The Pines at Catskill Center for Nursing & Rehabilitation

Based on record review and staff interview, the facility did not ensure that residents received adequate supervision and assistance devices to prevent accidents for 3 (#s 43, 66, and 131) of 24 residents reviewed, during the standard recertification survey. Specifically, the facility did not ensure that a resident received the appropriate diet and supervision during a meal, resulting in the resident choking, did not ensure that the same resident who was at high risk for falls, had documented on the care card that the resident was not to be left unattended in the bathroom. The resident was left unsupervised in the bathroom and fell, resulting in a fracture. The facility did not ensure that a resident was properly supervised as ordered during meals and did not ensure adequate supervision to prevent resident to resident contact. This is a repeat deficiency from the standard recertification survey of 10/08/09. This resulted in actual harm for Resident #66 that is not immediate jeopardy. The findings were:

1. Resident #66
The facility did not ensure that the resident received the appropriate diet and supervision during a meal, resulting in choking. Additionally, the facility did not ensure supervision for the resident while she was in the bathroom, a fall occurred and she sustained a fracture.

The resident was admitted on 6/8/07 with diagnoses of mental retardation, right cerebrovascular accident and diabetes mellitus. The Minimum Data Set (MDS) dated 8/11/10 assessed the resident as having both short term and long term memory impairment and modified independence in decision making ability.

Finding #1
The nurse's notes documented on 4/26/10 (not timed), that staff were called to the resident's room. The resident was sitting in a chair with her head back. Her color was gray and the lunch tray was in front of her. The resident was assisted to sit forward by this writer, was unresponsive and appeared to be choking. Food was visible, and a finger swipe was done by the other licensed practical nurse (LPN) on unit. Noodles and a large chunk of meat were removed from the resident's mouth. Vitals signs (blood pressure, pulse and respirations) were taken, oxygen was applied and the resident was put back to bed and began to become more responsive and was yelling out. Oxygen saturation dropped to the 80's with oxygen off (normal range 90 to 100%). The physician was notified and an order to send the resident to the emergency room (ER) was obtained. The supervisor and family were made aware of the incident and transfer.

A nurse's note dated 4/26/10 at 11:00 pm, documented that the resident had returned from the ER at 6:45 pm. The ER called to give report and informed the nurse that after resident arrived at ER and was positioned on her side, a large tubular shaped amount of food came out of the residents mouth. Shortly after, the resident was talking with staff and no longer was showing signs or symptoms of distress. After the resident arrived at the nursing home and was put in a straight back chair in her room, she had two more episodes of emesis. Both times emesis was yellow with a small amount of blood noted. The nurse practitioner (NP) was in the building and evaluated the resident. A new order for a one time dose of 25 milligrams (mg) of Phenergan (an anti nausea medication) to be given intramuscularly (IM) was obtained. The medication was given at 8:00 pm with good effect. The resident offered no complaints of nausea and no further emesis noted.

Physician's orders dated 4/16/10 documented the diet ordered as no concentrated sweets (NCS), ground consistency, thin liquids, no bread except on sandwiches and no crust.

A speech therapy evaluation dated 11/28/08 documented the resident was seen for a choking incident on 11/26/08. The recommendations included: provide extra moisture to all ground consistency, cue slow pace at meals. Another evaluation dated 4/30/10 documented the reason for referral was a choking incident on 4/26/10. The recommendations were to continue an all ground consistency diet as tolerated, ensure proper positioning, ensure slow pace and to notify speech therapist of any changes.

The resident's care card (a tool that Certified Nurses Aides (CNA) use to identify a resident's specific care needs) from the time of the incident was not available, as the facility did not keep them.

The Comprehensive Care Plan (CCP) titled, Impaired Swallowing, initiated on 6/17/07 documented that the resident had impaired swallowing due to a cognitive deficit, poor dentition and dyskinesia (abnormal muscle movements). It noted a previous episode of choking on 11/26/08. Goals included to increase the resident's oral range of motion and to decrease her rapid pace of intake of food. The diet was noted to be ground; apply aspiration precautions ( used to prevent choking), keep the resident up at a 90-degree angle for meals; keep head/trunk upright for 45 minutes after meals; and to supervise the resident during meals. On 4/26/10, the care plan noted the resident was given the wrong diet with a subsequent choking episode. Changes to the care plan at that time included the resident eating in the dining room for lunch and dinner supervised and given one portion at a time.

The CCP titled, Nutrition rewritten on 1/13/10 identified that the resident was on a no concentrated sweets (NCS) diet, all ground foods with soft salad sandwiches and no crust, and thin liquids. The care plan documented that the resident had a chewing deficit and a history of swallowing deficit and decreased cognitive status. An intervention (undated) documented that the resident was to eat in the dining room, with staff to offer one item at a time in separate bowls. The CCP was updated on 4/26/10 and noted that the resident had a choking episode and would be changed to dining room service with staff, to closely supervise. A 5/20/10 update noted that staff was giving one item at a time with frequent cues to slow down.

The Incident and Accident report (I&A) dated 4/26/10, written by the LPN, described the incident as documented above, in the nurse's notes. The resident was noted to have been given whole foods, when the resident's diet called for ground. Attached to the I&A was a statement from the CNA who provided the resident's meal that day. The CNA stated that she took the resident's tray, to her room and did not realize it was the wrong diet.

The Summary of Investigation Report, of 4/26/10, noted the resident was served the wrong diet. The procedure used to plate and serve the resident's diet was evaluated and modified. The resident's plan of care was changed, so that she would now eat in the dining room for lunch and dinner, with 1:1 supervision.

The emergency room report from the hospital dated 4/26/10, noted that the patient was sent from a nursing home and that staff had stated the resident choked on a meatball. Assessment of the resident noted that she had been lying on the stretcher and began vomiting. She vomited a very large amount of undigested food, including a piece of meat that was approximately 4 inches long and cylindrical in shape. History of the present illness noted that the resident's health care proxy (HCP) was present in the hospital and familiar with the resident's care. The HCP stated that she was not present for the incident, but that the resident eats very fast, had some swallowing issues in the past and had her diet consistency changed in the past. The resident received a chest X-ray, which showed minimal congestion. The resident was discharged back to the nursing home.

During an interview on 9/13/10 at 10:30 am the CNA who provided the tray to the resident, stated she was supposed to double check the resident's diet and she did not do so on this occasion. She stated that the resident should have been supervised because she ate fast, needed cueing and was in her room. She stated this had always been the case, even prior to this incident. When asked why she did not supervise the resident or double check the tray, the CNA did not answer.

During an interview on 9/13/10 at 11:00 am the LPN who responded and wrote the I&A stated a CNA alerted her to the resident's condition and she responded. When she arrived in the room, the resident appeared to be choking. Another LPN# 2 came and they began attending to the resident. This LPN #2 stated that she immediately questioned why the resident was in the room alone unsupervised along with having received the incorrect diet. She stated she remembered checking the resident's care card, which indicated the resident required supervision.

During an interview on 9/13/10 at 11:15 am with the Registered Nurse Manager (RNM) of the unit, she stated she was not on the unit at the time it occurred, but she was informed about it later. When asked if the resident should have been receiving supervision at the time, the RNM stated she believed the care card at the time indicated she required supervision, which would mean she would need to be observed at all times. The RNM stated the care cards are not kept by the facility.

During an interview on 9/13/10 at 11:35 am, with the Director of Nursing (DON), she stated that she would expect staff to be aware of why a resident was on an altered diet and that usually it was related to choking. She stated this resident should have been supervised.

During a telephone interview on 9/14/10 at 2:45 pm, with the Speech and Language Pathologist (SLP) who completed both evaluations in 2008 and in April 2010, she stated that the resident was on a ground diet due to pacing concerns. She stated that the resident required supervision during meals and this was the case prior to this choking incident. She stated the resident should have been receiving supervision at the time of the incident in April 2010.

