Medford Multicare Center for Living
May 3, 2018 Certification Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2018
Corrected date: July 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Specifically, 1 of 41 residents reviewed for Care Plan, (Resident #188) who had a [DIAGNOSES REDACTED]. Additionally, Resident # 188, who had a [DIAGNOSES REDACTED]. The finding is: 1 A) Review of the facility policy titled Comprehensive Care Plans: Resident Assessment dated (MONTH) 1, 2002, documented that the facility is to develop a Comprehensive Care Plan (CCP), beginning on admission, that focuses on the resident as an individual with distinct problems and needs: it is the tool used to provide continuity of care on a 24 hour basis. The CCP is developed within seven calendar days after completion of the Comprehensive Assessment; an interim care plan is developed to guide staff in giving care prior to development of the full CCP. The CCP should be reviewed and revised on an ongoing basis. Resident #188 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Delta Set valve resists siphoning of Cerebral Spinal Fluid (CSF) from brain's ventricular system) , [MEDICAL CONDITION] Disorder, and Chronic [MEDICAL CONDITION]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #188 had unclear speech, sometimes made himself understood, and could usually understand. The resident's Brief Interview for Mental Status (BIMS) score was 4, indicating Resident #188 had severe cognitive impairment. The resident required extensive assist of two staff members for bed mobility, transfer, dressing, and toilet use. The resident had no limitations in Range of Motion. Resident #188 was receiving medications which included Antianxiety, Anticoagulant and Diuretic medications. Resident #188 was observed on 4/25/18 at 12:17 PM, 5/3/18 at 2:15 PM and 5/3/18 at 3:33 PM in his room, seated in front of the nursing station and in the dining room respectively. The resident was well groomed, acknowledged greetings but his speech was unclear. The resident was observed on all observations to be sitting with his head bent forward with his hands holding his head. The resident was observed to have his left eye shut with slight swelling. Resident #188's family member was interviewed on 4/26/18 at 11:13 AM. The family member stated the resident had been in the hospital in (MONTH) (YEAR), and was transferred to the facility in (MONTH) for rehabilitation. The resident's family member stated the resident had an infection in his abdomen and the drain that had been in his head for [AGE] years was not working. The resident's family member stated the resident had to have surgery to have a new drain put in. The Nursing Admission Assessment/Initial Care Plan dated 3/13/2018 documented under Admission Diagnosis: [REDACTED]. Under the section titled Skin Exam the following was documented: 1. Incision Site: left side of scalp, Reason: Surgical procedure, closure: Staples, Description: 16 staples; clean, dry, intact 2. Incision Site: left side of scalp, Reason: Surgical procedure, Length: 0.75 centimeters (cm) Width: 0.1 cm, closure : staples, Description: 2 staples-clean, dry, intact. The Nursing Admission Progress Note dated 3/13/18 documented in the Skin Impairment Section: Incision site : left occipital, Reason: VP shunt, closure: staples. The Physician's initial History and Physical Progress Note dated 3/14/2018 documented Resident #188 had VP (Ventriculoperitoneal) shunt removed and placement of Ventriculostomy with Delta Set Valve. Review of the resident entire CCPs revealed that there was no CCP developed for the monitoring and care of the resident's Ventriculostomy. The Registered Nurse (RN) MDS Coordinator was interviewed on 5/3/18 at 12:45 PM. The RN stated that she may have signed off on the MDS but that she was not responsible for the completion of every section. The RN stated the MDS nurse does not usually complete the Care Plans but would coordinate with the Clinical Care Coordinator (CCC). The RN further stated she would follow -up with the CCC and the MDS nurse that completed the residents assessments. Interviews were conducted with the RN MDS nurse and the RN CCC concurrently on 5/3/18 at 1:18 PM. The RN CCC stated she had completed the Initial Nursing Assessment/CCP form for Resident #188 and that she had assessed the resident's Ventriculostomy site on admission. The RN CCC stated that there were no orders regarding monitoring of the shunt and that staff were checking the area daily. The MDS nurse stated she had completed nursing care areas of the MDS for Resident #188. The RN stated that there should have been a care plan developed for the monitoring of Resident #188's Ventriculostomy. The Primary Care Physician (PCP) for Resident #188 was interviewed on 05/03/18 at 2:15 PM. The physician stated she was familiar with Resident #188 and that the resident had a surgical procedure, Ventriclostomy, and that the Ventriculostomy (EVD) should be monitored. The PCP stated the hospital had not sent instructions with the resident on discharge regarding monitoring of the Ventriculostomy (EVD). The PCP stated that the resident had been followed by Neurosurgery. The PCP stated that she would meet with the staff on the unit and develop a plan for monitoring Resident #188's Ventriculostomy. The Director of Nursing (DNS) was interviewed on 5/3/18 at 2:40 PM and acknowledged that a CCP for the Ventriculostomy should have been developed. The RN Admission Nurse that completed the resident's admission progress note was interviewed on 05/03/18 at 3:33 PM. The RN stated that she had admitted Resident #188 on the evening shift on 3/13/18 and on admission she initiated the initial four care plans which include Skin, Pain, Fall/Safety, and Elopement. The RN Admissions nurse stated that depending on the number of admissions, she may have the unit RN CCC assist her with the CCPs and that the CCC initiates the remainder of the CCPs. The RN further stated that she was aware that Resident #188 had a Ventriculostomy and that a CCP should have been developed for the care and monitoring. 1 B) The Physician initial History and Physical Progress Note dated 3/14/2018 documented Resident # 188 had Bilateral Lower Leg [MEDICAL CONDITION] with Left Lower Extremity Chronic [MEDICAL CONDITION]. The progress note documented under the plan section: Chronic [MEDICAL CONDITION], continue [MEDICATION NAME]. The Nursing Admission Assessment/Initial Care Plan dated 3/13/2018 documented [MEDICAL CONDITION] under the Skin Condition section. The Nursing Admission Progress Note dated 3/13/18 documented in the PM Primary Medical History section that Resident #188 had Bilateral pedal [MEDICAL CONDITION] with 3 + (a measurement used in [DIAGNOSES REDACTED]. The Physician Orders dated 4/8/2018 documented an order for [REDACTED]. Review of the CCPs revealed there was no CCP developed for the monitoring and care of the resident's [MEDICAL CONDITION]. The Registered Nurse (RN) MDS Coordinator was interviewed on 5/3/18 at 12:45 PM. The RN stated that she may have signed off on the MDS but that she did not complete it. The RN stated that the MDS nurse does not usually complete the Care Plans but would coordinate with the Clinical Care Coordinator (CCC). During the interview, which was conducted concurrently with the RN MDS nurse and the RN CCC, on 5/3/18 at 1:18 PM the RN CCC stated she had completed the Initial Nursing Assessment/CCP form for Resident #188 and that she had assessed the resident's legs and feet on admission. The RN CCC stated there were no orders regarding monitoring of Resident #188 [MEDICAL CONDITION]. The RN CCC further stated that there should be a CCP in place to monitor the [MEDICAL CONDITION]. The MDS nurse stated she had completed nursing care areas of the MDS for Resident #188. The RN stated that there should have been a care plan developed for monitoring of [MEDICAL CONDITION]. The Primary Care Physician (PCP) for Resident #188 was interviewed on 05/03/18 at 2:15 PM. The physician stated she was familiar with Resident #188 and that the resident had chronic [MEDICAL CONDITION]. The PCP stated a plan should be in place to monitor the condition and that she would meet with the team to institute a plan of care for the [DIAGNOSES REDACTED]. The Director of Nursing was interviewed on 5/3/18 at 2:40 PM and acknowledged that a CCP for [MEDICAL CONDITION] should have been developed. The RN Admissions Nurse that completed the resident's admission progress note was interviewed on 05/03/18 at 3:33 PM. The RN stated that she had admitted Resident #188 on the evening shift on 3/13/18 and stated that on admission she initiates the initial four care plans which include Skin, Pain, Fall/Safety, and Elopement. The RN Admissions nurse stated that depending on the number of admissions, she may have the unit RN CCC assist her with the CCPs. The RN Admissions nurse stated that the CCC initiates the remainder of the CCPs. The RN further stated that she was aware that Resident #188 had [MEDICAL CONDITION] and a CCP should have been developed for care and monitoring. 415.11(c)(1)

