Preview
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023
Exhibit D
4
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
NYS Health Profiles
NYSCEF w
DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023
RK Department
ATE of Health Find and Compare New York Health Care Providers
Buffalo Center for Rehabilitation and Nursing
April 8, 2022 Certification/complaint Survey
Standard Health Citations
FF11 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS
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REGULATION: §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the
necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2022
Corrected date: June 1, 2022
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023
Citation Details Plan of Correction: ApprovedMay 4, 2022
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED Fingernail care was provided to resident # 92 0n
TO PROTECT CONFIDENTIALITY** Based on 4/8/22. Resident # 155 was seen by podiatrist on
observation, record review, and interview conducted 4/7/22 and refused services despite health teaching.
during a Standard survey started on 4/4/22 and Facility will reapproach resident to attempt toenail
completed on 4/8/22, the facility did not ensure that care/trimming. The responsible party (daughter) for
residents who are unable to carry out activities of daily resident # 155 was notified of resident refusals for
living (ADL's) receive the necessary services to podiatry. Arrangements are being made for daughter to
maintain grooming and personal hygiene. Specifically, attend next scheduled podiatry visit which will hopefully
two (Resident #92 and Resident #155) of six residents increase compliance of resident. The UM responsible
reviewed for ADL's had issues with long dirty fingernails for referral to podiatry for resident # 155 is no longer
(#92), and toenails that were long and curled inward employed at facility. The DON at the time of resident
(#155). Additionally, the lack of follow up regarding a #155 grievance was counseled by the Regional RN
family request for a podiatry visit in (MONTH) 2022 regarding need to ensure that referrals to podiatry are
(#155). The findings are: A review of the policy and completed as indicated. There were no adverse effects
procedure (P&P) titled ADL- Nail Care dated 3/2021 to either resident noted from the lack of timely ADL
documented that nail care includes daily cleaning and care. All aides and licensed nurses caring for resident?
regular trimming. Proper nail care can aid in the ÇÖs # 92 and # 155 on the dates identified in the SOD
prevention of skin problems around the nail bed and were counseled by the DON/designee regarding
trimmed and smooth nails prevent the resident from appropriate ADL care and subsequent documentation
accidentally scratching and injuring their skin. The P&P including refusals of care if indicated. All residents have
documented residents' will be referred to the Podiatrist the potential to be affected by the deficient practice. A
based on assessment of the resident's toenails by full house review of all residents will be conducted by
nursing staff and the physician; and the podiatrists will the Unit Managers/ designees. This review will ensure
evaluate, and trim resident toenails based off the that all residents have appropriate ADL/hygiene care
physician order. A review of the P&P titled ADL - including fingernail and toenail care. Issues noted will
Personal Hygiene dated 10/2021 documented that nail be immediately addressed. In addition, any residents
care should be provided as needed for the resident and needing podiatry services will be referred as indicated.
that residents with certain medical conditions will Policies for ADL Personal Hygiene and ADL nail care
require a licensed professional to perform. Further were reviewed by the Regional RN with no revisions
review of the P&P documented that staff should review required. Nursing staff and facility leadership will be
the resident's care plan and Certified Nurse Aide (CNA) educated by the RN Regional Nurse/ designee
Visual/Bedside Kardex Report for any special care or regarding ADL care for residents. Emphasis will be
needs of the individual resident. 1. Resident #92 was placed on nail care. Education will include process for
admitted to the facility with [DIAGNOSES REDACTED]. referral to podiatry services; CNA staff will report any
The Minimum Data Set (MDS - a resident assessment referrals to the UM who will notify the Medical Records
tool) dated 2/18/22 documented Resident #92 was clerk in writing via email. The Medical Records clerk is
moderately cognitively impaired and required extensive the point of contact for Podiatry and coordinates
assist of two persons for personal hygiene. The Podiatry visits. A weekly audit will be conducted by the
Comprehensive Care Plan (CCP) dated 4/16/21 Unit Managers; ten residents from each unit will be
documented that Resident #92 was an extensive staff audited for a period of 12 weeks. The audit will include
assist for personal hygiene. The CNA Visual/Bedside fingernail and toenail care, and overall hygiene. Any
Kardex Report (guide used by staff to provide care) issues identified will be immediately addressed. The
dated 4/7/22 documented Resident #92 required Regional RN will review these audits weekly and
extensive staff assist to perform personal hygiene. provide input as needed. Podiatry visit list will be
During an observation on 4/4/22 at 1:31 PM revealed reviewed monthly by the QAPI Committee to ensure
Resident #92's fingernails were ?? inch to ?½ inch long compliance with the podiatrist referral process. Results
with brown debris underneath. An observation on of the audits will also be reviewed with the QAPI
4/7/22 at 9:38 AM revealed that the resident's left Committee for input. The QAPI Committee will then
thumbnail was ?½ inch long with brown debris determine if further audits are needed. Responsibility:
underneath; the rest of the fingernails on the left hand DON
were between ?? inch to ?½ inch long and dirty with
brown debris. The fingernails on the right hand were ??
inch to ?½ inch long and dirty with brown debris
underneath. During an interview on 4/7/22 at 9:49 AM,
CNA #2 and CNA #3, stated that Resident #92's nails
were long, and they needed to be trimmed. CNA #2
further stated that the resident will scratch themselves
in certain areas and accumulate brown debris
underneath their nails. During an interview on 4/7/22 at
9:52 AM, Licensed Practical Nurse (LPN) #2 stated
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
Resident
NYSCEF #92's
DOC. NO.nails
697were long and needed to be RECEIVED NYSCEF: 07/09/2023
trimmed. During an interview on 4/7/22 at 10:00 AM,
Registered Nurse (RN) #1 Unit Manager stated they
expect staff to trim the residents' nails if the resident is
not a diabetic and to clean them. RN #1 also stated that
they have wooden orange sticks (a manicure tool that
can remove dirt underneath fingernails) available.
During an interview on 4/8/22 at 9:30 AM, the Director
of Nursing (DON) stated they expect staff to trim
fingernails at least every two weeks and to make sure
that the nails are clean. The DON also stated that
unless the resident is a diabetic or has another medical
condition, the CNA's can trim fingernails. 2. Resident
#155 was admitted to the facility with [DIAGNOSES
REDACTED]. The MDS dated [DATE] revealed the
resident was severely cognitively impaired. The
Comprehensive Care Plan (CCP) dated 4/21/22
documented the resident requires physical assist of
one person for all ADL's. Review of a Grievance Form
and attached documents dated 2/3/22 documented a
family member of Resident #155 reported a concern
regarding grossly overgrown toe nails and requested
that Resident #155 be seen by the podiatrist. Review of
a Progress Note dated 2/8/22 at 9:34 AM documented
the intradisciplinary team spoke with the daughter over
the phone and Resident #155 was to be placed on the
podiatry list to have their toenails cut. Review of the
Podiatry list dated 2/18/22 revealed there was no
documented evidence Resident #155 was added to the
list or seen by podiatry as requested. During an
observation on 4/7/22 at 9:09 AM CNA #3 removed the
nonskid sock from Resident #155's right foot. The
resident's toenails were long and curled inward over the
top of the first toe, the other toe nails were
approximately one inch long, thick and appeared fungal
looking. Review of the Progress Notes and
miscellaneous section of the electronic medical record
(EMR) from 2/8/22 through 4/8/22 revealed there was
no documented evidence Resident #155 was seen by
the podiatrist. During an interview on 4/7/22 at 9:14 AM,
CNA #3 stated Resident #155 was usually combative
with hands on care, most of the time refuses shower
and it was very difficult to cut their nails, staff have to
catch Resident #155 at the right moment. During a
phone interview on 4/7/22 at 10:21 AM, the Podiatry
Office Manager stated the facility sends an email if a
resident needed to be added to the list. The interview
further revealed there was no request submitted by the
facility for Resident #155 to be added to the list in
February. During an interview on 4/7/22 at 10:47 AM,
RN #1 Unit Manager stated residents were to be seen
by the podiatrist on a routine bases. If a resident
needed to be added to list we let medical records know
and the resident gets added. If a resident refused and
was not seen for some other reason they will not be
seen until the next scheduled visit. Resident #155
should have been seen in February. During an
interview on 4/8/22 at 12:32 PM, the Regional Director
of Nursing stated the unit manager would be
responsible for making sure the appointment was
scheduled for the podiatrist. 415.12(a)(3)
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023
FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY
REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from
sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food
items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This
provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to
compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude
residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve
food in accordance with professional standards for food service safety.
