Avon Nursing Home, LLC

Based on observations, record reviews, and staff interviews, it was determined that the facility did not store, prepare, distribute, or serve food under sanitary conditions. The issues were inadequate washing of potentially hazardous food and inadequate air drying of dishware. This affected the one main kitchen, resulting in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is widespread. This is evidenced by the following:

1. In an observation on 1/5/11 at 8:40 a.m., fresh melons (cantaloupe) were being prepared for service. There was a melon on the cutting board which had been cut in half, skin intact, and a product label visible on the skin. Another melon was cut into slices. Some slices had been peeled and cut into smaller pieces. When asked at this time about preparation, a Food Service (FS) Worker said she first cut the melon then "kind of washed it." At 8:46 a.m., she said after cutting the melons in half, she rinses them with water, "inside and out." The FS Worker said there was no brush to clean the skin of the melons, and she had been told "just rinsing is enough." On 1/5/11 at 8:50 a.m., a cook joined the discussion and said a brush is to be used to "remove dirt and germs from the ground" from the skin of the melon. She pointed to a brush available for this use. On 1/5/11 at 10:49 a.m., this cook said the melons should have been put into a sink with water, then washed and scrubbed with a brush. She added the melon would not be served.

In an interview on 1/6/11 at 7:50 a.m., the cook and FS Worker said a commercial produce wash was not available.

In an interview on 1/6/11 at 9:00 a.m., the Registered Dietitian (RD) said the kitchen does not have a commercial wash for use and the expectation is that staff will thoroughly wash the skin/surfaces of fresh produce prior to preparation.

In an interview on 1/7/11 at 8:34 a.m., the cook said all the residents would have received the melon if it had been served.

A review of the undated facility policy, "Working in Prep Area," revealed to rinse all raw fruits and vegetables using "victory wash" or adequate substitute. Allow produce to dry, then use as necessary.

2. In an observation of the tray line on 1/5/11 at 11:42 a/.m., three residents were receiving tray service to their room. When pulled apart, water splattered from and was visible on three of three dome lids and bottoms. Additionally, 12 of 13 dome lids and 7 of 8 dome bottoms were wet and had been stacked without air drying. In an interview at this time, a FS Worker said, "I take the domes from the dish machine and stack them right here on the rack--one on top of the other. We don't have a lot of room for air drying."

During an interview on 1/6/11 at 9:00 a.m., the RD said the expectation is that staff will air dry dishware and was not aware there were not enough drying racks in the dish room.

A review of the undated facility policy entitled, "Operating Dish Machine" revealed that staff are to check dishes for cleanliness and ensure all items are air dried before stacking on proper racks and dollies.

[10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.81, 14-1.116]

Based on observations and staff interviews, it was determined that the facility did not properly equip corridors with handrails. The issue was related to a resident use corridor that did not have a handrail. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY of 12/30/09. This affected one of four smoke zones, resulting in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

An observation on 1/5/11 at 3:05 p.m. revealed that an approximately 6 foot long section of the corridor in smoke zone #4 did not have a handrail. This section of the corridor includes the main office desk and leads into the dining room/television lounge.

Observations made on 1/6/11 include the following:

a) At 9:01 a.m., Resident #39 walked independently without an assistive device from the Dining/TV lounge through the corridor. At this time, half the corridor was wet from mopping.

b) At 12:02 p.m., Resident #18 walked unassisted along the corridor with a four wheeled walker into the Dining /TV lounge area.

c) At 9:21 a.m., Resident #5 entered the corridor unassisted using a four-wheeled walker and walked into the Dining/TV lounge.

When interviewed on 1/6/11 at 12:14 p.m., the Activities/Hospitality aide stated that residents do use the corridor to go into the Dining Room/ TV lounge.

During an interview on 1/6/10 at 12:42 p.m., the Environmental Services Director stated he added handrails to areas specified under the previous deficiency. When asked if other areas were assessed for handrails as per the Plan of Correction, he stated there were no other areas that needed handrails. When shown the area along the corridor leading into the TV lounge, he was not aware that it needed a handrail. He stated residents walk on the other side of the hall into the lounge. At this time, the Administrator joined the conversation and stated this corridor was not cited in the previous deficiency and was not addressed as an area that needed a handrail.