Plan of Correction: ApprovedMay 25, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-656
The Medford Multicare Center (MMC) for Living submits that its policies, procedures and systems are in place to ensure each resident has a resident centered comprehensive care plan with measurable goals, and time frames to meet their medical, nursing, mental and psychosocial needs as identified in their assessment. The plan of correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate at the time of the survey or the facility did not have policies, procedures and systems in place to maintain compliance with all requirements.
Corrective action (s) for resident(s) affected:
Resident #188's care plan was reviewed and revised on 511/18 by the RN Clinical Care Coordinator (CCC) of the unit in which the resident resides. The RN CCC developed and implemented a comprehensive person-centered care plan for the care and monitoring of the Ventriculostomy site and chronic [MEDICAL CONDITION] in accordance with the resident's assessment and per the facility's policy and procedure.
The RN CCC was counseled on her failure to develop and implement a care plan that reflects the resident's [DIAGNOSES REDACTED]. RN CCC was educated on how to complete a person-centered care plan that has measurable objectives, time frames and actions to meet the needs of the resident per their comprehensive assessment.
Identification of residents that could be affected by the deficient practice:
All residents could be affected by this deficient practice as every resident should have a comprehensive care plan that reflects their needs as identified in the comprehensive assessment.Each care plan will include an objective goal and time frames.
Systemic measures to prevent recurrence:
The Policy and Procedure for the development of a person-centered care plan was reviewed and revised.
All RN's will be educated by the MDS Director and/or Designee on:
1)The development and implementation of a person-centered care plan based on the needs of the resident identified by the comprehensive assessment.
2) Each care plan must include measurable goals, timeframes and actions based on the needs to meet the residnets medical, nursing, mental and psychosocial needs.
3) Including problems/strengths specific to the resident.
4) The revised policy and procedure.

