Alpine Rehabilitation and Nursing Center

Based on observation, staff and resident interview, and record review conducted during the standard survey, it was determined the facility did not ensure beverages were provided as planned for 3 of 13 residents reviewed for menus and nutritional adequacy (Resident #12, 13, and 14). Specifically, Residents #12, 13, and 14 did not receive fluids at meals in accord with their menu slips, comprehensive care plan, and/or preferences. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE December 2, 2009 SURVEY.

Findings include:

1) Resident #14's diagnoses included congestive heart failure (CHF), osteoarthrosis, and diabetes.

The resident's Nutrition Risk Assessment, dated July 9, 2010, documented the resident had a history of fractures including ribs, an ankle and a femur (upper leg bone), a history of low albumin (indicator of protein stores) and skin issues. The assessment documented the resident's protein needs were 65 grams per day; she did not eat meat, and her supplements of super cereal, power potatoes, and double strength milk (fortified foods) remained appropriate, to ensure she met her needs.

The resident's Minimum Data Set (MDS) assessment, dated July 12, 2010, documented the resident made poor decisions, required cues/supervision, and noted the resident had osteoporosis.

The quarterly dietary progress note, dated September 22, 2010, documented the resident continued not to eat meat with meals, received 2 eggs and super cereal at breakfast, power potatoes at lunch, and double strength milk at 3 times a day to meet the resident's protein needs. The note documented the resident was at a moderate nutritional risk, and would continue to be monitored.

The comprehensive care plan (CCP), reviewed September 22, 2010, documented the resident's oral intake should be encouraged at meals to meet her estimated needs. One of the goals documented on the CCP was to maintain and improve the resident's hydration status.

The resident care guide, dated October 4, 2010, and used as guidance for certified nurse aides (CNAs) documented the resident ate in the main dining room and required set-up assistance.

A facility food service computer printout, provided by the facility's registered dietitian (RD)/Food Service Director on October 7, 2010, documented the resident's fluids at meals included:
- at breakfast: 4 ounces of juice, 8 ounces of double strength skim milk, 8 ounces of hot cocoa, and 4 ounces of cold milk;
- at lunch: 4 ounces of a cold beverage, 8 ounces of skim milk, and 8 ounces of hot cocoa/milk;
- at supper: 4 ounces of a cold beverage, 8 ounces of double strength skim milk, and 8 ounces of hot cocoa/milk.

On October 5, 2010 from 5:15 PM to 6 PM, the surveyor observed an activity aide providing the resident with her beverages. The activity aide poured milk from a plastic container into a 8 ounce plastic cup. The surveyor observed the activity person go into the kitchen and heat the cup of milk, and then give it to the resident. There was no cover, and no label, that identified the milk as double strength (DS).

When interviewed on October 5, 2010 at 5:45 PM, the activity aide who served the resident her fluids at supper stated she did not see the "DS milk" specified on the resident's meal ticket. She stated the milk she heated/served to the resident was regular skim milk.

The surveyor observed the lunch meal on October 6, 2010 between 12:15 PM and 12:45 PM, when the resident was provided with an 8 ounce hot beverage. The resident had a 4 ounce cup, and an 8 ounce cup, at her place setting that remained empty during the meal.

When the surveyor observed the breakfast meal on October 7, 2010 between 8:20 AM and 8:55 AM, the resident was not served 8 ounces of double strength milk, until after she completed her meal.

The surveyor interviewed the CNA who passed liquids at breakfast in the dining room on October 7, 2010 at 8:55 AM, (after the resident finished eating.) The CNA stated the resident received special milk that came from the kitchen and that she liked the milk warmed. She said she was getting the milk heated, and had not served it to the resident. She stated she poured the resident's other liquids, and had forgotten the milk.

During an interview on October 7, 2010 at 11:05 AM, the facility's RD stated double strength milk was pre-poured in the kitchen, and it came out of the kitchen on a cart. The RD stated the cover on the milk cup was labelled with the resident's name and double strength milk. The RD said the only staff that would know it was double strength milk was the staff that removed the cover and gave it to the resident, as double strength milk looked the same as regular milk. The RD stated she did not monitor the dining room during meals, because she was supervising the kitchen staff during mealtime.

In summary, the facility did not ensure the resident was consistently provided the type and amount of fluids in accordance with her nutritional assessment, CCP, and her preferences.

