of abdominal pain at 2:00 AM and at 4:40 AM his abdomen became more distended. LPN #5 stated she did not notify the physician about the resident's change of condition, however she did notify the RN Supervisor who evaluated the resident, and she believed they will be ordering an abdominal flat plate. LPN #5 stated the resident did have MOLST (Medical Orders for Life-Sustaining Treatment) limitations of care. LPN #5 stated that a long time ago, the resident had similar complaints with flu-like symptoms. LPN #5 stated it was unusual for this resident to complain about abdominal pain.Review of an RN Assessment Documentation form dated [DATE] at 7:00 AM revealed the resident had a BP of ,[DATE], a pulse of 102, and respiratory rate of 26 and a temperature of 96.1. The resident had shallow breathing; a tender distended abdomen with hypoactive bowel sounds and the [MEDICAL CONDITION] stoma was bright red. The RN documented that the resident's abdomen was tender with palpation and the resident had emesis x 1 brown.Observation on [DATE] at 7:37 AM revealed that CNA #8 entered the resident's room to answer the call light, the resident told CNA #4 that his abdomen hurts, and CNA #8 told the resident that staff were getting help for him.Review of Physician's Telephone Orders dated [DATE] at 8:30 AM revealed orders for a Stat (immediate) abdominal flat plate (X-ray of the abdomen), a CBC (complete blood count (CBC - blood test to determine the components of cells in the blood) with differential, BMP - (basic metabolic profile - blood test including basic chemistry studies of the blood), a Chest x-ray, and to provide a clear liquid diet for 24 hours.Review of a Nurses' Note dated [DATE] at 10:45 AM revealed at 9:30 AM the resident had no pulse and no respirations.Additional review of Nurses' Notes and the 24 Hour Report Summary Data report dated [DATE] revealed no documented evidence that the resident was monitored, including vital signs and a comprehensive assessment of the resident including an examination of the resident's abdomen, pain, and nausea, from 7:15 AM to 9:30 AM when the resident expired.Interview with the Acting DON on [DATE] at 9:47 AM revealed at approximately 6:40 AM the night RN Supervisor reported to her that the resident had a change of condition with abdominal distention and the resident's vital signs were stable.The RN Supervisor stated during an interview on [DATE] at approximately 12:35 PM, that he went to assess the resident after the night charge LPN informed him of her concern regarding the resident's abdomen. The RN Supervisor stated that the resident's abdomen was tympanic, hard and more distended than normal as he documented in his note at 4:40 AM on [DATE]. The RN Supervisor stated he told the DON that we may want to get an abdominal flat plate and stated he did not notify the Physician because he did not know what the resident's baseline abdominal assessment was like. The RN Supervisor stated that the resident had hypoactive bowels sounds, everything else was normal, and the plan was to continue to monitor the resident. Regarding physician notification, the RN Supervisor stated since it was late in the shift he notified the oncoming supervisor. The RN Supervisor stated that he should have been informed at 2:00 AM when the change first occurred.Further interview with the Acting DON on [DATE] at approximately 12:50 PM revealed that when the RN Supervisor gave her report at approximately 5:30 AM and she (the DON) did not know whether the physician was notified; she left the night RN Supervisor to handle the issue. When questioned about the delay in LPN #5 notifying the RN Supervisor about the resident's change of condition at 2:00 AM, the DON stated that LPN #5 should have contacted the RN Supervisor immediately, and physician notification for a change of condition should happen right away.Interview with CNA #8 on [DATE] at 11:25 AM revealed she and CNA #9 were in the resident's room ,[DATE] times during the day shift on [DATE] and the resident stated his stomach was real uncomfortable. CNA #8 stated that the floor nurse and the charge nurse knew about the resident's pain/ discomfort and the doctor had been called. CNA #8 stated she responded to the resident's cries for help an emergent situation happened at approximately 9:15 AM because the resident was saying Help me, help me and when she entered the room, the resident was real congested. CNA #8 stated she immediately went to get the RN Coordinator and when they arrived the resident was throwing up a lot and they got the suction equipment and suctioned the resident.Interview with the Nurse Practitioner (NP) on [DATE] at approximately 1:37 PM revealed the RN Coordinator called her and informed her that the resident's [MEDICAL CONDITION] was not putting out stool and the resident's belly was distended. The NP stated she ordered Stat diagnostic and labs (laboratory tests). The NP did not know at the time of the interview that the resident's problems started at 2:00 AM; she thought the change of condition had just occurred at the time of the call this morning at 8:30 AM. The NP stated that the providers should have been notified immediately; there is on-call service ,[DATE]. The NP stated the resident had recently signed his own DNR order with no hospitalization ; however, she was familiar with the resident and stated he still wanted medical treatment and he could make his own decisions and people change their minds all the time. And he may have opted for treatment. The flat plate most likely would have showed a need for emergent treatment for [REDACTED].Interview with the resident's physician on [DATE] at approximately 8:00 AM, in the presence of the Acting DON, revealed that the physician provided medical care for the resident for years; the resident had a [MEDICAL CONDITION] for chronic constipation and severe skin issues. The DON stated that the nurse suctioned fecal material from the resident yesterday morning when the emergent situation occurred around 9:15 AM. The attending MD stated the cause of the resident's death was probably bowel obstruction or perforation. When the MD was informed that the resident was alert until the final event, the MD stated that although the resident recently made himself a DNR with no hospitalization s, the resident could (and frequently did) change his mind and medical staff would honor his decision in that situation, he might have opted for treatment.Review of the facility policy entitled Notifying MD/ Responsible Party of Residents change of condition revised on ,[DATE] documented an occurrence of resident change of condition must be communicated in a timely manner to the attending MD by the nursing supervisor. Each Unit Nurse who identifies a change of condition must notify the Nursing supervisor immediately.2. Resident #56 had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has moderatecognitive impairment, understands, is understood, and is frequently incontinent of bowel and bladder.Review of an Acute Visit Note, written by the NP, dated [DATE] revealed that the resident was admitted to the facility for short term rehabilitation. The NP documented a plan to refer the resident to a [MEDICATION NAME] (a physician specially trained in the management of diseases of the gastrointestinal tract and liver) due to positive stool for occult blood (blood in the stool that is not visible).Review of a hospital Discharge Summary dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The DischargeSummary documented that the resident should be followed by a nephrologist and it will be up to the primary care Physician to arrange this.Review of an Acute Visit Note, written by the NP, dated [DATE] revealed the resident is to be referred to nephrology (a kidney specialist) due to his Stage IV [MEDICAL CONDITION]. The NP documented that the resident had [MEDICALCONDITION]/ positive stool for occult blood and he is to follow-up with [MEDICATION NAME] after discharge from short-term rehabilitation services.Review of Physician's Orders dated [DATE] revealed an order to obtain a Nephrology consult.Additional review of Acute Visit Notes, written by the NP, revealed the following:- [DATE] - The resident was evaluated for rectal bleeding/diarrhea with plans to change the GI (gastrointestinal) appointment to next week.- [DATE] - The resident was evaluated again for rectal bleeding/diarrhea with plans for a [MEDICATION NAME] appointment for [DATE].- [DATE] - The resident was evaluated again for rectal bleeding/diarrhea. The resident was not seen by the [MEDICATION NAME] due to a mix-up with transportation and the appointment was rescheduled or [DATE]. The NP documented that the resident







