The Brightonian, Inc
January 9, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.24(a)(1)(b)(1)-(5)(i)-(iii):ACTIVITIES DAILY LIVING (ADLS)/MNTN ABILITIES

REGULATION: §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #11 and #12) of three residents reviewed for rehabilitation and restorative care, the facility did not provide the treatment and services in the resident's plan of care to maintain functional ability. Specifically, the residents were not ambulated by staff per the resident's plan of care and therapy recommendations. This is evidenced by the following: 1. Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/5/18, included that the resident was cognitively intact, required assist of staff to walk in her room and walking in the corridor did not occur at that time. Review of the Certified Nursing Assistant (CNA) Resident Care Plan, dated 9/28/18, directed staff to ambulate the resident with supervision of one assist and a rolling walker up to 150 feet independently and 10 to 20 feet in the room. Review of Rehabilitation Recommendations to Nursing form, dated 11/2/18, revealed recommendations to ambulate the resident with supervision of one assist with a rolling walker twice daily up to 150 feet and 10 to 20 feet in her room. Review of the Physical Therapy (PT) discharge summary, dated 11/20/18, revealed the resident's current level for walking was independent and 300 feet with modified independence (assistive device or extra time needed). Review of the CNA-ADL (activities of daily living) Tracking Form, from 12/12/18 through 1/7/19, revealed that the resident was independent walking in her room but walking in the hallway was documented the entire timeframe as did not occur. During intermittent observations of the unit on 1/3/19 through 1/8/19 the resident was observed in her room on multiple occasions, including eating all meals in her room but never ambulating in the hallway. When interviewed on 1/3/19 at 10:31 a.m., the resident stated that her husband used to walk with her daily but he had not been in for a week or more because he got sick and was hospitalized . The resident said no one at the facility walks with her. She said that staff would walk her, but she has to ask. She said that she made an appointment with the nurse to walk in the hall the previous day, but no one showed up. The resident said that she thinks it is very important that she walks daily. Interviews conducted on 1/8/19 include the following: a. At 9:13 a.m., the primary CNA stated that the resident's husband was walking in the hallway with her every day but he got sick and had not been in since before last week. The CNA stated she has not ambulated the resident in the hall since her resident husband has been sick. b. At 10:41 a.m., CNA #2 stated he has never walked with the resident in the hallway. When interviewed on 1/9/18 at 9:00 a.m., the Director of PT stated that therapy documents recommendations to nursing on the form and sends it to nursing. He said nursing is responsible for updating the CNA care plan. He said the 11/2/18 form is the most recent one and that staff are expected to supervise her walking in the hallway regardless of what the husband does. 2. Resident #12 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/9/18, included that the resident was cognitively intact and required extensive assist of staff for transfers and walking in his room or in the corridor did not occur at that time. The Rehabilitation Recommendations to Nursing form, dated 12/4/18, and the CNA Resident Care Plan, dated 12/5/18, both directed staff to ambulate the resident in the hallway with one assist and a rolling walker up to 100 feet with a wheelchair to follow and 5 to 10 feet in the resident's room. Review of the PT discharge summary, dated 12/27/18, revealed the resident was able to ambulate 175 feet with stand by assist, close enough to reach the patient if assist needed with a front wheeled walker in order to increase level of independence. Review of the CNA-ADL Tracking Forms, dated (MONTH) (YEAR) and (MONTH) 2019, revealed documentation that the resident ambulated in his room ten times and seven times in the corridor in the past 38 days. Intermittent observations of the resident throughout the day shift on 1/4/19, 1/7/19 and 1/8/19 revealed the resident was in his room in a wheelchair watching TV. At no time was the resident observed ambulating. When interviewed on 1/3/19 at 3:22 p.m. and again on 1/8/19 at 1:20 p.m., the resident stated that he was not getting therapy that week. He said that he does not walk in the hall with staff at all but did walk in therapy. The resident said he did not think he was supposed to walk in the hallway. In an interview on 1/8/19 at 1:29 p.m., the primary CNA stated the resident does not walk anymore and has not in about a month. The CNA stated that he does not walk to the bathroom but just transfers to the toilet. Interviews conducted on 1/9/19 included the following: a. At 9:06 a.m., the Director of PT stated that the resident was no longer in therapy and that he ambulated well. He said that resident required a rolling walker and assist of one staff with a wheelchair follow up to 100 feet. The PT Director said that staff should notify him if a resident is unable to complete the task unless it is just for a day or so. He said no one had informed him that the resident had changed. b. At 11:20 a.m., the Registered Nurse Manager stated that it was his expectations that the staff ambulate the resident's daily if it is on the care card and if unable to notify him. (10 NYCRR 415.12(a)(1)(ii))

Plan of Correction: ApprovedFebruary 2, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó The care plan pertaining to ambulation of resident #11 was reviewed by the Physical Therapist and revised as appropriate. Designated times for ambulation by nursing have been added to the C.N.A Care Card. ?Çó Resident #12 was re-assessed for ambulation by the Physical therapist, and care plan revised as appropriate. Designated times for ambulation by nursing have been added to the C.N.A Care Card. ?Çó The Nurse Manager will provide counseling for the assigned C.N.A ?Çÿs responsible for the care of residents #11 and #12. ?Çó The Comprehensive Care Plan and C.N.A Care Card of all residents are being reviewed by the respective Nurse Managers to ensure that nursing ambulation that is recommended is being provided. ?Çó The policy and procedure on Activities of Daily Living with emphasis on ambulation will be reviewed with nursing staff by Staff Development Coordinator. ?Çó A Quality Assurance audit was conducted, and will be conducted monthly for three months and regularly thereafter to ensure that nursing ambulation of residents is provided according to each resident?ÇÖs plan of care. Results of the audits will be presented to the Quality Assurance Committee for action if necessary. Director of Nursing will oversee compliance of this plan.

FF11 483.21(a)(1)-(3):BASELINE CARE PLAN

REGULATION: §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 10 (Residents #7, #9, #11, #12, #15, #30, #33, #35, #41, and #43) of 11 residents reviewed for Baseline Care Plans, the facility did not develop a care plan that included the minimum required health care information with 48 hours of admission and/or provide the resident and/or their representative with a written summary of the resident's Baseline Care Plan. This is evidenced by the following: The facility policy, Baseline Care Plan, dated 11/28/17, revealed a care plan would be developed within 48 hours of admission for each resident that included the instructions needed to provide effective person-centered care of the resident. The care plan will contain a minimum: initial goals, based on admission orders [REDACTED]. The Baseline Care Plan will be presented to the resident and/or representative and a copy filed with the resident's Comprehensive Care Plan. 1. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessments, dated 7/6/18 and 10/7/18, revealed the resident was cognitively intact and participated in the assessments. The computer generated Baseline Care Plan, dated 7/6/18, included under approaches to attach a copy of the Activity of Daily Living (ADL)/Certified Nursing Assistant (CNA) Care Card and physician orders [REDACTED]. There was no documentation that the resident was presented with a Baseline Care Plan. When interviewed on 1/3/19 at 10:56 a.m., the resident stated he did not recall getting a summary of his care plan and did not know if his family received a copy. 2. Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/18/18, revealed the resident had moderately impaired cognition. The computer generated Baseline Care Plan, dated 7/17/18, included under approaches to attach a copy of the ADL/CNA Care Card and physician orders [REDACTED]. There was no documentation that the resident was presented with a Baseline Care Plan. When interviewed on 1/3/19 at 10:30 a.m., the resident stated she did not recall receiving a summary of her Baseline Care Plan on admission. During an interview on 1/9/19 at 9:20 a.m., the Director of Nursing (DON) stated it was her expectation that the Baseline Care Plan be completed within 48 hours of admission and included a copy of the physician orders [REDACTED]. The DON stated the Baseline Care Plan and attached copies should be signed by the resident and/or representative and located either in the care plan book or in the medical record. 3. Resident #43 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/14/18, revealed the resident was cogntively intact and required assistance of staff for all ADLs. The resident's Baseline Care Plan revealed that it was initiated on 11/7/18 by a Licensed Practical Nurse (LPN) Manager but did not include care related to the resident's ADLs (such as transfers, ambulation, toileting, and eating), therapy orders, or physician orders [REDACTED]. Review of the unsigned and undated Comprehensive Care Plan Meeting Form revealed that neither the resident or a designated representative was invited to the care plan meeting. There was no documented evidence that a care plan meeting or a family meeting was held since the resident was admitted . When interviewed on 1/9/19 at 12:37 p.m., the LPN Manager stated that she initiates the Baseline Care Plan and reviews it with the resident including the orders and ADLs but she has no documentation. She said that the Social Worker (no longer at the facility) usually invites the resident and/or family to a family meeting but not until the resident is ready for discharge. The LPN Manager said that she did not think a meeting was held yet for the resident. She said that she has never invited residents and/or families to the care plan meetings (including following admission) as they do not usually come.

Plan of Correction: ApprovedFebruary 5, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó Any components of the Baseline Care Plans for Residents # 7, #9, #11, # 12, #15, #30, #33, #35, #41, and #43 have been incorporated in their Comprehensive Care Plan. ?Çó The Director of Nursing will educate all nursing management on the policy and procedure for completing a Baseline Care plan. All in -house admissions within the past 30 days will be reviewed and a BCP will be provided to resident and or family. ?Çó The Staff Development Coordinator will conduct an inservice on the policy and procedure of developing a Baseline Care Plan within 48 hours for all other disciplines involved in the care plan process. Template for BCP has been developed and staff will be inserviced on proper use by Staff Development Coordinator. ?Çó The Director of Nursing or designee will conduct Quality Assurance audits after each new admission to the facility for three months and regularly thereafter regarding completion and presentation of the Baseline Care Plan process. Results will be presented to the Quality Assurance Committee for further action if needed. Director of Nursing will oversee compliance of this plan.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review conducted during the Recertification Survey it was determined for four of five residents reviewed for unnecessary medications and one of three residents reviewed for dental, the facility did not develop a comprehensive person-centered care plan that included measurable objectives and addressed the resident's medical, physical mental and psychosocial needs. The issues involved the lack of development of a care plan for [MEDICAL CONDITION] medications that included the target symptoms for use and person-centered non-pharmacological approaches (Residents #5, #7, #9, and #35) and the lack of a care plan for dental (Resident #15). This is evidenced by, but not limited to, the following: The facility policy, Comprehensive Care Plan, dated (MONTH) (YEAR), revealed the care plan summarizes the team approach to active and or potential problems or concerns based on the Care Area Assessment per regulatory requirements. The CCP includes measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. 1. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/25/18, revealed that the resident's cognitive skills for daily decision making were severely impaired (never or rarely made decisions), no behaviors or hallucinations, received an antipsychotic medication on a routine and as needed basis and an antidepressant. Physician orders, dated 12/21/19, included Quetiapine ([MEDICATION NAME] an antipsychotic) and [MEDICATION NAME] ([MEDICATION NAME] an antidepressant). A physician note, dated 10/25/18, included attempts were made to decrease the [MEDICATION NAME], however, due to agitated behaviors and anxiety he failed the attempt. The resident received [MEDICATION NAME] for hallucinations and [MEDICATION NAME] for anxiety and [MEDICAL CONDITION]. A Nurse Practioner note, dated 12/21/18, included [MEDICATION NAME] for dementia with behaviors. The Comprehensive Care Plan (CCP), dated 8/29/18 included the resident received a [MEDICAL CONDITION] medication related to advanced dementia with behaviors. The goal was that the resident would not exhibit adverse drug reaction and approaches included to provide non-pharmacological interventions as able. The Certified Nursing Assistant (CNA) Resident Care Plan, dated 1/4/19, did not include behavior monitoring and or non-pharmacological interventions. Interviews conducted on 1/8/19 included the following: a. At 9:18 a.m., the CNA stated the resident did not have behaviors and was calm. She stated if a resident had behaviors the nurse would tell them in report and the behaviors and approaches would be on the care plan. b. At 3:05 p.m., the Licensed Practical Nurse (LPN) Manager stated the resident used to be very agitated getting out of bed and crawling on the floor. She said currently the resident tries to stand up. 2. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/6/18, revealed the resident was cognitively intact, had little interest or pleasure in doing things, and felt bad about himself. The CCP, dated 9/7/18, revealed the resident received an antidepressant ([MEDICATION NAME]) for depression and pain and [MEDICATION NAME] for depression. The goal was that the resident would not exhibit signs of drug related side effects. Interventions included to provide non-pharmacological intervention as able. Physician orders, dated 10/30/18, included to discontinue the [MEDICATION NAME] (antidepressant). Physician orders, dated 12/10/18, included Duloxetine ([MEDICATION NAME]) for depression and chronic pain. The CNA Care Card, dated 12/5/18, did not identify behaviors and or non-pharmacological interventions. When interviewed on 1/9/19 at 9:20 a.m., the Director of Nursing (DON) stated the CCP was initiated by the Nurse Managers. She said Registered Nurse should review care plan initiated by a LPN Manager. The DON stated her expectation was that the care plan includes the rational for the use of the [MEDICAL CONDITION] medication including specific behaviors exhibited and the diagnosis. The DON stated the interventions would include the basic ones provided for all residents with behaviors with some individuality. The DON reviewed the CCP for Resident #5 and Resident #7, and then stated the care plan should include the resident target symptoms for the use of the psychoactive medication and specific non-pharmacological approaches for each resident. She stated the CNA Care Card should include behaviors and approaches. 3. Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/18/18, revealed the resident had moderately impaired cognition and no dental issues. The current CCP and CNA Care Card does not include the use of a partial plate or potential concerns with missing teeth. Dental evaluations, dated 7/8/18 and 11/6/18, revealed one root tip was missing (tooth #5), and a tooth broke off of the upper partial. When interviewed on 1/9/19 at 9:20 a.m., the DON said that the resident's CCP should address her dental status including the partial denture. She said the CNA Care Card should also include the use of a partial denture. (10 NYCRR 415.11(c)(1))