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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2022
Corrected date: June 1, 2022
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023
Citation Details Plan of Correction: ApprovedApril 29, 2022
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED
TO PROTECT CONFIDENTIALITY** Based on TO PROTECT CONFIDENTIALITY** All food
observation, interview, and record review conducted equipment has been cleaned thoroughly including the
during a Standard survey completed [DATE] through floors. All expired food were disposed. Storage
[DATE], the facility did not store, serve and distribute containers were replaced and dated Outed temperature
food in accordance with professional standards for food logs were replaced and updated. The Food Service
service safety. Specifically, one of one main kitchen had Department sanitation audit was conducted to identify
issues with unclean equipment and floors, areas of concerns. Kitchen staff cleaning assignments
outdated/undated food items and lack of documented have been established. A deep cleaning of the kitchen
walk-in refrigerator and freezer temperatures. The floor will be completed by [DATE] by the Housekeeping
finding is: Review of a policy and procedure (P&P) titled Department. All food service personnel have been
Food and Nutrition Services dated ,[DATE] documented educated in proper food handling, storage, sanitation,
high standards of cleanliness and sanitation will be cleaning sanitizing, food temperatures and daily
defined and maintained. Cleaning is the use of water, cleaning assignments A daily audit will be completed on
chemicals, and elbow grease to remove all food and all refrigerated areas by the Supervisors/Designees to
debris from equipment and work surfaces. Food assure areas are clean, free of debris and
contact surfaces need to be cleaned and sanitized. food/beverages are properly stored, labeled and dated.
Production, storage, and service equipment are A Food Service Department sanitation audit will be
cleaned and sanitized as required and recommend by completed two times weekly x 6 months than monthly
the manufacture. There were no P&P provided as x2 months. The Administrator will review the audits
requested regarding labeling and dating of food items. weekly monthly x 6 months than monthly thereafter to
1. During an observation of the main kitchen on [DATE] assure compliance. Additionally, the
at 8:31 AM revealed: -The slicer and surrounding table Administrator/Designee will do a random visual audit of
were soiled with smudges and greasy food debris. - the kitchen round monthly x 6. The audits will be
Stored on the wire shelf next to the manual sink there submitted to the QAPI committee at the monthly QAPI
was an open bottle of dill weed spice dated [DATE], meeting for review. The responsible party is the
that expired [DATE] and an opened undated 32-ounce Administrator.
bag of chocolate chips. - The walk-in freezer floor was
covered with frozen green peas and the walk-in cooler
and freezer doors had temperature logs in clear plastic
sheaths dated for (MONTH) 2022. - The rice, flour, and
sugar containers stored on the bottom shelf across
from the stove were undated, and the rice container
was uncovered. The top shelf prep area was dirty with
large amounts of moist and dried food debris. - The
toaster next to the coffee station was dirty and had a
large amount of brown/tan crumb like food debris
covering the internal compartment under the rotating
rack. -The six-burner stove top was dirty and had tan
dried, peeling food debris covering four of the burners. -
The stand-up cooler next to the ice machine
contained/stored six undated meat and cheese
sandwiches. - The kitchen floor was dirty with dried
food debris throughout. At the time of the observations
there were three dietary staff members on tray line and
there were no other staff or managers available. During
an interview on [DATE] at 9:25 AM, the Administrator
stated the Registered Dietitian (RD)/Food Service
Director (FSD) #1 from their sister facility should be in
soon as they have been covering at this facility a few
days a week. During additional observations of the
main kitchen on [DATE] at 10:20 AM and 12:04 PM
revealed the items listed above from the previous
observations at 8:31 AM remained unchanged. During
an interview on [DATE] at 10:41 AM, with the covering
Registered Dietitian (RD)/Food Service Director (FSD)
#1 stated the FSD walked out last Thursday and they
have been helping a couple days a week. The RD/FSD
#1 also stated when they walked into the kitchen that
the kitchen needed a thorough cleaning. During an
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
observation
NYSCEF DOC. of
NO.the697
main kitchen on [DATE] at 8:03 AM RECEIVED NYSCEF: 07/09/2023
revealed: - The open bottle of Dill Weed spice dated
[DATE] expired [DATE] and the undated and opened
32-ounce bag of chocolate chips, remained stored on
the wire shelf next to the manual sink. -The walk in
cooler and freezer doors still had the same temperature
logs dated (MONTH) 2022 and the walk-in freezer floor
was covered with frozen green peas. - The rice, flour,
and sugar containers on the bottom shelf across from
the stove remained undated and the rice container
remained uncovered. The top shelf prepping area
contained large amounts food debris. - The toaster next
to the coffee station still had a large amount of
brown/tan food debris on the internal compartment
under the rotating rack. - The kitchen floor was still dirty
with dried food debris throughout. During an interview
on [DATE] at 10:39 AM, Dietary Aide #1 stated no one
cleans the kitchen the way it should be done because
there is not enough time or staff. During an interview on
[DATE] at 11:14 AM, the Diet Technician (DT) #1 stated
the kitchen was far from perfect on what should be
done in regard to cleanliness. During an interview and
observation on [DATE] at 2:05 PM with the Regional
FSD and covering RD/FSD #1, the RD/FSD #1 stated
the toaster, slicer, stove and prepping areas should be
cleaned after each use. The stove top should be
cleaned after each meal. All spices should be dated or
discarded if expired. All prepared foods should be
labeled and dated. The peas on the freezer floor should
have been cleaned up when they were spilled and they
does not know how long the pees have been there.
Temperatures for the walk- in coolers and freezers
should be checked and documented in the morning and
when the kitchen was closed for the day. The sugar,
rice and flour bins should be dated, and the rice bin
should have a cover. The floors should be swept after
each service and moped at the end of the day.
415.14(h)
FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT
REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free
from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This
includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or
chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2022
Corrected date: June 1, 2022
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023
Citation Details Plan of Correction: ApprovedApril 29, 2022
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED Resident # 126 and # 146 were both seen and
TO PROTECT CONFIDENTIALITY** Based on assessed by RN, examined by Medical Provided and
observation, interview, and record review conducted Psychiatry Provider post incident of 4/4/22. No adverse
during a Complaint Investigation (Complaint #NY 471) effects or injuries was noted to either resident. CNA
during the Standard survey completed 4/4/22 through #13 assigned to 1:1 for resident # 126 on the dates
4/8/22, the facility did not ensure the resident's right to cited in the SOD was counseled by the Unit Nurse
be free from abuse for two (Resident # 126, 146) of Manager regarding appropriate distance when
eleven residents reviewed. Specifically, one to one providing 1 :1. All Nurses and CNA assigned on Unit 4
(1:1) supervision was not provided as planned for a at the time of the incident were re-educated regarding
resident with a history of physical aggression (#126), 1:1 supervision and keeping resident within arm?ÇÖs
resulting in resident-to-resident abuse. This involved length. All residents have the potential to be affected by
Resident (#146). The finding is: The facility policy and the deficient practice. Care Plans and Tasks for all
procedure (P&P) titled Abuse dated 2/19 documented residents on 1:1 were reviewed by IDT with no issues
the facility prohibits the mistreatment, neglect, and identified. Policies for 1:1 Supervision were reviewed
abuse of residents by anyone including staff, family, by the Regional RN; revisions were made to clarify that
friends, etc. The facility has designed and implemented 1:1 will be specified: at arms length. All Nursing staff
processes, which strive to ensure the prevention of will be educated by the RN Facility Educator on 1:1
suspected or alleged resident abuse, neglect, Supervision and clarification that 1:1 Supervision is at
mistreatment. The facility documented physical abuse arms length. Audit will be conducted by Nurse
as hitting, slapping, pinching, scratching, spitting, Managers and Nursing Supervisors. There will be 10
holding roughly, kicking, etc. The P&P titled Supervision Audits per week on random shifts for a period of 12
1:1 dated 12/21 documented the facility is to provide weeks. Audit will include Observation of residents on
the highest quality of care to our residents; by providing 1:1 supervision to ensure that staff are providing
staff with the most efficient, resident centered supervision within arms length with the resident as per
procedures for the care of our residents per Federal facility policy. Any issues noted will be immediately
and State Regulations. This includes but is not limited addressed. The DON will review these audits weekly
to, resident safety and supervision. Residents who and provide input as needed. Results of the audits will
require increased frequency of monitoring can be/will also be reviewed with the QAPI Committee for input.
be placed on 1:1. The use for 1:1 is determined Responsibility: DON
necessary when a resident's safety risk cannot be
appropriately monitored through frequent supervision or
in danger of injuring themselves or another resident.