2) Resident #13 had diagnoses including diabetes, morbid obesity, and schizoaffective disorder.

The resident's Minimum Data Set (MDS) assessment, dated June 30, 2010, documented the resident had some difficulty with daily decision making in new situations only, required set-up assistance with eating, was 64 inches tall, and weighed 229 pounds.

On September 4, 2010, the resident's physician documented the resident lost 5 pounds, and continued to try to lose weight.

On September 9, 2010, the physician ordered the resident to receive a no salt, no concentrated sweets, low fat, low cholesterol, regular consistency diet.

On September 22, 2010, the facility's diet technician documented the resident's quarterly assessment, including the resident's need for 82 to 90 grams of protein per day, due to a low albumin; she weighed 224 pounds; lost 6 pounds in 1 month; and continued to try to lose weight. The assessment documented dietary provided the resident with 8 ounces of skim milk at all meals, to meet her protein needs; and specified her albumin level was 3.3 g/dl (normal = 3.5 to 5.0 g/dl). The plan documented the resident remained at moderate nutritional risk, and to continue the current meal plan.

The comprehensive care plan (CCP), dated September 22, 2010, documented the resident had a low albumin, and a planned weight loss. The CCP documented the resident's intake should be monitored, and changes/problems should be reported to the interdisciplinary care plan team. The CCP documented the resident should be interviewed for dietary preferences, and the meal pattern should be updated based on the resident's preferences/requests.

A facility food service computer printout, provided by the facility's registered dietitian (RD)/Food Service Director on October 7, 2010, documented the resident was to be provided with 4 ounces of juice, 8 ounces of skim milk, 8 ounces of a hot beverage at breakfast; 4 ounces of a cold beverage, 8 ounces of skim milk, and 8 ounces of a hot beverage at lunch; and 4 ounces of a cold beverage, 8 ounces of skim milk, and 8 ounces of a hot beverage at dinner.

During a dinner meal observation on October 5, 2010 between 5:15 PM and 5:45 PM, the resident was heard telling the dining room staff she did not want the chocolate milk and coffee she had been given. She told staff she wanted cranberry juice and diet cola.

On October 6, 2010 between 12:15 PM and 12:45 PM, the surveyor observed the resident as she ate lunch in the main dining room. The resident's meal ticket documented she was to receive 4 ounces of a cold drink, 8 ounces of skim milk, and 8 ounces of a hot beverage. The resident was observed with 4 ounces of juice, 8 ounces of soda, and 8 ounces of a hot beverage. The resident did not receive 8 ounces of skim milk as planned.

When interviewed on October 7, 2010 at 11:05 AM, the facility registered dietitian (RD) stated the resident came to the dietary office every day and changed what she ordered on her meal ticket every day for several weeks. She stated she did not think it was a problem for the resident not to get milk for a few meals (although it was planned). The RD stated there was no documentation the resident was educated regarding the consequences of not following her planned menu, in relation to her nutritional needs and desire to lose weight.

In summary, the facility did not ensure the resident was consistently provided the type and amount of fluids, according to her nutritional assessment, her CCP, and her preferences.

3) Resident #12 had diagnoses of congestive heart failure, chronic kidney disease, hypertension, and chronic asthma.

The comprehensive care plan (CCP) for nutritional status dated September 1, 2010 documented the resident was at potential/actual alteration in hydration status due to chronic kidney disease, with abnormal lab values. The CCP documented the resident signed waivers refusing honey thick liquids and a low protein diet.

The Minimum Data Set (MDS) assessment, dated August 18, 2010, documented the resident had short term memory problems, had modified independence in decision making skills, with some difficultly in new situations only.

A facility food service computer printout, provided by the facility's registered dietitian (RD)/Food Service Director on October 7, 2010, documented the resident was to be provided with 4 ounces of juice, 4 ounces of milk, 8 ounces of a hot beverage at breakfast; 4 ounces of a cold beverage, 4 ounces of milk, and 8 ounces of tea at lunch; and 4 ounces of a cold beverage, 4 ounces of milk, and 8 ounces of coffee at dinner.

The surveyor observed the resident at lunch on October 6, 2010, at 12:20 PM to receive 3 ounces of milk in a 4 ounce glass, and 6 ounces of coffee in an 8 ounce cup.

