Cobble Hill Health Center Inc

Based on observation, record review, and interviews conducted during the Abbreviated survey (NY00307820), the facility failed to ensure that the services provided or arranged by the facility meets professional standards of quality. This was evident in 1 out of 3 residents (Resident #1) sampled. Specifically, on 12/27/22 at approximately 06:30am on the night shift (11:00pm-07:00am), Resident #1 was observed on the floormat in their room and was picked up and put back into their bed by Registered Nurse #1. An x-ray result dated 12/28/22 documented that Resident #1 sustained an acute nondisplaced right femur intertrochanteric fracture. The facility's Investigation Summary dated 12/29/22, revealed that Registered Nurse #1 did not report the fall. There was no documented evidence that Resident #1 was assessed by Registered Nurse #1. The facility became aware of Resident #1's fall on 12/29/22 during an interview with Registered Nurse #1.
The findings are:
The facility Policy and Procedure titled Reporting and Documenting Resident Accident/Incident with reviewed date 11/2023 documented that All residents involved in accident/incidents are assessed by the nurse and the physician. The Registered Nurse assesses all resident's condition when an accident/incident occurs or when resident is eased to the floor. Notifies the physician if the resident's condition requires immediate medical attention or transfer to the hospital. If transfer to the hospital is indicated, notify the designated representative immediately.
The facility Policy and Procedure on Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 11/2023 documented that the facility is committed to providing residents with an environment that is free from abuse, neglect, or mistreatment.
Resident #1 was admitted to the facility with diagnoses including Osteoarthritis, Osteoporosis, and Dementia.
The Minimum Data Set 3.0 dated 12/02/22 documented that Resident #1 was moderately impaired in cognition and required extensive assistance of one-person in transfer, and ambulation and extensive assistance of two persons in bed mobility.
A nursing progress note dated 12/27/22 at 3:07pm, by Licensed Practical Nurse #1 who worked on the 07:00am - 03:00pm, documented that Resident #1 had a right hip pain and that bruising was observed on Resident #1's right lower extremity with some scratches. Nursing Supervisor #2 and Nurse Practitioner #1 were notified.
A nursing progress note, by Licensed Practical Nurse #2 who worked on the 03:00pm - 11:00pm, dated 12/27/22 at 04:21pm documented Resident #1 observed with two reddened circular areas to the left lateral aspect of Resident #1's left lower extremity. A liner reddened area appeared to be a scratch was observed at Resident #1's inner right lower extremity, and Resident #1 had facial grimacing when Resident #1 was turned.
A Physician's Order dated 12/27/22 at 05:06pm documented a bilateral hip x-ray.
A late note dated 12/28/22 at 09:22am, by Nurse Practitioner #1, documented that Resident #1 was evaluated on 12/27/22 (no time identified) with facial grimacing and occasional moaning. No falls reported.
A Radiology Report dated 12/28/22 documented that a service was provided on 12/28/22 and that the results revealed an Acute nondisplaced, right femur intertrochanteric fracture.
A nursing progress note, by Licensed Practical Nurse #3, dated 12/28/22 at 11:22pm documented that Resident #1 was transferred to the hospital for evaluation at 11:20pm.
A Hospital After Visit Summary dated 01/04/23 documented that Resident #1 was status post intramedullary nail of the right femur on 12/30/22 without complication.
A Facility Investigation Summary dated 12/29/22, documented there was evidence of neglect. Registered Nurse #1 failed to report an incident that led to injury. Initially, Registered Nurse #1 reported that nothing unusual happened on 12/27/22. However, on 12/29/22 Registered Nurse #1 was informed that Resident #1 had sustained an acute right femur intertrochanteric fracture and Registered Nurse #1 sighed and stated that Resident #1 fell on the ground and that they picked up Resident #1, assessed Resident #1, but did not report the fall.
During a telephone interview on 02/13/24 at 03:34pm, Certified Nursing Assistant #1 stated that they worked on 12/26/22 on the 11:00pm - 07:00am shift. Certified Nursing Assistant #1 stated that they heard shouting coming from Resident #1's room and asked Registered Nurse #1 to check Resident #1's room. Certified Nursing Assistant #1 stated that they also went to Resident #1's room and observed Registered Nurse #1 in the process of transferring Resident #1 from the floormat to the bed. Certified Nursing Assistant #1 stated that they assisted with putting Resident #1 back in bed. Certified Nursing Assistant #1 stated that they did not observe Registered Nurse #1 assess Resident #1. Certified Nursing Assistant #1 stated that after Registered Nurse #1 put Resident #1 back in bed, Registered Nurse #1 left the room.
During a telephone interview on 02/14/24 at 9:10am, Registered Nurse #1, who worked on 12/26/22 on the 11:00pm - 07:00am shift, and that they were at the nursing station when they were asked to go to Resident #1's room. Registered Nurse #1 stated that they went to Resident #1's room and observed Resident #1 on the floormat. Registered Nurse #1 affirmed that they picked up Resident #1 from the floormat and Certified Nursing Assistant #1 assisted them. Registered Nurse #1 stated that they assessed Resident #1's body for bruising and that range of motion was done and that Resident #1 was not in pain. Registered Nurse #1 stated that Resident #1 was observed on the floormat around 06:30am (close to end of shift) and that they did not report the fall. Registered Nurse #1 stated that that were not sure that they wrote about the fall. A subsequent telephone interview on 02/28/24 at 03:27pm, Registered Nurse #1 said that they were aware of the Policy and Procedure on Incident/Accident and that they should have notified their nursing supervisor and medical doctor. Registered Nurse #1 also stated that they should have documented their assessment of Resident #1. Registered Nurse #1 stated that they did not report the fall because it was close to the end of their shift.
During a telephone interview on 02/15/24 at 9:47am, Nursing Supervisor #2 stated that Licensed Practical Nurse #1 notified them on 12/27/23 at approximately 08:00am that Certified Nursing Assistant #2 reported to Licensed Practical Nurse #1 that Resident #1 was not themself. Nursing Supervisor #2 stated that they assessed Resident #1 together with Licensed Practical Nurse #1 and Certified Nursing Assistant #2. Nursing Supervisor #2 stated that Resident #1 had a small scratch on their right hip and pushed Nursing Supervisor #2's hand when Resident #1's right hip was touched. There was no swelling or discoloration to bilateral hip and Nurse Practitioner #1 was notified. Nurse Practitioner ordered an x-ray of bilateral hip, Diclofenac gel to apply to right hip and to continue with Acetaminophen for pain.
There was no documentation of Nursing Supervisor #2's assessment and findings.
During a telephone interview on 02/14/24 at 1:37pm, Nurse Practitioner #1 stated that they were informed on 12/27/22 (can't remember the time and who informed them) that Resident #1 seemed to be in pain when moving their right leg. Nurse Practitioner #1 stated that they were in the building and immediately examined Resident #1. Nurse Practitioner #1 stated that Resident #1 had occasional moaning and facial grimacing when Resident #1 moved their right hip. Nurse Practitioner #1 stated that the x-ray result revealed an acute non-displaced right femur intertrochanteric fracture. Nurse Practitioner #1 stated that they did not order a STAT x-ray because there were no reported falls or trauma.
During an interview on 02/06/24 at 3:00pm, the Director of Nursing stated that they conducted the investigation and that Registered Nurse #1 initially stated that nothing unusual happened to Resident #1. The Director of Nursing stated that when they informed Registered Nurse #1 that Resident #1 sustained a right hip fracture, Registered Nurse #1 stated that Resident #1 fell on their shift. The Director of Nursing stated that Registered Nurse #1 stated that they did not report the incident to Nursing Supervisor #1 because they were tired and wanted to go home. The Director of Nursing stated that Registered Nurse #1 failed to report the fall and there was evidenced of neglect.
10 NYCRR 415.11(C)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification and abbreviated survey (NY00316471) from 2/8/2024 to 2/15/2024, the facility did not ensure allegations involving abuse were reported to the New York State Department of Health within 2 hours of occurrence. This was evident for 2 (Resident #246 and #210) of 38 total sampled residents. Specifically, Residents #246 and #210 were involved in a resident-to-resident altercation that was not reported to the New York State Department of Health within 2 hours.
The findings are:
The facility policy titled Abuse, Mistreatment, Neglect and Exploitation and Misappropriation of Resident Property dated 11/2023 documented the Administrator and Director of Nursing has the responsibility to report all alleged violations in which there is reasonable cause to believe that abuse, neglect, or misappropriation has occurred.
Resident #246 had diagnoses of hypertension and dementia.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #246 was severely cognitively impaired.
Resident #210 had diagnoses of hypertension and dementia.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #210 was severely cognitively impaired.
The facility Incident Report dated 5/11/2023 documented Resident #246's son witnessed Resident #210 grab and hit Resident #246.
Nursing Note dated 05/11/2023 documented Resident #246's son reported to the nursing staff that Resident #210 grabbed and hit Resident #246.
The Aspen Complaint Tracking System intake dated 05/12/2023 documented the facility reported the resident-to-resident altercation between Resident #246 and #210 on 5/12/2023 at 01:38 PM.
There was no documented evidence the resident-to resident altercation between Resident #246 and #210 was reported to the New York State Department of Health within 2 hours of occurrence.
On 02/14/2024 at 02:08 PM, the Director of Nursing was interviewed and stated the facility reported allegations of abuse and injury of unknown origin to the New York State Department of Health within 2 hours of occurrence. The incident between Resident #246 and #210 occurred on 5/11/2023 at 03:05 PM and was reported to the New York State Department of Health on 5/12/2023 at 10:20 AM. The Director of Nursing stated they interviewed staff and obtained statements prior to reporting an incident. If the facility determined abuse occurred after gathering statements, the incident would be reported. Resident #210 did not intend to harm Resident #246.
On 02/15/2024 at 10:38 AM, the Administrator was interviewed and stated suspected abuse and injury were reported to the New York State Department of Health as soon as possible. Resident #246 did not sustain injury and Resident #210 did not have a history of abuse. Staff also did not witness the incident between Resident #246 and #210. The incident was reported the same day.
