Brighton Manor
November 30, 2018 Certification/complaint Survey

Standard Health Citations

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: November 30, 2018
Corrected date: January 11, 2019

Citation Details

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The issues involved foods served and held at improper temperatures. This is evidenced by the following: The facility policy, Food Temperatures, dated 3/1/12, revealed that the facility will prepare and hold foods at a temperature of no less than 140 degrees Fahrenheit (*F) with a goal of serving foods to the resident at a palatable temperature at point of service. During the initial tour of the kitchen on 11/26/18 at 8:18 a.m., the pancakes were in a full pan on a steam table, stacked high and uncovered. Review of the Production Temperature Logs revealed that the temperatures of the pancakes were not taken. When interviewed at that time, the cook said there was not a spot available to document the temperature of the pancakes. The cook said he was unsure what the temperature should be, and then said 145*F. The temperature of the pancakes on the steamtable was taken at 8:30 a.m., using a thermocouple thermometer and measured 139.4*F. At that time, the surveyor requested a test tray be sent to the second floor. On 11/26/18 at 8:35 a.m., the surveyor followed the food truck containing the test tray from the kitchen to the second floor. When the last tray was passed from the truck at 8:45 a.m., the surveyor and Food Service Director used the thermocouple thermometer to measure the food temperatures. The temperature of the sausage was 106*F and the pancakes were 100*F (the coffee and oatmeal were acceptable temperatures). When interviewed at that time, the Food Service Director said the pancakes should be hotter. She said the regular cook was not working that day, and he usually will batch the pancakes. When interviewed on 11/28/18 at 4:00 p.m., the Food Service Director said that her goal was to have food temperatures at 160*F at the point of service. (10 NYCRR 415.14(h), 14-1.40(a), 14-1.40(b))

Plan of Correction: ApprovedDecember 19, 2018

Corrective Action Taken for Those Residents Affected-
The cook responsible for cooking the pancakes and ensuring they are held at the appropriate temperature was educated regarding his responsibility to do so.
The cook responsible for checking the temperature was educated regarding proper food temperatures.

Corrective Action Taken for Those Residents Having Potential to be Affected-
The facility respectfully recognizes all residents as having potential to be affected and it was determined through staff and resident interviews and record reviews that there was no negative outcome due to the deficient practice. Food temperature logs were reviewed to ensure food being served meets the regulation.

Systemic Monitoring-
The policy for Food Temperatures was reviewed. The policy includes ensuring preparing and holding food at no less than 140F. The In-Service Coordinator will be responsible to in-service all dietary staff regarding the policy.

Quality Assurance Monitoring-
The facility will develop an audit tool to monitor and ensure compliance with the policy for Food Temperatures. The audit will include ensuring food is prepared and held at no less than 140F and that staff verbalize understanding regarding the policy. The Director of Dietary or designee will be responsible to complete these audits weekly for 12 weeks and then monthly for 9 months, at which time it will be reviewed for continued frequency guidance at QA. The Director of Dietary will report findings at the QACM monthly for follow up and review.


Person Responsible for the Correction of this Deficiency- Director of Dietary

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

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: January 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey (complaint #NY 076), it was determined that for one (Resident #177) of two residents reviewed for abuse, the facility did not ensure that an allegation of abuse was reported to the Administrator. This is evidenced by the following: Resident #177 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The facility policy, Abuse, Neglect and Misappropriation, dated 2/8/12, documented that the facility requires reporting of any potential or actual violations to administration who will take immediate action to address the incident. A Nursing Progress Note, dated 10/15/18, revealed that the resident's family took her out of the facility against medical advice and spoke to the Social Worker before they left. The Social Worker provided the surveyor with a copy of the face sheet that she had in her files. There was documentation on the back of the face sheet that included an undated entry that revealed a family complaint was made that a night aide grabbed the resident, and other male aides were in the room laughing and saying this is the last day you will live. Interviews conducted on 11/29/18 included the following: a. At 1:49 p.m., the Social Worker said that she did not recall speaking to the resident's family. After reviewing the entry on the back of the face sheet, the Social Worker said she did not write a note or complete a grievance because the resident left so fast and she forgot. b. At 2:14 p.m., the Registered Nurse Minimum Data Set Coordinator said she would have expected the allegation to be reported and investigated. c. At 3:31 p.m., the Director of Nursing (DON) said she remembers the resident left against medical advice. She said that she did not have any interaction with the family but remembers the family was upset because their mother had a problem with a large black woman. She said that she was not the DON at the time and was not involved. The DON said she did not know who investigated the incident. d. At 3:53 p.m., the Administrator said she was not aware of the resident's allegation until that day. She said she would have expected that the allegation be reported immediately. (10 NYCRR 415.4(b)(2-3))

Plan of Correction: ApprovedDecember 19, 2018

Corrective Action Taken for Those Residents Affected-
Resident # 177 no longer resides at the facility.
The social worker was educated regarding her responsibility to ensure any and all allegations of abuse are reported to the Administrator to ensure they are properly investigated.
The Acting Director of Nursing was educated regarding her responsibility to ensure upon hearing of an abuse allegation, reporting it to the Administrator to ensure the allegation is properly investigated.