1:1 is to be provided by one staff member sitting side
by side with the resident for a minimum of 2 hours. 1:1
may also constitute visual observation which will be
specified in the plan of care. 1. Resident #126 was
admitted to the facility with [DIAGNOSES REDACTED].
The Minimum Data Set (MDS - a resident assessment
tool) dated 12/16/21 documented Resident #126 was
moderately cognitively impaired, sometimes
understood and sometimes understands. The
Physicians Order Summary Report documented an
order dated 1/29/21 that Resident #126 was to be
provided with 1 to 1 at all times every shift for close
observation. There was no documented end date.
Resident #126's undated Visual/Bedside Kardex Report
(guide used by staff to provide care) documented under
Safety: 1:1 visual observation. Resident #126 was
independent with ambulation. The comprehensive care
plan (CCP) with an initiated date of 2/14/22
documented Resident #126 had periods of agitation,
physical aggression and history of hitting another
resident. The plan included 1 to 1 visual observation
and small group activities. Resident #146 was admitted
to the facility with [DIAGNOSES REDACTED]. The
MDS dated [DATE] documented Resident #146 was
severely cognitively impaired, was usually understood
and usually understands. Resident #146's undated
Visual/Bedside Kardex Report documented the resident
was independent for ambulation and transfers.
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
Resident
NYSCEF DOC.#146's
NO.CCP
697 plan dated 11/21/19 documented RECEIVED NYSCEF: 07/09/2023
they were at risk for being a victim due to inability to
understand surroundings related to dementia. The CCP
documented Resident #146 had been involved in
resident-to-resident altercations. Documented planned
interventions included but not limited to 1:1 visits from
all departments as needed; provide support and ensure
resident was free from abuse and resident to be offered
food and activities to keep resident occupied. Review of
the in-service and education dated 5/29/21 provided by
the facility documented when a patient is made 1:1 with
care there was to be a caregiver with that resident at all
times. During an observation on 4/4/22 at 9:20 AM,
Resident #126 was seated next to Resident #146
(within an arm's length) at a dining room table across
from the 4th floor nurse's station. Resident #146
repetitively stated Okie dokie, Okie dokie. Resident
#126 partially stood from their chair and yelled Shut up
and slapped Resident #146 on the shoulder and back.
There were three Certified Nurse Aides (CNA's) behind
the nurses' station and CNA #13 was sitting in the right
corner of the dining room [ROOM NUMBER] feet from
Resident #126. During an interview on 4/4/22 at 11:05
AM, CNA #13 stated they were the assigned 1:1 aide
for Resident #126 and needed to be within visual view,
meaning within an eyes view of the resident due to
aggressive behaviors. CNA #13 stated they were not
within an arm's reach of Resident # 126. The Facility
Full QA (quality assurance) Report provided by the
facility initiated on 4/4/22 documented the resident-to-
resident altercation was reviewed signed by the
Director of Nurses (DON) on 4/5/22. The investigation
documented a conclusion the resident-to-resident
altercation was unprovoked and witnessed.
Additionally, documented there was no abuse, neglect
or mistreatment identified. During an interview on
4/8/22 at 9:35 AM, CNA #8 stated they were not familiar
with Resident #126. When the care plan stated 1:1
supervision the CNA providing the 1:1 should be within
arm's reach of that resident. To prevent the resident
from getting agitated they would remain behind the
resident, deter any triggers, and still be close enough to
prevent the resident from harming others. During an
interview on 4/8/22 at 9:45 AM, CNA #2 stated they
were familiar with Resident #126 and Resident #126's
behaviors were sporadic and unpredictable. When a
resident was care planned for 1:1 supervision the CNA
assigned should be within an arms distance from the
resident when assisting with care or when the resident
would be in bed asleep. During an interview on 4/8/22
at 9:53 AM, Licensed Practical Nurse (LPN) #2, stated
with 1:1 supervision the staff member must be within
one arm's length away from the resident and have
visual view at all times to protect other residents on the
floor from being injured. Injuries could occur when the
assigned 1:1 aide was too far away. During an
interview on 4/8/22 at 10:06 AM, CNA #10 stated
Resident #126's behavior was unpredictable, making it
difficult to determine what could trigger an outburst. 1:1
supervision meant the aide must be with the resident at
all times within one arm's length. CNA #10 was aware
of the resident-to-resident altercation that occurred
between Resident #126 and Resident #146 on 4/4/22
and stated CNA #13 should have been seated next to
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
Resident
NYSCEF #126
DOC. at the
NO. 697table to prevent the incident from RECEIVED NYSCEF: 07/09/2023
escalating. During an interview on 4/8/22 at 11:28 AM,
Registered Nurse (RN) Educator stated Resident #126
required 1:1 supervision. The staff member assigned
shouldn't be too close where the resident could throw
something, or they could irritate the resident. Typically,
the staff were told to manage residents with aggressive
behaviors by staying two arms lengths away. Twenty
feet away was too far and would not prevent a resident-
to-resident altercation. The RN Nurse Educator stated
CNA #13 should have been two arm's lengths away
and may have prevented Resident #126 from making
physical contact with Resident #146. During an
interview on 4/8/22 at 11:34 AM, CNA #13 stated they
didn't think they were too far away but may have
prevented the altercation if they were seated next to
Resident #126 or moved them to a different table. I
didn't expect it and was unaware their behavior was so
unpredictable. During an interview on 4/8/22 at 11:51
AM, RN #1 Unit Manager (UM), stated staff assigned to
1:1 supervision was instructed to remain close, just
outside of an arm's length away from Resident #126.
The CCP didn't specify the required distanced and
should have. RN #1 UM stated they were off the floor at
the time of the incident on 4/4/22 but was told Resident
#126 was unprovoked, reached over the table and hit
Resident #146 in the shoulder and then on the back.
RN #1 UM stated the 1:1 aide seated and observed 20
feet away was too far away to effectively intervene. RN
#1 UM would have expected CNA #13 to intervene to
prevent escalation and the abuse from occurring.
During an interview on 4/8/22 at 12:16 PM, the DON
stated the policy, and the care plan were not specific of
how close the 1:1 aide needed to be and it should be.
During an interview on 4/8/22 at 12:22 PM, the
Regional DON stated the facility policy, and care plan
doesn't indicate the specific footage of what visual 1:1
should be. We need to be reasonable to the relation to
where Resident #126 is, what was occurring at the
time, and location of the other residents. With the
obvious agitation of Resident #146, I would have
expected CNA #13 to intervene quickly and redirect
Resident #146 away from Resident #126 to prevent the
escalated agitation. 1:1 supervision was implemented
for Resident #126 to protect other residents. The
Regional DON stated CNA #13 should have been with
in an arm's reach and was too far away. During an
interview on 4/8/22 at 1:23 PM, the Administrator stated
Resident #126 had unpredictable aggressive behaviors
directed towards others. 1:1 supervision was put in
place for the safety of other residents and meant staff
should be close enough to intervene to prevent
incidents. I would have expected CNA #13 to have
been seated with in an arm's length to Resident #126 in
the dining area to prevent the physical abuse. 415.4(b)
(1)(i)
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023
FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL
REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and
control program designed to provide a safe, sanitary and comfortable environment and to help prevent the
development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and
control program. The facility must establish an infection prevention and control program (IPCP) that must
include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting,
investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors,
and other individuals providing services under a contractual arrangement based upon the facility assessment
conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards,
policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance
designed to identify possible communicable diseases or infections before they can spread to other persons in
the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and
how isolation should be used for a resident; including but not limited to: (A) The type and duration of the
isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation
should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under
which the facility must prohibit employees with a communicable disease or infected skin lesions from direct
contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene
procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording
incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f)
_______
~---- ......................... ________
......................... _______
......................... .........................________
Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.