Plan of Correction: ApprovedFebruary 5, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó Nurse Manager updated the Comprehensive Care Plan and C.N.A Care Card for residents #5. #9, #35 and #7 regarding targeted behaviors for [MEDICAL CONDITION] medication use and non-pharma logical interventions as needed. ?Çó The Medical Provider reviewed the use of [MEDICAL CONDITION] medications based on residents?ÇÖ targeted behaviors and medical [DIAGNOSES REDACTED].# 9, #35 and #7. ?Çó The Nurse Manager updated the Comprehensive Care Plan and C.N.A Care Card for resident #15 to include her dental needs. ?Çó The Nurse Managers will review Comprehensive Care Plans and C.N.A Care Cards on respective units regarding identifying and updating the Comprehensive Care Plans and C.N.A Care Cards to include targeted behaviors for [MEDICAL CONDITION] medication use and non-pharma logical interventions on all residents that are prescribed [MEDICAL CONDITION] medications. ?Çó The Nurse Managers will observe residents?ÇÖ oral cavity on respective units regarding identifying any residents that may have dental needs and add such to the resident?ÇÖs Comprehensive Care Plan and C.N.A Care Card as needed. ?Çó The Staff Development Coordinator will conduct an inservice regarding care planning and use of [MEDICAL CONDITION] medications to include targeted behaviors and non-pharmacological interventions. Interdisciplinary Team will be part of this education, including Physician and NP. ?Çó The Director of Nursing or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to care planning (includes Comprehensive Care Plan and C.N.A Care Card) targeted behaviors and non-pharma logical interventions with [MEDICAL CONDITION] medication use. Results will be presented to Quality Assurance Committee for further action if needed. Director of Nursing will oversee compliance of this plan.

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey, it was determined that for two (Residents #5 and #14) of five residents reviewed for unnecessary medications, the facility did not ensure that pharmacy reported irregularities were distributed to the attending physician, Medical Director, Director of Nursing, and that the reports were acted upon timely. This is evidenced by the following: The facility policy, Pharmacy Services, dated (MONTH) (YEAR), revealed the pharmacist will report irregularities to the attending physician, the facilities Medical Director and the Director of Nursing (DON) and these reports must be acted upon. Irregularities included, but were not limited to, any drug that meets the criteria for an unnecessary drug. Any irregularity noted by the pharmacist must be documented on a separate written report that is sent to the attending physician, Medical Director and DON. The attending physician must document in the resident's medical record that the identified irregularity had been reviewed and what if any action had been taken. If there was no change in the medication, the physician should document his/her rational in the medical record. 1. Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/17/18, revealed the resident's cognitive skills for daily decision making were severely impaired (never or rarely made decisions), no behaviors, received an antipsychotic and antidepressant, and no Gradual Dose Reduction (GDR) had been attempted. The current physician orders [REDACTED]. A pharmacy recommendation, dated 4/1/18 and 8/1/18, revealed the resident was receiving [MEDICATION NAME] 2.5 milligrams (mg) twice a day, the half-life was between 21 and 54 hours, and suggested decreasing the dose to once a day. A pharmacy recommendation, dated 10/1/18, revealed a recommendation to discontinue the Trazadone. There was no documentation from medical regarding the recommendations. When interviewed on 1/9/19 at 11:32 a.m., the pharmacist stated that she recommended a GDR for the resident's [MEDICATION NAME] in (MONTH) (YEAR) and the physician did not respond. The pharmacist stated that the DON during that time, said he was sending out the pharmacy recommendations but she did not see them on the units. The pharmacist said she asked the nurses where the pharmacy recommendations were, and they did not know. The pharmacist stated she had sent recommendations regarding a GDR of the resident's Trazadone twice and several times for the [MEDICATION NAME] (March (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR)). In an interview on 1/9/19 at 12:20 p.m., the Nurse Practitioner (NP) stated she had not been receiving the pharmacy recommendations and she was not sure why. The NP said if she saw a recommendation related to the half-life of [MEDICATION NAME] and dosing, she would have ordered a GDR. 2. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 9/25/18, revealed the resident's skills for daily decision making were severely impaired, and the resident received an antipsychotic and an antidepressant. A pharmacy recommendation, dated 10/1/18, included to consider a taper attempt on Quetiapine (antipsychotic) and if contraindicated, update supporting documentation. The current dose of Quetiapine was 25 mg twice a day and the suggested dose was 12.5 mg in the morning and 25 mg every evening. There was no documentation from medical regarding the recommendation. When interviewed on 1/8/19 at 12:30 p.m., the pharmacist stated reports of irregularities are sent to the Administrator and DON and the Medical Director obtains a copy from them. The pharmacist said when she comes in each month she reviews if the prior months recommendations have been addressed. She said if the irregularity was not addressed, she would ask why and report the irregularity again. In an interview on 1/9/19 at 12:01p.m., the DON stated she received the pharmacy reports and distributed them to the units but did not send them to the Medical Director. When interviewed on 1/9/19 at 12:04 p.m. and 12:20 p.m., the NP stated she had not been receiving the pharmacy recommendations and she was not sure why. The NP said that she does not document her response to a pharmacy recommendation in the medical record. (10 NYCRR 415.18(c)(2))

Plan of Correction: ApprovedFebruary 2, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó The IDT assessed the [MEDICAL CONDITION] medication use for gradual dose reduction for resident #5 and #14. The Director of Nursing will provide the Medical Director and Attending Physician a copy of Pharmacy recommendations each month. ?Çó The facility will place copies of all the Pharmacy recommendation forms, after the medical provider has reviewed them, in a central location for the Pharmacist to review. ?Çó The Director of Nursing will review the policy and procedure for Pharmacy Services with all nursing management and medical providers at an in-service. ?Çó The Administrator or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility policy of Pharmacy Services. The results will be presented to Quality Assurance Committee for further action if needed. Administrator will oversee compliance of this plan.

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 8, 2019

Citation Details

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute and serve food under sanitary conditions. The issues involved thermometers that were not calibrated, the use of incorrect test strips for the chlorine sanitizer, and unlabeled food items. This is evidenced by the following: Observations and interviews conducted on 1/3/19 with the Director of Food Service (DFS) included the following: a. At 8:20 a.m. in the meat and dairy cooler, the following opened food items were undated: approximately one cup of tuna, four cups of shredded cheddar cheese in an open bag, one cup of shredded mozzarella cheese in an open bag, 20 slices of orange cheese in plastic wrap, one-pound chunk of ham wrapped in plastic wrap, two-pound chunk of ham wrapped in plastic wrap, a half of a gallon of apple cider in an open one-gallon jug, and 10 ounces of liquid in a Blender Bottle. Additionally, there was a four-cup container of cream cheese observed in the same cooler and it was dated 12/10. When interviewed at 9:05 a.m., the DFS said once a food product was opened it should be dated. He said the staff try to date the food. He said the apple cider was from a staff Christmas party and the ham was served to residents for New Years, but the leftovers were not dated. The DFS said cream cheese was normally kept for a few days and the Blender Bottle was a staff member's personal drink. b. At 8:35 a.m., in the two-door reach-in cooler, there was a tray of approximately 10 individual fruit cups which were undated and trays of approximately 20 individual custard cups that were uncovered and undated. When interviewed at that time, the DFS said the fruit cups were prepared that morning and the custard cups were made from scratch the day before. The DFS said he did not cover the custard cups immediately to allow them to cool and he missed the dates on both. c. At 8:37 a.m., there was no thermometer in the sliding glass door above the countertop cooler to allow the facility to monitor the air temperature. At that time, the surveyor's thermometer was placed in the cooler and it read 57 degrees Fahrenheit. When interviewed at that time, the DFS said the cooler should have a thermometer. He said that he obviously turns the stock around all the time in that cooler and it is going to be out of temperature because they are in and out of it for an hour for each meal. Observations and interviews conducted on 1/7/19 included the following: a. At 9:45 a.m., the surveyor and DFS calibrated two of two in-use facility bimetallic thermometers, both(NAME)model number -1. The DFS said the thermometers had been in use a couple of months. He provided a cup of ice with hardly any water in it and placed both facility thermometers into the cup. When the surveyor asked if there was enough water, he said calibration was not a religious science. He added more water, so that the calibration dimple of each thermometer was submerged. Facility thermometers read 25 and 36 degrees Fahrenheit. The surveyor's Aqua Tuff thermocouple, model , read 33 degrees Fahrenheit. The DFS recalibrated both thermometers to 32 degrees Fahrenheit. He said there were no calibration logs. b. At 10:20 a.m., a Dietary Aide had set up the three-compartment sink for use. He said he was washing trays, pots and pans, and adaptive ware because the dish machine was not working. The Dietary Aide said there was soap and water in the first sink. He said the middle sink was not holding water and he was dumping liquid waste (from items on trays) into it while running the faucet and rinsing soapy water off the dishware. The Dietary Aide said he was sanitizing items with bleach in the last sink. He said they had run out of the usual sanitizer and he did not know what it was called. When asked how much bleach he was using, he said another kitchen worker told him to put three capfuls into the sink. At that time, the DFS entered the kitchen and said there must be (quaternary) sanitizer and he would look for it. The DFS returned and said there was none, and he had no idea how long it had been gone because no one told him. The Dietary Aide was asked to check the concentration of the bleach sanitizer. He reached for in-use test strips which were not for a chlorine-based sanitizer. The surveyor stopped him and the DFS said he had the correct strips and would get them. The test strip read 200 parts per million. The DFS was asked for sanitizing logs. He said (MONTH) (YEAR) had been documented but (MONTH) 2019 had not been recorded at all. He said staff were not using the correct test strips so the documentation would not be accurate. Review of an undated facility policy, Policy and Procedure of Leftover Food, directed to cover food and clearly place dates of preparation and date to be discarded on the container. Discard any food that has been in storage for more than three days. Discard all other foods removed from their original containers after five days. A facility policy, Thermometer Calibration Log, dated (MONTH) 2007, directs that a thermometer calibration check will be completed and documented daily to ensure that food temperature readings are correct so that all food items are served at a safe and palatable level. Calibration procedures include to fill a coffee mug with ice and add approximately 3 ounces of water. Place the thermometer into ice water and mix. Let stand 20 seconds. Temperature should read 32 degrees Fahrenheit. (10 NYCRR 415.14(h))

Plan of Correction: ApprovedFebruary 4, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó Items in cooler have been dated. Thermometer placed in the sliding glass door above the countertop cooler. ?Çó Items in all coolers have been checked for correct labeling with no issues noted. Audits conducted on all coolers revealed thermometers are intact and operational with no issues noted. ?Çó Director of Food Service will Inservice Dietary staff regarding labeling of foods placed in the coolers and facility procedure regarding thermometers in each cooler. Director of Food Service will conduct Inservice regarding facility procedures regarding calibration of thermometer and testing chlorine sanitizer. Director of Food Service will Inservice Cooks on each shift in charge regarding his/her responsiblity to ensure calibration of thermometers and testing chlorine sanitizer. ?Çó Director of Food Service will or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility procedure regarding labeling of foods in coolers and maintaining thermometers in coolers. Results will be presented to the Quality Assurance Committee for further action as needed. Director of Food Service will oversee compliance of this plan.