[10 NYCRR 415.29]

Based on an observation, record reviews, and staff interviews, it was determined that for two of three residents reviewed for nutrition care planning, the facility did not monitor nutrition interventions to allow for evaluation of the resident's response, outcomes and needs, and to revise the nutrition care plan as necessary. The issue involved lack of documented intake of nutritional supplements served with meals. This affected Residents #36 and #44, resulting in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #36 has diagnoses including dementia and depression. The nutrition care plan (CP), dated 12/21/10, revealed that the resident has a history of poor appetite and weight loss, and receives supplements as needed. The meal tray cards currently in use show that the resident receives an 8-ounce health shake at breakfast and lunch, and 4 ounces of ice cream at lunch and supper.

During an interview on 1/5/11 at 11:22 a.m., the Licensed Practical Nurse (LPN) reported that individual tray supplement intake is not recorded on the daily intake board. The LPN explained that not all residents are monitored for intake daily, and if they are, fluid intake is recorded in ounces consumed and food solids as a percentage eaten. The types of fluids or solids are not identified.

In an interview on 1/6/11 at 9:00 a.m., the Registered Dietitian (RD) said there is no system in place to track or monitor the daily intake of specific tray supplements.

2. Resident #44 has diagnoses including dementia, depression, and Parkinson's disease. The nutrition CP, dated 12/21/10, revealed that the resident has a history of poor appetite and includes providing supplements as needed. The meal tray cards currently in place show that the resident receives high calorie, high protein "power potatoes" at lunch and supper. A review of the documented weights revealed that the resident experienced a significant weight change from 9/24 to 10/6/10 (20.4 pound loss/15 percent of body weight). The resident's weight since then ranged between 110.8 lbs. and 116.2 lbs.

In an interview on 1/6/11 at 9:00 a.m., the RD said the resident's name would be placed on the intake board for reasons including admission, Minimum Data Set Assessment purposes, and weight loss. She added that, at this time, the records kept on the intake board for meals does not separate supplement intake from meal intake, and a resident would only be monitored daily if a problem had been identified.

In observation of the lunch meal on 1/7/11 at 12:25 p.m., the resident was eating her power potatoes.

[10 NYCRR 415.11(c)(2)(i-iii)]

Based on observations, staff interviews, and record reviews, it was determined that for one of four residents observed for transfers the facility did not provide adequate supervision and assistance devices to prevent accidents. The issue involved the unsafe transfer of Resident #29 and the geri chair that was not locked during this transfer. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #29 has diagnoses including dementia with agitation, a history of a cerebral vascular accident, and a spinal compression fracture.

The 1/22/10 admission Minimum Data Set Assessment (MDS) revealed that the resident's cognitive skills for decision making are moderately impaired, the resident is socially inappropriate daily, and requires the assist of two for transfer.

The Certified Nursing Assistant (CNA) resident specific/accountability sheet, revised 10/8/10, revealed that the resident requires the assist of two for transfer, and a ready stand is used as a last resort.

The Comprehensive Care Plan, revised 12/28/10, revealed that the resident has the potential for decrease in activities of daily living (ADL) related to dementia. The approach is to monitor for decrease or increase in ability to perform ADLs.

When observed for care on 1/5/11 at 10:37 a.m., the resident was assisted by two CNAs. CNA #2 assisted the resident to a sitting position by lifting the resident's leg and sitting him upright on the side of the bed. CNA #1 was wearing a gait belt, but no attempt was made to apply it to the resident. Both CNAs held the resident under his arms, grabbed the back of his pants, and transferred him to an unlocked geri-chair. This chair moved back while the resident was being transferred. CNA #1 pulled the chair toward the resident by grabbing the armrest when the chair moved and held the resident with one hand under his arm. The resident was cooperative during the transfer.

When interviewed on 1/5/11 at 2:00 p.m., the Physical Therapist/Director of Rehabilitation said that currently the resident is a two person transfer. If the resident is unwilling to do the transfer, the CNAs are allowed to use the ready stand. The CNAs make the determination to use the lift. If CNAs are not using a ready stand, they should be using a gait belt.