Ongoing Monitoring:
The ADON/Designee will conduct an audit on all resident care plans in order to determine if the care plan reflects the needs of each resident based on their comprehensive assessment and the care plans include measureable goals and timeframes to meet the medical,nursing, mental and psychosocial needs. Any deficient practice will be revised and corrected by the RN Clinical Care Coordinator for that resident.
Every Clinical Care Coordinator/Designee will complete and audit on every new resident's care plan within 7 days from their admission to determine a care plan was developed in accordance with the Policy and Procedure for Resident -Centered Care Plans.
Audits will be tracked, trended and reported at every QAPI meeting.
Audits will continue until 100% of new admission care plans are compliant with the Policy and Procedure.
Responsible Person: Director of Nursing
Completion Date: 7/2/2018
F658
The Medford Multicare Center (MMC) for Living submits that its policies, procedures and systems are in place to ensure residents receive the services they need as outlined in their person-centered care plan. This plan of correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiences are accurate at the time of the survey or the facility did not have policies, procedures and systems in place to maintain compliance with all requirements.
Corrective action(s) for resident(s) affected:
Resident #32 was evaluated by her attending physician for her use/need for oxygen on an as needed basis. Resident is diagnosed with [REDACTED]. The resident's saturated oxygenation on room air continues to be monitored and reviewed by the Clinical Care Coordinator and has been maintained at <92% oxygenation since 5/3/18.
Care plan reviewed and revised to include Resident has [MEDICAL CONDITION] with anxiety and history of low oxygenation added to include if resident exhibits signs and/or symptoms of shortmness of breath, cyanosis.
Identification of residents that could be affected by the deficient practice:
All residents in MMC receiving oxygen orders could be affected by the deficient practice.
All residents receiving oxygen or with an oxygen order were reviewed to determine if the order is consistent with the resdident's current comprehensive assessment, clinical status and that the order is written and implemented in accordance with the policy and procedure.
Resident's that have not used PRN oxygen will be evaluated by MD and orders discontinued as warranted.
Residents with PRN oxygen orders will be monitored every shift and as needed to determine if the resident presents signs and symptoms indicating low oxygenation or complaining of shortness of breath (SOB). All signs and symptoms will be documented in accordance with the policy and procedure and oxygen applied per order.
All residents with continuous oxygen orders will be monitored by the unit nurse and treatment documented in accordance with policy and procedure.
Systemic Measures to prevent recurrence:
The policy and procedure for the administration of oxygen was reviewed by nursing, respiratory and the medical director and was revised.
The library (in the EMR) for oxygen orders has been revised and the library for care plans for residents on oxygen therapy was reviewed and revised in accordance with the revised policy and procedure.
All nurses and respiratory employees were educated on the revised policy and procedure, including the new libraries.
On-Going Monitoring:
An audit of 100% of all residents receiving oxygen will be completed monthly by the Director of Respiratory Therapy to ensure all orders, documentation and care plans are written and implemented in accordance with the revised policy and procedure.
Audits will continue until 100% compliance is achieved for a minimum of two months.
Any deficiencies will be corrected at the time of the audit.
All findings will be reported by the Director of Respiratory Therapy to the QAPI team on a monthly basis.
The Director of Respiratory Therapy is responsible for the correction of this deficiency.
Completion Date: 7/2/2018
F-758
The Medford Multicare Center (MMC) for Living submits that its policies, procedures and systems are in place to ensure residents medications are managed to promote each individuals highest practicable level of mental and psychosocial well being through the proper use of monotoring of psychoactive medications and that gradual dose reductions are implemented in accordance with the psychiatrist's recommendations. Revisions to the policies and systems have been implemented for continued quality of care and life for the residents at MMC.
Corrective action(s) for resident(s) affected:
Resident #117 continues to be seen by Psychiatry and medications were reviewed. The Psychiatrist recommended a gradual dose reduction of the [MEDICATION NAME] from 0.25mg BID to 0.25mg at every hour of sleep effective 5/7/18 and then discontinue on 5/1//18. The resident's care plan has been revised , the resident's representative has been updated on the GDR plan and is in agreement. The resident will be monitored for effectiveness of the dose reduction. The resident is to be re-evaluated by Psychiatrist in 3 months.
Identification of residents that could be affected by the deficient practice:
All residents on psychoactive medications , including antidepressants, antianxiety medications, and antipsychotics and hypnotics have the potential to be affected by this deficient practice.The use of pharmacological interventions for individuals with psychiatric [DIAGNOSES REDACTED].
All residents receiving antipsychotics, antidepressants, antianxiety agents and/or hypnotics will be evaluated by prescribing physician to determine if a gradual dose reduction should be ordered to ensure each individual attains or maintains the highest level of mental and psychosocial well being while residing at MMC. Appropriate orders and revised care plans will be implemented by the Clinical Care Coordinator in accordance with the physician's orders [REDACTED].
Systemic Measures to Prevent Recurrence:
The policy and procedure for gradual dose reduction has been reviewed and revised by the DNS in accordance with professional standards of practice.
The Nurse Educator/Designee will educate all staff, including licensed nurses,and social services on the use of psychoactive medications, including the revised policy and procedure.The Medical Director will in-service all physician's on the use of [MEDICAL CONDITION] medications and implementation of the gradual dose reduction.
On-Going Monitoring:
The ADON/Designee will conduct an inital audit of 100% of residents receiving a psychoactive medication as indicated to determine if the medication (antipsychotics, antidepressants, antianxiety agents and/or hypnotics) have been evaluated by the attending/psychiatrist/pharmacy consultant and if a GDR has been recommended and implemented.
The ADON/Designee will conduct monthly audits on 25% of all residents receiving psychoactive medications to ensure gradual dose reductions have been addressed and/or implemented. Any concerns will immediately be reported to the Medical Director for further evaluation. The ADON/Designee will report monthly findings to the DNS and the DNS will report findings quarterly at the QAPI meeting.
Responsible person: Director of Nursing
Completion Date: 7/2/2018
F-880
The Medford Multicare (MMC) for Living submits that its policies, procedures and systems are in place to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. This plan of correction is required by federal and state regulations and is not not to be construed as an admission that the cited deficiencies are accurate at the time of the survey and the facility did not have policies, procedures and systems in place to maintain compliance with all requirements.
Corrective Action(s) for resident(s) affected:
Resident #550 was not affected by the deficient practice.
The LPN immediately cleaned the bed control and performed hand hygiene after the observation was brought to his attention. The LPN was re-educated on his failure to maintain a sanitary environment and prevent transmission of communicable disease as per policy and procedure and accepted national standards.
Identification of residents that could be affected by deficient practice:
All residents could be affected by the deficient practice.
Systemic Measures to prevent recurrence:
The policy and procedure for hand hygiene has been reviewed by the DNS and ADNS/Infection Control coordinator and found to be compliant.
All licensed nursing staff will be re-educated by the Nurse Educator/Designee on infection control procedures during treatments including the removal of gloves and hand hygiene following a procedure.
The ADON/Designee will conduct a visual audit on 25% of the licensed nursing staff on infection control procedures, specifically hand hygiene during a procedure/treatment once a week for one month, then every three months until 100% compliance is achieved.
any deficient practice will be immediately corrected.The ADON/Designee will report monthly findings to the DNS, and the DNS will report findings quarterly at the QAPI meeting.
Responsible Person: Director of Nursing
Completion Date: 7/2/18
F-804
Corrective Actions for Residents Affected:
There were no negative outcomes of the residents due to the deficient practice.
Identification of all residents that could be affected by the deficient practice:
All residents who consume meals have the potential to be affected by the deficient practice.
Systemic Measures to Prevent Recurrence:
The Director of Nutrition; in conjunction with the Administrator reviewed and revised the meal cart system for tray distribution to residents on the units. The facility has updated their meal cart delivery system for residents who prefer to eat meals in their room. The Director of Food Service/Designee will be responsible for sending seperate meal carts to each wing on the unit for the nursing staff to deliver trays to resident rooms more efficiently and timely in order to assure safe and appetizing temperatures.
The Director of Nutrition and Administrator reviewed and revised the facility's dining room and meal service protocol. The Nurse Educator/Designee to all nursing staff on revised tray delivery system, specifically including delivering trays to residents in the dining room and in their rooms immediately after meal truck arrives on the unit to assure safe and appetizing temperatures.
The Director of Nutrition and Administrator reviewed and revised the facility's test tray policy and procedure, to include an initiation of a test tray audit to be conducted on the unit in response to resident's concerns of unappetizing food temperatures. The Director of Nutrition revised the test tray audit form to monitor efficiency of unit meal cart deliveries, efficiency of tray distribution, to ensure that food temperatures are maintained at appropriate temperatures.
On-Going Monitoring:
The Director of Food Service/Designee will utilize the test tray audit tool and three audit meals (breakfast, lunch and dinner) weekly for three months to ensure 100% compliance and quarterly thereafter. Deviation from 100% will be immediately corrected by the Food Service Director/Designee and investigated for root cause analysis.
The Director of Food Service/Designee will present audit findings at the quarterly QAPI meeting.
The Director of Food Service/Designee is responsible for this deficiency.
Completion Date: 7/2/18
F-812
Corrective Action:
There were no negative outcomes due to the deficient practice.
1) The dish machine was immediately serviced on 4/24/18 by Engel Brite. The final rinse temperature was corrected to 180 degrees F. The dish machine was also set to use a liquid sanitizer and checked for proper PPM 50. The Maintenance Director adjusted the mixing valve to the proper setting.
2) The stainless steel hood was immediately cleaned by the Dietary Aide according the cleaning procedure.
3) The stand up floor fan was immediately removed by the maintenance department and put out of service for proper cleaning.
Identification of all resident(s) that could be affected by the deficient practicE:
1) All residents who consume meals have the potential to be affected by the deficient practice.
Systemic Changes to Prevent Recurrence:
1) The Director of Nutrition and Administrator reviewed and revised the dish machine temperature log. The log was revised to indicate the appropriate range for final rinse at 180 degrees F or higher, and to indicate to use a liquid sanitizer if range is not reached. The Director of Nutrition and Administrator reviewed and revised the dishwashing machine policy to reflect the revision to the temperature log and to indicate that a back up chemical sanitizer will be hooked up and running at all times.
The Food Service Director/Designee will provide education to the food service supervisors and dietary aides on the revised dish machine temperature log and the dish washing machine policy and procedure.
2) The Director of Nutrition and Administrator reviewed and revised the policy and procedures for weekly cleaning schedules and cleaning work areas. The daily kitchen sanitation rounds report was reviewed and revised by the Director of Nutrition. The report now includes: daily monitoring by the food service supervisors that the cleaning assignments are completed by the dietary aides per schedule.
The Director of Food Service/Designee will provide education to all food services supervisors and dietary aides regarding above policy and procedure.
3)The Director of Nutrition and Administrator reviewed the maintenance request log book policy and procedure. The Administrator will provide education the Director of Food Service/Designee on the necessary utilization of the maintenance request log book. An emphasis was included on reporting any issues that require immediate attention to the Director of Plant Operations.
On-Going Monitoring
The Director of Food Service/Designee will audit the dish machine temperature log weekly for one month and quarterly thereafter to ensure 100% compliance. The Food Service Director/Designee will audit the daily kitchen sanitation rounds weekly for one month and quarterly thereafter to assure 100% compliance.Deviation from 100% will immediately be corrected and investigated for root cause analysis.The Director of Food Service/Designee will present audit findings to the QAPI Committee for evaluation and follow up.
The Director of Food Service/Designee is responsible for this deficiency.
Completion Date: 7/2/18


FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2018
Corrected date: July 2, 2018

