Park Nursing Home
February 22, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status. Specifically, resident's psychiatric [DIAGNOSES REDACTED]. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a total investigation sample of 56 residents. (Resident #36) The finding is: Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medical Progress Note dated 06/01/2018 documented that resident admitted from the hospital with [DIAGNOSES REDACTED]. The Psychiatry Note dated 06/05/2018 documented the resident's narrative is that he has no psychiatric illness and a recommendation was made to lower [MEDICATION NAME] to 15 mg PO daily. The Psychiatry Note dated 09/04/2018 documented a recommendation that the resident's [MEDICATION NAME] dosage be decreased to 10 mg PO daily. Physician's Monthly Progress note dated 10/18/2018 and 11/14/2018 documented that resident is receiving [MEDICATION NAME] 10 mg PO daily for [MEDICAL CONDITION] and Donepezil 10 mg PO for Dementia. Psychiatry Note dated 12/04/2018 documented that resident was seen by psychiatrist and recommendation made to decrease [MEDICATION NAME] to 7.5 mg PO daily. Psychiatry Progress note dated 02/12/2019 documented that resident was evaluated by psychiatrist, [MEDICATION NAME] was reduced to 5 mg PO daily, [MEDICATION NAME] 10 mg PO daily added, and [MEDICATION NAME] 10 mg PO daily. Comprehensive Care Plan on [MEDICAL CONDITION] Drug Use updated 06/12/2018 documented that resident is receiving [MEDICAL CONDITION] medication. The Quarterly MDS's completed on 9/2/18 and 11/27/18 documented in Section N0410 that Antipsychotics were received on 7 of 7 days, however Section N0450 documented that Antipsychotics were not received and did not reflect that Gradual Dose Reductions (GDR's) were being done. The facility did not ensure that MDS assessments were completed that accurately reflected the resident's status. On 02/20/2019 at 11:55 AM and 03:08 PM, the MDS Coordinator was interviewed. The MDS Coordinator stated that she has been doing MDS for a long time, has received training on proper documentation and has been in charge of the MDS at the facility for about 7 months. The MDS Coordinator further stated that she reviews the resident's current medication and [DIAGNOSES REDACTED]. The MDS Coordinator also stated that it was an oversight to have not coded the use of [MEDICAL CONDITION] medication accurately. She further stated that based on the residents orders GDR's had been attempted and should have been recorded on the MDS however, this too was an oversight. On 02/21/19 at 01:09 PM, the Director of Nursing Services (DNS) was interviewed and stated that she has not been overseeing the accuracy of the documentation of MDS but the MDS coordinator reports any issues regarding MDS to her. The DNS further stated she is involved minimally to ensure that MDS's are completed and submitted in a timely manner. The DNS further stated that there is a consultant who reviews MDS's on a monthly basis to ensure that all MDS assessments are completed and submitted but does not review the the accuracy of the documentation. 415.11(b)

Plan of Correction: ApprovedMarch 22, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Immediate Corrective Action for Resident affected:

i. The quarterly MDS dated [DATE] and 11/27/18 of resident sample # 36 were modified and submitted to QIES Assessment Submission and Processing (ASAP) system per RAI manual regulation; to reflect the use of antipsychotic and Gradual dose reduction (GDR) that were completed during the assessment look back period.
ii. The MDS assessor/coordinator was counselled and provided in-service education with focus on accuracy of MDS assessment and data coding specifically to reflect use of antipsychotic and GDR completed on section N0410A, and N0450
iii. Counselling and in service on file for validation.
2) Identification of other Resident:
i. The facility respectfully state that this practice has the potential to affect all residents.
ii. MDS coordinator compiled a list of All MDS assessment for the last six months and will be reviewed to ensure that antipsychotic use and GDR completed are accurately coded in the MDS section N0410A and N0450.
iii. Any negative findings will be corrected through MDS assessment review and submission of MDS data modification to the QIES ASAP system as necessary.

3) Systemic Changes made so the deficiency will not reoccur:
i. The facility?s policy and procedure on MDS 3.0 assessment was reviewed by the Administrator, Director of Nursing Services and MDS coordinator. Policy and procedure is in compliance of the regulation and no revision required at this time.

ii. All MDS assessor will receive in-service education on the Policy and procedure of MDS assessment with a focus on;
A. The accuracy of each MDS assessment and data entry to reflect the resident status;
B. Completing the MDS assessment accurately on scheduled look back period;
C. The individual MDS assessor assigned for the section is fully responsible for the accuracy of the data entered into the MDS and ensure that it accurately reflect the resident?s status during the look back period per the RAI/MDS manual and regulation.
D. The use of antipsychotic and the completion of the Gradual Dose Reduction (GDR) must be captured and coded in the MDS section N0410A and N0450 A-E.

iii. The lesson plan and attendance record will be filed for validation.

4) Quality Assurance Monitoring:
i. The Director of Nursing has developed a quality assurance monitoring tool to ensure compliance with MDS assessment to accurately reflect the resident specifically with antipsychotic use and GDR completion.

ii. Audit will be done weekly x 4 weeks for all
Scheduled MDS, followed by 20 % of random MDS scheduled monthly for 3 months and 20% of random scheduled MDS quarterly thereafter.
iii. Any negative findings will be addressed immediately as necessary.
iv. All findings will be brought to quality assurance committee at least quarterly for recommendations as necessary.
5) Responsible Discipline:
The Director of Nursing is responsible to ensure compliance.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) with measurable goals and objectives was developed and implemented to address a resident's medical needs. Specifically, 1) a CCP was not created for a resident with a left hand contracture who had been ordered a hand splint. This was evident for 1 of 2 residents reviewed for position/mobility out of a sample of 56 residents. (Resident #103). 2) a CCP was not developed and implemented for a resident provided with an assistive eating device which was observed not being utilized during meals. (Resident # 131). The findings are: The facility policy Comprehensive Person-Centered Care Plan/Baseline Care Plan dated 01/15/2018 documented: The Comprehensive care plan will be developed within 7 days after the completion of the Comprehensive Assessment (RAI/MDS). The Comprehensive Care Plan will include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with intact cognition, had impairment on one side of both lower and upper extremities, required extensive assistance of 1 person with Activities of Daily Living (ADL's) including transfer, dressing, toilet use, and personal hygiene. physician's orders [REDACTED]. PROM (Passive Range of Motion) to BLE (bilateral lower extremities) and RUE (right upper extremity) for 8 minutes per session BID (twice daily), AROM (Active Range of Motion) to BLE and RUE for 8 minutes per session BID, Left resting hand splint-remove for hygiene. On 02/13/19 at 04:12 PM, Resident #103 was observed wheeling self on the unit towards the elevator, Resident has a contracture on left hand with no hand splint device in place. On 02/14/19 at 11:59 AM, the resident was observed wheeling self in hallway towards the dining room with no splint device in place. On 02/19/19 at 08:50 AM, resident was observed in bed sleeping. No hand splint noted. On 02/20/19 at 10:30 AM, resident was observed wheeling self in hallway towards the nursing station with no hand splint in place. On 02/20/19 at 12:46 PM, resident was observed in room sitting on his wheel chair, and was interviewed about the splint device for his left hand. The resident stated yeah, yeah, yeah, opened the top drawer of the cabinet, took out the blue hand splint and handed it to CNA for assistance putting it on. There was no documented evidence that a CCP had been created to address the resident's contracture or use of splint device as ordered by the physician. On 02/20/19 at 11:18 AM, an interview was conducted with the Certified Nursing Assistant (CNA #1). CNA #1 stated that he started working in the facility in (MONTH) this year, and has been assisting the resident with care for about a month. CNA #1 also stated that resident is assisted in showering and in dressing as needed, but is able to shave himself with supervision and able to move around in the room and within the facility. CNA#1 further stated that resident has contracture of the left hand but is able to move it with some assistance, and is assisted to perform the range of motion on the left hand as tolerated every shift. CNA#1 also stated that resident has a splint to the left hand but does not know where the resident placed it because resident likes to put it on by himself. On 02/20/19 at 12:56 PM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN stated that the resident has order for splint on the left hand and that the staff always assist and encourage the resident to put it on everyday. The resident has a habit of taking it off to put on his jacket, but is always re-directed, encouraged and assisted to put it on constantly. On 02/19 at 09:46 AM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN #1 stated that it is the RN supervisor that is responsible for the initiation of the resident's care plan, and that she is only responsible for updating the nursing care plan as needed, monitoring the resident and documenting in the 24-hour report. LPN #1 also stated that if there is a new order for any device, Physical Therapy (PT) or Occupational Therapy (OT) will initiate the care plan. If that is not done, the RN manager will check and initiate the care plan. The LPN also stated that the unit RN supervisor responsible for creating the careplans has been out sick for about 3 weeks. On 02/22/19 at 10:35 AM, Director of Rehab (DOR) was interviewed. DOR stated that when a resident is evaluated and is determined to need an assistive device, it is procured from the supplier, an order is put in and the device delivered to the unit and staff is educated on how to place the device. DOR also stated that the OT or PT that recommends the device initiates the care plan. The resident is monitored and the care plan is updated usually every 90 days or as may be needed. DOR further stated that the splint device was initially recommended and ordered for the resident on 5/16/18 but was not care planned at that time. He stated that resident is supposed to be monitored for tolerance and the care plan update documented every 3 month, but this was missed and an update to the care plan would be made immediately. 02/22/19 at 10:57 AM, the Director of Nursing Services (DNS) was interviewed. DNS stated that if the new device is recommended and ordered, nursing department will be notified by OT or PT. The order will be picked up by the nursing and care plan initiated by the therapist and/or the nurse manager. DNS stated that the affected nurse manager has been out sick.
2. The Nursing policy and procedure titled Special Device dated 7/22/14 documented that residents will be evaluated for assistive devices upon admission, quarterly, annually and as needed. The policy and procedure titled Feeding Assistive Devices dated 7/2014 documented that feeding assistive devices are provided to residents who will benefit from them. This will aid the resident in being more independent in feeding himself/herself. Resident # 131 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 02/14/19 at 12:21 PM, Licensed Practical Nurse (LPN # 2) was observed feeding Resident # 131 with a regular spoon, not with the weighted/bent spoon that was provided on the tray. On 02/20/19 at 12:20 PM, Resident # 131 was observed in the dining room. Placed on the lunch meal tray was a weighted spoon and pureed foods were provided on a one-sided high rim plate. The Certified Nurse Aide (CNA) encouraged the resident to use the weighted spoon. The Resident scooped the food at least three times (3 x) using the weighted spoon and stopped. The CNA who was assisting her with feeding took the regular spoon and began to feed the resident. The physician's orders [REDACTED]. The (MONTH) 2019 Resident CNA Documentation Record plus Nursing Instructions did not document the use of the assistive device under the ADL eating. The Occupational Therapy form titled Feeding and Adaptive Equipment dated (MONTH) 2019 documented that Resident #131 uses a high-sided dish and weighted spoon. The Minimum Data Set ((MDS) dated [DATE] documented that Resident #131's hearing was adequate, speech was clear, can make herself understood and was able to understand others. Her vision is moderately impaired. Cognition is severely impaired. Mood symptoms were present on several days including feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite or overeating, and trouble concentrating on things. There was no behavior documented. ADLs documented total dependence with 1 person assist for eating. There were no Speech Language Pathologist SLP), Occupational Therapist (OT), Physical Therapist (PT) treatments documented. There was no restorative Nursing Program for eating and/or swallowing. The Comprehensive Care Plan (CCP) on Assistive Device last updated by Rehabilitation on 1/31/19 documented that the CCP Status was incomplete. The CCP on ADLs/Eating effective 9/22/16 documented the following: Goals: ADL needs will be adequately met by Staff daily. Resident will continue to function at current level daily. She will show improvement in at least 1-2 ADL function. Interventions: Assist with needs; encourage maximum action participation in ADL; monitor changes in functional status and refer to PT/OT if needed. Offer/provide protective dining apron at mealtime. The Resident's lunch meal ticket dated Wednesday, 2/20/19 documented No Concentrated Sweets (NCS), Puree diet, Bent spoon, high side dish. On 02/20/19 at 10:37 AM, Certified Nursing Assistant (CNA) #4 was interviewed. CNA #4 stated that she helps Resident #131 during feeding. She needs help during feeding; she can feed herself but it's hard for her. She has a weighted spoon, but I think it's heavy for her. On 02/20/19 at 02:31 PM, CNA #4 was re-interviewed. CNA stated that she knows the purpose of the assistive eating device- the weighted spoon because there was another Resident who had the fat-handled spoon. At one time, she heard a Physical Therapist (PT) talking to the resident who was having difficulty gripping the regular spoon, asking if the resident preferred the fat-handled spoon. The one-sided high rim plate is used so she could slide and scoop her food to feed herself. She stated that she never got any in-service on the use of the assistive eating device. On 02/20/19 at 12:41 PM, LPN #2 was interviewed and stated the weighted spoon is used to encourage the resident to eat with some independence. The plate edge will help her to spoon the food. If she wants to, she will use the spoon. On 02/20/19 at 12:56 PM, Director of Rehab (DOR) was interviewed. The DOR stated there is an order for [REDACTED]. The DOR also stated that when device is first provided to the resident the Rehab department would provide in-service on how the device is to be used. The DOR could not locate a CCP for the assistive device. 415.11(c)(1)

Plan of Correction: ApprovedMarch 22, 2019

1) Immediate Corrective Action for Resident affected:

i. Resident # 103:
Resident was evaluated by Rehab Therapist and examined by Physician. Stable at this time.
A Comprehensive Care Plan was developed, related to the left hand, contracture for Resident 103 and the need for a hand splint as ordered by the Physician.
ii. Resident # 131
Resident was evaluated by rehab therapist and provided assistive eating device per physician order.
A Comprehensive Care Plan was developed, related to the assistive eating device for Resident #131 as ordered by the Physician.
iii. An educational counseling has been provided to the Occupational Therapist for failure to initiate a CCP for Residents # 103 and #131
iv. Educational counseling on file for validation

2) Identification of other Resident:
i. A list of all residents that utilize Assistive Devices for Feeding and Adaptive Equipment was obtained from Physical and Occupational Therapy, to ensure that a Comprehensive Care Plan had been developed for each resident.
ii. The facility respectfully states that there were no other issues identified.

