Troy Center for Rehabilitation and Nursing
March 25, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.95(c)(1)-(3):ABUSE, NEGLECT, AND EXPLOITATION TRAINING

REGULATION: §483.95(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on- §483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. §483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property §483.95(c)(3) Dementia management and resident abuse prevention.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on record review and interviews during the recertificaiton survey, the facility did not ensure the development and implementation of a dementia care training program for staff. Specifically, the facility did not ensure staff was provided education on factors related to dementia care. This is evidenced by: Review of an undated in-service titled Understanding and Dealing with Agressive Residents in Nursing Home and other training modules provided by Registered Nurse (RN) #1 did not include information related to dementia care (ie. agitation, yelling out, delusions, conflict resolution between staff and residents, visitor and resident, and resident to resident conflicts, and anger management). During an interview on 3/22/19 at 10:35 AM, RN #1 stated they do not provide specific dementia care training, however information related to dementia care is included in other training modules. During an interview on 3/22/19 at 11:02 AM, Social Worker #7 stated she has not received in-servicing on dementia care. 10 NYCRR 415.49(b)

Plan of Correction: ApprovedApril 18, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. RN #1 and DSW #7 received OASIS 2.0 Dementia Training on 4/16/19.
2. All Residents with Dementia have the potential to be affected.
3. All of the Facility's staff will be in-serviced on Oasis 2.0- Dementia Care. The OASIS 2.0 course covers training on staff [MEDICATION NAME], confidence, competence, conflict resolution, staff burnout and non-pharmacological interventions with Dementia care.
4. An audit of all new hires for completion of Oasis Training will be performed by ADON or designee weekly x 12 weeks.
Results of these audits will be brought to the QAPI meeting monthly x3 and then at an interval determined by the committee.
6. The Director of Nursing will be responsible for continued compliance.

FF11 483.60(i)(4):DISPOSE GARBAGE AND REFUSE PROPERLY

REGULATION: §483.60(i)(4)- Dispose of garbage and refuse properly.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the area around the dumpster were not clean. This is evidenced by: During an observation on 3/25/19 at 9:29 AM, refuse along the side of the dumpster included plastic gloves, plasticware, and a crushed milk carton. Additionally, refuse along the fence behind the dumpster included milk cartons, an oatmeal container, and plasticware. During an interview on 3/25/19 at 9:31 AM, the Food Service Director (FSD) #4 stated the garbage is there from the snow melting and it should have been cleaned up. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedApril 18, 2019

1.The surrounding rubbish and litter around the dumpster were removed and refuse along the fence behind the dumpster was removed.
2. All residents have the potential to be affected by the deficient practice.
A one-day audit to monitor dumpster area to ensure free of litter it remains free of litter post each meal service will be conducted.
3. Policy of food related garbage and rubbish disposal was reviewed and adopted.
Dietary and housekeeping personnel will be educated to ensure dumpster areas are free of surrounding litter.
4. The FSD or designee will conduct audit daily x 2 weeks, then weekly x 2 weeks, then monthly x 4 months to ensure dumpster area is free of surrounding litter and rubbish.
Any issues will be immediately addressed.
The results of the audit will be brought to the QAPI committee monthly for five months and then at an interval determined by the committee.
5. The Administrator will be responsible for continued 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: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food preparation and serving areas and equipment are to be kept clean. Specifically, food preparation equipment in the main kitchen, and the freezer in 2 of 2 unit freezers were not clean. This is evidenced by: During an observation on 3/19/19 at 7:52 AM, kitchen equipment, including the stove and microwave oven, were soiled. During an observation on 3/19/19 at 8:10 AM, the north unit freezer was soiled. During an observation 3/19/19 at 8:16 AM, the south unit freezer was soiled. During an interview on 3/19/19 at 8:05 AM, Food Service Director (FSD) #4 stated the microwave oven should not be soiled and should be cleaned daily. Additionally, kitchen equipment should not be soiled, should be cleaned regularly. He stated he is in the process of developing a cleaning schedule. During an interview on 3/19/19 at 8:10 AM, FSD #4 stated he is unsure who is responsible for cleaning the refrigerators/freezers on the unit, but it should have been done. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedApril 18, 2019

1. The stove top was disassembled and cleaned. The microwave was cleaned and sanitized. All small food preparation equipment was cleaned and sanitized on 3/19/2019. The unit refrigerators and freezers were cleaned and sanitized on 3/19/2019.
2. All residents have the potential to be affected
An initial foodservice sanitation audit was conducted 3/19/19 to identify areas of concern. Issues identified were immediately addressed.
An audit for all unit pantries and refrigerators were conducted to identify areas of concern. Issues identified were immediately addressed.
3. The FSD generated new cleaning schedules to incorporate cleaning of stove, microwave and all small equipment daily and weekly as needed.
The unit refrigerators and freezers will be checked daily for cleanliness by FSD or designee and cleaned weekly by housekeeping personnel.
The FSD will in-service all food service personnel on sanitation standards and practices.
Policy on cleaning unit refrigerator and freezers was reviewed. All food, nutrition and nursing staff will be educated.
4. The FSD or designee will conduct kitchen sanitation and dish room audit weekly x4 weeks then monthly x 6 months to ensure all sanitation standards and practices are met.
FSD or designee will audit unit kitchenettes weekly x 4 weeks then monthly x 6 months to ensure refrigerators and freezers are maintained, cleaned and sanitized. Any issues will be immediately addressed.
Results of the audits will be forwarded to the QAPI committee monthly x7 months for review and input, and then at an interval determined by the committee.
5. The Administrator will be responsible for continued compliance.