During an interview on 9/14/10 at 3:14 pm with the Medical Director, he stated that someone at risk for choking should be supervised and cueing should be provided if necessary. He further stated this incident should not have happened.

Finding #2
The nurse's notes documented on 7/30/10 at 4:30 pm, that the resident was noted to be on the floor on her right side in her room. No injuries were noted and the supervisor, family and physician were made aware. No new orders were received. The resident ambulated to the dining room, no change in gait was noted, as well as no signs or symptoms of discomfort.

A nurse's note dated 8/18/10 at 1:05 pm, documented that the nurse was at the nurse's station when, calls for help were heard from staff in the dining room. The resident had fallen to the floor, hit her head and a laceration with a large amount of bleeding was noted. The resident was unresponsive for a short time and began vomiting. She was positioned on her side and then became more responsive. Emergency services arrived and transferred resident to the hospital.

A nurse's note dated 8/26/10 at 7:30 pm, noted that a CNA called the nurse stating the resident was on the bathroom floor. The nurse went to the room and observed that the resident was in the bathroom sitting up, with a bloody nose and a skin tear on top of the nose. The supervisor was called and came to the unit to examine the resident. The area was cleansed and left open to air. The physician was notified. On 8/26/10 at 2:10 pm, a nurse's note documented that the nose looked swollen, but the resident did not complain of pain or discomfort. The next note dated 8/27/10 written at 12:30 pm, documented that upon coming onto shift the resident was noted in bed, the nose was swollen with a small amount of dried blood noted at the right nostril. The supervisor and physician were updated, and a new order to send the resident to the ER for evaluation was obtained. The resident was transferred to the hospital. The hospital then called and reported that the resident had a urinary tract infection (UTI) and a fractured nose. A nurse's note dated 8/27/10 at 10:30 pm documented the resident returned from the hospital at 6:00 pm with the diagnosis of UTI, fractured nose and eye socket. Bactrim was ordered for the UTI, no bleeding of the nose was noted, but it was swollen and ecchymotic.

The I&A dated 8/26/10 described the incident as follows: the resident was sitting on a shower chair in the bathroom, the CNA left the bathroom to get the resident socks. The CNA went back into the bathroom and saw that the resident had leaned over and fell out of the chair. The attached fall investigation identified that the resident attempted to get up from shower chair as the suspected root cause of the fall. The summary of the investigation report findings were that the CNA left the resident unattended in shower chair, and the resident fell to the floor as the CNA returned. Immediate interventions included the CNA was educated on not leaving residents unattended.

The fall risk assessment dated 3/2010 and 6/2010 assessed the resident as a 7 (above 10 would be high risk for falls ) There were no documented assessments completed, after the resident's falls on 7/30/10, 8/18/10 or 8/26/10.

Prior to the incident dated 8/24/10, the resident's care card documented safety devices; bed alarm, chair alarm, low bed and mat.

The CCP titled Falls/Safety, undated, identified the resident with impaired cognition, due to a diagnosis of mental retardation. The care plan identified previous falls on 11/22/09, 1/16/10 and the most current ones of 7/30/10, 8/18/10, and 8/26/10. Interventions included, a low bed, a mat on floor (added 1/16/10) and that the resident was to be involved in activities during the day (added 7/30/10).

During a telephone interview on 9/14/10 at 1:00 pm with the CNA who was caring for the resident at the time of the fall, stated she was a per diem (as needed) staff. She stated she was aware the resident was a fall risk and had recently had several falls. She stated she knew she should not have left the resident unattended, but she realized the resident didn't have her socks and went to get them. She stated she could have either not worried about the socks or called for assistance if she needed it, instead of leaving the resident unattended.

During an interview on 9/13/10 at 2:45 pm the RNM stated that the resident probably shouldn't have been left alone in the bathroom. The RNM stated this was not specifically written on the resident's care plan.

During an interview on 9/14/10 at 9:15 am a CNA who regularly provided care to this resident, stated that she had never left this resident alone in the bathroom. When asked how she would know not to do that, she stated the resident had always been at risk for falls, with a chair alarm and bed alarm in place. She stated with the residents most recent falls the resident should not be left alone in the bathroom, even if it was not on the resident's plan of care.

During an interview on 9/13/10 at 3:15 pm, the DON stated the resident should not have been left alone in the bathroom, and that this circumstance could have been avoided.

During an interview on 9/14/10 at 3:15 pm, the Medical Director stated that if a resident was at risk for falls, they should be provided with adequate supervision at all times. He stated that this resident was at risk for falls, and should not have been left alone unattended in the bathroom.

2. Resident #43
The facility did not ensure the resident was properly supervised as ordered during meals.

The resident was admitted on 8/19/10 with diagnoses including respiratory failure, aspiration pneumonia and cerebral vascular accident. The MDS dated 8/23/10 assessed the resident as having short and long term memory intact, and the resident understands and was understood.

The physician's orders dated 9/8/10 documented the resident was started on a pureed diet with nectar thickened liquids. The order also documented the resident was to receive 1:1 supervision during all meals, proper positioning was to be ensured and that the resident was on aspiration precautions.

The resident's care card dated 9/9/10 documented, the resident was to receive a pureed diet with nectar thickened liquids and the resident was to have 1:1 supervision during all meals.

On 9/13/10 at approximately 12:50 pm, the resident was observed by the surveyor, lying in his bed in an upright position, with the over bed tray table in front of him. The resident was observed with a pureed diet tray on the table and was attempting to feed himself. There were no staff members observed in the room with the resident.

On 9/14/10 at approximately 1:00 pm, the resident was observed by the surveyor, lying in his bed in an upright position with the over bed tray table in front of him. The resident was observed with a pureed diet tray on the table and was attempting to feed himself. There were no staff members observed in the room with the resident. At 1:03 pm, a CNA was observed entering the resident's room. The CNA was observed in the resident's room until 1:06 pm.

During an interview on 9/14/10 at approximately 1:07 pm, the CNA stated she was assigned to care for this resident on 9/14/10. When asked about the amount of assistance the resident needed during meals, the CNA stated when he first started eating, she used to have to sit right with him, however now she just assists him. As an example, she stated, she pours milk on his cereal, pours his drinks into a smaller cup and then she just has to, "bop in and out" of the room to make sure he doesn't choke. When the CNA was shown the resident's care card, which instructed 1:1 supervision, the CNA stated I wouldn't have to sit right there with him, I just need to listen in case he chokes.

During another interview with the same CNA on 9/14/10 at 4:00 pm, the CNA stated 1:1 supervision meant, "him and me" or " him and another CNA." The CNA stated she was either with the resident or in the room with his roommate. When asked about the period of time on 9/13/10 between 1:00pm and 1:03 pm, when the surveyor observed the resident unsupervised, the CNA stated she was not in the room 100% of the time. The CNA stated she had left the room to answer a call light.

During an interview on 9/14/10 at 1:15 pm, the RNM stated 1:1 supervision meant a staff member should be with the resident at all times during meals.

During an interview on 9/15/10 at approximately 1:30 pm with the SLP who assessed the resident, stated 1:1 supervision means direct contact with the resident at all times. The SLP stated if a resident was on 1:1 supervision and the roommate needed any type of assistance, a second staff member should assist the roommate. When asked about this resident, the SLP stated she still saw the resident for 35 minutes a day, 5 days a week to work on strengthening. The SLP stated the resident's by mouth diet had just been initiated, and the resident remained at risk for aspiration, which was why she recommended the 1:1 supervision.

During interview on 9/15/10 at 11:50 am with the resident, he stated sometimes someone sits with him during meals, other times they were with his roommate and sometimes they weren't there at all. When staff were not there, the resident stated he could always ring his bell for help. When asked by the surveyor how frequently the staff were not with him, the resident stated he really did not know, it varied, they come and go.