Citation Details

Based on observation, record review and interview during the recertification survey, the facility did not ensure that sanitary conditions were being maintained in the kitchen. Specifically, during the initial tour of the kitchen, the final rinse water temperature gauge on the dish machine was observed in disrepair. The stainless steel hoods and a large floor stand up fan were observed rusted and soiled and in need of thorough cleaning. The findings are: A facility policy for Dishwashing Procedure dated 10/6/18 documented the following: The final rinse water should be at least 180 degrees Fahrenheit (F). A clearly marked thermometer should be positioned at eye level and easily read. The Food Service Director (FSD) was interviewed prior to the initial tour of the kitchen on 4/24/18 at 9:15 AM and stated the dish machine has a hot water final rinse. The FSD was unsure whether the current dish machine had a back up chemical sanitizer. 1) Observation of the dish machine on 04/24/18 at 9:45 AM revealed the dish machine was in use. The water temperature digital gauge on the dish machine read as follows: Wash - 161 F Rinse - 149 F. The final rinse water temperature was not visible and observed with three dashes, not displaying numbers. Further observation revealed that the chemical sanitizer back up system was not hooked up or running during the observation. An interview with two Food Service Employees on 4/24/18 at 9:45 AM while in the dish room stated the dish machine had already been running for a half hour. A review of the daily dish machine water temperature log sheet did not document any dish machine water temperatures for the morning of 4/24/18. 2) Observation on 4/24/18 at 9:25 AM revealed that the large standing floor fan blowing air directly into the dish machine room was visibly soiled and in need of cleaning. 3) Observation on 4/24/18 at 9:55 AM revealed the under side of the stainless steel hoods directly over the cooking area were heavily soiled with dried on splashes of food and in need of thorough cleaning. In addition, the under side of the hoods were observed to be rusted and in need of thorough cleaning. The FSD was interviewed on 4/24/18 at 12:00 PM and stated a metal knife was stuck on the magnetic sensor inside of the dish machine causing the problem with the digital read out. The FSD also stated that there was a problem with a hot water valve. An outside company report dated 4/24/18 documented the following; Found knife stuck in rinse cycle causing the dish machine not to rinse. Fixed problem. Also found Final Rinse Temperature not at 180 degrees F. Explained to FSD and to Maintenance department. Found defective check valve. also set the dish washer to use a liquid sanitizer and checked for proper Parts Per Million (PPM). 415.14(h)

Plan of Correction: ApprovedMay 29, 2018

F-812
Corrective Action:
There were no negative outcomes due to the deficient practice.
1) The dish machine was immediately serviced on 4/24/18 by Engel Brite. The final rinse temperature was corrected to 180 degrees F. The dish machine was also set to use a liquid sanitizer and checked for proper PPM 50. The Maintenance Director adjusted the mixing valve to the proper setting.
2) The stainless steel hood was immediately cleaned by the Dietary Aide according the cleaning procedure.
3) The stand up floor fan was immediately removed by the maintenance department and put out of service for proper cleaning.
Identification of all resident(s) that could be affected by the deficient practicE:
1) All residents who consume meals have the potential to be affected by the deficient practice.
Systemic Changes to Prevent Recurrence:
1) The Director of Nutrition and Administrator reviewed and revised the dish machine temperature log. The log was revised to indicate the appropriate range for final rinse at 180 degrees F or higher, and to indicate to use a liquid sanitizer if range is not reached. The Director of Nutrition and Administrator reviewed and revised the dishwashing machine policy to reflect the revision to the temperature log and to indicate that a back up chemical sanitizer will be hooked up and running at all times.
The Food Service Director/Designee will provide education to the food service supervisors and dietary aides on the revised dish machine temperature log and the dish washing machine policy and procedure.
2) The Director of Nutrition and Administrator reviewed and revised the policy and procedures for weekly cleaning schedules and cleaning work areas. The daily kitchen sanitation rounds report was reviewed and revised by the Director of Nutrition. The report now includes: daily monitoring by the food service supervisors that the cleaning assignments are completed by the dietary aides per schedule.
The Director of Food Service/Designee will provide education to all food services supervisors and dietary aides regarding above policy and procedure.
3)The Director of Nutrition and Administrator reviewed the maintenance request log book policy and procedure. The Administrator will provide education the Director of Food Service/Designee on the necessary utilization of the maintenance request log book. An emphasis was included on reporting any issues that require immediate attention to the Director of Plant Operations.
On-Going Monitoring
The Director of Food Service/Designee will audit the dish machine temperature log weekly for one month and quarterly thereafter to ensure 100% compliance. The Food Service Director/Designee will audit the daily kitchen sanitation rounds weekly for one month and quarterly thereafter to assure 100% compliance. Deviation from 100% will immediately be corrected and investigated for root cause analysis. The Director of Food Service/Designee will present audit findings to the QAPI Committee for evaluation and follow up.
The Director of Food Service/Designee is responsible for this deficiency.
Completion Date: 7/2/18

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2018
Corrected date: July 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure that a resident's medication regime was managed to promote the resident's highest and practicable mental and psychosocial well being by initiating a Gradual Dose Reduction (GDR) for an antipsychotic medication as recommended by the Psychiatrist and indicated in the resident plan of care. Specifically, for 1 (Resident # 117) of 5 residents reviewed for unnecessary medications, the resident had been receiving an Antipsychotic Medication, from admission to the facility (9/28/16), in the absence of a Psychiatric Diagnosis, and without an attempt at a GDR in the absence of clinical symptoms. The finding is: Resident # 117 was admitted to the facility on [DATE] from an acute hospital stay with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status Score of 9 indicating moderate cognitive impairment. The MDS documented the resident required staff assistance in all Activities of Daily Living and had rejected care one to three days during the assessment period. The MDS also documented there had been no symptoms of Depressed Mood on the resident interview and that there were no physical or verbal behaviors directed toward others. A Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use initiated 9/28/16 documented on 6/5/17 a Pharmacy recommendation to consider a GDR. The MD orders for [MEDICATION NAME] were maintained at 0.25 mg twice daily. A CCP update on 10/2/17 documented that the resident was seen by a Psychiatrist with recommendations to decrease the [MEDICATION NAME] to 0.25 Hour of Sleep (HS) and that the designated representative was not in agreement. The resident's Comprehensive Care Plan (CCP) dated 11/2/17 titled Mood Status documented the resident has [DIAGNOSES REDACTED]. The CCP documented the resident denied any symptoms of depressed mood and can refuse care at times and that the resident required encouragement to participate in the care process. The 11/15/17 Medical Assessment and Plan of Care documented the resident had no agitation, no aggression and no obsessive ideas with Depression. A Psychiatric Progress Note (PN) dated 2/12/18 documented a recommendation to discontinue the [MEDICATION NAME]. The current physician's orders [REDACTED]. The CCP for Behavior documented on 2/13/18 that the resident had refrained from inappropriate behaviors and the the plan of care should be continued. There was no documentation of any specific behaviors. Subsequent update to the Behavior CCP dated 3/13/18 documented the resident had no inappropriate behaviors. There was no documentation regarding the continued use of the Antipsychotic drug and no updates identifying behaviors or the need for non-pharmacological interventions. A Nursing PN dated 2/13/18 at 1:48 AM documented the resident had been seen by the Psychiatrist on 2/12/18 and the plan of care was to discontinue the Risperidal and to monitor for increased [MEDICAL CONDITION] or behavioral disturbances. On 2/13/18 at 12:07 PM a Nursing PN documented the resident's designated representative was not in agreement with the discontinuation with the antipsychotic medication. There was no further documentation addressing discussion with the resident's designated representative in the medical record. The medical record was reviewed from 2/14/18 through 5/3/18 and there were no documented incidents of the resident with behaviors and no documented agitation that required staff interventions. The resident's CCP for Psychiatric Drug Use, effective 9/28/16 and last updated 3/23/18, documented that the goals included the resident's medications will be reduced to the lowest possible therapeutic dose or discontinued in three months. The Nurse Practitioner/Registered Nurse (RN) documented on 4/30/18 an order to have a Psychiatric evaluation to consider GDR of the [MEDICATION NAME] for the resident with a [DIAGNOSES REDACTED]. A Pharmacy Consultant recommendation dated 4/30/18 documented that the resident was a candidate for GDR of [MEDICATION NAME]. The Physician's reply to the Pharmacy Consult recommendation documented on 4/30/18 that the family refused to discontinue the [MEDICATION NAME]. There was no documented evidence that the family was educated regarding the long term use of the antipsychotic for Resident # 117. The physician's orders [REDACTED]. The resident was observed in the dining room during lunch on 04/30/18 at 12:52 PM. The resident was calm, feeding herself lunch with staff supervision. There were no behaviors observed. The Licensed Practical Nurse (LPN)/Medication Nurse was interviewed on 4/30/18 at 12:30 PM. The LPN stated that the resident's behavior on the unit had been good without any agitation or aggression. The LPN stated that the resident was never noted to be a danger to herself or others. The resident was observed on 5/3/18 at 11:15 PM. The resident had been bent forward in the wheelchair with eyes closed. On approach, the resident's head lifted and when the resident was asked how she was doing the resident stated all right and then the resident stated that she was tired. The resident put her head forward and was holding her hand under her chin and closed eyes at the end of the interview. The Psychiatrist was interviewed on 5/3/18 at 11:38 AM. The Psychiatrist stated that he has had an opportunity to talk to the resident's family but could not recall the exact times. The Psychiatrist stated that he had made the recommendation to the Attending Physician to discontinue the resident's antipsychotic because her behavior had been stable. The Psychiatrist stated that Resident # 117 is a candidate for GDR. The Medical Director (MD) was interviewed on 5/3/18 at 11:47 PM. The MD stated that the attending physicians have to follow the regulations for the reduction of [MEDICAL CONDITION] Medications. The MD stated that for Resident # 117 the expectation would have been that the attending physician ordering the medication would have interviewed and talked to the family regarding the use of this antipsychotic medication. The MD stated that some of the Physicians are not comfortable with the Psychiatry issues and defer to the Psychiatrist for psychiatric medication management. 415.18(c)(1)

