Brooklyn Gardens Nursing & Rehabilitation Center
October 11, 2018 Certification Survey

Standard Health Citations

FF11 483.10(f)(10)(iii):ACCOUNTING AND RECORDS OF PERSONAL FUNDS

REGULATION: §483.10(f)(10)(iii) Accounting and Records. (A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. (B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. (C)The individual financial record must be available to the resident through quarterly statements and upon request.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 11, 2018
Corrected date: December 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that (1) a system that assures a full and complete and separate accounting, according to generally accepted accounting principles was established and maintained; and (2) individual financial records were available to the resident through quarterly statements. Specifically, a resident did not consistently receive quarterly statements from 7/1/17 to 9/30/18, and the quarterly statements prepared for the resident did not post the accrued interest. this was Resident # 174 the resident stated quarterly statements are provided upon request. This was evident for 1 out of 3 residents reviewed for Personal Funds (Resident #174). The finding is: The undated facility policy Resident Personal Funds Account documented that individual financial records will be available through quarterly statements and upon request to the resident or his or her legal or designated representative. Resident #174 is a resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition. On 10/03/18 at 03:15 PM, the resident was interviewed. The resident stated that the quarterly statement is provided upon request, and they are not given the quarterly statements without asking. The resident's quarterly statements documented the following: The Statement dated 07/01/17-09/30/17 was signed by the resident. The Statement dated 10/01/17-12/31/17 was not signed by the resident. The Statement dated 01/01/18 - 03/31/18 was signed by the resident. The Statement dated 04/01/18-06/30/18 was not signed by the resident. The Statement dated 07/01/18-09/30/18 was not signed by the resident. All quarterly statements reviewed did not contain a posting for the interest accrued on the account. There was no documented evidence that the resident was provided with the quarterly statements dated 10/1/17, 4/1/18 and 7/1/18. On 10/11/18 at 10:23 AM, an interview was conducted with the Finance Coordinator (FC) whose duties include distribution of cash and quarterly statements to residents and families of cognitively impaired residents. The FC stated every 3 months she distributes quarterly statements to the residents in the office and on the units. Quarterly statements are mailed to the family of non-cognitive residents. The FC tracks distribution with a list, the resident will sign the document and a copy is kept. For cognitively impaired residents, the family is mailed a copy to be signed along with a stamped addressed envelope for return. On 10/11/18 at 12:54 PM, an interview was conducted with the Controller. The Controller did not know why the accrued interest was not displayed on the quarterly statement of the resident. The Controller contacted the Certified Public Accountant (CPA) who also did not know why interest was not displayed and planned to contact the bank and software company. The Controller returned shortly and stated the software company was contacted and based on amount of interest it may not show on the statement. 415.26(h)(5)

Plan of Correction: ApprovedNovember 8, 2018

I. Immediate Corrective Actions
1. Quarterly statements for Resident # 174 were reviewed for the periods 7/1/17- 9/30/17, 10/1/17- 12/31/17,
1/1/18- 3/31/18, 4/1/18- 6/30/18, 7/1/18- 9/30/18 and found to be correct.
2. Resident #174 was given the statements for 10/1/17 to 12/31/17, 4/1/18- 6/30/18 and 7/1/-9/30/18 and signed
for those statements
3. Interest was reviewed and there was no interest adjustment required.
4. Reliable Health Systems was contacted by the facility which will be updating their system to include posting
for interest which will include a zero if there was no interest accumulated.
5. The Finance Coordinator will receive an educational counseling with focus on ensuring that the facility
maintain a system that assures that all funds entrusted to the facility on the residents behalf according to
accepted accounting principles. All residents quarterly financial statements will be issued to residents and
signed for,and, or mailed if requested.
II. Identification of Residents with the Potential to be Affected
Identification of Residents with the potential to be affected
1. All residents who entrust personal funds to the facility have the potential to be affected by the
discrepancies in accounting and records of personal funds.
2. Brooklyn Gardens Nursing and Rehabilitation Center has compiled a list of all residents who have entrusted
the facility with their personal funds. An audit has been conducted to ensure all quarterly statements
reflect accurate interest and have been mailed out or delivered to the residents within the required time
frame.
3. Additionally, all residents who choose to entrust their personal account to the facility will be provided
with the finance office contact information should they have any questions or concerns regarding their
account.
III. Measures and Systemic Changes
1.The policy and procedure for the application of interest to the residents personal accounts was reviewed and
revised. The staff in the finance department will receive in service education with a focus on:
a. Individual quarterly financial statements will be delivered to all residents who conduct financial business
through the facility and upon request. Quarterly financial statements will be will be mailed to families upon
request.
b. The finance department will deliver and review, where requested, quarterly statements to residents and
residents will sign for their copy. Copies will be maintained in the finance department. Any issues residents
have will be referred to the Social Worker if unresolved by the finance person.
c. The finance department staff will review the residents quarterly statements prior to distribution to ensure
that the accrued interest has been posted to the residents account statement.
d. In service education records will be maintained for validation.A copy of the lesson plan and sign in sheet
will be kept on record.
IV. Corrective Action Monitoring
1. The Administrator and Controller will have developed an audit tool to monitor all residents personal accounts
to ensure quarterly statements are being given in a timely manner and that all statements are acknowledged as
received by either the resident or designated representative.
2. An audit tool has been created which will be utilized on a monthly basis for the next four quarters,for one
year, to ensure proper documentation and timely distribution of residents quarterly personal account
statements. The results of these audits will be reported to the Quality Assurance Committee monthly times 3
months, then quarterly for the next 3 quarters, and if there is any negative finding it will be immediately
addressed.