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(continued... from page 8) continues with rectal bleeding with some diarrhea.- [DATE] - The resident was seen for hematochezia (passage of bloody stools) and diarrhea. The NP documented that the resident was seen by the [MEDICATION NAME] on [DATE], who recommended a colonoscopy. The resident continues with loose stools on a frequent basis.- [DATE] - The resident was evaluated status [REDACTED].Review of a [MEDICATION NAME] Colonoscopy Preliminary Report/ Communication Form dated [DATE] revealed a biopsy wastaken and a polyp was removed. A sticky note was attached to the top of the form directing to make a follow-up appointment with the [MEDICATION NAME].Review of the entire medical record on [DATE] revealed there was no documented evidence of a follow-up appointment with the [MEDICATION NAME] and there was no Nephrology consult completed for Resident #56.During an interview on [DATE] at approximately 10:00 AM, the NP stated that she could not identify whether the resident had a Nephrology consult performed after the [DATE] order.The Registered Nurse (RN) Coordinator stated during an interview on [DATE] at approximately 8:20 AM that as of [DATE] there was no follow-up appointment made with the [MEDICATION NAME] and the colonoscopy report was not in the medical record.The RN Coordinator was not aware that the Nephrology consult was not completed.3. Resident #37 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident is cognitively intact, understands, and is understood.Review of a Psychological Services Progress Note dated [DATE] revealed the resident is in good spirits, denied AH (auditiry hallucination) ameable to supportive Rx (treatment). Plan: Supportive Rx to increase reality orientation.Review of Nursing Progress Notes dated from [DATE] through [DATE] revealed no documentation of behaviors.Review of the Comprehensive Care Plan (CCP) dated [DATE] revealed that problem areas include antipsychotic drug use, potential for behaviors related to a [DIAGNOSES REDACTED].Review of a Physician's Order dated [DATE] revealed an order to refer for psych (psychiatric) medication evaluation and possible gradual dose reduction (GDR) for psychiatric medications.Review of an Acute Care Visit note, written by the NP, dated [DATE], revealed A referral has been placed for psychiatric evaluation of medication usage and possible GDR.Review of the chronological medical record revealed no documented evidence that the resident was seen by the Psychiatrist or the psychiatric NP in [DATE], [DATE], or [DATE].Interview with the Unit Clerk on [DATE] at approximately 11:00 AM revealed there was no documentation to be filed for Resident #37 related to a psychiatric visit.During an interview on [DATE] at approximately 11:11 AM, the Social Worker stated that the resident was not scheduled to be seen by the Psychiatrist and the last time the resident saw the Psychiatrist was last May (2015).Review of a list of residents to be seen by the psychiatric NP or the Psychiatrist, dated [DATE] to [DATE], revealed that Resident #37 was not on the list.Interview with the Director of Social Work on [DATE] at approximately 11:12 AM revealed that a resident is put on a list to be seen by the psychiatric NP or by the Psychiatrist after the residents are discussed during morning report. The Director stated that she will put the resident on the list to be seen [DATE].Review of a facility policy and procedure entitled [MEDICAL CONDITION] Medications and BMARC (Behavioral ManagementReview Committee) Team dated [DATE] revealed Nursing/ Social Work will report to the facility interdisciplinary team changes in medication, behavioral response, and intervention recommendations during morning report and during quarterly care plan meetings.415.12

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Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, interview, and record review conducted during the Standard survey completed on 1/21/15, the facility did not ensure that residents are given the appropriate treatment and services to maintain or improve ambulation abilities. One (Resident #56) of four residents reviewed for therapy services was not ambulated by staff as planned/ recommended by physical therapy.The finding is:1. Resident #56 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated11/6/15 revealed that the resident has moderate cognitive impairment, and understands, and is understood. The MDS documented that the resident requires total staff assistance for locomotion on and off the unit, limited assistance for ambulation, and has no limitations in range of motion (ROM) of the upper and lower extremities.Review of a Communication Form dated 11/5/15 revealed skilled Physical Therapy(PT) was discontinued with recommendations for restorative nursing ambulation for a distance of 150 feet (') with a rolling walker, gait belt, and limited assistance of one staff person.Review of the CNA (certified nurse aide) Care Guide dated 1/8/16 revealed an approach to ambulate the resident with the limited assistance of one staff, using a gait belt and rolling walker for a distance of 150'.Intermittent observations on Unit 4 on 1/19/16 and 1/20/16, from 6:00 AM to 3:30 PM, revealed staff transported the resident to the Main Dining Room and the 4th Floor Dining Room in a wheelchair. The resident was observed in bed or seated in the wheelchair during the intermittent observations on 1/19/16 and 1/20/16. Staff were not observed to assist the resident with ambulation.Interview with the resident on 1/20/16 at approximately 8:00 AM revealed staff have not provided him assistance with ambulation for quite a while, They don't have time. The resident also stated that he wants to go home and he came to the facility for rehabilitation services.Interview with the Physical Therapy (PT) Assistant on 1/20/16 at approximately 1:00 PM revealed the resident was initially planned for discharge back to home. The PT Assistant stated that when the resident's status changed to long term care, recommendations for the restorative nursing ambulation program were made and the CNAs are responsible to ambulate the resident once daily.Interview with the Unit 4 ROM (range of motion) CNA on 1/21/16 at approximately 7:45 AM revealed she is responsible to ambulate residents who on the restorative nursing ambulation program on Unit 4. The ROM CNA stated she has not worked as a ROM CNA during the survey and was assigned to work as a regular CNA with a resident assignment. The ROM CNA statedResident #56 was not in her assignment on 1/19/16 and 1/20/16 and she did not ambulate the resident on those days.415.12(a)(2)

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Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, interview, and record review conducted during the Standard Survey completed 1/21/16, the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Two (Resident's #36, 37) of three residents reviewed for ADLs involved for Resident #37 incomplete morning care with no oral care performed, nails had brown debris underneath after the resident's hands were washed and barrier cream was not applied after incontinent care. Resident #36 had an ill-kempt appearance upon entrance to the facility .The findings are:1. Resident #37 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - a resident assessment tool)dated 9/30/15 revealed that the resident is cognitively intact, understands and is understood. The resident is incontinent of







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(continued... from page 9) bowel and bladder, and is totally dependent on staff for bathing, toileting, and dressing.Review of the resident's Care Plan dated 11/24/15 revealed that the resident is care planned for alteration in function related to decreased functional ability and debility and that he is a total assist for bathing, grooming, dressing and to provide oral care in the morning and at night.During an observation of morning care on 1/15/16 at approximately 8:10 AM revealed the resident laying on his back in bed. Certified Nurse Aide (CNA) #6 removed the resident's hospital gown and proceeded to wash the resident's face and hands. The resident's fingernails were noted to have brown debris underneath after being washed. CNA #6 removed the resident's brief and provided incontinent care. CNA #6 did not apply a barrier cream. After completing care CNA #6 transferred the resident from his bed to his Geri chair via the mechanical lift. CNA #6 did not provide oral care. When CNA #6 was asked if she was done with morning care she stated Yes.During an interview with CNA #6 on 1/15/16 at approximately 8:41 AM, CNA #6 stated in discussing the resident's morning care that she did not apply a barrier cream after incontinent care. She also stated that the resident is supposed to get oral care in the morning and she didn't perform it and have her fingernails cleaned.An interview with Registered Nurse (RN) #3 on 1/15/16 at approximately 11:50 AM revealed that RN #3 expects her staff to perform complete morning care including cleaning nails and oral care.An interview with RN #4 on 1/15/16 at approximately 2:27 PM revealed that she expects the staff to apply a barrier cream on the resident after incontinent care.Review of the facility policy entitled Perineal Care - Female/ Male dated 1/2013 revealed under the Procedures section Procedure #21 to Apply barrier cream topically to buttocks per policy/ procedure.2. Resident #36 has [DIAGNOSES REDACTED]. The resident had no behaviors directed towards others, and no rejection of care. The resident requires total staff assistance for bed mobility, transfer, dressing, toilet use, personal hygiene and eating.During an observation on 1/14/15 at approximately 9:09 AM and at approximately 11:15 AM revealed the resident had fingernails with brown debris underneath, food debris on his upper lip and right index finger, and food debris on his clothing.During an interview with Registered Nurse (RN) #3 on 1/15/16 at approximately 11:50 AM revealed that RN #3 expects her staff to clean resident's nails and that residents should be clean.CNA #8 stated during an interview on 1/19/16 at approximately 8:45 AM that the resident is totally dependent on staff for all ADL's.415.12(a)(3)