The RD was interviewed on October 7, 2010 at 1 PM and stated the resident often requested some fluids not be served, or accepted 4 ounces instead of 8 ounces of fluid when staff passed them out. The RD stated the facility tried to honor the resident's requests; and said there was no way staff could record how much milk the resident consumed every meal.

In summary, the facility did not ensure the resident was consistently provided the type and amount of fluids according to the resident's nutritional assessment, the CCP and her preferences.

10NYCRR 415.14(c)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure 1 of 14 current sampled residents received adequate supervision to prevent accidents (Resident #6). Specifically, Resident #6's specific feeding strategy (no use of straws) was not consistently implemented during survey. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #6 had diagnoses which included Alzheimer's disease and dementia with behaviors.

The Minimum Data Set (MDS) assessment, dated June 18, 2010, documented the resident had short term memory impairment with moderate cognitive impairment, was withdrawn, and needed total assistance of 1 person for eating.

The comprehensive care plan (CCP), dated September 1, 2010, documented the resident was fed by staff, with a plan to use a nosey cup for liquids.

The pocket care guide, used by the certified nurse aides (CNA) to direct care and dated October 5, 2010, documented the resident was fed by staff and were instructed to use "NO STRAWS/use nosey cups."

The surveyor observed the resident on October 5, 2010 at 5:27 PM during the supper meal. As the CNA fed the resident, she gave her liquids from a nosey cup through a straw.

In an interview with the occupational therapist (OT) on October 6, 2010 at 3:10 PM, the OT stated the resident was not to be given liquids via a straw. She said she evaluated the resident, and found it was unsafe for the resident to consume liquids through a straw, as she could not form a seal around it. The OT stated giving the resident liquids through a straw would put the resident at risk for aspiration. She said the directive for using the nosey cup and no straws was specified on the CNA's pocket guide.

On October 6, 2010 at 4:45 PM in an interview with the CNA who fed the resident on October 5, 2010, the CNA stated the resident drank well using the straw. The CNA stated she did not know the resident should not be given liquids through a straw.

In summary the facility did not ensure adequate supervision to prevent accidents was provided, when a planned feeding strategy was not implemented.

10NYCRR 415.12(h)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure injuries of unknown origin were thoroughly investigated for 1 of 2 sampled residents (Resident #4), who had fracture to determine if abuse or neglect occurred. Resident #4 fell, resulting in a fracture, and the facility investigation contained conflicting information. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings included:

Resident #4 had diagnoses which included a right hip fracture, hypertension, chronic obstructive pulmonary disease, depression, and renal insufficiency.

The comprehensive care plan dated April 14, 2010, documented the resident was at risk for falls.

The Minimum Data Set (MDS) assessment dated July 8, 2010, documented the resident had no memory impairment, and had modified independence with daily decision making, that is some difficulty in new situations only. This assessment documented the resident needed extensive assistance of one for bed mobility, transfer, walking in her room, and toilet use. The MDS documented the resident had an unsteady gait, shortness of breath, and had fallen in the past 30 days.

The nursing notes dated August 17, 2010 at 9:49 PM, documented the registered nurse (RN) was called to the resident's room as the resident "had fallen off the toilet." This note documented the resident was assessed and had no significant injuries. Later in the evening the resident complained of back pain and was medicated with Lortab (a narcotic pain reliever) with effect "per usual."

The nursing note dated August 17, 2010 at 11:45 PM documented the resident continued to complain of back pain after the Lortab was administered. "Will monitor."

The Incident/Accident Report dated August 17, 2010 documented the following:
- the resident was found by another resident's family member (a visitor) in the bathroom at 4:15 PM;
- the resident fell from the toilet, and had two skin tears and a bruise on her right hand and arm;
- the resident was last seen by a certified nurse aide (CNA) at 3:30 PM in her wheelchair outside on the patio; and
- the chair alarm was sounding when she was found on the floor. The immediate plan of action was to counsel the resident.

The unsigned employee written statement dated August 17, 2010 documented the resident was returned to her room at "about" 3 PM and stated she had to go to the bathroom. She was put at the end of her bed, and the employee told one of the CNAs who was in the hallway. The employee documented she then left the unit. A written statement by the Director of Nursing (DON) was on the form, which documented the employee (an activity staff member) did not remember if the call bell was left within the resident's reach, and was reminded to be sure the resident could always reach the call bell. The DON documented the resident often used the call bell in the bathroom when she needed toileting.