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based staff interview and the Legionella Sampling and Water Management Plan (WMP) review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Section 4-2.4 requires that by (MONTH) 1, (YEAR) initial Legionella sampling shall be at periods not exceeding 90 days prior to annual sampling. Specifically, the facility did not test for Legionella as required by New York State regulation. This is evidenced by the following. The potable water system Legionella testing reports were reviewed on 03/19/2019. The reports were dated 12/21/2018, 05/14/2018, 11/16/2017, 09/27/2017, 05/17/17, and 03/24/2017. The facility could not provide water samples results for four consecutive periods not exceeding 90 days. The Director Maintenance and Environmental Services stated in an interview on 03/08/2019 at 2:15 PM that he thought the sampling was completed and was unaware that the facility was not compliance. 415.19(a)

Plan of Correction: ApprovedApril 18, 2019

1) Legionella tests were sent to the lab on 3/21/19.
2) This deficiency has the potential to impact all residents.
3) Testing is scheduled for 6/17/19, 9/13/19 and 12/11/19.
4) These testing timelines will be added to the QAPI committee agenda and reported quarterly by the Director of Maintenance throughout 2019, and then at an interval determined by the committee.
5) Responsible Party is the Director of Maintenance

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a recertification survey, the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident's reviewed. Specifically, the facility did not ensure facility staff performed proper hand hygiene and scissors were cleansed after each use. This was determined by: Resident #60: The resident was admitted to the facility on [DATE] from post-acute hospital with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident makes herself understood and can understand others. During an observation on 03/21/19 at 09:08 AM, Licensed Practical Nurse (LPN) #4 changed the resident's [MEDICAL CONDITION] wafer and pouch prior to the abdominal wound dressing change. In preparation of applying the wafer base over the stoma, LPN #4 cut the center of the wafer to a circular size, then hovered the wafer over stoma, withdrew the wafer to cut the inside for a second time to the final circumference to place over stoma. LPN #4 placed the scissors on the bedside table, removed gloves and washed her hands. LPN #4 donned new gloves and opened packages/supplies for the mid-abdominal dressing, picked up the scissors and used them to open packaging and placed them back on the table. The LPN proceeded to cleanse the wound as prescribed, removed gloves and washed her hands. LPN #4 did not cleanse the scissors after using them for the stoma sizing and before using them on supplies for the mid abdominal dressing, did not cleanse the scissors at the completion of the procedures when cleaning up supplies and did not change her gloves and wash her hands after opening the supplies for the dressing change. During an interview on 03/21/19 at 09:41 AM, LPN #4 stated she was going to change her gloves and wash her hands after opening the packaging, but did not. LPN #4 did not comment when asked about cleaning scissors for patient care. 10NYCRR415.19

Plan of Correction: ApprovedApril 18, 2019

1. Resident # 60 had the treatment done resulting in no infections.
The nurse involved in this treatment received written education regarding the proper procedure to follow when doing a dressing change.
2. All residents with treatments have the potential to be affected.
3. The Policy titled Dressings, Dry/Clean was reviewed and no changes were necessary.
All licensed nurses will be re-educated regarding the Dressings, Dry/ Clean policy.
4. An audit of 10 treatments a week x 4 weeks, then 5 treatments a week x 4 weeks, then 3 treatments a week x 4 weeks will be done to ensure that nurses are following standard precaution procedures when doing the treatment.
The results of the audit will be brought to the QAPI committee x3 months and then at an interval determined by the committee.
5. The DON will be responsible for continued compliance.

FF11 483.70(a)-(c):LICENSE/COMPLY W/ FED/STATE/LOCL LAW/PROF STD

REGULATION: §483.70(a) Licensure. A facility must be licensed under applicable State and local law. §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. §483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on observation and staff interviews during the recertification survey the facility did not immediately provide accurate facility information to the New York State Department of Health (NYSDOH). Specifically, the facility did not provide a CMS-802 (Roster/Sample Matrix) Form for new admissions in the last 30 days, at the time of the NYSDOH Survey Team's entrance to the facility. Additionally, the facility did not provide the Roster/Sample Matrix for all residents to the survey team within four hours of survey entrance, resulting in a delay in the survey process. This was evidenced by: The NYSDOH Survey Team entered the facility on 3/19/19 at 7:30 AM and were greeted by the Nursing Supervisor. During the Survey Entrance Conference on 3/19/19 at 7:55 am, the Survey Team Leader met with the Director of Nursing (DON). The NYSDOH Entrance Conference Worksheet and the Roster/Sample Matrix for admissions in last 30 days were reviewed for documents required immediately, documents required in one hour and documents required within 4 hours. The survey Team Leader sought out the Administrator and DON on 3/19/19 at 11:30 AM and 12:15 PM, to request documents not yet received with the explanation that the survey team could not move on with the survey process without the requested documents. The Matrix with all residents was delivered at 1:30 PM. The 30-day Matrix was requested again, and was received at 2:20 PM. During an interview on 3/25/19 at 11:15 AM, the DON stated the previous administrator had recently left, and the acting administrator had started this week. The DON was not aware of a 30-day Matrix being due on entrance of the NYSDOH, she was aware of the full Matrix being due in 1-4 hours. She had not seen a CMS Entrance Conference Worksheet prior to the survey entrance, and had not received prior notice from the administrator on what she needed to have ready for the survey team. 10NYCRR 400.2

Plan of Correction: ApprovedApril 18, 2019

1. The Roster Matrix was completed and presented to the survey team.
2. The Roster Matrix being late does not affect residents.
3. The Unit Managers of North and South units will complete and submit the Rooster Matrix of the 30-day admissions weekly. The full Resident Matrix will be submitted to the Director of Nursing every two weeks.
4. An audit tool of the Roster Matrix will be completed by the Director of Nursing or designee weekly x 4 weeks, then bi-weekly x 4 weeks, then once monthly x 1 month.
Results of these audits will be brought to the QAPI meeting monthly x3 months, and then at an interval determined by the committee.
3. The Director of Nursing will be responsible for continued compliance.