When asked about the resident's transfer status on 1/5/11 at 2:25 p.m., both CNAs said, "You have to know he does not cooperate. Sometimes he fights us. We decide how to transfer him. It is on our assignment sheet; it says to use the lift as a last resort. We decide if he is going to use it."" CNA #1 said, "Yes we should have used the gait belt. We let the nurse know if he has a problem with transfers."

In an interview on 1/5/11 at 2:43 p.m., the primary Licensed Practical Nurse (LPN) stated that staff discuss this resident all the time because he does not always cooperate. The lift or a pivot transfer can be used. The aides can decide when to use the lift. They would tell her if there was a problem.

Review of the facility's policy entitled, "Gait Belt Transfer," dated 1/31/08, revealed the resident's transfer status would be determined by the Physical Therapist and outlined in the resident's plan of care.

[10 NYCRR 483.25(h)(2)]

Based on family and staff interviews, and record reviews, it was determined that for one of three residents reviewed for nutrition the facility did not ensure that a comprehensive assessment of nutritional status was thoroughly documented in a timely manner to ensure that the resident's body weight was maintained within acceptable parameters. Specifically, Resident #44 experienced a 20.4 pound weight loss, or 15.5 percent body weight, from 9/24 to 10/6/10, which was not assessed for the potential cause and subsequently not addressed in the comprehensive care plan. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #44 was admitted to the facility on 9/24/10 after hospitalization for a right hip fracture and has diagnoses including Parkinson's disease, dysphasia (difficulty swallowing), dementia, hypothyroidism, and depression. The Minimum Data Set Assessment, dated 10/5/10, revealed that the resident requires supervision with meal setup for eating and has a poor appetite. The Certified Nursing Assistant (CNA) resident specific care sheet, last revised on 11/22/10, revealed that the resident receives thickened liquids and is independent with meals after setup.

Weights recorded on the 2010 Weight Record include the following: 9/24, 128.4 pounds (lbs.); 10/3, 131.2 lbs.; 10/6, 110.8 lbs.; 10/15, 113.4 lbs.; 10/18, 113.2 lbs.; 11/2, 116.2 lbs.; 11/10, 116 lbs.; 11/26, 111.5 lbs.; and 12/3, 113.2 lbs.

The medical evaluation and treatment plans, dated 11/17 and 12/1/10, both documented that the resident experienced a weight loss of 15 lbs. in 30 days but lacked an evaluation of the cause of this weight loss.

Nutrition notes revealed the following:

a) On 9/27/10, the resident's readmission weight was recorded at 125 lbs. A reweigh was requested, as the resident's weight during a July 2010 admission was 109 lbs.

b) On 11/2/10, the resident's weight was 131 lbs., up 2 percent from last month. This assessment did not address weights recorded on 10/6, 10/15, and 10/18/10, which documented an 18 lb. weight loss, approximately 14 percent weight loss, over a three-week time span.

c) On 11/29/10, the monthly weight was 116 lbs., down 9 percent from last month. The Registered Dietitian (RD) noted that the resident receives Lasix and that she spoke to nursing about the resident's weight loss. This assessment did not address weights recorded on 11/10 and 11/16/10, which documented further weight decline; overall 19.7 lbs./15 percent weight decline in two months.

d) On 12/13/10, a nutritional quarterly review note revealed that the resident's weight is down 3 lbs. This assessment also did not address weights recorded on 11/10 and 11/16/10.

During an interview on 1/6/10 at 9:00 a.m., the RD stated that she learned from the Physical Therapist (PT) that the resident had swelling and was losing weight due to fluid in her hip and that she had discussed this with the PT and nursing. The RD said she thought the significant weight loss that presented on 10/3/10 was related to this fluid loss and at the same time verified that nursing, the PT, and nutrition had not documented this in the record.