The licensed practical nurse (LPN) written statement dated August 17, 2010 documented that while she was passing medications, a visitor came out into the hallway and stated a resident had just fallen in the bathroom. The statement documented the LPN "responded to find resident on the bathroom floor."

There was no documented written statement from the visitor who found the resident.

The undated resident's written statement was "I fell into bed". The statement form included a written statement signed by the RN Unit Manager "resident does not recall falling in the bathroom."

The Investigation Summary, dated August 17, 2010, and signed by the DON, documented the following:
- "staff heard alarm sounding went to room found resident lying on BR (bathroom) floor with pants";
- staff last saw resident at 3:30 PM on the patio, alarm was in place, chair alarm was ringing and loud noises were heard, the resident was on the floor with pants partially down;
- all certified nurse aides described the same event;
- resident was at high risk for falls, alarm was on chair with history of self transfer, and care plan was followed.

The nursing note dated August 18, 2010, at 3:47 AM documented the the resident requested and was given Lortab at 2:30 AM for complaints of all over body pain.

The nursing note dated August 18, 2010, at 1:12 PM documented the resident had complaints of right hip and low back pain. There was a large bruise on the resident's inner right thigh. The physician was notified and and an X-ray ordered.

The x-ray report dated August 18, 2010, documented the resident had a displaced fracture of the pelvic bone.

The written statement from the RN Unit Manager dated August 18, 2010, documented a visitor had called her to the room, where the resident was found lying on the bathroom floor on her right side. The resident's pants were partially down and there was stool on the floor "it appears that resident was toileting herself and had fallen. Unable to determine if she fell from toilet or while standing."

The conclusion on the Incident Accident Report dated August 18, 2010, signed by the Director of Nursing (DON), the Administrator, the RN Unit Manager, and the occupational therapist, documented the resident's care plan was followed, the call light was not activated, the chair alarm was sounding, and staff responded promptly. (The Incident Accident Report Summary did not document that a visitor found the resident and alerted staff).

In an interview with the DON on October 6, 2010 at 3:20 PM, she stated she did not interview or obtain a written statement from the visitor who told the nurse the resident was on the floor. The DON said the activity aide did not remember who she told that the resident needed to use the bathroom. She stated several CNAs were present (after the resident was found on the floor) and none of them said the activity person told them. The DON said she "did not have any sense that there was any abuse or neglect." The DON stated the resident's chair alarm was ringing and the care plan was followed.

In summary, the facility did not ensure the resident's injury (fractured pelvis) was thoroughly investigated to determine if abuse or neglect occurred when they:
- did not investigate if the resident was toileted as requested, after being left in her room after an activity.
- did not investigate conflicting information between the Incident Accident Report Summary conclusion and the written statements from staff members (regarding a visitor informing staff that the resident was on the floor, versus staff responding to the chair alarm).

10NYCRR 415.4(b)(3)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure 1 of 2 sampled residents with a physical restraint was restrained only when medically necessary (Resident #6). Specifically, Resident #6's seat belt was not consistently released as planned during the survey. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #6 had diagnoses which included Alzheimer's disease, dementia with behaviors, and depression.

The Minimum Data Set (MDS) assessment, dated June 18, 2010, documented the resident had short term memory impairment, with moderate cognitive impairment; was withdrawn; with decreased social interaction; and needed assistance with ambulation and transferring.

The comprehensive care plan (CCP), dated September 1, 2010, documented the resident was to use an alarming seatbelt in the wheelchair, due to frequent falls, related to advanced Alzheimer's Disease. The CCP included a plan to release the seatbelt every 2 hours to provide meaningful position changes, exercise, range of motion, ambulation, and toileting.

The "Restraint/Device Utilization Review" form (dated September 1, 2010) documented the resident's alarming seatbelt would be continued due to her decreased safety awareness and need for assistance.

Physician orders (dated September 7, 2010) documented the resident was to have an alarming seatbelt for safety.

The pocket care guide (dated October 5, 2010,) and used by the certified nurse aides (CNA) for care information, documented the resident's alarming seatbelt restraint was to be removed during meals.

The restraint record (dated October 5, 2010) documented the resident was out of the alarming seatbelt restraint at 9 AM, in the restraint at 10 AM and 11 AM, and out of the restraint at 12 PM.