10 NYCRR 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification survey from 02/08/2024 to 02/15/2024, the facility did not ensure a person-centered Comprehensive Care Plans was developed and implemented to meet a resident's needs. This was evident for 1 (Resident #36) of 2 residents reviewed for Urinary Catheter out of 38 total sampled residents. Specifically, Resident #36's Comprehensive Care Plan was not developed with interventions to address their urinary (Foley) catheter.
The findings are:
The facility policy titled Comprehensive Care Planning and Baseline dated 10/2023 documented the Comprehensive Care Plan will include measurable goals and timetables to meet the resident's medical, nursing, and psychosocial needs.
Resident #36 had diagnoses of Benign Prostrate Hypertrophy and Diabetes Mellitus.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #36 was cognitively intact and had an indwelling catheter.
The Physician's Orders dated 12/29/2023 and renewed 1/23/2024 documented Resident #36 received urinary output monitoring every shift and Foley catheter care every shift and as needed.
The Comprehensive Care Plan related to urinary incontinence and indwelling catheter initiated 12/28/2023 documented interventions that included assisting with clothing management, maintaining dignity, and providing medications as ordered for Resident #36.
There was no documented evidence the Comprehensive Care Plan related to Resident #36's indwelling catheter included interventions to address monitoring the resident's urinary output and providing Foley catheter care.
On 02/15/2024 at 12:12 PM, Registered Nurse #5 was interviewed and stated the supervisors and nurses on the unit were responsible for developing Comprehensive Care Plans. Resident #36's care plan related to indwelling catheter should have addressed the resident's need for Foley catheter care.
On 02/15/2024 at 01:53 PM, the Assistant Director of Nursing was interviewed and stated the Registered Nurses were responsible for developing and completing care plans. Resident #36's care plan related to indwelling catheter should have been developed with goals and interventions that addressed their need for Foley catheter care.
10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification survey from 2/8/2024 to 2/15/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #243) of 3 residents reviewed for Limited Range of Motion out of 38 total sampled residents. Specifically, Resident # 243 did not have bilateral hand rolls in place according to Physician's Order.
The findings are:
The facility policy titled Activities of Daily Living Care Guidelines dated 10/2023 documented the Certified Nursing Assistant will apply splints, braces, and assistive devices as directed.
Resident #243 had diagnoses of Alzheimer's Disease and Anemia.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #243 was severely cognitively impaired, had functional limitations on their left upper extremity, and required assistance with activities of daily living.
On 2/8/2024 at 10:45 AM, Resident #243 was observed in bed with bilateral hand contractures and no hand rolls in place.
On 2/15/2024 at 10:46 AM, Resident #243 was observed with one hand roll in the left hand and no hand roll in the right hand.
The Physician's Order dated 3/29/2022 and renewed 01/30/2024 documented bilateral hand rolls were applied to Resident #243 during the day and removed every shift for skin inspection.
There was no documented evidence Resident #243's bilateral hand rolls were applied in accordance with the Physician's Order.
On 2/15/2024 at 11:10 AM, Certified Nursing Assistant #7 was interviewed and stated Resident #243 required bilateral hand rolls to help the resident extend their hand and fingers.
On 2/15/2024 at 11:56 AM, the Occupational Therapist was interviewed and stated Resident #243 was ordered to wear bilateral hand rolls that should only be taken on for hygiene purposes.
On 2/15/2024 at 11:10 AM, the Assistant Director of Nursing was interviewed and stated bilateral hand rolls should be in place for Resident #243 in accordance with Physician's Order to prevent further hand contractures.
10 NYCRR 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey 02/08/2024 to 02/15/2024, the facility did not ensure a resident requiring dialysis services received such services consistent with professional standards of practice. This was identified for 1 (Resident #645) of 38 total sampled residents. Specifically, there was no Physician's Orders for Resident #645 to receive hemodialysis treatment.
The findings are:
The facility policy titled Hemodialysis dated 09/04/2023 documented all dialysis residents will be monitored pre and post dialysis treatment.
Resident #645 was admitted to the facility on [DATE] with diagnoses of Hypertension, Diabetes, and Hyperlipidemia.
The Comprehensive Care Plan related to hemodialysis initiated 1/31/2024 documented Resident #645 received dialysis treatment at a dialysis center.
The Nursing Hemodialysis Communication Form dated 2/1/2024, 2/3/2024, 2/6/2024, 2/8/2024, and 2/10/2024 documented pre and post dialysis monitoring and vital signs for Resident #645.
There was no documented evidence Resident #645 had a Physician's Order to receive hemodialysis treatment 3 times weekly.
On 02/14/2024 at 11:37 AM, an interview was conducted with Registered Nurse #6 who stated Resident #645 received hemodialysis treatment 3 times weekly and the monitoring was documented on the Communication Form.
On 02/14/2024 at 03:39 PM, an interview was conducted with Medical Director #1 who stated Resident #645 had chronic kidney disease and received hemodialysis treatment from a dialysis center. There should have been a Physician's Order for Resident #546 to receive hemodialysis treatment.
10 NYCRR 415.12

Based on observations, record review, and interviews conducted during the Recertification survey from 2/08/2024 to 2/15/2024, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during kitchen observation. Specifically, expired food was observed in the kitchen refrigerator.
The findings are:
The facility policy titled Labeling and Dating Items dated 09/2023 documented all food items that enter the facility will have the date that the case was received to ensure that all food items entering the facility are utilized using the First In, First Out process. Any items found out of date will note be used and will be discarded.
On 02/08/2024 at 09:38 AM, the kitchen Refrigerator #1 was observed with 2 (5 lb) tubs of egg salad with a use by date of 2/07/2024 and 2 (5 lb) plastic containers of egg salad with a use by date of 1/26/2024. Refrigerator #3 was observed with 2 wrapped whole baked hams with a use by date of 2/6/2024.
On 2/12/2024 at 10:48 AM, Dietary Aide #1 was interviewed and stated they received food deliveries three times a week on Wednesday, Friday and Monday and rotated items using the First In, First Out method. Dietary Aide #1 stated they were shocked that food items were expired because they usually check for expired items in the refrigerators when they looked for inventory. Dietary Aide #1 stated they forgot to check for expired food items. The Food Service Director checked the refrigerators for expired items as well.
On 2/14/2024 at 11:45AM, the Food Service Manager was interviewed and stated they checked the refrigerators twice daily for expired items. If items were due to expire the next day, the Food Service Manager discarded them.
On 2/14/2024 at 01:23 PM, the Food Service Director was interviewed and stated that each manager did a kitchen walk through daily on each shift. All kitchen staff were instructed to check for expired foods and to use the First In First Out method of rotation. The expired food items found in Refrigerators #1 and #3 were overlooked.
10 NYCRR 415.14 (h)

Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, a Certified Nursing Assistant (CNA) was observed using a blood pressure cuff (BPC) on multiple residents without sanitizing the BPC and hands between residents. This was evident for 1 of 5 floors (Unit - 5B) observed for Infection Control.
The findings are:
The policy titled Cleaning Nursing Equipment last reviewed 03/2021 documented, in between use with each resident, the BPCs are cleaned with hydrogen peroxide wipes and given a 3-minute drying. Wipes are to be placed in the garbage, gloves removed, and hands washed.
On 12/01/2021 at 11:02AM, CNA #7 was observed on the 5B unit with ungloved hands, applying a BPC to the right upper arm of Resident #54. CNA #7 placed the BPC into the holder attached to the BP machine and walked to Resident #120 who was sitting at their room door. CNA #7 applied the BPC to the bare left lower forearm of Resident #120. CNA #7 entered the room and applied the BPC to the bare upper left arm of Resident #145, removed the BPC, exited the room, and placed the BPC and BP machine at the nursing station. CNA #7 did not sanitize the BPC and did not don gloves or perform hand hygiene in between each resident use.
On 12/01/2021 at 12:23PM, CNA#7 was interviewed, and stated BPCs and hands are to be sanitized in between each resident use. This prevents the spread of infection. CNA #7 would normally perform hand hygiene and sanitize the BPC in between each resident but was not thinking at the moment and did not sanitize the BPC or hands in between Resident #54, #120, and #145.
On 12/01/2021 at 12:35PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated shared equipment should be cleaned after each resident and should be sanitized and let it dry 3-5 minutes before using on the next resident. Staff must perform hand hygiene in between residents when using a shared device.
On 12/07/2021 at 03:28PM, the Infection Preventionist (IP) was interviewed and stated the IP does weekly observations of the facility, conducts monthly departmental infection control observations, and conducts audits and inservice if issues are found. Shared devices (i.e., BPCs) are to be sanitized and given 3 minutes in between each resident use. Staff are to don gloves and perform hand hygiene and change gloves in between each resident when using a shared device.
415.19 (a)(1),(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review conducted during the recertification and complaint survey (NY00281549), the facility did not ensure that an alleged violation involving Abuse was reported to the New York State Department of Health (NYSDOH) within the acceptable timeframe. Specifically, one allegation of resident to resident abuse, involving Resident #122 and #203, was not reported within 2 hours. This was evident for 2 of 8 residents reviewed for Abuse (Resident #122 and #203).
The findings are:
The facility policy titled Resident Abuse, Neglect, Exploitation, Mistreatment, Involuntary Seclusion, Misappropriation of Property effective 7/98 and reviewed 4/21 documented allegations of abuse are to be reported to the NYSDOH in adherence to state and federal requirements.
Resident #203 had a diagnosis of Schizophrenia, Depression, and Diabetes Mellitus.
The Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 203 had moderately impaired cognition and required limited to extensive assistance of one person for Activities of Daily Living (ADL).
A Nursing Note dated 8/10/2021 documented Resident #122 was sitting in the hallway when Resident #203 walked into Resident #122's room. Resident #122 followed Resident #203 into the room. The Certified Nursing Assistant (CNA) heard a commotion, entered the room, and observed Resident #122 and #203 arguing. Resident #122 scratched Resident #203 and Resident #203 punched Resident #122 in the back. Registered Nurse (RN) #6 assessed both residents and the Medical Doctor (MD) was made aware.
Resident # 122 had a diagnosis of Alzheimer's Disease, Essential Tremors, and Generalized body weakness.
The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #122 had severely impaired cognition and required extensive assistance of 1 person for Activities of Daily Living (ADL).