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Make sure that residents with reduced range of motion get propertreatment and services to increase range of motion.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, interview, and record review conducted during the Standard survey completed on 1/21/15, the facility did not ensure that a resident with limited range of motion (ROM) receives appropriate treatment and services to increase ROM and/ or prevent further decrease in ROM. One (Resident #36) of four residents reviewed for ROM did not receive passive range of motion (PROM - exercises provided by staff) as planned and recommended by therapy.The finding is:1. Resident #36 has a [DIAGNOSES REDACTED]. The MDS documented the resident had no behaviors directed towards others, no rejection of care, and requires total staff assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS also documented that the resident has limitations in range of motion (ROM) of bilateral upper and lower extremities.Review of a Physical Therapy - Rehabilitation Screening assessment dated [DATE] revealed the resident has bilateral contractures (loss of joint mobility) of the lower extremities (hips, knees, ankles, feet) with recommendations for PROM to the bilateral lower extremities daily.Review of an Occupational Therapy - Rehabilitation Screening Evaluation dated 11/5/15 revealed the resident has contractures of bilateral shoulders, elbows, and wrists with recommendations for PROM to the bilateral shoulders, elbows, and wrists one to two times daily for 15 minutes.Review of the CNA (certified nurse aide) Care Guide dated 1/19/16 revealed a plan to provide PROM to bilateral lower extremities (hips, knees, and ankles) and bilateral upper extremities daily (shoulder, elbow and left wrist) daily.Observation on 1/19/16 from approximately 8:30 AM to 8:45 AM revealed two CNA's (#4 and 8) provided personal care to the resident. PROM was not attempted or provided during the observation.Interview with the resident on 1/19/16 at approximately 8:50 AM revealed that staff do not provide exercises to his hands and feet.Interview with CNA #8 on 1/20/16 at approximately 11:25 AM revealed she did not provide ROM to Resident #36 yesterday. The CNA stated that the ROM CNA normally provides ROM to the residents.Interview with the Unit 4 ROM (range of motion) CNA on 1/21/16 at approximately 7:45 AM revealed she has not worked as a ROM CNA during the survey and she was assigned to work as a regular CNA with a resident assignment. The ROM CNA stated there used to be ROM books on the Unit, however, they have disappeared and she performs the case load by memory. Unit 4 ROM CNA stated she did not have Resident #36 in her resident assignment on 1/19/16.415.12(e)(2)

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Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, interview, and record review conducted during the Standard survey completed on 1/21/16, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #47) of three residents reviewed for accidents had issues. Specifically, multiple observations of the resident being transported by staff while seated on a four wheeled walker without foot pedals.The finding is:1. Resident #47 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated12/2/15 revealed the resident is independent with locomotion.Multiple observations revealed:-1/15/16 at 7:11 AM the resident is being pushed in rolling walker backwards by the Certified Nurse Aide (CNA) into the dining room. Resident is wearing nonskid socks on feet.-1/15/16 at 1:17 PM the CNA is pushing resident, who is sitting on the seat of the four wheeled walker, backwards down fourth floor long hallway approximately 40 feet. Resident is wearing nonskid socks on feet.Review of the Care Guide dated 12/1/15 revealed the resident ambulates with a four wheeled walker approximately 150 feet and has a wheelchair for distance.During an interview on 1/15/16 at 1:23 PM CNA #4 stated that she does transport the resident this way if his legs start to hurt, he'll sit down and she'll push him the rest of the way to his room. CNA #4 further stated that the resident doesn't have a wheelchair.During an interview on 1/19/16 at 9:26 AM the RN #3 ,Unit Manager stated the CNA should put the resident into a wheelchair or let him rest a while, while seated and shouldn't use the walker to transport the resident.During an interview on 1/20/16 at 12:11 PM the Director of Rehab stated that he would not recommend transporting a resident this way and this resident has a wheelchair if he needs to use it.415.12(h)(2)

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Make sure that each resident gets a nutritional and well balanced diet, unless it is not