The surveyor observed the resident seated in the wheelchair, with the alarming seatbelt restraint applied, on:
- October 5, 2010 at 12:55 PM. The resident was in the dining room being fed lunch. The certified nurse aide (CNA) sat in front of the resident with her legs positioned on either side of the resident's legs.
- October 5, 2010 at 1:30 PM, 2:30 PM, 3:30 PM, 4:30 PM, and 5 PM. The resident sat quietly with her eyes closed, in the common area near the nursing station.
- October 5, 2010 at 5:17 PM. The resident was in the dining room, sitting quietly while supper was being served to other residents.
- October 5, 2010 at 5:27 PM. While being fed supper, the resident was placed next to the table and the CNA sat in front of her with the CNA's legs positioned on either side of the resident. The resident's eyes were closed; the CNA called the resident's name; and told her she had to wake up and eat.
- October 5, 2010 at 5:35 PM. The resident was being fed supper with the CNA's legs positioned on either side of the resident's legs.

The surveyor observed the resident continuously from 9:30 AM to 12 PM on October 6, 2010. The resident sat quietly in her wheelchair, with the alarming seatbelt restraint applied, and her eyes closed. During this observation, the alarming seatbelt remained applied while the resident was taken to be weighed at 10:45 AM, and attended an activity from 11:05 AM until 11:35 AM.

In an interview on October 6, 2010 at 4:45 PM with the CNA (who fed the resident supper on October 5, 2010), the CNA stated the resident would not sit at the table, and would push away from the table. The CNA said she positioned the resident against the wall, while she was in front of her. The CNA said the resident usually had the seatbelt on during meals, because she was "fidgety".

The CNA assigned to care for the resident on the day shift of October 6, 2010 was interviewed on October 7, 2010 at 12 PM. The CNA told the surveyor the resident's restraint was to be released every 2 hours and during meals. She said she got the resident up to her chair at 9 AM, and had not released the resident's restraint after that time. The CNA stated that on October 6, 2010 she was busy helping other staff transfer other residents between 11 AM and 12 PM, and then left the facility for the day. She said the resident did not need to be toileted at 11 AM, because she was toileted at 9 AM.

In summary, the facility did not ensure the resident's restraint was the least restrictive, as the alarming seatbelt was not released during meals, during activities, when the resident sat quietly with her eyes closed for extended periods of time, and when in direct sight of the nursing station.

10NYCRR 415.4(a)(2) and (5)

Based upon observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not provide services that met acceptable standards of quality for 1 of 13 current residents (Residents #8) reviewed for standards of quality and care. Specifically, the facility did not ensure Resident #8 was assessed by qualified staff for possible injury after a fall. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #8 had diagnoses including dementia and Parkinson's disease.

The comprehensive care plan (CCP), dated as reviewed by the interdisciplinary team on January 20, 2010, documented the resident was at risk for falls, related to decreased safety awareness and decreased mobility.

The resident's Minimum Data Set (MDS) assessment, dated July 29, 2010, documented the resident's decision making skills were poor; cues/supervision were required; the resident required extensive assistance of 2 staff for transfers and ambulating in his room/hallway; and required total assistance of 1 staff person for mobility when in his wheelchair.

The resident's CCP was updated after he had multiple falls in 2010, including 2 falls in July, 1 fall in August, and 2 falls in September 2010.

A facility Incident/Accident Report, dated/timed September 29, 2010 at 12:50 PM, documented the resident "tipped himself over backwards in his wheelchair" in an unobserved fall, and did not sustain an injury. The report documented the resident was discovered by a licensed practical nurse (LPN #1). LPN #1 documented the resident was in his wheelchair in the hallway near the shower room, with his tube feeding pump plugged into the wall. LPN #1 specified she heard a loud crash, found the resident tipped over backwards in his wheelchair, with his head resting on the tube feeding machine. A registered nurse (RN) was called to assess the resident. A second LPN (LPN #2) documented the resident's physician was notified at 1 PM and the family was notified at 2:20 PM. There was no documented RN assessment of the resident.

On September 29, 2010, the physician ordered neurological checks every 4 hours for 24 hours due to his fall.

LPN #2's progress notes, dated/timed September 29, 2010 at 2:13 PM, documented staff heard a loud crash, and observed the resident tipped over in his wheelchair with his head lying on the tube feeding machine. LPN #2 documented the resident was assisted upright by staff, a small red mark was noted on his right upper back, and when asked if he hit his head, the resident responded "yes". LPN #1 documented there were "no lumps noted", his pupils were equal and reactive to light; the resident was alert, denied pain, was able to move all his extremities, and responded to stimuli.

