Coler Rehabilitation and Nursing Care Center
May 19, 2020 Complaint Survey

Standard Health Citations

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 19, 2020
Corrected date: July 6, 2020

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the COVID-19 Focus Infection Control Survey and Complaint Investigation Survey, ACTS reference # (NY 013), the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not follow the cohorting requirements documented in the Dear Administrator Letter (DAL) dated (MONTH) 29, 2020. This was evident on 5 of 21 units. (C11, C12, C14, C33, C34) The findings are: The Executive Order 202.11 dated (MONTH) 27,2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The New York State Department of Health DAL dated (MONTH) 29, 2020 documents the following: As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful separate out patients in individual facilities. The facility policy titled Guidance and Management for COVID-19 dated 5/4/20 documented the following: it is the policy of NYC/HHC/Coler to develop strategies consistent with the CDC, NYS DOH, NYC Health and Hospital guidelines aimed at the prevention of COVID-19 among residents, families, and staff and to outline appropriate procedures to limit the entry of [MEDICAL CONDITION] into the facility, provide quality of care to residents once they have become infected and control further spread of [MEDICAL CONDITION] within the facility. The policy and procedure further documented that residents who are confirmed COVID-19 positive must be placed in their own room or cohorted in rooms with other residents who are COVID-19 positive. Residents who are suspected COVID-19 positive but not tested positive must be placed in their own rooms or cohorted with other suspected residents. The policy further documented that roommates of confirmed COVID-19 positive residents are considered exposed and should be kept in a single room for 14 days, if possible and not be housed with unexposed residents. Preferentially pair this roommate with another potentially exposed residents, if possible, someone else from the same unit. The facility is an 815-bed capacity with a census of 485 as of 5/20/20. Upon request, the facility provided to the surveyor a list of 188 residents who tested positive for COVID-19. On 5/18/20 between the hours 10:00 AM and 12: 00 PM, observations were made on the following units: A51, A52, A53, A54, C11, C12, C13, C14, C21, C22, C23, C24, C41, C42, C43, and C44. Observations conducted on the units found the following concerns relating to cohorting: 1) Unit C11- room [ROOM NUMBER], a 4-bed occupancy room, with 3 COVID-19 positive residents and 1 COVID-19 negative resident. 2) Unit C11- room [ROOM NUMBER], a 4-bed occupancy room, with 1 COVID-19 positive resident and 3 COVID-19 negative residents. 3) Unit C12- room [ROOM NUMBER], a 3 bed occupancy room, with 2 COVID-19 positive residents and 1 COVID-19 negative resident 4) Unit C12- room [ROOM NUMBER], a 4-bed occupancy room, with 3 COVID-19 positive residents and 1 COVID-19 negative resident. 5) Unit C33-room [ROOM NUMBER], a 4-bed occupancy room, with 2 COVID-19 positive residents and 2 COVID-19 negative residents. 6) Unit C33-room [ROOM NUMBER], a 3-bed occupancy room, with 1 COVID-19 positive resident and 2 COVID-19 negative residents. 7) Unit C33-room [ROOM NUMBER], a 2-bed occupancy room, with 1 COVID-19 positive resident and 1 COVID-19 negative resident. 8) Unit C34-room [ROOM NUMBER], a 4-bed occupancy room, with 2 COVID-19 positive residents and 2 COVID-19 negative residents. 9) Unit C14- room [ROOM NUMBER], a 2-bed occupancy room, with 1 COVID-19 positive resident and 1 COVID-19 negative resident. All residents in these nine rooms were initially roommates when they tested positive for COVID-19. All of these residents were re-tested on [DATE]. The residents that tested negative were not moved from the rooms. The facility has designated a unit for residents who are confirmed COVID-19 positive. Those residents are to be moved to that unit after terminal cleaning of the unit. the facility is also utilizing a test-based strategy approach and will retest those residents who tested negative on 5/15/20 to confirm status. A review of the facility's resident roster dated 5/20/20 documented that 45 of 188 residents who tested positive for COVID-19 were moved to unit C5. There were 143 COVID-19 positive residents that were still residing on units with COVID-19 negative residents. During an interview on 05/18/20 at 11:32 AM, the Certified Nursing Assistant #1 (CNA #1) stated sometimes she is assigned to residents who tested COVID -19 positive. CNA #1 also stated she was told some of the cohorted residents were retested on [DATE] but are still being maintained on isolation precautions, so she has to wear full PPE when taking care of all the residents in the room. During an interview on 05/18/20 at 11:44 AM RN #2, the supervisor of Unit C33 stated that some rooms have COVID-19 positive and negative sharing the same room. The facility staff are in the process of moving the residents who tested positive to unit C5 today. RN# 2 further stated that those residents were all COVID positive and were retested on [DATE] at which time some residents tested negative. RN #2 also stated resident's vital signs are monitored on every shift and all residents are currently asymptomatic. During an interview on 5/18/20 at 3:00 PM, the Director Of Nursing (DON) stated that she was unaware of the residents who tested negative until this morning. The DON stated the residents were re-tested on Friday 5/15/20 and she was awaiting the results. The DON further stated the facility began relocating residents on 5/14/20 and that terminal cleaning was being completed on the unit that was being designated for residents who tested positive for COVID-19. During an interview on 05/19/20 at 03:18 PM, the Infection Control Preventionist (ICP) stated that the first COVID-19 positive resident was identified on 3/19/20, screening of residents began on 4/10/20, and a dedicated unit for symptomatic COVID-19 positive residents was opened on 5/18/20 . Positive asymptomatic and positive symptomatic residents are housed on the same unit but in different wings. The ICP also stated that once a resident has symptoms, we start isolation precautions and test all the roommates. The ICP further stated the residents inside the rooms with COVID positive and COVID negative rooming together were all COVID positive initially. The facility is now utilizing a test-based strategy, so they have to wait for 2 consecutive negative tests within a 14-day interval. 415.19(b)(1)