During interview on 9/15/10 at 2:20 pm, the resident's physician stated he would expect staff to be with the resident continuously throughout meals, as the order was written for 1:1 supervision during meals.

3. Resident #131
The resident was admitted on 6/18/10 with diagnoses of dementia, hypertension and chronic kidney disease. The MDS dated 7/15/10 assessed the resident to have long and short-term memory problems, usually understands and moderately impaired cognitive decision making skills. Additionally, the resident was assessed to be easily distracted with periods of restlessness. The MDS also assessed the resident to have behavior symptoms including wandering and socially inappropriate behavior.

Nurse's notes from 6/18/10 through 6/22/10 documented the resident to be alert with mild confusion and no inappropriate behaviors were noted. On 6/23/10 a nurse's note documented that the resident had increased inappropriate behaviors, starting in the morning. The resident was pushing a linen hopper up and down the hallway, "non-stop." This behavior was not redirectable for an extended period of time and it was very difficult to get the hopper away from him.

The nurse's notes documented that the resident had increased inappropriate behaviors and needed redirection from 6/23-6/25/10. A nurse's note dated 6/26/10 and an I&A dated 6/26/10 at 10:00 am, documented that the resident was found on 3 West, trying to get out the door, looking for "Michael." A second I&A dated 6/26/10 at 11:15 am, documented the resident was again found on 3 West trying to get out the door. A wandergard (device utilized to monitor residents with exit seeking behaviors) was issued and an elopement risk assessment sheet was completed.

A nurse's notes dated 7/3/10 at 1:00 pm, documented that during lunch in 3 East dining room, the resident was noted to be standing up in the corner of the dining room holding a chair in the air. A staff member held onto the chair to prevent the resident from throwing it. Staff approached the resident and he became increasingly agitated and pushed a staff member's arm away when they tried to have him release the chair.

A nurse's note dated 7/6/10 documented that the resident was in his room and he took another resident's coffee. The other resident's (roommate) daughter told Resident #131 that this was her father's cup. Resident #131 then took her coffee cup and spilled it on the floor. The daughter yelled for help. Prior to the family asking for help, Resident #131 had poured lotion all over his roommate's dresser and floor and threw his clothes on the bed. The family member told staff that she intervened when Resident #131 entered another room and began getting into that residents belongings, resulting in a verbal altercation.

A nurse's note dated 7/7/10 at 5:00 am documented that the resident was found sleeping in his roommate's bed. The CNA assisted him back to his own bed.

A nurse's note dated 7/8/10 at 9:00 pm, documented that the resident was walking up and down the hallway looking for his 12 year old son. He became angry with redirection and pulled the sign off the wall and started banging the sign on the walls. He refused to give it back and became aggressive when asked to. The supervisor came to the floor and the resident began hitting the supervisor with the sign. The physician was called for a medication order, but the medication was not given due to the resident calming down.

A nurse's note dated 7/10/10 at 6:00 pm, documented the resident to be pacing while pushing a dining room chair, refusing to stop. Approximately 5 minutes later, the resident grabbed a coffee carafe and started to hit the dining room window with his fist. The MD was called and an order was received for Diazepam (an anti-anxiety medication) 10 mg/2 ml intramuscularly. The resident was medicated with a positive effect.

A nurse's note dated 7/12/10 documented that the resident was walking in the hallway in his underwear. He was hard to redirect and difficult about being dressed. The physician came in to assess resident at 4:00 pm and reviewed incidents over the weekend. A new order to send the resident to the hospital for evaluation of behaviors was obtained.

A nurse's note dated 7/15/10 at 2:40 pm documented, that the resident arrived back to the unit. It further noted the physician reviewed the discharge summary from the hospital and medication changes were noted and made. The resident was to have 1:1 contact/supervision at that time.

Nursing notes from 7/17/10 through 7/19/10 documented that the resident was lethargic and medication was decreased, due to increased sedation. On 7/21/10 nurse's notes documented that the MD was updated regarding the resident's recurrence of restlessness and agitation and he would review this on 7/22/10 for possible medication changes. Namenda 10 mg 3 times a day was ordered at that time.

Nurse's notes dated 7/24/10 through 7/26/10 documented that the resident was repeatedly standing unassisted, ambulating without assistance and sitting on the floor at the nurse's desk. A nurse's note dated 7/26/10 documented that the resident had chased after his roommate with a plastic hangar and a CNA had to intervene.

A nurse's note dated 7/27/10 documented the resident was experiencing increased activity including standing. He was noted to be out of bed that morning with the bed sheets on the floor by the doorway. The resident was ambulating with Attends on and a bed spread over his head. The nurses note documented that the resident needed extensive supervision with confusion and guidance. At 5:30 pm the resident was seen eating a paper napkin, when the CNA went to take it away from him, he swallowed it. The physician was called and no new orders were received.

A nurse's note dated 7/28/10 at 3:00 am documented that the resident was found out of bed, naked, straddled over roommate in roommate's bed. Resident #131 appeared agitated. Resident #131 let the CNA return him to his own bed and the supervisor was called. The resident was placed on 1:1, the MD was notified and orders were received to transfer the resident to the hospital for evaluation.

The CCP titled, Behaviors dated 7/23/10 and recopied from 7/3/10, identified that the resident had dementia and was socially inappropriate, disruptive, and resistive to care. It noted episodes from 7/1/10, when the resident picked up a chair as if to throw it and the aggressive and agitated behaviors were not redirectable. Interventions included: observe resident behavior and attempt to determine cause, intervene as needed to ensure the safety of residents and others, speak in a calm gentle tone, redirect inappropriate behavior as needed and able, offer to go for a walk, involve in recreation activities on unit psychiatric evaluation and follow up and medication administration, per physician order.

The CCP for Behaviors also documented, under response, on 7/3/10 that the resident was redirected with a calm approach, was 1:1 for half an hour with good effect and had started Buspar 10 mg three times a day (an anti-anxiety medication) on 6/30/10. On 7/10/10 the resident was noted to have been pushing chairs while pacing in dining room and had picked up a coffee carafe while swinging at staff. On 7/12/10 it was noted that the resident had aggressive behaviors and was sent to the ER. On 7/15/10 it noted the resident had returned from the hospital with psychiatric medication changes and effects of this were being monitored. Additionally, the resident was on 1:1 until further notice. On 7/19/10 the resident's 1:1 care was documented as lifted, with close observation continuing while the resident was in the dining room with other residents. On 7/27/10 the psychiatrist saw the resident with medication changes noted. On 7/28/10 the resident was sent to the ER for evaluation after aggressive incident (not defined). On 8/6/10 the resident was moved to a private room.

During an interview with the two facility Social Workers on 9/16/10 at 11:45 am, they stated that the resident was placed on 1:1 observation, when he returned on 7/15/10 and that was lifted on 7/19/10. When the surveyor asked, why the 1:1 was lifted on this resident at that time, SW #1 indicated she believed this was due to increased lethargy. When asked why he was not put back on 1:1 supervision after the behaviors began again, the SWs did not know, and stated that that would be an interdisciplinary team (IDT) judgment. They were asked if the behaviors were identified at the IDT meetings, which were held daily and they responded, yes. They could not remember if they were consulted regarding placing the resident on 1:1 supervision. When asked why the resident was not placed in a private room for his safety and other residents upon returning to the facility on 7/15/10, they stated they were not consulted about this. They additionally stated something more should have been done between 7/22/10 when the resident's behaviors began to increase to when the resident had the negative interaction with his roommate on 7/28/10.

During an interview with the attending physician on 9/16/10 at 10:00 am, the physician stated that the resident's behavior was unpredictable, and that staff had tried a trial of many drugs to keep him safe. The physician stated that the resident should have had individual supervision upon return to the facility on 7/15/10 and that the resident should never have been placed with another resident.