3) Systemic Changes made so the deficiency will not reoccur:
i. The Director of Rehabilitation and Director of Nursing Services (DNS) reviewed and revised the facility P/P, regarding Adaptive Device/Equipment.
ii. The P/P will be in-serviced to all Rehab Therapy and licensed nursing staff with a focus on the following:
? An evaluation/assessment of a resident by the rehab staff will determine if an assistive device or splint will be recommended.
? The therapist will request a physician?s order for any device.
? The PT/OT staff will be responsible for reviewing and ensuring all Comprehensive Care Plans are developed and implemented as needed to address a resident?s current plan of care.
? The PT/OT staff will be responsible for ensuring that all Comprehensive Care Plans are reviewed/revised/or developed as needed to reflect a Resident?s current need at the care plan meeting quarterly or as needed.
? Nursing will transcribe the orders to the Certified Nursing Assistant Accountability instructions and ensure that adaptive device is present/provided per MD order.
iii. Lesson plan and in-service records will remain on file for validation.
4) Quality Assurance Monitoring:
i. The Rehab Director and DNS developed an audit tool to monitor the facility?s compliance with the development of Comprehensive Care Plans with the use of adaptive device.
ii. Audit will be done weekly x 4 weeks for 25% of resident with orders for adaptive device/equipment, followed by and 25 % monthly for 3 months and 25% quarterly
iii. All audit findings will be reported to the QA committee for follow-up and input as needed.
5) Responsible Discipline:
The Director of Rehabilitation is responsible to ensure compliance.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

Based on observations, record review and staff interviews, the facility did not ensure that food is prepared, cooked or stored under appropriate temperatures and with safe handling techniques. Specifically, 1) Foods were not being held at appropriate temperatures to prevent food borne illness.Danger zone temperatures which are between 41F and 135F. 2) the Food Service Staff did not wear beard restraints to prevent hair from contacting food. This was evident during the Kitchen task of the recertification survey. The findings are: 1) On 02/13/19 at 09:21 AM Supervisor #1 and the SA did an initial tour of the kitchen. The refrigerator temperature where juice, lactose milk, sandwiches, jello, applesauce, pudding dated, labeled and stored registered at 38F. On 02/19/19 at 08:40 AM, A follow-up tour of the kitchen was done. The refrigerator temperature where the sandwiches were stored registered at 39F. 02/19/19 11:46 AM Cook #1 took the trayline temperature. The following temperatures were read; Cheese sandwich = 62F; Cream Cheese and jelly sandwich = 62F. On 02/19/19 at 12:10 PM Dietary Aide #1 was interviewed. She stated that she has been doing the sandwiches for 1 year. Cheese sandwich was done at 8am. She takes the cheese out of the refrigerator first. She prepares the sandwich by the sandwich area. She prepared 8 cheese sandwiches on whole wheat bread and 8 cheese on white bread. Then she puts the sandwiches in the refrigerator right away. Sandwiches should be 34 - 40F once they are made. If the sandwich temperature is too high, like 50F, because of the sandwich will have bacteria and anybody who eats it could get sick. Cream cheese and jelly sandwich were done 9: 30am. She said she made about 10 cream cheese and jelly on whole wheat bread and 10 cream cheese and jelly on white bread. Bread was stored all the way in the back of the kitchen not in the refrigerator. No temperatures were taken before the sandwiches were made. No temperatures taken before and after the sandwiches at all. On 02/19/19 at12:18 PM DFS was interviewed. In-service training is done quarterly for food temperatures, monthly for hand washing and maintaining the area clean, wearing of appropriate attire. SA request for in-service training sign in sheets, policy and procedure for food temperature. On 02/19/19 12:42 PM 2nd floor 3S, the last of the 3 food trucks left in the kitchen; food was distributed. On 02/19/19 at 12:46 PM test tray done by DFS (Directo of Food Service). Chopped burger = 100F; rice =118F; soup =130F; milk= 58F; cheese sandwich= 62F; pears= 58F; collard greens=120F; Chopped chicken=100F. On 02/19/19 at 02:23 PM at Cook #2 was interviewed. He stated that he makes salads. The cold foods should have a temperature of 25-35F. Cold meal should not be closed to warm. He makes sure that when cold items are served for any meal, he makes sure that the steam table has a lot of ice so bacteria will not multiply. You can get sick; diarrhea, vomiting, upset stomach and they end up on a clear liquid diet. In-service training on cold service twice a month, and these in-services were documented. Temperature log sheets are done for hot and cold foods as well served on the trayleind. He doesn't deal with sandwiches, only the cold foods on the trayline. On 02/21/19 at 09:47 AM, Food Service Supervisor(FSS) was interviewed. There is no temp logbook for the sandwiches. Cold sandwiches should be below 32F. Hot food should be 165F and up. Test tray is a sample of what is serving at meals on the unit. The test tray is done once a week but we don't log it. She will inform the kitchen and will tell the kitchen and will come back down. The test tray is taken approx at 12pm on the 1st floor dining. Lunch on the first floor is approximately 12:00 PM. When all the meal trucks come out of the dining room, that's when I take the test tray temperature. There were no policies and procedures for testing food temperatures. 2) The facility policy and procedure titled Hairnets and(NAME)Guards dated 11/15/18 documented that hairnets and beard guards are to be worn at all times while performing any work in the kitchen, this includes outside Staff and any other personnel entering the kitchen. On 02/19/19 at 08:40, Cook #1 was cutting peppers. Facial hair was visible and he was not wearing a beard net. The DFS had a visible beard and was not wearing a beard net. On 02/19/19 at 09:07 AM, DFS was interviewed. DFS stated that anyone who has a beard that is loose must wear beard nets. All employees must wear hair nets. Male staff must wear a beard net once in the kitchen. Staff delivering foods on the floor do not need to wear beard nets. DFS stated he must wear a beard net once in the kitchen. On 02/19/19 at 02:23 PM, Cook #2 was interviewed. Cook #2 stated that it is mandatory especially for the cooks to wear a hairnet, beard nets, clean hands and gloves. Cook #2 has a visible beard and said he has to wear a beard net. They must wear hair nets so the hair particles don't fall into foods. In-service training on hair nets and beard guards are done about three times a month. 02/22/19 12:33 PM, Cook #1 was interviewed. Cook #1 stated that facial hair net must be worn since hair might fall into the food and contaminate the food. Hair might carry bacteria from the street while walking. If the hair falls off, we must throw the food because it is contaminated with germs. 415.14(h)

Plan of Correction: ApprovedMarch 22, 2019

1) Immediate Corrective Action for Resident affected:

For holding of foods at appropriate temperatures and prevention of food-borne illness.
i. The facility respectfully states that all the cream cheese and jelly sandwiches that were not stored in the refrigerator were immediately discarded by the Food Service Director (FSD) on 2/19/19.
ii. The Dietary aid that failed to properly store the cream cheese and jelly sandwiches was issued an educational counseling by the FSD on proper food storage/temperatures and holding of cold foods.
iii. The FSD revised the tray-line food temperature log to include the checking of sandwiches and other cold items prior to the start of each tray-line service.
iv. The FSD established a test tray log to validate and track the weekly test tray audits conducted.
Use of beard restraints to prevent hair from contaminating food.
i. Cook # 1 was issued an educational counseling by the FSD for not wearing a beard net when in the kitchen.
ii. The FSD was issued an educational counseling by the Administrator on wearing beard net when in the kitchen.

2) Identification of other Resident:
i. The facility respectfully states that all residents could have been affected.

3) Systemic Changes made so the deficiency will not reoccur:
I.
i. FSD and Corporate Dietitian reviewed and revised the current facility P&P on Sandwich Preparation and Storage.
ii. The revised P&P will be in-serviced to all dietary employees by the FSD. The lesson plan will concentrate on the following;
-Ensuring that all sandwiches are prepared with ingredients stored on an ice bath during the preparation process excluding the bread.
-Once the sandwiches are prepared, they will be immediately placed in the refrigerator for cooling and holding.
-To ensure that sandwiches are served at temperatures of 41 or below, all sandwiches will be prepared the day before and chilled for 24 hours prior to service.
-At the start of each tray-line service the designated staff will be responsible for checking and documenting the temperatures of a randomly selected sandwich on the established tray-line food temperature log.
iii. A copy of the lesson plan and sign-in sheet will be kept on file as validation.
II.
i. The FSD and the Corporate Dietitian established a new P&P and a corresponding log for conducting Test Tray Audits.
ii. The newly established P&P and log will be in-serviced to the FSS by the FSD. The lesson plan will concentrate on the following;
-Weekly the FSS will conduct random test tray audits using the established log.
-Test tray temps will be taken once all the trays have been disseminated to the residents.
-Any noted issues will be immediately corrected.
-All completed audits will be filed for six months in the designated binder located in the dietary office.
iii. The lesson plan and attendance record will be filed for validation.
III.
i. The FSD and the corporate Dietitian reviewed the current facility P&P on Hairnets and(NAME)Guard use and found same to be compliant. The current facility P&P was in-serviced to all dietary employees by the corporate FSD. The lesson plan concentrated on;
-Beard Guards must be worn at all times while performing any work in the kitchen if employee has a beard.
ii. The lesson plan and attendance record will be filed for validation.

4) Quality Assurance Monitoring:
I.
i. The FSD developed a QA audit to track the facility?s compliance with sandwich preparation, storage and service temperatures. Audits will be conducted by the FSD/designee with randomly selected employees preparing sandwiches and randomly selected tray-line food temperature logs. Audits will be conducted weekly x 4 weeks, monthly x 3 months and quarterly thereafter. Any negative findings will be immediately corrected.
ii. All audit findings will be presented to the Administrator and QA committee for follow up and input monthly times 3 months and quarterly thereafter.
II.
i. The FSD developed a QA audit tool to track the facility?s compliance with conducting and validating test tray audits. Audits will be conducted by the FSD weekly x 4 weeks, month x 3 months and quarterly thereafter by a direct review of the completed weekly test tray audits. Any negative findings will be immediately corrected.
ii. All audit findings will be presented to the Administrator and QA committee for follow up and input monthly times 3 months and quarterly thereafter.
III.
i. The FSD developed a QA audit tool for tracking the facility?s compliance with use of(NAME)Guards. Audits will be conducted by the FSD for all employees requiring(NAME)Guard use during random shifts. Audits will be conducted weekly x 4 weeks, monthly x 3 months and quarterly thereafter. Any negative findings will be immediately corrected.
ii. All audit findings will be presented to the Administrator and QA committee for follow up and input monthly times 3 months and quarterly thereafter.
5) Responsible Discipline:
The Food Service Director is responsible to ensure compliance.