The Accident/Incident Report was initiated 8/10/2021 and documented the facility investigated the incident between Resident #122 and #203. The investigation was completed and signed 8/16/21 by the Assistant Director of Nursing (ADNS).
The Hospital Emergency Response Data System (HERDS) documented the facility reported the incident to the NYSDOH on 8/17/2021.
An interview was conducted on 12/08/21 at 12:12 PM with the ADNS who stated they were unaware of the reporting requirements for abuse allegations and would need to check the NYSDOH regulation.
An interview was conducted on 12/08/21 at 01:05 PM with the Director of Nursing (DON) who stated suspected abuse should be reported to the NYSDOH within 24 hours. If the alleged abuse resulted in injury, a report should be made immediately. The facility has 5 days to complete their investigation and report to the NYSDOH.
415.4(b)(1)(i)

Based on observation, staff interview, and record review conducted during the Recertification survey, the facility did not ensure food storage in accordance with professional standards. Specifically, undated and expired food was observed in the Kitchen and Storage Room during the Kitchen Task.
The findings are:
The facility policy titled General Purchasing of Food and Non Food Products last revised 6/14 documented all items received in the kitchen will be dated by the storeroom worker. Refrigerated foods and opened boxes/cans/bottles are to be dated.
The following was observed in the facility Kitchen on 12/01/21 at 10:20 AM: 1) Refrigerator #3 and, 2 packages of sliced ham deli meat, 4 packages of smoked ham deli meat , and 9 packages of turkey breast deli meat undated; 2) the Cook's Refrigerator contained housemade cranberry sauce dated 11/20/21; raw cubed steak and pork shoulder unlabeled and undated; 4 plastic bins of cut vegetables without a date.
The following was observed in the Kitchen on 12/06/21 at 09:44 AM: 1) the Storage Room opened bottles of vinegar, sweet and sour sauce, honey, and crushed red pepper without a delivery, open, or use by date; 2) the Cook's Refrigerator: 2 packages of raw pork undated; plastic bins of cut vegetables not dated; 2 packages of ground turkey not dated; 1 package frank/sausage not dated or labeled with product name; 3) refrigerator #1 - 9 plastic bins with biscuits / pastries not dated; Rolls wrapped in plastic wrap not dated.
An interview was conducted on 12/07/21 at 02:55 PM with Dietary Aide (DA) #1 who food items are rotated on Monday to prepare for deliveries on Tuesday and Thursday. DA #1 uses a marker to write the delivery date on all boxes.
An interview was conducted on 12/07/21 at 03:08 PM with the Chef who stated DA #1 dates boxes delivered to the facility. Items that need to be defrosted or refrigerated are placed in a container and masking tape is used to label the container with the date. The Chef uses the manufacturers guidance to determine expiration dates; however, stated there were some items that were not stored according to manufacturers labeling.
An interview was conducted with the Food Service Director (FSD) on 12/07/21 at 03:48 PM who stated items are dated upon delivery. Food items that are taken out of their original packaging are dated when being stored. A orange sticker may be applied to foods that need to be used first.
415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the re-certification survey, the facility did not ensure completed Minimum Data Set 3.0 (MDS) comprehensive and non-comprehensive assessments were electronically submitted and transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System in a timely manner. Specifically, admission, annual, significant change, and quarterly assessments were not transmitted within fourteen (14) calendar days after the assessments were completed. This was evident for 18 of 19 residents reviewed for the Resident Assessment facility task (Resident #'s 7, 6, 11, 22, 17, 15, 21, 9, 35, 16, 19, 10, 20, 50, 18, 12, 13, and 14).
The findings include but are not limited to:
The facility does not have a policy and procedure for MDS Submission and Transmission.
CMS RAI Version 3.0 Manual (Dated October 2018)- Chapter 5 titled Submission and Correction of the MDS Assessments documented: The MDS completion date must be no later than 14 days after the assessment reference date (ARD) for all non-admission, OBRA, and PPS assessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date.
1) Resident #11 was admitted on [DATE]. The Annual assessment had an ARD 03/19/19. It was completed on 04/02/19 with care plan completion also on 04/02/19 and submitted on 05/08/19. The Quarterly assessment had an ARD 12/24/18. It was completed on 01/07/19 and submitted on 01/29/19. Another Quarterly assessment had ARD 07/10/18. It was completed on 07/16/18 and submitted on 08/13/18.
2) Resident #13 was admitted on [DATE]. The Annual assessment had an ARD of 07/13/18. It was completed on 07/24/18 with care plan completion on 07/26/18. It was submitted 08/13/18. The Quarterly assessment had an ARD of 12/24/18. It was completed on 01/07/19 and submitted on 01/29/19. Another Quarterly assessment had an ARD of 03/26/19. It was completed on 04/09/19 and submitted on 05/06/19.
3) Resident #22 was admitted on [DATE]. The Quarterly assessment had an ARD of 03/26/19. It was completed on 04/09/19 and submitted on 05/06/19.
4) Resident #17 was admitted on [DATE]. The Annual assessment had an ARD of 03/19/19. It was completed on 04/02/19 and submitted on 05/08/19.
5) Resident #10 was admitted on [DATE]. The Quarterly assessment had an ARD of 07/11/18. It was completed on 07/19/18 and submitted on 08/13/18. The Quarterly assessment had an ARD of 12/22/18. It was completed on 01/05/19 and submitted on 01/29/19. The Annual assessment had an ARD of 03/17/19. It was completed on 03/31/19 with care plan completion on 04/07/19 and submitted on 05/08/19.
On 05/14/19 at 11:29 AM, the RN MDS Director (RN #3) was interviewed. He stated they have 14 days from the ARD to complete, sign, and submit MDS assessments for annual and quarterly assessments. He stated he has 14 days from admission to complete and sign admission assessments, and after admission assessment is completed he has 14 days to submit it. RN #3 stated he started this position in December 2018 and is responsible for scheduling and auditing books as they are completed. He further stated he is not authorized to submit completed books yet because he is waiting to gain access. RN #3 stated he had already identified that MDS assessments were not all being submitted timely and it was discussed during quality assurance meetings. The previous MDS coordinator who was responsible for submitting books was overwhelmed, and that is why he was hired. Currently, the other MDS coordinator still does all the submitting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, a resident's Minimum Data Set 3.0 (MDS) assessment did not include the active treatment of Dialysis. This was evident for 1 of 38 sampled residents (Resident #160).
The finding is:
Resident #160 was admitted to the facility on [DATE] with diagnosis which include Renal Osteodystrophy, Type 2 diabetes, and Dependence on Renal dialysis.
The initial admission MDS dated [DATE] documented that the resident received dialysis before entering the facility and while in the facility in Section O.
The current Quarterly MDS dated [DATE] documented the resident had moderately impaired cognition. The MDS Section O - Special Treatments, Procedures, and Programs did not document the resident received dialysis while in the facility.
On 05/08/19 at 10:46 AM, Resident # 160 stated she is on dialysis and treated on Tuesdays, Thursdays, and Saturdays.
On 05/14/19 at 011:15 AM, an interview was conducted with Registered Nurse (RN#10). RN #10 stated Resident #160 has received dialysis since admission to the facility.
On 05/14/19 at 11:50 AM, an interview was conducted with RN #9. Upon RN #9 review of the Quarterly MDS dated [DATE], RN #9 stated it was an oversite that dialysis was not documented for Resident #160, and the oversite would be corrected right away. RN # 9 stated when completing the MDS, the progress notes, medications, ADT (admission Discharge and Transfer), and Doctor's orders are reviewed. RN # 9 also stated the look back period for Section O - Special Treatments, Procedures, and Treatment is 14 days.
On 05/14/19 at 2:30PM, the RN Director of MDS was interviewed. The Director stated when completing MDS, the staff doubled clicked on the box for dialysis instead of clicking once. This action caused the checked box to be removed which resulted in dialysis not being documented. The RN Director of MDS also stated the staff was aware of the resident's medical condition and manually added the diagnosis in Section I - Active Diagnosis, and dialysis was documented on previous MDS assessments.
415.11 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the re-certification survey, the facility did not ensure comprehensive care plans were developed and implemented. Specifically: (1) comprehensive care plans were not developed to describe the resident's medical, nursing, physical, mental and psychosocial needs, (2) comprehensive care plans interventions were not carried out to assist a resident in attaining or maintaining his/her highest practicable quality of life, and (3) comprehensive care plans did not include measurable objectives, goals, and time frames in order to evaluate the resident's progress toward his/her goal. This was evident for 4 of 38 sampled residents (Resident #395, #495, #11, and #496).
The findings are:
The facility policy and procedure titled, Completing Care Plans and Care Plan Meetings in the EMR (Dated 08/18) documented the following. As per CMS guidelines for Requirements of Participation for Long Term Care Facilities, Phase 2, facilities must have completed customized Care Plans for every resident within 48 hours of admission .the resident's care plan must be individualized, reflect interdisciplinary approach and reviewed within the specified time frames expressed for each goal .Clinical staff will assess/evaluate each resident upon admission/readmission and as focuses are identified. Clinical staff will initiate/update and review the resident's care plans as scheduled .Each care plan must have goals with review dates and goals should be measurable, specific, attainable, realistic, and time bonded. Interventions should address the needs of the resident, resolve the problem, maintain the resident's strengths, and identify which disciplines are responsible for each intervention .Care plans to be reviewed quarterly and updated as needed .Care plan meetings .The social worker will inform the resident/family/designated representative of the date and time of the care plan meeting.
1.) Resident #395 was admitted [DATE] with diagnoses which include: chronic obstructive pulmonary disease , acute respiratory failure with hypoxia , dependence of supplemental oxygen, presence of pacemaker, and chronic and secondary hyperaldosteronism.
The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The resident required the extensive assist of two persons for all activities of daily living (ADL) except eating which required set-up and supervision .
On 05/07/2019 at 11:04 AM, the resident was observed in bed. The resident was on oxygen via nasal cannula. The resident was observed with bilateral edema of the upper and lower extremities with no devices observed.
The Resident was visited again on 05/13/2019 at 10:55 AM. The oxygen was still in place. Bilateral edema of upper and lower extremities was noted. The resident was interviewed and stated there were no devices used for her edema.