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Rectification Survey, it was determined that for one of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime was free for unnecessary [MEDICAL CONDITION] medications. The issues involved the lack of a Gradual Dose Reduction attempt for the use of an antipsychotic and antidepressant, and the resident care plan did not include resident specific target behaviors or approaches, including non-pharmacological approaches. This is evidenced by the following: Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/17/18, revealed the resident had severely impaired congnition, no behaviors, [MEDICAL CONDITION] or hallucinations, her mood score was 8 of 30 which included feeling tired, little energy, trouble concentrating, short tempered and easily annoyed, daily use of both an antipsychotic and a antidepressant and physician documented clinically contraindicated Gradual Dose Reduction (GDR) on 9/20/18. Physician orders, dated 11/9/18, included [MEDICATION NAME] ([MEDICATION NAME]-an antidepressant) 50 milligrams (mgs) every day, [MEDICATION NAME] (antidepressant) 25 mgs every day and [MEDICATION NAME] ([MEDICATION NAME]-an antipsychotic) 2.5 mgs twice daily. The Certified Nursing Assistant (CNA) Resident Care Plan, dated 12/11/18, did not include any activities (blank) or behaviors other than the resident can become agitated during her shower and directed to approach her in a calm manner. The Comprehensive Care Plan, dated 10/25/18, included a category for [MEDICAL CONDITION] Drug Use for [MEDICATION NAME], Trazadone and [MEDICATION NAME]. Approaches for each medication included behavior log to be completed as needed, GDR per medical provider order, and provide non-pharmacological interventions as able, there were no resident specific approaches included. An Activity CCP, dated 10/25/18, directed to provide music, socials and visiting with family. A Behavioral Symptom CCP, dated 10/25/18, revealed the resident can refuse care and become agitated during showers, approaches are a calm approach, speak in calm voice, smile during care, and avoid putting the resident's face directly into the shower, use a wash cloth instead. Review of the Integrated Progress Notes, from 8/21/18 to 11/8/18, did not include any behaviors other than refusal of a shower on 10/9/18. Review of a Pharmacy Notebook revealed the following: a. [MEDICAL CONDITION] and Sedative/Hypnotic Utilization by Resident: Antidepressant, [MEDICATION NAME] 50 mg every day was ordered on [DATE]. The last GDR was 9/25/18; Antidepressant, [MEDICATION NAME] HCl 25 mg at bedtime was ordered on [DATE] and there was no GDR; and Antipsychotic, [MEDICATION NAME] 2.5 mg twice a day was ordered on [DATE] and there was no GDR. b. The Consultant Pharmacist's Medication Regimen Review notes, dated 3/1/18 to 4/1/18, 5/1/18 to 5/31/18, and 7/1/18 to 8/1/18 all revealed the same recommendations for the resident which was to consider a taper of the [MEDICATION NAME]. The current dose was 2.5 mg twice a day and the suggested dose would be [MEDICATION NAME] 2.5 mg daily, as the half-life was 21 to 54 hours. The last attempt was (MONTH) (YEAR) (medication started that date). There was no compelling reason to not trial dose reduction. There are no behaviors reported per provider note dated 5/3/18 which also revealed the resident was lethargic most of the time. c. The Consultant Pharmacist's Medication Regimen Review Note dated, 9/1/18 to 10/1/8, included to consider discontinuing [MEDICATION NAME] 25 mg each evening and implement resident centered non-pharmacologic interventions as a substitute for reduction in the medication. Observations and interviews conducted on 1/7/19 included the following: a. At 8:15 a.m., 8:23 a.m. and 1:18 p.m., the resident was sitting quietly, watching television either not engaged in the program or asleep in her chair. b. At 8:15 a.m. and 8:21 a.m., CNA #1 and CNA #2 said they did not know what the resident liked to do or if she has any behaviors. CNA #2 said the resident goes to things and sits there and she was not sure if the resident liked that or not. In an observation on 1/8/19 at 10:15 a.m., Resident #14 was in an exercise activity, participating, and greeted surveyor appropriately. Observations and interviews conducted on 1/9/19 included the following: a. At 9:20 a.m., 10:43 a.m., and 12:13 p.m., CNA #3 said she was the primary CNA for the resident. She said the resident's behavior was confusion. CNA #3 said the resident sleeps well, likes church but does not like more involved activities, like ball toss. She said the resident does not refuse cares other than she does not like to get her face wet. b. At 9:20 a.m., the Director of Nursing (DON) said care plans for psychoactive medication, like antidepressants and antipsychotics, can be initiated by the Licensed Practical Nurse (LPN) Manager and reviewed by a Registered Nurse. She said the CCP should include a specific rationale for drug use, specific behaviors, and non-pharmacological approaches. The DON said that current CCPs also include general standards of care. c. At 10:14 a.m., the resident was in the sitting room, asleep in her chair, in front of the television. LPN #1 said the resident was very quiet and does not have any behaviors other than she will occasionally yell out for someone by name and that was short lived. LPN #1 said staff use a behavior tracking sheet to monitor behaviors, which is located in the Medication Administration Record. LPN #1 said that behaviors are documented every shift for two weeks and then the form is sent to the medical provider for review. LPN #1 said that she starts a sheet when a medication used to treat behaviors or depression is changed. LPN #1 said she does that whether the provider orders it or not. d. At 10:18 a.m., the Unit Secretary said she does not know where behavior logs are filed. She said the logs may be in the nursing notes. e. At 11:32 a.m., a Consultant Pharmacist said the resident started on Trazadone 25 mgs which is a sedative dose on 1/29/18. She said the medication required two GDR attempts within the first year and that has not been done. The Consultant Pharmacist said she had written a note on 12/27/18 for the medical provider to again consider a GDR of [MEDICATION NAME]. She said there was no medical follow up in response to a GDR for [MEDICATION NAME]. She said the half-life of the drug is 21 to 54 hours, so it does not require twice a day dosing. The Consultant Pharmacist said that the staff implement resident centered interventions. f. At 12:05 p.m., the LPN Manager said the resident talks out loud and has a history of not sleeping. She said behavior logs are used for monitoring when a medication is started or changed but she does not know where those are kept. The LPN Manager said that she does not get pharmacy recommendations, those go to the Director of Nursing. She said the physician may look at the behavior logs but more likely talks to the nurses. The LPN Manager said the resident was verbal during cares but has not hurt herself or anyone else, although she may try to scratch caregivers. The LPN Manager said the resident does not like having a washcloth on her face but that would not be a clinical indication for the use of antipsychotic. She said perhaps the physician can change the dose. g. At 12:20 p.m., a Nurse Practitioner (NP) said the resident had some extreme behaviors, calling out randomly, but was not like that now. The NP said she thought because the resident was doing okay, no change was made in the dose of [MEDICATION NAME]. The NP said she has not been getting the pharmacy recommendations, and did not get the ones for [MEDICATION NAME] and [MEDICATION NAME]. She said if she had seen the recommendations to reduce the dose of [MEDICATION NAME] to daily from twice a day, due to the length of the drug half-life, she would have changed it. The NP said she would follow up that day. The NP said she would also follow up on the [MEDICATION NAME]. She said that if the medication was at a sedative level, the staff should be monitoring sleep patterns and reporting to medical for follow up. (10 NYCRR 415.12(l)(1)(2)(i))

Plan of Correction: ApprovedFebruary 5, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó The Interdisciplinary Team assessed the [MEDICAL CONDITION] medication use for gradual dose reduction for resident #14. ?Çó The Medical provider evaluated resident #14 for use of [MEDICAL CONDITION] medication for gradual dose reduction. ?Çó The Comprehensive Care Plan and C.N.A Care Card for resident #14 was reviewed and revised as appropriate to ensure that targeted behaviors and non-pharmacological interventions are addressed. ?Çó The Interdisciplinary Team will review all residents that have physician orders [REDACTED]. ?Çó The Nurse Manager will review and revise all [MEDICAL CONDITION] medication Comprehensive Care Plan and C.N.A Care Card of their respective units to ensure that targeted behaviors and non-pharma logical interventions are in place. ?Çó The Staff Development Coordinator will review the policy and procedure for Gradual Dose Reductions with the IDT team and medical providers, emphasizing targeted behaviors, non-pharmacological interventions and time frames. ?Çó Quality Assurance audit was conducted and will be conducted every three months and regularly thereafter to ensure the residents that have physician orders [REDACTED]. Results of the audits will be presented to the Quality Assurance Committee for action as necessary.

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: January 9, 2019
Corrected date: March 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 842), it was determined that for one (Resident #41) of three residents reviewed for wound care, the facility did not provide care using appropriate infection control techniques. Specifically, a staff member did not follow standard infection control practices in multiple areas related to wound care. This is evidenced by the following: The current facility policy, Wound Care, includes that proper standards of practice will be incorporated into the wound care regimen by the healthcare provider performing the treatment to any affected area. Healthcare providers will comply with the Centers for Disease Control recommendations for use of standard precautions regardless of resident [DIAGNOSES REDACTED]. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/7/18, revealed that the resident was cognitively intact, required assist of staff for all activities of daily living (except eating) and had one arterial/venous ulcer. The current Comprehensive Care Plan included that the resident has an infection of a pressure ulcer of the right great toe with osteo[DIAGNOSES REDACTED] and [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). Approaches included to change dressings per orders and maintain isolation precautions as applicable. Physician orders, dated 12/3/18, included to pack the toe ulcer with [MEDICATION NAME] (antiseptic strips) packing twice daily and cover with kling (gauze). In an observation on 1/3/19 at 10:11 a.m., the resident was sitting in her room in a chair, and her bare foot was sitting on the carpet, unwrapped, exposing an approximately 1/2 inch open ulcer in her right big toe. The sign on the door instructed visitors to see the nurse prior to entering. Licensed Practical Nurse (LPN) #1 stated that the surveyor would need to wear a mask only prior to entering the resident's room. A housekeeper was in the room at the time without any Personal Protective Equipment (PPE) and the Certified Nursing Assistant was in and out of the room without wearing any PPE of any kind. The resident's floor was littered with several pieces of garbage (empty cups and straws) at that time, including a toilet plunger sitting on the carpeted floor approximately 2 feet from the residents unwrapped foot. The foot was left on the floor unwrapped for an observed minimum 30 minutes while multiple staff were in and out of the room. When interviewed at that time, LPN #1 stated that the resident's foot was unwrapped so medical could view it when they arrived. In an observation of wound care on 1/4/19 at 10:20 a.m., LPN #2 applied a gown, gloves and mask and entered the resident's room. The gown was untied at the top exposing half of the nurse's upper torso and the mask was untied at the top causing the straps to drape over the resident's foot (including during the dressing change). A towel was set on the carpet under the resident's foot and the old kling was removed and discarded on an overbed table. LPN #2 changed her gloves setting the soiled gloves on the carpet. Approximately 4 to 5 inches of [MEDICATION NAME] packing was removed from the ulcer and while the nurse was looking for a place to discard it (no garbage can nearby, and nothing prepared to contain soiled materials), the blood tinged packing fell on the carpeted floor and was left there. The resident's foot was very dry with peeling skin. Without changing gloves, LPN #2 touched a bag of clean supplies and pulled out supplies including scissors and reached under her PPE searching for her eyeglasses. LPN #2 changed her gloves and the packing was sprinkled with normal saline, cut and packed into the wound using a cotton swab and covered with gauze. The foot was not washed and there was no peri-wound preventive skin care done. The scissors were not cleaned prior to cutting the packing and her hands were not sanitized between glove changes. There was no garbage bag to discard the soiled equipment and dressings so LPN #2 left the room to get one still wearing the PPE. LPN #2 did not wash or sanitize her hands prior to leaving the precaution room. When interviewed on 1/4/19 at 10:48 a.m., LPN #2 stated that she should have set up her supplies prior to starting the dressing change (i.e.: opened packages and making sure she had all needed supplies and a place to discard soiled supplies), should have tied her mask and gown on properly and did not realize the straps were hanging over the resident's foot. LPN #2 said she did not clean the scissors prior to using them, should not have put soiled supplies on the carpet, and did not clean around the wound because there were no orders. LPN said she should not have come out of the room wearing her PPE. LPN #2 that she did not normally complete the dressing change for the resident. When interviewed on 1/7/19 at 2:05 p.m., the Registered Nurse (RN)/Staff developer said the resident's foot should not be left unwrapped for that length of time unprotected and that she expected staff to clean the resident's wound (including peri-wound area) and obtain clarification if the order was not complete. She said the nurse should not put soiled supplies on the floor use scissors that have not been cleaned to cut packing. She said the nurse should not touch clean supplies with dirty gloves on and should not leave the room with PPE on. The RN stated that she has no record of staff training related to dressing changes and protocol when wearing PPE. She said the staff member was new and may have had some of that training during orientation but had was no documentation. She said if a staff member was uncomfortable with a specific treatment she should let the Nurse Manager know. (10 NYRR 415.19(a)(2))