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews during the re-certification and abbreviated survey (NY# 907) , the facility did not ensure other residents remained free from abuse. Specifically, a cognitively impaired resident who displays physical aggression towards others physically assaulted more than one resident, on more than one occasion. More specifically, interventions that were put in place to address this aggressive behavior were not evaluated for their effectiveness. This was evident in 1 out of 4 residents reviewed for resident to resident altercations and abuse care area (Resident #282). The finding is: The facility policy and procedure titled, Abuse Prevention (Dated 11/2018) documented the following: The facility policy is to provide a safe resident environment that protects residents from abuse including resident to resident abuse of any type. If any staff is made aware of any alleged violation of abuse, neglect, or mistreatment, the facility will thoroughly investigate the alleged violation, attempt to prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress, and take appropriate corrective action because of investigation findings. Any staff member that observed or is informed of any potentially abusive situation is mandated to report this to the registered nurse supervisor on staff. Investigation of the incident will include witness statements, resident statements, and medical evaluations. All attempts will be made by staff to prevent further potential abuse while the investigation is in progress. Resident #282 most recent admission was on 02/11/19. Resident has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] was reviewed and documented the following: resident has moderately impaired cognition with presence of physical behavior occurring daily including rejection of care occurring one to three days. Resident was identified as putting others at significant risk for physical injury. It was documented that resident exhibited short temper and annoyance daily. The MDS 3.0 quarterly assessment dated [DATE] was reviewed and documented the following: resident has moderately impaired cognition with self-injurious behaviors occurring daily. It was documented that resident exhibited short temper and annoyance daily. The Comprehensive Care Plan (CCP) for Resident to Resident Altercation (Last updated 11/01/18) was reviewed. The CCP identified resident at risk for altercations due to cognitive/mental status. Goal was documented with resident being free of altercations in ninety days. Interventions include staff observing during rounds and care (effective 05/11/16), initiate resident to resident altercation protocol (effective 05/11/16), social services will follow up to assess psychosocial well-being following an incident (effective 05/11/16), encourage resident to voice peer concerns to staff (effective 05/11/16), encourage resident to participate in activities of interest (effective 05/11/16), refer to psychiatrist and psychologist as needed (effective 05/11/16), and one to one observation (effective 04/10/18). The CCP for Behavioral Symptoms (Last Updated 02/20/19) was reviewed. The CCP identified resident with physical abusive and aggressive behaviors related to a [DIAGNOSES REDACTED]. Goal was documented that resident will demonstrate fewer episodes of inappropriate behavior and will have improved behavior in ninety days. Interventions include attempt to ascertain reason for behavior (effective 11/10/16), administer medications as per physician orders [REDACTED]. 04/25/18), maintain clutter free environment (effective 04/25/18), re-approach as needed (effective 06/12/18), assure resident medical issues will be addressed as they arise (effective 11/10/16), encourage participation in activities of choice (effective 11/10/16), provide a private room (effective 04/10/18), provide one on one observation (effective 04/10/18), diversional activities (effective 04/10/18), identify and meet resident needs (effective 04/10/18). The CCP documented no implementation of new interventions since 04/25/18. Physician orders [REDACTED]. Resident was placed on one to one observation from 04/10/18 to 10/23/18. The resident was placed on every thirty-minute checks from 10/4/18 to 10/9/18 and from 02/16/19 to 02/17/19. The resident was also placed on every fifteen-minute observation from 5/20/18 to 6/12/18. Investigation reports were reviewed for the past year from (MONTH) (YEAR) to current (MONTH) 2019. Resident has a history of incidents involving resident to resident altercations with resident as the aggressor. Incidents occurred on 04/10/18 (NY# 240), 04/29/18 (NY# 763), 06/19/18 (NY# 670), and 07/23/18 (NY# 651). All cases were investigated and closed. Investigation on a resident to resident altercation that occurred on 07/23/18 (NY# 907) at 01:00 PM was reviewed. Resident #282 was being wheeled in his wheelchair down the hallway to the scale by the Certified Nursing Assistant (CNA) when suddenly resident #282 hit resident #24 in the face who was passing by. Staff quickly intervened and separated residents. Resident #282 was monitored closely. Later, the same day at 02:50 PM, resident #282 attacked another resident #183 (NY# 651 Closed). Resident #282 was eventually sent out to the hospital on [DATE] for further evaluation of aggressive behaviors. The investigation summary provided did not include staff or witness statements. Nursing, Physician, and Social Work progress notes were reviewed from 04/2018 to current 02/2019. All disciplines documented incidents of resident to resident altercations. Interventions were not reviewed for effectiveness as no new interventions were implemented to prevent further incidents from occurring. Resident nursing instructions documented resident safety with one to one monitoring for safety (effective 10/27/17) and then only every 15-minute monitoring for safety (effective 07/19/18). On 02/21/19 at 11:26 AM and on 02/22/19 at 11:00 AM, the LPN #2 on the third floor was interviewed. Incidents on 04/29/18, 06/19/18, 07/23/18 occurred on third floor. LPN #2 stated resident behaviors include him acting up unexpectedly where resident will make sudden movements and attack others. LPN #2 stated she immediately separates the residents if there's an altercation and reports it to the supervisor. She stated when resident is asked why he hits others he cannot explain due to cognitive impairment. LPN #2 stated the resident was only on every 15-minute monitoring as an intervention and never on a one to one. She further stated resident was not on a one to one because a staff was not assigned on schedule for it. On 02/21/19 at 11:40 AM, the Registered Nurse Supervisor (RNS) #3 who is covering the second and third floor was interviewed. She stated she had just started working a couple of months ago and was not present when the above incidents occurred. She stated if any staff witness any incidents, the CNA will report to charge nurse who will report to the supervisor. Staff are expected to immediately intervene, keep resident safe, call for help, and report to supervisor. Supervisors then report to the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). RNS #3 stated the investigation is started right away by getting statements, complete assessments including physicals, and put a plan in place. Investigations should be completed within 24 to 48 hours. If there is suspicion of abuse, the ADON or DON will report it to the NYSDOH within 24 hours of incident occurring. On 02/22/19 at 10:37 AM, the Licensed Practical Nurse (LPN) #1 on the second floor was interviewed. Incident on 04/10/18 occurred on second floor. LPN #1 stated resident behaviors include being non-compliant with care, throws items on the floor, and becomes physically aggressive with residents and staff. She stated when a resident to resident incident occurs, she immediately separates the residents and places them in their room and notify the supervisor and physician. LPN #1 stated when incidents occurred on her floor, interventions included placing resident on a one to one and resident has been sent to the emergency room for a psychiatric evaluation. Resident was also being monitored every 15 minutes. There were no new interventions aside from those. On 02/21/19 at 03:49 PM and on 02/22/19 at 02:00 PM, the DON was interviewed. She stated when there is an incident, the staff on the unit will intervene right away by separating the residents and making sure they are safe. The staff who witness it reports it to the charge nurse and/or supervisor. The supervisor then reports it to the DON. The investigation is conducted right away. The ADON was responsible for making sure the investigation was completed. DON stated an investigation is comprised of a report of what had happened, staff statements, staff interviews, and resident interviews if possible. It should also include notification of the physician and family. An assessment is also completed to assess for injury. The resident will also be referred to social services and/or psychiatry or other disciplines as needed. The ADON did not complete the investigation and had resigned 10/2018. DON stated it was her responsibility as well to make sure investigations are completed with all the elements included. DON stated resident #282 behavior is spontaneous and unpredictable. Resident #282 was placed on every 15- or 30-minute monitoring. She then stated resident #282 was not always on one to one and was only on it briefly even though the physician orders [REDACTED]. DON stated the interdisciplinary team which is composed of the administrator, DON, corporate nurse, physical/occupational therapist, recreation, social work, and RNS, review effectiveness of interventions during MDS meetings and as needed. DON stated interventions that were carried out for resident #282 were keeping him away from other residents, monitor him closely, redirecting, changing units, putting him with residents who can defend themselves, and involving family. She further stated these interventions were not all documented and should have been. 415.4(b)(1)(i)

Plan of Correction: ApprovedMarch 22, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Immediate Corrective Action for Resident affected:

i. Resident # 282 was readmitted on [DATE] and he was placed in a private room and on a 1 to 1 monitoring. An IDCP meeting was held to address the aggressive behavior and there has been no altercations identified since re-admission.
ii. Resident was evaluated by primary physician and psychiatrist with orders carried out. Stable at this time.
iii. The Registered Nurse RN Supervisor who was responsible to have obtained the necessary statements is no longer employed by the facility
iv. A staff meeting held with registered nurse supervisors (RNS) to discuss the omission of all necessary staff statements that need to be obtained in a timely manner to ensure compliance with cited F tag 600 483.12(a)(1) Free from Abuse and Neglect.
v. An Educational counseling will be provided to the DNS for failure to ensure that all necessary statements were obtained before reporting to the DOH, to ensure completion of investigation on a timely manner and to ensure that resident care plan is reviewed and updated to reflect interventions provided.
vi. The IDT Team received an educational counseling for not updating and evaluating the effectiveness of care plan interventions.
vii. Educational counseling on file for validation.
2) Identification of other Resident:
i. The facility respectfully states that all residents have the potential to be affected by the deficient practice.
ii. Ownership/Designee will review all Incident/Accident Occurrences for the past 3 months to ensure compliance. Any findings will be immediately corrected

3) Systemic Changes made so the deficiency will not reoccur:
i. The Administrator, Director of Nursing (DNS) and Ownership/Designee have reviewed the facility?s P/P on Abuse prevention and Accident/Incident report completion.No revision necessary.
ii. The Nurse Educator will in-service all nursing staff & IDT Team on the policy of Abuse Prevention and Accident/Incident.
The focus will address
? Abuse prevention, abuse prohibition and protecting resident;
? That any staff member who witnesses or is informed of any potentially abusive situation is mandated to report to the immediate supervisor
? The immediate relocation of a resident as necessary to ensure their safety.
? The Completion of all Accident/Incident Occurrences in a timely manner, including witness statements.
? The review and reevaluation of the resident care plan to reflect all interventions provided to maintain safety.
Lesson plan and in-services records will remain on file for validation
iii. The DNS and ADON will conduct a weekly scheduled meeting ensuring that all Occurrence?s Reports are accurately recorded and accounted for. Additionally, they will ensure that all necessary statements have been obtained in a timely manner.

4) Quality Assurance Monitoring:
i. The Administrator and ownership/Designee has developed an audit tool to monitor the facility?s compliance with the timely and through completion of All resident to resident Occurrences as per P/P.
ii. The audit will be completed by Administrator/Designee for all resident to resident Occurrences weekly X4 weeks followed by 20% monthly X2 and quarterly thereafter. All audit findings will be reported to the QA Committee for follow up and input as needed
5) Responsible Discipline:
The Administrator is responsible to ensure compliance.

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

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews during the re-certification survey andand abbreviated survey (NY# 907, the facility did not take appropriate actions in response to an alleged violation of abuse, neglect, exploitation, or mistreatment. Specifically, the facility did not ensure an investigation involving a resident to resident altercation was thoroughly investigated to include witness statements and to prevent further incidents from occurring. This was evident for 1 of 4 residents reviewed for resident to resident altercation and abuse care area (Resident #282). The finding is. The facility policy and procedure titled, Abuse Prevention (Dated 11/2018) documented the following: The facility policy is to provide a safe resident environment that protects residents from abuse including resident to resident abuse of any type. If any staff is made aware of any alleged violation of abuse, neglect, or mistreatment, the facility will thoroughly investigate the alleged violation, attempt to prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress, and take appropriate corrective action as a result of investigation findings. Any staff member that observed or is informed of any potentially abusive situation is mandated to report this to the registered nurse supervisor on staff. Investigation of the incident will include witness statements, resident statements, and medical evaluations. All attempts will be made by staff to prevent further potential abuse while the investigation is in progress. Resident #282 most recent admission was on 02/11/19. Resident has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] was reviewed and documented the following: resident has moderately impaired cognition with presence of physical behavior occurring daily including rejection of care occurring one to three days. Resident was identified as putting others at significant risk for physical injury. The MDS 3.0 quarterly assessment dated [DATE] was reviewed and documented the resident has moderately impaired cognition with no presence of behaviors. The Comprehensive Care Plan (CCP) for Resident to Resident Altercation (Last updated 11/01/18) was reviewed. The CCP identified resident at risk for altercations due to cognitive/mental status. Goal was documented with resident being free of altercations in ninety days. Interventions include staff observing during rounds and care (effective 05/11/16), initiate resident to resident altercation protocol (effective 05/11/16), social services will follow up to assess psychosocial well being following an incident (effective 05/11/16), encourage resident to voice peer concerns to staff (effective 05/11/16), encourage resident to participate in activities of interest (effective 05/11/16), refer to psychiatrist and psychologist as needed (effective 05/11/16), and one to one observation (effective 04/10/18). The CCP for Behavioral Symptoms (Last Updated 02/20/19) was reviewed. The CCP identified resident with physical abusive and aggressive behaviors related to a [DIAGNOSES REDACTED]. Goal was documented with resident will demonstrate fewer episodes of inappropriate behavior and will have improved behavior in ninety days. Interventions include attempt to ascertain reason for behavior (effective 11/10/16), administer medications as per physician orders [REDACTED]. 04/25/18), maintain clutter free environment (effective 04/25/18), re-approach as needed (effective 06/12/18), assure resident medical issues will be addressed as they arise (effective 11/10/16), encourage participation in activities of choice (effective 11/10/16), provide a private room (effective 04/10/18), provide one on one observation (effective 04/10/18), diversional activities (effective 04/10/18), identify and meet resident needs (effective 04/10/18). The CCP reveals no new interventions were implemented since 04/25/18. Physician orders [REDACTED]. The resident was placed on every thirty minute checks from 10/4/18 to 10/9/18 and from 02/16/19 to 02/17/19. In addition, the resident was placed on every fifteen minute observation from 5/20/18 to 6/12/18. Investigation reports were reviewed for the past year from (MONTH) (YEAR) to current (MONTH) 2019. Resident has a history of incidents involving resident to resident altercations with resident as the aggressor. Incidents occurred on 04/10/18 (NY# 240), 04/29/18 (NY# 763), 06/19/18 (NY# 670), and 07/23/18 (NY# 651). All cases were investigated and closed. Investigation on a resident to resident altercation that occurred on 07/23/18 (NY# 907) at 01:00 PM was reviewed. Resident #282 was being wheeled in his wheelchair down the hallway to the scale by the Certified Nursing Assistant (CNA) when suddenly resident #282 hit resident #24 in the face who was passing by. Staff quickly intervened and separated residents. Resident #282 was monitored closely. Later on the same day at 02:50 PM, resident #282 attacked another resident #183 (NY# 651 Closed). Resident #282 was eventually sent out to the hospital on [DATE] for further evaluation of aggressive behaviors. The investigation summary provided did not include staff or witness statements. Nursing, Physician, and Social Work progress notes were reviewed from 04/2018 to current 02/2019. All disciplines documented incidents of resident to resident altercations. Interventions were not reviewed for effectiveness as no new interventions were implemented to prevent further incidents from occurring. Resident nursing instructions documented resident safety with one to one monitoring for safety (effective 10/27/17) and then only every 15 minute monitoring for safety (effective 07/19/18). On 02/21/19 at 11:26 AM and on 02/22/19 at 11:00 AM, the LPN #2 on the third floor was interviewed. Incidents on 04/29/18, 06/19/18, 07/23/18 occurred on third floor. LPN #2 stated resident behaviors include him acting up unexpectedly where resident will make sudden movements and attack others. LPN #2 stated she immediately separates the residents if there's an altercation and reports it to the supervisor. She stated when resident is asked why he hits others he cannot explain due to cognitive impairment. LPN #2 stated the resident was only on every 15 minute monitoring as an intervention and never on a one to one. She further stated resident was not on a one to one because a staff was not assigned on schedule for it. On 02/21/19 at 11:40 AM the Registered Nurse Supervisor (RNS) #3 who is covering the second and third floor was interviewed. She stated she had just started working a couple of months ago and was not present when the above incidents occurred. She stated if any staff witness any incidents, the CNA will report to charge nurse who will report to the supervisor. Staff are expected to immediately intervene, keep resident safe, call for help, and report to supervisor. Supervisors then report to the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). RNS #3 stated the investigation is started right away by getting statements, complete assessments including physicals, and put a plan in place. Investigations should be completed within 24 to 48 hours. If there is suspicion of abuse, the ADON or DON will report it to the NYSDOH within 24 hours of incident occurring. On 02/22/19 at 10:37 AM, the Licensed Practical Nurse (LPN) #1 on the second floor was interviewed. Incident on 04/10/18 occurred on second floor. LPN #1 stated resident behaviors include being non-compliant with care, throws items on the floor, and becomes physically aggressive with residents and staff. She stated when a resident to resident incident occurs, she immediately separates the residents and places them in their room, and notify the supervisor and physician. LPN #1 stated when incidents occurred on her floor, interventions included placing resident on a one to one and resident has been sent to the emergency room for a psychiatric evaluation. Resident was also being monitored every 15 minutes. There were no new interventions aside from those. On 02/21/19 at 03:49 PM and on 02/22/19 at 02:00 PM, the DON #1 was interviewed. She stated when there is an incident, the staff on the unit will intervene right away by separating the residents and making sure they are safe. The staff who witness it reports it to the charge nurse and/or supervisor. The supervisor then reports it to the DON. The investigation is conducted right away. The ADON was responsible for making sure the investigation were completed. DON #1 stated an investigation is comprised of a report of what had happened, staff statements, staff interviews, and resident interviews if possible. It should also include notification of the physician and family. An assessment is also completed to assess for injury. The resident will also be referred to social services and/or psychiatry or other disciplines as needed. The ADON did not complete the investigation and had resigned 10/2018. DON #1 stated it was her responsibility as well to make sure investigations are completed with all the elements included. DON #1 stated resident #282 behavior is spontaneous and unpredictable. Resident #282 was placed on every 15 or 30 minute monitoring. She then stated resident #282 was not always on one to one and was only on it briefly even though the physician orders [REDACTED].#1 stated the orders might have automatically renewed every month but staff was not on schedule to complete the one to one. DON #1 stated the interdisciplinary team which is composed of the administrator, DON, corporate nurse, physical/occupational therapist, recreation, social work, and RNS, review effectiveness of interventions during MDS meetings and as needed. DON #1 stated interventions that were carried out for resident #282 were keeping him away from other residents, monitor him closely, redirecting, changing units, putting him with residents who can defend themselves, and involving family. She further stated these interventions were not all documented and should've been. 415.4(b)(3)