On 05/14/2019 at 11:50 AM, the resident was observed. The edema of bilateral upper and lower extremities was still present.
Review of the Comprehensive Care Plan (CCP) dated 03/27/2019 documented Cardiac and Respiratory CCPs. The CCPs did not include any interventions to address the care needs for the resident's edema and permanent pacemaker.
The Nurse Practitioner Note dated 4/5/19 documented the resident had Pleural Effusion with dependent edema and Congestive Heart failure (CHF) with edema of upper and lower extremities. Diuretic EF (ejection fraction) 70% as per chart review. The Plan for care was to monitor for increased edema and signs and symptoms of CHF exacerbation. The NP documented the resident has a pacemaker, and the target PR (pacing rate) is 60-100 beats /minute .
The Pulmonology consult dated 4/5/19 documented the resident had diagnoses of significant endocrine and metabolic disorder with chronic and secondary hyperaldosteronism with pedal and upper extremities edema.
On 05/14/2019 at 10:50 AM , the Registered Nurse Unit Manager (RN #4) was interviewed and asked what care plan or interventions are in place for the edema and permanent pacemaker. She stated that she created the cardiac and respiratory care plans, but they do not have any specific information related to the edema and pacemaker.
2) Resident # 495 was admitted on [DATE] with diagnoses which include: Escherichia coli , Chronic Kidney Disease stage 2 on hemodialysis (HD), asthma and seizures.
The initial Minimum Data Set 3.0 assessment dated [DATE] identified the resident with intact cognition, able to make needs known.
On 05/14/2019 at 10:45 AM, the resident was interviewed. The resident stated she goes to hemodialysis three times per week.
The physician's orders dated 5/7/19 documented orders for hemodialysis three times a week, monitoring right chest permacatheter, and pre and post dialysis vital signs.
The comprehensive care plans (CCP ) dated 05/06/2019 was reviewed. The CCP did not contain any interventions to address the care needs for the resident's hemodialysis. In addition, the CCP for Genitourinary Status had no interventions.
On 05/14/2019 at 2:45 PM, the unit Registered nurse supervisor (RN #5) and licensed practical nurse (LPN #2) were interviewed and both stated the admitting licensed professional nurse will do the initial assessment and the care plan. The Completion of the care plans, revisions, and updates are done by the assigned nurse on the unit. There are 3 nurses in the morning and two nurses assigned on the 2nd and 3rd shifts. The care plans to be completed are distributed among them.
3) Resident #11 was admitted to the facility on [DATE] with diagnoses including but not limited to depression, anemia, and hyperlipidemia.
The Minimum Data Set (MDS) 3.0 Annual assessment dated [DATE] was reviewed. Resident is cognitively intact. Resident is mostly independent with set up for transfer, and locomotion on and off unit. Resident documented with currently using tobacco.
The Comprehensive Care Plan (CCP) titled, Smoking Plan of Care (Effective date 07/06/18) documented resident with a psychosocial history that reveals resident is a known smoker and is a unsupervised smoker. Goals were not marked off for resident. Interventions with effective dates of 09/13/18 included the following. Review smoking policy with resident and family on admission, readmission, and as needed. Check clothing regularly for signs of unsafe smoking. Provide smoking apron as needed. Encourage smoking cessation. Provide education on risks of smoking behavior.
The CCP reviewed did not specify goals with timeframes.
4) Resident #496 was admitted to the facility on [DATE] with diagnoses including but not limited to multiple myeloma and depression.
The MDS 3.0 admission assessment dated [DATE] was reviewed. Resident is cognitively intact. Resident documented with currently using tobacco.
The CCP titled, Smoking Plan of Care (Effective date 04/16/19) documented resident with a long history of smoking and is an unsupervised smoker. Goals were not marked off for resident. Interventions with effective dates of 04/16/19 included the following. Review smoking policy with resident and family on admission, readmission, and as needed.
The CCP reviewed did not specify goals with timeframes.
The smoking risk assessment dated [DATE] was reviewed. The assessment did not indicate if resident was educated on the smoking policy and/or rules.
The social work assessment and notes were reviewed from 04/10/19 to current. There was no documentation regarding educating on smoking safety and policy.
On 05/10/19 at 02:21 PM, and on 05/13/19 at 11:28 AM and at 12:21 PM, the Director of SW stated the following. The policy for smoking is residents going out in pass to smoke. Currently the policy is being worked on. In the meantime, the SW is responsible for identifying if a resident is a smoker or not upon admission. Then the SW will educate the resident that this is a non-smoking facility. The resident is also evaluated using the smoking risk assessment. If the resident is deemed alert and oriented, and a unsupervised/safe smoker, the resident can smoke outside in the front of the building. These same residents hold onto their own smoking materials since they are deemed safe. Smoking assessments can be completed by both nursing and SW and are done upon admission, quarterly, and as needed. The smoking rules are discussed with the resident and/or family during the time the smoking assessments are completed. Smokers are monitored and supervised by checking their clothes and determining if there was a significant change in their status. The SW is responsible for developing and updating the smoking CCP. There was no response as to why the smoking CCP was not completed to reflect measurable goals and if the interventions were effective or not. The CCP should be updated and revised quarterly and as needed.
415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). Resident #395 a [AGE] year-old admitted with diagnoses which include: Chronic Obstructive Pulmonary Disease, Acute Respiratory failure with hypoxia , Chronic Kidney Disease, presence of pacemaker and Chronic and Secondary Hyperaldosteronism.
The MDS (Minimum Data Set 3.00 assessment dated [DATE] identified the resident as moderately impaired with her cognition. The resident requires extensive assist with two ( 2) persons in all care areas except eating.
On 05/07/2019 at 11:04 AM the resident was observed in bed with 2 1/2 siderails up, lying in a bariatric bed, with Foley catheter connected to bedside bag with dark orange colored urine, with intravenous fluid of dextrose 5 % sodium chloride (D5NACL ) infusing on left forearm. Oxygen by nasal cannula connected to an oxygen tank at 2 liters. Resident was observed with bilateral edema of the upper and lower extremities with no devices in place.
Resident was visited again on 05/13/2019 at 10:55 AM and 05/14/2019 at 11:50 AM . Resident with oxygen and with Foley catheter connected to bedside bag . Bilateral edema of upper and lower extremities was noted . The resident was interviewed on 5/14/19 at 11:00 AM. The resident stated that no devices were being used on her upper or lower extremities.
The physician's notes located in the interdisciplinary notes of the resident's record documented: resident non - compliance with use of Bipap that resulted in CO2 retention leading to decrease mentation . PE with dependent edema /pressure ulcer-- under the breast stage 2 / cognitive impairment of dementia / Congestive Heart failure (CHF) with edema of upper and lower extremities . Diuretic EF ( ejection fraction ) 70 % as per chart review . Based on X-ray with pleural effusion . Plan : monitor for increase edema and signs and symptoms of CHF exacerbation. With pacemaker and target PR is 60-100 beat /minute . Resident has also a diagnosis of significant endocrine and metabolic disorder with chronic and secondary hyperaldosteronism positive to pedal and upper extremities edema.
The Comprehensive Care Plan (CCP ) for Cardiac care dated 03/27/2019 did not address resident's edema. It was not identified as a problem there were no measurable goals or interventions documented to ddress the edema. No other care plan in the record addressed the resident's edema.
On 05/14/2019 at 10:50 AM the Registered nurse unit manager (RNUM ) was interviewed. She was asked what care plan or interventions were in place for the resident's edema. She stated that she developed the CCP for cardiac and respiratory care, but that she did not develop plan of care that addressed edema or the resident's pace maker.
415.11(c)(2)(i-iii)
Based on observations, record reviews, resident and staff interviews, the facility did not ensure comprehensive care plans were reviewed and revised by the interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident. Specifically, (1) a comprehensive care plan for a resident who smokes was not evaluated for effectiveness of interventions and changing goals (Resident #11). 2) The care plan for Resident #395 was not revised to reflect identification of onset of edema. This deficient practice was evident for 2 of residents.
The facility policy and procedure titled, Completing Care Plans and Care Plan Meetings in the EMR (Dated 08/18) documented the following. As per CMS guidelines for Requirements of Participation for Long Term Care Facilities, Phase 2, facilities must have completed customized Care Plans for every resident within 48 hours of admission .the resident's care plan must be individualized, reflect interdisciplinary approach and reviewed within the specified time frames expressed for each goal .Clinical staff will assess/evaluate each resident upon admission/readmission and as focuses are identified. Clinical staff will initiate/update and review the resident's care plans as scheduled .Each care plan must have goals with review dates and goals should be measurable, specific, attainable, realistic, and time bonded. Interventions should address the needs of the resident, resolve the problem, maintain the resident's strengths, and identify which disciplines are responsible for each intervention .Care plans to be reviewed quarterly and updated as needed .Care plan meetings .
The findings are:
1) Resident #11 was admitted to the facility on [DATE] with diagnoses including but not limited to depression, anemia, and hyperlipidemia.
On 05/09/19 at 12:06 PM, resident #11 doorway frame was observed with a red flag. Resident#11 was then observed asleep in bed but easily awakened. Observed bedside drawer next to his bed and on top, there was an opened lap top. A Marlboro cigarette box and 8 lighters were observed placed on top of the keyboard out in the open.
On 05/09/19 at 03:05 PM, resident #11 was observed sitting outside in the designated smoking area which is up the ramp on the right side of the main entrance in his wheelchair next to the ash tray already smoking with his right hand. Observed resident #11 with a burnt hole on his right pant leg by the knee. Observed resident #11 holding the cigarette above the same area where the burnt hole is but the ashes were not landing on his knee and was being blown away instead. Resident #11 then completed the cigarette and threw it on the floor. Resident #11 then took another cigarette to smoke and lighted it up.
On 05/09/19 at 04:56 PM, resident #11 bedside drawer next to his bed were a total of 9 lighters, 8 on the laptop and 1 by the side of the laptop, and a box of Marlboro cigarettes.
The Minimum Data Set (MDS) 3.0 Annual assessment dated [DATE] was reviewed. Resident is cognitively intact. Resident is mostly independent with set up for transfer, and locomotion on and off unit. Resident documented with currently using tobacco.
