Rivera Mansions RCF

1.a. The facility will provide a daily program of social and recreational activities that are based upon individual and group interests, physical, mental and psychosocial needs, and creates opportunities for active participation in the community at large.1.b. The facility will provide equipment, supplies and space to meet individual and group activity needs.2.a. The Activities Coordinator will plan a monthly calendar of social and recreational activities. More offerings and greater variety will be added to meet individual and group interests on a daily basis. A printed calendar will be distributed to all residents monthly. If there is a change to calendar or scheduled activities the Activities Coordinator will notify residents as soon as possible and give a back-up activity plan. A back-up activity plan will be available and accessible to residents and direct care staff.2.b. The Activities Coordinator will interview and survey the residents and community to:- identify residents' individual and group activity preferences- gather feedback on current and on going activity offering and gather resident suggestions and wishes- explore options for residents to participate in activities in and around the community at large- create and update individual resident activity profiles2.c. Direct Care Staff and Activities Coordinator will document and track resident participation in daily social and recreational activities. 2.d. The Activities Coordinator will document a summary of each resident activity preference and participation quarterly and as needed.2.e. All Staff will be trained and re-trained in their role on Resident Services including daily program of social and recreational activities.3.a. Activities Coordinator will evaluate this plan of correction at least monthly.4.a. The Life Enrichment director and Activities coordinator are responsible for ensuring these corrections are compeleted/monitored.

1. a. Facility updated Resident #1 service plan to reflect resident's current identified needs and provide clear direction to staff.1.b. Staff education, coaching and monitoring provided to ensure service plan is followed. 2. a. Facility will incorporate all elements that are identified in the person-centered service into the residents service plan. We will ensure that the service plan reflects the resident's needs and preferences as identified during evaluation.2. b. Service plans will be made readily available to staff and provide clear direction of services including a description of who will provide services and what, when, how and how often the services shall be provided.2. c. Services will be provided by staff according to the current service plan. Ongoing monitoring will be implemented to ensure delivery of these services.2. d. Daily team huddle will be implemented to communicate to staff any updates or changes and get feedback on service plans.2. e. Service Plan team meeting will be conducted before move-in and quarterly.2. f. Electronic Health Record system will be changed to a better system that integrates all aspects of resident services. Facility is moving from an old sytem QuickMar to PointClickCare.3. a. All Service plans will be reviewed and updated if needed during this period in the next 60 days.3. b. Moving forward, service plans will be completed prior to move-in date with updates and changes as appropirate within 30 days of move-in; during quarterly evaluations; and when a resident has a significant change in condition.4. a. Facility Administrator, Facility RN & RCC are responsible for ensuring these corrections are compeleted/monitored.

1. a. Facility RN re-assessed Resident #1 and completed documentation of resolution of short-term change in condition related to missed Carvedilol 6.25mg. 2. a. Facility staff will identify and monitor residents for any short-term changes in condition and determine and document what actions or interventions are needed.2. b. Any short-term changes in condition will be communicated to staff on each shift. Staff instructions and interventions will be resident specific. Monitoring will be documented by progress notes at least weekly until condition resolves. 2. c. Utilization of Temporary Service Plan or Alert Flowsheet to allow staff to:- have a guide in identifying and recognizing short-term changes in condition- determine what actions and interventions are needed - what and when to monitor, document and report- who and when to notify Administrator, RN or Healthcare provider2. d. Utilization of 24-hour report log for short-term changes in condition to be used as:- communication tool for all staff on all shifts- tracking tool to ensure timely monitoring and documentation until resolution2. e. Daily team huddle to be led by Officer-in-charge to go over any new/resolving changes in condition including short-term changes.2. f. Daily review by Officer-in-charge of health record system reports or dashboards for any missed or refused medications and treatments.2. g. Electronic Health Record system will be changed to a better system that integrates all aspects of resident care and allow for a more streamlined and timely documentation of monitoring and intervention for short-term changes of condition. Facility is moving from an old sytem QuickMar to PointClickCare.2. h. All Staff will be trained or re-trained on identifying changes in residents' condition and corresponding policies and procedures on staff responsibilities, reporting, monitoring, documentation until resolution.3. a. Officer in charge/RCC will review at least daily.3. b. RN/Administrator will evaluate at least weekly. 4. a. Facility Administrator, Facility RN & RCC are responsible for ensuring these corrections are compeleted/monitored.