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(continued... from page 10) possible to do so.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 1/9/15.Based on interview and record review during a complaint investigation (Complaint #NY 061) conducted during the Standard survey completed 1/21/16, the facility did not ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and receives a therapeutic diet when there is a nutritional problem. Seven (Resident #51, 56, 102, 134, 154, 174, 187) of eight residents reviewed for nutrition had issues involving the lack of a comprehensive nutritional assessment within 14 days of admission, annually, and when there was a change in a resident's condition (#51,56,102,134,174) and lack of interventions to address nutritional concerns. Specifically, there was a lack of nutritional interventions to address abnormal laboratory results and the presence of a pressure sore (Resident #102), lack of implementation of nutritional interventions to address a significant weight loss (#187), lack of addressing increased fluid needs for a resident with loose stools (#51), lack of a nutritional interventions to address a resident with a low BMI (body weight index) and fluctuating meal intake (#154), lack of nutritional interventions to provide additional protein for a resident with declining [MEDICATION NAME] level(Resident #174), lack of timely assessment for a resident on [MEDICAL TREATMENT]with a fluid restriction (Resident #134) and lack of a timely assessment for a resident with diabetes and stage 4 kidney disease (Resident #56).The findings include but are not limited to:1. Resident #187 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated11/26/15 revealed the resident is severely impaired for decision making.Review of the resident's Weight Change History revealed the following weight trend:- 8/14/15 - 116# (pounds)- 8/19/15 - 118#- 9/23/15 - 117- 11/11/15 - 121#- 12/10/15 - 108#- 12/14/15 - 107.4#Review of a Nutritional Screening/ assessment dated [DATE] revealed the resident weighed 116# and was within an Ideal Body Weight (IBW) range of 104 to 127#.The next nutrition documentation is a Quarterly Nutrition Progress Note dated 12/11/15 indicating that the resident receives a regular ground diet; has poor meal acceptance; and receives fortified cereal at breakfast and fortified milkshakes at lunch and supper. The plan was to obtain a reweigh because there was a 13.2 # loss from November to December.Review of a Nutrition Note dated 12/14/15 revealed the reweigh was 107.4# representing a further weight loss. The plan was to provide snacks at PM and HS and conduct a 3 day intake study.Review of Nutrition Progress Notes and the entire medical record on 1/19/16 revealed there was no further documentation by Dietary related to the results of the intake study.Review of Nourishment Acceptance Sheets dated 12/14/15 through 1/15/16 revealed no documented evidence that the resident was provided PM and HS snacks as planned on 12/14/15. In addition, review of Meal Acceptance sheets revealed there was incomplete documentation of the resident's intake and multiple refusals of the fortified cereal and fortified shakes provided with meals.Interview with the Registered Dietitian (RD #1) on 1/20/16 at 10:10 AM revealed he knew he scheduled an intake study, he was unable to find the document, and he started a new intake study today. RD #1 stated he just added the PM and HS snacks to the scheduled between meal snacks today; they were not added in December (12/16).Additional review of the Weight Change History sheet revealed on 1/18/16 the resident's weight was 102#. This represented a 5.4# weight loss in one month and a 19# weight loss in 90 days without the implementation of nutritional interventions.2. Resident #102 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was admitted on [DATE]with a stage 2 pressure sore and is cognitively intact.a.) Review of a Nutritional Progress Note dated 11/11/15 revealed the resident was receiving a carbohydrate consistent diet (CCD), liberal renal regular diet with a 1200 cubic centimeter (cc) fluid restriction. The Progress Note documented that no pressure sores reported and full Assessment to follow.Review of a New/ Readmission Assessment initiated 11/10/15, revealed a notation by the Registered Nurse (RN) dated 11/15/15 documented that the resident had a Stage 2 pressure ulcer on the right buttock.Review of Routine Chemistry laboratory report dated 11/12/15 revealed an [MEDICATION NAME] level (measure of protein in the blood) of 2.3 (normal of 3.3 - 4.8), BUN (blood urea nitrogen - blood test to determine kidney function and hydration status) was 60 (normal 5 - 27), a creatinine (blood test to determine kidney function) of 2.56 (normal 0.40-1.6) and a glucose level of 196 (normal 60-100).Review of a physician's orders [REDACTED].>Review of a Routine Chemistry laboratory report dated 11/19/15 revealed the BUN increased to 72, the creatinine increase to 2.85, the glucose level was 159, and the [MEDICATION NAME] was 2.3.Review of a physician's orders [REDACTED].Review of an Acute Care Visit Note, written by a Nurse Practitioner (NP), dated 11/18/15 revealed the [MEDICATION NAME] was increased due to increased swelling in the BKA amputation site with a plan to monitor the BMP (basic metobolic profile - blood test including chemistry studies of the blood).Review of a Nurse's Note dated 11/21/15 revealed the resident was admitted to the hospital with [REDACTED].Review of the entire medical record revealed there was no documented evidence that a comprehensive nutritional assessment was completed following the resident's admission on 11/10/15, including an assessment of calorie and protein needs, and there were no interventions implemented to address the abnormal laboratory results or the pressure sore. The only Nutrition Note was on 11/11/15.b.) Review of readmission physician's orders [REDACTED].Review of Swallowing Rehab (rehabilitation) Note dated 12/1/15 revealed the resident was receiving nectar thick liquids and a regular consistency diet. The Note documented there was an order for mechanical soft (ground) in chart.Review of a Nursing Note dated 12/2/15 revealed the resident was admitted to the hospital.Review of the medical record revealed there was no Dietary documentation regarding the resident's discharge to the hospital, readmission, or the diet change. The only Nutrition Note was dated 11/11/15.Interview with Registered Dietitian (RD #2) on 1/20/16 at 9:43 AM revealed In a perfect world, they are done within 14 days of admission. After that a quarterly assessment is done and after three quarterly notes they would get an Annual Assessment. I was the only RD here at the time and I only work part-time two days a week covering all three floors.Interview with RD #1 on 1/15/16 at 11:30 AM revealed he started at the facility on 10/12/15 and he had no prior long term care experience. The RD stated it took a while for him to catch on and catch up with the back log of assessments and documentation that needed to be done. The RD stated Ideally, nutritional assessments should be completed within 14 days. The labs (laboratory results) should be charted on, especially the abnormal ones.3. Resident #134 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, understands, and is understood.Review of the comprehensive Care Plan (CCP) dated 11/3/15 revealed the resident has [MEDICAL CONDITION] and was identified at risk for dehydration due to [MEDICAL TREATMENT] three times a week and nutritional impairment due to [MEDICAL CONDITION].Review of admission physician's orders [REDACTED].Review of the Physician's history and physical examination [REDACTED].Review of a Nutritional Progress Note dated 6/17/15 revealed the resident was admitted to the facility with a no-added salt (NAS), renal diet and a fluid restriction of 1200 cc daily. The Nutrition Note documented that the resident's weight data was pending and the dietary department will follow the resident per protocol.Additional review of Nutritional Progress Notes revealed the following:







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(continued... from page 11)- 7/23/15 - The resident was noted to refuse meals at times. The Progress Note documented that the Food Service Supervisor provided the resident with menu substitutions.- 9/2/15 - The resident had a weight loss of unknown origin.- 9/25/15 - The Registered Dietician (RD) reviewed the chart for fluid requirements. The resident was receiving a NAS renal diet with a 1200 cc per day fluid restriction as per physician's orders [REDACTED].Review of a Nutritional Screening assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with a no added salt (NAS) renal diet with a 1200 cc per day fluid restriction.Additional review of the CCP dated 11/3/15 revealed approaches to provide a NAS renal diet with a 1200 cc per day fluid restriction total from medications, meals, and snacks.Interview with RD #1 on 1/19/16 at approximately 1:35 PM revealed that all residents admitted to the facility are to have a nutritional assessment within 10 days of admission to the facility. The RD reviewed the resident's record and stated the resident was admitted to the facility on [DATE] and the nutritional assessment was not completed until 10/20/15.Interview with the Third Floor Unit Clerk on 1/19/16 at approximately 1:40 PM revealed the Unit Clerk went through the resident's entire Medical Record and stated that all Nutritional Progress Notes are in the resident's record. The Unit Clerk stated that the Nutritional assessment dated [DATE] was the initial nutritional assessment for Resident #134.4. Resident #154 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands, and is understood. The MDS documented that the resident had a Body Mass Index (BMI) of less than 22 and is not receiving nutritional supplements.Review of the medical record Face Sheet revealed the resident was admitted to the facility on [DATE].Review of a Nutritional Progress Note dated 11/6/15 revealed the resident was admitted on [DATE]. The Progress Note documented the resident was receiving a regular diet, Assessment to follow.Review of physician's orders [REDACTED].>Review of a Nutritional Screening/ Assessment completed on 12/21/15 revealed resident is 64 inches tall and weighed 106.4#. The Assessment documented that the resident's appetite varied from fair to good. There was no documentation that the resident was receiving a nutritional supplement.Review of Meal Acceptance Sheets dated 11/15/15 through 1/9/16 revealed the resident's average intake ranged between 25 to 75%.During an interview on 1/19/16 at 2:48 PM, the resident stated I know I am underweight. Everyone here tells me that I am underweight all the time. My family brings me in a supplement from home. They have never offered me one here, if they had offered me a supplement I would take one because I used to weigh 135# and have lost some weight since I got sick.During an interview on 1/19/16 at 3:07 PM, the Registered Dietitian (RD #1) stated I knew there was going to be an issue with the assessments not being written in time. Initial assessments should be written within 14 days of admission, then every quarter and annually. When she was due, I had just started and I did not have that unit assigned to me. With a BMI of less than 22, a fortified supplement should have been offered. I did go over preferences with her, but never offered a fortified supplement.5. Resident #51 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment, understands, and is understood.Review of the medical record Face Sheet revealed the resident was readmitted to the facility on [DATE].Review of Nurse's Notes revealed resident had loose stools on 11/22/15 and 11/23/15.Review of physician's orders [REDACTED].Review of physician's orders [REDACTED].Review of the Dietary section of the medical record revealed the last Annual Nutritional Assessment was completed 10/14/14, followed by Quarterly Nutritional Assessments on 1/2/15, 4/10/15 and 7/8/15.A Nutritional Progress Note dated 11/24/15 documented that the resident's loose stools continue. The Note documented that the resident was receiving Hy-fiber BID (twice a day) for bowel management and a stool sample was obtained for [MEDICAL CONDITION]. The Note also documented a plan to add 120 cc of fluid to each meal to ensure proper hydration and [MEDICATION NAME] lost fluids through stools.Review of Meal Acceptance Sheets dated 11/22/15 through 11/27/15 revealed that 11 out of 18 meals were not documented for food and fluid intake.During an interview on 1/19/16 at 3:07 PM, RD #1 stated I knew there was going to be an issue with the assessments and them not being written in time. Initial assessments should be written within 14 days of admission, then every quarter and annually. When she was due, I had just started and I did not have that unit assigned to me. I only went up there and wrote a note because I heard something about the resident having loose stools.During an interview on 1/20/16 at 9:43 AM, RD #2 stated In a perfect world, the assessments are to be done within 14 days of admission. After that quarterly assessment and after three quarterly notes, they would get an Annual Assessment. I did not do the assessment. I have no excuse. I do not know if I was notified. I was the only RD here at the time and I only work part-time two days a week covering all three floors.Review of a policy and procedure (P&P) entitled Meal and Fluid Intake dated 2/2015 revealed meal/ fluid intake will be monitored for the amount of food and fluid a resident consumes at each meal and any substitutions offered. Findings will be documented.Review of a P&P entitled Resident Hydration/ Fluid Needs dated 2/2015 revealed each resident's fluid needs are calculated and documented upon admission and updated quarterly by the RD or diet technician. Individual assessments will determine such need.6. Resident # 56 has was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has moderate cognitive impairment, understands, is understood, and receives a therapeutic diet.Review of a Nutritional Screening assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with diabetes, [MEDICAL CONDITION], hypertension,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease),[MEDICAL CONDITION] (elevated fat levels in the blood), Stage 4 [MEDICAL CONDITIONS] disorder, and [MEDICAL CONDITION]. The Assessment documented that thethe resident had loose stool with a diet order for a lactose restricted regular diet with CCD and no added salt. Supplements of fortified cereal were ordered and at night the resident receives a sandwich. The resident had a high BUN/ Creatinine, a low [MEDICATION NAME] of 2.8, low calcium of 7.3, a low glomerular filtration rate (blood test to measure level of kidney function and determine the stage of kidney disease), low total protein of 5.5, and low hemoglobin of 7.2 (protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues). The resident was evaluated as significantly underweight and planned for the provision of foods that meet his estimated nutritional needs.The Nutritional Screen was not completed within 14 days after the resident's readmission to the facility.415.12(i)(1)