The Comprehensive Care Plan (CCP) titled, Smoking Plan of Care (Effective date 07/06/18) documented resident with a psychosocial history that reveals resident is a known smoker and is a unsupervised smoker. Goals were not marked off for resident. Interventions with effective dates of 09/13/18 included the following. Review smoking policy with resident and family on admission, readmission, and as needed. Check clothing regularly for signs of unsafe smoking. Provide smoking apron as needed. Encourage smoking cessation. Provide education on risks of smoking behavior. Notes documented on 10/15/18 and 3/18/19 that resident have no changes and is an unsupervised smoker in front of the building.
The Smoking Risk Assessments were reviewed from 04/2017 to current as per availability. Smoking Risk Assessments were completed on 04/04/17, 07/03/17, 10/01/17, 12/30/17, 01/11/19, and 05/10/19. There were no Smoking Risk Assessments completed for the year of 2018. All assessments documented resident as an unsupervised smoker.
Social Work assessments were reviewed from 1/2018 to Current, 5/2019 and there were no documentation regarding smoking found.
Social Work notes were reviewed from 1/2018 to Current, 5/2019 and the following were documented.
On 01/16/19, .Worker educated the resident about upcoming changes to our smoking policy which will mean that residents must keep their smoking materials at the nursing station. Worker informed him that this change would be taking place in the near future for .to be prepared .Staff will continue to monitor his smoking and functional ability for proper placement alternatives.
On 01/23/19, .is still able to go out on a daily basis to smoke and remain independent in eating and transferring and able to leave the facility to smoke .
On 01/28/19, .he continues to follow the smoking guidelines
There was no documentation regarding staff acknowledging resident with a burnt hole on his pants.
There was no documentation in both facility policies and resident record regarding where smoking paraphernalia should or supposed to be kept.
On 05/09/19 at 12:06 PM and at 03:05 PM, resident #11 stated he smokes four (4) times a day where smoking is allowed out in the front on the ramp where there's an ash tray. Resident #11 stated he just goes downstairs without telling anyone and he tells the security guard by the entrance that he's going outside. He further stated staff does not question him and he does not need a pass to go outside. Resident stated he was not assessed for safe smoking and did not sign any contract or agreement. He further stated he has always held on to his own cigarettes and lighters and he does not keep it locked up anywhere.
On 05/10/19 at 02:21 PM, and on 05/13/19 at 11:28 AM and at 12:21 PM, the Director of SW stated the following. The policy for smoking is residents going out in pass to smoke. Currently the policy is being worked on. In the meantime, the SW is responsible for identifying if a resident is a smoker or not upon admission. Then the SW will educate the resident that this is a non-smoking facility. The resident is also evaluated using the smoking risk assessment. If the resident is deemed alert and oriented, and a unsupervised/safe smoker, the resident can smoke outside in the front of the building. These same residents hold onto their own smoking materials since they are deemed safe. Smoking assessments can be completed by both nursing and SW and are done upon admission, quarterly, and as needed. The smoking rules are discussed with the resident and/or family during the time the smoking assessments are completed. Smokers are monitored and supervised by checking their clothes and determining if there was a significant change in their status. The director of SW further stated he has not seen smoking materials in resident room or burn holes on resident clothes before since resident had always compiled with the rule to smoke out in the front. He further stated a smoking contract is only provided to residents who were determined to be a unsafe smoker. The SW is responsible for developing and updating the smoking CCP. There was no response as to why the smoking CCP was not completed to reflect measurable goals and if the interventions were effective or not. The CCP should be updated and revised quarterly and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews during the re-certification survey, (1) the facility did not ensure residents' environment remained free of accident hazards, specifically, eight (8) lighters were observed not locked or stored away leaving it accessible to others, (2) the facility did not ensure 1 of 3 residents (Resident #11) who smokes was assessed in a timely manner to determine the need for supervision while smoking to ensure that the resident, other residents and the environment was free of accident hazards, and (3) the facility designated the area directly in front of the building as a smoking area, however it did not ensure adequate supervision to a resident (Resident #11) who smokes and was observed putting out lit cigarette on the ground in front of facility entrance and not in ashtray. The resident was also observed with with a burn hole on his pants. This was evident in 1 of 3 residents (Resident #11) reviewed for smoking activity for smoking out of a sample of 38 residents.
The finding is.
The facility admission booklet documented on page 15 the following. Cobble Hill is a smoke free facility. Smoking by patients, visitors and staff is strictly prohibited within Cobble Hill Health Center and on its grounds. Smoking is a major concern for the health and safety of everyone at Cobble Hill. We ask everyone's cooperation in following these regulations.
The facility policy and procedure titled, Smoking (Dated 04/01/2009) documented the following. Smoking is prohibited throughout the entire building. Ashtrays are available outside the entrances to facilitate extinguishing of smoking materials prior to entering the facility. For residents who moved to Cobble Hill Health Center prior to January 1, 2009, every effort will be made to provide smoking cessation programs and/or relocate them to a facility where smoking is permissible. Prospective residents and their families shall be informed of the Smoke Free policy in advance of admission. The Smoke Free policy will be explained again at the time of admission. During initial social work interview, the social worker will review the Smoke Free policy with the resident or designated representative.
The facility Behavioral Contract (Not Dated) documented the following. Purpose of contract is to educate the resident that Cobble Hill Health Center is a smoke free facility and no one is permitted to smoke anywhere inside or outside or on the grounds of the facility .The facility will offer both Medical and Psychological support to help you stop smoking, assist you in transferring to an appropriate setting that allows smoking if you wish. The resident will never smoke in his room or anywhere in the facility or on the facility grounds, ask the staff for assistance should they wish to stop smoking. Behavior Contract Consequences. The first time I attempt to smoke, the staff of Cobble Hill will review and answer questions I may have regarding medical and psychological support available to help me quit. The second time I attempt to smoke in or on the grounds of the facility the staff will begin the transfer/discharge process to assist me in finding an appropriate alternative setting that permits smoking.
Resident #11 was admitted to the facility on [DATE] with diagnoses including but not limited to depression, anemia, and hyperlipidemia.
On 05/09/19 at 12:06 PM, resident #11 doorway frame was observed with a red flag. Resident#11 was then observed asleep in bed but easily awakened. Observed bedside drawer next to his bed and on top, there was an opened lap top. A cigarette box and 8 lighters were observed placed on top of the keyboard out in the open.
On 05/09/19 at 03:05 PM, resident #11 SA#1 (State Agency Surveyor) was observed sitting outside in the designated smoking area; which is up the ramp on the right side of the main entrance in his wheelchair next to the ash tray. The resident was smoking a cigarette with his right hand. Observed resident #11 with a burn hole on his right pant leg by the knee. Observed resident #11 holding the cigarette above the same area where the burn hole was, but the ashes were not landing on his knee and was being blown away instead. Resident #11 then completed the cigarette and threw it on the floor. Resident #11 then lit another cigarette to smoke.
On 05/09/19 at 04:56 PM, SA #2 observed in the room of resident #11, bedside drawer next to his bed were a total of 8 on the laptop and 1 by the side of the laptop, and a box of Marlboro cigarettes.
The Minimum Data Set (MDS) 3.0 Annual assessment dated [DATE] was reviewed. Resident is cognitively intact. Resident is mostly independent with set up for transfer, and locomotion on and off unit. Resident documented with currently using tobacco.
The Comprehensive Care Plan (CCP) titled, Smoking Plan of Care (Effective date 07/06/18) documented resident with a psychosocial history that reveals resident is a known smoker and is a unsupervised smoker. Goals were not marked off for resident. Interventions with effective dates of 09/13/18 included the following. Review smoking policy with resident and family on admission, readmission, and as needed. Check clothing regularly for signs of unsafe smoking. Provide smoking apron as needed. Encourage smoking cessation. Provide education on risks of smoking behavior.
The Smoking Risk Assessments were reviewed from 04/2017 to current as per availability. Smoking Risk Assessments were completed on 04/04/17, 07/03/17, 10/01/17, 12/30/17, 01/11/19, and 05/10/19. There were no Smoking Risk Assessments completed for the year of 2018. All assessments documented resident as an unsupervised smoker.
Social Work assessments were reviewed from 1/2018 to current, 5/2019 and there were no documentation regarding smoking found.
Social Work notes were reviewed from 1/2018 to current, 5/2019 and the following were documented.
On 01/16/19, .Worker educated the resident about upcoming changes to our smoking policy which will mean that residents must keep their smoking materials at the nursing station. Worker informed him that this change would be taking place in the near future for .to be prepared .Staff will continue to monitor his smoking and functional ability for proper placement alternatives.
On 01/23/19, .is still able to go out on a daily basis to smoke and remain independent in eating and transferring and able to leave the facility to smoke .
On 01/28/19, .he continues to follow the smoking guidelines
There was no documentation regarding staff acknowledging resident with a burnt hole on his pants.
There was no documentation in both facility policies and resident record regarding where smoking paraphernalia should or supposed to be kept and/or stored.
On 05/09/19 at 12:06 PM and at 03:05 PM, resident #11 stated he smokes four (4) times a day where smoking is allowed out in the front on the ramp where there's an ash tray. Resident #11 stated he just goes downstairs without telling anyone and he tells the security guard by the entrance that he's going outside. He further stated staff does not question him and he does not need a pass to go outside. Resident stated he was not assessed for safe smoking and did not sign any contract or agreement. He further stated he has always held on to his own cigarettes and lighters and he does not keep it locked up anywhere.
On 05/10/19 at 11:10 AM, the Certified Nursing Assistant (CNA) #1 stated she is familiar with resident and have been assigned to him for 3 to 4 months. She stated she is not familiar with the smoking policy but is aware the resident is a smoker. CNA #1 stated she did not notice any cigarette and/or lighters in his room yesterday. She also stated she has not noticed any burn holes on his clothes.