Plan of Correction: ApprovedFebruary 5, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó The Nurse caring for Resident #41 was re-educated by Staff Development Coordinator regarding the provision of wound care in accordance with standard infection control techniques. The Nurse caring for Resident #41 was re-educated regarding the proper use of Personal Protective Equipment. ?Çó The Nurse Managers and Staff Development Coordinator are oberving each Nurse performing wound dressing change in order to ensure that proper standard infection control techniques are followed. ?Çó The Consultant RN Infection Control Nurse will conduct an Inservice reviewing facility policy and procedure re: Infection Control and dressing changes. A demonstration of wound dressing changes will be given and repeat demonstration required by Nurses in attendance. A demonstration of donning and doffing Personal Protective Equipment will be given and return demonstrations preformed. ?Çó Quality Assurance audits will be conducted on proper infection control techniques including dressing changes and the use of Personal Protective Equipment by Nurse Managers and Staff Development Coordinator. Results of audits will be presented to the Quality Assurance Committee for action as necessary. Staff Development Coordinator will oversee compliance of this plan. Directed Plan of Correction The Brightonian's Quality Assurance Committee was convened on 1/31/2019 at 11:00am and utilized route cause analysis to determine the cause of this deficiency. A. Complete an assessment of the causative factors that may have contributed to the issues identified in the above deficiency. 1. After reviewing information and interviewing the LPN completing the dressing change it was determined that the Nurse did not follow proper wound care technique and use of Personal Protective Equipment. Quality Assurance Committee in agreement that Nurse does not have recent experience with dressing changes since she usually works nights and is in need of reeducation. Additional factor was nervousness due to Surveyor standing and observing Nurse. 2. General staff did not follow proper use of Personal Protective Equipment prior to entering the Resident's room. 3. Proper storage of equipment not followed per facility procedure. B. Identify the specific steps / interventions undertaken or proposed to eliminate and correct the causative factors identified during the assessment phase. 1. Nursing (RN and LPN) staff will be Inserviced by an Infection Control Consultant, (NAME) Tinoglio, regarding proper infection control techniques and standard infection control practices. Dates of Inservice are (MONTH) 25, 26, 28, and (MONTH) 4. 2. All staff will be Inserviced by Infection Control Consultant, (NAME) Tinoglio, regarding proper use of Personal Protective Equipment. Dates of Inservice are (MONTH) 25, 26, 28, and (MONTH) 4. 3. Proper storage of equipment will be reviewed with all staff by Staff Development Coordinator. C. Identify the routine triggers or parameters the facility will implement for the above deficiency, that will signal or alert all staff of an evolving problem or deficient practice situation. Indicate how this will be carried out by the facility. 1. Staff Development Coordinator or designee will do periodic observation of standard infection control practice related to wound care by Nurses. 2. Staff Development Coordinator will audit adherence to facility procedure regarding use of Personal Protective Equipment by all staff. Results of audits will be presented to Quality Assurance Committee for further action as necessary. D. Specify how the facility will measure whether efforts are successful or unsuccessful in maintaining compliance. Staff Development Coordinator or designee will conduct audits regarding use of Personal Protective Equipment and standard infection control practice related to wound care per facility procedures. Immediate corrective action will be taken, if needed. Results of the audits will be presented to the Quality Assurance Committee for further action as necessary. Staff Development Coordinator will oversee compliance of this plan.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of two residents reviewed for abuse, the facility did not investigate an allegation of rough treatment (Resident #13) or an injury of unknown origin (Resident #3) in order to rule out abuse, neglect or mistreatment. This is evidenced by the following: 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/10/18, included that the resident was cognitively intact and required extensive assist of two staff for transfers. The Certified Nursing Assistant (CNA) Resident Care Plan, dated 10/4/18, included that the resident required a Hoyer mechanical lift for transfers to bed. In an interview on 1/3/19 at 10:54 a.m. the resident stated that she had a problem with a staff member who was very rough, pushed me, slammed me into one of the posts of the lift. The resident said that she had told the Nurse Practitioner (NP) who took care of it immediately as the resident has not seen the staff member since. In an interview on 1/7/19 at 11:15 a.m., the NP stated that the resident reported that complaint to her and that she handed it over to the management. The NP stated she thought it was the Director of Nursing (DON) at that time (several weeks ago) and that she was pretty sure the facility investigated the incident and may have ended with someone being terminated but she was not sure. When interviewed on 1/8/19 at 9:41 a.m., the acting DON stated she could not find any investigation related to any complaints made by the resident and it may have been reported to the prior DON. She said she spoke with the Administrator who verified that they have no investigation regarding any allegations of staff behavior. In an interview on 1/9/19 at 12:35 p.m., the Licensed Practical Nurse (LPN) Manager stated that she thought but was not sure that she was the manager on that unit at that time. The LPN Manager said she was unaware of any complaints from the resident regarding rough treatment by staff. 2. Resident #20 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/26/18, revealed that the resident had severely impaired cognition and required extensive assist of staff for all Activities of Daily Living. Review of physician orders, dated 10/30/18 and 1/7/19, revealed orders for tubi-grips (compression sleeves) to upper extremities always and to remove for care. The Comprehensive Care Plan, dated 12/28/18, included that the resident had impaired skin integrity as evidenced by anticoagulation therapy and fragile skin resulting in skin tears and bruising. Interventions included skin observations daily, report new bruising, and apply tubi-grips to both upper and lower extremities. Review of progress notes, dated 12/26/18 and 1/2/19, revealed staff documented no new skin issues. Observations on 1/3/19 at 12:21 p.m. and on 1/7/19 at 11:01 a.m., a purple area oblong in nature and about 1.5 centimeters in length was noted at the base of the resident's right thumb web base. On 1/4/18 at 12:02 p.m., the LPN Manager was observed providing nail care to the resident. In an observation and interview on 1/7/19 at 12:57 p.m., the LPN Manager stated that the resident does not always have a purple area on his right hand. She stated she had not been there the previous two days and would check with the nurse that was on to see if an Incident/Accident (I/A) Report had been initiated. The LPN Manager stated there should be an I/A Report and a note in the progress notes. A nursing progress note, dated 1/7/19 after surveyor intervention, documented a bruise to the right thumb web space and upper extremity. On 1/8/19 at 1:22 p.m., the LPN Manager stated she had initiated the I/A Report and was in process of completing the investigation and obtaining interviews with staff who worked over the past 72 hours. She said weekly skin checks are completed on shower days by the nurse and documented. The LPN Manager stated the bruise should have been reported before 1/7/19. In an interview on 1/9/19 at 1:39 p.m., the CNA stated that the resident had dry, itchy skin. She said the resident had a bruise at one time on his arms and that he wore tubi-grips on both arms. Review of facility policy, Abuse, Neglect, and Exploitation Prohibition, Training, Investigation and Reporting Policy, dated (MONTH) (YEAR), includes that the facility shall investigate and report any accident/incident/grievance and crime where there is reasonable cause for suspicion of staff abuse, neglect, exploitation, involuntary seclusion, injury of unknown source or mistreatment of [REDACTED]. (10 NYCRR 415.4(b)(3))

Plan of Correction: ApprovedFebruary 5, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó The Nurse Manager completed a skin observation on Resident #20, an investigation was initiated and completed with findings of abuse, neglect or mistreatment. ?Çó Resident #13 no longer resides at the facility. Retrospective investigation completed for Resident #13. ?Çó The Nurse Managers and or assigned designees completed skin observations for the residents on respective units. The Director of Nursing is reviewing the Accident and Incident reports over the past three months to ensure that any bruise or issue of unknown origin was investigated. ?Çó Residents are being interviewed to determine satisfaction/gentle care/treatment. ?Çó The Director of Nursing educated all nursing management on the facility?ÇÖs policy and procedure for investigating and reporting abuse, neglect, exploitation, injury of unknown origin and mistreatment. ?Çó The Staff Development Coordinator will conduct an in service for all staff on the facility?ÇÖs policy and procedure for investigating and reporting abuse, neglect, mistreatment or exploitation, and injury of unknown origin. ?Çó The Director of Nursing or designee will conduct Quality Assurance audits weekly for three months, then monthly for 3 months, and regularly thereafter regarding adherence to facility policy for investigating and reporting abuse, neglect, mistreatment or exploitation and injury of unknown origin. Results will be presented to the Quality Assurance Committee for further action if needed. Director of Nursing will oversee compliance of this plan.

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: Pattern
Severity: Potential to cause minimal harm
Citation date: January 9, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for three (Residents #200, #201, and #202) of five residents reviewed for resident rights, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries to notify them of their appeal rights under the regulations. Specifically, the facility did not provide the beneficiary with a Medicare Non-coverage letter prior to discharge to the community. This is evidenced by the following: Resident #200 was admitted to the facility on [DATE] and discharged to the community on 11/9/18 with Medicare Part A days remaining. There was no evidence that a Medicare Non-coverage letter was provided with the appropriate liability and appeals notice prior to discharge to notify them of their appeal rights under the regulations. Resident #201 was admitted to the facility on [DATE] and discharged to the community on 11/4/18 with Medicare Part A days remaining. There was no evidence that a Medicare Non-coverage letter was provided with the appropriate liability and appeals notice prior to discharge to notify them of their appeal rights under the regulations. Resident #202 was admitted to the facility on [DATE] and discharged to the community on 11/12/18 with Medicare Part A days remaining. There was no evidence that a Medicare Non-coverage letter was provided with the appropriate liability and appeals notice prior to discharge to notify them of their appeal rights under the regulations. During an interview on 1/8/19 at 11:51 a.m., the Administrator stated that she does not have any Notice of Medicare Non-coverage notices (appeals) for any of the residents because the business manager who is no longer employed at the facility was not doing them. The Administrator stated the business manager left approximately three weeks ago and she was unaware of how long the notices were not being done. (10 NYCRR 415.3(g)(2)(i))

Plan of Correction: ApprovedFebruary 2, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó Resident #200, Resident #201, and Resident #202 have been discharged from the facility to home upon completion of Therapy program therefore liability and appeal notices to Medicare beneficiaries no longer appropriate. ?Çó Residents currently under Medicare coverage reviewed to determine if appropriate liability and appeal notices to Medicare beneficiaries have been issued in a timely manner with no issues noted. ?Çó Administrator will conduct Inservice to Business Office and Social Work staff regarding liability and appeal notices to be issued to Medicare beneficiaries to notify them of their appeal rights under the regulations. ?Çó Administrator or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility procedure regarding issuance of liability and appeal notices to Medicare beneficiaries. Results will be presented to the Quality Assurance Committee for further action as needed. Administrator will oversee compliance of this plan.