Responsible Party
Administrator

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 11, 2018
Corrected date: December 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, during the recertification survey, the facility did not ensure that a resident's comprehensive care plan (CCP) was reviewed and revised with changes in the resident's needs and conditions. Specifically, a resident's (CCP) was not reviewed and revised after the resident was newly diagnosed and treated for [REDACTED].#202). The finding is: 1) Resident #202 is a resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident had no unhealed pressure ulcers or other wounds and skin problems. The Comprehensive Care Plan for Skin dated 1/27/18, last revised 10/1/18 documented the resident was at high risk for skin breakdown related to Braden scale score, decreased mobility, incontinence, [MEDICAL CONDITIONS] and malnourishment. The CCP goal was for the resident to maintain intact skin. The Physician's (MD) Orders dated 9/25/18 documented new orders for [MEDICATION NAME] 0.1% topical ointment. Apply by Topical route two times per day for four weeks to the right foot for Mycosis [MEDICATION NAME]. The Physician's Progress Note dated 9/27/18 documented the resident was seen and evaluated for a fungal rash on the groin and perineal areas. The Assessment and Plan section documented the resident had Dermatophytosis in the groin and perineal areas that would be treated with [MEDICATION NAME] 1 % topical solution. The note further documented the resident was also being treated with [MEDICATION NAME] 0.1% topical ointment on the right foot . The MD Orders dated 9/29/18 documented orders for [MEDICATION NAME] 1% topical cream. Apply by topical route 2 times per day for 8 weeks to the groin area for Tinea Cruris The Treatment Administration Record documented that the resident received [MEDICATION NAME] 0.1% topical ointment for Mycosis [MEDICATION NAME] beginning on 9/25/18 and [MEDICATION NAME] 1% Topical Cream for Tinea Cruris beginning on 9/29/18 and received these treatments twice daily since ordered. There was no documented evidence that the CCP was reviewed and revised to address the resident's new [DIAGNOSES REDACTED]. On 10/10/18 at 4:42 PM, an interview was conducted with the Registered Nurse Supervisor (RN #1) who stated when there is a new problem, care plans are initiated right away so everybody could be on the same page. I was on vacation when the resident developed the rash. The nurse supervisor who was on duty did not create the care plan. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedNovember 8, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions
1.On (MONTH) 11, (YEAR) the care plan was reviewed and revised to address resident #202 new [DIAGNOSES REDACTED].
treatments. Review was completed for patient number 202 for a 90 day look back period to ensure all new
[DIAGNOSES REDACTED]. There were no
negative findings.
II. Identification of Residents with the Potential to be Affected
1. All residents have the potential to be affected by the deficient practice.
2.A review was completed by the DNS/Designee for all residents with new [DIAGNOSES REDACTED].
to ensure that care plans were in place and that they were revised to reflect any changes in the residents
care.
III. Measures and Systemic Changes
1.The Policy and Procedure for Care Planning was reviewed by the DNS and Administrator and found to be
compliant.
2.All RN Supervisors will be re-in serviced by the Staff Educator on the care planning policy and procedure
with emphasis on the need to review and revise care plans to reflect changes in resident?s conditions,
including new diagnoses.
IV. Corrective Action Monitoring
1.Audits will be completed on each unit on a weekly basis by the RN Supervisors to ensure that all care
plans are reviewed and revised to reflect changes in resident condition for four weeks, then monthly for
two months, and quarterly for one year.
2.Any negative findings will be immediately reported to the Director of Nursing for correction and follow
up.
3.Results of all audits will be reported to the QA committee on a quarterly basis.
Responsible Party
Director of Nursing
Date of Correction
December 7, (YEAR)

FF11 483.10(j)(1)-(4):GRIEVANCES

REGULATION: §483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 11, 2018
Corrected date: December 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Recertification survey, the facility did not ensure the prompt resolution of grievances made by residents. Specifically, resident council grievances regarding adequate quantities of linen were not resolved. This was evident for the Resident Council. The findings are: The facility policy and procedure Linen effective 5/2018 documented the environmental department will supply a sufficient quantity of linen for proper resident care and comfort in accordance with established par levels with the nursing department. During an interview with Resident #174 on 10/03/18 at 03:50 PM, the resident stated the floor does not get enough sheets, towels and gowns and wash cloth is sometimes used to dry off, shortage has occurred in the morning during the week. During an interview with Resident # 130 on 10/04/18 at 10:49 AM, the resident stated towels, sheets and washcloths run out at night on weekends. During the Resident Council meeting conducted on 10/04/18 at 02:09 PM with the State Agent, Resident #175 stated that there are not enough supplies in the facility like towels, night gowns and sheets. The resident also stated that a meeting was held in (MONTH) about that matter, but so far there has been no change in the shortage of supplies. The Resident Council Meeting minutes dated 6/14/18 documented that the issue of linen shortage was discussed by the president of the resident council. Linen was addressed there was an issue with the company which has been resolved and there should be no further issues. The Resident Council Meeting minutes dated 7/12/18 documented that a resident stated they need more towels, sheets, and nightgowns. There was no documentation in the minutes as to how this issue was to be addressed. The Resident Council Board Meeting for August minutes dated 8/9/18 documented resident shared that there is a need for more towels on the units. Each resident is supposed to get one towel and there are forty residents per floor. There was no documentation in the minutes as to how this issue was to be addressed. The Resident Council Meeting minutes for 9/14/18 documented read the minutes from (MONTH) 9, (YEAR) meeting and were accepted. There was no old business to reply to from (MONTH) (YEAR) meeting. There was no documented evidence presented by the facility that the recurring concern about a shortage of linens was re-addressed and monitored since 6/14/18. A review of the invoice dated 10/11/18 of linen delivered by FDR Services Corp. in comparison with the facility's undated PAR levels and Daily linen distribution showed that the 55 blankets delivered were below the PAR and daily distribution amount of 60 per day; 160 fitted sheet delivered were above the PAR of 120 but below the daily distribution amount of 180 per day; 170 gowns delivered were below the PAR of 180 and daily distribution amount of 185 per day; 800 towels delivered were above the PAR and daily distribution amount of 600 per day; 160 pillow cases delivered were above the PAR and daily distribution amount of 120 per day; 770 gowns delivered were above the PAR and daily distribution amount of 540 per day. The facility's PAR and daily distribution for gowns and fitted sheets differs in quantity. Also based on these amounts gowns, blankets and fitted sheets did not have extra linen for Sunday. On 10/09/18 at 03:18 PM, an interview was conducted with a Certified Nursing Assistant (CNA # 7) who stated there is shortage of linen supplies. On occasion, we have received 5 gowns for the floor for approximately 40 beds and have had the residents use their own clothes if there is not enough gowns. The shortage occurs most often on the weekends. When supplies are needed we call housekeeping. In the evenings for about a week, there has been linens on the cart for the next shift. On 10/09/18 at 03:50 PM, an interview was conducted with the Environmental Associate (EA) who routinely delivers prepacked linen supplies to each floor during the 3 -11 and 11-7 shifts. The 5th floor receives 30 towels, sheets, and flat sheets, roughly 10-15 gowns, and 2 packs of wash cloths. The EA stated the same quantity is provided on the weekends. When staff requests more linen, it is initially taken from the night cart then from the storage room. Racks for linen are refilled each morning, 6 racks each shift. Sometimes the facility does not have enough linens, but 8 out of 10 times the linen is adequate. On 10/09/18 at 04:09 PM, an interview was conducted with CNA #5. CNA #5 stated the supply of linens is not good enough and should be better. Almost everyday, the floor is usually short of everything - gowns, towels, and sheets. When more supplies are needed the nursing staff call downstairs and housekeeping brings up supplies from the night shift. The CNA stated that GT ([DEVICE]) fed residents sometimes have diarrhea and require more sheets. The weekends are sometimes good and sometimes not so good. The CNA also stated the floor usually receives 20 sheets and towels and 10 gowns; supplies of 30 is still not enough. On 10/09/18 at 04:21 PM, an interview was conducted with CNA #6. CNA #6 stated linens are sometimes short, but for the last 3 weeks the floor has received enough linens. The CNA stated there are about 38 to 40 residents on the floor, and the unit is now receiving 30 gowns, 30 sheets, and 32 towels. She stated that the unit does need more than the 2 packs of wash cloths provided. When linens were previously low, it would occur about 1-2 times per week as per the CNA. On 10/10/18 at 03:41 PM, an interview was conducted with a Licensed Practical Nurse (LPN #7). LPN #7 stated a shortage of linens such as gowns, towels, and sheets occurs quite often, about once a week, including weekends. CNAs will inform the LPN when linens are needed, housekeeping is called and most of the time linens are taken from the night shift supply. When housekeeping cannot supply the additional linens, for example gowns, a CNA would go to the other floors, which is very rare, or may use the residents' clothes. A shortage occurred two evenings in September, usually on the weekend. Housekeeping places the linen supplies in storage which is transferred to the cart by the CNA. On 10/11/18 at 10:06 AM, an interview was conducted with the Director of Facilities Management (DFM) who stated the Periodic Automatic [MEDICATION NAME] (PAR) levels for linens are provided by Nursing which is then used to supply the morning, evening and night shifts. The FDM stated he was not being sure if the PAR levels were updated. Linen deliveries by FDR Services Corp occurs six days per week and totals a 7 day supply, each delivery contains extra linen for Sunday's supply. Staff sometimes calls for extra linen, and housekeeping is available until 11pm. The DFM stated he is aware of a linen shortage at 5am. The DFM stated requests for extra linens should be tracked. The need for linen may be due to the type of care needed which and may change PAR levels. The DFM stated Nursing must inform him when PAR levels have changed. 10/11/18 11:55 AM an interview was conducted with Director of Nursing (DON) who stated PAR levels are determined by when sheets are changed usually when the resident is showered or soiled. Staff often calls her directly when linen is needed and she has only heard from staff during the 3pm-11pm shift. The DON further stated that she spoke to the DFM to increase the PAR levels of sheets and towels by ten a month ago. The DON stated she has not heard of any complaints since the increase. The DON stated that moving forward the PAR levels will be reviewed monthly. The DON also stated she had not reviewed the previous PAR levels and only asked to have the sheets and towels increased by 10. 415.3(c)(1)(i)