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Develop policies and procedures for influenza and pneumococcal immunizations.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on interview and record review conducted during the Standard Survey completed on 1/21/16, the facility did not develop policies and procedures that ensure that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has been immunized. Two (Resident #2, 134) of five residents reviewed for pneumococcal immunization had a lack of documentation on the nursing admission assessment or medical record that the resident was offered a pneumococcal vaccination, refused or had the immunization in the past.The findings are:1. Resident #2 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS- a resident assessment tool) dated 11/11/15 revealed the resident understands, is understood and has severely impaired cognition.Review of the facility [MEDICATION NAME] Skin Testing and Vaccine Administration Record dated 5/4/15, the date of the resident's admission to the facility, revealed a lack of documentation that the resident received a pneumococcal vaccine. Further review of the medical record revealed the resident signed a consent to receive a yearly influenza vaccine and a pneumococcal vaccine.Review of the entire medical record dated 5/4/15 through 1/15/15 revealed a lack of documentation that the resident and responsible party was offered a pneumococcal vaccine, had a pneumococcal vaccination in the past or was refused.







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(continued... from page 12)Review of the entire medical record with the RN Unit Coordinator revealed a lack of documentation that the pneumococcal vaccine was offered, refused or given prior to admission to the facility.2. Resident #134 has [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS dated [DATE] revealed the resident understands, is understood and has a moderately impaired cognition ability.Review of the physician's orders [REDACTED].Review of the Physician's Admission History and Physical dated 6/17/15 revealed a lack of documentation that the resident has received a pneumococcal vaccination.Review of the resident's entire medical record including the vaccine administration record dated 6/16/15 with the Third Floor RN Unit Coordinator revealed the medical record does not contain documentation that the resident refused the pneumococcal vaccination, was offered a pneumococcal vaccination, or received the pneumococcal vaccination prior to admission to the facility.Interview with the Infection Control Registered Professional Nurse (RN) on 1/18/16 at approximately 1:00 PM revealed that all residents should have the pneumococcal vaccine addressed within 1-2 weeks of admission. It is to be recorded on the vaccine administration record when given, the date of administration if given prior to admission to the facility or date of resident or responsible party's refusal of the vaccine.415.19(a)(1)

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Store, cook, and serve food in a safe and clean way