FF11 483.10(g)(17)(18)(i)-(v):MEDICAID/MEDICARE COVERAGE/LIABILITY NOTICE

REGULATION: §483.10(g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on record review and interviews during a recertification survey, the facility did not ensure the resident and/or resident representative were provided with timely and specific notification when the facility determined that the resident no longer qualified for Medicare Part A skilled services and the resident had not used all the Medicare benefit days for that episode for three of three residents reviewed. Specifically: for Resident #'s 66 & 75, the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form CMS- , did not include an accurate reason for the possiblility for Medicare's denial of payment and did not include the resident's option choice to pay for the continuation of services or for the cessation of services, the resident's Medicare appeal rights for each option choice; and for Resident #74, the facility did not ensure the resident/ resident representative was provided notification of the termination of services using the Notice to Medicare Provider Non-coverage (NOMNC), form CMS- . This is evidenced by: Review of the medical record for Resident #66 on 3/19/19, revealed that the resident was discharged from physical therapy and occupational therapy on 3/8/19. The SNFABN form did not: accurately document the care that would be continued and that would no longer be paid for by Medicare; did not provide the resident with accurate information to make an informed decision about care; did not include the resident's option to chose to receive services and appeal to Medicare, to receive the services but not bill Medicare with loss of the option to appeal, and to not receive the services and not be billed. Review of the medical record for Resident #75 on 3/19/19, revealed that the resident was discharged from physical therapy on 10/19/18. The SNFABN form did not: accurately document the care that would be continued and that would no longer be paid for by Medicare; did not provide the resident with accurate information to make an informed decision about care; did not include the resident's option to chose to receive services and appeal to Medicare, to receive the services but not bill Medicare with loss of the option to appeal, and to not receive the services and not be billed. Review of the medical record for Resident #74 on 3/19/19, documented that the resident was discharged from the facility on 2/20/19. The record did not include a NOMNC to inform the resident of their right to an expedited review of a service termination. During an interview on 3/19/19 at 1:48 PM, the Business Office Manager stated she completes the top of the SNFABN and NOMNC, at the request of the unit managers. She stated she inputs the data exactly as it is provided to her from the unit managers and then provides the Director of Social Work with this form to be reviewed with the resident/ resident representative and completed. During an interview on 03/19/19 at 1:53 PM, the Director of Social Work stated she was responsible for providing the notifications when a resident's Medicare Part A services were terminated. She stated residents and/or resident representatives were not given notice prior to the discontinuation of Medicare Part A services when being discharged from the facility. She stated she was not aware that the NOMNC was required prior to discharge from the facility. Additionally, she stated she did not complete the top portion of the SNFABN and was too busy to have a resident choose whether they wanted to continue to receive services and be billed or obtain an official decision on payment from Medicare prior to the discontinuation of services. She stated she did educate the resident that the service stated on the top of the SNFABN would be discontinued, as Medicare would no longer cover the skilled service specified. During an interview on 03/19/19 at 2:30 PM, the Administrator stated the expectation is that the SNFABN and NOMNC would be completed accurately, the resident and resident representative would be provided appropriate notification on their right to appeal when a service is identified as potentially no longer covered under their Medicare Part A coverage. 10NYCRR 415.3 (g)

Plan of Correction: ApprovedApril 18, 2019

1. Resident number # 74 and 75 have been discharged from the facility. Resident # 66 has been presented with an appropriate ABN form.
2. All resident's with Medicare coverage have the potential to be affected.
3. The administrator will be provided the utilization review tracker for residents that will have services terminated in the near future.
Director of Social Work and the Business Office Manager have been educated and designated to issue all ABN notices moving forward.
4. The Administrator will review all SNFABN forms prior to presentation to the resident or desgnee or four weeks. Will then audit weekly for 4 weeks then monthly for 2 months.
The results of the audit will be brought to the QAPI committee monthly for four months and then at an interval determined by the committee.
5. The administrator will be responsible for continued compliance.

FF11 483.60(c)(1)-(7):MENUS MEET RESIDENT NDS/PREP IN ADV/FOLLOWED

REGULATION: §483.60(c) Menus and nutritional adequacy. Menus must- §483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on observation, record review and interviews during the recertification survey, the facility did not ensure the menus meet the nutritional needs of residents in accordance with established national guidelines. Specifically, the facility did not provide adequate protein to meet the resident's nutritional needs at breakfast and dinner meals on 3/19/19. This is evidenced by: During an observation on 3/19/19 at 9:08 AM, residents in the dining room were provided with pancakes, syrup, and cream of wheat on their meal trays. During an observation on 3/19/19 at 4:25 PM, Cook #2 placed two slices of cheese on each grilled cheese sandwich during meal preparation. During an observation on 03/19/19 04:35 PM, Food Service Director (FSD) #4 weighed two slices of cheese, and stated they weighed 1 ounce total. The week 4 menu documented the 3/19/19 breakfast meal was assorted juice, buttermilk pancakes, syrup, margarine, and grits. The dinner meal was grilled cheese with tomato sandwich, buttered pasta, and fruited jello. Review of a meal ticket (Resident #73) documented that the 3/19/19 breakfast meal was 4 ounces of juice, 6 ounces of grits, 1 package of syrup, 1 margarine, salt, pepper, and sugar. The dinner meal was 4 ounces of orange juice, 1 grilled cheese sandwich with tomato, 1/3 cup buttered pasta, 1/2 cup fruited jello, salt, pepper, and sugar. During an interview on 3/19/19 at 4:31 PM, Cook #2 stated when grilled cheese sandwiches are served, two slices of cheese are placed on the sandwich. During an interview on 3/19/19 at 4:38 PM, Registered Dietitian (RD) #1 stated she is responsible for the nutrition adequacy of the menu. She stated the recipes are put into a computer system and a nutrition analysis is calculated for her review. She stated she would expect a source of protein would be provided at each meal, including breakfast, and the total protein offered should 80-100g/day. She stated there should have been a source of protein at breakfast, and there should be 3 ounces of cheese on the grilled cheese sandwich. She stated prior to today, 1 ounce of cheese was being provided. 10NYCRR415.14(c)1-3

Plan of Correction: ApprovedApril 18, 2019

1. The dinner menu was adjusted 3/19/19 to include an additional protein source for resident consumption. An addition of 1 cup cottage cheese or suitable substitution was provided for all po resident trays.
The cycle 4 menu was revised on 3/19/19.
1 hard-boiled egg was added to breakfast menu and 3 oz baked fish on a bun was added to the dinner menu.
2. All residents have the potential to be affected.
An audit of all 4 cycle menus were reviewed 3/20/19 to assess menu adequacy for all meals. The nutrient analysis was printed and compared. No issues were found.
3. A review of the menu planning policy and menu adequacy check policy was completed and adopted.
In-service to food service director and all food service staff will be conducted to review menu items at meals and portions to ensure adequacy prior to service.
Menu adequacy audit tool was devised by the RD to ensure all week?s menus meet nutritional needs.
FSD will be educated by the RD to utilize the menu planning for nutritional adequacy work sheet to facilitate menu development.
4. The RD will complete a menu adequacy review weekly x 4 weeks then monthly x 5 months to ensure weekly menus meet nutritional guidelines and parameters. Any issues will be immediately addressed.
Results of the audits will be forwarded to the QAPI committee monthly for review and input x6 months, unless the committee feels that further audits are indicated.
5. The Administrator will be responsible for continued compliance.