Plan of Correction: ApprovedNovember 8, 2018

I. Immediate Corrective Action
1. A grievance was initiated for residents 174, 175, and 130 by the Social Worker regarding the complaints
of linen shortages and given to the Director of Facilities Management.
2. Par levels for all types of linen on all floors and shifts were reviewed by the DNS, Administrator and
Director of Facilities Management and updated on 10/19/18.
3. Residents 174,175, and 130 were interviewed by Social Work on 11/6/18 and were satisfied with the amounts of
linen provided and their grievances were resolved.
4. An adhoc meeting was held on 10/19/18 to establish baseline par levels for linen and was communicated to the
residents at the 11/8/18 Resident Council Meeting.
5. The facility recording secretary of the resident council minutes was provided an educational counseling by
the Director of Social Work on 11/8/18 for ensuring that all reported grievances are immediately referred to
the Director of Social Work/Designee, in writing, after each Resident Council Meeting for immediate follow
up and resolution, and for ensuring that all minutes reflect resolutions from prior grievances under the Old
Business sections.
II. Identification of Residents with the Potential to be Affected
1. Brooklyn Gardens Rehabilitation and Nursing Center respectfully states that all residents have the potential
to be affected by this deficient practice.
2. All grievances under the Resident Council minutes were reviewed for the past five months (from (MONTH) (YEAR)
through (MONTH) (YEAR)), by the Director of Social Work/Grievance Officer, the Director of Therapeutic
Recreation, and Administrator for any unresolved or potentially outstanding grievances. No identified
unresolved or outstanding grievances were found.
3. On 10/19/18 A review of the linen levels was conducted and an assessment for linen requirements on each unit
and developed appropriate par levels for each unit.
4. Established par levels will be given to the housekeeping staff to ensure that adequate amounts of linen will
be continued to be delivered daily.Additionally, the PAR levels will be reviewed and revised, as needed,
monthly by the Director of Facilities Management, Administrator/Designee and DNS/Designee and provided to the
Housekeeping staff as indicated.
III. Measures and Systemic Changes
1. On 11/1/18 the Grievance Officer reviewed and revised the current facility policy and procedure for
Resident Council and Resident Council Bylaws. The revised P&P will be in-serviced to all Department Heads,
all activities staff and social service staff by the Grievance Officer/Designee. The revised Policy and
Procedure lesson plan will concentrate on the following;
a.The agenda for the resident council meetings will be set by the Executive Resident Council Board at a
separate meeting with the Director of Recreation/designee.
b.During the Council Meeting the established agenda will be discussed. The recording secretary and or the
facility?s Director of Recreation/designee will take minutes during the meeting.
c.The agenda at the Resident Council meetings will begin with the reading of the prior month?s Resident
Council meeting minutes. The person reading the minutes will start by reading the information noted under
the Old Business and any corrective actions taken by the facility for any reported greivances.
d.With the permission of the residents, any new concerns or complaints that are brought up during these
meetings will be documented by the Director of Recreation/designee on a ?Resident Council Communication
Form?. These forms will be given to the social worker right after the resident council meeting for
further follow-up.
e.The responses to the ?Resident Council Communication Forms? will be reported back to the resident
council by the social worker or recreation designee the following month. This would be designated under
?old business?. If the resident council is not satisfied with the response, it will be forwarded to the
administer for further interventions.
f.The recording secretary will collaborate with the Director of Recreation/designee to type the minutes
to each resident council meeting.
g.The resident council minutes as well as the ?Resident Council Communication Forms? will be kept by the
recreation director on file for 3 years from the issuance of the grievance decision.
A copy of the lesson plan and sign-in sheets will be retained as validation.
2. On 10/19/18 the Director of Facilities Management, DNS and Administrator reviewed and revised the current
facility policy and procedure maintaining appropriate PAR levels of linens on each unit. The DNS/Designee
revised P&P will
be in-serviced to Nursing Management staff. The lesson plan will concentrate on the following;
a. On maintaining appropriate PAR levels of linens to meet the needs of the current resident census on units.
The nurse manager/RN Supervisors are responsible to assess that the needs of the residents are being met
with the established PAR levels for linens,or more often as needed, and how to communicate to
the appropriate departments.
A copy of the lesson plan and sign-in sheets will be retained as validation.
3. The resident council policy and by laws were reviewed and revised to include more details regarding the
protocol for grievances and will be brought to the resident council meeting on (MONTH) 8, (YEAR) for review
and acceptance.
IV. Corrective Action Monitoring
1. Beginning (MONTH) (YEAR), the resident council meeting will be utilizing the communication form to address any
resident concerns. The Director of Social Work/Grievance Officer and the Director of Therapeutic Recreation
will do a monthly QA to assure that all communication forms are properly addressed and resolutions will be
discussed at the following months resident council meeting and quarterly at the QA meetings for the next four
quarters.
2. An audit tool was developed to interview residents regarding linen services. Social work will audit 30
residents a month ascertain satisfaction with linen amounts. Any negative findings will have immediate
corrective actions and be reported to the Director of Social Work. Minutes of the meeting will be retained as
validation.
3. Resident satisfaction audits will be presented by the Grievance Officer quarterly to the QA
committee for review and follow up as needed.
Responsible Party
Director of Social Work/Grievance Officer
Date of Correction
December 7, (YEAR)

FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 11, 2018
Corrected date: December 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , record review, and staff interviews during the Recertification survey, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to prevent further decrease in range of motion. Specifically, (1) a resident was not provided with a hip abductor pillow status [REDACTED]. This was evident for 2 of 6 residents reviewed for Position/Mobility (Resident #133 and #168). The findings are: The policy and procedure for Adaptive Equipment Policy revised 03/15/2018 documented: It is the facility policy that assistive /adaptive equipment is issued after resident's evaluation by the Licensed Rehabilitation Therapist. Based on the resident's evaluation, the therapist will provide the adaptive device and document its use in the ADL (Activities of Daily Living) care plan section of the medical record, and an MD (Physician's) order will also be entered. The nursing department and the rehabilitation department will monitor care and proper use of the adaptive device. The CNAs are accountable to ensure presence and proper functioning of the devices every shift. The Charge Nurse and the Nursing Supervisor will monitor daily and PRN (as needed) the use of positioning devices. 1) Resident #133 is a resident re-admitted [DATE] to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition and the ability to express ideas and wants. The resident required the extensive assist of one person for bed mobility, transfer, dressing, toileting, and locomotion on unit. The resident required the total assist of one person for eating, personal hygiene, bathing, and locomotion off unit. The MDS further documented the resident used a wheelchair for mobility. The resident was observed numerous time during the survey period at different time and shift . On 10/10/2018 at 12:30 PM, the resident was observed in bed lying on the right side. There was no hip abductor pillow in between his legs. The resident was observed from 2:30 PM to 5:00 PM in bed. The resident was still positioned on the right side with no hip abductor pillow in place. The Physical Therapy (PT) Note and assessment dated [DATE] documented the resident was readmitted to the facility S/P right hermiarthroplasty with staples, right knee immobilizer, and hip abduction pillow. The resident was evaluated s/p admission and presented with impaired transfers, ambulation, and bed mobility skills. The assessment documented the resident would benefit from skilled PT intervention to improve mobility and ambulation status. The MD Orders dated 10/03/2018 documented orders for hip abductor pillow while in bed to maintain hip precautions. On 10/10/2018 at 12:45 PM, the Certified Nursing Assistant (CNA #2) was interviewed and stated the resident did not have a hip abduction pillow when he was transferred to the unit from the 3rd floor. The CNA further stated she placed a regular pillow, but the resident removes it. In a follow-up interview on 10/11/2018 at 10:00 AM, the CNA stated, This morning when I came, I saw the abduction pillow on the chair, but he did not have that before. I know how to put it on. The CNA was asked if she told anybody and said, the Charge Nurse # 2 and Unit Manager Registered Nurse (UMRN) # 3. The Licensed Practical Nurse Charge Nurse (LPN #2) was interviewed on 10/10/2018 at 12:45 PM. She stated that she thinks the hip abductor pillow was discontinued, and they have it documented in the chart. On 10/10/2018 at 4:20 PM CNA #9, the afternoon CNA, was interviewed. The CNA stated, I just place a regular pillow and sometimes he removes it. On 10/10/2018 at 11:00 AM, the Physical Therapist (PT) was interviewed. The PT stated tht the resident had the hip abductor pillow when he was admitted to the facility. He further stated he verbally instructed the CNA and two licensed nurses on how to apply it. The Physical Therapy Assistant (PTA) was interviewed on 10/10/2018 at 4:45 PM. The PTA stated Technically, he is past using the pillow, and, as of today, I cannot find it. He has been in the hospital several times. The Director of Rehabilitation was interviewed on 10/10/2018 at 5:00 PM. The Director stated the resident should have the hip abductor pillow. The Unit Manager Registered Nurse (RN #3) was interviewed on 10/11/2018 at 11:17 AM. RN #3 stated that they were aware that the hip abductor pillow was missing when the resident returned from the hospital, and the PT department was informed.
2) Resident #168 is resident initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Multiple observations were made of the resident on 10/03/18 at 11:02 AM, 10/04/18 at 10:36 AM, 10/05/18 at 09:32 AM, and 10/09/18 at 08:57 AM. The resident was lying in a Geri chair without a knee separator in place. The Comprehensive Care plan ADL (Rehab) Impaired Physical Mobility/ADL Performance initiated 10/04/18 documented the following interventions: Nursing Program (ROM) Days per week 7, knee separator while in the bed and chair as tolerated. The Comprehensive Care plan Skin Integrity revised 9/25/18 documented the following interventions: knee separator, low air mattress, maintain turning and positioning every 2 hours as recommended. The physician's orders [REDACTED]. The Certified Nurse Assistant (CNA) Accountability Record dated (MONTH) (YEAR) documented instructions to place pillows in between and under knees for positioning. On 10/10/18 at 11:13 AM, an interview was conducted with CNA #8. CNA #8 stated that the resident required total assist with ADLs and transfer with a Hoyer lift OOB (out of bed) to Geri chair. The resident has contractures on the upper and lower extremities. The CNA stated that the resident needed to have a pillow between the knees. The CNA further stated that she gets knowledge of resident's care needs from the CNA accountability and the charge nurse morning report in the beginning of the shift. The CNA stated that she forgot to put the pillow between and under the knees today. The CNA also stated that she received in-services regarding ADL care regularly and as needed. On 10/11/18 at 9:24 AM, an interview was conducted with the Registered Nurse (RN #4). RN #4 stated that she is new to the floor and does rounds in the morning and during the day to monitor if the CNAs performed all necessary tasks. She stated the resident has an order for [REDACTED]. On 10/11/18 at 12:47 PM, an interview was conducted with Director of Nursing (DNS). The DNS stated that there are a lot of new employees and the facility is in the process of orienting them. She stated that before starting, the RNs receive formal orientation and it is an individualized process depending on the experience of the staff. The RNs get a preceptor on the floor and are supervised while performing tasks. The DNS also stated that the RN's responsibilities include monitoring the CNA's performance. 415.12(e)(2)

Plan of Correction: ApprovedNovember 8, 2018

I. Immediate Corrective Action

1.On (MONTH) 10, (YEAR) resident 133 was immediately reassessed for the use of a hip abductor pillow and the
determination was made that the resident continues to require a hip abduction pillow which
was then provided and care planned for.
2.Nursing staff on the unit were in serviced on the use of the hip abductor pillow for resident number 133
by the Director of Rehabilitation on 10/10/18.
3. LPN #2 was issued an educational counseling by the Director of Nurses for failing to ensure that
residents on her unit have the appropriate adaptive devices.
4. The PTA was issued issued an educational counseling by the Director of Rehab for not ensuring that
resident was provided the appropriate ordered devices.
5. The RN #3 was issued an educational counseling by the Director of Nurses for not ensuring appropriate
measures were taken once she was aware the residents abductor pillow was missing.
Resident 168:
1.On (MONTH) 10,2018 Resident 168 was re-assessed by the Director of Rehab and the resident continues
to require of a knee separator. The residents care plan and CNAAR were updated to reflect the continued
need for same.
2. In-service was provided to nursing staff on the unit by the Director of Rehabilitation.
3. CNA number 8 was issued an educational counseling by the DNS for failing to ensure that she followed
the residents plan of care as outlined in the CNAAR.
4. RN number 4 was issued an educational counseling by the DNS for failing to adequately supervise the CNA
staff.