Plan of Correction: ApprovedJune 3, 2020

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All COVID positive residents in Unit C11room [ROOM NUMBER], Unit C11- room [ROOM NUMBER], Unit C12- room [ROOM NUMBER], Unit C12- room [ROOM NUMBER], Unit C33-room [ROOM NUMBER], Unit C33-room [ROOM NUMBER], Unit C33-room [ROOM NUMBER], Unit C34-room [ROOM NUMBER], Unit C14- room [ROOM NUMBER] were moved to Units C53-C54 and C51 that are designated COVID positive area.
CNA#1 and RN#2 were reeducated regarding facility COVID Policy titled
Guidance and Management for Covid-19
Nursing leadership and head nurses were educated regarding specific staff assignment to COVID positive units.
RN#2 was educated regarding facility COVID policy and cohorting requirements according to CDC
Guidelines to ensure as soon as a patient COVID test become negative to be transferred to Non-COVID areas.
All residents in the facility were reviewed in order to ensure all COVID positive residents are relocated to dedicated units for Covid 19 positive residents only.
In addition facility will test the remaining residents for COVID 19 to establish a baseline to detect current infections, maintain proper cohorting and prevent spreading COVID 19 across the health care facility.
The facility policy titled Guidance and Management for COVID-19 was reviewed and revised to reflect latest CDC guidelines.
All Nursing Staff will be reeducated regarding COVID 19 P&P and cohorting protocols.
Facility has established designated areas for COVID positive, PUI, unknowns and COVID negative units and has relocated residents to appropriate beds.
Nursing leadership will establish bed board color coordination to assist staff with cohorting effectively.
Associate DONs and head nurses will be reeducated to ensure to act on cohorting protocol on receipt of Labs to prevent spreading COVID 19 across the health care facility.
Nursing and MD will monitor Atlas lab dashboard for test results to maintain proper cohorting 7 days a week.
Infection Control Preventionist will keep a log of resident test results and to ensure appropriate cohorting and communicate with nursing department.
Associate DON?s will audit 10% of residents test results weekly x 4 and then monthly x 3 to ensure cohorting procedures are being followed according to facility P & P and latest
CDC guidelines.
DON/ Designee will review audit outcomes and will present the outcomes to QAPI committee for monitoring and evaluation monthly x 4


FF11 483.90(i)(4):MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

REGULATION: §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 19, 2020
Corrected date: July 6, 2020