[10 NYCRR 415.12(i)(1)]

713-2.2 - Nursing units

(c) Service areas. The service areas described in this subdivision shall be located in, or be readily accessible to, each nursing unit. The size and location of each service area will depend upon the number and types of residents served and the efficiency of the facility's staffing patterns. Although identifiable spaces are required to be provided for each of the indicated service areas, consideration will be given to design solutions which would accommodate some services without a specific designation of areas or rooms. Decentralized service areas within nursing units will be encouraged. The following service areas shall be provided:

(12) Residents' bathing facilities. Bathing rooms for scheduled bathing shall be provided on each nursing unit at a ratio of one bathing fixture for each fifteen (15) residents or fraction thereof, who are not otherwise served by bathing facilities within resident's room and shall be located away from public areas of the nursing unit. Each tub or shower shall be in an individual room or enclosure with space provided for the private use of the bathing fixture, for drying and dressing, and for a wheelchair and an attendant. The dressing area and the showers, without curbs, shall be designed to permit use by a wheelchair resident with staff assistance.

Based on observations and a staff interview, it was determined that the facility did not comply with Subpart 713-2, Standards of Construction for New Nursing Homes. The issue was related to an inadequate ratio of bathing/showering facilities to the number of residents. This affected the entire facility, and resulted in no actual harm with the potential for minimal harm that is widespread. The findings are:

Observations during the tour of the resident environment on 1/4/11 at 8:50 a.m. revealed the facility has two showering rooms, each of which has a single showering fixture (head). A tub room is also present but the space has been converted into a storage room to store items such as pads, fall mattresses, toilet chairs, tubing, and shelving with clothes. In an interview at this time, the Director of Environmental Services stated that the fixture is no longer used or available for resident use.

Current building construction standards require that b athing rooms for scheduled bathing shall be provided on each nursing unit at a ratio of one bathing fixture for each fifteen (15) residents or fraction thereof, who are not otherwise served by bathing facilities within residents' rooms and shall be located away from public areas of the nursing unit. At the time of the survey, the census was 40, and the facility is certified for 40 beds. Therefore, the facility must have a minimum of three bathing fixtures for residents to use.

Based on record review, it was determined that for one of six employee files reviewed for the Criminal History Record Checks (CHRC), the facility did not have complete documented evidence of employee supervision while the facility was awaiting CHRC results. This resulted in a pattern of no actual harm with the potential for more than minimal harm, and is evidenced by the following:

When reviewed on 1/5/10 at 10:00 a.m., one employee personnel file lacked proper documented evidence of supervision during the period between their hire date and the facility receipt of CHRC final determination results. The employee had a start date of 3/24/10, and the facility received a negative determination letter on 6/1/10. A final determination letter, dated 6/25/10, stated that the employee was approved to work. The facility provided documentation that the employee was supervised weekly, however, the record lacked supervision documentation between 4/18 - 4/29/10, and from 5/30 - 6/24/10. The Director of Environmental Services then provided documentation which showed the employee had worked during the above timeframes for which supervision was not documented.

[10 NYCRR Section 402.4(b)(i), 402.6(d)]

Based on record reviews and staff interview, it was determined that for 3 of 13 residents reviewed for the Pre-Admission Screening and Resident Review (PASRR) qualified screener's ten digit identification number (ID#) assigned by the New York State Department of Health was not accurate. This resulted in a pattern of no actual harm with potential for minimal harm for Residents #12, #24, and #44, and is evidenced by the following:

1. Resident #12 was admitted on 11/19/10 with diagnoses including dementia and subarachnoid hemorrhage. The Screener ID# on the PASRR contained only eight digits.

2. Resident #24 was admitted on 8/24/10 with diagnoses including depression. The PASRR Screener ID# only contained eight digits.

3. Resident #44 was admitted on 9/24/10 with diagnoses including Parkinson's disease, dementia, and depression. The PASRR Screener ID# only contained eight digits.

When interviewed on 1/5/11 at 11:40 a.m., the Social Worker stated she does not check the Screener ID# to ensure there are ten digits.

[10 NYCRR 400.11]

Based on observation, staff interviews, and review of medication literature, it was determined that for one of one medication room and for residents receiving influenza vaccines, the facility did not ensure proper labeling of medication. The issues involved three vials of Flulaval (flu vaccine) that were not dated when opened. This resulted in a pattern of no actual harm with potential for more than minimal harm, and is evidenced by the following:

When observed on 1/6/10 at 9:50 a.m. with the medication Licensed Practical Nurse (LPN), three of five multidose vials of flu vaccine were opened and undated. When interviewed at this time, the LPN said she did not know how long flu vaccine was good for after being opened, but they should be dated. When interviewed at 9:58 a.m. that day, the Director of Nursing said she believed that flu vaccine was good for 30 days after being opened, and the opened vials should be dated.