On 05/10/19 at 11:24 AM, the Licensed Practical Nurse (LPN) #1 stated she is familiar with resident and is aware resident is a smoker. LPN #1 stated when a resident is a smoker, a red flag is placed by the door to indicate they are a smoker. She stated residents used to smoke in the backyard with supervision back in 2018 and now no one is supposed to smoke around the premises anymore but some people smoke in the front of the building. LPN #1 stated smoking materials are supposed to be stored in the medication room. If a resident wants to go out to smoke, the resident will come to us and we go down stairs with the resident while the nurse holds onto the cigarette and lighter until they are in the front of the building. The nurse will stay with the resident until smoking is finished and the lighter is brought back to the medication room. LPN #1 stated she has never completed a smoking risk assessment for any resident and is not aware of it. She further stated she never saw lighters and/or cigarettes in the resident room out in the open. She stated she didn't notice burn holes as well on his clothing.
On 05/10/19 at 11:42 AM and on 05/14/19 at 10:07 AM, the Registered Nurse (RN) Supervisor #1 stated she is familiar with resident and is aware resident is a smoker. She stated the smoking policy was not clear, and she doesn't recall if there was any policy in place. RN #1 stated she did not notice any smoking materials in his room or burn holes on his clothes. She stated nursing and SW are responsible for completing the smoking risk assessments which are completed quarterly. She further stated the assessments for 2018 and the one that was supposed to be done on April 2019 was not done and it may be because it was overlooked. RN #1 stated SW is responsible for developing and updating the smoking CCP.
On 05/10/19 at 02:21 PM, and on 05/13/19 at 11:28 AM and at 12:21 PM, the Director of SW stated the following. The policy for smoking is residents going out on pass to smoke. Currently the policy is being worked on. In the meantime, the SW is responsible for identifying if a resident is a smoker or not upon admission. Then the SW will educate the resident that this is a non-smoking facility. The resident is also evaluated using the smoking risk assessment. If the resident is deemed alert and oriented, and a unsupervised/safe smoker, the resident can smoke outside in the front of the building. These same residents hold onto their own smoking materials since they are deemed safe. Smoking assessments can be completed by both nursing and SW and are done upon admission, quarterly, and as needed. The smoking rules are discussed with the resident and/or family during the time the smoking assessments are completed. Smokers are monitored and supervised by checking their clothes and determining if there was a significant change in their status. The director of SW further stated he has not seen smoking materials in the resident room or burn holes on resident clothes before since resident had always complied with the rule to smoke out in the front. He further stated a smoking contract is only provided to residents who were determined to be a unsafe smoker. The SW is responsible for developing and updating the smoking CCP. There was no response as to why the smoking CCP was not completed to reflect measurable goals and if the interventions were effective or not. The CCP should be updated and revised quarterly and as needed.
On 05/10/19 at 04:26 PM, the RN #2 is familiar with resident and is aware resident is a smoker. RN #2 stated the smoking rule is that lighters are not supposed to be left hanging around in the room and normally somebody would goes down stairs with the resident, but now resident can go independently. Residents are allowed to smoke in front of the building. RN #2 stated she did not notice the smoking materials in residents room and has not noticed any burn holes on his clothes. She further stated she is not familiar with completing smoking assessments.
On 05/09/19 03:36 PM, 05/10/19 02:55 PM and 03:25 PM, the Director of Nursing (DON) and Administrator was interviewed with mainly the DON responding to questions. The DON stated they are currently following the old policy dated 04/01/09 for smoking and the new policy will not be implemented until next week. The new policy has a date of 10/25/09 which refers to the template of the new policy and was reviewed on 11/26/18 and 5/1/19. The DON stated we have no process in the old policy. In the mean time, the DON stated residents are deemed safe through observation and smoking materials are not taken away from them based on regulations that do not require them to take it away and do not need to be supervised if they are deemed safe smokers. The DON stated SW and/or Nursing are responsible for completing the smoking assessments which will identify and determine if a resident is a unsupervised or safe smoker. These assessments are done quarterly. A unsupervised/safe smoker does not need to wear a smoking apron. She further stated residents who are deemed unsupervised/safe are not monitored but the security guard can see them from the security camera. Residents are supervised and monitored for continued safety via completing smoking risk assessments and checking their clothing for burn holes. The DON stated staff were educated about smoking based on the 2009 policy and they are not aware of the new policy.
415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews during the re-certification survey, the facility did not ensure a resident's entire drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well being. Specifically, Resident #256 was prescribed Quetiapine ( a psychoactive medication used to treat psychosis, major depressive disorder) without an appropriate and clinical indication for use and documented evaluation of effectiveness, risks and benefits of the medication to the resident. The resident was admitted to the facility with diagnosis of Alzheimer's Dementia and no known past history of psychosis or use of antipsychotic medication prior to residing in the facility. This was evident in 1 of 5 residents reviewed under the unnecessary medication care area out of a final resident sample of 38 residents.
The facility's policy and procedure dated 09/07/05 revised on 2/1/10 and 1/17/17 titled Use of Psychoactive Medications documented the following. The treatment of emotional and behavioral disorder will be initiated for residents with challenging behaviors after all non-pharmaceutical approaches are exhausted.
SEROQUEL (Quetiapine) is a prescription medicine used to treat:
schizophrenia in people [AGE] years of age or older
bipolar disorder in adults, including:
depressive episodes associated with bipolar disorder
manic episodes associated with bipolar I disorder alone or with lithium or divalproex
Seroquel has a Antipsychotic Drug Black Box Warning from the FDA (Federal Drug Administration)
This is the full text of the warning:
WARNING: Increased Mortality in Elderly Patients With Dementia-Related Psychosis
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration* of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infections (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear.
The finding is:
Resident #256 was a [AGE] year old female who was initially admitted to the facility on [DATE]) with diagnoses including but not limited to Dementia and agitation. The resident did not have a diagnosis of psychosis upon admission.
The resident's history of Admission, Discharge and Transfer documented the following: resident was transferred to the hospital on 2/20/19 and was discharged on 2/26/19 and readmitted to the facility on the fourth(4th) floor unit. On 3/2/19, she was transferred to the hospital and on 3/4/19 was readmitted to the facility on the 4th floor unit. On 3/29/19, she had a room change from the 4th floor to the second floor of the same building.
The Patient Review Instrument(PRI) dated 2/26/19 documented that resident had a hospital admission on [DATE] and was discharged to the facility on 2/26/19. Diagnosis and prognosis: Pneumonia; secondary: CHF Congestive Heart Failure), A-fibb (Atrial Fibrillation), DM (Diabetes Melitus), HTN (Hypertension), CKD (Chronic Kidney disease). Discharge Information, 2/26/19: HPI and Hospital Course: 95 y.o. with a PMHx of systolic CHF, afib-rate controlled; compliant), DM and controlled HTN, CKD presents to the ED brought in by EMS from home by son and HHA for lethargy and decreased PO intake x 3days. The PRI documented that the resident had a sudden decline in mental status as is confused, decreased PO intake and was not ambulatory since 2 days. No shortness of breath at rest. The resident was prescribed Zoloft. No other antipsychotropic or antipsychotic medication prescribed. There was no diagnosis of psychosis or delirium noted.
Nursing Progress Notes on 3/2/19 Episodic Behavior Note forms documented the problem that resident presents with behaviors that are not directed towards others. It was assessed and observed with recurrent behavior symptoms which was constantly standing from chair or climbing out of bed. The evaluation note documented that behavior still present, continue to monitor for safety. Resident was up at night, refused to lay in bed despite repeated attempt and encouragement.
The PRI dated 3/12/19 documented that resident had a hospital admission on [DATE] and was discharged on 3/4/19. Primary diagnosis was Aspiration Pneumonia. Patient's Home Medications on admission: Rivaroxaban, Insulin Detemir, Simvastatin, Metoprolol Tartrate, Pantoprazole, Ferrous Sulfate, Docusate Sodium, Senna. Patient's Home Medications on discharge: Continue taking the following medication/these medications are not changed: Rivaroxaban, Metoprolol Tartrate, Pantoprazole, Insulin Detemir, Simvastatin, Ferrous Sulfate, Docusate Sodium, Senna. Start taking the new medication Levaquin, 75 mg oral tablet once a day for 1 day. The resident was not prescribed or received antipsychotic medication, there was no diagonsis of psychosis or delirium documented.
The Medical Doctor's(MD) Assessment documented on 3/29/19 documented plan of care includes wound care to continue and comfort care(DNR, DNI, DNH); no labs; documented not on any psychotropic medications. No diagnosis of psychosis.
The Physician's Medication Order for Quetiapine documented the following: 4/1/2019 Quetiapine, 25mg tablet by PO, once daily for Generalized Anxiety Disorder. 4/1/19 Consultation/Psychiatric for: resident start on Quetiapine, 25mg. The resident's Medication Administration Record documented that the resident started to receive Quetiapine on 4/1/19.
The Psychiatric assessment dated :4/2/2019 documented that the reason for consult is to evaluate for behaviors and management. The psychiatrist documented in the Psychiatric Consultation form history of dementia with episodic verbal outbursts. Seroquel started in CHHC. History of present illness included no depressed mood, no psychotic symptoms, no suicidal ideas, no sleep disturbance and no appetite disturbance Resident presentation is suggestive of delirium, psychomotor agitation/impulsive aggressive behavior, aggressive or resistive to care. Current psychotropic medications: Seroquel, 25 mg PO, qt daily(not indicated for GAD, but for delirium). Mental status examination documented she is alert, oriented x 1, neutral mood, no feelings of helplessness of hopelessness, no hallucinations or delusions, recent and remote memory not intact, language function not intact with impaired insight and judgment. Diagnoses: Delirium and Dementia Alzheimer's type. Plan/Recommendations: continue Seroquel, 25 mg PO daily for delirium. A second assessment dated [DATE]: follow - up after starting Seroquel/Quetiapine. Problem list: Dementia, Agitation/leg edema Plan: feeling better with Seroquel, HS and sleeping better. (Pharmacology use: Schizophrenia, bipolar disorder and depression).
The Medication Record Review(MRR) dated 4/2/19 for the resident documented that resident was recently
admitted on Quetiapine/Seroquel with no clear diagnosis to support current use. Please consider obtaining a psychosocial workup as soon as possible to assess for underlying causes of behaviors. Should the workups and nursing behavioral monitoring reveal no significant behaviors or identification of a chronic psychiatric condition, please consider implementing a tapering schedule and or discontinue. On 4/3/2019, the physician's response to the pharmacist review was a Psychiatrist consult. there was no other note from the physician.