Plan of Correction: ApprovedMay 29, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-758
The Medford Multicare Center (MMC) for Living submits that its policies, procedures and systems are in place to ensure residents medications are managed to promote each individuals highest practicable level of mental and psychosocial well being through the proper use of monotoring of psychoactive medications and that gradual dose reductions are implemented in accordance with the psychiatrist's recommendations. Revisions to the policies and systems have been implemented for continued quality of care and life for the residents at MMC.
Corrective action(s) for resident(s) affected:
Resident #117 continues to be seen by Psychiatry and medications were reviewed. The Psychiatrist recommended a gradual dose reduction of the [MEDICATION NAME] from 0.25mg BID to 0.25mg at every hour of sleep effective 5/7/18 and then discontinue on 5/1//18. The resident's care plan has been revised , the resident's representative has been updated on the GDR plan and is in agreement. The resident will be monitored for effectiveness of the dose reduction. The resident is to be re-evaluated by Psychiatrist in 3 months.
Identification of residents that could be affected by the deficient practice:
All residents on psychoactive medications , including antidepressants, antianxiety medications, and antipsychotics and hypnotics have the potential to be affected by this deficient practice.The use of pharmacological interventions for individuals with psychiatric [DIAGNOSES REDACTED].
All residents receiving antipsychotics, antidepressants, antianxiety agents and/or hypnotics will be evaluated by prescribing physician to determine if a gradual dose reduction should be ordered to ensure each individual attains or maintains the highest level of mental and psychosocial well being while residing at MMC. Appropriate orders and revised care plans will be implemented by the Clinical Care Coordinator in accordance with the physician's orders [REDACTED].
Systemic Measures to Prevent Recurrence:
The policy and procedure for gradual dose reduction has been reviewed and revised by the DNS in accordance with professional standards of practice.
The Nurse Educator/Designee will educate all staff, including licensed nurses,and social services on the use of psychoactive medications, including the revised policy and procedure.The Medical Director will in-service all physician's on the use of [MEDICAL CONDITION] medications and implementation of the gradual dose reduction.
On-Going Monitoring:
The ADON/Designee will conduct an inital audit of 100% of residents receiving a psychoactive medication as indicated to determine if the medication (antipsychotics, antidepressants, antianxiety agents and/or hypnotics) have been evaluated by the attending/psychiatrist/pharmacy consultant and if a GDR has been recommended and implemented.
The ADON/Designee will conduct monthly audits on 25% of all residents receiving psychoactive medications to ensure gradual dose reductions have been addressed and/or implemented. Any concerns will immediately be reported to the Medical Director for further evaluation. The ADON/Designee will report monthly findings to the DNS and the DNS will report findings quarterly at the QAPI meeting.
Responsible person: Director of Nursing
Completion Date: 7/2/2018

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2018
Corrected date: July 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure that an infection prevention and control program (IPCP) designed to help prevent the development and transmission of infection was maintained. This was identified for one (Resident #550) of two residents reviewed for Respiratory Care. Specifically, during observation of [MEDICAL CONDITION] care for Resident #550, the Licensed Practical Nurse (LPN) did not remove his gloves and perform hand hygiene before handling the resident's bed control after he completed [MEDICAL CONDITION] care. The finding is: Resident #550 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE] documented the resident required the assistance of one to two staff members for all areas of Activities of Daily Living (ADLs). The resident was alert but verbally unresponsive with no speech, however, his eyes follows objects and the resident will nod his head in response. A physician's orders [REDACTED]. During a [MEDICAL CONDITION] care observation conducted on 5/1/18 at 10:15 AM, the LPN was observed to set up a clean field. The LPN then gathered all necessary supplies and placed them on the clean field and opened all the necessary items needed for the [MEDICAL CONDITION] care. The LPN then washed his hands, donned clean gloves, then removed the soiled gauze from [MEDICAL CONDITION] site. The LPN then was observed to wash his hands and don clean gloves. After cleansing and drying the [MEDICAL CONDITION] site the LPN changed the [MEDICAL CONDITION] ties and the inner cannula. The LPN then placed clean gauze around the [MEDICAL CONDITION] site to complete the [MEDICAL CONDITION] care. The LPN was observed after [MEDICAL CONDITION] care to handle the bed control without removing his gloves and performing hand hygiene. During an interview conducted immediately on 5/1/18 at 10:30 AM with the LPN, the LPN acknowledged he should have removed the soiled gloves and performed hand hygiene before handling the bed control. The LPN cleaned the bed control after the observation was brought to his attention. During an interview with Registered Nurse (RN) Staff Educator on 5/1/18 at 12:04 PM, the RN stated the nurse should have removed his gloves and perform hand hygiene after completing the [MEDICAL CONDITION] care before handling the bed control. During an interview conducted on 5/3/18 at 2:42 PM with the Director of Nursing Services (DNS) she stated that the expectation is that the nurse remove his gloves after [MEDICAL CONDITION] care and perform hand hygiene before handling the bed control. 415.19(a)(1-3)

Plan of Correction: ApprovedMay 29, 2018

F-880
The Medford Multicare (MMC) for Living submits that its policies, procedures and systems are in place to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. This plan of correction is required by federal and state regulations and is not not to be construed as an admission that the cited deficiencies are accurate at the time of the survey and the facility did not have policies, procedures and systems in place to maintain compliance with all requirements.
Corrective Action(s) for resident(s) affected:
Resident #550 was not affected by the deficient practice.
The LPN immediately cleaned the bed control and performed hand hygiene after the observation was brought to his attention. The LPN was re-educated on his failure to maintain a sanitary environment and prevent transmission of communicable disease as per policy and procedure and accepted national standards.
Identification of residents that could be affected by deficient practice:
All residents could be affected by the deficient practice.
Systemic Measures to prevent recurrence:
The policy and procedure for hand hygiene has been reviewed by the DNS and ADNS/Infection Control coordinator and found to be compliant.
All licensed nursing staff will be re-educated by the Nurse Educator/Designee on infection control procedures during treatments including the removal of gloves and hand hygiene following a procedure.
The ADON/Designee will conduct a visual audit on 25% of the licensed nursing staff on infection control procedures, specifically hand hygiene during a procedure/treatment once a week for one month, then every three months until 100% compliance is achieved.
any deficient practice will be immediately corrected.The ADON/Designee will report monthly findings to the DNS, and the DNS will report findings quarterly at the QAPI meeting.
Responsible Person: Director of Nursing
Completion Date: 7/2/18