FF11 483.15(d)(1)(2):NOTICE OF BED HOLD POLICY BEFORE/UPON TRNSFR

REGULATION: §483.15(d) Notice of bed-hold policy and return- §483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e)(1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not ensure written notice was provided to the resident and/or the resident's representative of the bed hold and return policy for 2 (Resident #'s 33 and 54) of 2 residents reviewed for hospitalization . Specifically, the facility did not ensure there was documented evidence that the resident and the resident's representative received written notice of the bed hold policy when the resident was admitted to the hospital. This was evidenced by: The Policy & Procedure (P&P) titled Bed-Holds and Returns dated (MONTH) (YEAR) documented, it is the practice of this facility to provide to residents and/or representatives written information regarding the bed-hold and return policy of the facility prior to/at the time of hospitalization s. Resident #33: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact, was able to make herself understood and was able to understand others. A hospital discharge summary dated 12/12/18, documented the resident was admitted from the long-term care facility to the hospital on [DATE] with uremia (high level of urea in the blood) and chest pain and was discharged on [DATE]. A review of the medical record did not include a copy of a notice of the bed hold policy. Resident #54: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact, was able to make herself understood and was able to understand others. The nursing progress note dated 3/10/19, documented the physician was notified and an order was received to send the resident to the emergency room . The resident was admitted to the hospital with [REDACTED]. The nursing progress note dated 3/18/19, documented the resident was readmitted from the hospital. A review of the medical record did not include a copy of a notice of the bed hold policy. Interview: During an interview on 3/22/19 at 11:08 AM, the Business Office Manager #5 stated the bed hold notices were not sent, and they should have been. 10NYCRR415.3(h)(4)(i)(a)

Plan of Correction: ApprovedApril 30, 2019

1. Residents #33 and 54 were readmitted to their beds without incident.
All residents who have been sent to the hospital since (MONTH) have been audited to ensure that the resident or representative have received the written notice of the bed hold policy. Those found not in receipt of it will be provided one at this time.
2. All residents being transferred have the potential to be affected.
3. The ?Notice of Bed Hold Policy? form has been added to the Supervisors Office.
The Business Office Manager has been educated regarding the need to notify the resident's representative in writing of the bed hold policy when the resident was transferred to the hospital.
A copy of the bed hold policy notice that is sent to the family will be placed in the patient's chart.
4. All hospital transfers and therapeutic leaves will be audited monthly to ensure that the bed hold form was provided to the resident and/or representative prior the resident leaving the facility monthly x 3 months.
Results of the audit will be reported to the QAPI Committee for 3 months for review, and then at an interval determined by the committee.
5. The Finance Manger will responsible for continued compliance.

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not ensure 2 (Resident #'s #33 and #54) of 2 residents reviewed for hospitalization received written notice of transfer/discharge and the reasons for the transfer in a language and manner they understand. Specifically, the facility did not ensure that there was documented evidence that written notification of facility-initiated transfer/discharge was provided to the resident, the resident's representative(s), and/or the ombudsman. This was evidenced by: The Policy & Procedure (P&P) titled Transfer/Discharge Process dated 12/2018, did not include documentation regarding notice of transfer/discharge to the resident and/or resident's representative in the event of hospitalization . Resident #33: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact and was able to make herself understood and able to understand others. A hospital discharge summary dated 12/12/18, documented the resident was admitted from the long-term care facility to the hospital on [DATE] with uremia (high level of urea in the blood) and chest pain and was discharged on [DATE]. A review of the medical record did not include a copy of a transfer/discharge notice. Resident #54: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was cognitively intact, was able to make herself understood and was able to understand others. The nursing progress note dated 3/10/19, documented the physician was notified and an order was received to send the resident to the emergency room . The resident was admitted to the hospital with [REDACTED]. A review of the medical record did not include a copy of a transfer discharge notice. Interviews: During an interview on 3/22/19 at 10:50 AM, the Social Worker (SW) #6 stated she did not send written notice to the ombudsman upon resident transfer/discharge. She stated she was not aware she had to write it down. She stated she is not responsible for the transfer notices for transfer discharge to the hospital. During an interview on 3/25/19 at 2:01 PM, the Supervising Corporate Administrator #9 stated she was aware the transfer/discharge notifications were not being completed. 10NYCRR415.3(h)(1)(iv)(a-e)

Plan of Correction: ApprovedApril 18, 2019

1. Residents # 33 and 54 were all readmitted without incident.
2. All residents being transferred/discharged have the potential to be affected.
3. Nursing and Social Services has been educated regarding the Notice of Transfer / Discharge Policy.
The Policy titled Transfer / Discharge Process has been reviewed and revised to include documentation regarding providing notice of transfer / discharge to the resident and or representative.
The Transfer/Discharge forms are available in the Supervisors office, on the units and the Unit Managers Office.
Social Services have been educated regarding the need to notify the Ombudsman of any transfers / discharges.
4. All transfers and discharges will be audited monthly to ensure that the Notice of Transfer/Discharge form was provided to the resident, resident?s representative and Office of the State Long-Term Care Ombudsman.
Results of the audit will be reported to the QAPI Committee for review and any appropriate action monthly x 3 months, and then at an interval determined by the committee.
5. The Director of Social Work will be responsible for continued compliance.

FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE

REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition status were maintained for 1 (Resident #19) of 4 residents reviewed. Specifically, the facility did not ensure the resident who had weight loss received assistance with meals as care planned. This is evidenced by: Resident #19: The resident was admitted to the facility on [DATE], with [MEDICAL CONDITION], depression, and [MEDICAL CONDITION]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make herself understood. A weight record documented: 1/15/19 - weight 144.5lbs, 2/27/19 - weight 136lbs (5.88% significant weight loss over the past 30 days), 3/11/19 - weight 131lbs (9.34% weight loss over the past 60 days and 3.68% over the past 30 days) A quarterly nutrition assessment dated [DATE], documented the resident was to receive an advanced mechanical soft diet with 120 mL Ensure (nutritional supplement) twice daily. The resident's usual body weight was 140lbs, and the resident's weight was stable for the last 3 months. The resident fed herself and was eating 75% of meals and 100% of the Ensure supplement. No new recommendations were made. A dietary progress note dated 2/6/19, documented the resident was changed to a one-person limited assist for feeding, and resident trays were being sent to the dining room instead of the unit. A dietary progress note dated 2/22/19, documented the resident was pocketing food and a screen was sent to speech therapy. The resident's diet was changed to pureed. A dietary progress note dated 2/27/19, documented the resident had a significant weight loss over the past month, has been more confused and has needed more help with feeding. During an observation on 3/21/19 at 8:26 AM, the resident was in her bed with her breakfast tray on her overbed table without staff present. The resident had consumed 0% of her meal at 8:55 AM. The resident was in her bed feeding herself without staff present, and had consumed less than 25% of her meal. At 9:00 AM, the resident's tray was removed from the residents room by Nurse Manager (NM) #2. The resident had consumed less than 25% of her meal. During an observation on 3/21/19 at 11:54 AM, a certified nursing aide (CNA) stated to the LPN that the resident was refusing to get up for lunch; at 12:14 PM, LPN #4 stated I set up her tray and she took a few bites; at 12:18 PM, the resident was feeding herself in her bed and no staff entered the room until 12:58 PM, when CNA #2 removed the tray from the resident's room. The resident consumed less than 25% of her meal. During an interview on 3/21/19 at 2:08 PM, CNA #2 stated she is unsure what level of assistance the resident needed for eating because she doesn't have her on her assignment. During an interview on 3/21/19 at 2:11 PM, Licensed Practical Nurse (LPN) #4 stated the resident is a set up with guidance for eating. During an interview on 3/21/19 at 2:16 PM, Registered Nurse (RN) #2 stated if a resident was a limited assist x 1 for eating, she would expect the aide assigned to the area for meal times to go into the room to assist the resident at least a handful of times during the meal. During an interview on 3/21/19 at 3:20 PM, the Director of Nursing (DON) stated therapy is responsible for determining the feeding status of a resident. During an interview on 3/21/19 at 2:42 PM, the Registered Dietitian (RD) #1 stated the resident is a one person physical assist with meals and she would expect someone to be sitting with the resident during meal times to assist her. During an interview on 3/25/19 at 10:47 AM, Occupational Therapist (OT) #3 stated if a resident is a limited assist x 1 for eating, the resident is still able to participate in self feeding, but needs more than set up or supervision. The resident would be encouraged to be in the dining rooms, and if the resident requested to eat in her room, she would expect a staff member to be sitting with her during the meal to provide assistance. 10 NYCRR 415.12 (j)

Plan of Correction: ApprovedApril 18, 2019

1. Staff have been re-educated regarding Resident # 19 need for extensive assistance with meals.
2. All residents requiring assistance with meals have the potential to be affected.
A full house audit of residents requiring assistance with meals has been conducted to ensure that they are receiving the appropriate level of assistance. Any problems identified will be corrected at the time.
SLP will re-screen those requiring assistance with meals to ensure that they are receiving the proper level of assistance.
3. Staff have been educated regarding the need to follow the care plans as written to ensure that they provide the appropriate assistance.
4. Ten residents 3 x weekly x 4 weeks then ten residents 2 x weekly x 4 weeks and then 10 residents weekly x 4 weeks will be audited to ensure that they are receiving the required supervision.
The results will be brought to the QAPI committee x3 months, and then at an interval determined by the committee.
5. The DON will be responsible for continued compliance.

FF11 483.10(h)(1)-(3)(i)(ii):PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

REGULATION: §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on observation and interview during a recertification survey, the facility did not maintain a resident's right to personal privacy and confidentiality of his personal health information for one (Resident #66) of one resident reviewed for privacy. Specifically, for Resident #66, the facility did not ensure personal resident information was kept confidential. This is evidenced by: Resident #66: During an observation on 3/19/19 at 3:18 PM, the Director of Social Work (DSW) was heard informing a resident that an assisted living facility would not accept the resident due to a mental health diagnosis. The resident was seated in his wheelchair outside of occupied residents' rooms and a Certified Nursing Assistant was pushing a resident in a wheelchair waiting to pass by the resident and the DSW when this was stated. During an interview on 3/19/19 at 3:45 PM, the DSW stated she should have brought the resident to a private area prior to mentioning personal health information. During an interview on 3/20/19 at 12:10 PM, the Administrator stated the expectation of all staff was that privacy would be maintained and all private health information of residents should not be shared in a common area. 10NYCRR415.3(d)(1)

Plan of Correction: ApprovedApril 18, 2019

1. DSW has received written education regarding HIPPA Compliance.
2. All residents have the potential to be affected.
3. The Policy titled Confidentiality of Information and Personal Privacy has been reviewed adopted.
All staff will be educated regarding the new policy.
4. 10 staff conversations will be audited by the Administrator or designee to insure no HIPAA violations occur, 3 x weekly x 4 weeks, then 2 x weekly x 4 weeks, then once weekly x 4 weeks to listen for any HIPPA violations.
Results of these audits will be brought to the QAPI meeting monthly for three months and then at a frequency determined by the QAPI committee.
5. the Administrator will be responsible for continued compliance.

FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure medical records were maintained in accordance with accepted professional standards and practices, and readily accessible for three (3) (Residents #'s 11, 21, and #68) of eighteen (18) residents reviewed. Specifically: For Resident #11, the facility did not ensure the resident's medical record included the results of an eye exam dated (MONTH) (YEAR); For Resident #68, the facility did not ensure the Pharmacists consultation report for recommendations was readily available for physician review; for Resident #21,the facility did not ensure the medical record included Psychotherapy Progress Notes from 9/2018 to 3/2019; and for Resident #42, the facility did not ensure physician immunization documentation accurately reflected the resident's actual immunization. This is evidenced by: Resident #11: The resident was admitted to the facility on [DATE] and readmitted on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, was able to understand others and was able to make herself understood. Review of the resident's paper and electronic health record, did not include documentation of the residents (YEAR) eye exam. During an interview on 3/21/19 at 02:35 PM. Licensed Practical Nurse (LPN) #2 reviewed the resident's medical record and was unable to find documentation of the eye exam. LPN #4 stated the facility has its own optometry person who comes in to perform eye exams and to check with the unit secretary. The consults go in the paper medical record. During an interview on 3/21/19 at 02:46 PM, Unit Secretary (US) #8 stated she will verify if the resident had or has an upcoming eye exam. The documentation should be in the paper chart. US #8 did not provide documentation of the exam after review of the medical record. US #8 called the optometry service and confirmed the residents last exam was on 3/7/19 and asked to have a record of the exam faxed to the facility. During an interview on 3/22/19 at 11:04 AM, US #8 stated she had obtained the optometry exam and provided a copy of the exam. US #8 placed a copy in the doctor's book for follow up. Resident #68: The resident was admitted to the facility on [DATE] and readmitted on [DATE]. The MDS dated [DATE], documented the resident's cognition was severely impaired. The resident was able to understand others and could make herself understood. Review of the EHR progress note dated 1/11/19 documented the Pharmacist did a Medication Regimen Review (MRR) with reference that the consultation report noted irregularities and/or miscellaneous comments/recommendations. The consultation report document was not found. During an interview on 3/22/19 at 2:00 PM, the Corporate Registered Nurse (CRN) #5 stated the pharmacist consultation reports are sent via email to the Director of Nursing (DON), printed out and placed in a book on the unit for the physician to address. CRN #5 reviewed the pharmacist email from 1/2019, and printed the pharmacist consultation notes. CRN #5 stated they have printed out all the Pharmacist consultation notes for (MONTH) and (MONTH) 2019 for immediate review by the physician. Resident #21: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition. The resident was able to make himself understood and understand others. The physician order [REDACTED]. Review of the medical record on 3/21/19, did not include documented evidence of Psychotherapy Progress Notes. The Psychotherapy notes dated 8/24/18, 8/30/18, 9/6/18, 10/3/18, 10/26/18, 11/6/18, 1/19/19, 2/3/19, and 3/19/19 were delivered to the facility on [DATE]. During an interview on 3/21/19 at 2:00 PM, the Social Work Director (SWD) stated the Psychologist does not provide her documentation on the date of service to the resident, the Psychotherapy notes are sent to the facility after the fact. The facility contacted the Psychology office today and were told there had been a problem sending the notes to the facility. The notes for Resident #21 dated from 9/2018 to present, will be sent to the facility today. The SWD was not aware the facility did not receive the Psychology notes. During an interview on 03/21/19 at 03:00 PM, the Director of Nursing (DON) stated the psychologist verbally communicates recommendations to the nurses after seeing a resident. The consult notes are sent to the facility sometime after they leave. The consults notes are placed in the physician's communication book for their review and initials. The unit secretary then places the consults in the chart. The DON did not know the Psychology notes from (MONTH) (YEAR) to present were not in the medial record, there should have been more attention paid to the arrival of the notes. 10NYCRR415.22(a)(1-4)

Plan of Correction: ApprovedApril 24, 2019

1. Residents #'s 11, 21, and #68 were not negatively be affected by this practice.
2. All residents have the potential to be affected.
A full house audit will be conducted to ensure that we have received written recommendations for all of the residents that have had appointments since December.
A full house audit of all current residents will be completed to ensure that they have immunizations correctly documented in the resident chart.
3. Nursing will now obtain a list of residents seen by all consultants on a consultant tracker.
A hard copy of all consultant recommendations will be provided to the MD and Unit Manager to initial then the consults will be placed in the Resident?s chart.
The policy titled Charting Documentation has been reviewed and revised to include documenting immunizations in the medical record.
All licensed nurses will be educated on the Charting Documentation Policy.
4. 100% of all consults will be audited by DON or designee 3 x weekly x 4 weeks, then 2 x weekly x 4 weeks, then once weekly x 4 weeks to ensure that the facility has received a written report of the visit and that recommendations have been followed.
All new admissions will be audited to ensure that the immunizations are correctly documented in the medical record.
Results of these audits will be brought to the QAPI meeting monthly x3 months, and then at an interval determined by the committee.
5. The Director of Nursing will be responsible for continued 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 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on observation and staff interview during the recertification survey and abbreviated survey (Case #NY 445), the facility did not provide effective housekeeping and maintenance services. Specifically, floors were not clean on 2 of 2 resident units. This is evidenced as follows. The floors were spot checked on 03/21/2019 at 8:15 AM. The floors in resident room #'s 4, 11, 19, 20, 33, and #34 and the South Unit Resident Lounge were soiled with food particles, wrappers and had a build of brown debris in the corners of the resident rooms. The Director of Maintenance and Environmental Services stated in an interview on 03/21/2019 at 1:10 PM, that the soiled floors need to be kept clean and that would instruct housekeeping staff to clean more thoroughly. 483.10(i)(2)

Plan of Correction: ApprovedApril 18, 2019

1. The floors on both of the units were cleaned.
2. All residents have the potential to be affected.
3. Housekeepers will check all of the rooms early every morning and will clean at that time if needed, in addition to the regular cleaning throughout the day.
All rooms will be scheduled for a deep clean at least monthly.
A floor scrubber has been purchased and implemented for the main corridors.
4. Ten rooms will be audited 3 x weekly times 4 weeks, then 2 x weekly times 4 weeks and then weekly x 4 weeks to ensure that they are free of debris.
The results will be brought to the QAPI committee x3 months, and then at an interval determined by the committee.
5. The Director of Maintenance and Environmental Services will be responsible for continued compliance.