FF11 483.12(a)(3)(4):NOT EMPLOY/ENGAGE STAFF W/ ADVERSE ACTIONS

REGULATION: §483.12(a) The facility must- §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 7, 2019

Citation Details

Based on an interview and record reviews conducted during the Recertification Survey, it was determined that for two (Certified Nursing Assistants #1 and #2) of five employee files reviewed, the facility did not screen two employees for prior findings of abuse. Specifically, the facility did not conduct a Nurse Aide Registry Check. This is evidenced by the following: 1. Review of Certified Nursing Assistant (CNA) #1's personnel file revealed CNA #1 was hired on 11/6/18. There was no documentation that showed a New York State Nurse Aide Registry check had been conducted prior to employment at the facility. 2. Review of CNA #2's personnel file revealed CNA #2 was hired on 11/13/18. There was no documentation that showed a New York State Nurse Aide Registry check had been conducted prior to employment at the facility. During an interview on 1/7/19 at 9:20 a.m., the Administrator stated both CNA #1 and CNA #2 are still employed at the facility. The Administrator also stated she believes the Nurse Aide Registry checks were conducted prior to hire, but were misfiled and she cannot locate them. She stated it is her standard practice to check the Nurse Aide Registry for each job candidate prior to their job interview and print the report for the personnel file. Additionally, the Administrator stated Nurse Aide Registry checks are not addressed in any facility policy or procedure. (10 NYCRR 415.4(b)(1)(ii)(b))

Plan of Correction: ApprovedFebruary 4, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó New York State Nurse Aide Registry Check was printed out and placed in personnel files of Certified Nursing Assistants #1 and #2. ?Çó Audits conducted of personnel records regarding printing of Nurse Aide Registry Checks as part of personnel files has been conducted with no issues noted. ?Çó Administrator will conduct Inservice to Payroll Clerk regarding printing and filing of New York State Nurse Aide Registry Check for each employee prior to first day of employment. ?Çó Administrator or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility procedure regarding printing and filing of New York State Nurse Aide Registry Check for each new employee. Results will be presented to the Quality Assurance Committee for further action as needed. Administrator will oversee compliance of this plan.

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: Widespread
Severity: Potential to cause minimal harm
Citation date: January 9, 2019
Corrected date: March 8, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, conducted during the Recertification Survey, it was determined that for one (Resident #1) of one resident reviewed for Notice of Transfer or Discharge and Ombudsman Notification, the facility did not send a copy of the notice of transfer or discharge to the representative at the Office of the State Long-Term Care Ombudsman program. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/10/18, revealed the resident had severely impaired cognition. The Hospital Discharge Summary revealed that the resident was hospitalized from [DATE] through 12/14/18 due to a bacterial urinary tract infection. Interviews conducted on 1/8/19 included the following: a. At 10:35 a.m., the Acting Director of Nursing said the facility did not currently have an Ombudsman, and she did not believe anyone was reporting discharges to the local office. She asked if this was a new requirement. b. At 1:06 p.m., the Administrator said that the notices were not being sent to the Office of the State-Long Term Care Ombudsman program because a sister facility told her that the Ombudsmen program did not want the notices. The Administrator said she had a call in to the Ombudsman office for clarification. (10 NYCRR 415.3(h)(1))

Plan of Correction: ApprovedFebruary 4, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó Resident #1 has been readmitted to the facility, therefore notification of discharge to Ombudsman is no longer appropriate. Resident #1 added to the facility discharge log. ?Çó Clarification received from Ombudsman and ongoing discharge log maintained to be sent to Ombudsman on a monthly basis versus individual discharge notices per request of Ombudsman office. ?Çó Administrator will conduct Inservice to Social Work staff regarding notification of discharges to be sent to Ombudsman office. ?Çó Administrator or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility procedure regarding notification of discharges to Ombudsman office. Results will be presented to the Quality Assurance Committee for further action as needed. Administrator will oversee compliance of this plan.

FF11 483.25(k):PAIN MANAGEMENT

REGULATION: §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined for one (Resident #39) of one residents reviewed for pain, the facility did not ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensives person-centered care plan and the resident's goals and preferences. The issues involved the lack of a pain assessment at the time of admission, the lack of reevaluation or monitoring of the effectiveness after the addition of a routine pain medication, the lack of medical provider notification after continued complaints of pain, the lack of a care plan for pain, and the lack of the use of an adaptive cushion for comfort. This is evidenced by the following: Resident #39 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/6/18, revealed the resident was cognitively intact, had no scheduled routine pain medications, received as needed pain medication, and complained of occasional mild pain. The admission physician orders, dated 11/29/18, included [MEDICATION NAME] (Tylenol) 650 milligrams (mg) every six hours as needed for pain. The Nursing Admission Assessment, dated 11/29/18, documented that the resident had pain in her buttocks that was rated an eight out of ten (ten being the worst pain you can imagine). An undated Admission Pain Assessment Flow Sheet was blank (no data entered). The current Comprehensive Care Plan (CCP) did not include pain. The Admission History and Physical, dated 12/3/18, revealed that the resident used [MEDICATION NAME] 0.5 mgs every six hour as needed for pain and Tylenol 650 mgs every six hours as needed for pain as an outpatient. The physician documented that the resident was having low back pain at that time and Tylenol was available as needed. The resident had some tenderness over the sacral region. A skin exam revealed a scabbed area on the left buttock and redness of both heels. Physician orders, dated 12/3/18, included to change Tylenol to 650 mg four times a day routinely and 650 mg once per day as needed for pain. There was no documentation that the resident's pain was being monitored consistently for effectiveness. A Pain Assessment Interview, dated 1/3/19, revealed the resident had occasional severe pain (rated an eight) over the last five days. The current Certified Nursing Assistant (CNA) Resident Care Card directed the use of a ROHO cushion (specialty pressure reducing cushion). During an observation and interview on 1/3/19 at 1:20 p.m., the resident said she usually has pain in her buttocks. The resident was observed sitting on a gel cushion (not ROHO). The resident said staff apply butt paste and she also gets Tylenol but it does not do any good. The resident said she has reported that to staff but they have not done anything to change it. When interviewed on 1/4/19 at 11:30 a.m., a Licensed Practical Nurse (LPN) Manager said she visits the resident frequently to talk about pain in her bottom. She said the resident sits all day and her bottom gets red. The LPN Manager said she knows the Tylenol does not provide pain relief but medical will not order [MEDICATION NAME] (narcotic) for a bottom unless it is open. The LPN Manager said that she completed a pain assessment the day before and the resident rated her pain as an eight out of ten. Observations and interviews conducted on 1/7/19 included the following: a. At 8:33 a.m., CNA #1 said she did not know what kind of cushion the resident uses in her recliner or wheelchair. She said it looks like a gel cushion. b. At 8:53 a.m., the resident was sitting in her recliner with a gel cushion (not ROHO). c. At 12:01 p.m., the resident was sitting in her chair with a gel cushion (not ROHO). She said her bottom hurt. Observations and interviews conducted on 1/8/19 included the following: a. At 9:05 a.m., a Certified Occupational Therapy Assistant (COTA) said she did not know what type of cushion was in use. The COTA returned with the Director of Therapy who said she should have a ROHO cushion in place due to her complaints of buttock pain. He had the resident stand up, pulled up cushion and said it was not a ROHO. He was unable to locate the ROHO cushion in the resident's room, checked several chairs on the unit, and then said he did not know where it had gone. b. At 9:14 a.m., CNA #2 said the resident uses a ROHO cushion and that is what is in her chair. c. At 9:18 a.m., the Director of Therapy returned to the unit with a Harmony cushion (a foam cushion with egg crate on top) and placed it in the resident's chair. He said if the resident continues to complain of pain, then she should not be on her butt that much. d. At 10:17 a.m., a Registered Nurse (RN) said if a resident is on a routine pain medication and complains of pain, a pain assessment should be done. e. At 10:44 a.m., during an observation with RN #2 and the surveyor, RN #2 asked the resident to stand. The resident said standing up made her hip hurt. RN #2 looked at the resident's back side and felt the area. The resident complained of pain. RN #2 said the resident complained of pain when she was touched on the spine near the tailbone. RN #2 said the area was red but blanchable. RN #2 suggested the resident not lean in the chair and said staff could get her a chair and adaptive equipment so that she could sit up better. RN #2 said she should be positioned away from the back of the chair. The resident said it hurts when she pushes herself back into the chair. The resident said she cannot go to the bathroom by herself, relies on staff, and does not go back to bed during the day. At that time, the resident told RN #2 that Tylenol does not relieve her pain. RN #2 asked her to rate her pain at the worst, and the resident said it was a ten. f. At 11:01 a.m. and 11:12 a.m., RN #2 said the Pain Admission Flow Sheet was blank and it should have been completed within three days of admission. RN #2 said she would initiate a pain flow sheet that day as staff should continue to monitor the effectiveness of her routine pain medication. RN #2 reviewed the hospital discharge information and said the resident had been receiving both as needed Tylenol and [MEDICATION NAME], and whoever did the initial pain assessment should have had an RN review and bring that to the attention of medical to determine a plan for pain management. g. At 2:01 p.m., the Director of Nursing said a pain flow sheet should have been implemented at that time the resident's pain medication was changed to routine to evaluate the effectiveness and it was not. When interviewed on 1/9/19 at 9:48 a.m., the LPN Manager said she knew the resident had pain but did not notify the medical team. (10 NYCRR 415.12)

Plan of Correction: ApprovedFebruary 2, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó The Medical Provider evaluated Resident #39 for further pain management and provided orders. The Nurse Manager reviewed and revised Comprehensive Care Plan and C.N.A Care Card and revised accordingly to include pain management and assigned cushion for resident #20. ?Çó The Nurse Managers on their respective units will review all residents to determine that residents have assigned cushions as listed on C.N.A Care Card. The Nurse Managers on their respective units will review all residents to determine if the Comprehensive Care Plan reflects pain management. ?Çó The policy and procedure for pain management will be reviewed with all care giving staff at an in service conducted by the Staff Development Coordinator. An in service will also be conducted for all caregiving staff on cushion placement by the Director of Therapy. ?Çó The Director of Nursing or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility policy on pain management and cushion placement. The results will be presented to the Quality Assurance Committee for further action if needed. Director of Nursing will oversee compliance of this plan.