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 1/19/15.Based on observation, interview, and record review conducted during the Standard survey completed on 1/21/16, the facility did not store, prepare, distribute, and serve food under sanitary conditions. One of one Main Kitchen had issues that included: a plumbing clean out (a capped pipe which provides access to a sewer line, allowing cleaning of the line or removal of blockages in the line) was open and uncapped, light bulbs were not properly protected to prevent broken glass from falling into food or onto food-contact surfaces, food items that had been removed from their original packaging were not labeled, dated, and/ or protected from contamination, a packaged food item was stored in contact with a liquid, and a container of alcohol based hand sanitizer was stored with food items. In addition, the Unit 2 Nourishment Room that was visibly dirty had unlabeled and undated food in the refrigerator and the microwave had splatters of old food on it.The findings are:1. Observation of the Main Kitchen on 1/13/16 at approximately 9:10 AM revealed an unsealed opening in the floor below the dish washing machine. The opening had an open threaded pipe in it.Interview with the Food Service Director (FSD) at the time of the observation revealed the FSD did not know the purpose of the open threaded pipe or if the threaded pipe had a cap and how long the pipe had been open.Interview with the Environmental Director on 1/14/16 at approximately 9:45 AM revealed she did not know the purpose of the open threaded pipe in the floor below the dishwashing machine. The Environmental Director revealed that the threaded pipe appeared to be missing a cap and she was not sure how long it had been open and uncapped.Interview with the Environmental Director on 1/14/16 at 1:13 PM revealed she had contacted an outside plumbing contractor that worked on the building's plumbing and learned that the open unsealed threaded pipe in the floor below the dishwashing machine was a plumbing clean out for the kitchen's plumbing pipes. The Environmental Director stated that the clean out should have been capped.2. Observation of the Main Kitchen on 1/13/16 at approximately 9:15 AM revealed four approximate eight foot long uncovered fluorescent light bulbs were located above two preparation areas in the kitchen. Further observation revealed an approximate two gallon uncovered pan full of pasta was stored in the preparation areas near the two bay sink directly below two of the uncovered light bulbs. The two approximate eight foot long uncovered fluorescent light bulbs were located above a shelving unit in the kitchen that contained one 1000 count open box of plastic forks, one 1000 count open box of plastic knives, one 1000 count open box of plastic spoons, and an open plastic bag that contained approximately 100 foam plates. The two approximate four foot long uncovered fluorescent light bulbs were located above the dishwashing machine area of the kitchen and two approximate eight foot long uncovered fluorescent light bulbs were located in the kitchen near the walk-in cooler.Interview with the FSD at the time of the observation revealed she was not sure how long the fluorescent light bulbs had been uncovered and that the Environmental Director would know.Observation on 1/14/16 at 9:37 AM revealed an approximate 18 inch by 26 inch uncovered pan of fried rice was stored in the preparation area near the two bay sink directly below two of the uncovered light bulbs.Interview with the Environmental Director on 1/14/16 at 11:44 AM revealed some of the fluorescent light bulbs had been replaced in the kitchen and that the covers for the bulbs were on back order.Review of a purchase order on 1/14/16 revealed 14 eight foot long bulb protectors and 13 four foot long bulb protectors had been ordered from an out of state company on 6/16/15.Interview with the Environmental Director on 1/19/16 at 9:44 AM revealed the kitchen light bulbs are not shatter proof style bulbs and they needed to be covered.3. Observation of the Main Kitchen on 1/14/16 at approximately 9:05 AM revealed the following:- An approximately three pound piece of salami stored in a plastic tub in the walk-in cooler and the tub had an approximate one quarter inch deep layer of a pink colored liquid in it. The salami had been removed from its original packaging, was wrapped in plastic wrap, and the plastic wrap was wet and soiled with the liquid. Continued observation revealed an approximate five pound processed turkey in its original plastic package was also stored in the bottom of the plastic tub in contact with the pink liquid.- The following items stored in the walk-in cooler were removed from their original packaging and wrapped in plastic wrap were not labeled or dated: approximately 20 pieces of an orange colored cheese, an approximate four pound block of an orange colored cheese, and three pounds of parmesan cheese.- One partially full 18 ounce pump style container of alcohol based hand sanitizer was stored between two cardboard boxes full of tea bags and two 64 ounce pump style containers of food grade thickener.Interview with the FSD at the time of the observation revealed she did not where the hand sanitizer came from.Review of the facility policy and procedure entitled Purchasing, Receiving and Storage of all Food and Supplies revised 1/2013 under the heading Procedure: #6 revealed All toxic substances, detergents and sanitizers, whenever possible, should be stored in original containers in the designated storeroom away from all food and paper supplies. If a product is transferred from its original container, the new container must have the name of the product clearly written on the outside.4. During the initial tour observation of the Unit 2 Nourishment Room on 1/13/16 at 9:55 AM revealed the following:- In the refrigerator was an unlabeled and undated Styrofoam container with goulash and green beans.- In the freezer there was a half empty 5.8 ounce container of vanilla ice cream not labeled or dated.- Counter above the microwave had brown ground coffee like debris all over it with paper products placed on top of the debris.- The microwave's opening had an approximately ½ inch rust ring build up around the opening. The inside and outside of the microwave had splatters of old food debris on it. The inside of the microwave had a very strong odor.- Garbage can was full of garbage with no cover on it.- The corners of the drawers had a build-up of crumb debris.- The vent on wall above the microwave had a thick buildup of dust.415.14(h)New York State Sanitary Code Subpart 14-114-1.9014-1.110(b)(c)(d)14.140(a)14-1.43(e)14.-1.174







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Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED ON 2/20/14 AND 1/9/15.Based on observation, interview, and record review conducted during a Standard survey completed on 1/21/16 , the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date when applicable. Three of three units (Units 2, 3, 4) observed for medication storage had issues with an open vial of insulin that was in the refrigerator past the expiration date and a resident who was discharged on [DATE] had medication left in the medication room that was not properly disposed of (Unit 4); an open bottle of heparin (anticoagulant) with no date on it (Unit 2); and an outdated bottle of liquid Tylenol and an open bottle of insulin that was on a medication cart (Unit 3).The findings are:1. An observation of the Medication Room on Unit 4 on 1/13/16 at 9:39 AM revealed an opened bottle of Chlorhexidine 0.12% (an oral antiseptic) that was half full with a pharmacy fill date of 4/29/15. There was no date opened date on the label or the bottle. While in the medication room with Licensed Practical Nurse (LPN) #1 when asked why the opened bottle of Chlorhexidine was in the medication room replied I don't know. The resident isn't here anymore. I don't know where the box for return meds (medication) are. It should be in here. Continued observation of the medication refrigerator in the top door shelf revealed a box with an open vial of insulin with a label that read date opened 12/8/15. The label also read Do not use after 1/12/16. This was 35 days after the open date.An interview with the Licensed Practical Nurse (LPN) #4 on 1/13/16 at approximately 9:56 AM revealed that the expired medications or medications from residents who are no longer reside at the facility should be pulled by the nurses and given to the Director of Nursing (DON). The DON then returns them to the pharmacy.An interview with the Unit Clerk on 1/13/16 at 10:11 AM revealed that the resident who had the bottle of Chlorhexidine was discharged on [DATE]. The Unit Clerk was not sure why the medication was still in the Medication Room.An interview with the acting DON on 1/20/16 at approximately 1:30 PM revealed that multidose bottles or vials of medication like insulin or heparin should be initialed and dated when they are opened and that they are good for 28 days after that. She also stated if they are medications left over from a resident who was discharged they should be properly disposed of. The DON then stated if the medications are in blister packs they should be returned to the pharmacy.A review of the facility policy entitled Pharmacy Services - labeling and storing medications dated 2/2015 under Section #6 revealed all medications stored in Medication Room or refrigerator must have an expiration date listed, once the medication is opened and under Section #8 revealed all multi-dose vials of medications must be dated when opened. All multi-dose vials must be discarded after 28 days from the date the vial was opened, and under Section #9 revealed any vial of medication opened and undated is considered expired and must be discarded.2. During an observation of the Unit 2 medication cart on 1/13/16 at 9:55 AM revealed one heparin bottle was opened and three fourths empty with no date marked on it when it was opened.During an interview on 1/13/16 at 9:55 AM LPN #6 stated, The heparin should have been dated when opened. I will throw it away right now.3. Observation of the Unit 3 medication cart on 1/12/15 at approximately 10:00 AM revealed one bottle of opened insulin, approximately one fourth full, was noted to be past the do not use date of 1/11/16 on the bottle. Another bottle of stock liquid medication, approximately one third full, was noted in the medication cart with an expiration date of 10/2015.Interview with LPN #3 on 1/12/15 at approximately 10:00 AM revealed on the day of opening a bottle of insulin, it is to be dated for expiration 28 days from that date. LPN #3 stated that the bottle of insulin should have been disposed of on 1/11/15 and not used on 1/12/15. LPN #3 stated that stock medications stored in the medication cart are to be checked routinely. The bottle of medication was removed and replaced.415.18(d)