Plan of Correction: ApprovedMarch 22, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Immediate Corrective Action for Resident affected:

i. Resident #282 readmitted to the facility on [DATE] and was placed in a private room and placed on 1 to 1 monitoring. Care plan meeting held with interdisciplinary team. Plan of care was reviewed, and revised plan of care found to be appropriate for resident?s need.
ii. Resident was evaluated by primary physician and psychiatrist with orders carried out. Resident stable at this time and No behavior occurrence has been displayed since hospital return.
iii. A meeting was held with the Administrator, Director of Nursing and Assistant Director of Nursing to discuss the omission of necessary documentation that needs to be obtained in a timely manner to ensure compliance with cited F tag 600 483.12(a)(1) Free from Abuse and Neglect.
iv. The ADNS/RN who was responsible to obtain completed occurrence investigation and witness statements in (MONTH) 23, (YEAR) is no longer employed at the facility.
v. The DNS who completed occurrence reporting received counselling for failure to ensure that all witness statements were collected, investigation completed timely, and resident?s plan of care reviewed and evaluated to reflect all interventions provided.
vi. Educational counseling on file for validation.
2) Identification of other Resident:
i. The facility respectfully states that all residents have the potential to be affected by the deficient practice.
ii. Ownership/Designee will review all resident to resident Incident/Accident Occurrences for the last three months.
iii. Any negative findings will be immediately corrected.

3) Systemic Changes made so the deficiency will not reoccur:
i. The Administrator, Director of Nursing (DNS) and Ownership/Designee have reviewed the facility?s P/P on Abuse Prevention and accident/incident investigation and reporting. Policy is in compliance and no revision needed at this time.
ii. The Nurse Educator will in-service all staff on the Abuse Prevention Policy and Completion of all Accident/Incident Occurrences in a timely manner.
The focus will address:
? The timely investigation of the incident including: completed witness statements including their discipline, the time of statement, the shift worked and any additional information requested. Resident statements and medical evaluation.
? The immediate initiation of a Resident to Resident Report of the Accident/ Incident Report.
? That any staff member that observed or is informed of any potentially abusive situation and/or allegation is mandated to report this to the immediate supervisor immediately.
? The immediate re-location of a resident as necessary to ensure their safety.
? The timely notification to the Immediate Supervisor, Director of Nursing, physician and resident?s family.
? The DNS and ADON will conduct a weekly scheduled meeting of all Occurrences to ensure that all Occurrence?s Reports are accurately recorded and accounted for. Additionally, they will ensure that all necessary statements have been obtained in a timely manner.

iii. The lesson plan and attendance record will be filed for validation.

4) Quality Assurance Monitoring:
i. The Ownership/Designee and administrator has developed an audit tool to monitor the facility?s compliance with the timely and thorough completion of All resident to resident Occurrences as per P/P.
ii. The audit will be completed by Administrator/Designee for all resident to resident Occurrences weekly X4 weeks, followed by 20% monthly X2 and quarterly thereafter. All audit findings will be reported to the QA Committee for follow up and input as needed
5) Responsible Discipline:
The Administrator is responsible to ensure compliance.

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that treatment and care to address the resident's range of motion needs were provided in accordance with professional standards of practice. Specifically, splint devices for a resident's left hand contracture were not applied as ordered by the physician and a Comprehensive Care Plan (CCP) was not created for range of motion or splint device use. This was evident for 1 of 2 residents reviewed for position/mobility out of a sample of 56 residents. (Resident #103). The findings are: The facility policy Comprehensive Person-Centered Care Plan/Baseline Care Plan dated 01/15/2018 documented: The Comprehensive care plan will be developed within 7 days after the completion of the Comprehensive Assessment (RAI/MDS). The Comprehensive Care Plan will include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with intact cognition, had impairment on one side of both lower and upper extremities, required extensive assistance of 1 person with Activities of Daily Living (ADL's) including transfer, dressing, toilet use, and personal hygiene. physician's orders [REDACTED]. PROM (Passive Range of Motion) to BLE (bilateral lower extremities) and RUE (right upper extremity) for 8 minutes per session BID (twice daily), AROM (Active Range of Motion) to BLE and RUE for 8 minutes per session BID, Left resting hand splint-remove for hygiene. On 02/13/19 at 04:12 PM, Resident #103 was observed wheeling self on the unit towards the elevator, Resident has a contracture on left hand with no hand splint device in place. On 02/14/19 at 11:59 AM, the resident was observed wheeling self in hallway towards the dining room with no splint device in place. On 02/19/19 at 08:50 AM, resident was observed in bed sleeping. No hand splint noted. On 02/20/19 at 10:30 AM, resident was observed wheeling self in hallway towards the nursing station with no hand splint in place. On 02/20/19 at 12:46 PM, resident was observed in room sitting on his wheel chair, and was interviewed about the splint device for his left hand. The resident stated yeah, yeah, yeah, opened the top drawer of the cabinet, took out the blue hand splint and handed it to CNA for assistance putting it on. The hand splint device was not applied as ordered by the physician and there was no documented evidence that the resident was monitored for the appropriate use of the device. There was no documented evidence that a CCP had been created to address the resident's contracture or use of splint device as ordered by the physician. On 02/20/19 at 11:18 AM, an interview was conducted with the Certified Nursing Assistant (CNA #1). CNA #1 stated that he started working in the facility in (MONTH) this year, and has been assisting the resident with care for about a month. CNA #1 also stated that resident is assisted in showering and in dressing as needed, but is able to shave himself with supervision and able to move around in the room and within the facility. CNA#1 further stated that resident has contracture of the left hand but is able to move it with some assistance, and is assisted to perform the range of motion on the left hand as tolerated every shift. CNA#1 also stated that resident has a splint to the left hand but does not know where the resident placed it because resident likes to put it on by himself. On 02/20/19 at 12:56 PM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN stated that the resident has order for splint on the left hand and that the staff always assist and encourage the resident to put it on everyday. The resident has a habit of taking it off to put on his jacket, but is always re-directed, encouraged and assisted to put it on constantly. On 02/19 at 09:46 AM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN #1 stated that it is the RN supervisor that is responsible for the initiation of the resident's care plan, and that she is only responsible for updating the nursing care plan as needed, monitoring the resident and documenting in the 24-hour report. LPN #1 also stated that if there is a new order for any device, Physical Therapy (PT) or Occupational Therapy (OT) will initiate the care plan. If that is not done, the RN manager will check and initiate the care plan. The LPN also stated that the unit RN supervisor responsible for creating the careplans has been out sick for about 3 weeks. On 02/22/19 at 10:35 AM, Director of Rehab (DOR) was interviewed. DOR stated that when a resident is evaluated and is determined to need an assistive device, it is procured from the supplier, an order is put in and the device delivered to the unit and staff is educated on how to place the device. DOR also stated that the OT or PT that recommends the device initiates the care plan. The resident is monitored and the care plan is updated usually every 90 days or as may be needed. DOR further stated that the splint device was initially recommended and ordered for the resident on 5/16/18 but was not care planned at that time. He stated that resident is supposed to be monitored for tolerance and the care plan update documented every 3 month, but this was missed and an update to the care plan would be made immediately. 02/22/19 at 10:57 AM, the Director of Nursing Services (DNS) was interviewed. DNS stated that if the new device is recommended and ordered, nursing department will be notified by OT or PT. The order will be picked up by the nursing and care plan initiated by the therapist and/or the nurse manager. DNS stated that the affected nurse manager has been out sick. 415.12

Plan of Correction: ApprovedMarch 22, 2019

1) Immediate Corrective Action for Resident affected:

i. The resident sample # 103 was examined by Primary physician on 2/27/19 and found to be clinically stable. Resident was also seen by OT and PT Therapist and left hand splint and range of motion will be continued per MD order. Resident was educated by therapist and will be assisted by nursing staff in placement of left hand splint.
ii. Care plan for resident #103 was developed for the use of hand splint and range of motion exercises per MD order on 2/22/19.
iii. CNA #1 was counselled and provided in-service education with focus on ensuring that resident is assisted to put the left hand splint on and to ensure that it stays in place as per plan of care. CNA was also educated to notify licensed nurse if left hand splint is not in place or removed by resident.
iv. LPN#1 was counselled and provided in-service education to ensure that left hand splint was put on with the assistance of the CNA and to notify RN supervisor for any issues with the splint application and care plan.
v. RN supervisor who failed to initiate the care plan is no longer employed at the facility
vi. OT staff was counselled and provided in-service education for failure to initiate the care plan with left hand splint use and educated to ensure that adaptive devices ordered will have a care plan initiated and nursing staff education will be provided.
vii. Counselling and in service on file for validation.
2) Identification of other Resident:
i. The facility respectfully state that this practice has the potential to affect all residents.
ii. Director of Rehabilitation (DOR) and Director of Nursing Services (DNS) compiled a list of all resident with orders for splints and adaptive device/equipment. The list is used to ensure that all ordered adaptive devices/equipment are in place and care plan is initiated.
iii. Any negative findings will be immediately corrected as necessary.

3) Systemic Changes made so the deficiency will not reoccur:
i. The facility?s Policy and Procedure on Adaptive Device/Equipment Policy was reviewed and revised by the Administrator, Director of Nursing Services and Director of Rehabilitation to ensure compliance with Quality of Care and ensure that residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan and the resident?s choices.

ii. The Nursing and Rehabilitation staff will be educated and in serviced on the revised policy with focus on;
A. To enhance quality of care by ensuring that residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan and the resident?s choices.
B. To ensure that treatment and care to address the resident?s range of motion needs are provided in accordance with professional standards of practice.
C. Residents are evaluated by therapist for range of motion needs and for adaptive device use as necessary.
D. Care plan will be initiated by the therapist and education will be provided to resident and nursing staff when an adaptive devise/equipment is ordered by the Physician.
E. Nursing staff will ensure that:
1. The care plan is in place;
2. The ordered adaptive device/equipment is applied/provided daily as per plan of care, and
3. Will notify rehabilitation therapist for any concerns regarding adaptive device/equipment use.
F. Therapist will address immediately any concerns regarding range of motion and adaptive device/equipment use as necessary.
G. A quarterly reevaluation will be completed by therapist for resident?s range of motion need and adaptive device/equipment use.
iii. The lesson plan and attendance record will be filed for validation.