MRR dated 4/24/19 documented that no recommendations made.
On 05/07/19 at 11:56 AM the SA observed resident #256 sleeping in her room. On 05/08/19 at 11:14 AM, resident #256 was observed on continuous oxygen therapy. On 05/08/19 at 01:15 PM the resident was observed sleeping. On 05/10/19 at 10:05 AM the resident was observed in bed with oxygen on. Resident was alert but screaming unintelligible words.
The Minimum Data Set (MDS) admission assessment dated [DATE] was reviewed and documented the following. Resident #256 had adequate hearing, clear speech, highly impaired vision, unable to complete the interview with no acute mental status change/no signs and symptoms of delirium, unable to complete the mood interview. No rejection of care exhibited. She is total dependent with two-person assist on bed mobility and transfer, total dependence with one-person assist on eating and toilet use. No diagnosis of any Psychiatric or Mood Disorder noted.
No signs or symptoms of delirium noted.
Comprehensive Care Plan (CCP) dated 4/7/19 had a focus on Psychotropic/Psychoactive Drug Use. The documented goal was that resident will be on the lowest therapeutic dose of psychotropic/psychoactive medication. Resident will maximize his/her functional potential and well-being while minimizing us of medication and side effect. Intervention: always inform MD if behavior insist; attempt psychotropic/psychoactive medication dosage elimination; encourage to verbalize thoughts, fears and concerns. Monitor for changes in behavior and mood, side effects.
CCP dated 4/3/19 Focus on Comfort Care. Goal: Res/Family wishes regarding end of life care will be honored. Residents physical, psychological and spiritual needs will be met. Intervention: Maintain supportive environment for Res, family, significant other. Provide food preferences and nutritional supplements as needed. Offer fluids and nutritional support. Provide spiritual/emotional support to Res / family through counseling.
Medical Doctor notes On 4/8/19: follow-up after starting Seroquel/Quetiapine. On physical examination, it was documented no edema, non tender extremities. The problem list documented Dementia, Agitation/leg edema Plan: feeling better with Seroquel, HS and sleeping better.
The physician notes documented on 4/17/19 Quetiapine, 25mg tab, PO once daily due to know physiological. 4/24/19 Consult/Psychiatric: resident start on Quetiapine, 25mg. 4/24/19 renewal Quetiapine, 25mg tablet.
The resident's MAR for April documented that the resident received Quetiapine 25mg at 9 PM daily from 4/17/19-4/30/19.
On 05/13/19 at 09:15 AM LPN #1 was interviewed. She stated that the family decided to keep her on palliative care. The resident was on pain medication, Zinc and Vitamin C. Quetiapine was discontinued as per family request since she was sleeping most of the day. LPN said she called the doctor but cannot recall when. LPN #1 checked the MAR and the last time she received Quetiapine was on 5/10/19 at 9pm. It was not discontinued by the Doctor. There was no documentation why it was not discontinued. She started on Quetiapine on 4/1/19 and a consult was put in for the psychiatrist. From the hospital, resident was on Xanax and the son, too, said that she was on Xanax. But MD#7 said no to the Xanax but put on Quetiapine instead(no rationale was documented). The Quetiapine was ordered the same day of the psychiatric consult.
On 05/13/19 at 11:18 AM MD#1 was interviewed. The resident gets Xanax and Quetiapine prior to admission. Due to numerous medications, the son agreed to comfort care/ palliative care for less agitation, pain, depression and lastly, recently she cannot take the medications orally . Pain medications include Tramadol, fentanyl patch, morphine ER. Seroquel helped her for agitation and depression. There was a psychiatric consult and the psychiatrist did not say no to Seroquel of 25 mg dose of Seroquel which is the lowest dose, well-manageable, and since the resident's son is very involved, he did not receive any calls from son.
On 05/14/19 at 03:19 PM RN#1 was interviewed. She stated that Resident # 256 was readmitted by RN #2 on 3/29/19 to this unit from the hospital due to advance directive of comfort - DNI, DNR, DNH signed by the son.
She was admitted on Seroquel, 25mg, PO at HS on 4/2/19 by MD#2. From the day of admission, she was on Seroquel, 25 mg at HS. Resident was not refusing the oral medication but she was unable to swallow. Since Seroquel is in tablet form, the route of administration, as I see them do it is, the LPNs crushed the meds and mixed it with applesauce as per recommendation on the Speech Evaluation on 4/1/2019 that resident's consistency is Puree. On 4/18/19, due to diarrhea, the MD discontinued Senna and Lactulose, put Colace on hold but, did not discontinue all medications. She is on Seroquel as per MD's order and MD#2 agreed to continue her on Seroquel due to delirium. RN stated that resident's signs of delirium included mood/behavior such as agitation, screaming without apparent reason and episodic verbal outburst. Interventions done by staff included trying to hold her on the shoulder to calm her, and talk to her; she also has a private health aide. The health aide has been with her for 6 years now. RN said that Seroquel is a psychotropic drug. This medication is used in the facility on a case-to-case basis.
On 05/14/19 at 03:48 PM MD#2 was called on his cellphone by RN#1 using her cellphone. State Agency(SA) explained to him the reason for the call. RN#1 read out to him his psychiatric consult of 4/2/19. readmission date of 3/29/19. MD#2 immediately stated that the first(1st) medication error regarding the use of Seroquel for resident #256 was that the Seroquel was started at the hospital and not at the facility for delirium. The second(2nd) error was that the signs and symptoms of delirium was checked on the consult as no. Yes should have been checked. The management of delirium is relatively short - term, and should not be more three(3) months, that is, my general practice which is consistent with the general practice in psychiatry. He also checks with Nurses, and if the residents are adjusting well, the antipsychotic medication will be discontinued. The resident is impulsive, restless and agitated. If we see she has a very stable behavior, we would discontinue it early on. Seroquel was continued, and her comfort level is improving. He stated, too, that he was continuing the care from the hospital. He stated that Seroquel is an antipsychotic medication. Seroquel is given in geriatrics with delirium in small dose. Delirium in geriatrics may present as being quiet, psychologically distressed or with psychotic syndrome. Regarding black -boxed warning, he said there is no approved Food and Drug Administration medication for delirium. MD#2 is aware of the black-boxed warning. Antipsychotic medications carry a black-boxed warning when it's used to treat dementia - related behavior or psychosis. Some people develop psychosis in dementia. Throughout the presence of dementia, occurrence of psychosis is quite common. However, it is not always treated with antipsychotic medications. Most of this presentation could be treated with behavior interventions and comfort care. Because we did not start the use of Seroquel, we just want to continue until she is comfortably adjusting. Total length of treatment with Seroquel would only be a few weeks, generally speaking, about 4-10 weeks. Delirium can be caused by her underlying medical problem. In my notes, I could have listed her medical diagnoses, the main reason why she has delirium. The medical conditions in older people are infections, any kind of fracture, hospitalization itself and the medications themselves contribute to delirium. Resident with delirium are more vulnerable to develop dementia. I don't recall having spoken to the son, but as a standard process, I do contact the family. The physicians assess the residents as they come in, There is no assistant to assist him and he is available 24 hours a day /7 days a week. If he goes on vacation, there will be another psychiatrist to cover for him.
The resident expired in the facility on 5/11/19.
415.18(c)(1).

Based on observations, record review and staff interviews during the re-certification survey, the facility did not ensure food was handled under sanitary conditions. Specifically, (1) a food service worker did not have on gloves before touching raw food (2) a food service worker did not have on gloves before covering a pan of cooked baked chicken with aluminum foil after touching the lid of a garbage can and (3) a food service worker did not wear a hairnet during the entire lunch meal service on one of the unit's dining room. This pattern of deficient practice was evident during the kitchen and dining facility tasks of the re-certification survey.
The finding is.
The facility's policy and procedure titled Proper Use of Gloves documented that disposable gloves should be discarded after a specific task. The policy and procedure titled Personal Hygiene documented wear a hairnet, hat or hair coverings while on duty to confine hair.
On 05/09/19 at 11:08 AM, [NAME] #1 was observed using an uncovered round, gray garbage can with wheels to discard the plastic wraps of 8 rolls of a ten(10) pound (lb) raw ground beef which were individually wrapped. The ground beef were on a food push cart which was situated next to the steam kettle. The uncovered garbage can was next to the food cart. He slit open the plastic wrap open in the middle with a knife. He then puts the raw ground beef into the industrial-type steam kettle. He discards the plastic wrap into the uncovered garbage can. He stated that he is putting the raw ground beef in a kettle so he could partially removed the blood by draining with water. Approximately after opening the 4th of the 5th the plastic bag, he rinsed the knife in the sink, pushed the uncovered plastic, gray garbage can with his gloved hand, holding the top of the lined garbage can with his gloved hand to the side of the kettle. He continued slitting the remaining rolled, plastic-wrapped raw ground beef and putting the rest of the ground beef in the kettle.
On 05/09/19 at 11:18 AM, another garbage can with no lid was observed in the other section of the cook's area where thawed fish was being seasoned for the night's dinner.
On 05/09/19 at 02:38 PM, [NAME] #2 was observed at his cook's table, threw out something in the garbage can which was covered and lifted the lid with his bare hand. Then he went back to his working table where he was covering baked chicken in a quarter pan, and covered the pan of chicken with an aluminum foil [NAME] did not wash his hands or donned gloves before touching the aluminum .
On 05/09/19 at 02:53 PM, [NAME] #1 was interviewed regarding the garbage can that has no lid and was pushed to the side on 05/09/19 11:08 AM. He stated that there was no lid that morning, it could have been behind it. He stated that the proper procedure for the use of gloves is that he will put his gloves on and put the paper inside the garbage can, then throw out the gloves, wash the hands and dry them good before touching the aluminum foil to cover the chicken(baked) in a quarter pan. There is a possibility of bacteria contamination and possibly people will get sick eating the contaminated food. We get in-service on the wearing gloves, how to sanitize equipment, how to clean his knives and handling meats.