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Have a program that investigates, controls and keeps infection from spreading.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED ON 2/20/14 AND 1/9/15.Based on observation, interview and record review conducted during the Standard survey completed on 1/21/16, the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease. Two (Residents #37, 155) of six residents observed for infection control practices during resident care had issues which included staff not removing gloves and washing hands after removal of a resident's soiled brief, staff not removing soiled gloves and washing hands prior to continuing on with a resident's care after the performance of perineal care (the area between the anus and genitalia), and emptying a basin of water used to bathe a resident into a shared sink.The findings are:1. Resident #155 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - a resident assessment tool)dated 10/28/15 revealed the resident understands, is understood and is cognitively intact.During an observation of the resident's morning care on 1/15/16 at approximately 10:08 AM with the resident's assigned Certified Nursing Aide (CNA #5), CNA #5 was noted to wash her hands and apply disposable gloves prior to the onset of the resident's care. The resident was assisted to transfer from the wheel chair to the toilet. Prior to sitting onto the toilet, the resident's brief was loosened and removed. The brief was noted to contain urine, a small amount of soft brown stool and a dime sized dot of red substance which appeared as blood. CNA #5 rolled up the brief then placed the brief into the garbage can. While wearing the same gloves, CNA #5 continued on with the resident's care including: gathering clean linen and personal hygiene supplies and placement of a clean pad onto the resident's wheel chair cushion. CNA #5 ran the warm water, wet the washcloths and handed them to the resident to wash his face and hands. CNA #5 assisted the resident to bathe the remaining areas, dress and transfer to the wheel chair. CNA #5 removed her gloves and washed her hands.Interview with CNA #5 on 1/15/16 at approximately 11:45 AM revealed that the soiled brief CNA #5 removed from the resident upon transfer onto the toilet contained urine, stool and a small area of red material that appeared to be blood. CNA #5 stated that at this point, her gloves should have been removed, hands washed and clean gloves applied prior to handling clean linens and proceeding on with the resident's care.Interview with the Registered Nurse (RN) Unit Coordinator on 1/16/16 at approximately 12:00 PM revealed that staff are expected to remove soiled gloves and wash their hands after removal and disposal of a soiled brief.Interview with the Infection Control Nurse on 1/16/16 at approximately 11:30 AM revealed that the staff are expected to remove their soiled gloves and wash their hands after handling soiled briefs or performing incontinent care.Review of the facility policy and procedure entitled Perineal Care dated 8/1990 revealed that staff are to remove gloves upon completion of perineal care and wash hands. Staff to apply clean gloves to proceed on with other care needs.2. Resident #37 has [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the resident is cognitively intact, understands and is understood. The resident is incontinent of bowel and bladder, and is totally dependent on staff for bathing, toileting, and dressing.Review of the resident's Care Plan dated 11/24/15 revealed that the resident is care planned for alteration in function related to decreased functional ability and debility and that he is a total assist for bathing, grooming, dressing and to provide oral care in the morning and at night.During an observation of morning care on 1/15/16 at approximately 8:10 AM revealed CNA #6 placed the resident on his side and removed his brief that was soiled with a moderate amount of brown stool. CNA #6 threw out the brief, removed her gloves, and washed her hands for approximately five seconds and put on new gloves. CNA #6 then wiped the resident's perineal area and buttocks with a wet washcloth that became soiled with stool. CNA #6 then placed the wet washcloth on a barrier and then proceeded to place her hands into the basin to obtain another washcloth to clean and rinse the resident's back. CNA #6 then removed her glove from her right hand. CNA #6 went into the resident's closet and retrieved a new brief and clothing to dress the resident. CNA #6 placed the brief on the resident with an ungloved hand and began to dress the







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(continued... from page 14) resident with assist of CNA #2. CNA #6 then obtained the sling to transfer the resident from his bed to his Geri chair. Once in the Geri chair, CNA #6 then emptied the wash basin containing the dirty water into the sink the resident shared with another resident. CNA #6 washed her hands for approximately five seconds.During an interview with CNA #6 on 1/15/16 at 8:41 AM stated regarding the morning care that she did not wash her hands or change her gloves after providing the resident incontinent care. CNA #6 stated she should have washed her hands for at least 15 seconds. CNA #6 also stated that she shouldn't have emptied the dirty water from the basin into the resident's shared sink; she should've poured it into the toilet.During an interview with RN #3 on 1/15/16 at approximately 11:50 AM revealed that RN #3 expects her staff to wash their hands for at least 30 seconds after performing incontinent care.During an interview with RN #4 on 1/15/16 at 2:27 PM revealed that she expects the staff to wash their hands for approximately 30 to 60 seconds after performing incontinent care and to empty the used water from the basin into the toilet and rinsing it in the sink.Review of the facility policy entitled Handwashing dated 7/2010 under Procedures section three revealed wash hands well beneath running water for 20-25 seconds using a rotary motion and friction.415.19(a)(1-3)

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Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 1/9/15.Based on observation, interview, and record review during the Standard survey completed on 1/21/16, the facility did not maintain an effective pest control program so that the facility was free of pests and rodents. One of one kitchen and two (First, Fourth Floors) of four resident use floors had issues involving the re-occurrence of flying insectsThe findings are:1. Observation on the First Floor on 1/13/16 at approximately 9:10 AM revealed small flies were observed flying around the beverage station located in the dining room.2. Observation on the First Floor on 1/13/16 at approximately 9:36 AM revealed small flies were observed flying around the dishwashing machine located in the Kitchen.3. Observation on the Fourth Floor on 1/13/16 at approximately 10:19 AM revealed small flies were observed flying around in the corridor between the resident dining room/lounge and the nourishment room.4. Observation on the First Floor on 1/13/16 at approximately 11:04 AM revealed small flies were observed flying around in the corridor between the resident dining room and the employee break room.5. Observation on 1/14/16 at approximately 11:19 AM revealed small flies were observed flying around the tray line as the lunch meal was being prepared and plated in the Kitchen.6. Observation on the First Floor on 1/19/16 at approximately 11:05 AM revealed small flies were observed flying around in the activities room.Record review on 1/14/16 of a Customer Service report dated 11/30/15 from the outside contractor that provided extermination services for the building revealed Small flies noted during service. A couple flies found at drink station in dining room.Record review on 1/14/16 of a Customer Service report dated 12/23/15 from the outside contractor that provided extermination services for the building revealed Small flies noted during service under dishwasher area.Interview with the Food Service Director and the Environmental Director on 1/14/16 at approximately 2:49 PM revealed the Kitchen's drains were treated every Friday night with a blue liquid to deal with the drain flies. Further interview with the Food Service Director and the Environmental Director at this time revealed the blue liquid was purchased by the facility from the outside contractor that provided extermination services for the building. Continued interview with the Food Service Director and the Environmental Director at this time revealed they were not aware of any current issues with drain flies in the building.Review of the drain cleaning schedule logs on 1/14/16 revealed the facility had documentation that seven drains had been cleaned at least two times a month from 4/17/15 through 12/31/15.Interview with the Food Service Director on 1/15/16 at approximately 1:25 PM revealed five drains located in the Kitchen and two drains located in the dining room near the beverage station were the drains that were recorded on the drain cleaning schedule logs.415.29(j)(5)14-1.160