4) Quality Assurance Monitoring:
i. The DNS and DOR has developed a quality assurance monitoring tool to ensure compliance with F684 specifically to ensure resident?s range of motion need and adaptive device/equipment use are provided in accordance with professional standards of practice.

ii. Audit will be done weekly x 4 weeks for 25% of resident with orders fo adaptive device/equipment, followed by and 25 % monthly for 3 months and 25% quarterly thereafter.
iii. Any negative findings will be addressed immediately as necessary.
iv. All findings will be brought to quality assurance committee at least quarterly for recommendations as necessary.
5) Responsible Discipline:
The Director of Nursing is responsible to ensure compliance.

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: February 22, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews during the re-certification survey and abbreviated survey (NY# 907, the facility did not ensure that alleged violations involving abuse, neglect, exploitation or mistreatment were reported to the proper authorities within prescribed time frames. Specifically, an allegation of abuse that occurred in (MONTH) (YEAR) was not reported to the NYS DOH until (MONTH) (YEAR). This was evident in 1 out of 4 residents reviewed for resident to resident altercation and abuse care area (Resident #282). The finding is: The facility policy and procedure titled, Abuse Prevention (Dated 11/2018) documented the following: Reporting/Response-immediately reporting all alleged violations to the Administrator and to the DNS; Reporting, when necessary, to the police and the NYS DOH within specified timeframes. Resident #282 most recent admission was on 02/11/19. Resident has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] was reviewed and documented the following: Resident has moderately impaired cognition with presence of physical behavior occurring daily including rejection of care occurring one to three days. Resident was identified as putting others at significant risk for physical injury. It was documented that resident exhibited short temper and annoyance daily. The MDS 3.0 quarterly assessment dated [DATE] was reviewed and documented the following: Resident has moderately impaired cognition with self injurious behaviors occurring daily. It was documented that resident exhibited short temper and annoyance daily. Investigation reports were reviewed for the past year from (MONTH) (YEAR) to current (MONTH) 2019. Resident has a history of incidents involving resident to resident altercations with resident as the aggressor. Incidents occurred on 04/10/18 (NY# 240), 04/29/18 (NY# 763), 06/19/18 (NY# 670), and 07/23/18 (NY# 651). All cases were investigated and closed. Investigation on a resident to resident altercation that occurred on 07/23/18 (NY# 907) at 01:00 PM was reviewed. Resident #282 was being wheeled in his wheelchair down the hallway to the scale by the Certified Nursing Assistant (CNA) when suddenly resident #282 hit resident #24 in the face who was passing by. Staff quickly intervened and separated residents. Resident #282 was monitored closely. Later on the same day at 02:50 PM, resident #282 attacked another resident #183 (NY# 651 Closed). Resident #282 was eventually sent out to the hospital on [DATE] for further evaluation of aggressive behaviors. The facility documented there is reasonable cause to believe that abuse, neglect, mistreatment, exploitation or misappropriation has occurred and as a result the NYSDOH was notified. The investigation was completed on 7/27/18, however was not reported to NYSDOH until 10/15/18. On 02/21/19 at 11:40 AM, the Registered Nurse Supervisor (RNS) #3 who is covering the second and third floor was interviewed. She stated she had just started working a couple of months ago and was not present when the above incidents occurred. She stated if any staff witness any incidents, the CNA will report to charge nurse who will report to the supervisor. Staff are expected to immediately intervene, keep resident safe, call for help, and report to supervisor. Supervisors then report to the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). RNS #3 stated the investigation is started right away by getting statements, complete assessments including physicals, and put a plan in place. Investigations should be completed within 24 to 48 hours. If there is suspicion of abuse, the ADON or DON will report it to the NYSDOH within 24 hours of incident occurring. On 02/21/19 at 03:49 PM and on 02/22/19 at 02:00 PM, the DON was interviewed. She stated when there is an incident, the staff on the unit will intervene right away by separating the residents and making sure they are safe. The staff who witness it reports it to the charge nurse and/or supervisor. The supervisor then reports it to the DON. The investigation is conducted right away. The ADON was responsible for making sure the investigation were completed. DON stated an investigation is comprised of a report of what had happened, staff statements, staff interviews, and resident interviews if possible. It should also include notification of the physician and family. An assessment is also completed to assess for injury. The resident will also be referred to social services and/or psychiatry or other disciplines as needed. The ADON did not complete the investigation and had resigned 10/2018. DON stated it was her responsibility as well to make sure investigations are completed with all the elements included. 415.4(b)(2)

Plan of Correction: ApprovedMarch 22, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Immediate Corrective Action for Resident affected:

i. Resident # 282 was readmitted on [DATE] and he was placed in a private room and on a 1 to 1 monitoring. An IDCP meeting was held to address the aggressive behavior and there has been no altercations identified since re-admission. Resident was evaluated by primary physician and psychiatrist with orders carried out. Stable at this time.
ii. An Ad-Hoc QAPI meeting was held on 10/3/18 with the Administrator, Director of Nursing Services (DNS), Department heads and Ownership/Designee. The meeting was held to discuss the identified delay in reporting Resident to Resident Altercations and Reportable Altercations that had not been reported to the Department of Health (DOH) timely. The QAPI team reviewed and identified Resident to Resident Altercations between (MONTH) (YEAR) and (MONTH) (YEAR) and re-opened occurrences investigation as needed and Reported to the DOH when reporting criteria was met. This case with Resident #282 was reported to the DOH on 10/15/18 by the Director of Nursing as part of the QAPI finding.
iii. The Administrator and Director of Nursing received an educational counseling on 10/3/18 by Ownership/Designee for failure to report the Resident to Resident investigations to the DOH in a timely manner.
iv. The Administrator and Director of Nursing received an educational counseling by Ownership/Designee for failure to ensure compliance with Federal Regulation 483.12(c)(1)(4) F 609.
v. Educational counseling on file for validation

2) Identification of other Resident:
i. The facility respectfully states that all residents have the potential to be affected by the deficient practice.
ii. Ownership/Designee has reviewed all Resident to Resident Altercations since (MONTH) (YEAR) and through (MONTH) 2019. All reportable incidents have been reported to the NYS Department of Health.
iii. No other issue identified

3) Systemic Changes made so the deficiency will not reoccur:
i. The Administrator, DNS and Ownership/Designee have reviewed the facility?s P/P on Abuse Prevention and accident/incident occurrence reporting. No revisions necessary.
ii. The Nurse Educator will in-service all facility staff regarding timely reporting of all occurrences specifically, Resident to Resident.
The focus will address
? Completing Resident to Resident and Accident/ Incident Reports in a timely manner.
? All Resident to Resident/Reportable Incidents to be reported to Administration, DNS/Designee at time of occurrence.
? Timely reporting to NYS DOH as per reporting manual Version (YEAR).
iii. Lesson plan and in-service records will remain on file for validation.
4) Quality Assurance Monitoring:
i. The Administrator and Ownership/Designee has developed an audit tool to monitor the facility?s compliance with the timely reporting of Resident to Resident Altercations and Reportable incidents as per P/P
ii. The audit will be completed by Administrator/DNS for all Resident to Resident Altercations/Reportable Incidents weekly X4 weeks followed by 20% monthly X3 and quarterly thereafter. All audit findings will be reported to the QA Committee for follow-up and input as needed.
5) Responsible Discipline:
The Administrator is responsible to ensure compliance.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility did not ensure that the residents rights to a dignified existence and treat each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Specifically, Nursing staff were standing over residents while assisting them to eat. This is evident for 9 out of 56 residents observed during the dining task of the recertification survey (Resident #s 9, 41, 46, 55, 115, 130, 131, 175, 180.) The findings are: On 02/13/19 at 12:31 PM, Certified Nurse Aide/s(CNA/s) fed three residents by standing next to them instead of seated in front of them. (Resident # 46 by CNA #6, Resident # 130 by CNA#7, and Resident #180 by CNA #3). A Licensed Practical Nurse (LPN #2) took over feeding a resident (Resident #4). LPN#2 also fed the resident while standing next to the resident. On 02/14/19 at 12:17 PM, LPN #2 was feeding Resident #131 while standing next to the resident. LPN #2 then fed another resident (Resident #115). LPN #2 also fed the resident while standing. On 02/14/19 at 12:22 PM to 12:31 PM, four CNAs were observed feeding four residents while standing next to them. (Resident #46 by CNA #8, Resident #130 by CNA #7, Resident #55 by CNA #9 and Resident #180 by CNA#3.) CNA#10 was observed sitting down in the beginning of the meal while feeding the resident. CNA #10 then stood up and began feeding Resident #41. On 02/14/19 at 12:38 PM, in the Small Dining Room (SDR), two residents were fed by 2 CNAs standing next to them (Resident #9 by CNA#11 and Resident #175 was fed by CNA #12). The facility policy and procedure titled Meal Pass and dated 2/20/19 documented on procedure #16 that residents who need to be fed should be fed immediately after the tray is placed before him/her. All persons feeding residents should be seated. On 02/20/19 at 10:37 AM, CNA #4 was interviewed. CNA helps out feeding a resident. This resident can feed herself but it's hard to feed herself, so she needs to be fed. She has a weighted spoon, but I think it's heavy for her. On a later interview (02/20/19 at 02:31 PM), she stated that staff should be sitting next to the resident during feeding; but there are only 2-fold up green chairs that are used for feeding. If another staff is using them, I cannot use it. These 2 chairs are used for both the main DR and the small dining rooms. Everybody is aware including LPN#2 but not RN#3 and RN #4 may not know about the green chairs. The former Floor Manager knows about the green chairs. On 02/20/19 at 02:47 PM, CNA#5 was interviewed. CNA #5 stated she is responsible for feeding 3 other residents. CNA#5 said she is supposed to be sitting down but we don't have anything to sit on. They have these [MEDICATION NAME] chairs which are too low for her since she is tall. The CNA's have only 2 [MEDICATION NAME], green chairs which are used in the main dining room. They had stools which had wheels but residents sit on them, and one resident who sat on it almost fell on the floor, so they were taken away. On 02/20/19 at 03:10 PM, LPN#2 was interviewed. LPN#2 stated that staff stands next to the resident while feeding them. There is no issue feeding the resident standing up. She stated that she doesn't know if it is the proper way. She stated, I usually feed them standing up. On 02/20/19 at 03:52 PM, RN#3 was interviewed. RN#3 stated that the CNA's are not supposed to be standing next to the residents while feeding them; they should be sitting. They are supposed to have eye contact with the resident and not towering over them. Staff needs to be engaging the residents. There was no in-service training provided to staff on feeding the residents. On 02/22/19 at 09:09 AM, CNA # 3 was interviewed. CNA#3 stated that if there's a chair she will be sitting next to the resident while feeding. Chairs came up yesterday. Sometimes, it is comfortable sitting to feed them because they take a long time to eat. She stated that it's better for the resident because you are in the same eye level as the resident. Feeding residents while sitting next to them encourages them to eat more because they see you at an eye level. On 02/22/19 at 09:19 AM, CNA #6 was interviewed. CNA stated that LPN #2 trained her how to feed a resident. CNA#6 stated that she just finished training at an institute last September. She learned that the State regulation states that she needs to sit next to the resident while feeding because it will be less intimidating, they see you at eye level, they could see who was feeding them and interact with them. CNA said she was standing next to the residents while feeding them last week. There might not be a chair due to space in between the two residents. 415.3(c)(1)(i)

Plan of Correction: ApprovedMarch 22, 2019

1) Immediate Corrective Action for Resident affected:

i. All resident?s identified on units two (2) and three (3) as well as other residents are being assisted with meal/fed by all staff seated at eye level. Ensuring/promoting dignity and enhancing resident?s quality of life.
ii. All nursing staff CNAs and licensed nurses who were observed standing while assisting residents with meals/feeding received educational counseling regarding residents rights specifically with a focus on:
A. Resident?s dining experience, promoting quality of life and dignity by always sitting at eye level while assisting with meals/feeding residents.
B. Enhancing/maintaining quality of life and dignity by engaging in positive pleasant conversation while assisting with meals/feeding residents.
C. Allowing residents time to complete meals while encouraging completion of meals.
iii.
A. The resident that was fed by CNA #4 will be reevaluated for the use of the weighted spoon by the Occupational Therapist.
B. The CNA (#4) received educational counselling focused on;
1. Always reporting to charge nurse any change in resident?s condition immediately, namely; noting any changes with resident?s ability to feed self or use adaptive eating device.

iv. LPN #2 received educational counselling regarding Resident?s rights with a focus on; promoting enhancing a quality of life with dignity.
Namely and specifically during mealtime;
A. All staff assisting with meals feeding residents must be seated at eye level to residents.
B. All staff should be engaging in positive and pleasant conversation when possible during mealtime.
C. Staff must allow resident time to complete meals while encouraging completion of meals.
v. Counselling and In service record on file for validation.
vi. The facility has ordered 30 adjustable sitting stools for all dining areas/rooms specifically intended for CNA to sit while assisting Residents with mealtime feeding. A partial ordered has been received.
2) Identification of other Resident:
i. The facility respectfully state that this practice has the potential to affect all residents.
ii. All dining areas were observed/monitored by the licensed nurse to ensure that staff assisting residents with meals/feeding are seated at eye level promoting resident?s dignity and quality of life.
iii. During Observation and monitoring all staff were seated while feeding residents at mealtime.