FF11 483.25:QUALITY OF CARE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 13, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for two of four residents reviewed for non-pressure related skin conditions, the facility did not ensure that the residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental and psychosocial needs. Specifically, physician orders [REDACTED].#43), and physician orders [REDACTED].#38). This is evidenced by the following: 1. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/14/18, revealed the resident was cognitively intact, required the assistance of staff for all Activities of Daily Living (ADLs), and no skin ulcers. Physician orders [REDACTED]. a. On 11/7/18, the orders included to weigh the resident on Mondays, Wednesdays and Fridays and to call medical if weight gain is greater than or equal to 5 pounds and to apply [MEDICATION NAME] (compression stockings to treat [MEDICAL CONDITION]) toes to knees, apply in the morning and remove in the evening. b. On 11/15/18, the orders were to elevate the resident's legs at all times in a chair for [MEDICAL CONDITION], to use a double layer of [MEDICATION NAME] toes to knees, apply in morning, and remove in the evening. c. On 12/6/18, the orders included to elevate the resident's legs at all times in a chair, weights on Mondays, Wednesdays, and Fridays, and continue use of [MEDICATION NAME]. d. On 12/9/18, elevate the resident's legs at all times when in a chair. e. On 1/2/19, the orders changed to use abdominal pads due to weeping [MEDICAL CONDITION] and ace wraps to the resident's legs instead of [MEDICATION NAME]. f. On 1/3/19, the orders added to use [MEDICATION NAME] (skin ulcer treatment) to the right leg wound (new) and to apply ace wraps to the resident's legs in the morning and remove in the evening. The Comprehensive Care Plan (CCP), dated 11/21/18, and the Certified Nursing Assistant (CNA) Resident Care Plan did not include that the resident had [MEDICAL CONDITION], required elevation and wraps or frequent weights. Review of the Treatment Administration Records (TAR), from (MONTH) (YEAR) through 1/4/19, revealed four weights were completed in (MONTH) (YEAR), two weights in (MONTH) (YEAR) (indicating a 10 pound weight loss since admission), and no weights currently in (MONTH) 2019. In an observation and interview on 1/3/18 at 9:09 a.m., the resident stated that her legs were so swollen they started bleeding the previous night. The right leg was wrapped in an ace wrap with bloody drainage seeping through and the right foot was severely swollen. The left leg and foot were both swollen and not wrapped. Both feet were dependent on the floor. The resident stated that she knows she should keep them up, but her chair bottom will not go up. Another chair was in the room but out of reach of the resident. Observations on 1/4/19 at 9:34 a.m., and again on 1/7/19 at 9:30 a.m., the resident was sitting in her chair in her room with both legs dependent on the floor. On 1/7/19, the resident did not have any ace wraps on her legs until approximately 2:00 p.m. Interviews conducted on 1/7/19 included the following: a. At 1:40 p.m., the CNA stated that she got the resident up around 10:00 a.m. but she does not do anything with the resident's legs as the nurses do it. The CNA said that weights are done monthly unless told by the nurse and she was not told anything different. b. At 1:50 p.m., the resident stated that no one has come to do her leg dressing yet and apply her stockings. c. At 1:52 p.m. and again on 1/9/19 at 11:13 a.m., the Registered Nurse Manager (RNM) stated that the resident should have had the ace wraps applied that morning but there was no nurse. He said a nurse from another unit administered the medications but did not do treatments yet. The RNM said that if weights are ordered more often than monthly, the nurses are expected to let the CNAs know and then document them on the TARS. He said the resident's legs should be elevated at all times. The RNM said that he was not aware of any refusals of care and that the resident frequently asks to have her legs elevated as she cannot lift the chair. d. At 2:00 p.m., the Nurse Practitioner stated that she expects the weights to be done three times a week and has had to ask several times to no avail and that was unacceptable. 2. Resident #38 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/13/18, revealed the resident had severely impaired cognition, required extensive assistance of one staff for personal hygiene, physical assistance of staff for bathing, and received application of ointments or medications to areas other than the feet. Physician orders, dated 12/11/18, directed staff to use one percent anti-dandruff shampoo with showers. The undated current CNA Resident Care Plan included under bathing that the resident was dependent in bed. The CCP, dated 10/4/18, included that the resident had a deficit in ADLs and for staff to maintain proper hygiene, observe skin care and report changes. Review of the current shower schedule revealed the resident was to receive two showers a week. Review of the shower sheet, from 12/1/18 through 1/4/19, revealed seven of ten scheduled showers were not documented as given. In an observation on 1/3/19 at 9:44 a.m., the resident was sitting in a Geri chair near the nurses' station. On the back of his head there were two half dollar size (circular) areas visible where the hair was matted, knotted, and the scalp was encrusted with visible specks of white and dark brown debris and flakes. Observations and interviews conducted on 1/4/19 included the following: a. At 10:58 a.m., the hair on the back of his head remained matted, knotted, and the encrusted areas remained with visible specks of white and dark brown colored debris and flakes. b. At 12:10 p.m. and then at 12:30 p.m., CNA #1 said the resident does not refuse cares, that he gets a shower on the evening shift and that staff document it on the shower sheet when given. CNA #1 reviewed the (MONTH) 2019 shower sheet and said no showers had been given to date. CNA #1 later said that the resident has cradle cap and there was a special shampoo to be used on shower days. c. At 12:15 p.m. and again at 12:31p.m., CNA #2 stated the resident does not refuse any care and after reviewing the shower sheets said the (MONTH) sheet was missing signatures. She said the resident had been given several bed baths but it did not look like he had been shampooed recently. CNA #2 said that sometimes the resident's scalp bleeds with a shampoo. d. At 12:20 p.m. and then at 12:35 p.m., LPN #1 said a skin check is performed on shower days and documented in the medical progress notes, even if the shower is refused. LPN #1 said that this was the first time she had seen the back of the resident's head and it looked like he had crust on his scalp. LPN #1 said that the resident should have a shampoo with his shower or bed bath. The LPN said that the shampoo was kept in the medication room and removed a bottle of [MEDICATION NAME] 2 percent (antifungal) shampoo, dated 6/11/18, and was 3/4 full. e. At 12:36 p.m., and again at 4:08 p.m., the LPN Manager observed the resident and said it appeared he had not been showered or shampooed on Wednesday because his head should not look like that. The LPN Manager said shower and skin checks are to be documented in the progress notes, but the last skin check was documented 11/24/18. She looked at the bottle of shampoo and said, if used as directed, it should not be this full and that a lack of showering and shampoo was unacceptable. f. At 3:00 p.m., the Acting Director of Nursing said the [MEDICATION NAME] 2 percent was discontinued on 4/30/18 and anti-dandruff 1 percent shampoo was ordered. g. At 4:05 p.m., CNA #3 and CNA #4 said they are floats to the unit and know to check the shower schedule, sign the shower sheet when completed, and have a nurse check the resident's skin but could not comment on recent showers for the resident. (10 NYCRR 415.12)

Plan of Correction: ApprovedFebruary 2, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó Physician orders [REDACTED].#43 severe [MEDICAL CONDITION] were reviewed with care giving staff by the Nurse Manager. ?Çó Physician orders [REDACTED].# 38 were reviewed with the care giving staff by the Nurse Manager. ?Çó Comprehensive Care Plan and C.N.A Care Card were revised to reflect the current physician orders. ?Çó The C.N.A ?Çÿs were counseled on the importance of documenting showers and other care delivery. The Nurse Manager was counseled on ensuring that Comprehensive Care Plan and C.N.A Care Card contain physician orders [REDACTED]. ?Çó All physician orders [REDACTED].N.A Care Card have been appropriately transcribed. ?Çó The Staff Development Coordinator will review the policy and procedure on physician orders [REDACTED]. ?Çó Quality Assurance audit was conducted and will be conducted every three months and regularly thereafter to ensure that resident Comprehensive Care Plan and C.N.A Care Card contain necessary information from physician orders. Results of the audits will be presented to the Quality Assurance Committee for action if necessary. Director of Nursing will oversee compliance of this plan.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 6, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #4 and #34) of three residents reviewed for resident rights, the facility did not ensure that the residents exercised their right as citizens or resident of the United States. Specifically, during the Resident Council Meeting residents reported that they were not provided with access to vote in the election held in (MONTH) (YEAR). This is evidenced by the following: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/22/18, revealed the resident was cognitively intact. Resident #34 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/28/18, revealed the resident was cognitively intact. A review of the current Admission Activity Assessments for Resident #4 and Resident #34 revealed both had previously exercised their right to vote. The section following that was incomplete regarding if they wanted to continue to vote. During an interview at the Resident Council Meeting on 1/4/19 at 1:35 p.m., Resident #4 and Resident #34 said they would have liked to vote during the (MONTH) (YEAR) elections but information about voting and what assistance was available to them had not been presented. Review of a Quality Assurance Activities Department Third Quarter Activities Statistics form from (MONTH) (YEAR) through (MONTH) (YEAR) included a goal Just a reminder anyone need help voting in the upcoming election we are available to help. The form lacked specifics as to how that would occur. A review of (MONTH) (YEAR) and (MONTH) (YEAR) Resident Council Meeting minutes did not include a review of voting rights. In an interview on 1/4/19 at 3:58 p.m., the Administrator said it is the responsibility of the Activities Director to identify residents who want to vote and provide services for them to do so. Interviews conducted on 1/9/19 included the following: a. At 9:42 a.m., the Activities Director said there were three residents who voted in the last election (November (YEAR)). She said she thought the right to vote and the process had been addressed during a Resident Council Meeting. The Activities Director said if a resident wants to vote, she documents that on the Admission Activity assessment. The Activities Director provided a list of residents who had voted in the (MONTH) (YEAR) election, and Residents #4 and #34 were not on the list. b. At 10:05 a.m., the Activities Director said she would look for documentation that voting rights had been addressed in a Resident Council Meeting. She said she does not maintain any record of residents who vote or a resident's voting history. At 11:20 a.m., the Activities Director said she thought the right to vote had been discussed at the (MONTH) (YEAR) Resident Meeting Council, but it was not documented in the minutes. Review of a facility policy, Resident Voting Policies and Procedures, dated (MONTH) (YEAR), directs it is policy to accommodate and provide assistance to residents that are interested in voting. The Activities Department shall inquire during admission assessments if the resident is a voter and if they wish to continue with voting while staying at the nursing home. If a resident switches from short-term rehab to a long-term placement, the resident will be re-approached to determine if their voting preference has changed. Voter registration and absentee ballot forms will be available from the Activities Department. They will assist with filling out these forms, if necessary, and shall mail it in a timely manner. If the resident is short-term rehab, voting options will be reviewed with resident and/or family member. The Activities Department will maintain a current list of voters and update as necessary. (10 NYCRR 415.3(c)(1)(i))

Plan of Correction: ApprovedFebruary 4, 2019

?Çó Activities Director spoke with Resident #4 and Resident #34 regarding assistance available to them regarding their right to vote. ?Çó Activities Director spoke with residents on each unit regarding assistance available to them regarding their right to vote; no further issues identified. ?Çó Activities Director will provide Inservice to Activities Staff as well as general staff regarding assistance Activities Department will provide to residents who would like to vote during elections. Information regarding voting will be presented to Resident Council as appropriate during timeframe of elections. ?Çó Activities Director or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility policy on resident right to vote and assistance available to exercise this right. Results will be presented to the Quality Assurance Committee for further action as needed. Activities Director will oversee compliance of this plan.

FF11 483.10(f)(5)(i)-(iv)(6)(7):RESIDENT/FAMILY GROUP AND RESPONSE

REGULATION: §483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility. (i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner. (ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation. (iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. (iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. (A) The facility must be able to demonstrate their response and rationale for such response. (B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group. §483.10(f)(6) The resident has a right to participate in family groups. §483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 6, 2019

Citation Details

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that the facility did not act upon grievances of residents affecting resident care and life in the facility. Specifically, the facility did not address grievances brought up by the residents in Resident Council Meetings in a timely and effective manner. This is evidenced by the following: During an interview on 1/4/19 at 1:35 p.m., Resident Council Representatives said that the facility administration had not reported back to the group regarding issues including slow response to call bells, delay in getting assistance to go to the bathroom, a lack of proper tray set up, and removal of trays before meal completion. They said these issues have been ongoing problems and no one has informed the Resident Council of resolutions. Two Resident Council Representatives said they have soiled themselves due to slow call bell response time, and another Resident Council Representative said staff are irritable about providing meal time help. The Resident Council Representatives said the Activity Director was the person responsible for organizing the Resident Council Meetings and reporting on issues at the next meeting. Review of Resident Council Meeting Minutes from (MONTH) (YEAR) to (MONTH) (YEAR) revealed the following: a. In (MONTH) (YEAR), the old business revealed breakfast trays were being taken away before residents were done eating. The new business lacked a response to that concern. Additionally, new business included a request to have a movie on Sunday. b. In (MONTH) (YEAR), the old business revealed meal trays were being taken away before residents were done eating, food was delivered late and was cold, and call bells are ignored by the evening staff. The new business lacked a response to removal of trays, request for a movie on Sunday, and response to call bells. c. In (MONTH) (YEAR), the old business revealed food is warmer and residents are able to finish their meals. The new business lacked a response to request for a movie on Sunday. Additionally, new business revealed after 8:00 p.m., the call bell response was slow, but night shift was worse, and staff responds slowly to requests to use the bathroom. d. In (MONTH) (YEAR), the old business revealed call bells are not answered in a timely manner with wait times of an hour or more. The new business lacked a resolution to call bell response time and request for a movie on Sunday. Additionally, new concerns included blinds were not being closed as requested per signage in room and meals were being dropped off and not being properly set up. e. In (MONTH) (YEAR), the old business revealed call bells are not being answered in a timely manner and blinds are left open. The new business reported that call bell response had improved. There was no response for a movie on Sunday, blinds being left open, and meals dropped off without proper set up. Review of the facility Grievance Log for the past year revealed grievances for missing items. No other issues are documented. Resolutions are listed directly on the forms. Interviews conducted on 1/8/19 included the following: a. At 2:49 p.m., the Activities Director said she does not fill out a grievance form for any concerns presented at Resident Council. She said she reports Resident Council concerns to staff at morning report. The Activities Director said she passes on the information but there was no formal follow up and that minutes are not kept for morning report. b. At 2:51 p.m., the Administrator said the Activities Director notifies a department head about specific concerns. She said if something needs a quick response, the Activities Director reports to her right away. The Administrator said the Activities Director should report follow up at the next Resident Council Meeting and get feedback from the residents. She said staff talk about follow up, like for call bell response time, and sometimes she will ask a resident. The Administrator said that repetitive concerns are addressed through orientation and on-going education via department managers. She said the facility has a no pass policy which means the resident is told that you cannot help them right now, but you will be back as soon as possible or notify someone else to respond. The Administrator said there was no form for grievances identified at Resident Council unless the concern was related to abuse. She said department heads report that a concern has been addressed but there is no formal documentation process for follow up. In an interview on 1/9/19 at 12:37 p.m., the Activities Director returned copies of the Resident Council Meeting minutes from (MONTH) (YEAR) to (MONTH) (YEAR), which included handwritten notes. She said she had added the notes that day to include what she remembered from the meetings. (10 NYCRR 415.5(c)(5)(6))

Plan of Correction: ApprovedFebruary 4, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó Activities Director met with Resident Council President to review meeting format and address plan for outstanding concerns as well as new format for next Resident Council meeting. ?Çó Residents on units notified of plans for addressing outstanding concerns presented at last Resident Council. Results to be reviewed at next Resident Council for further resident feedback. ?Çó Administrator to provide Inservice to Activities Department regarding expectations for addressing resident concerns expressed by Resident Council and facility procedure to immediately address these concerns. ?Çó Administrator or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility policy regarding resolution of grievances expressed by residents and/or family members. Results will be presented to the Quality Assurance Committee for further action as needed. Administrator will oversee compliance of this plan.