......................... _______
, ...................................
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2022
Corrected date: June 1, 2022
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023
Citation Details Plan of Correction: ApprovedMay 2, 2022
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED Resident?ÇÖs # 7, 30 and 32 remain in the facility in
TO PROTECT CONFIDENTIALITY** Based on stable condition. There were no adverse effects noted
observation, interview and record review conducted related to improper glucometer cleansing. LPNs # 12
during the Standard survey completed 4/4/22 through and 6 were counseled by the DON regarding correct
4/8/22, the facility did not establish and maintained an infection control protocols when cleansing glucometers
infection prevention and control program designed to between resident use. All residents have the potential
provide a safe, sanitary and comfortable environment to be affected. A full house review of all residents
and to help prevent the development and transmission receiving blood glucose checks will be conducted by
of communicable diseases and infections for two (3rd the UMs/designees. This review will ensure that all
&4th floor) of three resident floors. Specifically, nursing Units are cleansing and disinfecting glucometers
staff did not properly clean and disinfect shared between resident use as per manufacturer?ÇÖs
glucose meters between resident use in accordance guidelines. Any issues noted will be immediately
with the manufacture's guidelines. Residents #7, #30 addressed. The Policy entitled ?Ç£Blood Glucose
and #32 were involved. The finding: The facility's policy Monitoring Cleaning?Ç¥ was reviewed by the Regional
and procedure (P&P) titled Blood Glucose Monitoring DON with no revisions required. All licensed Nurses will
Cleaning 4/2019 documented the blood glucose be re-educated regarding correct procedure for
monitor equipment will be cleaned and disinfected cleansing glucometers between residents. This
between resident use, utilizing the manufacturers education will include which wipes are indicated for
recommended process. Review of the (Brand Name) disinfection, appropriate dry time and ramifications of
Blood Glucose Monitoring System User Guide dated not performing disinfection as per facility policy. All
2019 provided by the facility did not document the use licensed Nurses will complete competencies for
of 70% [MEDICATION NAME] Alcohol as EPA cleansing/disinfection of glucometer meters. Any issues
(Environmental Protection Agency) validated identified will be immediately corrected. The
disinfectant. Review of the CDC (Center for Disease UMs/designee will each audit 5 Nurses per week (all
Control) Infection Prevention during Blood Glucose shifts) x 12 weeks to ensure correct technique when
Monitoring and Insulin Administration dated 2/6/13 cleansing glucometers. Any issues identified will be
revealed, Whenever possible, blood glucose meters immediately corrected. The results of the audits will be
should be assigned to an individual person and not be shared with the QAPI Committee for review and input.
shared. If blood glucose meters must be shared, the Responsibility: DON
device should be cleaned and disinfected after every
use, per manufacturer's instruction, to prevent carry-
over of blood and infectious agents. If the manufacturer
does not specify how the device should be cleaned and
disinfected, then it should not be shared. 1. During an
observation and interview on the 4th floor 4/6/22 at
4:16 PM Licensed Practical Nurse (LPN #12)
completed a blood glucose meter (portable medical
device used to measure blood sugar levels) test on
Resident #7 with a (Brand Name) blood glucose meter.
After obtaining the blood specimen LPN #12 used a
70% Alcohol prep pad to clean the blood glucose meter
for three seconds, and placed the glucose meter
directly on the medication cart to air dry. LPN #12 then
stated the required dry time was five minutes. During a
follow up telephone interview on 4/7/22 at 12:31 PM,
LPN #12 stated the glucose meters were shared
between residents and cleaned in between with 70%
alcohol prep pad or germicidal wipes. LPN #12 stated
there were no germicidal wipes on the medication cart,
so they chose to use the 70% alcohol prep pad. LPN
#12 stated the germicidal wipes were available in the
supply room and should have used them to clean the
blood glucose meter to reduce the risk of infection.
During a continuous observation on the third floor
4/7/22 at 8:24 AM, LPN #6 removed the glucose meter
from the top drawer of the medication cart and used an
alcohol prep pad to clean the glucose meter, allowed it
to air dry and entered Resident #32's room. The LPN
placed the glucose meter on the resident's overbed
table without a barrier, obtained the resident's blood
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
glucoseDOC.
NYSCEF reading
NO.and
697placed the glucose meter back RECEIVED NYSCEF: 07/09/2023
onto the overbed table. LPN #6 then left the resident's
room, placed the glucose meter directly on top of the
medication cart without a barrier and performed hand
hygiene. The glucose meter remained in the same
spot, on top of the medication cart. At 8:59 AM, LPN #6
used two alcohol pads to clean the glucose meter,
entered Resident #30's room, and placed the glucose
meter on the overbed table without a barrier. LPN #6
obtained the resident's blood glucose reading and
placed the glucose meter back on the overbed table
without a barrier. At 9:08 AM, LPN #6 left the resident's
room and placed the glucose meter directly on top of
the medication. During an interview on 4/7/22 at 9:10
AM, LPN #6 stated they wished they remembered to
use the germicidal wipes to clean the glucose meter
and was supposed to clean it for 90 seconds. During
further interview at 12:31 PM, LPN #6 stated residents
didn't have individual glucose meters, and that they had
access to the germicidal wipes. During a telephone
interview on 4/7/22 at 4:16 PM, the Service Support
Technician for the (Brand Name meter) stated 70%
alcohol prep pads were not a validated EPA product to
disinfect the glucose meter. During an interview on
4/8/22 at 10:04 AM, Registered Nurse (RN) Unit
Coordinator #1, stated glucose meters were to be
thoroughly wiped with germicidal wipes, remain wet for
one minute, and air dried on a barrier to reduce the
spread of infection and prevented cross contamination.
During an interview on 4/8/22 at 10:58 AM, the Infection
Preventionist (IP) stated nurses were expected to lay a
clean barrier down, wipe the glucose meters using
germicidal wipes, leave the meter wet for one minute
and allow to air dry. Alcohol prep pads do not contain
disinfecting mechanisms needed to kill microorganisms
and were unacceptable. During an interview on 4/8/22
at 1:32 PM, the Regional DON stated nurses were
expected to use the germicidal bleach wipes to clean
glucose meters between resident use and they were
expected follow the manufacturer's recommendations.
415.19 (a)(1)
FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE
REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both
percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based
on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains
acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and
electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident
preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and
health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care
provider orders a therapeutic diet.
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2022
Corrected date: June 1, 2022
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023
Citation Details Plan of Correction: ApprovedApril 29, 2022
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED Resident #35 was assessed by the RD and reviewed
TO PROTECT CONFIDENTIALITY** Based on by the interdisciplinary team. Care plan was updated to
observation, interview, and record review during a reflect weight and interventions Meal plan and
Standard survey conducted from 4/4/22 to 4/8/22, the supplement adjusted. Resident #35 was evaluated by
facility did not maintain acceptable parameters of the provider Dietary staff educated on the importance
nutritional status, such as usual body weight or of ensuring adaptive eating devices available and
desirable body weight range and electrolyte balance, applied at each meal service Resident #35 remains at
unless the resident's clinical condition demonstrates the facility with no adverse effect. A full house audit was
that this is not possible or resident preferences indicate conducted for missing or needed reweighs. All were
otherwise for one (Resident #35) of three residents obtained. A full house audit of noted weight change was
reviewed for nutrition. Specifically, there was a delay in conducted of RD assessment, intervention and care
the resident's significant weight loss being addressed plan update. All findings were corrected A full house
by a Registered Dietician (RD) and there were no new audit completed for all residents who receive adaptive
nutritional interventions initiated to address the eating devices. Inventory of all adaptive eating devices
significant weight loss. Additionally, the resident was was completed and replacements ordered for anything
not provided with adaptive equipment (spill proof cup missing The facility policy titled Weight Assessment and
with handle and inner lipped plate) during meals and Policy?Ç¥ and Resident Nutrition Services/Dining with
their care plan was not updated to reflect the significant Dignity were reviewed. No revisions necessary Nursing
weight loss. The finding is: The facility policy titled leadership, Registered dietitian and Diet technician will
Weight Assessment and Interventions last date revised be reeducated on the policy and procedures above
5/2021 documented monthly weights would be emphasizing accuracy of weight monitoring, timely
obtained by the 7th of each month. Weights would be assessment of resident needs and care plan update.