FF11 483.60(d)(1)(2):NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP

REGULATION: §483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2018
Corrected date: July 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey, the facility did not ensure that food was provided to residents at an appetizing temperature. Specifically, seven residents (Resident #'s 16, 24, 125, 189, 274, 277, 280) on 4 out of 8 nursing units (units 3A, 3B, 3C, and 2B) complained about receiving hot meals that were served cold. A lunch meal tray was tested on Unit 3C on 5/1/18 and this test revealed that food items on the meal tray were served below appetizing temperatures. The findings include but are not limited to: 1) Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/25/2018 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A Comprehensive Care Plan (CCP) for Nutrition for Resident #16, effective 1/29/2015 and last updated 5/2/2018, documented the resident prefers to eat in her room. On 4/24/2018 at 11:15 AM Resident #16 (Unit 3B) was interviewed. She stated that she gets cold food. The resident was unable to recall specific dates and times. 2) Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/19/2018 Quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact. A CCP for Nutrition for Resident #24, effective 4/6/2015 and last updated 5/1/2018, documented the resident prefers to eat in their room and requests early tray at meals. On 4/24/2018 at 11:32 AM Resident #24 (Unit 3C) was interviewed. He stated that he gets cold food. 3) Resident #277 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/12/2018 Quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact. A CCP for Nutrition for Resident #277, effective 2/2/2015 and last updated 4/16/2018, documented that the resident prefers to eat their in room. On 4/24/2018 at 9:39 AM Resident #277 (Unit 3B) was interviewed. She stated that she gets her meals from the second truck delivery. She stated that her food is never hot. Resident comments from the 2/1/2018 Menu and Food Committee meeting included soup, coffee, and food is luke warm. Resident comments from the 3/1/2018 Menu and Food Committee meeting included cold food quite often, cold coffee. On 4/24/2018 at 11:11 AM the Ombudsman was interviewed. He stated that unresolved complaints are always about the food. Two test trays with accurate working thermometers were requested for the second-truck lunch on 5/1/2018 at 11:11 AM and requested to be sent to units 3B and 3C. Concerns were identified with the test tray for Unit 3C. The lunch test tray for Unit 3C arrived on the unit with the second truck on 5/1/2018 at 12:34 PM (the posted arrival time for the second lunch truck on Unit 3C is 12:25 PM). At 12:37 PM after all resident trays were removed by staff members for delivery to the residents, the test tray was retrieved for temperature testing. On the tray was a facility-provided thermometer. The lunch consisted of sliced roast beef with gravy, mashed potatoes, and baby carrots. The roast beef was 110 degrees F, and the carrots were 100 degrees F. The Assistant Food Service Director was interviewed on 5/3/2018 at 2:03 PM, because the Food Service Director was unavailable for interview. He stated that he has attended three food committee meetings since working in the facility. He stated at the last food committee meeting he attended residents expressed concern regarding the temperature of coffee and soup, that these items could be hotter. He stated measures have been put in place to make sure that the coffee and the soup are not served too much ahead of the trays. He stated that there is a pellet system and it is working properly and that there are back-up pellets. He further stated the serving carts are not enclosed. Instead, the serving carts are covered with large plastic bags over the open carts to maintain heat. He stated that temperatures are taken off the steam table to make sure food temperatures are maintained and that random test trays have been checked prior to leaving the kitchen. He stated test trays have not been tested on the units. He added, in his opinion, there was a disconnect regarding timeliness of when the food trucks are delivered to the unit and when the food is actually handed out to the residents, especially during breakfast. Resident #24 was re-interviewed on 5/1/2018 at 12:25 PM. He stated that he had lunch already in his room and it was luke warm to cold. Resident #16 was re-interviewed on 5/3/2018 at 2:30 PM. She stated that she prefers to eat in her room and that she had told the staff about the cold food. Resident #277 was re-interviewed on 5/3/2018 at 2:33 PM. She stated that she prefers to eat in her room. She added that she remembers telling the Dietician about the cold food, but could not recall if she told him lately. The Unit 3B Registered Nurse (RN) was interviewed on 5/3/2018 at 2:52 PM. She stated that residents are encouraged to eat meals with other residents, but their choices have to be respected. 415.14(d)(1)(2)

Plan of Correction: ApprovedMay 29, 2018

F-804
Corrective Actions for Residents Affected:
There were no negative outcomes of the residents due to the deficient practice.
Identification of all residents that could be affected by the deficient practice:
All residents who consume meals have the potential to be affected by the deficient practice.
Systemic Measures to Prevent Recurrence:
The Director of Nutrition; in conjunction with the Administrator reviewed and revised the meal cart system for tray distribution to residents on the units. The facility has updated their meal cart delivery system for residents who prefer to eat meals in their room. The Director of Food Service/Designee will be responsible for sending separate meal carts to each wing on the unit for the nursing staff to deliver trays to resident rooms more efficiently and timely in order to assure safe and appetizing temperatures.
The Director of Nutrition and Administrator reviewed and revised the facility's dining room and meal service protocol. The Nurse Educator/Designee to all nursing staff on revised tray delivery system, specifically including delivering trays to residents in the dining room and in their rooms immediately after meal truck arrives on the unit to assure safe and appetizing temperatures.
The Director of Nutrition and Administrator reviewed and revised the facility's test tray policy and procedure, to include an initiation of a test tray audit to be conducted on the unit in response to resident's concerns of unappetizing food temperatures. The Director of Nutrition revised the test tray audit form to monitor efficiency of unit meal cart deliveries, efficiency of tray distribution, to ensure that food temperatures are maintained at appropriate temperatures.
On-Going Monitoring:
The Director of Food Service/Designee will utilize the test tray audit tool and three audit meals (breakfast, lunch and dinner) weekly for three months to ensure 100% compliance and quarterly thereafter. Deviation from 100% will be immediately corrected by the Food Service Director/Designee and investigated for root cause analysis.
The Director of Food Service/Designee will present audit findings at the quarterly QAPI meeting.
The Director of Food Service/Designee is responsible for this deficiency.
Completion Date: 7/2/18