Manufacturer's product information states, "Once entered, a multidose vial, and any residual contents, should be discarded after 28 days."

[10 NYCRR 415.18(d)]

Based on observations and document review conducted during the Life Safety Code survey, it was determined that the facility did not provide a compliant automatic sprinkler system. The issues were related to obstructions to sprinkler head spray patterns and an area that lacked sprinkler protection. This affected portions of three (Zones 1, 2, and 4) of four smoke compartments and one of one main entrance, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

During the initial tour of the resident environment on 1/4/10 from 8:20 a.m. to 12:48 p.m. observations revealed the following areas contained sprinkler heads that were obstructed by ceiling mounted devices located in close proximity to the sprinkler heads:

1. In the wheelchair room (Zone 2), the sprinkler head's deflector plate extends down 2 inches from the ceiling and is located 5.5 inches from an approximately 10-inch x 4-foot long ceiling mounted light fixture that extends down 2 3/4 inches from the ceiling.

2. In the training bathroom next to the linen room (Zone 2), the sprinkler head's deflector plate extends down 2 inches from the ceiling and is located 5.5 inches from an approximately 10-inch x 4-foot long ceiling mounted light fixture that extends down 2 1/2 inches from the ceiling.

3. In the shower room next to physical therapy (Zone 2), the sprinkler head's deflector plate extends down 2 inches from the ceiling and is located 4 inches from an approximately 10-inch x 4-foot long ceiling mounted light fixture that extends down 3 1/2 inches from the ceiling.

4. In the receptionist area across from the main entrance (Zone 2), a sprinkler head's deflector plate extends down 2 inches from the ceiling and is located 4 inches from an approximately 10-inch x 4-foot long ceiling mounted light fixture that extends down 3 1/2 inches from the ceiling.

5. In the ladies locker room (Zone 4), the sprinkler head's deflector plate extends down 2 inches from the ceiling and is located 5 inches from an approximately 10-inch x 4-foot long ceiling mounted light fixture that extends down 3 1/2 inches from the ceiling.

6. In the employee break room (Zone 4), each of the two sprinkler head's deflector plates extends down 2 inches from the ceiling and are located 9 inches from ceiling mounted light fixtures that are approximately 10-inches x 4-feet long and extend down 3 1/2 inches from the ceiling.

7. In the activities room (Zone 4), the sprinkler head's deflector plate extends down 2 inches from the ceiling and is located 6 inches from an approximately 10-inch x 4-foot long ceiling mounted light fixture that extends down 3 1/2 inches from the ceiling.

8. In the hallway outside Rooms #25 and #26 (Zone 1), a sprinkler head's deflector plate extends down 2 inches from the ceiling and is located 6 inches from a 12-inch diameter circular ceiling mounted light fixture that extends down 6 1/2 inches from the ceiling.

9. Additionally, observation on 1/5/11 at 9:30 a.m. revealed the front entrance to the building has an overhang area that is approximately 15 feet long x 8 feet wide and is comprised of wood supports and a partial wood ceiling. This area was not provided with sprinkler protection. The Administrator provided the surveyor with a document from a contractor that stated the canopy is to be sprinklered this year, but did not specify a completion date. A complete automatic sprinkler system providing full coverage of the building (in accordance with NFPA 13) is required due to the building construction type (Type III, 211). A Type III building construction type refers to a mix of combustible and non-combustible structural elements.

The 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems, requires that for standard pendant and upright sprinkler heads, horizontal and vertical distances related to separation between obstructions and sprinkler head deflector plates must conform to Table 5-6.5.1.2 "Positioning of Sprinklers to Avoid Obstructions to Discharge." For example, this table requires obstructions that are within 12 inches of the deflector plate to be even with or higher than the deflector plate. NFPA 13 also requires sprinklers to be installed under exterior roofs or canopies exceeding 4 feet (1.2 m) in width.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.1.6.2, 19.3.5.1, 9.7.1.1; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 13 1999: 5-6.5.1.2, 5-13.8.1]