The facility could not provide documentation an RN, or other qualified person, assessed the resident after his fall.

The comprehensive care plan (CCP), revised September 29, 2010, documented the resident tipped over backwards in his wheelchair, and his wheelchair anti-tipping devices were replaced.

During an interview on October 6, 2010 at 3:05 PM with the RN notified at the time of the resident's fall (on September 219, 2010), she stated staff had the resident sitting up when she arrived on the unit. She stated she assessed him, and did not think she documented her assessment.

When interviewed on October 6, 2010 at 4:15 PM, the Director of Nursing (DON) stated RN staff should document their resident assessments in the medical record.

In summary, the facility did not ensure the resident was assessed by qualified staff after experiencing a fall, with possible head injury.

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

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not provide a therapeutic diet when prescribed by the physician for 1 of 21 current sampled residents (Resident #12). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #12 had diagnoses of chronic kidney disease, chronic obstructive asthma, and hypertension.

A waiver statement was signed by the resident on August 10, 2010 refusing the recommended low protein diet.

The Minimum Data Set assessment (MDS), dated August 18, 2010, documented the resident had some difficulty in making daily decisions, and displayed short term memory problems.

The comprehensive care plan (CCP), updated on September 1, 2010, documented the resident received a no added salt diet, and had signed a waiver refusing a low protein diet restriction.

Physician orders dated and signed on September 23, 2010 documented a low sodium, low protein diet order.

An interview with the registered nurse (RN) Unit Manager was conducted on October 7, 2010 at 11 AM. She stated she was not sure when the resident signed a waiver refusing the low protein diet. She stated the low protein diet was carried over to the current physician order sheets that were preprinted from pharmacy. The Unit Manager said low protein diet should have been discontinued, after the resident signed the waiver. She stated she was unaware specific physician orders were required to address waiver requests; and was not aware waivers refusing treatment did not give the facility the ability to disregard physician orders.

The facility registered dietitian (RD) was interviewed on October 7, 2010 at 11:30 AM. She stated the resident's diet was documented as regular, with no added salt. She stated the resident signed a waiver refusing the low protein diet "sometime in August" (2010). The RD was unaware a low protein diet was on the current physician orders. She stated she was not aware waivers refusing treatment did not give the facility the ability to disregard physician orders.

The physician was interviewed on October 7, 2010 at 12:10 PM, and stated he was aware the resident signed the waiver refusing the low protein diet. He said he wanted to follow the resident's wishes and would discontinue the current low protein diet order.

In summary, the facility did not provide Resident #12 a therapeutic diet when it was prescribed by the physician.

10NYCRR 415.14(e)

Based on observation and staff interview review conducted during the standard survey, it was determined the facility did not ensure services were provided to maintain a sanitary and orderly interior. Environmental concerns included:
- poorly maintained tile floor surfaces, affecting 10 of 18 sampled resident rooms (resident rooms #100, 102, 103, 113, 114, 206, 209, 210, 213, and 217);
- lighting concerns, affecting 5 of 12 resident rooms sampled (rooms #103, 106, 117, 201, and 211);
- corridor divots, affecting the one main corridor, the only corridor with a concrete floor surface;
- poorly maintained carpets, affecting all carpeted areas of the building;
- ventilation concerns, affecting 2 of 12 sampled resident rooms sampled (rooms #201 and 221);
- furniture in poor condition, affect 1 resident room (#116).
This resulted in no actual harm with potential for minimum harm.
Findings include:

1) Resident room #210 was observed on October 5, 2010 at 3:45 PM. Surfaces in the toilet room (which was shared with room #208) were in poor condition, due to three 1 foot square vinyl floor tiles which were loose (no longer adhered to the floor), one 3 foot section of cove base missing, and one loose 3 foot section of cover base.

When the Environmental Services Director was interviewed on October 5, 2010 between 3:45 and 4 PM, he stated he was not aware floor tiles were coming up in room #210 and was not aware of a work order.

2) The resident room #209 toilet room was observed on October 7, 2010 at 12:07 PM. The floor tiles were stained under the toilet and there was dark wax buildup along the edges. There was a spot of a dark brown foreign substance on the floor.