During an interview with the DON on 9/16/10 at 12:40 pm, she stated that the resident should never have been placed with another resident. She stated that this happened, due to lack of support from the previous Administrator. She additionally stated that the resident should have been supervised 1:1, because he was very strong and his behavior was very unpredictable.

10NYCRR 415.12(h)(1)

Based on observation and staff interview, the facility did not ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys in 2 (2 West and 2 East medication/nourishment room) of two medication/nourishment rooms observed, during the recertification survey. Specifically, the 2 West medication/ nourishment room had multiple medications including; intravenous antibiotics and albuterol sulfate, along with boxes of syringes with needles, that were located in unlocked cabinets. The 2 East medication room was also noted to have been unlocked. This resulted in no actual harm with the potential for more then minimal harm that was not immediate jeopardy. The findings were as follows:

During an observation of the medication/nourishment room on 2 West on 9/9/10 at 2:40 pm, the surveyor entered through the unlocked door. The following medications were observed in a cabinet that was not locked: 3 boxes containing albuterol sulfate, 3 packages of ampicillin (IV antibiotic)- one of which was leaking onto the other contents in the cabinet, multiple bottles of aspirin, two bottles of ferrous sulfate, one box of saline prefilled syringes, one half-full box of heparin flush syringes and two boxes of syringes with needles.

During an observation on 2 East on 9/9/10 at 2:15 pm, a Licensed Practical Nurse (LPN) attempted to access the medication/nourishment room, which was locked. LPN #1 then asked LPN #2, why it was locked. LPN #1 then waited for a staff member from central supply to open the room. Upon entering with the surveyor, multiple bottles of ferrous sulfate, normal saline, alcohol and aspirin were noted in a cabinet which was unlocked.

During an interview on 9/9/10 at 2:20 pm, LPN #1 stated the room was never locked and she didn't have a key. She stated she never had a key to the room and wasn't certain who did as, she never required assistance to get into it.

In an interview with both the Registered Nurse Manager (RNM) and LPN #3 on 9/9/10 at 2:45 pm, LPN #3 stated that the medication/nourishment room was always unlocked, because it was the nourishment room, so Certified Nurse Aides and other staff ,also had access. LPN 3# stated that the unlocked cabinet with the above-mentioned medications, was usually locked. Additionally, she stated, the resident-specific medications should not have been in the cabinet. She stated those medications should have been on the medication cart, where they would have been locked. The RNM concurred and further noted that the syringes with needles were also a concern and should be locked.

10NYCRR 415.18 (d)

Based on observation, medical record review and staff interview, the facility did not ensure that documentation regarding residents' Advance Directives (end of life wishes) were consistent with the resident's/family's wishes for Advance Directives, for 3 (#s 44, 56 and 64) of 40 residents reviewed during the standard recertification survey. Specifically, the physician's orders for Advanced Directives were not consistent with the resident's/family's documented wishes. This resulted in no actual harm with potential for more than minimal harm that was not immediate jeopardy. This was evidenced by:

Finding #1
The facility's policy titled, Do Not Resuscitate (DNR)-NY, dated 4/2001 documented, that u pon admission, the option of choosing to resuscitate or not to resuscitate will be offered and reviewed with the resident/family/surrogate/designated representative. The consent/refusal form will be signed and witnessed. Physician's orders must be written accordingly. Documentation of the resident's or surrogate's choice to opt for resuscitation or not to resuscitate will be maintained on the chart under the section titled, Documentation by the Nursing Staff, was written, A 'DNR' identification shall appear on the following records for those residents with an active DNR order and on a face sheet of resident chart. Under the section titled, Procedure, was documented, If the resident/designated representative wishes to execute a DNR, social worker will inform attending physician immediately to conduct appropriate assessment and have appropriate forms signed. Attending physician will complete appropriate documentation and write DNR order on the order sheet and write corresponding progress note.

1. Resident #56
The resident was admitted on 5/24/10 with diagnoses of dementia, congestive heart failure and hypertension. The Minimum Data Set (MDS) dated 8/8/10 assessed the resident as having impaired short and long term memory. The resident understands and is was able to be understood.

The Social Service(SS) progress note dated 4/30/10 documented the resident's wife signed a DNR order.

There was also a, Non Hospital Order Not to Resuscitate DNR order which was signed and dated by the physician on 5/3/10.

The SS progress note dated 5/24/10 documented the resident's spouse expressed a desire to maintain the resident's DNR status

The Face Sheet in the resident's chart (identified by staff as being a place to check the resident's Advance Directives) dated 8/16/10, documented the resident did have Advanced Directives and a Do Not Resuscitate order.

The physician's order dated 6/24/10, 7/20/10 and 8/17/10 documented the resident was a "Full Code"

During an interview on 9/9/10 at approximately 2:20 pm, the licensed practical nurse (LPN) administering medications on the unit stated, she would check the resident's identification (ID) band and then the resident's face sheet, if she was to find a resident with no heartbeat and not breathing. The LPN also stated if the resident was not wearing an ID band, she would check the face sheet, the physician's orders and the Advance Directives section of the resident's chart.

During an interview on 9/9/10 at approximately 3:40 pm, the Director of Social Services (DSS) stated he was responsible to perform comprehensive audits of the medical records every 2 weeks. The DSS stated that during his audits, he checks to make sure the resident's face sheet, physician's orders, information in the Advance Directive section of the chart, SS documentation and the resident's identification band are all consistent and match. If there was an inconsistency during the audit, the DSS stated he would go to the nurse and relay the information to her, and if there was a discrepancy with the physician's order, the nurse would be responsible to obtain the correct order. The DSS also stated he had completed audits for all the residents in the facility within the past month, but could not remember if he had found any discrepancies. He stated that he did not document those audits, so there was nothing to refer to. He also stated that he did not forward the results of his audits to any other administrative person or quality committee in the facility.

During an interview on 9/9/10 at approximately 4:15 pm, the Director of Nursing (DON) and the Administrator both stated, they would expect a physician's order to be obtained immediately, if a resident/family expressed a desire to be a DNR. The DON stated that the facility did not obtain a physician's order for DNR, in a timely manner for this resident.

2. Resident #44
The resident was admitted on 8/30/10 with diagnoses of sepsis, diabetes mellitus and pulmonary fibrosis. The MDS dated 9/3/10 assessed the resident as having intact short and long term memory, understands and was understood.

The Social Service Progress note dated 8/30/10 documented the resident wanted to be resuscitated.

The Face Sheet in the resident's chart dated 8/30/10 documented under the section titled, Advance Directives, DNR order-no; Advance Directives-yes.

The History and Physical Form signed and dated by the physician on 8/31/10 did not identify the resident's Advance Directives status.

The physician's order dated 8/31/10 documented the resident was a DNR.

During an interview on 9/9/10 at approximately 2:20 pm, the LPN administering medications on the unit stated, she would check the resident's ID band and then the resident's face sheet, if she was to find a resident with no heartbeat and not breathing. The LPN also stated if the resident was not wearing an ID band, she would check the face sheet, the physician's orders and the Advance Directives section of the resident's chart.

During an interview on 9/9/10 at approximately 3:40 pm, the DSS stated he was responsible to perform comprehensive audits of the medical records every 2 weeks. The DSS stated that during his audits, he checks to make sure the resident's face sheet, physician's orders, information in the Advance Directive section of the chart, SS documentation and the resident's identification band are all consistent and match. If there was an inconsistency during the audit, the DSS stated he would go to the nurse and relay the information to her, and if there was a discrepancy with the physician's order, the nurse would be responsible to obtain the correct order. The DSS also stated he had completed audits for all the residents in the facility within the past month, but could not remember if he had found any discrepancies. He stated that he did not document those audits, so there was nothing to refer to. He also stated that he did not forward the results of his audits to any other administrative person or quality committee in the facility.