3) Systemic Changes made so the deficiency will not reoccur:
i. The facility?s policy titled ?Meal Pass? was reviewed and revised by the Director of Nursing Services (DNS).
The revision includes key importance and main focus;
All staff must make every effort to ensure a pleasurable mealtime experience for all residents.
The resident?s rights to a dignified existence must always be considered, as such;
A. Staff must be seated at eye level while assisting with meals/feeding.
B. Staff must engage the resident with positive, pleasurable conversation.
C. Staff must allow resident?s time necessary to complete meals, while encouraging resident to complete meals.
ii. All nursing staff, CNAs and licensed nurses will receive in-service education on the revised Policy and Procedure with the focus on;
The significance of promoting dignity and enhancing quality of life for residents during mealtime and while assisting with meals/feeding.
iii. The lesson plan and attendance record will be filed for validation.

4) Quality Assurance Monitoring:
i. The Director of Nursing has developed a quality assurance monitoring tool to ensure compliance.
ii. All unit dining rooms will be audited daily during mealtime by the licensed nurses for thirty (30) days followed by once weekly on random days for 30 days and quarterly thereafter.
iii. Any negative findings will be addressed immediately and brought to the attention of the DNS for disciplinary action as necessary.
iv. All findings will be brought to quality assurance committee at least quarterly for recommendations as necessary.
5) Responsible Discipline:
The Director of Nursing is responsible to ensure compliance.

FF11 483.10(g)(6)-(9):RIGHT TO FORMS OF COMMUNICATION W/ PRIVACY

REGULATION: §483.10(g)(6) The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. This includes the right to retain and use a cellular phone at the resident's own expense. §483.10(g)(7) The facility must protect and facilitate that resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to: (i) A telephone, including TTY and TDD services; (ii) The internet, to the extent available to the facility; and (iii) Stationery, postage, writing implements and the ability to send mail. §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident's own expense. §483.10(g)(9) The resident has the right to have reasonable access to and privacy in their use of electronic communications such as email and video communications and for internet research. (i) If the access is available to the facility (ii) At the resident's expense, if any additional expense is incurred by the facility to provide such access to the resident. (iii) Such use must comply with State and Federal law.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

Based on resident and staff interviews and record reviews during the re-certification survey, the facility did not ensure resident rights were maintained. Specifically, residents did not receive their mail including letters, packages, and other materials in a timely manner. This was evident in fourteen (14) of 14 residents (#20, 38, 162, 8, 6, 65, 154, 39, 2, 35, 68, 179, 57, 148) who attended the Resident Council meeting. The finding is: The facility policy and procedure titled, Privacy and Confidentiality (Dated 11/2017) was reviewed. .Mail is delivered to residents within 24 hours of receiving it on regularly scheduled days . On 02/14/19 from 11:00 AM to 11:30 AM, a Resident Council meeting was held with 14 residents. All 14 of 14 residents reported mail is not always delivered stating staff would say mail will be delivered whenever they get around to it. Residents also stated they receive mail up to 3 weeks late. They know this because they see when the letter is postmarked. All residents further stated they do not sign off on anything when they receive mail and there's no set scheduled for when they receive mail. They also stated they do not receive mail on the weekend including Saturdays. On 02/22/19 at 09:31 AM, the Director of Recreation was interviewed. She stated mail is delivered to the facility where Book Keeping/Finance sorts it. All resident mail is then given to recreation to sort resident's mail per floor and assigned to staff members for daily distribution, Monday through Friday. It is normally distributed towards the end of the day otherwise it will be handed out the next day. Mail is not distributed over the weekend, including Saturday because Book Keeping/Finance is not here. Weekend mail is not taken care of until Monday. The Director of Recreation further stated she does not keep track of mail being delivered to the residents, specifically, which resident received mail and when it was delivered. On 02/22/19 09:41 AM, the Book Keeper was interviewed. She stated mail is delivered to the facility where she sorts it. All resident letters go to recreation for distribution. The book keeper stated the mail comes late so sometimes it gets sorted the same day or the next. She further stated mail is not handled over the weekend, including Saturdays due to nobody working. The weekend mail gets sorted on Monday. The book keeper then stated she does not keep a log or tracking documentation to show they received and handed out mail. 415.3(d)(2)(i)

Plan of Correction: ApprovedMarch 22, 2019

1) Immediate Corrective Action for Resident affected:

i. A meeting will be held with the Residents, with the focus;
A. Residents Right to receive mail including letters, packages and any other materials in a timely manner.
B Review the facility?s newly developed Policy and procedure titled ?Distribution of Residents mail, packages and materials; All mail and other mailed materials will be delivered daily Monday through Sunday between the hours of 3 PM and 5 PM.
C. Mail and other material delivered will be logged in and Resident?s signature, date and time will be requested for tracking timeliness.
ii. The facility will request the attendance of all residents who attended the resident council meeting on 2/14/19 at 11 AM, as well as all other residents.
iii. The bookkeeping and recreating director received educational counselling regarding;
A. The importance of observing Resident?s Right to receive mail and any other mailed material in a timely manner; notable within 24 hours of facility receiving.
B. Daily distribution of Residents mailed materials received Monday through Sunday between hours of 3PM and 5PM.
C. Mail and all other mailed materials will be logged in book with date and time of delivery and signature (where possible) of resident for tracking of timely delivery.
iv. Counselling and in service record on file for validation.
2) Identification of other Resident:
i. The facility respectfully submits that this practice has the potential to affect all residents.
ii. All mail, letters, packages and other mailing materials will be delivered to all residents within 24 hours of the facility receiving. Delivery will be daily Monday through Sunday between the hours of 3PM and 5PM

3) Systemic Changes made so the deficiency will not reoccur:
i. The administrator has developed a policy and procedure entitled? Resident?s Right; timely distribution of resident mail, packages and other mailed materials?.
ii. The policy and procedure specifically notes ;
A. Daily distribution of all residents? mail, packages and other materials Monday through Sunday 3PM to 5 PM within 24 hours of facility receiving.
B. The use of logging book with date and time to ensure daily delivery and tracking with each Resident?s signature (when possible), date and time.

iii. The bookkeeping staff and recreation staff will receive In-service education on the newly developed policy and procedure.
The education will focus on;
A. Resident?s right to receive mail, packages and any other material daily within 24 hour of the facility receiving.
B. Delivery of all received mailed materials will be distributed daily between the hours of 3PM and 5 PM Monday through Sunday.
C. All resident receiving any mailed material will be documented in the log book with Resident?s signature when possible.
iv. Attendance record and lesson plan will be filed for validation.
4) Quality Assurance Monitoring:
i. The Administrator developed a quality assurance monitoring tool to track compliance with timely delivery of all mailed materials to residents.
ii. The administrator or designee will complete daily audits by reviewing the log books for one month followed by twenty (20) percent random audits for three months and quarterly thereafter.
iii. Any negative findings will be addressed by the administrator immediately.
iv. All findings will be reported to the quality assurance performance improvement committee at least quarterly for review and recommendations as necessary.
5) Responsible Discipline:
The Administrator is responsible to ensure compliance.

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the re-certification survey, the facility did not ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior. Specifically including but not limited to, resident furniture was observed to be in disrepair. This was evident on 2 of 3 resident care units. (Units 2 and 3.) The finding is. 1) On 02/14/19 at 02:30 PM and on 02/21/19 at 09:13 AM, Resident #180 room on floor 3 North was observed with a missing drawer from its wardrobe closet. 2) On 02/21/19 at 08:45 AM, Surveyor observed in the room of Resident #157, a rectangular white patch below the window. It was a different paint color from the paint in the rest of the room. The floor 3 North Maintenance Book was reviewed from 1/2018 to Current. There was no documentation regarding above resident closet drawer missing. Almost 99% documentation in the book is documented as Checked by (initial of worker). On 02/21/19 at 09:14 AM, the Certified Nursing Assistant (CNA #3) who cares for resident #180 stated she had reported the missing drawer to maintenance awhile ago verbally only. She further stated there's a maintenance book but staff does not document in it. It's only for maintenance to document that they completed a job that needed to be done that was reported to them verbally.
3) During multiple observations made between 02/13/19 03:10 PM and 02/19/19 12:21 PM, many housekeeping and maintenance issues were found. In Resident room [ROOM NUMBER]-worn, chipped head board. Wall dirty with brownish marks next to bed. Bathroom doors in disrepair, chipped with splinters. Paper holder ajar. In Resident room [ROOM NUMBER]-stained ceiling tile, dusty window ledges, bathroom door with mismatched patches, outer base of tub discolored, peeling paint, radiator in bathroom dusty, wall tiles in bathroom dusty and dirty, and unpainted wall next to sink, closet drawers off tracks. In Resident room [ROOM NUMBER]- outer base of bath tub discolored with chipped peeling paint. In Resident room [ROOM NUMBER]-dust over wall socket and wire housing, dusty window ledges, brownish spills on wall under socket, multiple unsightly patches on bolted bathroom door, different colored patches of paint on bedroom wall, and rusted window blinds. In Resident room [ROOM NUMBER]-lower base of tub discolored, soiled towel on top of covered tub, bathroom door with multiple patches, chipped dressers, bathroom door frame rotted at lower left corner. In Resident room [ROOM NUMBER]- radiator cover loose in corner. Dusty window ledges. Room door with chipped, separating plywood. The Bathroom doors were in disrepair, both patched in several places, and mismatched wall paint in several areas in bedroom. In Resident room [ROOM NUMBER] there was mismatched paint on walls, dusty window ledges, dust and dirt on wiring housing. In the men's bathroom next to room [ROOM NUMBER] there was a heavy urine odor, mismatched paint on wall above 1st sink. In the last toilet stall there was a heavy urine odor, dried brown stains on edges of stall floor, stall walls were soiled with whitish substances in several places. There was mismatched paint on stall walls, stained ceiling tiles, rust at base of dividing stall walls, and ground in brown stains on floor tiles. The privacy curtains were soiled with brownish black marks, hanging askew from curtain rod. The men's bathroom next to room [ROOM NUMBER] there were soiled wall tiles. There were curtain hooks above the door with no curtain hanging. A patched, unpainted area on bathroom wall. In adjacent bathroom two badly worn mirrors, dusty, dirty radiator cover. There were whitish splashes on stall walls and tiles and ground in brown stains on floor tiles. In room [ROOM NUMBER] there was a strong urine odor that could be smelled from the hallway. There were orange colored stains underneath bed B. There was mismatched wall paint in corridors past room [ROOM NUMBER]. In multiple rooms the corners and floors needed sweeping and mopping. Table edges at the 2nd floor nursing station noted with chipped edges. Resident's charts on the table at the nursing station with brownish stains. On 02/21/19 at 03:05 PM and on 2/22/19 at 10:09 AM, interviews were held with the Housekeeping/Maintenance Director. He stated he does a minimum of weekly rounds and as often as possible. This includes all resident rooms being checked for cleanliness and broken or missing furniture on the unit where the unit is picked randomly. A checklist is used to indicate what was checked in each resident room. A check mark is satisfactory, and an X mark is unsatisfactory. He stated that he has a check list too which includes the dusting of the windows. There is a schedule of the staff's daily assignments. This schedule instructs the staff on what needs to be done daily. The schedule is posted on the bulletin board in porter's room. He stated that he has as a log, which he uses to check that the work is done as scheduled. If any staff is lacking on the assignment, he or she is instructed to re-do it. Some resident rooms are difficult to maintain, but efforts are made to ensure every room is kept clean and tidy. The Maintenance Director stated that the facility had a staff member assigned to strip and mop the floor, but recently lost him. The facility is in the process of hiring someone to take over that task. As for the overbed tables that are in disrepair, the director stated that the facility has purchased a new set of tables to replace all the rusted overbed tables. He further stated that the facility is in the process of fixing and replacing the damaged and missing drawers. The maintenance director stated that rooms noted with strong urine odor are always given special treatment, staff are instructed to pay special attention to all the affected rooms. The director stated that the facility also just hired a plumber to fix all the damaged and leaking pipes and tiles. The maintenance communication book for the second floor was reviewed. The book was checked off daily by maintenance staff. However, there was not consistent documentation noting the reporting of maintenance or housekeeping issues. It also did not document any observations or reporting of faulty equipment. 415.5(h)(2)