II. Identification of Residents with the Potential to be Affected

1.All residents requiring the use of adaptive devices have the potential to be affected by this deficient
practice.
2.A full house audit of all adaptive devices in the facility will be completed by the Rehabilitation
Department by 12/7/18 to ensure all devices to be used by the resident are present, care planned, and
documented in the CNAAR.
III. Measures and Systemic Changes

1. The policy and procedure on adaptive devices has been reviewed by the Director of Rehabilitation and
found to be compliant.
2. A full house audit of all adaptive devices will be completed by the Director of Rehab to ensure all
devices are present and care planned for.
3. All therapist will be re-educated on the policy and procedure on adaptive devices and proper care
planning. A copy of this in-service as well as lesson plan will be kept on file for validation.
4. The DNS has reviewed the policy and procedure on ADL care and found the same to be compliant. The
current policy and procedure will be re-inserviced to all CNAs and nursing staff by the DNS/designee. The
lesson plan will concentrate on the application of adaptive devices as per established care plan and CNARR
information. A copy of the lesson plan and inservice will be kept on file for validation.
5. A communication form has been created for the Rehabilitation and Nursing Departments to better
communicate any changes or new referrals for adaptive devices. All nursing employees will be re-educated as
to the policies and procedures for adaptive devices and correctly documenting the presence and monitoring
of these devices in the resident?s medical record. A copy of the lesson plan and in-service will be kept on
file for validation.
IV. Corrective Action Monitoring

1.An audit of all patients requiring adaptive devices will be completed by the director of rehabilitation
by 12/7/18.
2.A list of all patients, devices, and orders will be maintained and updated on a weekly basis to be shared
between the nursing and rehabilitation departments.
3.After the full facility audit has been completed an audit of twenty percent of the residents requiring
adaptive devices will be performed weekly for four weeks, followed by monthly for two months, then
quarterly. Any negative findings will be immediately addressed.
4.All audit results will be reported to the QA Committee.
Responsible Party
Director of Rehabilitation
Date of Correction
December 7, (YEAR)

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 11, 2018
Corrected date: December 7, 2018

Citation Details

Based on staff interviews and review of the facility Legionella Water Sampling and Management Plan (WMP) during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Part 4, Protection Against Legionella, Section 4-2.4(a)(2) requires that Legionella sampling be conducted at periods not exceeding 90 days after the adoption of the WMP for the first year and annually thereafter. The facility did not provide evidence that it had conducted water testing in accordance with the regulation. The findings are: On (MONTH) 12, (YEAR) New York State Department of Health issued a Health Advisory that put forth the regulation of the Protection Against Legionella. Part 4 of the Sanitary Code Protection Against Legionella, instruct: Routine Legionella culture sampling and analysis at intervals not to exceed 90 days in the first year and annually thereafter. On (MONTH) 1, (YEAR), the New York State Department of Health informed the facility that the Sampling and Water Management Plan (SMP) submitted for review was found to be missing essential components of a functional Sampling and Management Plan. The Legionella Sampling Plan and Procedures for Responding to Sampling Exceedances were not included in the SMP. The facility's Policy and Procedure on Legionella Bacteria Sampling and Management Plan For Potable Water revised 09/2018 was reviewed. The facility's policy and Procedure on Legionella Bacteria Sampling and Management Plan for Portable Water documented risk assessment to identify where legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. The plan include a water management program that includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environment testing for pathogens. The plan include testing protocols and acceptable ranges for control measures, water system description, legionella sampling strategy, sampling procedure and management plan for portable water systems. The plan also include a water management team. In addition, the plan also include short and long term control measures for legionella, legionella remediation treatments and prevention and protocols for the prevention and control of transmission of legionella. There was no documented evidence that the facility conducted quarterly testing of the facility's portable system for Legionella and other waterborne pathogens in (YEAR) and in (YEAR). The Legionella sampling plan does not specify the corrective measures to be taken if the pathogen levels are exceeded. The water management plan is missing the Legionella Sampling plan, and procedures for responding to Sampling Exceedance were not included in the SMP. In addition, Page 12 of the facility's Policy and Procedure on Legionella Bacteria Sampling and Water Management Plan is incomplete. An interview was conducted with the Director of Facility Maintenance (DFM) on 10/11/18 at 12:53 PM who stated that the facility uses an outside company to do potable testing. The DFM also stated that water testing was done on two occasions in (YEAR) for the cooling towers. Potable testing was not done in (YEAR) and or so far in (YEAR) because the facility did not have a contract in place for potable testing. The DFM further stated that he noticed that potable testing was not being done; he contacted the company and they stated there is no contract in place for portable testing. In addition, the DFM stated that a new contract was signed last week for quarterly water testing. An interview with the Assistant Director of Nursing (ADNS) was conducted on 10/11/18 at 12:30 PM who stated that we do water testing in a regular time frame. If there are concerns with the results of water testing; we would review the water management plan and contact the Health Department for guidance. The ADNS further stated we would also contact the corporate office to get guidance on how to proceed.

Plan of Correction: ApprovedNovember 8, 2018

I. Immediate Corrective Actions
1.Brooklyn Gardens Nursing and Rehabilitation Center respectfully states that no specific resident has been
affected by the deficient practice. Our water management plan has been updated to include the Legionella
Sampling plan and procedures for responding to sampling exceedances.
2.The facility has contracted the services of Vertex Companies on 10/4/18 to conduct a water sampling pick
up at a minimum of quarterly beginning 10/16/18 and for one year annually after.
II. Identification of Residents with the Potential to be Affected
1. Although no residents were affected by the facility?s inability to conduct water sampling during the
specific time frame stated in the deficient practice statement (2017-2018), Brooklyn Gardens recognizes that
all residents have the potential to be affected.
III. Measures and Systemic Changes
1. The members of the Water Management Team met and conducted a review and update of the Water Management
Plan to include that the water samples would be collected quarterly for one year than once per year
thereafter.
2. Samples will be screened by a certified lab for the legionella bacteria and all chain of custody
documentation forwarded to the facility by Vertex Companies to be maintained on file. All records of
testing, lab reports, and changes to the water management plan would be maintained on site for a minimum of
three years.
3. The facility will discuss the results in a quarterly QA meeting. If sample results exceed a positive
result above the thirty percent threshold, the facility will notify the local AHJ immediately of test
results and immediately institute short term control measures (outlined in the water management plan). The
water system shall then be re-sampled within seven days and no later than four weeks after disinfection to
determine the efficacy of the treatment. Results will be promptly reported to the local AHJ, if retest is
over thirty percent positive short-term measures will be repeated. If results are less that the thirty
percent threshold the facility will resume monitoring with the sampling and water management plan.
4. All results will be evaluated by the engineer and discussed in the Water Management Team meeting
immediately upon receipt.
IV. Corrective Action Monitoring
1. The water management plan will be evaluated immediately and weekly for four weeks by both the
administrator, infection preventionist, and water management team, then monthly for two months, then
quarterly thereafter.
2. Any changes in the policies or procedures associated with the water management plan will be reviewed with
the water management team and reported to all department heads during morning report.
3. All results will be reported quarterly to the QA team.
4.Any negative findings will be immediately reported to the AHJ and short term measures will be implemented
throughout the facility. The facility will work with both the lab, AHJ, DOH, and any other governing
authority to ensure all results are documented and reported in an appropriate time period.
Responsible Party
Administrator/designee
Date of Correction
December 7, (YEAR)