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2018
Corrected date: July 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey the facility did not ensure that the Physician order [REDACTED]. Specifically, Resident #32 had a physician's orders [REDACTED]. Oxygen had been applied for seven days in (MONTH) (YEAR) without documented evidence that the SPO2 had been determined or any signs and symptoms of respiratory distress were observed. The finding is: Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/27/2018 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS did not document that the resident had been administered O2 during the assessment period. A physician's orders [REDACTED]. On 4/24/2018 at 8:57 AM during the medication pass observation for Resident #32 the resident was receiving oxygen via nasal cannula from an oxygen concentrator that was set at 2 LPM. Review of the Treatment Administration Record (TAR) for 4/24/2018 revealed that the PRN oxygen had not been signed as administered and that there was no documentation in the Nursing Progress Notes (P/N) that O2 was administered or that a SPO2 had been determined. Review of the resident's Respiratory Therapy progress notes documented that on 4/5/2018, 4/6/2018, 4/8/2018, 4/13/2018, 4/20/2018, 4/21/2018, 4/22/2018, and 4/23/2018 the resident had been receiving oxygen via nasal cannula. For these dates the oxygen was not signed for by nursing in the (MONTH) (YEAR) TAR and there was no nursing documentation (including SPO2 level) as to why the resident was placed on oxygen. Further review of the (MONTH) (YEAR) TAR revealed that the use of PRN oxygen was not signed as administered by nursing until 4/25/2018. The resident's Licensed Practical Nurse (LPN) medication/treatment nurse was interviewed on 4/25/2018 at 9:05 AM. She stated the LPNs check the SPO2 and apply the oxygen to make sure the resident's SPO2 is above 92%, and if it is above 92% the oxygen is taken off. She stated that the use of the PRN oxygen and the SPO2 should be documented daily every shift in the TAR. Resident #32 was interviewed on 4/25/2018 at 10:38 AM. The resident stated that the oxygen is on all the time. The unit Registered Nurse (RN) Supervisor was interviewed on 4/30/2018 at 8:59 AM. She stated that she was new on the unit and would look into what is supposed to happen when PRN oxygen is applied, who is putting on the oxygen, how is the use of the oxygen determined, and where is the documentation. The RN was unable to give information regarding the documentation of the PRN O2 order. The RN Inservice Nurse was interviewed on 4/30/2018 at 11:34 AM. The RN stated that she reviewed the medical record and it did not document who applied the oxygen on 4/5/2018, 4/6/2018, 4/8/2018, 4/13/2018, 4/20/2018, 4/21/2018, 4/22/2018, and 4/23/2018. The RN stated that there was no documentation as to why the PRN oxygen used. A Respiratory Therapist who saw the resident on 4/13/2018 was interviewed on 4/30/2018 at 12:48 PM. The 4/13/2018 RT progress note documented that the resident was observed on 2 LPM oxygen and the SPO2 was 98%. The RT stated her visit was to just check on the resident. She stated that she could have taken off the oxygen, but the resident was OK. She stated as long as everything is OK with the resident and she does not have to make any changes, there is no need to discuss with nursing. The Director of Nursing Services (DNS) was interviewed on 5/1/2018 at 8:45 AM. She stated she would have expected the nurses to sign off that the PRN oxygen was being used and a progress note written documenting why the oxygen was being used. The Assistant Director of Nursing Services (ADNS) was interviewed on 5/3/2018 at 1:11 PM. She stated that comprehensive care plans (CCPs) for oxygen use and [MEDICAL CONDITION] had not been created and they should have been. She stated that the RN supervisors on the units are responsible for creating the care plans. She stated that the resident had recently moved from one unit to another and she had spoken to the RN supervisors on both units already. 415.11(c)(3)(i)

Plan of Correction: ApprovedMay 29, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F658
The Medford Multicare Center (MMC) for Living submits that its policies, procedures and systems are in place to ensure residents receive the services they need as outlined in their person-centered care plan. This plan of correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiences are accurate at the time of the survey or the facility did not have policies, procedures and systems in place to maintain compliance with all requirements.
Corrective action(s) for resident(s) affected:
Resident #32 was evaluated by her attending physician for her use/need for oxygen on an as needed basis. Resident is diagnosed with [REDACTED]. The resident's saturated oxygenation on room air continues to be monitored and reviewed by the Clinical Care Coordinator and has been maintained at <92% oxygenation since 5/3/18.
Care plan reviewed and revised to include Resident has [MEDICAL CONDITION] with anxiety and history of low oxygenation added to include if resident exhibits signs and/or symptoms of shortmness of breath, cyanosis.
Identification of residents that could be affected by the deficient practice:
All residents in MMC receiving oxygen orders could be affected by the deficient practice.
All residents receiving oxygen or with an oxygen order were reviewed to determine if the order is consistent with the resdident's current comprehensive assessment, clinical status and that the order is written and implemented in accordance with the policy and procedure.
Resident's that have not used PRN oxygen will be evaluated by MD and orders discontinued as warranted.
Residents with PRN oxygen orders will be monitored every shift and as needed to determine if the resident presents signs and symptoms indicating low oxygenation or complaining of shortness of breath (SOB). All signs and symptoms will be documented in accordance with the policy and procedure and oxygen applied per order.
All residents with continuous oxygen orders will be monitored by the unit nurse and treatment documented in accordance with policy and procedure.
Systemic Measures to prevent recurrence:
The policy and procedure for the administration of oxygen was reviewed by nursing, respiratory and the medical director and was revised.
The library (in the EMR) for oxygen orders has been revised and the library for care plans for residents on oxygen therapy was reviewed and revised in accordance with the revised policy and procedure.
All nurses and respiratory employees were educated on the revised policy and procedure, including the new libraries.
On-Going Monitoring:
An audit of 100% of all residents receiving oxygen will be completed monthly by the Director of Respiratory Therapy to ensure all orders, documentation and care plans are written and implemented in accordance with the revised policy and procedure.
Audits will continue until 100% compliance is achieved for a minimum of two months.
Any deficiencies will be corrected at the time of the audit.
All findings will be reported by the Director of Respiratory Therapy to the QAPI team on a monthly basis.
The Director of Respiratory Therapy is responsible for the correction of this deficiency.
Completion Date: 7/2/2018

Standard Life Safety Code Citations

ESTABLISHMENT OF THE EMERGENCY PROGRAM (EP)

REGULATION: The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: May 3, 2018
Corrected date: May 24, 2018

Citation Details

Based on documentation review and staff interview during the recertification survey, the facility did not establish a comprehensive Emergency Program (EP) that complied with all applicable Federal, State and Local EP requirements. The finding is: During a review of the facility's emergency preparedness manual on 04/27/18 between 9:00am and 2:30pm, it was noted that a comprehensive Emergency Program (EP) was not developed that complied with all applicable Federal, State and Local EP requirements. The EP plan did not address the following items (not all inclusive): - Annual updates that documented accurate facility-based and community-based risk assessments. - Process for EP collaboration. No policy for collaboration and contact with local, Regional, State, Federal EP officials etc. - Development of EP Policies and Procedures for all risks assessed. - Policy and Procedure for Sheltering in place. - Subsistence needs for staff during a shelter in place. There was no policy and procedure for addressing food, water, medical and pharmaceutical supplies for staff. - Procedures for tracking staff and patients during a disaster or evacuation. - Policy and Procedure for Medical Documentation that secures and maintains the availability of medical records. - Policy and Procedures for Volunteers in addressing surge needs that includes the process and roles for integrating State and Federally designated health care professionals. - Arrangement with other Facilities. No transfer agreements with other healthcare facilities to maintain the continuity of services to evacuated residents. - Roles declared under a Waiver Declared by the Secretary. - Names and contact information for Staff, Residents Physicians, other LTC facilities, and volunteers. - Development of a communication plan - Emergency Official Contact information such as the Office of the State Long-Term Care Ombudsman - Methods for Sharing Information and medical documentation for residents with other health care providers to maintain the continuity of care. - LTC and ICF/IID Family Notifications. No method for sharing information on the EP that the facility has determined appropriate with the residents and their families/representatives. In an interview on the same day at approximately 12:00pm, the Director of Plant Operations stated that the person responsible for developing the EP is no longer employed at the facility. During the sanitarian exit conference on the same day at approximately 2:15pm, the facility's personnel (DNS, Administrator, Director of Plant Operations) took note of the concerns and stated that all the missing information would be included in a revised and comprehensive EP.

