PRINTED: 05/18/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 075390 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/23/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 89 WIED DRIVE BEACON BROOK HEALTH CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NAUGATUCK, CT 06770 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 000 INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 000 A COVID-19 Focused Survey was conducted on April 23, 2020 at Beacon Brook to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19. Abbreviations which may be used throughout this document include the following: ADL ('s) - activities of daily living ADNS/ADON - Assistant Director of Nursing APRN - Advanced Practice Registered Nurse BID - twice a day BIMS- Brief Interview for Mental Status BM - Bowel Movements BUN - Blood Urea Nitrogen C-Diff - Clostridium Difficile (Colitis) COPD - chronic obstructive pulmonary disease CVA - cerebrovascular accident (stroke) DNS/DON - Director of Nursing DTI - deep tissue injury (pressure related) ED/ER - emergency department of acute care hospital ESBL - Extended spectrum beta-lactamase ESRD - End Stage Renal Disease FSS/FSD - Food Service Director/ Food Service Supervisor GI - gastrointestinal HS - Bedtime I&O - intake and output monitoring/measuring IV - intravenous LPN - Licensed Practical Nurse MD - Medical Doctor MDS - Minimum Data Set (interdisciplinary assessment tool) LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE TITLE Electronically Signed 05/08/2020 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ISSE11 Facility ID: CT0016 If continuation sheet Page 1 of 6 PRINTED: 05/18/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 075390 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/23/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 89 WIED DRIVE BEACON BROOK HEALTH CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NAUGATUCK, CT 06770 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 000 Continued From page 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 000 MI - myocardial infarction (heart attack) MRSA - Methicillin Resistant Staphylococcus Aureus MDRO - Multi Drug Resistant Organisms NA - Nurse Aide OT - Occupational Therapist PCV13 - Pneumococcal conjugate vaccine Prevnar 13 PPSV23 - Pneumococcal polysaccharide vaccine - Pneumovax 23 PT - Physical Therapist QD-every day RCP - resident care plan RN - Registered Nurse SW - Social Worker VRE - Vancomycin Resistant Enterococcus F 880 Infection Prevention & Control SS=D CFR(s): 483.80(a)(1)(2)(4)(e)(f) F 880 5/18/20 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ISSE11 Facility ID: CT0016 If continuation sheet Page 2 of 6 PRINTED: 05/18/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 075390 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/23/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 89 WIED DRIVE BEACON BROOK HEALTH CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NAUGATUCK, CT 06770 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 2 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ISSE11 Facility ID: CT0016 If continuation sheet Page 3 of 6 PRINTED: 05/18/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 075390 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/23/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 89 WIED DRIVE BEACON BROOK HEALTH CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NAUGATUCK, CT 06770 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 3 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 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. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and review of the facility policy, for 9 of 9 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, and #9) reviewed for COVID-19 infection control the facility failed to ensure communal dining and residents seated next to one another in communal areas were suspended. The findings include: a. Observation on 4/23/2020 at 8:45 AM identified Resident #1, Resident #2, Resident #3, and Resident #4 seated inches apart from one another at the end of the hallway at 2 small tables. Nurse Aide (NA) #2, NA#3, and NA#4 were feeding the residents the breakfast meal. Interview with NA #2 on 4/23/2020 at 8:46 AM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ISSE11 a. Residents 1,2,3,4, are not seated near each other and eating meals in their rooms. Residents are potentially at risk. Residents at risk have been reviewed and are eating meals in their rooms. Staff were re-inserviced that residents need to eat in their rooms. Random weekly audits will be conducted of adherence meals being served in their rooms until substantial compliance is achieved. DNS or designee is responsible for overall compliance. B. Residents 5,6,7,8,9 have not been seated near each other. Residents are potentially at risk. Residents at risk have Facility ID: CT0016 If continuation sheet Page 4 of 6 PRINTED: 05/18/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 075390 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/23/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 89 WIED DRIVE BEACON BROOK HEALTH CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NAUGATUCK, CT 06770 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 4 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 indicated the residents that need to be fed or supervised during meals are placed at these tables at the end of the hallway due to the dining room being closed. Interview with NA #3 on 4/23/2020 at 8:48 AM indicated he/she did assist with bringing the residents out of his/her room to the tables in the hallway to feed them the meal. NA #3 could not explain why the residents were not fed in the his/her room. Interview with NA #4 on 4/23/2020 at 8:49 AM indicated since the dining room was closed the residents that need to be fed or supervised with meals are brought out to the tables in the halls. NA #4 could not recall who instructed him/her to bring residents out in the hall for meals nor why the residents were not fed in his/her room. NA #4 identified he/she did receive education on COVID-19, infection control, social distancing, and the transmission of the virus. NA #4 further identified Residents #1, #2, #3, and #4 were not sitting 6 feet apart. been reviewed and are wearing masks when out of their rooms. Staff were reinserviced that residents can not sit close to one another in communal areas and that if a resident leaves their room they will wear a mask and resident will be educated on risks of exposure. Random weekly audits will be conducted of adherence of no communal activities, resident mask use if leaving room and resident education on risks of exposure, until substantial compliance is achieved. DNS or designee is responsible for overall compliance. Observation and interview with the Administrator and Director of Nurses (DNS) on 4/23/2020 at 9:10AM identified Resident #1, #2, #3, and #4 sitting at the end of the hallway on the 1st floor inches apart from one another at the table. The DNS indicated staff were educated that residents are to be fed in his/her room and he/she would expect staff to follow the policy due to COVID-19 all communal dining was stopped. b. Observation on 4/23/2020 at 8:58 AM on the 1st floor across from the nurses station in the communal resident area identified Residents #5, #6, #7, #8, and #9 were sitting close to one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ISSE11 Facility ID: CT0016 If continuation sheet Page 5 of 6 PRINTED: 05/18/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 075390 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/23/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 89 WIED DRIVE BEACON BROOK HEALTH CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED NAUGATUCK, CT 06770 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 another and not wearing masks. Interview with Licensed Practical Nurse (LPN) #3 on 4/23/2020 at 8:59 AM indicated he/she was aware the dining room was closed due to COVID-19. LPN #3 identified the residents were just sitting in the resident communal area. Observation and Interview with the Administrator and DNS on 4/23/2020 at 9:10 AM identified Residents #5, #6, #7, #8, and #9 were seated in the communal area across from the nurse station on the 1st floor. The DNS indicated the residents should not be sitting together in the communal area and he/she would expect staff to re-direct the residents back to his/her room. Upon surveyor inquiry the DNS implemented a plan of action: all staff will be educated again that all residents need to eat in his/her room, residents can not sit close to one another in communal areas, if residents leave his/her room they will wear a mask, and residents will be educated on risks of exposure. A review of the facility Coronavirus policy identified group activities such as communal dining or recreational programs may be canceled under guidance from CMS, CDC, and local state agencies. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ISSE11 Facility ID: CT0016 If continuation sheet Page 6 of 6