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: October 11, 2018
Corrected date: December 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and staff interviews during the recertification survey, the facility did not ensure the infection control practices and procedures were maintained. Specifically, 1) An oxygen tubing was observed touching the floor. 2) A Licensed Practical Nurse did not cleanse glucometer after usage. This was evident for 2 observations made during the survey. The findings are: 1) Resident # 9 is a resident who was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident is cognitively intact, requires extensive assistance of two persons with most activities of daily living and is receiving oxygen therapy. On 10/03/18 at 10:07 AM and 10/04/18 at 9:08 AM, the resident's oxygen tubing was observed touching the floor. On 10/09/18 at 11:01 AM, Licensed Practical Nurse (LPN) #1 stated that the resident is on continuous oxygen therapy. LPN #1 also stated that the resident is assessed frequently to ensure the nasal canula is placed correctly and to ensure the oxygen tubing is off the floor. LPN #1 further stated that If we notice anything out of the ordinary, we correct it right away. On 10/09/18 at 12:01 PM, Registered Nurse Supervisor #1 stated that the resident came to the facility with continuous oxygen therapy. RN Supervisor # 1 stated that she makes frequent rounds to ensure the resident is stable. On 10/11/18 at 10:59 AM, Charge Registered Nurse # 2 stated that typically she checks on all of the resident at the begining of her shift. Since the resident is on continuous oxygen therapy, resident is on constant monitoring. Charge Registered Nurse #2 further stated that she checks the oxygen tubing to ensure that the tubing is off the floor. Charge Registered Nurse # 2 also mentioned that the oxygen tubing should be placed in a bag. On 10/11/18 at 11:03 AM, RN Supervisor #1 stated that she makes rounds of the entire unit and she checks on all of the residents. The RN Supervisor # 1 also stated those who are on oxygen are checked on periodically to ensure the nasal canula is properly placed. If the oxygen tubing is found on the floor, we would change the tubing. If the oxygen tubing is really long, we would place it in way so it would not touch the floor. The RN Supervisor #1 further stated that she recently updated the CNA accountability log to ensure CNAs check all of the residents' oxygen tubing. In addition, she stated that the resident was also educated about keeping the oxygen tubing off the floor.
2) The Facility's Policy and Procedure Titled: Glucometers Usage and Cleaning with a review/revision date of 4/18 documented that Glucometers are to be cleaned before and after use, by wiping aerial surface of device with a germicidal disposable 'Sani-Cloth.' It further documented '#11- Clean glucometer with a germicidal disposable Sani-Cloth wipe EPA registered(Purple top) allow to air dry and store in designated area on medication cart.' On 10/04/2018 at 04:25 PM the following was observed: after using the glucometer to perform a finger stick {FS) on a resident, the Licensed Practical Nurse (LPN #8) placed the used glucometer on top of the medication cart, then placed it into the top drawer of the medication cart, without cleaning the glucometer. On 10/05/18 at 05:06 PM the Licensed Practical nurse was interviewed. LPN # and stated she was absent minded and totally forget to clean the glucometer. LPN #8 stated that what she should have done was after using the glucometer, clean it with Purple Sani-Cloth, then let dry for two minutes and then put it in the medication cart drawer. She also stated that the glucometer must be cleaned between residents. On 10/10/18 at 10:46 AM the In-Service Educator was interviewed. She stated that after each usage, the staff must wipe the glucometer with the Purple Sani-Cloth, allow to air dry for two minutes. After it dries, it should be stored in the medication cart. On 10/11/18 at 11:50 AM the Assistant Director of Nursing, who is also the Infection Control Coordinator (ICC) was interviewed. The ICC stated that the glucometer must be cleaned after each use, the staff must wipe the glucometer with the Purple Sani-Cloth, which is EPA certified. Allow to air dry for full two minutes, after it dries store in medication cart.

Plan of Correction: ApprovedNovember 8, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions
Oxygen Tubing
1.Oxygen tubing in question was immediately replaced
2.CNA accountability was updated to remind CNA to check oxygen tubing placement and ensure it is off the
floor. In the event it is observed resting on the floor the nurse is to be made aware so it may be cleaned
or replaced.
3.LPN #1, RN Supervisor #1, and Charge RN #2 were all re-educated on the policy and procedure regarding
infection control in reference to oxygen tubing.
4.Resident #9 was educated on infection control practices regarding oxygen tubing. The resident was
educated to keep oxygen tubing off the floor and to notify staff if she requires assistance in this area.
Glucometer
1.Glucometer, medication cart drawer and top were immediately cleaned using germicidal EPA sani-cloth
wipes.
2.Immediate education was provided to LPN #8 by the staff educator regarding infection control practices
for cleaning glucometers. The following information was reviewed with the nurse: Glucometers are to be
cleaned after each use, between every resident and prior to placement in the medication cart, glucometers
are to be cleaned the with ?purple top? EPA sani-cloth wipes, and Glucometer Cleaning Competency completed.
II. Identification of Residents with the Potential to be Affected
The Assistant Director of Nursing reviewed all residents in the facility with orders for oxygen or [DIAGNOSES REDACTED].
1.CNAs and licensed nursing staff will be educated on infection control prevention regarding Oxygen tubing.
Oxygen tubing in use is to be kept off the floor and when not in use stored in a plastic bag
2.All residents with orders for oxygen will be observed to determine if there is any issue in regard to the
placement of the tubing and if identified CNA accountability and resident plan of care will be updated to
reflect such.
3.Cognitively competent residents will be educated on infection control practices regarding oxygen tubing
and to keep oxygen tubing off the floor and to notify staff if assistance is required
4.All RNs and LPNs who perform glucometer testing will be re-inserviced and complete a competency to ensure
facility policy and procedure of glucometer testing is being followed and performed correctly.
III. Measures and Systemic Changes

1.A review of the oxygen tubing policy and procedure was completed by the Director of Nursing and Assistant
Director of Nursing and has been revised to include- Oxygen tubing to be kept off the floor and when not in
use will be stored bedside in a plastic bag; CNARR will include these instructions; and cognitively
competent residents will be educated regarding infection control practices related to oxygen tubing.
2.A review of the Glucometer Cleansing policy and procedure was completed by the Director of Nursing and
Assistant Director of Nursing and has been found to be compliant.
3.All nursing staff members will be re-educated by the staff educator on the policy and procedure for
oxygen tubing. A copy of the lesson plan and sign in sheets will be kept on file.
4.All licensed nurses will be re-educated by the staff educator on the policy and procedure for glucometer
cleaning. A copy of the lesson plan and sign in sheets will be kept on file.