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Keep accurate, complete and organized clinical records on each resident that meet professional standards**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**THIS IS A REPEAT DEFICIENCY FROM THE PARTIAL EXTENDED Survey on 8/13/15.Based on interview and record review conducted during a Complaint investigation (Complaint #NY 061) during the Standard survey completed on 1/21/16, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. Four (Resident's #36, 51, 154, 187) of 31 residents reviewed for complete and accurate Medical Records had an issue with a lack of documentation of pain medication administration, lack of pain assessment by a Licensed Practical Nurse (LPN) and lack of documentation of suctioning. (Resident #36). Additionally, there was a lack of complete documentation of meal acceptance, supplements with meals, and between meal nourishments (Residents #51, 154, 187).The finding include but are not limited to:1. Resident #36 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 11/4/15revealed the resident is cognitively intact, understands, is understood, had no behaviors directed towards others and no rejection of care. The resident requires total staff assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident did not receive scheduled or as needed (PRN) pain medication, and had no pain per resident interview.Review of the current Comprehensive Care Plan (CCP) documented the resident has a [MEDICAL CONDITION] (artificialconnection of the bowel to the surface of the skin) /[MEDICAL CONDITION] (surgical creation of opening in the small intestine) with planned approaches for an ongoing assessment for abdominal distention and stool character. The CCP for Nutrition documented that the resident has the potential for altered BM (bowel movement) function with a goal to maintain normal ostomy (surgical opening between an internal organ and the body surface function).Review of the nurse's note revealed the following:- 1/20/16 at 4:40 AM - LPN #5 documented that the abdomen was more distended and firm, hypoactive (a reduction in the loudness, tone, or regularity of bowel sounds indicating the intestinal activity has slowed), bowel sounds and the stoma (an opening that connects the intestine to the surface of the abdomen) of the [MEDICAL CONDITION] was enlarged. The LPN documented that the resident had a medium soft and watery stool present in bag ([MEDICAL CONDITION] drainage bag). The LPN also documented that the supervisor was notified and assessment made (5:30 AM). Still no relief from pain, Tylenol 650 mg (milligrams) repeated. Still complaining of nausea, no emesis, will monitor. There is no pain assessment documented by the LPN at 5:30 AM when the Tylenol was administered.Review of the Medication Administration Record [REDACTED]little relief, there is no documentation of the administration or result of the Tylenol reported as given in the LPN nurses notes at 5:30 AM.Review of RN Nurse's note dated 1/20/16 9:00 AM New order - obtain stat (immediate) abdominal flat plate (x-ray of the abdomen) and stat chest x-ray, obtain stat CBC (complete blood count (CBC-blood test to determine the components of cells in the blood )with differential and BMP (basic metabolic profile-blood including basic chemistry studies of the blood), call placed to responsible party. The nurses note dated 1/20/16 at 10:45AM revealed that at 9:30 AM the resident had no







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(continued... from page 15) pulse, no respirations.Interview on 1/21/16 at approximately 8:00 AM with the resident's attending Medical Doctor (MD) in the nursing office with the Acting Director of Nursing (DON) present, revealed that the MD provided medical care for the resident for years and the resident had a [MEDICAL CONDITION] for chronic constipation and severe skin issues. During this interview, the Acting DON stated that the nurse suctioned fecal material from the resident yesterday morning when he experienced the change of condition around 9:00 AM. There is no documentation in the resident's medical record of the fecal material suctioned from the resident on 1/20/16.2. Resident #187 has [DIAGNOSES REDACTED]. Review of the MDS dated ,[DATE] revealed the resident is severely impaired for decision making.Review of the Nutritional Screening/ assessment dated [DATE] revealed the resident weighed 116# (pounds) within Ideal Body Weight (IBW) of 104 - 127#. The resident is receiving fortified cereal at breakfast and fortified milkshakes at lunch and supper.Review of the Quarterly Nutrition Progress Note dated 12/11/15 revealed the resident receives a regular ground diet, has poor meal acceptance and receives fortified cereal at breakfast and fortified milkshakes at lunch and supper.Review of a Nutrition Note dated 12/14/15 revealed the resident had a significant weight loss from November to December and planned to monitor intake and weights.Review of the Meal Acceptance Sheets for 12/6/15 through 1/2/16 revealed a lack of documentation of resident's acceptance of meals for 23 of 84 opportunities during that time and a lack of supplement acceptance for 40 of 84 opportunities.Interview with Registered Dietitian RD #1 on 1/19/16 at 3:18 PM revealed he identified an issue with the Meal Acceptance Sheets not being completed and let administration know about it.Interview with RD #2 on 1/20/16 at 9:43 AM revealed the intake sheets have been a problem at the facility for quite some time. RD #1 just brought the problem up at our last Quality Assurance (QA) meeting. I have not brought it up in QA because I have not had time. I'm only here part time.Review of a facility policy entitled Nourishments dated 1/02 revealed nursing assistants will pass all nourishments within 30 minutes after removal from the refrigerator. They have a clip board where they will mark the amount consumed.3. Resident #51 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is understood andunderstands and is severely cognitively impaired.Review of Nursing Progress Notes revealed resident had loose stools on 11/22/15 and 11/23/15.Review of Physician order [REDACTED]. In addition an order to have stool sent for possible [MEDICAL CONDITION].Review of Physician order [REDACTED].Review of Dietary section of chart revealed the last Annual Assessment was completed 10/14/14, followed by Quarterly Assessments on 1/2/15, 4/10/15 and 7/8/15. Nutritional Progress Note written on 11/24/15 revealed loose stools continue. Receiving Hy-fiber BID (twice a day) for bowel management. Stool sample taken for [MEDICAL CONDITION]. Will add 120 cc (centimeters) fluids to each meal to ensure proper hydration and [MEDICATION NAME] lost fluids through stools.Review of the Meal Acceptance Sheets dated 11/22/15 through 11/27/15 reveals 11 out of 18 meals were not documented for food and fluid intake.During an interview on 1/19/16 at 3:18 PM the Registered Dietitian (RD #1) stated I found that the meal acceptance sheets were not being completed by nursing and I had just recently brought this up at Quality Assurance (QA).During an interview on 1/20/16 at 9:43 AM the RD #2 stated The meal acceptance sheets have been a problem here for quite some time here. I have not brought the problem up at QA because I just have not had time to go to QA. RD #1 has recently brought it up at QA.Review of the Policy titled Meal and Fluid Intake dated 2/2015 reveals meal/ fluid intake will be monitored for the amount of food and fluid a resident consumes at each meal and any substitutions offered. Findings will be documented.415.22 (a) (1-4)

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Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

Based on observation, interview, and record review conducted during Post Survey Revisit #1 completed on 3/28/16, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee develops and implements appropriate plans of action to correct identified quality deficiencies. The QAA Committee did not ensure that the plan of correction (POC) was implemented following the Standard survey completed 1/21/16 and continuing deficiencies were identified related to housekeeping and maintenance, revisions of the resident care plan, services provided in accordance to the resident's care plan, and preventing a decrease in range of motion.The findings are:Refer to the following Continuing Deficiencies:F253- Housekeeping & Maintenance Services, S/S = EF280- Right to Participate Planning Care/Revise Care Plan, S/S= EF282- Services by Qualified Persons/Per Care Plan, S/S= EF318- Increase/Present Decrease in Range of Motion, S/S= DReview of the accepted POC for the Standard Survey completed 3/1/16 revealed the facility's latest date of alleged compliance was 3/6/16.During an interview with the Administrator on 3/28/16 at 12:30 PM, the Administrator stated that the QA Subcommittee that consisted of all Department Heads had met weekly and a full QA Committee meeting which included the Medical Director has met monthly since the recertification survey in January 2016. The Administrator stated the last QA Committee meeting was conducted on 3/10/16. The Administrator stated that he oversaw the development of a spreadsheet schedule to address each deficiency and required each department head to report to the QA Committee on progress made to address the deficiencies cited. The Administrator stated that the Director of Maintenance Services had assumed the responsibility of supervising Housekeeping Services due to the lack of a Housekeeping Director. The facility was currently hiring additional Housekeeping personnel. In addition, the Administrator stated that the current Registered Nurse (RN) Director of Nursing (DON) has been in the position for approximately six weeks.During an interview with the DON on 3/28/16 at 1:18 PM, the DON stated that while implementing the POC, additional staffing and management problems were identified within the facility. The facility is in the progress of hiring additional Unit Managers. The DON stated that initial nursing staff in-services related to the POC were conducted in small groups of nursing and aide staff. The DON stated she has started one-on-one re-education of all nursing staff regarding the implementation of the resident's plan of care. The DON stated she is learning through the one-on-one meeting of the problems staff are having implementing the plan of care.415-27(c)(3)(v)



full report jan. 21 2016

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