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the COVID 19 Focus Infection Control Survey and Complaint Investigation Survey, ACTS reference # (NY 013), the facility did not ensure it maintained an effective pest control program so that the facility is free of pests and rodents. Specifically, (1). several filth flies and fruit flies were observed flying around a 4-bed occupancy room and crawling on the surface of a resident's personal belonging that had been removed from the room, and (2). a live mouse was observed scurrying across the floor of a resident's room. This was evident on 2 of 15 units. (A51 and C11) The findings are: The facility policy titled Cleaning of Resident Care Unit and Equipment dated 4/26/19 documents it is the facility policy to ensure that the proper procedures are developed to provide residents and staff with an environment of care that is safe, clean, and free of odor where the microorganisms that could cause infection are maintained at their lowest level in order to further reduce the risk of transmission of infection and communicable disease. The sanitary condition of the environment of care shall be maintained to include resident rooms, floors, horizontal surfaces, resident equipment. 1). On 5/18/20 at 11:00 AM, Room A 51- 4, a 4- bed occupancy room was observed with a large pile of soiled crumpled napkins 3 browned bananas, an orange, and used soda cups on the floor. Approximately five flies were observed flying around in the area. There was a used soda cup with approximately 10 fruit flies inside the cup observed on a resident dresser, which had been moved out of the room into the hallway. Unit A51 Exterminator Service Request Log did not document any concerns regarding flies since 3/12/20. On 5/18/20 at 11:05 AM, an interview was conducted with Housekeeper (HSK) # 1. HSK #1 stated it is difficult for the housekeepers to clean the room because Resident #1 will become agitated and may even become physical. HSK #1 also stated they need assistance from other departments to properly clean the area and inform nursing staff when they are unable to clean the room. On 5/18/20 at 11:15, an interview was conducted with Resident # 2 who stated she has been rooming with Resident #1 for almost a year and the resident has always had this hoarding issue. Resident #2 also stated that there is old food and garbage all around that part of the room because Resident # 1 keeps the fruit from her tray and stashes it in her bedside table. There are flies everywhere and she often sees roaches in the room. Resident #2 further stated that the facility rarely cleans Resident #1's space and the last time there was a deep cleaning in this room was probably over 6 months ago and staff does not clean that area on a daily basis. On 5/18/20 at 11:30 AM, an interview was conducted with RN# 1. RN #1 stated when staff want to clean the resident's area, they call the resident's representative, Social Worker and sometimes even the Assistant Director of Nursing since it takes a team effort. The team discuss which things are garbage and need to be thrown out. This is done once every 6 weeks or so. RN#1 further stated that they usually do not let it get to the point where the mess overflows into the other resident's areas. RN# 1 also stated they clean whenever the resident is out of the room which can be difficult especially now because of the quarantine. They do not clean if she is in the room because she gets upset. The resident is usually cooperative but when it comes to staff touching her stuff, she does not tolerate it. 2). On 05/18/2020 at 10:35 AM, a live mouse was observed scurrying across the floor of room [ROOM NUMBER] on Unit C11. Exterminator Service Request Log entry dated 04/14/2020 documented there was a call made to the exterminator about a mouse in the medication room and nurses' station. The exterminator subsequently provided service to that unit. Exterminator Service Request Log entry dated 05/05/2020 documented a call was made to the exterminator about a mouse in Units C11 and C12. The exterminator provided service. On 05/18/2020 at 11:35 AM, an interview was conducted with the Exterminator. The Exterminator stated that he comes at least three times a week and responds to all calls. The Exterminator also stated that he will also come on other days if needed and does preventative work as well as responding to calls. On 05/18/2020 at 2:50 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA#1 stated he had not seen any pests or rodents and would report to housekeeping or the exterminator. On 05/18/2020 at 3:12 PM, an interview was conducted CNA #2 assigned to Unit C11. CNA #2 reported no issues with pests or rodents. CNA#2 also stated if she saw a pest or rodent she would report it to the charge nurse who would call the exterminator. 415.29(j)(5)

Plan of Correction: ApprovedJune 3, 2020

A terminal cleaning was done for Room A 51- 4.
Units C11 and C12 were cleaned and pest control activity was performed.
Resident # 1 was reeducated regarding her room terminal cleaning according to the facility P & P.
All units will be audited to ensure facility keeps a clean and sanitary environment and to maintain an effective pest control program so that the facility is free of pests and rodents.
Review of known food hoarders and resident with unsafe sanitary conditions will be conducted to ensure their areas are kept clean.
Housekeeping staff is being reeducated on the facility policy titled Cleaning of Resident Care Unit and Equipment. ?
Environmental rounds 3 times a week to include review of issues contributing to pest control concerns.
Pest Control contractor will conduct weekly rounds of identified food hoarders and address any issues.
Director of housekeeping/CNO or designee will conduct weekly rounds on residents identified to have food hoarding behavior to ensure the bedsides are at appropriate level of cleanliness.
Director of housekeeping will ensure pest control issues and Exterminator Service Request Logs are being addressed daily and as needed.
Pest control visits will be increased to 7 days a week to address current pest concerns and perform ongoing monitoring in all buildings for pest activity.

Pest control visits and Exterminator Service Request Logs will be audited weekly x 4 then monthly X 3
Associate Executive Director/Designee will review exterminator logs and will present the outcomes to QAPI committee for monitoring and evaluation monthly x 4
Weekly pest control report from Ecolab to ensure implementation of appropriate actions x 4 months.
Outcomes of weekly CNO/ Housekeeping Director rounds will be reported to QAPI committee for monitoring and evaluation X 4 months