IV. Corrective Action Monitoring

1.Infection Control Practices and nursing rounds will be completed daily on all shifts at various times to
check placement of oxygen tubing, the following will be monitored; all oxygen tubes are off the floor and
Oxygen tubing not in use are stored in plastic bags. All issues will be addressed immediately with staff
education/resident education and tubing cleaned or replaced
2.Audits will be completed on all shifts during med pass time to ensure infection control practices
regarding Glucometer Cleaning are being followed as per facility policy.
3.Audits will be completed weekly for four weeks, then monthly for two months, then quarterly for one year.
Audits will be reported to the QA committee on a quarterly basis. Any negative findings will be addressed
immediately.
Responsible Party
Assistant Director of Nursing
Date of Correction
December 7, (YEAR)

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 11, 2018
Corrected date: December 7, 2018

Citation Details

Based on observation and record review the facility did not ensure that a separately locked, permanently affixed compartment for storage of controlled drugs was provided. Specifically, the Licensed Practical Nurse (LPN) was observed using one key to open both locked compartments of the narcotic box. This was evident for 1 of 6 floors reviewed for Medication Storage and Labeling (7th floor). The Finding is: The facility Policy and Procedure titled Controlled Substance Destruction Rules/ Storage Monitoring dated 6/18 documented: Controlled drugs must be kept under lock and key in a separate locked compartment in the medication room on each unit. The storage box should have 2 locked doors with 2 separate keys. (One key cannot open both locks) On 10/02/2018 at 03:29 PM, during observation of medication storage on the 7th floor unit, the Licensed Practical Nurse (LPN) was observed using one key to open both locked compartments of the controlled drugs box. On 10/03/2018 at 8:55am, the Licensed Practical Nurse medication nurse was interviewed. The LPN stated she used one key to open both locks of the narcotic box, and she did not know there must be two keys. The LPN could not recall receiving in-services on how many keys should be used. On 10/3/2018 at 9:05am the LPN Charge Nurse was interviewed. The LPN stated there are two keys for the narcotic box. The Charge Nurse should have one key that only opens one of the doors, which she has. She further stated the Medication Nurse should have the other key for the second door on the narcotic box. When they need to access the narcotics, the Medication Nurse must go to the Charge Nurse for the other key. The LPN stated she noticed the Medication Nurse never asked her for the key. She did not know the key held by the Medication Nurse could open both locks. On 10/11/18 at 10:20 AM, the Director of Nursing (DNS) was interviewed. The DNS stated the Narcotic box must be locked with two doors. Each door should have a separate lock with different keys. If the keys, locks, or narcotic storage box malfunctions or breaks, the Nurse must report the situation to maintenance so it can be repaired. 415.18(d)

Plan of Correction: ApprovedNovember 8, 2018

I. Immediate Corrective Actions
1. Brooklyn Gardens Nursing and Rehabilitation Center respectfully states that no specific resident was affected
by the deficient practice.
2. On 10/3/18, Maintenance replaced the lock on unit seven with a separate lock with a separate key so
that there are two locks with two separate keys on two separate doors. Immediate corrective action completed
on 10/3/18.
II. Identification of Residents with the Potential to be Affected
1. Brooklyn Gardens respectfully states that no residents were affected by the facility?s deficient practice
but all residents have the potential to be affected.
2. The narcotic box locks on all units were checked for a potential problem, and all other units were found to
have two locks, two keys, and two separate doors with no issues identified.
III. Measures and Systemic Changes
1. All nurses were re-educated to immediately report any issues with narcotic box locks and that all narcotic
boxes must have two locks, two keys, and two separate doors.
2. The In Service Coordinator will conduct educational training on 100% of the licensed nursing staff to ensure
that they are knowledgeable on the facility?s policy and procedure, the lesson plan will emphasize that of
all narcotic boxes having two locks, two keys, and two separate doors.
3. In service education records will be maintained for validation.
IV. Corrective Action Monitoring
1. Monthly audits will be conducted by the DNS/Designee to ensure all narcotic boxes have two locks, two keys, and two separate
doors. Any negative findings will be immediately corrected and the results of all audits will be reported to
the QA Committee monthly for three months, then quarterly for 3 quarters.
Responsible Party
Director of Nursing
Date of Correction
December 7, (YEAR)

FF11 483.20(c):QRTLY ASSESSMENT AT LEAST EVERY 3 MONTHS

REGULATION: §483.20(c) Quarterly Review Assessment A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 11, 2018
Corrected date: December 7, 2018

Citation Details

Based on record review and staff interviews conducted during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 quarterly assessments were completed in a timely manner. Specifically, the quarterly assessment was not completed within 14 days of the Assessment Reference Date (ARD). This was evident for 1 of 35 residents reviewed in the investigation sample (Resident #8). The finding is: The facility policy and procedure titled Minimum Data Set (Dated 11/17) documented the following the assessment completion refers to the date that all information needed has been collected and recorded for a particular assessment type and staff have signed and dated that the assessment is completed. For non comprehensive and discharge assessment, assessment completion is defined as completion of the MDS only, meaning that the RN assessment coordinator has signed and dated the MDS completion attestation. Except for the OBRA admission Assessment, assessments must be completed within 14 days of the ARD of the assessment. The CMS RAI Version 3.0 Manual (Dated (MONTH) (YEAR)) was referenced. Chapter 2 titled Assessments for the RAI was reviewed. Assessment Completion refers to the date that all information needed has been collected and recorded and staff have signed and dated the assessment is complete. Assessment Transmission refers to the electronic transmission of submission files to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system using the Medicare Data Communication Network (MDCN). CMS RAI Version 3.0 Manual (Dated (MONTH) (YEAR)) was referenced. Chapter 5 titled Submission and Correction of the MDS Assessments was reviewed. The MDS completion date must be no later than 14 days after the ARD for all non-admission, OBRA, and PPS assessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. Resident #8 was initially admitted to facility on 12/14/2014. The Quarterly MDS Assessment with reference date of 09/22/18 was reviewed on 10/09/18. The scheduled completion date documented in the electronic record was 10/5/18. The assessment was incomplete on 10/9/18, 4 days after the scheduled completion date. On 10/09/18 at 03:06 PM, the MDS coordinator was interviewed and stated that for the quarterly assessment, we complete the book two weeks after the ARD. After the completion, we have one more week to submit the book. The book is still incomplete because of the rehab department. The rehab section is still not signed. On 10/09/18 at 3:22 PM, the Director of Rehab who is responsible for signing the rehab section of the MDS was interviewed. The Director stated, the book is over due for about four days, this is no good. Today is October, 9th (YEAR) and the book was supposed to be completed on (MONTH) 5th. I am sorry, I missed it. 415.11(a)(4)

Plan of Correction: ApprovedNovember 8, 2018

I. Immediate Corrective Actions
1.The late MDS assessment was immediately completed on 10/9/18 upon identification, by the responsible
discipline Rehabilitation.
2.In-service education was provided to the MDS coordinator and Rehabilitation Director, by the staff
educator, on the importance of completing assessments in a timely manner.
II. Identification of Residents with the Potential to be Affected
1. All residents have the potential to be impacted by the deficient practice.
2. An audit was completed by the MDS Coordinator for the last 3 months to ensure all MDS assessments were
completed timely.
3. All staff members involved in completing MDS assessments will be re-educated by the Staffing
Educator/designee on the importance of timely completion of the MDS assessment.A copy of the lesson plan
and sign in sheet will be kept on file.
III. Measures and Systemic Changes
1. MDS Assessment Policy and Procedure was reviewed and found to be compliant.
2. An audit of all books that are due will be conducted weekly for four weeks, then 20% of books due will
be audited monthly for two months, then 10% of books due will be audited for one year to ensure that all
MDS assessments are completed on the scheduled completion date, by the MDS Coordinator.
IV. Corrective Action Monitoring
1. All audits will be reviewed by the MDS Coordinator to ensure that all assessments are completed by the
scheduled completion date.
2. Any negative findings will be addressed immediately, by the respective discipline.
3. The results of all audits will be reported quarterly to the QA Committee.
Responsible Party
MDS Coordinator
Date of Correction
December 7, (YEAR)