Corrective Action Taken for Those Residents Having Potential to be Affected-
The facility respectfully recognizes all residents as having potential to be affected and it was determined through staff and resident interviews and record reviews that there was no negative outcome due to the deficient practice.
A full house review of resident discharges was completed to ensure there were no further complaints requiring follow up.

Systemic Monitoring-
The policy for Abuse, Neglect and Misappropriation was reviewed. The policy includes ensure the allegations of abuse, neglect and misappropriation are reported to the Administrator and are investigated properly. The In-Service Coordinator will be responsible to rein-service all staff regarding the policy.
The policy for Discharge Planning was reviewed. The policy was updated to include review of all Against Medical Advice (AMA) discharges to ensure a root cause analysis is completed when a resident leaves the facility AMA. The In-Service Coordinator will be responsible to rein-service all licensed nursing staff, social work, the facility Administrator, medical staff and members of the IDT regarding the policy.

Quality Assurance Monitoring-
The facility will develop an audit tool to monitor and ensure compliance with the policy for Abuse, Neglect and Misappropriation. The audit will include ensuring the allegations of abuse, neglect and misappropriation are reported to the Administrator and are investigated properly and that staff verbalize understanding regarding the policy. The In-Service Coordinator or designee will be responsible to complete these audits weekly for 12 weeks and then monthly for 9 months, at which time it will be reviewed for continued frequency guidance at QA. The Director of Nursing will report findings at the QACM monthly for follow up and review.
The facility will develop an audit tool to monitor and ensure compliance with the policy for Discharge Planning. The audit will include review of all Against Medical Advice (AMA) discharges to ensure a root cause analysis is completed when a resident leaves the facility AMA and that staff verbalize understanding regarding the policy. The Social Worker or designee will be responsible to complete these audits weekly for 4 weeks and then monthly for 3 months, at which time it will be reviewed for continued frequency guidance at QA. The Social Worker will report finding at the QACM monthly for follow up and review.

Person Responsible for the Correction of this Deficiency- Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

REGULATION: Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: January 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview conducted during the Life Safety Code Survey, it was determined that for one (third floor) of three resident use floors, the facility did not properly maintain egress corridor width. Specifically, chairs were stored in egress corridors and were not properly secured, and/or projected more than 24-inches into the required corridor width. The findings are: 1. Observations on 11/26/18 between 7:56 a.m. and 8:27 a.m. revealed two unoccupied and unsecured sitting chairs in the egress corridor outside the third-floor dining room. An interview with the Maintenance Director revealed the chairs are usually not out there, but some residents like to eat in the hallway and staff forget to put the chairs back in the dining room. Further observations revealed an unoccupied, unsecured sitting chair under a wall mounted computer screen in the egress corridor outside room [ROOM NUMBER]. 2. Observations on 11/27/18 at 8:53 a.m. revealed wheeled high-back chairs stored in the egress corridor outside Rooms #300 and #319. The chairs were such that the usable egress widths were 3-feet 8-inches and 4-feet 3-inches, respectively. 3. Observations on 11/28/18 at 8:30 a.m. revealed a wheeled high-back chair stored in the egress corridor outside room [ROOM NUMBER] leaving 4-feet 1-inch of usable egress width. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.3.4)

Plan of Correction: ApprovedDecember 24, 2018

Corrective Action Taken for Those Residents Affected:
The unsecured sitting chairs in the egress corridor outside of the third-floor dining room and at the wall mounted computer screen have been removed.
The highbacked chair storage in the egress of corridors on the third floor has been limited to an area that will ensure there is a maintained distance of 6 feet of usable space available for egress.
The staff working the 3rd floor on 11/26/18 and 11/27/18 were educated regarding ensuring the hallway corridor width is maintained.
The Maintenance Director was educated regarding his responsibility to ensure the aisles or corridors serving an exit area are clear and unobstructed to maintain a minimum corridor access of 6 feet providing for the convenient removal of non-ambulatory residents on stretchers.
Corrective Action Taken for Those Residents Having Potential to be Affected:
The facility respectfully recognizes all residents as having potential to be affected and it was determined through record reviews, staff and resident interviews, that there were no negative outcomes due to the deficient practice. A review of unit corridors has been completed and it was determined that there are no further incidents of unsecured chairs sitting in corridors or high back chair storage limiting the width of the egress aisle or corridors.
Systemic Monitoring
The Life Safety Code regulation for maintaining Aisle, Corridor, or Ramp Width was reviewed. The In-Service Coordinator will be responsible to in-service all staff regarding the regulation, specifically maintaining the width of the egress aisle or corridor in accordance with the regulation.
Quality Assurance Monitoring
The facility will develop an audit tool to monitor and ensure compliance with the Life Safety Code regulation for maintaining the proper width of unobstructed space in a corridor or aisle of egress. The audit will include the ensuring the corridors are free of obstructions, and that staff verbalize understanding regarding the regulation. The Director of Maintenance or designee will be responsible to complete audits weekly X 12 weeks and then monthly for 9 months. The Director of Maintenance will present audit findings at QAPI meetings monthly for review and guidance.
Person Responsible for the Correction of this Deficiency: Director of Maintenance