During an interview on 9/9/10 at approximately 4:15 pm, the DON and the Administrator both stated, they would expect a physician's order to be obtained immediately, if a resident/family expressed a desire to be a DNR. The DON stated that the facility did not obtain a physician's order for DNR, in a timely manner for this resident.

3. Resident #64
The resident was admitted on 6/22/10 with diagnoses of Alzheimer's disease, Parkinson's disease and possible malabsorption syndrome. The MDS dated 7/21/10 assessed the resident as having impaired short term memory, long term memory was intact the resident usually understands and was sometimes understood.

The Social Service Progress note dated 6/23/10 documented the resident's daughter signed a consent for DNR.

The Social Service Progress note dated 7/14/10 documented during a care conference which the resident's family attended, Advanced Directives and DNR were discussed and the orders were to continue as written.

There was a Non Hospital Order Not to Resuscitate (DNR) order in the resident's chart which was signed and dated by the physician on 6/24/10.

The physician's order dated 6/24/10 and 7/18/10 documented that the resident was a "Full Code."

The physician's order dated 7/19/10 documented the order for Full Code was discontinued and an order for DNR was initiated.

During interview on 9/9/10 at approximately 2:20 pm, the LPN administering medications on the unit stated she would check the resident's ID band and then the resident's face sheet if she was to find a resident with no heartbeat and not breathing. The LPN also stated if the resident was not wearing an ID band, she would check the face sheet, the physician's orders and the Advance Directives section of the resident's chart.

During interview on 9/9/10 at approximately 3:40 pm, the DSS stated he was responsible to perform comprehensive audits of the medical records every 2 weeks. The DSS stated that during his audits, he checks to make sure the resident's face sheet, physician's orders, information in the Advance Directive section of the chart, SS documentation and the resident's identification band are all consistent and match. If there was an inconsistency during the audit, the DSS stated he would go to the nurse and relay the information to her, and if there was a discrepancy with the physician's order, the nurse would be responsible to obtain the correct order. The DSS also stated he had completed audits for all the residents in the facility within the past month, but could not remember if he had found any discrepancies. He stated that he did not document those audits, so there was nothing to refer to. He also stated that he did not forward the results of his audits to any other administrative person or quality committee in the facility.

During interview on 9/9/10 at approximately 4:15 pm, the DON and the Administrator both stated, they would expect a physician's order to be obtained immediately, if a resident/family expressed a desire to be a DNR. The DON stated that the facility did not obtain a physician's order for DNR, in a timely manner for this resident.

10NYCRR 415.3(e)(2)(iii)

Based on record review and staff interview, the facility did not ensure that that all alleged violations involving mistreatment neglect or abuse, including injuries of unknown source, were thoroughly investigated and/or reported to the appropriate state agency in accordance with state law for 2 (#s 64 and 66) of 5 residents reviewed for investigations, during the standard recertification survey. Specifically, the facility did not thoroughly investigate episodes of choking, a fall resulting in a fracture, a resident to resident altercation and a bruise of unknown origin. This is a repeat deficiency from the standard recertification survey of 10/08/09. This resulted in no actual harm, with the potential form more then minimal harm that is not immediate jeopardy. The findings are:

1. Resident #66
The facility did not ensure that two separate incidents, one a choking episode and one a fall with a fracture, were thoroughly investigated or reported to the state agency.

The resident was admitted on 6/8/07 with the diagnosis of mental retardation, right cerebrovascular accident, and diabetes mellitus. The Minimum Data Set (MDS) dated 8/11/10 assessed the resident as having both short term memory impairment and modified independence in decision making ability.

Finding #1
The nurse's notes documented on 4/26/10 (not timed), that staff were called to resident's room. The resident was sitting in her chair with her head back and her color was gray, with her lunch tray in front of her. The resident was sat forward by the writer, was unresponsive and appeared to be choking. The resident's mouth was visually checked. Food was visible, and a finger sweep of the mouth was done, by the other licensed practical nurse (LPN) on the unit. Noodles and a large chunk of meat were removed. Vital signs were taken, oxygen was applied, and the resident was put back to bed. She then began to become more responsive and was yelling out. Oxygen saturation dropped to the 80's, when the oxygen was not running, (normal 90 to 100%) and the oxygen was kept on. The physician was notified and gave an order to send resident to emergency room (ER). The nursing supervisor and the resident's family were made aware of the incident and the transfer.

Another nurse's note, dated 4/26/10 at 11:00 pm, documented that the resident had returned from the ER at 6:45 pm. The reports received upon the resident's return noted, that she had a large amount of emesis (vomiting) while still in ambulance. The ER staff reported by phone to the nursing home, that after resident arrived at the ER and was positioned on her side, a large tubular shaped amount of food came out of the resident's mouth. Shortly after that, the resident was talking with the staff, no longer showing signs or symptoms of distress. After the resident arrived back at the nursing home and she was seated in a straight back chair in her room and she had two more episodes of emesis. Both times emesis was yellow, with a small amount of blood noted. The nurse practitioner (NP) was in the building, evaluated the resident, and gave a new order for a one-time dose of 25 milligrams (mg) of Phenergan (an anti-nausea medication) to be administered intramuscularly (IM). The medication was given at 8:00 pm with good effect. The resident offered no complaints of nausea and no further emesis was noted.

Physician's orders dated 4/16/10 documented the diet ordered as: no concentrated sweets (NCS), ground consistency, thin liquids, no bread except sandwiches, and no crust.

Residents care card (tool that Certified Nurses Aides- CNA- use to identify a residents specific care needs) from this time was not available, as the facility does not keep them.

The Comprehensive Care Plan (CCP) for impaired swallowing initiated on 6/17/07 documented that the resident had impaired swallowing due to a cognitive deficit, poor dentition and dyskinesia (abnormal muscle movements). A previous episode of choking on 11/26/08 was documented on the CCP. Goals for speech therapy included increased oral range of motion, decrease rapid pace of eating at meals. The diet was noted to be all ground with aspiration precautions, to keep resident up at a 90-degree angle for meals, keep head/trunk upright for 45 minutes after meals, and supervise client during meals. On 4/26/10, the care plan noted the resident was given the wrong diet with a subsequent choking episode. Changes to the care plan at that time included resident eating in dining room for lunch and dinner, supervised and given one portion at a time

A speech therapy evaluation dated 11/28/08 documented the resident was seen for a choking incident on 11/26/08. The recommendations included: provide extra moisture to all ground consistency, cue slow pace at meals. Another evaluation dated 4/30/10 documented the reason for referral as choking incident on 4/26/10. The recommendations were to continue all ground consistency as tolerated, ensure proper positioning, ensure slow pace, notify speech of changes.

Review of the incident and Accident report (I&A) dated 4/26/10, and written by the LPN described the incident as it was in the nurses notes described above. In addition, the comment was included that the resident was noted to have been given a whole foods diet although the order called for ground foods. Attached to the I&A was the statement from the CNA who provided the resident's meal that day. The CNA stated that she took the residents tray to her room and did not realize it was the wrong diet. There was no other statement from any other nurse or CNA on duty on the unit at the time.

The summary of investigation report documented under investigative findings that the resident was served the wrong diet. The procedure used to plate and serve residents diet was evaluated and modified. The resident's plan of care was changed so that after this incident she would eat in the dining room for lunch and dinner with 1:1 supervision.

During an interview with the Registered Nurse Manager (RNM) on 9/13/10 at 11:15 am, she stated she was not present when the incident occurred. She stated that for an incident like this, the facility expectation is that the nurse would complete and incident and accident report (I&A), and interview all staff that were present at the time of the incident, including nurses aides and other nurses. After discussing the Summary of Investigation Report, the RNM indicated that the resident was not supervised as she should have been and that piece of information should have been included in the investigation results. Also, staff should have been counseled regarding supervision as well. Additionally, in regards to the summary findings indicating no reasonable cause to believe any alleged neglect had occurred, she indicated that she believed this to be true, as the staff did not intend to harm the resident.