Standard Life Safety Code Citations

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 11, 2018
Corrected date: November 9, 2018

Citation Details

2012 NFPA 99: 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. Based on observation and staff interview, the facility failed to ensure that oxygen storage cylinders were stored properly. This occurred on 1 of 7 floors within the facility. The findings are: On 10/4/2018 between the hours of 8am and 3:30pm during the recertification survey, the following was observed: In Physical Therapy on the 1st floor, 1 E sized oxygen tank was stored directly on the floor. Additionally, in the Recreation Office on the 1st floor, 2 H sized Helium tanks were being stored on the floor. A restraining chain was hanging on the wall adjacent to the Helium tanks. The chain was not secured around the tanks to prevent them from falling over. In an interview on 10/4/2018 at approximately 11:10 am with the Director of Maintenance, he will adjust the chain. He also stated he will remove the E tank. 2012NFPA99 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedOctober 22, 2018

Immediate Corrective Actions:
Brooklyn Gardens Rehabilitation and Nursing Center respectfully states that no specific resident has been affected by the deficient practice. The helium tank was immediately secured with a chain and the empty oxygen tank was immediately removed from the rehab room placed securely in an oxygen holder in Central Supply.
Identification of Residents with the Potential to be Affected:
All residents have the potential to be affected by unsecured cylinders. All tanks throughout the facility were checked by the Facility Manager to ensure proper storage and security, all cylinders were found to be secured properly.
Measures and Systemic Changes:
Facility wide audit of all oxygen and helium tank storage has been added to the maintenance department weekly checklist. This audit will be conducted using a facility developed audit tool. All rehabilitation, recreation, central supply, and maintenance staff will be in serviced on the protocol for monitoring the storage and securing of oxygen and helium tanks. Attendance record and lesson plan will be kept on file for validation. An audit tool has been developed for the recreation department to monitor the storage and security of helium tanks on a daily basis for four weeks and a weekly basis for the next three months. Any issues identified will have immediate corrective action.
Corrective Action Monitoring:
A monthly audit tool was developed to check all oxygen and helium tank storage areas for proper security of cylinders. All negative findings will be immediately corrected and reported to the QA Committee monthly. Monthly reports will be submitted to the QA Committee quarterly for review over the next four quarters.
Responsible Person
Director of Facilities Management

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 11, 2018
Corrected date: November 9, 2018

Citation Details

2012 NFPA 101: 19.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8. 7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated as follows: (1) During conditions of stair use, the minimum illumination for new stairs shall be at least 10 ft-candle (108 lux), measured at the walking surfaces. (2) The minimum illumination for floors and walking surfaces, other than new stairs during conditions of stair use, shall be to values of at least 1 ft-candle (10.8 lux), measured at the floor. (3) In assembly occupancies, the illumination of the walking surfaces of exit access shall be at least 0.2 ft-candle (2.2 lux) during periods of performances or projections involving directed light. (4)*The minimum illumination requirements shall not apply 7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area. where operations or processes require low lighting levels. Based on observation and staff interview, the facility did not ensure that illumination of means of egress, including exit discharge, was arranged in accordance with 7.8. This was noted on 1 of 7 floors within the facility. The finding is: On 10/04/18 between 8am and 3:30pm during the recertification survey, no exit discharge lighting was provided near the exit door adjacent to the Administrator's office. In an interview on 10/04/18 at approximately 10am, the Maintenance Chief stated that he can add lighting above the exit door. He also stated that door was the only exit door that did not have exit lighting. 2012 NFPA 101: 19.2.8, 7.8. 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedOctober 22, 2018

Immediate Corrective Action:
Brooklyn Gardens Rehabilitation and Nursing Center respectfully states that no specific resident has been affected by the deficient practice. Outside photo-cell lighting was immediately purchased and installed above the said exit door.
Identification of Residents with Potential to be Affected:
All residents have the potential to be affected by the lack of illumination over the exit door. Exit door photo-cell lighting was installed on 10/5/18. All exit door lighting was checked by the Facility Manager and found to be in place and functioning properly.
Measure and Systemic Changes:
The newly installed exit door lighting has been added to the daily maintenance check list. All maintenance staff will be in serviced on the protocol for monitoring the exit door lighting. Attendance record and lesson plan will be kept on file for validation. All exit door lighting will be monitored for four weeks, then monthly for the next three months. Any issues identified will have immediate corrective action.
Corrective Action Monitoring:
A monthly audit tool was developed to monitor the daily maintenance check on the exit door lighting. All negative findings will be immediately corrected and reported to the QA Committee monthly. All monthly reports will be submitted to the QA Committee quarterly for review over the next four quarters.
Responsible Person:
Director of Facilities Management

PLAN BASED ON ALL HAZARDS RISK ASSESSMENT

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: October 11, 2018
Corrected date: November 9, 2018

Citation Details

Based on document review and staff interview, the facility failed to ensure that the facility based and community based risk assessment included missing residents. This occurred while reviewing the facility's emergency preparedness documentation. The finding is: On 10/4/2018 between the hours of 8am and 3:30pm during the recertification survey, the following was noted: Documentation review of the facility's emergency preparedness manual revealed that the facility and community based risk assessment conducted, did not include missing residents. In an interview on 10/4/2018 at approximately 2pm with the Administrator, she stated she will look into it.

Plan of Correction: ApprovedOctober 23, 2018

Immediate Corrective Actions:
Brooklyn Gardens Nursing and Rehabilitation Center respectfully states that no specific resident has been affected by the deficient practice. Our elopement/ missing resident policy and procedure has been added to our emergency preparedness manual and facility and community based risk assessment has been conducted.
Identification of Residents with the Potential to be Affected:
All residents have the potential to be affected by the lack of the risk assessment conducted for the emergency preparedness manual. A facility and community based risk assessment has been conducted for elopement/missing resident and added to the emergency preparedness manual.
Measures and Systemic Changes:
The members of the Emergency Preparedness Committee will receive in service on the importance of including elopement/ missing resident policy and procedures to the emergency preparedness manual. All members of the Emergency Preparedness Committee will be educated on their role in the procedure for elopement/missing resident.
will be informed of the addition of the elopement/missing resident policy and procedure to the Emergency Preparedness Manual. In service training and lesson plan will be kept on file for validation.

Corrective Action Monitoring:
The emergency preparedness manual will be reviewed quarterly to ensure all policies and procedures are in place, specifically elopement/ missing resident. This will be reviewed at the QA Committee meeting for the next four quarters.

Responsible Person
The In Service Coordinator will be responsible to assure the P(NAME) for E 006 is completed.