recorded in the electronic health record (EHR) for each The facility has revised their risk management team
resident and any weight change of 5 lb. (pounds) in a meeting process. Residents with suspected or actual
month since their last weight assessment will be weight changes amongst centers established high risk
retaken within 48 hours for confirmation and verified by criteria will be discussed regularly at-risk management
nursing. Reweight should be reviewed by the licensed meetings. Team interventions and approaches will be
nurse, dietician notification should be documented documented in the medical record. A weight team has
within the resident's medical record, and the dietician or been established to obtain weight and reweights. RD/
diet technician would respond within 72 hours of receipt diet technician will conduct weekly weight review to
of notification. The Dietician/Diet Tech will review the ensure weights and reweighs obtained as scheduled
resident weights monthly and negative trends would be Unit Manager/Registered Dietitian will monitor and
evaluated to determine whether or not t
Preview
FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023 Exhibit D 4 FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 NYS Health Profiles NYSCEF w DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023 RK Department ATE of Health Find and Compare New York Health Care Providers Buffalo Center for Rehabilitation and Nursing April 8, 2022 Certification/complaint Survey Standard Health Citations FF11 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS , - - - - ·························- - -························· - - - - · · ······················ · - - - · · ······················ · - - - -························· - - - ···································· REGULATION: §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; '----·························---·························----·························---·························----·························---······················· Scope: Isolated Severity: Potential to cause more than minimal harm Citation date: April 8, 2022 Corrected date: June 1, 2022 FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023 Citation Details Plan of Correction: ApprovedMay 4, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED Fingernail care was provided to resident # 92 0n TO PROTECT CONFIDENTIALITY** Based on 4/8/22. Resident # 155 was seen by podiatrist on observation, record review, and interview conducted 4/7/22 and refused services despite health teaching. during a Standard survey started on 4/4/22 and Facility will reapproach resident to attempt toenail completed on 4/8/22, the facility did not ensure that care/trimming. The responsible party (daughter) for residents who are unable to carry out activities of daily resident # 155 was notified of resident refusals for living (ADL's) receive the necessary services to podiatry. Arrangements are being made for daughter to maintain grooming and personal hygiene. Specifically, attend next scheduled podiatry visit which will hopefully two (Resident #92 and Resident #155) of six residents increase compliance of resident. The UM responsible reviewed for ADL's had issues with long dirty fingernails for referral to podiatry for resident # 155 is no longer (#92), and toenails that were long and curled inward employed at facility. The DON at the time of resident (#155). Additionally, the lack of follow up regarding a #155 grievance was counseled by the Regional RN family request for a podiatry visit in (MONTH) 2022 regarding need to ensure that referrals to podiatry are (#155). The findings are: A review of the policy and completed as indicated. There were no adverse effects procedure (P&P) titled ADL- Nail Care dated 3/2021 to either resident noted from the lack of timely ADL documented that nail care includes daily cleaning and care. All aides and licensed nurses caring for resident? regular trimming. Proper nail care can aid in the ÇÖs # 92 and # 155 on the dates identified in the SOD prevention of skin problems around the nail bed and were counseled by the DON/designee regarding trimmed and smooth nails prevent the resident from appropriate ADL care and subsequent documentation accidentally scratching and injuring their skin. The P&P including refusals of care if indicated. All residents have documented residents' will be referred to the Podiatrist the potential to be affected by the deficient practice. A based on assessment of the resident's toenails by full house review of all residents will be conducted by nursing staff and the physician; and the podiatrists will the Unit Managers/ designees. This review will ensure evaluate, and trim resident toenails based off the that all residents have appropriate ADL/hygiene care physician order. A review of the P&P titled ADL - including fingernail and toenail care. Issues noted will Personal Hygiene dated 10/2021 documented that nail be immediately addressed. In addition, any residents care should be provided as needed for the resident and needing podiatry services will be referred as indicated. that residents with certain medical conditions will Policies for ADL Personal Hygiene and ADL nail care require a licensed professional to perform. Further were reviewed by the Regional RN with no revisions review of the P&P documented that staff should review required. Nursing staff and facility leadership will be the resident's care plan and Certified Nurse Aide (CNA) educated by the RN Regional Nurse/ designee Visual/Bedside Kardex Report for any special care or regarding ADL care for residents. Emphasis will be needs of the individual resident. 1. Resident #92 was placed on nail care. Education will include process for admitted to the facility with [DIAGNOSES REDACTED]. referral to podiatry services; CNA staff will report any The Minimum Data Set (MDS - a resident assessment referrals to the UM who will notify the Medical Records tool) dated 2/18/22 documented Resident #92 was clerk in writing via email. The Medical Records clerk is moderately cognitively impaired and required extensive the point of contact for Podiatry and coordinates assist of two persons for personal hygiene. The Podiatry visits. A weekly audit will be conducted by the Comprehensive Care Plan (CCP) dated 4/16/21 Unit Managers; ten residents from each unit will be documented that Resident #92 was an extensive staff audited for a period of 12 weeks. The audit will include assist for personal hygiene. The CNA Visual/Bedside fingernail and toenail care, and overall hygiene. Any Kardex Report (guide used by staff to provide care) issues identified will be immediately addressed. The dated 4/7/22 documented Resident #92 required Regional RN will review these audits weekly and extensive staff assist to perform personal hygiene. provide input as needed. Podiatry visit list will be During an observation on 4/4/22 at 1:31 PM revealed reviewed monthly by the QAPI Committee to ensure Resident #92's fingernails were ?? inch to ?½ inch long compliance with the podiatrist referral process. Results with brown debris underneath. An observation on of the audits will also be reviewed with the QAPI 4/7/22 at 9:38 AM revealed that the resident's left Committee for input. The QAPI Committee will then thumbnail was ?½ inch long with brown debris determine if further audits are needed. Responsibility: underneath; the rest of the fingernails on the left hand DON were between ?? inch to ?½ inch long and dirty with brown debris. The fingernails on the right hand were ?? inch to ?½ inch long and dirty with brown debris underneath. During an interview on 4/7/22 at 9:49 AM, CNA #2 and CNA #3, stated that Resident #92's nails were long, and they needed to be trimmed. CNA #2 further stated that the resident will scratch themselves in certain areas and accumulate brown debris underneath their nails. During an interview on 4/7/22 at 9:52 AM, Licensed Practical Nurse (LPN) #2 stated FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 Resident NYSCEF #92's DOC. NO.nails 697were long and needed to be RECEIVED NYSCEF: 07/09/2023 trimmed. During an interview on 4/7/22 at 10:00 AM, Registered Nurse (RN) #1 Unit Manager stated they expect staff to trim the residents' nails if the resident is not a diabetic and to clean them. RN #1 also stated that they have wooden orange sticks (a manicure tool that can remove dirt underneath fingernails) available. During an interview on 4/8/22 at 9:30 AM, the Director of Nursing (DON) stated they expect staff to trim fingernails at least every two weeks and to make sure that the nails are clean. The DON also stated that unless the resident is a diabetic or has another medical condition, the CNA's can trim fingernails. 2. Resident #155 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident was severely cognitively impaired. The Comprehensive Care Plan (CCP) dated 4/21/22 documented the resident requires physical assist of one person for all ADL's. Review of a Grievance Form and attached documents dated 2/3/22 documented a family member of Resident #155 reported a concern regarding grossly overgrown toe nails and requested that Resident #155 be seen by the podiatrist. Review of a Progress Note dated 2/8/22 at 9:34 AM documented the intradisciplinary team spoke with the daughter over the phone and Resident #155 was to be placed on the podiatry list to have their toenails cut. Review of the Podiatry list dated 2/18/22 revealed there was no documented evidence Resident #155 was added to the list or seen by podiatry as requested. During an observation on 4/7/22 at 9:09 AM CNA #3 removed the nonskid sock from Resident #155's right foot. The resident's toenails were long and curled inward over the top of the first toe, the other toe nails were approximately one inch long, thick and appeared fungal looking. Review of the Progress Notes and miscellaneous section of the electronic medical record (EMR) from 2/8/22 through 4/8/22 revealed there was no documented evidence Resident #155 was seen by the podiatrist. During an interview on 4/7/22 at 9:14 AM, CNA #3 stated Resident #155 was usually combative with hands on care, most of the time refuses shower and it was very difficult to cut their nails, staff have to catch Resident #155 at the right moment. During a phone interview on 4/7/22 at 10:21 AM, the Podiatry Office Manager stated the facility sends an email if a resident needed to be added to the list. The interview further revealed there was no request submitted by the facility for Resident #155 to be added to the list in February. During an interview on 4/7/22 at 10:47 AM, RN #1 Unit Manager stated residents were to be seen by the podiatrist on a routine bases. If a resident needed to be added to list we let medical records know and the resident gets added. If a resident refused and was not seen for some other reason they will not be seen until the next scheduled visit. Resident #155 should have been seen in February. During an interview on 4/8/22 at 12:32 PM, the Regional Director of Nursing stated the unit manager would be responsible for making sure the appointment was scheduled for the podiatrist. 