On 05/09/19 at 03:02 PM, [NAME] #2 was interviewed. He stated that there are two( 2 )big cans by the cook's area. The garbage cans must be covered at all times, basically for contamination reason and odors. The person who eats contaminated food may end up sick and might end up in the hospital. The garbage receptacles, the gray ones, which you need to lift the cover to throw out something. The lid is still contaminated so they need to use gloves. Most of the time, the cooks need to wear gloves, especially when handling meat. The cooks are not supposed to lift the lid with bare hands and touch any food because of cross-contamination when preparing food and feeding residents.
On 05/09/19 at 03:12 PM, the Food Service Director(FSD) was interviewed. She stated that lifting the lids with bare hands, and then touching the food will result in food becoming contaminated(cross contamination). NYS laws state that you cannot use bare hands while preparing and cooking food.
On 05/09/19 at 12:40 PM Dietary Aide(DA) was observed serving the soup in the dining room of one of the units. She was not wearing a hairnet although wearing disposable gloves. On 05/09/19 at 12:43 PM Staff was asked if she was wearing a hair net and she stated she is not wearing a hairnet. She forgot to put on one.
On 05/09/19 at 02:44 PM DA was interviewed. She said you need to wear a hairnet so food will be healthy. She stated that there is no bacteria in her hair since the hair was pulled very tight away from her face. She also stated that if there is hair on the food, the food will be nasty, there will be bacteria and it is not healthy. The people who eats them may feel disgusted and, not healthy. She said she had in-service, this is the first time it happened, and never happened to her.
On 05/09/19 at 03:12 PM, FSD was interviewed. Dietary aides on the floors who dishes out the meals for the Residents are all required to wear a hairnet when serving the food. It's basic food safety, prevention of cross - contamination and prevention of food - borne illness. Food safety also includes washing hands, wearing hairnets/beard guards.
415.4(h)

Based on observations, record review, and staff interviews during the re-certification survey, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, garbage receptacles filled with refuse and not currently being used were not covered. The State Agency Surveyor (SA) observed two (2) gray, round, garbage receptacles on wheels, filled with garbage uncovered in the cook's area in the kitchen. This was observed during the initial tour of the kitchen.
The finding is.
The facility's policy and procedure titled Garbage Pails and Cans (Dated 06/14) documented garbage cans are covered with lids to be used for next scheduled meal.
On 05/07/19 at 10:03 AM, one (1) round, gray garbage receptacle with wheels was observed in the cook's area with no lid.
On 05/07/19 at 12:15 PM, the garbage receptacle in the dining room on the second floor was not covered. It was half-filled with left-over food.
On 05/07/19 at 12:32 PM, the garbage can in the dining room on the second floor was still not covered.
On 05/08/19 at 11:56 AM, on the second floor dining room, the round, gray garbage receptacle was not covered. The receptacle is three-quarters (3/4) full with left-over bread, disposable spoon and paper. It was located between the microwave oven and by soiled dishes truck which was put in the soiled dishes bin.
On 05/09/19 at 11:18 AM, another garbage can with no lid was observed in the other section of the cook's area where thawed fish was being seasoned for the night's dinner.
On 05/08/19 at 11:58 AM, CNA #3 was interviewed. She said that housekeeping maintains the garbage can on the floors. It is usually covered and the lid is in the back of the can. She put the lid on the garbage can. She said she cannot leave the garbage can uncovered because of infection control.
On 05/09/19 at 02:53 PM, [NAME] #1 was interviewed regarding the garbage can in the kitchen that has no lid and that he pushed to the side on 05/09/19 at 11:08 AM. He stated that there was no lid that morning, it could have been behind it.
On 05/09/19 at 03:02 PM, [NAME] #2 was interviewed and stated that there are two (2) big garbage cans by the cook's area. He stated that the garbage cans must be covered at all times. Basically for contamination reason and odors, the garbage cans must be covered. The person eats contaminated food may get sick and might end up in the hospital.
05/09/19 03:12 PM, the Food Service Director was interviewed. The garbage cans in the kitchen and on the floors must be covered at all times.
415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life. Specifically, a resident was observed on two different occasions with crumbs, food debris, and wet spill stains on their clothing. This was evident for 1 resident reviewed for Dignity (Resident #296).
The finding is:
The facility admission agreement documented residents are provided with assistance and/or supervision, when required, with activities of daily living (ADLs) under the basic daily rate.
The facility policy on AM care /PM care, revised on 12/1/2014, documented: AM care begins at 5:00 AM and PM care begins at 6:30 PM. All residents unable to care for themselves are provided total care. The purpose is to refresh the resident, maintain cleanliness, comfort and neatness.
Resident #296 was admitted to the facility with diagnoses which include Hypertension , Peripheral Vascular Disease , Non- Alzheimer's dementia , and Depression.
The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and was rarely understood. The resident required the extensive assist of one person with dressing and hygiene, and the resident was able to feed herself after set-up assistance.
On 05/07/2019 at 11:20 AM, during the initial tour of the unit, the resident was observed wearing a hospital gown covered with crumbs and pieces of food debris. The resident's breakfast tray was still on the table in front of her.
On 05/13/2019 at 2:34 PM, the resident was observed seated in her geri chair in the entrance of her room dressed in a gray T-shirt and sweat pants. The T-shirt was wet from the neck down, and there were food particles on the chest area and the resident's mouth. The State Agent (SA) could smell the scent of the food that was eaten for lunch on the resident. Lunch was served at 12:00 PM and completed at 1:00 PM.
The Comprehensive Care Plan (CCP) for ADLs documented the resident had self-care deficits related to impaired cognition and dementia. The CCP goals for 90 days were to have ADL and personal needs met, for resident to be clean and odor free daily, and for resident to be appropriately dressed and groomed daily. The interventions included assist with dressing needs and provide AM and PM care.
On 05/13/2019 at 2:35 PM, the Certified Nursing Assistant (CNA) assigned to the resident was interviewed. The CNA stated that she assisted the resident with setting up the meal tray, but she did not remove the resident's meal after she finished the meal. She stated that someone else assisted her because she was attending to another resident.
On 5/13/19 the unit charge Registered Nurse was also interviewed. She stated that the staff should be on top of this.
415.3 (c0(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not ensure that residents consistently received quarterly statements for their personal funds accounts. Specifically, a resident had not received a written quarterly statement since admission. This was evident for 1 of 2 residents reviewed for Personal Funds (Resident #322).
The finding is:
The facility policy on Resident Funds Management, revised 10/06 documented: Quarterly statements detailing all transactions on the account will be provided to the resident on a quarterly basis. Requests for statements at other times will be accommodated on an individual basis. The policy documented quarterly statements are part of the procedures for the finance office / resident account clerk.
Resident #322 was admitted to the facility 12/17/18 with diagnoses which include Hypertension, Diabetes Mellitus, and Non- Alzheimer's dementia.
The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition.
On 05/10/2019 at 12:15 PM, the resident was interviewed. The resident stated she has a personal account and receives fifty dollars ($50.00) per month. The resident also stated that she never received a written financial statement for her account.
On 05/14/2019 at 12:00 PM, the unit Social Worker (SW #1) was interviewed regarding the resident's personal funds and statement. She stated financial statements should be given on a quarterly basis, and if the resident is cognitively impaired, it is mailed to the family or next of kin. SW #1 stated that she mailed the quarterly statement to the resident's brother. She stated she is now aware that she should have given it to the resident, but she does tell the resident how much money is in the account when asked.
On 05/14/19 at 03:04 PM, the facility Administrator #2 provided the facility policy and was interviewed. He stated the facility outsources the management of the resident personal funds accounts to an outside company. The company is responsible for mailing all the quarterly statements to the last known address of the residents or the next of kin for all residents, including those who are alert and oriented. A copy of the statements comes to the facility, and the social workers are responsible for delivering them to the residents. The Administrator was not sure which address was provided to the company from the residents' facesheets. He stated that they do not receive a lot of statements back due to the address being unknown.
415.26(h)(5)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the recertification survey, the facility did not ensure that residents and/or families were informed and provided with written information concerning the right to formulate and advance directive. Specifically, advance directives were not explained to or discussed with a cognitively intact resident. This was evident for 1 of 1 resident reviewed for Advance Directives (Resident #322).
The finding is:
The facility policy on advance directives, revised 04/16/2018, documented the facility shall inform and support residents and/or their designated representatives of their right to formulate advance directives. The purpose of the policy is to ensure that all residents are informed and supported to exercise the right to formulate written or oral instructions regarding their health care in the event they become incapacitated and or are unable to direct their own care.
Resident #322 was admitted to the facility 12/17/18 with diagnoses which include: Hypertension, Diabetes Mellitus, and Non- Alzheimer's Dementia.
The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The assessment further documented the resident was able to make needs known. The resident was independent with most activities of daily living.
On 05/13/2019 at 11:20 AM, the resident was observed and interviewed in her room. The resident was well-groomed, appropriately dressed, and seated in her bed watching TV. The resident did not know what advance directives were when asked about them. The State Agent (SA) explained what an advance directive is to the resident. The resident responded, It has not been discussed with me, and I don't know what it is.
The Comprehensive Care Plan (CCP) for Advance Directives documented the resident has an involved family, and the resident does not have advance directives. The CCP goal is that resident /representative / legal guardian will be provided education regarding advance directives upon admission and during their stay in the facility. The CCP documented the following interventions: assess resident's capacity/cognitive ability as needed; discuss and review materials with the resident/ family/ legal representative to clarify understanding of advanced directives; document no DNR (Do Not Resuscitate) status; educate the resident/family regarding advance directives upon admission and periodically as indicated.
The Social Work admission Assessment Note dated 12/24/2018 documented the resident had no advanced directives at the time. The note further documented the resident had intact cognition and decision making capacity. The resident was able to make simple decisions but needed assistance in care planning and discharge planning.
The Social Work Note dated 03/28/2019 documented there were no changes to advance directives during the review period.
On 05/13/2019 at 11:36 AM, the Social Worker (SW #1) was interviewed. The SW stated she has not discussed advance directives with either the resident or her brother. She further stated that she has had multiple conversations with the brother on the phone. When asked if information about advance directives was mailed to the brother, the SW stated she would have to review her notes.
415.3(e)(1)(ii)