Plan of Correction: ApprovedMay 24, 2018

E 001
I Corrective Action for Area Affected
The Director of Plant Operations with assistance from the facility?s Disaster Committee immediately reviewed and revised the facility?s Emergency Operations Program and Plan Manual to include all applicable Federal, State and Local EP requirements.
II Identification of Other Areas Potentially Affected by the Deficient Practice
The Director of Plant Operations reviewed the newly revised and comprehensive Emergency Operations Program and Plan Manual.
No additional compliance issues were identified.

III Systemic Changes
No systemic changes are needed as corrective actions will bring the facility into compliance.
Please refer to the corresponding information based on the survey findings identified in the SOD.
Location of corresponding information in the Emergency Operations Program and Plan Manual:
1. Annual updates that documented accurate facility-based and community-based risk assessments.
Page 11
2. Process for EP collaboration. No policy for collaboration and contact with local, Regional, State, Federal EP officials etc.
Page 21
3. Development of EP Policies and Procedures for all risks assessed.
Page 23
4. Policy and Procedure for Sheltering in place.
Page 67
5. Subsistence needs for staff during a shelter in place. There was no policy and procedure for addressing food, water, medical and pharmaceutical supplies for staff.
Page 69
6. Procedures for tracking staff and patients during a disaster or evacuation.
Page 33
7. Policy and Procedure for Medical Documentation that secures and maintains the availability of medical records.
Page 61
8. Policy and Procedures for Volunteers in addressing surge needs that includes the process and roles for integrating State and Federally designated health care professionals.
Page 19
9. Arrangement with other Facilities. No transfer agreements with other healthcare facilities to maintain the continuity of services to evacuated residents.
Pages 20 & 33
10. Roles declared under a Waiver Declared by the Secretary.
Page 89
11. Names and contact information for Staff, Residents Physicians, other LTC facilities, and volunteers.
Page 93
12. Development of a communication plan.
Page 93
13. Emergency Official Contact information such as the Office of the State Long-Term Care Ombudsman.
Page 3
14. Methods for Sharing Information and medical documentation for residents with other health care providers to maintain the continuity of care.
Page 61
15. LTC and ICF/IID Family Notifications. No method for sharing information on the EP that the facility has determined appropriate with the residents and their families/representatives.
Page 94
MMC has already submitted an inclusive Emergency Operations Program and Plan Manual to the DOH during the annual survey. Manual will be emailed again to the Sanitarian.
IV Quality Assurance and On-going Monitoring
Facility?s Emergency Operations Program and Plan Manual will be reviewed annually and updated as necessary by the Disaster Committee.
Changes and updates will be approved by the Administrator and presented at the quarterly QAPI meetings.

The Director of Plant Operations is responsible to ensure the corrective action is implemented.
5/24/2018

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: May 3, 2018
Corrected date: May 24, 2018

Citation Details

2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2010 NFPA 72: 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. Based on staff interview and documentation review, the facility did not ensure that a fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code in that the last documented sensitivity test was conducted in (YEAR). The findings are: On 4/27/18 at approximately 11:56am during the recertification survey, the facility fire alarm system maintenance and testing documentation was reviewed. The last documented sensitivity testing was conducted on 9/15/15. In an interview on 4/27/18 at approximately 1:00pm, the Director of Plant Operations stated that he will schedule to have the sensitivity test done every two years. 2012 NFPA 101: 9.6.1.3 2010 NFPA 72: 14.4.5.3.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 24, 2018

K 345
I Corrective Action for Area Affected:
MMC immediately contacted (NAME)son Controls/SimplexGrinnell a licensed fire alarm system service contractor to schedule the fire alarm system sensitivity test at MMC.
(NAME)son Controls/SimplexGrinnell is scheduled to conduct the fire alarm system sensitivity test on (MONTH) 29, (YEAR).
II Identification of Other Areas Potentially Affected by the Deficient Practice:
On (MONTH) 30, (YEAR) Director of Plant Operations reviewed the facility?s fire alarm system maintenance and testing documentation.
No additional compliance issues were identified.
III Systemic Changes:
The Director of Plant Operations reviewed and revised the facility?s Fire Alarm Systems Testing and Maintenance policy and procedure to include fire alarm system sensitivity testing every alternate year.
IV Quality Assurance and On-going Monitoring:
The Director of Plant Operations has developed an audit tool for facility?s Fire Alarm Systems Testing and Maintenance to monitor all code required maintenance, inspections and tests for MMC.
The Director of Plant Operations/designee will conduct inspections monthly utilizing the new audit tool.
Negative findings during the audit will be corrected immediately.
The Director of Plant Operations/designee will present negative findings to the QAPI Committee monthly for evaluation and follow up as indicated.
The Director of Plant Operations is responsible to ensure the corrective action is completed.
5/24/2018

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: May 3, 2018
Corrected date: May 24, 2018

Citation Details

415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public. (b) Equipment. The nursing home shall maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. This requirement is not met as evidenced by: Based on observation, staff interview and documentation review during the recertification survey, the facility did not demonstrate a preventive maintenance program for resident electric wheelchairs. During the survey conducted on 04/26/18 and on 04/27/18 between 9:00am and 2:30pm, the facility did not provide evidence of an ongoing preventive maintenance program for resident electric wheelchairs. For example, there were no maintenance records provided for the electric wheel chairs identified for the residents in rooms 209, and 207 of the 2A-Unit. In an interview on 04/26/18 at approximately10:15am the Director of Plant Operations stated that he would immediately implement a preventive maintenance program for the wheelchairs. He further stated that the wheelchairs are checked for positioning and functionality by the rehabilitation department. In a separate interview on 04/27/18 at approximately 10:45am, the Director of Plant Operations stated that there is a total of three electric wheelchairs identified in the facility and that a preventive maintenance program has been implemented for them. NYCRR 415.29

Plan of Correction: ApprovedMay 24, 2018

I 310
I Corrective Action for Area Affected
On (MONTH) 26, (YEAR) Maintenance inspected electric wheelchairs identified for the residents in rooms 209, and 207 of the 2A-Unit.
Both electric wheelchairs passed the visual inspection.
II Identification of Other Areas Potentially Affected by the Deficient Practice
On (MONTH) 26, (YEAR) Maintenance conducted a survey of all residents for electric wheelchairs. Total of three electric wheelchairs were identified. Preventive maintenance program has been implemented for all electric wheelchairs.
III Systemic Changes
The Director of Plant Operations reviewed and revised the facility?s Non-Clinical Electrical Equipment Inspection/Testing policy and procedure to include visual inspections of electric wheelchairs.
Maintenance Technicians will inspect all electric wheelchairs prior to use at MMC. Annual visual inspection shall be conducted or whenever equipment integrity warrants.
IV Quality Assurance and On-going Monitoring
The Director of Plant Operations has revised an audit tool for facility?s Non-Clinical Electrical Equipment Inspection/Testing to include routine visual inspections of electric wheelchairs.
Maintenance Technicians will conduct a facility wide inspection of all electric wheelchairs monthly for three months and then annually thereafter.
Negative findings during the audit will be corrected immediately, if not wheelchair would be removed immediately from service and family notified.
The Director of Plant Operations provided education to all Maintenance Technicians on the facility?s Non-Clinical Electrical Equipment Inspection/Testing policy and procedure.
A copy of the lesson plan and attendance record will be filed for reference and validation.
The Director of Plant Operations/designee will present negative findings to the QAPI Committee monthly for evaluation and follow up as indicated.
The Director of Plant Operations is responsible to ensure the corrective action is completed.
5/24/2018