During interview on 9/13/10 at 11:35 am with the Director of Nursing (DON), after reviewing the I&A and subsequent investigation of the incident the DON confirmed that a thorough investigation had not occurred. She stated that she was not employed at the facility at the time of the incident. She stated typically after an incident like this; every staff member on the unit should have been interviewed. She indicated that it was a case of not following the care plan, which is neglect, and should have been called in to the Department of Health.

Finding #2
The I&A dated 8/26/10 described the incident as follows: the resident was sitting on a shower chair in the bathroom, the CNA left the bathroom to get socks. The CNA went back into the bathroom and saw the resident lean over and fall out of the chair. The attached fall investigation identified that the resident attempted to get up from shower chair as the suspected root cause. The summary of investigation report findings were that the CNA left the resident unattended in shower chair, and the resident fell to the floor as the CNA returned. Immediate interventions included the CNA being re-educated on not leaving residents unattended. The only written statement provided in the investigation was the one written by the CNA caring for the resident.

The nurse's notes documented on 8/26/10 at 2:10 pm, that the resident's nose looked swollen, but the resident did not complain of pain or discomfort. The next note dated 8/27/10 written at 12:30 pm documented that upon coming onto shift the resident was noted in bed, with her nose swollen and a small amount of dried blood at the right nostril. The supervisor and physician were updated, and an order was obtained to send the resident to the ER for evaluation, which was done. The hospital called the nursing home later and reported that the resident had a urinary tract infection (UTI) as well as a fractured nose. A note dated 8/27/10 at 10:30pm documented the resident returned from the hospital at 6:00pm with the diagnosis of UTI, fractured nose and fractured eye socket. Bactrim was ordered for the UTI, no bleeding of the nose was noted, but it was swollen and ecchymotic bruised.

The resident's care card prior to incident dated 8/24/10 under safety devices listed: bed alarm, chair alarm, low bed and mat. The care card dated 8/29/10 said same as above. On 8/31/10 (5 days after the swelling was observed) the care card stated the resident was not to be left in bathroom alone on toilet or shower chair, and the caregiver should gather all necessary items for care and dressing before bringing the resident to the shower room or bathroom.

The CCP for falls/ safety did not have an initiation date, but a first fall was documented on 11/22/09. It identified the resident had impaired cognition due to a diagnosis of mental retardation. The care plan identified previous falls on 11/22/09, 1/16/10 and the most current ones of 7/30/10, 8/18/10, and 8/26/10. Interventions included a low bed and mat(s) on the floor (added 1/16/10); involve the resident in activities during the day was an intervention added 7/30/10. On 8/26/10 it noted that the resident was not to be left alone in the bathroom, and to gather belongings beforehand.

During interview with the RNM on 9/13/10 at 2:45 pm, the RNM stated she was not clear on who was responsible for completing investigations.

During interview with the DON on 9/14/10 at 11:00 am, she identified her signature and stated that she had signed off on the investigation. She further acknowledged that she did not review the entire investigation, only the summary findings. After reviewing the investigation with the surveyor, the DON stated that the investigation was not complete. She stated she would have obtained more statements from other staff members. She further indicated that a more thorough investigation might have lead to the determination that the incident should be called in to the Department of Health.

2. Resident #64
The facility did not thoroughly investigate an incident of resident to resident behavior, and a bruise of unknown origin.
The resident was admitted on 6/22/10 with diagnoses of Alzheimer's disease, Parkinson's Disease and possible malabsorption syndrome. The minimum data set dated 7/21/10 assessed the resident as having impaired short term memory, long term memory was intact the resident usually understands and is sometimes understood.

The nurse's notes dated 6/22/10 (no time documented) documented the resident was Spanish-speaking, alert and confused and had poor safety awareness.

The nurse's note dated 7/21/10 at 1:35pm documented the resident was alert, ambulating and needed to be redirected from other resident's rooms.

Nurses notes dated 7/22/10 at 2:08am,7/24/10 at 12:20am, and 7/27/10 at 12:10am documented the resident received the medication Haldol (which was used for this resident for aggression) at those times. Observations of the resident's behavior in these notes included that he was increasingly aggressive, was resistive to care, was restless and was going into other residents' rooms. The medication was documented as effective for these behaviors.

The nurse's notes dated 7/27/10 documented "at approximately 2:00am, the resident's roommate was observed on top of resident #64, on resident #64's bed, on his knees. The resident's roommate was verbally agitated, but easily removed by the certified nurse's aide (CNA). The nurse documented there was no physical contact, no apparent injury, and resident #64 was emotionally shaken.

The nurse's note dated 7/28/10 at 2:00am entitled "late entry" documented the resident's roommate was discovered out of bed and on top of resident in resident's bed. Roommate was on his knees and straddled over resident #64. Roommate sounded verbally agitated, staff was unable to determine what the roommate was saying. Roommate came off the bed, returned to his own bed and fell asleep. Resident #64 remained anxious, rambling verbally in Spanish and then settled down. Staff was placed in room for 1:1 supervision while the supervisor notified the administration. The note also documented there were no obvious injuries to this resident.

The nurse's note dated 7/28/10 at 11:30am documented the resident carried on his usual routine and did not appear to be distressed. The resident refused to allow his blood pressure to be taken, was "deterred" from being inquisitive about the fire alarm box, and deterred and guided from other resident's room multiple times.

The nurse's note dated 7/28/10 at 11:00pm documented the resident was found with a bump to the right forehead, the resident was alert and oriented to self, neurological checks were intact and the physician was notified.

The nurse's note also dated 7/28/10 at 11:00pm documented the resident's family was made aware, the daughter spoke to the resident on the phone and stated the resident was just mumbling and did not tell her what happened. The note also documented that before this, the resident was very restless and in and out of resident's rooms despite multiple attempts to encourage resident to sit and rest.

The nurse's note dated 7/30/10 at 8:30pm documented the CNA noted a large bruise on the resident's left buttock. The note also documented the resident offered no complaints, the supervisor and the resident's family were notified.

The nurse's note dated 7/31/10 at 11:00am documented a bruise was noted to the right side of the resident's forehead measuring 2.5 centimeters (cm) X 1.8cm and was purple/red in color. The resident also was noted with a large bruise to the left buttock measuring 7.3cm X 13cm. A CAT scan was scheduled for 8/2/10 and neurological checks remained within normal limits.

The Accident and Incident Report (A&I) dated 7/28/10 documented the CNA found the resident's roommate straddled over the resident , on his bed, verbally yelling at resident #64. Review of the incident report documented a statement from the nursing supervisor who was in charge that night, a telephone conversation from the nursing supervisor, and a statement from the CNA who found the residents (and was assigned to the resident that evening). The statement from the CNA documented resident #64 was "very upset and scared" of his roommate. There were no additional statements from any other staff.

The summary of this A&I dated 7/30/10 and signed by the director of nursing (DON) and administrator on 8/18/10, documented(under the section entitled "description of event" the resident was found being straddled by a naked roommate. This form also documented no physical contact was made, no injuries occurred, and the resident was being intimidated by a roommate with known diagnoses of Alzheimer's with behavioral aggression issues. The section entitled "immediate interventions" documented the roommate was sent to the emergency room for evaluation. Under the section entitled "Conclusion" it was documented "Due to continuing restlessness, resident (#64) needs to be engaged in more tiring daytime activities to promote sleep at night."

The A&I dated 7/30/10 at 7:00pm documented the CNA noted a large bruise on the resident's left buttock which measured 16cm X 7cm. The A&I also documented the physician was notified at 7:30pm, but did not examine the resident. The investigation report included a statement from the CNA caring for the resident the night the bruise was discovered.

The "Summary of Investigation report" dated 9/2/10 and signed by the DON on 9/5/10 documented under conclusion, "Bruise most likely attributed to resident to resident altercation".