415.12(a)(3) FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023 FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. '-----·························- - - - - - -·························--------·························-------·························--------·························-------···································· Scope: Pattern Severity: Potential to cause more than minimal harm Citation date: April 8, 2022 Corrected date: June 1, 2022 FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023 Citation Details Plan of Correction: ApprovedApril 29, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on TO PROTECT CONFIDENTIALITY** All food observation, interview, and record review conducted equipment has been cleaned thoroughly including the during a Standard survey completed [DATE] through floors. All expired food were disposed. Storage [DATE], the facility did not store, serve and distribute containers were replaced and dated Outed temperature food in accordance with professional standards for food logs were replaced and updated. The Food Service service safety. Specifically, one of one main kitchen had Department sanitation audit was conducted to identify issues with unclean equipment and floors, areas of concerns. Kitchen staff cleaning assignments outdated/undated food items and lack of documented have been established. A deep cleaning of the kitchen walk-in refrigerator and freezer temperatures. The floor will be completed by [DATE] by the Housekeeping finding is: Review of a policy and procedure (P&P) titled Department. All food service personnel have been Food and Nutrition Services dated ,[DATE] documented educated in proper food handling, storage, sanitation, high standards of cleanliness and sanitation will be cleaning sanitizing, food temperatures and daily defined and maintained. Cleaning is the use of water, cleaning assignments A daily audit will be completed on chemicals, and elbow grease to remove all food and all refrigerated areas by the Supervisors/Designees to debris from equipment and work surfaces. Food assure areas are clean, free of debris and contact surfaces need to be cleaned and sanitized. food/beverages are properly stored, labeled and dated. Production, storage, and service equipment are A Food Service Department sanitation audit will be cleaned and sanitized as required and recommend by completed two times weekly x 6 months than monthly the manufacture. There were no P&P provided as x2 months. The Administrator will review the audits requested regarding labeling and dating of food items. weekly monthly x 6 months than monthly thereafter to 1. During an observation of the main kitchen on [DATE] assure compliance. Additionally, the at 8:31 AM revealed: -The slicer and surrounding table Administrator/Designee will do a random visual audit of were soiled with smudges and greasy food debris. - the kitchen round monthly x 6. The audits will be Stored on the wire shelf next to the manual sink there submitted to the QAPI committee at the monthly QAPI was an open bottle of dill weed spice dated [DATE], meeting for review. The responsible party is the that expired [DATE] and an opened undated 32-ounce Administrator. bag of chocolate chips. - The walk-in freezer floor was covered with frozen green peas and the walk-in cooler and freezer doors had temperature logs in clear plastic sheaths dated for (MONTH) 2022. - The rice, flour, and sugar containers stored on the bottom shelf across from the stove were undated, and the rice container was uncovered. The top shelf prep area was dirty with large amounts of moist and dried food debris. - The toaster next to the coffee station was dirty and had a large amount of brown/tan crumb like food debris covering the internal compartment under the rotating rack. -The six-burner stove top was dirty and had tan dried, peeling food debris covering four of the burners. - The stand-up cooler next to the ice machine contained/stored six undated meat and cheese sandwiches. - The kitchen floor was dirty with dried food debris throughout. At the time of the observations there were three dietary staff members on tray line and there were no other staff or managers available. During an interview on [DATE] at 9:25 AM, the Administrator stated the Registered Dietitian (RD)/Food Service Director (FSD) #1 from their sister facility should be in soon as they have been covering at this facility a few days a week. During additional observations of the main kitchen on [DATE] at 10:20 AM and 12:04 PM revealed the items listed above from the previous observations at 8:31 AM remained unchanged. During an interview on [DATE] at 10:41 AM, with the covering Registered Dietitian (RD)/Food Service Director (FSD) #1 stated the FSD walked out last Thursday and they have been helping a couple days a week. The RD/FSD #1 also stated when they walked into the kitchen that the kitchen needed a thorough cleaning. During an FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 observation NYSCEF DOC. of NO.the697 main kitchen on [DATE] at 8:03 AM RECEIVED NYSCEF: 07/09/2023 revealed: - The open bottle of Dill Weed spice dated [DATE] expired [DATE] and the undated and opened 32-ounce bag of chocolate chips, remained stored on the wire shelf next to the manual sink. -The walk in cooler and freezer doors still had the same temperature logs dated (MONTH) 2022 and the walk-in freezer floor was covered with frozen green peas. - The rice, flour, and sugar containers on the bottom shelf across from the stove remained undated and the rice container remained uncovered. The top shelf prepping area contained large amounts food debris. - The toaster next to the coffee station still had a large amount of brown/tan food debris on the internal compartment under the rotating rack. - The kitchen floor was still dirty with dried food debris throughout. During an interview on [DATE] at 10:39 AM, Dietary Aide #1 stated no one cleans the kitchen the way it should be done because there is not enough time or staff. During an interview on [DATE] at 11:14 AM, the Diet Technician (DT) #1 stated the kitchen was far from perfect on what should be done in regard to cleanliness. During an interview and observation on [DATE] at 2:05 PM with the Regional FSD and covering RD/FSD #1, the RD/FSD #1 stated the toaster, slicer, stove and prepping areas should be cleaned after each use. The stove top should be cleaned after each meal. All spices should be dated or discarded if expired. All prepared foods should be labeled and dated. The peas on the freezer floor should have been cleaned up when they were spilled and they does not know how long the pees have been there. Temperatures for the walk- in coolers and freezers should be checked and documented in the morning and when the kitchen was closed for the day. The sugar, rice and flour bins should be dated, and the rice bin should have a cover. The floors should be swept after each service and moped at the end of the day. 415.14(h) FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; Scope: Isolated Severity: Potential to cause more than minimal harm Citation date: April 8, 2022 Corrected date: June 1, 2022 FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023 Citation Details Plan of Correction: ApprovedApril 29, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED Resident # 126 and # 146 were both seen and TO PROTECT CONFIDENTIALITY** Based on assessed by RN, examined by Medical Provided and observation, interview, and record review conducted Psychiatry Provider post incident of 4/4/22. No adverse during a Complaint Investigation (Complaint #NY 471) effects or injuries was noted to either resident. CNA during the Standard survey completed 4/4/22 through #13 assigned to 1:1 for resident # 126 on the dates 4/8/22, the facility did not ensure the resident's right to cited in the SOD was counseled by the Unit Nurse be free from abuse for two (Resident # 126, 146) of Manager regarding appropriate distance when eleven residents reviewed. Specifically, one to one providing 1 :1. All Nurses and CNA assigned on Unit 4 (1:1) supervision was not provided as planned for a at the time of the incident were re-educated regarding resident with a history of physical aggression (#126), 1:1 supervision and keeping resident within arm?