1.a. Strictly implement proper use of mask and PPE according to current Federal, State and County guidelines.2.a. Frequent rounding, reminder and correction by Officer in Charge and Infectious disease specialist for proper mask and PPE use.2.b. Staff and resident training and re-training on proper mask and PPE use to include current rules, how, where and when to use.3.a. At least daily rounding by officer in charge3.b. Evaluated at least weekly by Infectious disease specialist.4.a. Infectious disease specialist will be responsible to see that corrections are completed and monitored.

1.a. Strictly implement for all medications administered by the facility will be stored in locked containers in a secured environment such as a medcart or medication room. Only authorized facility staff (Medtech/RCC/Officer-in-charge/dietitian/RN/Administrator) will have access to these storage units and must be kept secure and locked when not in direct sight by authorized facility staff.2.a. Frequent rounding, reminder and correction by Officer in Charge, RCC and RN to ensure medication storage units are secure.2.b. Staff training and re-training on medication storage and security.3.a. At least daily rounding by Officer-in-charge/RCC.3.b. Evaluated at least weekly by RN/Administrator.4.a. The Facility Administrator/Facility RN & RCC will be responsible to see that corrections and completed and monitored.

1. a. Facility corrected medication and treatment orders for Resident #2 by:- Notifying PCP according to order parameters of blood pressure medication- Requested PCP for clarification of frequency of notification for any out of range vital signs- Making sure supply of as needed cream available and accessible to medtech1. b. Facility corrected medication and treatment orders for Resident #1 by:- Medtech staff education, coaching and monitoring of medtech staff on dosing frequency parameters for prn Oxycodone and timely and accurate documentation of Nystatin and other treatments.- Adding additional eMAR controls to space prn Oxycodone doses according to order.2. a. Medication and treatment orders by a legally recognized practitioner will be carried out as prescribed. All medications and treatments facility administers will be documented in the resident's record. 2. b. Medication and treatment orders including associated parameters for administering and reporting, ie. Blood pressure parameters, will be followed and documented accordingly.2. c. Medication and treatment orders will be reviewed for completeness and clarity. Any unclear parameters will be clarified with ordering practitioner. ie. Oxycodone 1 tablet PO daily PRN need clarified if daily means 24hours apart in dosing or day-by-day allowance to take prn with parameter on how many hours in between daily dose.2. d. Medication and treatment supplies will be available and on hand at all times in order to be carried out and administered as prescribed. Medications and treatments will be ordered and re-ordered timely to ensure adequate supply and stored in a location accessible to authorized staff.Medtech should take steps in locating, re-ordering and reporting any missing medications and treatments.2. e. All facility administered medications and treatments will be documented timely in resident's record by responsible medtech.2. f. Facility will conduct an audit of all medications and treatment orders for all residents to address the following:- Ensure there are corresponding signed orders from each resident's legally recognized practitioner and that these orders are correctly written on residents facility record. - Orders will be reviewed for completeness and clarity and facility will make every effort to request for clarification from ordering practitioner.- Ensure all medications and treatments administered by facility are available and on hand. 2. g. All new medication and treatment orders will be reviewed via triple-check process per facility policy.2. h. Daily review by Officer-in-charge/RCC of health record system reports or dashboards for any missed entries, missed administration or refused medications and treatments.2. i. Electronic Health Record system will be changed to a better system that integrates all aspects of resident care including Medication and Treatment management and documentation. Facility is moving from an old sytem QuickMar to PointClickCare with scheduled GoLive date in mid-April 2023. New system will allow for tracking dashboards, setting and flagging parameters on medications, re-ordering medications and documentation.2. j. All Medtechs will be trained or re-trained on Medication and Treatment Administration and Policies and Procedures.3. a. Officer in charge/RCC will review at least daily.3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met.3. c. All medications and treatments will be audited and updated if needed during this period of correction, in the next 60 days. Moving forward, Medications and treatments will be reviewed prior to and at resident move-in day, as needed and quarterly thereafter. 4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

1. a. Facility made correction to rule on Resident Right to Refuse for Resident #2 by:- Notified PCP of medication and treatment refusals - Requested PCP clarification of frequency of notification for any medication or treatment refusal2. a. Facility will notify physician or prescriber of any refusals of medication or treatment order. Subsequent refusals will be reported as requested by physician or prescriber.2. b. Medtechs will report and document each refusal per physician or prescriber order. 2. c. Officer in charge/RCC will review any refusals and ensure Medtechs have reported and documented per physician orders. Review will be done at least daily during rounding and electronic health record dashboard review. 2. d. For subsequent or frequent refusals and if no parameters are set Officer in-charge/RCC will request review and parameters from physician or prescriber on frequency of notification for frequently refused medications and facility records to be update as necessary.2. e. All Medtechs will be trained or re-trained on Resident Right to Refuse in relation to medications and treatments and related Policies and Procedures.3. a. Officer in charge/RCC will review at least daily.3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met.3. c. All resident refusal parameters will be audited and updated if needed during this period of correction, in the next 60 days. Moving forward, edications and treatments refusals will be audited every quarter and as needed.4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