During interview on 9/16/10 at 12:40pm, the DON was shown the above investigations. The DON stated she did not feel that the incident of the resident's buttock bruise and the resident to resident altercation were related. The DON stated her signature was on both of the investigations, and her signature indicated she had reviewed and agreed with the investigations. When shown the statement in the conclusion, stating the "bruise most likely attributed to resident to resident altercation", the DON stated she did not see that statement when she signed the investigations. The DON stated if she had seen the above statement, she would have interviewed more people involved in the incident. The DON stated there should have been more CNAs that cared for the resident interviewed, and the DON stated if she had thoroughly read the conclusion, she would have re-interviewed the resident and the resident's family regarding the resident-to-resident incident.

b 10NYCRR 415.4(b)(1)(ii)

Based on medical record review and staff interviews during a complaint investigation (Case # NY00089543), the facility did not ensure that one (Resident #1) of two residents reviewed, who entered the facility without pressure sores, did not develop pressure sores unless the resident's clinical condition demonstrated that they were unavoidable. Specifically, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed with preventative measures and interventions, prior to the development of a stage II area on the resident's left heel. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by the following:

Resident #1
The resident was admitted to the facility on 7/2/10 with a diagnoses of diabetes mellitus, chronic renal failure and vascular neuropathy. The Minimum Data Set dated 7/15/10 assessed the resident with intact memory and cognition, required limited assistance with ambulation and bed mobility. The resident was also assessed with no foot problems.

The Pressure Ulcer Risk Assessment dated 7/2/10 assessed the resident was at risk for the development of pressure sores with a score of 16.

The CCP titled, Alteration in Skin Integrity, dated 7/11/10, documented the resident had bilateral outer shin cellulitis. The CCP did not identify the resident's risk factors of diabetes and neuropathy.

Nurse's note dated 7/26/10 at 8:00 pm documented that during care, an open area was found on the resident's left heel measuring 6 centimeters (cm) by 3.3 cm with no drainage.

The CCP titled, Pressure Ulcers, dated 7/26/10, the day the pressure ulcer was first observed, documented a Stage II pressure ulcer to the left heal and documented interventions to include a skill care cushion while in bed and to observe the resident's skin before applying and removing assistive devices. The CCP also included the interventions to turn and position every two hours.

The Physician's Order form dated 7/26/10 documented an order for Mepilex to the left heel ulcer, every three days and as necessary. The diagnosis documented was pressure ulcer.

All nurse's notes written from the discovery of the heel pressure sore, until the resident's discharge on 7/29/10, documented that the dressing was dry and intact.

Nurse's note dated 7/29/10 at 11:55 am documented a wound assessment in which the wound to the left heal measured, 8 cm by 5.75 cm with serious drainage.

During an interview with the Director of Nursing (DON) on 8/13/10 at 11:30 am, she stated that based on the Pressure Ulcer Risk Assessment dated 7/2/10 which assessed the resident at low risk for pressure ulcers, a CCP should have been developed by the Unit Registered Nurse, however, the CCP was not completed for this resident.

10NYCRR 415.12(c)(1)

Based on medical record review and staff interview, the facility did not ensure that residents remained free of any significant medication errors. Specifically, for 1 (#91) of 2 residents reviewed for use of medication patches, medication was not discontinued as ordered. Additionally, two days after the Exelon patch was ordered to be discontinued, the resident was found with two Exelon patches on after being admitted to the hospital for bradycardia (slow heart rate) and unresponsiveness. This is a repeat deficiency from the standard recertification survey of 10/08/09. This resulted in no actual harm with potential for more than minimal harm which was not immediate jeopardy. This was evidenced by the following:

Resident #91
The resident was admitted to the facility on 7/06/10 with diagnoses of Alzheimer Dementia, symptomatic bradycardia, hypertension and carotid artery disease. The Minimum Data Set (MDS) assessed the resident to have long- and short-term memory problems and moderately impaired cognitive skills for daily decision making.

Physician orders dated 7/16/10 documented an Exelon patch 9.5 milligram (ml) /24 hour release, to applied topically once a day.

Physician orders dated 8/12/10 (unsigned) documented that the Exelon patch 9.5 ml was to be discontinued on 8/12/10.

The medication administration record (MAR) documented that the Exelon patch was placed on the resident's right chest on 8/11/10 and 8/12/10. Additionally, the MAR documented that the medication was discontinued on 8/12/10.

Nursing notes dated 8/13/10 at 3:50 am documented staff found the resident on the floor. The resident stated she hit her head on the floor, skin tears were noted on her wrist, and a hematoma was found on the left forehead with slight abrasion of skin. The resident complained of pain to right cheek which was pink and tender with slight swelling. The physician was called and orders were received to send the resident to the hospital for a CT scan. Nursing notes dated 8/13/10 at 8:45 am, documented the CT was negative and the resident returned to the facility.

Nursing notes dated 8/15/10 at 10:00 am, documented the resident was unresponsive in the wheelchair, and skin cold to touch. The resident was put back in bed and was becoming aroused. The physician was called and an order was given to send the resident to the emergency department.

Nursing notes dated 8/16/10 (not timed) documented as a late entry for 8/15/10, documented the resident was admitted to the hospital at 1:39 pm, with bradycardia and questionable medication overdose.

The hospital admission summary dated 8/15/10 documented the resident to be 95 years old, and upon admission was found to have a heart rate high 40's (Normal is average 60 to 100). It was also noted that the resident was found with two 9.5 milligram Exelon patches on. The hospital admission summary documented the Exelon was to be discontinued on 8/12/10, according to the physician orders.

During an interview with the Licensed Practical Nurse (LPN) on 8/15/10 at 8:30 am, she stated she placed the patches on 8/11/10 and again on 8/12/10. She stated she did not see any other patch on the resident prior to placing the patch on the resident on 8/12/10. The LPN stated after the Exelon was discontinued she did not remove the patch from the resident.

The 2010 Physicians Desk Reference (PDR) none pages 2438-2439 information on Exelon included as part of the Precautions section, that medication errors with Exelon patches have resulted in serious adverse events, some cases have required hospitalization. The majority of medication errors have involved not removing the old patch when putting on a new one and the use of multiple patches at the same time. The PDR also stated that the sites of application of the Exelon patch should be rotated to minimize skin irritation, and the same site should not be used within 14 days. The previous day's patch should be removed before placing a new patch to a different skin location. Additionally, as stated in the information, patients and caregivers should be informed that the drug still remains in the patch after 24 hours. The PDR further advised under Cardiovascular Conditions, drugs in the category of Exelon may have an effect of decreasing the heart rate (bradycardia) The potential for this action may be important in patients with cardiac conduction conditions.

10NYCRR 415.12(m)(2)

Based on medical record reviews and staff interviews, the facility did not ensure services provided met professional standards of quality, for 4 (#s 42, 43, 44 and 61) of 24 residents reviewed, during the standard recertification survey. Specifically, the facility did not ensure physician's orders were followed, did not ensure insulin sites were documented and rotated and did not ensure the placement of a controlled medication patch was checked and documented. This is a repeat deficiency from the standard recertification survey from 10/8/09. This resulted in no actual harm with potential for more than minimal harm that was not immediate jeopardy. This was evidenced by:

1. Resident #42
The facility did not ensure physician's orders were followed.

The resident was admitted on 8/13/10 with diagnoses of right tibial fracture, diabetes mellitus and coronary artery disease. The Minimum Data Set (MDS) dated 8/23/10 assessed the resident as having intact short and long term memory, understands others and was understood.

The physician's orders dated 9/7/10 documented that the resident was to receive Actos (diabetic medication to maintain blood sugar levels) 45 milligrams (mg) once a day.

The medication administration record (MAR) dated 9/7/10 documented the resident did not receive the Actos on 9/11/10 and 9/12/10. The back of the MAR documented on 9/12/10 the Actos was not available.