FF11 483.10(e)(1); 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #20) of one resident reviewed for restraints, the facility did not ensure that the resident was free from physical restraints. Specifically, there was lack of an appropriate assessment identifying a seatbelt as a restraint, a medical [DIAGNOSES REDACTED]. This is evidenced by the following: Resident #20 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/26/18, revealed the resident had severely impaired cognition, required the extensive assistance of staff for transfers, and that no restraints were being used. Review of the facility policy,Use of Restraints, dated (MONTH) 2011, revealed restraints shall only be used after other alternatives have been tried unsuccessfully and to treat the resident's medical symptom. The resident and or surrogate shall be informed about potential risk and benefits of all options under consideration including the use of restraints, not using restraints, and alternatives to restraints. The policy, Device/Restraint Evaluation, dated February/2017 revealed the form was completed on admission and upon the initiation or consideration of initiation of a new device. Risk and benefits will be discussed with the resident/designated representative and documented on the form. Care planning will include information on the reason for use, frequency, and duration of device use. If a new or different device is utilized, a new Device/Restraint Evaluation form is to be completed. Review of the Device/Restraint Evaluation form, dated 2/7/17, revealed the use of a seatbelt for safety and that the resident was able to unfasten it on command. Intermittent updates revealed no changes including the most recent update, dated 12/28/18 and signed by the Physical Therapist (PT). The Certified Nursing Assistant (CNA) Care Plan, dated 12/9/18, included the use of a seatbelt when in the wheelchair. Review of a progress note, dated 12/28/18, unsigned but identified as a 'rehab' note, revealed that the resident was now unable to release the seatbelt on multiple attempts even when cued. Physician orders, dated 12/28/18 and 1/7/19, included the use of a seatbelt for safety and to release every two hours. The order did not include the medical symptom being treated for [REDACTED]. The Comprehensive Care Plan (CCP), dated as updated on 12/28/18, included the resident was at risk for falls related to dementia and that a seatbelt was in place to remind him to not get up without assistance. The CCP did not include that the seatbelt was a restraint, that it was the least restrictive device being utilized, and/or how often to be used. There was no documented evidence that the resident's representative was informed and/or educated regarding the risks and benefits of the seatbelt. In observations on 1/4/19 at 11:50 a.m., 12:45 p.m. and 1:35 p.m., the seatbelt was in place. In an observation on 1/7/19 at 10:22 a.m., the resident was sitting in the common area, and the seatbelt was not buckled and staff were not present. At 11:01 a.m., the Licensed Practical Nurse (LPN) Manager buckled the seatbelt. Interviews conducted on 1/7/19 included the following: a. At 1:22 p.m., the LPN Manager stated the Interdisciplinary Team completed the restraint assessment and that when the seatbelt was released the resident should be monitored. The Director of Nursing (DON) stated that the resident used to remove the seatbelt on command. The DON said safety was not a medical symptom for a restraint and that staff should change his position when released. The DON said the CCP and Care Card should include the reason for the use of the restraint and care provided when the seatbelt was released. b. At 1:40 p.m, the PT stated he completed the restraint assessment form when asked. He stated his signature meant the assessment was reviewed and was correct. The PT stated the resident was being seen by Occupational Therapy who determined the resident could no longer release the seatbelt and nursing would do the necessary paperwork. (10 NYCRR 415.4(a)(2-7))

Plan of Correction: ApprovedFebruary 2, 2019

Preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by provisions of State and Federal laws. ?Çó The IDT reassessed resident # 20 safety needs and use of seat belt. Care plan reviewed and revised accordingly. The IDT including the Physical therapist is in the process of trailing less restrictive alternatives. ?Çó The Medical Provider updated resident #20 ?Çÿs order to include appropriate medical diagnosis. ?Çó The Nurse Manager reviewed the care plan with resident #20?ÇÖs representative, who is in agreement with the use of the seatbelt at present time. ?Çó The Nurse Managers reviewed all residents to determine if any device or method in use is considered a physical restraint, no other physical restraints are in use. ?Çó The policy and procedure for Physical Restraints will be reviewed with all care giving staff at an in service conducted by the Physical Therapist. ?Çó The Director of Nursing or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility policy on the use of physical restraints and documentation compliance of restraints. Results will be presented to the Quality Assurance Committee for further action as needed. Director of Nursing will oversee compliance of this plan.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 8, 2019

Citation Details

Based on observations and interviews conducted during the Life Safety Code Survey, corridor doors were held open/obstructed from closing by devices that did not release when the door was pushed or pulled. This affected one (South Wing) of four resident units and one of one Therapy Gym. The findings are: 1. An observation in the Therapy Gym on 1/3/19 at 9:55 a.m. revealed the corridor door was being held in a fully open position by a hand weight. During an interview at that time, a Therapy staff member stated they use the weight to keep the door from creeping shut. The Director of Environmental Services stated they should not be doing that. 2. Observations in the South Wing on 1/4/19 at 12:15 p.m. and again on 1/7/19 at 9:30 a.m. revealed the corridor door to Resident Room South 1 was being held in a fully open position by a garbage can. During an interview on 1/7/19 at 9:33 a.m., the Director of Environmental Services stated the door should not be held open. He said he was unaware that they were doing that, and he can adjust the door so it does not creep shut. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.6.3, 19.3.6.3.10)

Plan of Correction: ApprovedFebruary 5, 2019

?Çó Weight in front of Therapy Gym door was removed and door adjusted. Garbage can in front of Resident Room was removed and door adjusted. ?Çó Audits conducted by Director of Environmental Services revealed no further issues with doors held open by any objects. ?Çó Director of Environmental Services will conduct Inservice regarding corridor doors being free from obstruction. ?Çó Director of Environmental Services or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility procedure regarding corridor doors being free from obstruction. Results will be presented to the Quality Assurance Committee for further action as needed. Director of Environmental Services will oversee compliance of this plan.

DEVELOP EP PLAN, REVIEW AND UPDATE ANNUALLY

REGULATION: §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. .

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the written Emergency Preparedness Plan contained inconsistencies that were not identified or corrected during the annual review. The findings are: 1. Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed a document called Section A: Policies and Planning. According to that document, Upon admission, residents and their responsible parties will be provided with an Emergency Communications Plan Guide (see Appendix H). Further review of the Emergency Preparedness Plan revealed no Appendix H and no evidence of an Emergency Communications Plan Guide. During an interview on 1/4/19 at 11:00 a.m., the Director of Environmental Services stated there was no Communications Plan Guide, but general emergency information was in the welcome packet for new residents. Review of the welcome packet for new residents revealed an undated one-page sheet that gave general information, including that the facility has an emergency preparedness plan which is updated annually, and the facility is a member of the local mutual aid group, but no Emergency Communications Plan Guide. 2. Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed a document called Section B: Procedures Applicable to All Responses. According to that document, the goal was for the facility to sustain itself for 96 hours, and includes a chart called Baseline Assessment of 96 Hour Capabilities. In that chart, the box for minimum and expected food supplies was filled in as greater than three days, and the box for loss of boilers was filled in as the facility would switch to fuel oil, N/A gallons, which would last approximately three days. The Brightonian Emergency Preparedness Plan also contained a page called, 7.68 Unavailability of Supplies, which said the facility maintains a five-day supply of nursing, housekeeping, and maintenance supplies. During an interview on 1/4/19 at 11:13 a.m., the Director of Environmental Services stated the facility could be self-sustaining for 96 hours. He said that the facility's emergency generator runs on natural gas, which could run indefinitely, and he would not switch to fuel oil. He said 96 hours was correct for the food inventory. 3. Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed a document called Section B: Procedures Applicable to All Responses. According to that document, the facility uses the following coded announcements: Code Alert = disaster situation, Code Yellow = bomb threat, Code White = building lockdown, Code Green = evacuation, Code Red = fire, Code Gray = hostage/intruder, and Code Orange = missing resident. The Brightonian Emergency Preparedness Plan also included a document called, Brightonian Terrorism Response Alert Procedures Threat of Attack Procedures , which is dated 2001. During an interview on 1/4/19 at 11:17 a.m., the Director of Environmental Services stated Code Green was a terrorism response. He said he was unaware that another document was called evacuation Code Green, and he does not recall changing the codes in the last [AGE] years. Further review of The Brightonian Emergency Preparedness Plan revealed a collection of hazard-specific information for various hazards. The section for Hostage Taking/Person With Weapon/Armed Robbery was called Code Dr. Calm, and a different section for Hostage Taking/Person With Weapon was called Code Gray. During an interview on 1/4/19 at 2:18 p.m., the Director of Environmental Services stated he does not know why Hostage Taking and Person With Weapon have two different codes, but Code Gray was the one that was used, and the facility has never used Dr. Calm. During an observation and interview on 1/7/19 at 2:20 p.m., a Registered Nurse's (RN) identification badge had codes written on the back. The codes included Green = evacuation, Yellow = basic disaster/tornado watch, Black = major disaster/tornado warning, White = lockdown, Gray = hostage/weapon, and MR = missing resident. When interviewed at that time, the RN said her identification badge was obtained at the corporate level because she worked at another facility with the same ownership. The RN said she was unaware of the differences in the codes used. 4. During an interview on 1/4/19 at 11:23 a.m., the Director of Environmental Services stated the outside vendor who supplies water to the facility was Poland Springs. At that time, the Administrator stated Poland Springs was the regular and emergency water supplier for the facility, and they had serviced the facility for years. She said that she does not know if the facility has a written agreement with them. During a second interview on 1/4/19 at 2:26 p.m., the Director of Environmental Services stated Byrne Dairy was now the facility's water supplier for regular and emergency supply. He stated he was unaware that the Food Service Director switched suppliers. At that same time, the Director of Environmental Services asked the Food Service Director when he switched suppliers, and he replied that it was done on 11/5/18. Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed a list of water/milk/liquid suppliers, and Poland Springs does not appear, and the only phone number for Byrne Dairy was from Syracuse, New York. 5. Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed a document called Equipment Served by the Emergency Generator. It stated the facility's emergency generator was 100 kilowatts. During an interview on 1/4/19 at 11:26 a.m., the Director of Environmental Services stated the facility got a new generator about two years ago. He said the new generator was maybe 120 or 125 kilowatts. He said the information must be updated to the new generator. 6. Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed a document called Locations of Telephones Not Part of the Main Phone System. It stated the phones in Resident Rooms W-15, W-8, L-15, and L-18 are not part of the main phone system. During an interview on 1/4/19 at 11:27 a.m., the Director of Environmental Services stated all resident room phones are separate from the facility's main line. He said it has always been like that, and it should be written in the Emergency Preparedness plan like that. He stated he was not sure where the resident rooms that start with L are located, possibly the lobby. 7. Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed a document called Disaster Kit Contents which documented that the disaster kit was located in the Med Room. During an interview on 1/4/19 at 2:24 p.m., the Director of Environmental Services stated the facility has three med rooms. The disaster kit was kept in the West Wing Med Room, but got moved to the Basement in (MONTH) (YEAR). He stated that information probably should have been updated during the annual plan review, but everyone knows where it is located. During an interview on 1/7/19 at 2:10 p.m., a Registered Nurse stated the disaster kit was kept in the Main Dining Room closet. During an interview on 1/4/19 at 10:35 a.m., the Director of Environmental Services stated the facility's written Emergency Preparedness Plan was a compilation of a template from an outside vendor, local mutual aid group documents, and the facility's own disaster plans. He stated he received the template from the outside vendor around (MONTH) (YEAR), read it, and changed it at that time to make it specific to the facility. Additionally, on 1/4/19 at 2:30 p.m., the Director of Environmental Services stated the information in that book needs to be reorganized and an index needs to be compiled in proper form so that it can be useful in an emergency. He said if there was an off-hours emergency, on-duty staff would call him, and he would come into the facility and utilize the book himself. During an interview on 1/4/19 at 11:09 a.m., the Administrator stated she reviewed the whole emergency preparedness book during (MONTH) (YEAR) and completed the review on 1/22/18 when she signed the review sheet. Additionally, on 1/4/19 at 2:30 p.m., the Administrator stated a Nurse Manager was always on-duty, and they would know what to do in an emergency from experience. She said they know to follow the procedures without using the book. (42 CFR 483.73-Emergency Preparedness; 42 CFR: 483.73(a))