Plan of Correction: ApprovedMarch 22, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Immediate Corrective Action for Resident affected:

i. The Maintenance Director and Housekeeping Director received an educational counselling/disciplinary action for not ensuring that housekeeping and maintenance services maintained a sanitary, orderly and comfortable homelike environment, and ensure that furniture should be in good repair. Education to focus on maintaining and checking work orders, consistent rounds, following schedules for set routine preventative maintenance, ensuring that all repairs are corrected timely, sanitary issues and routine cleaning schedules addressed and corrected timely.
ii. Educational counseling on file for validation
iii. Resident #180 ? Missing Drawer from wardrobe closet replaced.
iv. Resident #157 ? White patch below window is in the process of being painted to match paint in room.
v. Resident room [ROOM NUMBER] ? worn chipped head board, replaced; wall with dirty brownish marks cleaned and painted; bathroom door replaced; and paper holder repaired.
vi. Resident room [ROOM NUMBER] ? Stained ceiling tiles replaced, dusty window ledges cleaned, outer base of tub repainted and peeling paint removed, radiator and wall tiles in bathroom cleaned and dusted; unpainted wall next to sink painted; and closet drawers repaired and placed on track.
vii. Resident room [ROOM NUMBER] ? outer base of tub repainted and peeling paint removed.
viii. Resident room [ROOM NUMBER] ? wall socked, wire housing and ledges cleaned and dusted; brownish spills on walls and multiple unsightly patches on bathroom door and bedroom wall are in the process of being repainted; rusted window blinds replaced.
ix. Resident room [ROOM NUMBER] ? lower base of tub, bathroom door with multiple patches and frame were ordered and are in the process of being replaced; soiled towel removed; chipped dressers being replaced.
x. Resident room [ROOM NUMBER] ? Radiator cover repaired. Dusty window ledges cleaned; Room door repaired and painted, and bathroom door replaced. Mismatched wall was repainted.
xi. Resident room [ROOM NUMBER] - Room repainted; dusty window ledges and wiring housing cleaned and painted.
xii. Men?s Bathroom next to 209 ? All stalls in bathroom will be replaced and have been ordered, bathroom cleaned and no urine order; mismatched paint above sink and on stall walls repainted; Floor tiles are in the process of being cleaned to remove brown stains; wall stains repainted; privacy curtains replaced. Ceiling tiles replaced;
xiii. Men?s Bathroom next to 237 - Soiled wall cleaned, floor tiles in the process of being cleaned; missing curtains replaced, patched unpainted area repainted on bathroom wall; worn mirrors replaced; radiators cleaned.
xiv. room [ROOM NUMBER] ? room cleaned and floor is in the process of being scraped and waxed.
xv. Corridors near 223 are in the process of being repainted.
xvi. All rooms? corners and floors were cleaned appropriately, swept and mopped.
xvii. Table edges with chips at the 2nd floor nursing station in process of being replaced.
xviii. Resident?s charts on second floor at nursing station cleaned and new charts are being ordered.

2) Identification of other Resident:
i. The Administrator compiled a list of all residents? rooms and resident areas.
ii. List will be used by Administrator, Maintenance Director and Housekeeping Director to conduct a comprehensive inspection of all resident rooms? areas. All identified quality issues will be immediately addressed.

3) Systemic Changes made so the deficiency will not reoccur:
i. The Maintenance Director, Housekeeper Director and the Administrator reviewed and revised the Policy and Procedure on Preventative Maintenance, the Policy and Procedure for Cleaning and Sanitizing Rooms, Policy and Procedure on Rounds/Housekeeping.
ii. All Housekeeping/ Maintenance , Nursing staff will receive in-services. The lesson plan for Preventative Maintenance will focus on:
The focus will address:
? All staff will understand the importance of ensuring that residents are provided with a safe, sanitary, comfortable and homelike environment and document.
? All staff are responsible to complete a Maintenance Request sheet (work order request) if they find any equipment or furniture in disrepair, unsafe or not in sanitary condition. Staff member is responsible to complete the Maintenance Request Sheet with all pertinent information, sign and date. Staff member to then place the Maintenance Request Sheet in the Maintenance Log Book.
? Maintenance Director will check the log book daily for Maintenance Request Sheets and sign and date indicating that log book was reviewed. He/She will then assign the Maintenance Request Sheets to the maintenance staff to fix or replace broken equipment. Once the requested work has been completed, the maintenance staff member will sign the bottom portion validating the work has been completed and give the completed Maintenance Request sheet to the Maintenance Director for confirmation.
? Equipment not safely functioning will be taken out of service and stored for repair or replacement.
? Maintenance Director and Housekeeping Director will maintain appropriate logs, make rounds and ensure that all resident equipment is cleaned and in good repair.
? All furniture and resident equipment used to provide homelike environment will be evaluated for safety and repair according to set schedules. Information will documented on Maintenance Request Sheet and any quality issues will be immediately corrected.
? Furniture, equipment found broken and unsafe will be removed from resident?s room.

iii. Housekeeping will receive an in-service on Daily Cleaning Routine to ensure that housekeeping maintain a safe, sanitary environment.
The focus will address:
? Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a daily basis and when spills occur.
? All resident?s rooms ,bathrooms, and resident areas, shall be cleaned thoroughly daily according to set daily routine, according to set infection control standards.
? Environmental surfaces will be disinfected on a daily basis and when surfaces are soiled.
? Walls, window ledges, furniture, blinds, and radiators in resident areas will be cleaned and dusted.
? During cleaning if any furniture, blinds, equipment are found broken, staff member is responsible complete a Maintenance Request Sheet and place in the log book.
iv. The lesson plan and attendance record will be filed for validation.

4) Quality Assurance Monitoring:
i. The Administrator, Maintenance Director and Housekeeping Director will develop an audit tool to monitor compliance with systems related to ensuring that residents are being provided a safe, sanitary, orderly and comfortable interior and routine rounds are conducted.
ii. Audits of 20 resident rooms/resident areas will be conducted by the Maintenance Director/Housekeeping Director weekly times four weeks, and findings reviewed at QA Morning Report, then 20 resident/resident areas monthly for the first three months, 20 resident/resident areas quarterly thereafter.
iii. Any negative findings will be corrected immediately.
iv. Audit findings will be presented to the QA committee weekly for the first month, monthly for the first three months, and then quarterly for evaluation and follow up as indicated. Findings will be reviewed for compliance.
5) Responsible Discipline:
The Administrator is responsible to ensure compliance.

FF11 483.90(i):SAFE/FUNCTIONAL/SANITARY/COMFORTABLE ENVIRON

REGULATION: §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that the residents received care in a safe, clean, comfortable and homelike environment. Specifically, the facility did not ensure that a safe, functional, sanitary, and comfortable environment is provided for residents, staff and the public. This was evidenced by multiple observations of the residents' rooms, bathrooms, and nursing station. Findings are: The facility policy and procedure titled Policy & Procedure on Environmental Rounds/Houskeeping dated 12/2017, documented that: It is the policy of Park Nursing Home to provide a safe, clean, comfortable and homelike environment for all residents. During multiple observations made between 02/13/19 03:10 PM and 02/19/19 12:21 PM, the following was observed on the second floor: room [ROOM NUMBER] - worn, chipped head board. Wall dirty with brownish marks next to bed. Bathroom doors in disrepair, chipped with splinters. Paper holder ajar. room [ROOM NUMBER] 5 - stained ceiling tile, dusty window ledges, bathroom door with mismatched patches, outer base of tub discolored, peeling paint, radiator in bathroom dusty, wall tiles in bathroom dusty and dirty, unpainted wall next to sink, closet drawers off tracks. room [ROOM NUMBER] - outer base of bath tub discolored with chipped peeling paint; room [ROOM NUMBER] - dust over wall socket and wire housing, dusty window ledges, brownish spills on wall under socket, multiple unsightly patches on bolted bathroom door, different colored patches of paint on bedroom wall, rusted window blinds; room [ROOM NUMBER] - lower base of tub discolored, soiled towel on top of covered tub, bathroom door with multiple patches, chipped dressers, bathroom door frame rotted at lower left corner; room [ROOM NUMBER]- radiator cover loose in corner. Dusty window ledges. Room door with chipped, separating plywood. Bathroom doors in disrepair-both patched in several places, mismatched wall paint in several areas in bedroom; room [ROOM NUMBER] - mismatched paint on walls, dusty window ledges, dust and dirt on wiring housing; Men's bathroom next to room [ROOM NUMBER]-unoccupied, heavy urine odor, mismatched paint on wall above 1st sink, last toilet stall heavy urine odor, dried brown stains on edges of stall floor, stall walls soiled with whitish substances in several places, mismatched paint on stall walls, stained ceiling tiles, rust at base of dividing stall walls, ground in brown stains on floor tiles, curtains soiled with brownish black marks, hanging askew from curtain rod. Men's bathroom next to room [ROOM NUMBER]-soiled wall tiles, curtain hooks above door-no curtain hanging, patched, unpainted area on bathroom wall. In adjacent bathroom [ROOM NUMBER] badly worn mirrors, dusty, dirty radiator cover, whitish splashes on stall walls and tiles, ground in brown stains on floor tiles. room [ROOM NUMBER] - strong urine odor from hallway, orange colored stains underneath bed B. Mismatched wall paint in corridors past room [ROOM NUMBER]. The table top with chipped edges on second floor nursing station. There were resident's charts on the table at the nursing station stained with brownish dirt On 02/21/19 at 03:05 PM and on 2/22/19 at 10:09 AM interviews were held with the Housekeeping/Maintenance Director. He stated he does a minimum of weekly rounds and as often as possible. This includes all resident rooms being checked for cleanliness and broken or missing furniture on the unit where the unit is picked randomly. A checklist is used to indicate what was checked in each resident room. A check mark is satisfactory, and an X mark is unsatisfactory. He stated that he has a check list to which includes the dusting of the windows. There is a schedule of the staff's daily assignments. This schedule instructs the staff on what needs to be done daily. The schedule is posted on the bulletin board in porter's room. He stated that he has as a log, which he uses to check that the work is done as scheduled. If any staff is lacking on the assignment, he or she is instructed to re-do it. Some resident rooms are difficult to maintain, but efforts are made to ensure every room is kept clean and tidy. The Maintenance Director stated that the facility had a staff member assigned to strip and mop the floor, but recently lost him. The facility is in the process of hiring someone to take over that task. As for the overbed tables that are in disrepair, the director stated that the facility has purchased a new set of tables to replace all the rusted overbed tables. He further stated that the facility is in the process of fixing and replacing the damaged and missing drawers. The maintenance director stated that rooms noted with strong urine odor are always given special treatment, staff are instructed to pay special attention to all the affected rooms. The director stated that the facility also just hired a plumber to fix all the damaged and leaking pipes and tiles. The maintenance communication book for the second floor was reviewed. The book was checked off daily by maintenance staff. However, there was not consistent documentation noting the reporting of maintenance or housekeeping issues. It also did not document any observations or reporting of faulty equipment. 415.29

Plan of Correction: ApprovedMarch 22, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Immediate Corrective Action for Resident affected:

i. The Administrator received an educational counselling for not ensuring that the residents received care in a safe, clean, comfortable and homelike environment for residents, staff and public.
ii. The Maintenance Director and Housekeeping Director received an educational counselling/disciplinary action for not ensuring that housekeeping and maintenance services maintained a sanitary, orderly and comfortable homelike environment, and ensure that furniture should be in good repair. Education focused on maintaining and checking work orders, consistent rounds, following schedules for set routine preventative maintenance, ensuring that all repairs corrected timely, sanitary issues and routine cleaning schedules addressed and corrected timely.
iii. Resident #180 ? Missing Drawer from wardrobe closet replaced.
iv. Resident #157 ? White patch below window is in the process of being painted to match paint in room.
v. Resident room [ROOM NUMBER] ? worn chipped head board, replaced; wall with dirty brownish marks cleaned and painted; bathroom door replaced; and paper holder repaired.
vi. Resident room [ROOM NUMBER] ? Stained ceiling tiles replaced, dusty window ledges cleaned, outer base of tub repainted and peeling paint removed, radiator and wall tiles in bathroom cleaned and dusted; unpainted wall next to sink painted; and closet drawers repaired and placed on track.
vii. Resident room [ROOM NUMBER] ? outer base of tub repainted and peeling paint removed.
viii. Resident room [ROOM NUMBER] ? wall socked, wire housing and ledges cleaned and dusted; brownish spills on walls and multiple unsightly patches on bathroom door and bedroom wall are in the process of being repainted; rusted window blinds replaced.
ix. Resident room [ROOM NUMBER] ? lower base of tub, bathroom door with multiple patches and frame were ordered and are in the process of being replaced; soiled towel removed; chipped dressers being replaced.
x. Resident room [ROOM NUMBER] ? Radiator cover repaired. Dusty window ledges cleaned; Room door repaired and painted, and bathroom door replaced. Mismatched wall was repainted.
xi. Resident room [ROOM NUMBER] - Room repainted; dusty window ledges and wiring housing cleaned and painted.
xii. Men?s Bathroom next to 209 ? All stalls in bathroom will be replaced and have been ordered, bathroom cleaned and no urine order; mismatched paint above sink and on stall walls repainted; Floor tiles are in the process of being cleaned to remove brown stains; wall stains repainted; privacy curtains replaced. Ceiling tiles replaced;
xiii. Men?s Bathroom next to 237 - Soiled wall cleaned, floor tiles in the process of being cleaned; missing curtains replaced, patched unpainted area repainted on bathroom wall; worn mirrors replaced; radiators cleaned.
xiv. room [ROOM NUMBER] ? room cleaned and floor is in the process of being scraped and waxed.
xv. Corridors near 223 are in the process of being repainted.
xvi. All rooms? corners and floors were cleaned appropriately, swept and mopped.
xvii. Table edges with chips at the 2nd floor nursing station in process of being replaced.
xviii. Resident?s charts on second floor at nursing station cleaned and new charts are being ordered.