During an interview on 9/13/10 at approximately 11:15 am, the resident stated she had not received her Actos for three days. The resident stated she had spoken with a nurse, who told the resident she would look into the concern; however, that nurse never returned. The resident could not remember the nurse's name. The resident then told a second nurse, who stated she would look into it. That second nurse returned in an hour, and told the resident the medication had not arrived from the pharmacy, however that nurse stated she had ordered the Actos. The resident stated she did receive the medication within the next hour.

The nurse who did not administer the Actos was unavailable for interview.

The facility's After Hours Emergency Paging Procedure, which was not dated, documented the phone number to reach the pharmacy and instructions which documented, if no response, call the Administrator, with a phone number listed.

The nurse who omitted the Actos was unavailable for interview.

During interview on 9/16/10 at approximately 11:50 am, the registered nurse unit manager (RNUM) stated the Actos was not given on 9/11/10 or 9/12/10. The RNUM stated if a medication was not available from the pharmacy, it was the nurse's responsibility to notify the pharmacy.

2. Resident #61
The facility did not ensure physician's orders were followed.

The resident was admitted on 8/24/10 with diagnoses of diabetes mellitus, hypertension and osteoporosis. The MDS dated 8/31/10 assessed the resident as having intact short and long term memory, understands others and was understood by others.

The physician's orders dated 8/24/10 documented that the resident was to receive Purified Protein Derivative (PPD - a test for tuberculosis) 0.1 milliliters (ml) intradermally (under the skin) for one dose and to read results in 48 hours. The order continued, if the test was negative, it was to be repeated in 2 weeks and be read in 48 hours.

The MAR dated 8/24/10 through 9/23/10, documented that the resident received a PPD on 8/24/10, which was documented as being negative on 8/26/10. The MAR documented that the second PPD was to be administered on 9/7/10 and read on 9/9/10. There was no documented evidence that a second PPD was administered.

During an interview on 9/14/10 at approximately 11:20 am, the RNUM stated the second PPD was not administered as ordered by the physician. The RNUM stated the second PPD should have been administered on 9/7/10, as indicated on the MAR.

3. Resident #44
The facility did not ensure the placement of a controlled medication patch was checked and documented.

The resident was admitted on 8/30/10 with diagnoses of sepsis, diabetes mellitus and pulmonary fibrosis. The MDS dated 9/3/10 assessed the resident as having intact short and long term memory, understands others and was understood by others.

During a interview on 9/9/10 at 8:30 am, the registered nurse unit manager (RNUM) stated the facility's policy was to document that two nurses checked the placement of Duragesic (a controlled narcotic medication patch used for pain relief) patches, every shift and document this on the resident's MAR.

The physician orders dated 8/31/10 documented the resident was to receive Duragesic.

The MAR dated 8/30/10-9/29/10 documented, that the resident received the Duragesic patch on 9/1/10, 9/4/10, 9/7/10 and 9/10/10.

The facility's policy titled, Controlled Drugs: Duragesic Patch, dated 1/2010 documented that the patch should be checked every shift for continued application and evidence of tampering. This check should be documented on the MAR.

There was no documented evidence on the MAR to indicate the placement of the patch was checked between 9/1/10 and 9/10/10.

During an interview on 9/14/10 at 10:15 am, the RNUM stated the placement of the Duragesic patch should have been checked and documented on the MAR. The RNUM stated without documentation, there was no way to verify that 2 nurses checked the placement.

10NYCRR 415.11(c)(3)(i)

Based on observation and staff interview, it was determined that the facility did not dispose of garbage and refuse properly, during the standard recertification survey. Specifically, three of 3 refuse dumpsters and the dumpster area were not maintained in a sanitary manner. This resulted in no actual harm with the potential for minimal harm. This was evidenced as follows:

Observation 09/09/2010 at 9:00 am revealed that the 3 refuse dumpsters, did not have plugs in the clean-out drain holes, one dumpster was not closed, and the dumpster area was littered with refuse.

During an interview with the Director of Food Service on 09/09/2010 at 9:00 am, concurrent with survey observations, revealed acknowledgement of the dumpster observations as noted above.

10 NYCRR 415.14(h)

Based on observation, staff interview and record review, it was determined that the facility did not maintain the integrity of 1 of 1 smoke barriers observed. 2000 NFPA 101 section 8.3.6 requires that space between pipes, conduits, cables, wires, air ducts and similar building service equipment passing through smoke barriers shall be filled with a fire rated material that is capable of maintaining the smoke resistance of the smoke barrier, during the standard recertification survey. Specifically, the three East smoke barrier had multiple unfilled penetrations and non-fire-rated materials were used to fill other penetrations. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced with the following:

Record review of the facility floor plan on 09/13/2010 revealed, the locations of the smoke barrier walls on the third floor.

During an observation of the three East smoke barrier on 09/13/2010 at 1:00 pm revealed, three 3 inch diameter and one 6 inch square holes in room #331; one 2 inch square hole and three 1 inch diameter unfilled penetrations in room #330; four 1 inch diameter unfilled penetrations in room #329; one 4 inch square hole in the lift alcove and extensive use of fill material that was not a Union Labeled (UL)-approved fire stopping system.

During an interview with the Director of Building Services on 09/13/2010 at 1:00 pm, concurrent with survey observations, revealed acknowledgement of the construction and maintenance condition of the smoke barrier noted above.

2000 NFPA 101 19.3.7.3, 8.3; 1997 NFPA 101 13-3.7.3, 6-3; 10 NYCRR 415.29, 711.2(a)(1)

Based on observation, staff interview and record review, it was determined that the facility did not maintain all areas in which smoking is permitted in accordance with adopted regulations, during the standard recertification survey. 2000 NFPA 101 Life Safety Code Section 19.7.4 requires that ashtrays and metal containers with self-closing cover devices into which ashtrays can be emptied shall be provided in all smoking areas. Specifically, one of 2 designated smoking areas, the employee smoking area, did not have ashtrays and a metal container into which ashtrays can be emptied. Additionally, cigarette butts littered the grounds of the employee smoking area. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced as follows:

Observation of the employee smoking area on 09/09/2010 at 9:05 am revealed cigarette butts littering the area and the absence of ashtrays and a metal container into which ashtrays can be emptied.

During an interview with the Director of Food Services on 09/09/2010 at 9:05 am revealed, he acknowledgement of the observations noted above.

Record review of the facility's smoking policy on 09/13/2010 revealed that the facility provided a smoking area that was separate from the resident smoking area.

2000 NFPA 101 19.7.4 (d); 1997 NFPA 101 13-7.4 (d); 10 NYCRR 415.29(a)(2), 711.2

Based on observation, staff interview, and record review it was determined that the facility did not maintain the integrity of 1 of 1 elevator shaft vertical openings. 2000 NFPA 101 section 8.2.5 requires that walls to vertical openings be constructed as both a smoke barrier and fire barrier, have a 1-hour fire resistance rating, and be continuous from floor to roof, during the standard recertification survey. Specifically, the walls of the elevator shaft servicing elevator cars 1 and 2 were not continuous from floor to roof thereby not maintaining a fire resistance rating. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced as follows:

Record review of the facility floor plan at 09/13/2010 revealed, the locations of the elevator shafts.

During an observation of the walls of the elevator shaft servicing elevator cars 1 and 2 on 09/13/2010 at 1:25 pm, revealed multiple and extensive areas of loose and/or missing mortar between the concrete blocks composing the walls; this rendered these walls non-continuous.

During an interview with the Director of Building Services on 09/13/2010 at 1:25 pm, concurrent with survey observations, revealed acknowledgement of the construction of the elevator shaft noted above.

2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3.2.3.1(2), 8.2.3.2.4.2; 1997 NFPA 101 13-3.1.1, 6-2.4.2, 6-2.3.2.3.1(a), 6-2.3.2.4.2; 10 NYCRR 415.29, 711.2(a)(1)