ÇÖs resulting in resident-to-resident abuse. This involved length. All residents have the potential to be affected by Resident (#146). The finding is: The facility policy and the deficient practice. Care Plans and Tasks for all procedure (P&P) titled Abuse dated 2/19 documented residents on 1:1 were reviewed by IDT with no issues the facility prohibits the mistreatment, neglect, and identified. Policies for 1:1 Supervision were reviewed abuse of residents by anyone including staff, family, by the Regional RN; revisions were made to clarify that friends, etc. The facility has designed and implemented 1:1 will be specified: at arms length. All Nursing staff processes, which strive to ensure the prevention of will be educated by the RN Facility Educator on 1:1 suspected or alleged resident abuse, neglect, Supervision and clarification that 1:1 Supervision is at mistreatment. The facility documented physical abuse arms length. Audit will be conducted by Nurse as hitting, slapping, pinching, scratching, spitting, Managers and Nursing Supervisors. There will be 10 holding roughly, kicking, etc. The P&P titled Supervision Audits per week on random shifts for a period of 12 1:1 dated 12/21 documented the facility is to provide weeks. Audit will include Observation of residents on the highest quality of care to our residents; by providing 1:1 supervision to ensure that staff are providing staff with the most efficient, resident centered supervision within arms length with the resident as per procedures for the care of our residents per Federal facility policy. Any issues noted will be immediately and State Regulations. This includes but is not limited addressed. The DON will review these audits weekly to, resident safety and supervision. Residents who and provide input as needed. Results of the audits will require increased frequency of monitoring can be/will also be reviewed with the QAPI Committee for input. be placed on 1:1. The use for 1:1 is determined Responsibility: DON necessary when a resident's safety risk cannot be appropriately monitored through frequent supervision or in danger of injuring themselves or another resident. 1:1 is to be provided by one staff member sitting side by side with the resident for a minimum of 2 hours. 1:1 may also constitute visual observation which will be specified in the plan of care. 1. Resident #126 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 12/16/21 documented Resident #126 was moderately cognitively impaired, sometimes understood and sometimes understands. The Physicians Order Summary Report documented an order dated 1/29/21 that Resident #126 was to be provided with 1 to 1 at all times every shift for close observation. There was no documented end date. Resident #126's undated Visual/Bedside Kardex Report (guide used by staff to provide care) documented under Safety: 1:1 visual observation. Resident #126 was independent with ambulation. The comprehensive care plan (CCP) with an initiated date of 2/14/22 documented Resident #126 had periods of agitation, physical aggression and history of hitting another resident. The plan included 1 to 1 visual observation and small group activities. Resident #146 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented Resident #146 was severely cognitively impaired, was usually understood and usually understands. Resident #146's undated Visual/Bedside Kardex Report documented the resident was independent for ambulation and transfers. FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 Resident NYSCEF DOC.#146's NO.CCP 697 plan dated 11/21/19 documented RECEIVED NYSCEF: 07/09/2023 they were at risk for being a victim due to inability to understand surroundings related to dementia. The CCP documented Resident #146 had been involved in resident-to-resident altercations. Documented planned interventions included but not limited to 1:1 visits from all departments as needed; provide support and ensure resident was free from abuse and resident to be offered food and activities to keep resident occupied. Review of the in-service and education dated 5/29/21 provided by the facility documented when a patient is made 1:1 with care there was to be a caregiver with that resident at all times. During an observation on 4/4/22 at 9:20 AM, Resident #126 was seated next to Resident #146 (within an arm's length) at a dining room table across from the 4th floor nurse's station. Resident #146 repetitively stated Okie dokie, Okie dokie. Resident #126 partially stood from their chair and yelled Shut up and slapped Resident #146 on the shoulder and back. There were three Certified Nurse Aides (CNA's) behind the nurses' station and CNA #13 was sitting in the right corner of the dining room [ROOM NUMBER] feet from Resident #126. During an interview on 4/4/22 at 11:05 AM, CNA #13 stated they were the assigned 1:1 aide for Resident #126 and needed to be within visual view, meaning within an eyes view of the resident due to aggressive behaviors. CNA #13 stated they were not within an arm's reach of Resident # 126. The Facility Full QA (quality assurance) Report provided by the facility initiated on 4/4/22 documented the resident-to- resident altercation was reviewed signed by the Director of Nurses (DON) on 4/5/22. The investigation documented a conclusion the resident-to-resident altercation was unprovoked and witnessed. Additionally, documented there was no abuse, neglect or mistreatment identified. During an interview on 4/8/22 at 9:35 AM, CNA #8 stated they were not familiar with Resident #126. When the care plan stated 1:1 supervision the CNA providing the 1:1 should be within arm's reach of that resident. To prevent the resident from getting agitated they would remain behind the resident, deter any triggers, and still be close enough to prevent the resident from harming others. During an interview on 4/8/22 at 9:45 AM, CNA #2 stated they were familiar with Resident #126 and Resident #126's behaviors were sporadic and unpredictable. When a resident was care planned for 1:1 supervision the CNA assigned should be within an arms distance from the resident when assisting with care or when the resident would be in bed asleep. During an interview on 4/8/22 at 9:53 AM, Licensed Practical Nurse (LPN) #2, stated with 1:1 supervision the staff member must be within one arm's length away from the resident and have visual view at all times to protect other residents on the floor from being injured. Injuries could occur when the assigned 1:1 aide was too far away. During an interview on 4/8/22 at 10:06 AM, CNA #10 stated Resident #126's behavior was unpredictable, making it difficult to determine what could trigger an outburst. 1:1 supervision meant the aide must be with the resident at all times within one arm's length. CNA #10 was aware of the resident-to-resident altercation that occurred between Resident #126 and Resident #146 on 4/4/22 and stated CNA #13 should have been seated next to FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 Resident NYSCEF #126 DOC. at the NO. 697table to prevent the incident from RECEIVED NYSCEF: 07/09/2023 escalating. During an interview on 4/8/22 at 11:28 AM, Registered Nurse (RN) Educator stated Resident #126 required 1:1 supervision. The staff member assigned shouldn't be too close where the resident could throw something, or they could irritate the resident. Typically, the staff were told to manage residents with aggressive behaviors by staying two arms lengths away. Twenty feet away was too far and would not prevent a resident- to-resident altercation. The RN Nurse Educator stated CNA #13 should have been two arm's lengths away and may have prevented Resident #126 from making physical contact with Resident #146. During an interview on 4/8/22 at 11:34 AM, CNA #13 stated they didn't think they were too far away but may have prevented the altercation if they were seated next to Resident #126 or moved them to a different table. I didn't expect it and was unaware their behavior was so unpredictable. During an interview on 4/8/22 at 11:51 AM, RN #1 Unit Manager (UM), stated staff assigned to 1:1 supervision was instructed to remain close, just outside of an arm's length away from Resident #126. The CCP didn't specify the required distanced and should have. RN #1 UM stated they were off the floor at the time of the incident on 4/4/22 but was told Resident #126 was unprovoked, reached over the table and hit Resident #146 in the shoulder and then on the back. RN #1 UM stated the 1:1 aide seated and observed 20 feet away was too far away to effectively intervene. RN #1 UM would have expected CNA #13 to intervene to prevent escalation and the abuse from occurring. During an interview on 4/8/22 at 12:16 PM, the DON stated the policy, and the care plan were not specific of how close the 1:1 aide needed to be and it should be. During an interview on 4/8/22 at 12:22 PM, the Regional DON stated the facility policy, and care plan doesn't indicate the specific footage of what visual 1:1 should be. We need to be reasonable to the relation to where Resident #126 is, what was occurring at the time, and location of the other residents. With the obvious agitation of Resident #146, I would have expected CNA #13 to intervene quickly and redirect Resident #146 away from Resident #126 to prevent the escalated agitation. 1:1 supervision was implemented for Resident #126 to protect other residents. The Regional DON stated CNA #13 should have been with in an arm's reach and was too far away. During an interview on 4/8/22 at 1:23 PM, the Administrator stated Resident #126 had unpredictable aggressive behaviors directed towards others. 1:1 supervision was put in place for the safety of other residents and meant staff should be close enough to intervene to prevent incidents. I would have expected CNA #13 to have been seated with in an arm's length to Resident #126 in the dining area to prevent the physical abuse. 415.4(b) (1)(i) FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023 FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) _______ ~---- ......................... ________ ......................... _______ ......................... .........................________ Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. ......................... _______ , ................................... Scope: Isolated Severity: Potential to cause more than minimal harm Citation date: April 8, 2022 Corrected date: June 1, 2022 FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023 Citation Details Plan of Correction: ApprovedMay 2, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED Resident?