The resident room #211/213 toilet room was observed on October 7, 2010 at 12:10 PM. The toilet room floor surface was dark/discolored and the floor surface of room #213 was dark/discolored in sink alcove and a 5 by 5 foot area adjacent to the sink alcove and toilet room.

The floor surface in the toilet room of resident room #217 was observed on October 7, 2010 at 12:13 PM; the floor tiles under the toilet were dark /discolored.

The unit Housekeeper was interviewed on October 7, 2010 at 12:15 PM regarding the discolored floor surface in the toilet room of resident room #217. She stated the discoloration was due to wax buildup.

3) During the building tour on October 5, 2010 between 2 PM and 4 PM, light fixtures did not operate properly (1 or more bulbs would not turn on after tested multiple times) in 5 rooms, as follows:
- Resident room #103 window side bottom bulb in the overbed light;
- Resident room #106 top bulb in the overbed light;
- Resident room #117 door side top bulb in the overbed light;
- Resident room #201 top bulb in the overbed light;
- Resident room #211 door side top bulb in the overed light.

When the Environmental Services Director was interviewed on October 5, 2010 between 3 and 4 PM, he stated staff did environmental rounds monthly, and the overbed lights were not routinely checked during environmental rounds.

4) The main corridor (connecting the 2 nursing units with the lobby, therapy, and activity rooms) was observed on October 5, 2010 between 10 AM and 11 AM. The surveyor observed divots/depressed spots in the concrete floor surface in the main corridor near the staff lunchroom, 2 spots outside the social worker's office, and 1 spot outside the activity room.

When the Environmental Services Director was interviewed on October 7, 2010 between 1:15 PM and 1:30 PM, he stated a thin layer of concrete had been poured over the existing concrete floor without all the adhesive being removed, in some spots the new layer of concrete did not adhere very well to the old floor, and the low spots were repaired on an ongoing basis.

5) The surveyor observed the floor in the North and South nursing stations on October 5, 2010 between 10 AM and 11 AM, and between 2 PM and 4 PM. The carpet in both nursing stations was soiled with paper debris and small, hard black spots of foreign matter stuck in the carpet. The carpet in the South nursing station no longer adhered to the floor in the center and the surface was uneven.

When the Environmental Services Director was interviewed October 5, 2010 between 3:30 PM and 4 PM, he stated he was unaware of the facility's plan to address the carpet in poor condition in the nursing stations.

When the surveyor observed North and South nursing stations on October 6, 2010 between 11:30 AM and 11:40 AM, and between 4:10 PM and 4:15 PM, the floor surfaces remained soiled.

The surveyor observed the condition of the carpeted floor surfaces in the 2 nursing stations remained soiled on October 7, 2010 between 9:30 AM and 9:45 AM and between 3:45 PM and 3:55 PM.

The Housekeepers on the North and South unit were interviewed on October 7, 2010, between 9:50 AM and 11 AM. One Housekeeper stated the carpet in the nursing station was normally vacuumed 2 to 3 times per week. The other Housekeeper stated she did not vacuum the carpet in the nursing station.

When the Environmental Services Director was interviewed on October 7, 2010 at 11:15 AM, he stated the carpets in the nursing stations were vacuumed daily, and were no longer scheduled for shampooing.

6) The surveyor observed louvers in the exhaust ventilation grilles in the toilet rooms of resident rooms #201 and #221 to be closed on October 5, 2010 between 2:45 PM and 4 PM. There was no detectable exhaust ventilation when tested at that time.

When the Environmental Services Director was interviewed on October 5, 2010 between 2:45 and 4 PM, he stated he was not aware the louvers had been closed.

7) An upholstered chair in resident room #116 was observed by the surveyor on October 7, 2010 between 9:45 AM and 10 AM. The surface of the chair's arm was split, with foam stuffing protruding.

When the Environmental Services Director was interviewed on October 7, 2010 between 1:15 PM and 1:30 PM, he stated he had not seen the chair in poor condition.

In summary, the environment was not maintained in a sanitary and orderly manner due to tile and carpeted floor surfaces that were discolored, soiled and/or had loose tiles, concrete floor surface that was not maintained in smooth, even condition, lighting fixtures that were not operating properly, and exhaust ventilation that was not operating properly.

10NYCRR 415.5(h)(2), 415.29(j)(1)