FF11 483.40(b)(3):TREATMENT/SERVICE FOR DEMENTIA

REGULATION: §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey the facility did not ensure a resident with dementia received the appropriate treatment and services to attain or maintain her highest practicable physical, mental and psychosocial well-being for 1 (#42) of 3 residents reviewed. Specifically, for Resident #42, the facility did not ensure that a physician ordered consult for psychological service was provided. This was evidenced by: Resident #42: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition and was able to make herself understood and able to understand others. The comprehensive care plan (CCP) titled Behavioral symptoms dated 12/12/18 documented; Potential for Alteration in Behavior as evidenced by, physical behavioral symptoms directed towards staff, verbal behavioral symptoms directed towards others, behavioral symptoms not directed towards others-punching and kicking at doors, rejects evaluation or care. The CCP titled Psychosocial - new admitted d 12/21/18 documented; potential for an alteration in their psychosocial well-being as evidenced by not adjusting to facility. The nursing notes dated 1/29/19, documented the resident was uncooperative; standing from wheelchair, banging on desk, ambulating down hallway, and wants to get out of here. Tyhe resident was looking for a bus to go home, swearing and asking where is the way out. The medical doctor (MD) aware of behaviors and new order for [MEDICATION NAME] (antipsychotic medication) may give as one dose if needed and a new order for Psychology consult was received. A physician order [REDACTED]. Review of the medical record did not include documentation of a psychology consult. During an interview on 03/25/19 at 10:46 AM, Registered Nurse Manager (RNM) #3 stated she was not working at the facility when the order was written. She did not know why the psychology consult was not done. When a physician writes an order for [REDACTED]. During an interview on 03/25/19 at 11:00 AM, the Social Work Director stated she was not aware of an order for [REDACTED]. The resident has not been seen by psychology. During an interview on 03/25/19 at 11:22 AM, the Director of Nursing (DON) stated an order for [REDACTED]. There should be a system to keep track of the ordered consults. 10NYCRR415.5

Plan of Correction: ApprovedApril 18, 2019

1. Resident #42 has been seen by Psychiatry on 4/1/19 with the appropriate recommendation.
2. All residents with current orders of Psychological services have the potential to be affected.
The DSW or Facility's designee will obtain a list of residents with orders to be seen by Psychology or Psychiatry to ensure that they have all been seen.
3. Psychology Consult orders will be discussed in morning meeting 5 times weekly to ensure that the DSW is aware of all orders requested.
An email listing the orders will also sent daily, Monday-Friday to the DSW as a follow up.
A consultation tracker will be implemented by DSW or Facility's Designee. The Psychology appointment will be added to the new consult tracker by the DSW or Designee.
4. 100% audit of all psychology orders will be performed by DON or designee weekly x3 months, to ensure that no orders have been missed.
Results of these audits will be brought to the QAPI meeting monthly x3 months, and then at an interval determined by the committee.
5. The Director of Nursing will be responsible for continued compliance.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that PCREE is maintained with consideration of the owner's manual and inspected before placed into operation. Specifically, an inspection log was not maintained for PCREE and PCREE observed was not maintained as prescribed in the owner's manuals. This is evidenced as follows. Record review on 03/20/2019, revealed that the facility did not maintain a record of PCREE being inspected during (YEAR). The Director of Maintenance and Environmental Services stated in an interview on 03/20/2019 at 9:15 AM, that the facility did not maintain a record of inspections of PCREE before it was placed into service for (YEAR). Observations of resident rooms were conducted on 03/21/2019 at 8:30 AM. Two residents were using oxygen concentrators in room [ROOM NUMBER] while the concentrators were against their beds. A resident was using an oxygen concentrator in room [ROOM NUMBER] while the concentrator was against the wall. A resident was using an oxygen concentrator two inches from a nightstand. The nebulizer in resident room [ROOM NUMBER] was in not use and was plugged into an electrical receptacle. Record review of the oxygen concentrators and nebulizers owner's manuals on 03/21/2019 revealed concentrators must be 12 from walls and furnishings when in operation and the nebulizers are to be unplugged after use. Observations on 03/20/2019 at 8:45 AM revealed that the suction machine in the main dining room was missing a bacteria filter. The suction machine operation manual, reviewed on 03/21/2019, states that the bacteria filter must be attached between the collection canister and pump. The Director of Nursing stated in an interview on 03/21/2019 at 3:15 PM, that she was unaware that nursing staff was not operating oxygen concentrators and nebulizers in accordance to the owner's manuals, and the suction machine in the dining room was missing the bacteria filter. Furthermore, she stated the staff will be in-serviced to operate suction machines, nebulizers, and oxygen concentrators in accordance to the owner's manuals. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3, 10.5.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedApril 19, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Oxygen concentrators were moved 12 inches from the wall, nebulizers were unplugged, and bacteria filters were placed in suction machine.
2) All residents have the potential to be impacted.
3) The Director of Maintenance has created a log to document the inspections of all equipment before it is put into use. All relevant staff will be educated in proper use of all PCREE: Oxygen Concentrator, Nebulizers, Suction Machine, AED Defibrillators, Blood Pressure Cuff, Bladder Scanner, Scales, Electric Portable Lift, Electric Beds, Pressure relieving mattress, Bed/Door/Floor alarms, [MEDICAL CONDITION] machines.
4) The Director of Maintenance or his designee will conduct audits weekly x4 and then monthly x3 to ensure all PCREE is being used properly.
The results of the audits will be brought to the QAPI committee for 4 months, and then at an interval determined by the committee.
5) The responsible person is the administrator.