ÇÖs # 7, 30 and 32 remain in the facility in TO PROTECT CONFIDENTIALITY** Based on stable condition. There were no adverse effects noted observation, interview and record review conducted related to improper glucometer cleansing. LPNs # 12 during the Standard survey completed 4/4/22 through and 6 were counseled by the DON regarding correct 4/8/22, the facility did not establish and maintained an infection control protocols when cleansing glucometers infection prevention and control program designed to between resident use. All residents have the potential provide a safe, sanitary and comfortable environment to be affected. A full house review of all residents and to help prevent the development and transmission receiving blood glucose checks will be conducted by of communicable diseases and infections for two (3rd the UMs/designees. This review will ensure that all &4th floor) of three resident floors. Specifically, nursing Units are cleansing and disinfecting glucometers staff did not properly clean and disinfect shared between resident use as per manufacturer?ÇÖs glucose meters between resident use in accordance guidelines. Any issues noted will be immediately with the manufacture's guidelines. Residents #7, #30 addressed. The Policy entitled ?Ç£Blood Glucose and #32 were involved. The finding: The facility's policy Monitoring Cleaning?Ç¥ was reviewed by the Regional and procedure (P&P) titled Blood Glucose Monitoring DON with no revisions required. All licensed Nurses will Cleaning 4/2019 documented the blood glucose be re-educated regarding correct procedure for monitor equipment will be cleaned and disinfected cleansing glucometers between residents. This between resident use, utilizing the manufacturers education will include which wipes are indicated for recommended process. Review of the (Brand Name) disinfection, appropriate dry time and ramifications of Blood Glucose Monitoring System User Guide dated not performing disinfection as per facility policy. All 2019 provided by the facility did not document the use licensed Nurses will complete competencies for of 70% [MEDICATION NAME] Alcohol as EPA cleansing/disinfection of glucometer meters. Any issues (Environmental Protection Agency) validated identified will be immediately corrected. The disinfectant. Review of the CDC (Center for Disease UMs/designee will each audit 5 Nurses per week (all Control) Infection Prevention during Blood Glucose shifts) x 12 weeks to ensure correct technique when Monitoring and Insulin Administration dated 2/6/13 cleansing glucometers. Any issues identified will be revealed, Whenever possible, blood glucose meters immediately corrected. The results of the audits will be should be assigned to an individual person and not be shared with the QAPI Committee for review and input. shared. If blood glucose meters must be shared, the Responsibility: DON device should be cleaned and disinfected after every use, per manufacturer's instruction, to prevent carry- over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. 1. During an observation and interview on the 4th floor 4/6/22 at 4:16 PM Licensed Practical Nurse (LPN #12) completed a blood glucose meter (portable medical device used to measure blood sugar levels) test on Resident #7 with a (Brand Name) blood glucose meter. After obtaining the blood specimen LPN #12 used a 70% Alcohol prep pad to clean the blood glucose meter for three seconds, and placed the glucose meter directly on the medication cart to air dry. LPN #12 then stated the required dry time was five minutes. During a follow up telephone interview on 4/7/22 at 12:31 PM, LPN #12 stated the glucose meters were shared between residents and cleaned in between with 70% alcohol prep pad or germicidal wipes. LPN #12 stated there were no germicidal wipes on the medication cart, so they chose to use the 70% alcohol prep pad. LPN #12 stated the germicidal wipes were available in the supply room and should have used them to clean the blood glucose meter to reduce the risk of infection. During a continuous observation on the third floor 4/7/22 at 8:24 AM, LPN #6 removed the glucose meter from the top drawer of the medication cart and used an alcohol prep pad to clean the glucose meter, allowed it to air dry and entered Resident #32's room. The LPN placed the glucose meter on the resident's overbed table without a barrier, obtained the resident's blood FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 glucoseDOC. NYSCEF reading NO.and 697placed the glucose meter back RECEIVED NYSCEF: 07/09/2023 onto the overbed table. LPN #6 then left the resident's room, placed the glucose meter directly on top of the medication cart without a barrier and performed hand hygiene. The glucose meter remained in the same spot, on top of the medication cart. At 8:59 AM, LPN #6 used two alcohol pads to clean the glucose meter, entered Resident #30's room, and placed the glucose meter on the overbed table without a barrier. LPN #6 obtained the resident's blood glucose reading and placed the glucose meter back on the overbed table without a barrier. At 9:08 AM, LPN #6 left the resident's room and placed the glucose meter directly on top of the medication. During an interview on 4/7/22 at 9:10 AM, LPN #6 stated they wished they remembered to use the germicidal wipes to clean the glucose meter and was supposed to clean it for 90 seconds. During further interview at 12:31 PM, LPN #6 stated residents didn't have individual glucose meters, and that they had access to the germicidal wipes. During a telephone interview on 4/7/22 at 4:16 PM, the Service Support Technician for the (Brand Name meter) stated 70% alcohol prep pads were not a validated EPA product to disinfect the glucose meter. During an interview on 4/8/22 at 10:04 AM, Registered Nurse (RN) Unit Coordinator #1, stated glucose meters were to be thoroughly wiped with germicidal wipes, remain wet for one minute, and air dried on a barrier to reduce the spread of infection and prevented cross contamination. During an interview on 4/8/22 at 10:58 AM, the Infection Preventionist (IP) stated nurses were expected to lay a clean barrier down, wipe the glucose meters using germicidal wipes, leave the meter wet for one minute and allow to air dry. Alcohol prep pads do not contain disinfecting mechanisms needed to kill microorganisms and were unacceptable. During an interview on 4/8/22 at 1:32 PM, the Regional DON stated nurses were expected to use the germicidal bleach wipes to clean glucose meters between resident use and they were expected follow the manufacturer's recommendations. 415.19 (a)(1) FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. Scope: Isolated Severity: Potential to cause more than minimal harm Citation date: April 8, 2022 Corrected date: June 1, 2022 FILED: NEW YORK COUNTY CLERK 07/09/2023 04:48 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 697 RECEIVED NYSCEF: 07/09/2023 Citation Details Plan of Correction: ApprovedApril 29, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED Resident #35 was assessed by the RD and reviewed TO PROTECT CONFIDENTIALITY** Based on by the interdisciplinary team. Care plan was updated to observation, interview, and record review during a reflect weight and interventions Meal plan and Standard survey conducted from 4/4/22 to 4/8/22, the supplement adjusted. Resident #35 was evaluated by facility did not maintain acceptable parameters of the provider Dietary staff educated on the importance nutritional status, such as usual body weight or of ensuring adaptive eating devices available and desirable body weight range and electrolyte balance, applied at each meal service Resident #35 remains at unless the resident's clinical condition demonstrates the facility with no adverse effect. A full house audit was that this is not possible or resident preferences indicate conducted for missing or needed reweighs. All were otherwise for one (Resident #35) of three residents obtained. A full house audit of noted weight change was reviewed for nutrition. Specifically, there was a delay in conducted of RD assessment, intervention and care the resident's significant weight loss being addressed plan update. All findings were corrected A full house by a Registered Dietician (RD) and there were no new audit completed for all residents who receive adaptive nutritional interventions initiated to address the eating devices. Inventory of all adaptive eating devices significant weight loss. Additionally, the resident was was completed and replacements ordered for anything not provided with adaptive equipment (spill proof cup missing The facility policy titled Weight Assessment and with handle and inner lipped plate) during meals and Policy?Ç¥ and Resident Nutrition Services/Dining with their care plan was not updated to reflect the significant Dignity were reviewed. No revisions necessary Nursing weight loss. The finding is: The facility policy titled leadership, Registered dietitian and Diet technician will Weight Assessment and Interventions last date revised be reeducated on the policy and procedures above 5/2021 documented monthly weights would be emphasizing accuracy of weight monitoring, timely obtained by the 7th of each month. Weights would be assessment of resident needs and care plan update. recorded in the electronic health record (EHR) for each The facility has revised their risk management team resident and any weight change of 5 lb. (pounds) in a meeting process. Residents with suspected or actual month since their last weight assessment will be weight changes amongst centers established high risk retaken within 48 hours for confirmation and verified by criteria will be discussed regularly at-risk management nursing. Reweight should be reviewed by the licensed meetings. Team interventions and approaches will be nurse, dietician notification should be documented documented in the medical record. A weight team has within the resident's medical record, and the dietician or been established to obtain weight and reweights. RD/ diet technician would respond within 72 hours of receipt diet technician will conduct weekly weight review to of notification. The Dietician/Diet Tech will review the ensure weights and reweighs obtained as scheduled resident weights monthly and negative trends would be Unit Manager/Registered Dietitian will monitor and evaluated to determine whether or not t