1. a. Facility corrected Resident #3 medication orders adding clear parameters and instructions that reflect resident's preference and ability to self-direct use of one or more PRN medication for the same condition.1. b. Facility corrected Resident #1 medication by:- adding clear parameters and instructions that reflect resident's preference and ability to self-direct use of more than 1 PRN medication for pain and bowel medications.- education, coaching and monitoring of staff on bowel monitoring and following prn bowel medications per order- requested PCP clarification of prn Meclizine order to eliminate ranges if possible. RN reviewed order and set clear parameters for staff to follow.1. c. Facility corrected Resident #2 bowel monitoring and prn Lactulose for instructions to match according to current order.2. a. Facility will keep an accurate Medication Administration Record (MAR) as ordered by a legally recognized prescriber. All medications and treatments facility administers will be documented in the resident's record. 2. b. Medication and treatment orders including associated parameters for administering and reporting will be followed and documented accordingly. 2. c. Medication and treatment orders will be reviewed for accuracy, completeness and clarity to ensure unlicensed caregivers are able to understand and follow without use of their own discretion in administering these orders. Resident specific parameters and clear instructions for prn medications will be established and reviewed by or in collaboration with community RN, community pharmacist or legal recognized prescriber.2. d. Medication and treatment monitoring parameters will likewise be reviewed, documented and followed accordingly. ie. bowel monitoring reviewed to use prn Lactulose 2. e. Facility will conduct an audit of all medications and treatment orders for all residents to address the following:- Ensure there are corresponding signed orders from each resident's legally recognized practitioner and that these orders are correctly written on residents facility record. - Orders will be reviewed for completeness and clarity and facility will make every effort to request for clarification from ordering practitioner or consult/collaborate with community RN/community pharmacy partner for any additional resident and order specific parameters2. f. All new medication and treatment orders will be reviewed via triple-check process per facility policy.2. g. Daily review by Officer-in-charge/RCC of health record system reports or dashboards for any PRN medications used2. h. Electronic Health Record system will be changed to a better system that integrates all aspects of resident care including Medication and Treatment management and documentation. Facility is moving from an old sytem QuickMar to PointClickCare with scheduled GoLive date in mid-April 2023. New system will allow for tracking dashboards, setting and flagging parameters on medications, re-ordering medications and documentation.2. i. All Medtechs will be trained or re-trained on Medication and Treatment Administration and Policies and Procedures.3. a. Officer in charge/RCC will review at least daily.3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met.3. c. All medications and treatments will be audited and updated if needed during this period of correction, in the next 60 days. Moving forward, Medications and treatments will be audited and reviewed prior to and at resident move-in day, as needed and quarterly thereafter. 4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

1. Facility re-evaluated Resident #1 for preference and ability to self-administer medications and requested his primary care physician for a written order approval. In the meantime, staff have been educated, coached and monitored to follow proper medication administration policies and procedures. 2. a. Facility will evaluate Residents who choose to self-administer their own medications upon move in, quarterly and as needed or when a resident prefers to start self-administering their medications.2. b. Trained staff will evaluate resident for safety in self-administration of medication and will document this evaluation. This evaluation will conclude with a physician's written order of approval for the self-administration of prescribed medications. If approved for self-administration, this will be noted in the MAR for medtech/staff to follow. Residents will likewise be notified and education provided on self-administration of medications when applicable.2. c. All Medtechs will be trained or re-trained on Self-Administration of Medications and corresponding Policies and Procedures.3. a. Frequent rounding, reminder and correction by Officer in charge/RCC at least daily to ensure policy on self-administration is followed.3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met.3. c. All resident medications and treatments will be audited and updated if needed during this period of correction, in the next 60 days. Moving forward, self-medication will be audited and reviewed prior to and at resident move-in day, as needed and quarterly thereafter.4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