MAINTENANCE, INSPECTION & TESTING - DOORS

REGULATION: Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 30, 2018
Corrected date: January 11, 2019

Citation Details

Based on observations, interview, and record review conducted during the Life Safety Code Survey, it was determined that for three (first, second, and third floors) of three resident use floors, the facility did not properly test and inspect fire doors. Specifically, there was no record of annual testing of fire doors in accordance with NFPA 80. The findings are: Observations on 11/26/18 between 7:56 a.m. and 10:25 a.m. revealed fire rated doors and frames to exit stairwell enclosures on all three floors at the east and west ends of the building. Record review at 1:55 p.m. revealed monthly door inspections throughout the building, however, the inspection only covered door opening/closing and latching. When interviewed the Administrator stated that the door inspection per NFPA 80 had not been done yet. The 2010 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives, requires fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the Authority Having Jurisdiction. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 7.1.3.1, 8.3.3.1; 2010 NFPA 80: 5.2.1; CMS S&C 17-38-LSC)

Plan of Correction: ApprovedDecember 24, 2018

Corrective Action Taken for Those Residents Affected:
The fire rated doors and frames to exit stairwell enclosures on all three floors at the east and west ends of the building were inspected in accordance with NFPA 80. A written record of inspection and testing will be maintained and available for review.
The Maintenance Director and Administrator were educated regarding their responsibility to ensure the proper Inspection and Testing of the Fire Doors is completed annually in accordance with NFPA 80 and records ensuring records are maintained and available for review.
Corrective Action Taken for Those Residents Having Potential to be Affected:
The facility respectfully recognizes all residents as having potential to be affected and it was determined through record reviews, staff and resident interviews, that there were no negative outcomes due to the deficient practice. The Director of Maintenance reviewed the remainder of the doors in the facility and ensure they were in compliance with the code requirement for NFPA 80. The fire rated doors were inspected accordingly and a written record of the testing and inspection report will be maintained and available for review.
Systemic Monitoring
The Life Safety Code regulation for NFPA 80, Annual Inspection of Fire Safety Doors and the maintenance of written records was reviewed. The Maintenance Director was educated to the regulation and the annual need for the inspection by the In-Service Coordinator.
Quality Assurance Monitoring
The facility will develop an audit tool to monitor and ensure compliance with the Life Safety Code regulation for maintaining Fire Safety Door Inspection according to NFPA 80. The audit will include the ensuring the Inspection has been completed and that written records are available for review, and that the maintenance staff verbalize understanding regarding the regulation. The Director of Maintenance or designee will be responsible to complete audits monthly for 12 months. The Director of Maintenance will present audit findings at QAPI meetings monthly for review and guidance.
Person Responsible for the Correction of this Deficiency: Director of Maintenance

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: January 11, 2019

Citation Details

Based on observations and record review conducted during the Life Safety Code Survey, it was determined that for three (first, second, and third floors) of three resident use floors, the facility did not properly maintain smoke barrier walls. Specifically, sections of smoke barrier walls were not constructed of a minimum 30-minute fire resistance rated assembly. The findings are: 1. Observations above the suspended ceilings on 11/26/18 from 10:45 a.m. to 11:17 a.m. revealed portions of the smoke barrier walls on the first, second, and third floors did not meet the required 30-minute fire resistance rating. The walls, while resistant to the passage of smoke, were observed to be comprised of a single angled 5/8-inch gypsum board partition. Locations included, but were not limited to, the following: above the smoke barrier doors outside Room #309 and the nourishment room, above the smoke barrier doors outside Room #209, and above the double doors to the first-floor dining room. When interviewed at that time, the Maintenance Director said that no work had been performed since the last survey to repair the smoke barrier walls. 2. A review of facility records on 11/26/18 at 11:25 a.m. revealed a FSES (Fire Safety Evaluation System) was performed at the facility on 12/6/17, which indicated a passing score. The FSES identified smoke barrier walls on all three floors of the facility as lacking the required 30-minute fire resistance rating which is not permitted by the 2012 Life Safety Code. An interview with the Administrator at that time, revealed the FSES was forwarded on to the New York State Bureau of Architecture and Engineering Review (BAER) in conjunction with a waiver request. The Centers for Medicare & Medicaid Services recognizes the 2013 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety, (also known as the Fire Safety Evaluation System or FSES). This standard provides alternative approaches to life safety based on equivalent safety concepts. A building determined to have equivalent safety to the requirements of the NFPA 101, Life Safety Code, is deemed to be compliant for the identified deficient requirement. (10NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.7.3, 8.5.2.2)

Plan of Correction: ApprovedDecember 26, 2018

The FSES completed on 12/6/2017 reflects the facility meets the intent of the Life Safety Code with regard to the smoke barrier walls. The FSES has deemed the facility to be in compliance with the previous Life Safety Code inspections. A limited time waiver has been requested in order to complete renovations needed to bring the facility into compliance with today's Life Safety Code.