Plan of Correction: ApprovedFebruary 13, 2019

?Çó Emergency Preparedness Plan has been revised accordingly in these areas by the Administrator: Section A and Section B to reflect correct wording regarding Emergency Preparedness Plan; proper emergency codes;vendor who supplies water to the facility; new generator information; locations of telephones; location of Disaster Kit. ?Çó Audits completed by Administrator regarding Emergency Preparedness Documentation kept throughout the facility are accurate with no issues noted. ?Çó Staff Development Coordinator will conduct Inservice regarding Emergency Preparedness Plan to inform staff of changes noted. ?Çó Staff Development Coordinator or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility procedure regarding Emergency Preparedness Plan. Results will be presented to the Quality Assurance Committee for further action as needed. Staff Development Coordinator will oversee compliance of this plan.

EP TRAINING PROGRAM

REGULATION: §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

Based on observations, interviews and record reviews conducted during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, employees interviewed for knowledge of emergency procedures lacked basic knowledge of the emergency procedures. The findings are: 1. During an interview on 1/4/19 at 2:58 p.m., the Administrator stated all staff members received Emergency Preparedness training through an in-person overview of the program, including the Emergency Preparedness binder and its contents. She also stated the staff were instructed that the binder was kept at the front reception desk, and they were encouraged to take the binder, during their shift, and review it in more depth on their own. The Administrator added that the topic of Emergency Preparedness has always been included in General Orientation for new employees. 2. Interviews with various employees, regarding their knowledge of emergency procedures, on 1/7/19 from 11:35 a.m. until 2:25 p.m. revealed the following: a. A Certified Nursing Assistant (CNA) A stated she has worked in the facility for six years, and she attended a training that included the topic of evacuation, but she could not recall when this training occurred, and she could not recall the code word for emergencies. A few minutes later, CNA A stated the code word for emergencies was Code Black. b. CNA B stated she has worked in the facility for four years, and she said every summer she attends a training led by the local fire department, and they discuss how to keep residents safe during a storm. CNA B stated she was unsure if there was a code word for emergencies, but if she needed to find out, she would look for the Emergency Preparedness binder at the Nurses' Station. c. Registered Nurse (RN) A stated he has worked at the facility for four years, and he has attended trainings on Emergency Preparedness. He stated he was familiar with Code Red and Code Blue, the codes for fire and cardiac event, but was unsure if there was a code word for emergencies. He stated there was a list of all code words hanging on the wall at the East Wing Nurses' Station next to the survey results, and he would refer to that list if he ever needed to know the code words. Observation at the East Wing Nurses' Station on 1/7/19 at 2:20 p.m. revealed the survey results were hanging on the wall, but there was no list of codes found in the vicinity. d. RN B stated she was the East Wing Nurse Manager, and she does not know where a list of code words are located. She stated the list of code words is located on her identification badge. At that time, she read the following codes from her badge: Green = evacuation, Yellow = basic disaster/tornado watch, Black = major disaster/tornado warning, White = lockdown, Gray = hostage/weapon, MR = missing resident. RN B stated she obtained her identification badge from the corporate level because she used to work at another facility with the same ownership. Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed a document called Section B: Procedures Applicable to All Responses. According to this document, the facility uses the following coded announcements: Code Alert = disaster situation, Code Yellow = bomb threat, Code White = building lockdown, Code Green = evacuation, Code Red = fire, Code Gray = hostage/intruder, and Code Orange = missing resident. During an interview on 1/4/19 at 11:04 a.m., the Director of Environmental Services stated the facility uses Code Alert as the general disaster code word. Review of sign-in sheets for the facility's Emergency Preparedness training sessions from (YEAR) revealed CNA A attended the in-person overview of the program on 8/1/18, and CNA B attended on 7/23/18. Per Centers for Medicare and Medicaid Services (CMS), Long Term Care facilities must do all of the following: I. Provide initial training in Emergency Preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. II. Provide emergency preparedness training at least annually. III. Maintain documentation of the training. IV. Demonstrate staff knowledge of emergency procedures. (42 CFR 483.73-Emergency Preparedness; 42 CFR: 483.73(d)(1))

Plan of Correction: ApprovedFebruary 13, 2019

?Çó Staff have been verbally Inserviced regarding emergency codes used in the facility. ?Çó Audits conducted by Administrator or designee regarding emergency codes used in the facility did not reveal further issues regarding staff knowledge of emergency codes. ?Çó Staff Development Coordinator will conduct Inservice regarding Emergency Codes utilized by the facility. ?Çó Staff Development Coordinator or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility procedure regarding Emergency Codes. Results will be presented to the Quality Assurance Committee for further action as needed. Staff Development Coordinator will oversee compliance of this plan.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 9, 2019
Corrected date: March 8, 2019

Citation Details

Based on observations and interviews conducted during the Life Safety Code Survey, the facility did not have means of egress that were continuously maintained free of all obstructions to full instant use in case of emergency. This affected one of one South Wing exit corridor. The findings are: 1. Observations in the South Wing exit corridor on 1/3/19 at 10:00 a.m. revealed a set of practice steps and a wheelchair scale that were stored in the exit access corridor. During an interview at that time, the Director of Environmental Services stated the set of stairs and the wheelchair scale have always been stored in that location, and the scale folds up to about 6 inches wide, but it is rarely in the folded position. Also, on 1/7/19 at 10:30 a.m., the Director of Environmental Services stated these two items can be moved but do not get moved during a fire drill. 2. An observation on 1/7/19 at 10:30 a.m. revealed these items reduced clear corridor width from 8 feet down to approximately 65 inches (5 feet, 5 inches) of clear width at the set of steps and approximately 53 inches (4 feet, 5 inches) of clear width at the scale. Continued observation revealed the perimeter of the scale was marked on the carpet with a line of tape. Additionally, an illuminated exit sign was observed above the exit door in that corridor. During an interview on 1/7/19 at 3:00 p.m., the Administrator stated she would classify the set of steps as a piece of furniture. According to the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, where the corridor width is at least 8 feet, fixed furniture is permitted when it is securely attached to the floor or wall and it does not reduce the clear unobstructed corridor width to less than 6 feet. The 101 Life Safety Code also states projections into the required corridor width shall be permitted for wheeled equipment, when it does not reduce the clear unobstructed corridor width to less than 60 inches, the fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency, and the wheeled equipment is limited to equipment in use, medical emergency equipment not in use, or patient lift and transport equipment. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2, 19.2.1, 19.2.3.4, 19.2.3.5, 7.1.10, 7.1.10.1)

Plan of Correction: ApprovedFebruary 5, 2019

?Çó Therapy staff relocated steps used for resident treatment. Nursing staff relocated weight scale. ?Çó Audits conducted by Director of Environmental Services revealed no further issues with obstruction of corridors within the facility. ?Çó Staff Development Coordinator or designee will conduct Inservice regarding area required related to obstruction of corridors. ?Çó Director of Environmental Services or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility procedure regarding obstruction of corridors. Results will be presented to the Quality Assurance Committee for further action as needed. Director of Environmental Services will oversee compliance of this plan.

PLAN BASED ON ALL HAZARDS RISK ASSESSMENT

REGULATION: §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

Based on interviews and record reviews conducted during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility risk assessment did not reasonably assess the facility-based or community-based risk or vulnerability level of potential hazards. The findings are: Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed it contained a Hazard Vulnerability Assessment (HVA) for the facility, which was comprised of a chart that listed Technological Hazards, Human Hazards, and Natural Hazards. The date 6/16/18 was handwritten on the bottom of the document. Further review revealed for each event, numbers 0 through 4 were handwritten in columns called Probability, Human Impact, Property Impact, and Business Impact, but the column called Relative Risk contained the type-written number 0.00 for each hazard. Additionally, the word Present was handwritten in the column called Internal Response for most of the hazards. Further review revealed the Brightonian Emergency Preparedness Plan also contained another HVA, but during an interview on 1/4/19 at 11:33 a.m., the Director of Environmental Services stated the HVA, dated 6/16/18, was the most accurate and should be used. The Director of Environmental Services stated he did not fill out the last column, and he needs to do the math to figure out the relative risk for each hazard. Additionally, he stated the former Staff Development Nurse may have included the word Present in the Internal Response column, and he does not know what that means. (42 CFR 483.73-Emergency Preparedness; 42 CFR: 483.73(a)(1))

Plan of Correction: ApprovedFebruary 13, 2019

?Çó Hazard Vulnerability Assessment Form revised accordingly. ?Çó Staff Development Coordinator will conduct Inservice regarding Hazard Vulnerability Asssessment Form. ?Çó Staff Development Coordinator or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility procedure regarding updating Hazard Vulnerability Form. Results will be presented to the Quality Assurance Committee for further action as needed. Staff Development Coordinator will oversee compliance of this plan.

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(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 facilities]. 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: Widespread
Severity: Potential to cause minimal harm
Citation date: January 9, 2019
Corrected date: March 20, 2019

Citation Details

Based on an interview and record review conducted during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Preparedness Plan did not address the facility's role under a waiver declared by the Secretary in accordance with section 1135 of the Act. The finding is: Per Centers for Medicare and Medicaid Services (CMS) The Emergency Preparedness Rule requires that some providers have policies and procedures, which address 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. This may include policies and procedures on what a facility would do if they had to provide care at an approved alternate site, as well as processes on how they would let the community know they are operating at a different care site and any reporting they may need to do if they were under an approved 1135 Waiver. Review of The Brightonian Emergency Preparedness Plan, last updated 1/22/18, revealed information on the facility's role under a waiver declared by the Secretary in accordance with section 1135 of the Act was not addressed. During an interview on 1/7/19 at 1:45 p.m., the Administrator stated she was unsure if the Emergency Preparedness Plan addressed 1135 Waivers without looking page by page. (42 CFR 483.73-Emergency Preparedness; 42 CFR: 483.73(b)(8))

Plan of Correction: ApprovedFebruary 13, 2019

?Çó Policy and Procedure addressing role of the facility under a 1135 waiver declared by the Secretary has been written. ?Çó Staff Development Coordinator will conduct Inservice regarding policy and procedure regarding 1135 Waiver. ?Çó Staff Development Coordinator or designee will conduct Quality Assurance audits monthly for three months and regularly thereafter regarding adherence to facility policy regarding 1135 waiver. Results will be presented to the Quality Assurance Committee for further action as needed. Staff Development Coordinator will oversee compliance of this plan.