1. a. Facility corrected Resident #2 use of psychotropic medications by:- added clear instructions, parameters and documentation of non-pharmacologic interventions for behaviors prior to administration of psychotropic medications- updated prescriber of frequency of behaviors that lead to use of psychotropic medications and requested update on recommendations to manage behaviors2. a. Facility will use psychotropic medications only according to a prescription from a legal authorized prescriber that specifies the circumstances, dosages and duration of use. These medications can only be used when required to treat a resident's medical symptoms or to maximize a resident's functioning and must have resident-specific paramters. 2. b. Staff will attempt and document all non-pharmacologic interventions tried prior to administration of prn psychotropic medications. 2. c. Officer in charge/RCC will review any psychotropic medication administration and corresponding non-pharmacological behavior interventions tried. Review will be done at least daily during rounding and electronic health record dashboard review. 2. d. All Direct Care Staff will be trained or re-trained on non-pharmacologic behavior interventions and related Policies and Procedures. Additionally, all Medtechs will be trained or re-trained on use of psychotropic medications when non-pharmacologic interventions are ineffective and related documentation and policies and procedures.3. a. Officer in charge/RCC will review at least daily.3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met.3. c. All resident Psychotropic medication orders and non-pharmacologic behavioral intervention will be audited and updated if needed during this period of correction, in the next 60 days. Moving forward, these will be reviewed and audited before and at move-in, every quarter and as needed.4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

1a. We will direct our landscape maintenance subcontractor fill in the pathway drop-offs with grave, soil, and/or bark dust to ensure that the drop-offs on each side of the exterior pathway do not exceed an 1 inch drop-off. On a bi-annual basis, we will have our maintenance crew, including our lanscape maintenance contractor inspect and make sure these drop offs on each side of the exterior pathways do not exceed more than an inch. 1b. The items along the exterior corridor were already cleaned and removed. On a bi-weekly basis, we will have our housekeeping and maintenance crew inspect the exterior of the facility and ensure that it is kept orderly and free of litter and refuse. 2. See comments under 1a and 1b above.We will also re-train and re-orient all maintenance and housekeeping staff regarding this deficiency, and corrective actions and processes that are (or will be) setup to address this issue. 3. Please see 1a and 1b above. 4. The Business Support/Accounting Specialist will be the responsible person to inspect the exterior walkways and drop offs/edges are kept to an inch or less. The Resident Care Coordinator will be responsible to oversee the Housekeeping staff and ensure that the exterior grounds are kept orderly and free of litter/refuse on a bi-weekly basis, as part of their cleaning plan.

1a. We will engage a third party subcontractor to repair and repaint the resident doors, hallways, including handrails and baseboard materials for all buildings.1b. Please note that the old (existing) wing of Building A will be under renovation as part of the ongoing 8 bedroom construction/addition, which is expected to be complete by by end of June 2023. All of the observed wall scrapes, missing paint, and / or gouges throughout Building A be replaced and/or repaired and re-painted.1c. We will re-orient and re-train all housekeeping staff to follow the daily cleaning routine tasks that is designed to maintain the cleanliness and orderliness, of all the interior surfaces of the three buildings, which includes the floors, walls, ceiling, doors, windows, furniture, light fixtures, and all equipment. 1d. We will create a repairs and maintenance checklist including routine inspections that will list and identify preventive measures to ensure that all equipment furniture and fixtures are operating effectively and efficinetly. We will also re-orient and re-train all interior maintenance staff to ensure that they understand the process and procedures regarding maintenance so appropriate actions are taken to repair and maintain all facility equipment, furniture and fixtures.2. Please see 1a - 1d above. In additon, we will conduct spot audits by the Administrator/Resident Care Coordinator staff and monthly inspections to ensure that the housekeeping and maintenance activities are carried out timely and properly. 3. Please see item 2 above.4. Please see item 2 above. In addition, the Administrator will coordinate all of the repairs and renovation of Buildings B and C with the Building Owners.

1. We implemented use of detergents with disinfectant properties when washing soiled linens and soiled clothing. 2. Laundry policy and procedures has been updated to include disinfecting detergent use for soiled linen. A laundry in-service training will be conducted with all direct care staff emphasizing the importance of proper laundry care, including adding detergents with disinfecting properties when washing soiled linen and soiled clothing. Written, clear laundry instructions will be made available for staff.3. Initial evaluation will be done within 60 days of this correction period. Policies and procedures will be monitored monthly until substantial compliance reached then quarterly and as needed thereafter. 4. The Administrator, and the Resident Care Coordinator will be the accountable persons in ensuring that all direct care staff are trained on this process.

1. We will replace all gas fireplaces in all building with electric fireplace(s) to avoid the risks associated with this deficiency. For Building A, the fireplace replacement was included in the scope of the renovation that is expected to be completed by end of June 2023. For Buildings B and C, we will include the replacement of the gas fireplace with electric fireplaces in the scope of the painting and minor renovation. In the interim, we will disable the use of the gas fireplaces.2. Please see item 1 above.3. Once the gas fireplaces are replaced, this deficiency will be eliminated and resolved permanently.4. The Administrator will work with the Building Owners to make sure that this task is completed.