LOCAL, STATE, TRIBAL COLLABORATION PROCESS

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years (annually for LTC facilities). The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the facility did not engage with local emergency preparedness (EP) officials in collaborative planning for an integrated emergency response. This is evidenced as follows. During a review of the Emergency Plan on 03/19/2019, the facility could not provide documentation that local EP officials were involved in the development of the facility's Emergency Plan. The Corporate Administrator stated in an interview on 03/20/2019 at 3:00 PM, that she can not find documentation that local EP officials were involved in the development of the facility's Emergency Plan. 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedApril 18, 2019

1) The facility has contacted(NAME)Gaunay, Emergency Preparedness Cooridnator, Rensselaer County Bureau of public Safety, and(NAME)Claus, Public Health Preparedness Coordinator, Rensselaer County Department of Health.
2) This deficiency has the potential to impact all residents.
3) The facility will meet with both and develop a written plan for collaboration and will participate in county preparedness meetings and drills going forward.
4) The Director of Maintenance will report on progress to the QAPI committee monthly for 3 months, and then semi-annually.
5) Responsible Party is the Director of Maintenance

MAINTENANCE, INSPECTION & TESTING - DOORS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the means of egress was not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.3.3.1 requires that door assemblies in exit enclosures be tested not less than annually and a record maintained in accordance with Chapter 5 of NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition. Section 4.2.1 requires that listed doors be identified by a label (tag) that is not defaced or made illegible. Section 5.1.5 requires that repairs shall be made, and defects that could interfere with operation shall be corrected without delay. Specifically, the fire-rated doors were not inspected within the past year, tags were not clearly visible, and defects were not repaired. This is evidenced as follows. Record review on 03/20/2019 revealed that the facility did not maintain an inspection log of fire-rated doors in (YEAR). Observations on 03/21/2019 revealed the fire-rated smoke compartment doors on both the South and North Resident Units were not closing tightly and were missing latching hardware. The tags on the fire-rated smoke compartment doors separating the center compartment and the south resident unit were painted over. The fire-rated door on the copier room had four 1/4 -inch through holes. An approximately 1-inch by 3-inch unpainted space was observed on the side of the smoke compartment doors separating the Center area and South unit, this space is similar in size and location of where rated-door tags are placed. The Director of Maintenance and Environmental Services stated in an interview on 03/21/2018 at 2:20 PM, that he does not have a record of the (YEAR) door inspections. He will ensure the smoke compartment fire-rated doors close properly, have clearly visible labels, and the required hardware is re-installed. Furthermore, he stated that the center and south smoke compartment doors are fire-rated and he will make arrangements to recertify the fire-rated doors that were missing tags. 42 CFR 483.70 (a)(1); 2012 NFPA 101 19.2.1, 7.2.1.15; 2010 NFPA 80 Chapter 5; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 8.2.3.2.1

Plan of Correction: ApprovedApril 19, 2019

1) All doors have been inspected for appropriate latching hardware. 4 sets of doors require new hardware, and all through holes need to be closed, or the doors replaced. The doors will be repaired or replaced, using fire-rated hardware. The doors will also be re-tagged so that the identifying label is legible.
2) This deficiency has the potential to impact all residents.
3) The Director of Maintenance will inspect all smoke and fire doors annually.
4) The results of the remedial work will be reported to the QAPI committee in June. The results of the annual audit will be reported to the QAPI committee annually.
5) Responsible Party is the Director of Maintenance.

ROLES UNDER A WAIVER DECLARED BY SECRETARY

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:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan did not include provisions detailing their role for the care and treatment of [REDACTED]. This is evidenced as follows. A review of the Emergency Plan on 03/19/2019, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Corporate Administrator stated in an interview on 03/19/2019 at 9:15 AM, that emergency preparedness officials will be contacted, and the Emergency Plan will be revised to include provisions outlining their role for care at an alternate care site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedApril 18, 2019

1) The facility has contacted(NAME)Gaunay, Emergency Preparedness Coordnator, Rensselaer County Bureau of public Safety, and(NAME)Claus, Public Health Preparedness Coordinator, Rensselaer County Department of Health.
2) This deficiency has the potential to impact all residents.
3) The facility will develop a written plan with the county for collaboration of resident care in the event of relocation to an alternate care site.
4) The Director of Maintenance will report on progress to the QAPI committee monthly for 3 months, and then semi-annually.
5) Responsible Party is the Director of Maintenance

K307 NFPA 101:SMOKING REGULATIONS

REGULATION: Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2019
Corrected date: May 24, 2019

Citation Details

Based on observation, staff interview and record review during the recertification survey, the facility did not maintain smoking areas in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 19.7.4 requires that ashtrays of non-combustible design and metal containers with self-closing cover devices into which ashtrays can be emptied shall be provided in all smoking areas. Specifically, ashtrays and metal containers with self-closing cover devices into which ashtrays can be emptied were not provided in smoking areas. This is evidenced as follows. Observations of the trash compactor/kitchen outdoor entrance area on 03/20/2019 at 1:10 PM, revealed numerous cigarettes butts on the ground in this area. Ashtrays and a metal container with a self-closing cover device were not availble. The Director of Dietary was in this area during the observation. The Director of Dietary stated in an interview on 03/20/2019 at 1:20 PM, that staff are not allowed to smoke on the grounds, but he knows staff smoke by the outdoor entrance to the kitchen, especially at night. The Administrator stated in an interview on 03/20/2019 at 2:15 PM, that smoking is prohibited on the facility grounds. The facility smoking policy was reviewed on 03/21/2019. This policy allows smoking in designated areas on the facility. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.4; 10 NYCRR 415.29(a)(2), 711.2, 2000 NFPA 101 19.7.4

Plan of Correction: ApprovedApril 19, 2019

1) The areas identified have been cleaned of cigarette butts. The smoking policy has been updated to indicate that(NAME)Centers is a smoke free campus. The smoking policy has been posted and orientation materials updated. The Admission Agreement already reflects this. No Smoking signs have been ordered.
2) This deficiency has the potential to impact all employees and residents.
3) All staff will be trained on the facility no smoking policy. Violation of the smoking policy by staff will result in corrective action. In particular the Dietary staff will be trained that smoking by the kitchen entrance is not permitted.
4) The Maintenance Director will complete rounds three times per week for four weeks,and weekly for 8 weeks, providing rounding results to the Administrator weekly and to the QAPI committee monthly for 3 months. The QAPI committee will then determine the frequency of auditing.
5) Responsible Party is the Director of Maintenance