2) Identification of other Resident:
i. The Administrator compiled a list of all residents? rooms and resident areas.
ii. List will be used by Maintenance Director and Housekeeping Director to conduct a comprehensive inspection of all resident rooms? areas. All identified quality issues will be immediately corrected.

3) Systemic Changes made so the deficiency will not reoccur:
i. The Maintenance Director, Housekeeper Director and the Administrator reviewed and revised the Policy and Procedure on Preventative Maintenance, the Policy and Procedure for Cleaning and Sanitizing Rooms, Policy and Procedure on Rounds/Housekeeping.
ii. All Housekeeping/ Maintenance , Nursing staff will receive in-services. The lesson plan for Preventative Maintenance will focus on:
? All staff will understand the importance of ensuring that residents are provided with a safe, sanitary, comfortable and homelike environment and document.
? All staff are responsible to complete a Maintenance Request sheet (work order request) if they find any equipment or furniture in disrepair, unsafe or not in sanitary condition. Staff member is responsible to complete the Maintenance Request Sheet with all pertinent information, sign and date. Staff member to then place the Maintenance Request Sheet in the Maintenance Log Book.
? Maintenance Director will check the log book daily for Maintenance Request Sheets and assign them to the maintenance staff to fix or replace broken equipment. Once the requested work has been completed, the maintenance staff member will sign the bottom portion validating the work has been completed and give the completed Maintenance Request sheet to the Maintenance Director for confirmation.
? Equipment not safely functioning will be taken out of service and stored for repair or replacement.
? Maintenance Director and Housekeeping Director will maintain appropriate logs, make rounds and ensure that all resident equipment is cleaned and in good repair.
? All furniture and resident equipment used to provide homelike environment will be evaluated for safety and repair according to set schedules. Information will documented on Maintenance Request Sheet and any quality issues will be immediately corrected.
? Furniture, equipment found broken and unsafe will be removed from resident?s room.

iii. Housekeeping will receive an in-service on Daily Cleaning Routine to ensure that housekeeping maintain a safe, sanitary environment.
The focus will address:
? Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a daily basis and when spills occur.
? All resident?s rooms ,bathrooms, and resident areas, shall be cleaned thoroughly daily according to set daily routine, according to set infection control standards.
? Environmental surfaces will be disinfected on a daily basis and when surfaces are soiled.
? Walls, window ledges, furniture, blinds, and radiators in resident areas will be cleaned and dusted.
? During cleaning if any furniture, blinds, equipment are found broken, staff member is responsible complete a Maintenance Request Sheet and place in the log book.
iv. The lesson plan and attendance record will be filed for validation.

4) Quality Assurance Monitoring:
i. The Administrator, Maintenance Director and Housekeeping Director will develop an audit tool to monitor compliance with systems related to ensuring that residents are being provided a safe, sanitary, orderly and comfortable interior and routine rounds are conducted.
ii. Weekly Audits of 20 resident rooms/resident areas will be conducted weekly by the Maintenance Director/Housekeeping Director weekly times four weeks, and findings reviewed at QA Morning Report, then 20 resident/resident areas monthly for the first three months 20 resident/resident areas quarterly thereafter.
iii. Any negative findings will be corrected immediately.
iv. Audit findings will be presented to the QA committee weekly for the first month, monthly for the first three months, and then quarterly for evaluation and follow up as indicated findings will be reviewed for compliance.
v. Responsible Discipline:
The Administrator is responsible to ensure compliance.

Standard Life Safety Code Citations

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 22, 2019
Corrected date: April 18, 2019

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address policies and procedures regarding the use of volunteers in an emergency. Specifically, the facility's emergency policy did not address utilizing and credentialing volunteer support of health care professionals. The findings are: On 2/15/2019 between 10 am and 1 pm during the recertification survey, review of the Emergency Preparedness plan revealed that the facility lacked a policy regarding the use of volunteers and how to utilize volunteer support of health care professionals. In an emergency, facilities may need to accept volunteer support from individuals with varying levels of skills and training, including health care professionals. The facility's Emergency Preparedness plan identified the Volunteer Unit Leader role but they lacked a policy addressing how to facilitate the volunteer support. In an interview on 2/15/2019 at approximately 1:15 pm, the Administrator stated the policy would be updated to include information regarding the use and credentialing of volunteer healthcare professionals.

Plan of Correction: ApprovedMarch 6, 2019

I) Immediate Corrective Action for Resident affected:
i. The facility?s Emergency Preparedness Plan was reviewed on 3/4/19, regarding Utilizing Volunteer Support in an emergency. The policy was updated specifically to include utilizing Medical Volunteers and how to verify said volunteers? credentials and to facilitate their support.
ii. There were no residents identified in the SOD for this deficiency.

II) Identification of Other Resident:
The facility respectfully states that no residents were involved in this deficiency, however all residents were potentially affected.
III) Systemic Changes made so the deficiency will not reoccur:
i. The revised policy will be in-serviced to the Administrator, DNS, ADNS & HR by ownership/designee.
ii. Lesson plan will be developed to specifically include utilizing Medical Volunteers and how to verify said volunteers? credentials and to facilitate their support.
iii. In-service records will be kept on file for verification.
iv. The Administrator / Designee will review the Emergency Preparedness Plan and update as necessary.The plan will be reviewed/updated annually thereafter.

IV) Monitoring of the Corrective Action/Quality Assurance:

i. The Administrator will develop an audit tool to monitor compliance with the use of volunteer policy requirement.
ii. An audit will be completed by the administrator quarterly. Any negative findings will be immediately corrected and presented to the QA committee for follow up.

V) Responsibility:
Administrator

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2019
Corrected date: April 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101: 19.3.5.5 In Type I and Type II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered. 2012 NFPA 101: 9.7.3.1 In any occupancy where the character of the fuel for fire is such that extinguishment or control of fire is accomplished by a type of automatic extinguishing system in lieu of an automatic sprinkler system, such system shall be installed in accordance with the appropriate standard, as determined in accordance with Table 9.7.3.1. 2012 NFPA 101: Table 9.7.3.1 Fire Suppression System Installation Standards Fire Suppression System Installation Standard Low-, medium-, and high-expansion foam systems NFPA 11, Standard for Low-, Medium-, and High-Expansion Foam Carbon [MEDICATION NAME] systems NFPA 12, Standard on Carbon [MEDICATION NAME] Extinguishing Systems Halon 1301 systems NFPA 12A, Standard on Halon 1301 Fire Extinguishing Systems Water spray fixed systems NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection Deluge foam-water sprinkler systems NFPA 16, Standard for the Installation of Foam-Water Sprinkler and Foam-Water Spray Systems Dry chemical systems NFPA 17, Standard for Dry Chemical Extinguishing Systems Wet chemical systems NFPA 17A, Standard for Wet Chemical Extinguishing Systems Water mist systems NFPA 750, Standard on Water Mist Fire Protection Systems Clean agent extinguishing systems NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems 2009 NFPA 17: 5.7.4 Connection to the Alarm System. The extinguishing system shall be connected to the fire alarm system, if provided, in accordance with the requirements of NFPA 72, National Fire Alarm Code®, so that the actuation of the dry chemical system will sound the fire alarm as well as provide the function of the extinguishing system Based on observation and staff interview, the facility failed to ensure that the facility was protected throughout by an automatic extinguishing system, specifically the dry chemical extinguishing system in the roof top elevator machine room was not tied into the fire alarm system . This is a repeat citation from the recertification survey of 5/11/2017. The findings are: During the life safety portion of the recertification survey on 2/14/2019 at approximately 10:00 am during the life safety portion of the recertification survey, it was noted that the dry chemical extinguishing system installed in the rooftop elevator machine room was not tied into the building's fire alarm system. Document review of the Plan of Correction from the previous survey of 5/11/2017 stated The facility has contracted with Safety Sprinkler System Company, to connect the dry chemical system to the fire alarm system. Completion of work should be by (MONTH) 21, (YEAR). The work was found not to be completed during the current survey of 2/14/2019. Upon interview at the time of the exit conference on 2/15/2019 at approximately 2:00 pm, the Administrator stated that the facility would investigate and have the extinguishing system connected to the fire alarm. . 2009 NFPA 17 2012 NFPA101 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 6, 2019

I) Immediate Corrective Action for Resident affected:
1) The facility has already contracted with Fire Guys Inc. on 2/15/19 to replace the chemical extinguishing system in the rooftop elevator machine room. Fire Guys will also connect the system to the Facility?s fire alarm so that the alarm will sound if the chemical system is actuated. Fire Guys Inc. started the project immediately, it is ongoing with a tentative completion date of 5-6 weeks.
2) There were no residents identified in the SOD for this deficiency.
II) Identification of Other Resident:
The facility respectfully states that no residents were involved in this deficiency, however all residents were potentially affected.
The Director of Maintenance/designee will oversee completion of the installation of the chemical extinguishing system and its connection to the facility?s fire alarm system.
III) Systemic Changes made so the deficiency will not reoccur:
The Administrator will review and revise, if necessary, the facility?s P&P on inspecting fire extinguishers. The P&P will specifically address inspecting the chemical extinguishing system and its connection to the fire alarm system.
The policy will be in-serviced to the Maintenance staff.
Lesson plan and sign-in sheet will be kept on file for verification.

IV) Monitoring of the Corrective Action/Quality Assurance:
1) The Director of Building Services will ensure that the system is inspected monthly.
2) The Administrator/Designee will develop a QA log to track the facility?s compliance with inspecting the chemical extinguishing system.
3) The Administrator/Designee will review the log quarterly to ensure timely inspections are being done. Results will be reported to the QA Committee quarterly.
IV) Responsibility:
Administrator

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 22, 2019
Corrected date: April 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives 2010 NFPA 80: 6.3.1.7* Clearances. 6.3.1.7.1 The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1?8 in. ± 1?16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1?8 in. (3.18 mm) for wood doors. . Based on observation and staff interview during the recertification survey, the facility failed to ensure that doors in smoke barriers closed automatically and fully, and that the doors are maintained with the correct fire resistance rating. This occurred on three out of three floors of the facility. The findings include but are not limited to: During the life safety portion of the recertification survey of 2/14/2019 between 9:30 am and 2:00 pm, the following were noted: 1) The set of cross- corridor smoke barrier doors near the third -floor south nursing station was lacking a fire rating label. 2) The cross- corridor smoke barrier doors near the first -floor rehabilitation room had a greater than 1/8 gap at the meeting edge of the doors. 3) The cross-corridor smoke barrier doors near room [ROOM NUMBER], near the second-floor south storage room [ROOM NUMBER], and near the second floor south dental office lacked fire rating labels, and had a greater than 1/8 gap at the meeting edge. Upon interview concurrent with these findings, the Director of Building Services stated that the doors lacking rating labels would be recertified and the gaps at the meeting edges of doors would be closed. 2012 NFPA 101 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedMarch 6, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I) Immediate Corrective Action for Resident
1) The facility contracted with Accurate Fire & Life Safety LLC to recertify & relabel the set of cross- corridor smoke barrier doors near the third -floor south nursing station.
2) The Facility contracted with Accurate Fire & Life Safety LLC to recertify & relabel the sets or cross-corridor smoke barrier doors near room [ROOM NUMBER], near the second-floor south storage room [ROOM NUMBER], and near the second floor south dental office.
3) The facility immediately reduced the gap at the meeting edge of the cross- corridor smoke barrier doors near the first -floor rehabilitation room to less than 1/8?.
4) The facility immediately reduced the gap at the meeting edge of the cross-corridor smoke barrier doors near room [ROOM NUMBER], near the second-floor south storage room [ROOM NUMBER], and near the second floor south dental office to less than 1/8?.
5) There were no residents identified in the SOD of this deficiency.

II) Identification of Other Resident:
The facility respectfully states that no residents were involved in this deficiency, however all residents were potentially affected.
III) Systemic Changes made so the deficiency will not reoccur:
1) The Administrator will review and revise the current facility P&P for Inspecting Smoke Barrier Doors.
2) The Revised P&P will be in-serviced to the Maintenance Staff by the Administrator / Designee. The lesson plan will focus on the following;
-All smoke barrier doors will be inspected quarterly by Maintenance staff.
-When conducting inspections of the smoke barrier doors, the following areas must be checked;
a) Fire Rating label affixed to door/door frame.
b) Door is self/automatic closing.
c) Clearance between the top and vertical edges of the door and frame, and the meeting edges of doors swinging shall be 1/8?-1/16? for steel doors and shall not exceed 1/8? for wood doors.
A copy of the lesson plan and sign-in sheet will be kept on file as validation.
7) All smoke barrier doors in the facility will be inspected in accordance with the newly revised P & P and any deficiencies will be immediately addressed.

IV) Monitoring of the Corrective Action/Quality Assurance:
1) The Administrator will develop a QA audit tool to track the facility?s compliance with inspecting smoke barrier doors. The audit will be completed by the Administrator/Designee on 3 randomly selected smoke barrier doors monthly x3 months and quarterly thereafter. All negative findings will be immediately corrected by the Maintenance Director/Designee. All audit findings will be presented to the QA committee monthly x 3 months and quarterly thereafter.
V) Responsibility:
Administrator