Chittenango Center for Rehabilitation and Health Care

Deficiency Details, Certification Survey, October 28, 2011

PFI: 0403
Regional Office: Central New York Regional Office

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F364 483.35(d)(1)-(2): FOOD PROPERLY PREPARED, PALATABLE, ETC.

Scope: Widespread

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

Each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; and food that is palatable, attractive, and at the proper temperature.

Citation date: October 28, 2011

Based on observations, record reviews and staff and resident interviews conducted during the standard survey, it was determined for all residents, including Residents #3, 5, 8, 12, 17, 18, 19, 20, 21, and 9 anonymous residents at the group meeting, the facility did not ensure food was prepared by methods to conserve flavor, and did not serve food that was palatable or at proper temperatures. Specifically, Residents #5, 17, 18, 20, and 9 anonymous residents at the group meeting reported concerns with food temperature and taste. Residents #3, 8, 12, 19, and 21 were not provided with meals that were palatable or at proper temperature. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

PALATABILITY AND TEMPERATURE CONCERNS:
1) During a supper meal observation on October 24, 2011 between 6 PM and 7:20 PM, the following interviews were conducted:
- Resident #5 stated his supper meal was usually cold when he received it.
- Resident #17 said the food was "always cold" and the coffee was served "warm" not hot.
- Resident #20 stated she always ate in her room, and the hot food served at supper was usually cold and not well-seasoned.

During the initial kitchen inspection on October 24, 2011 at 6:35 PM, the dietary Supervisor stated in an interview, the facility performed daily test trays at lunch, and the temperatures were not always taken at the time the last resident was served and assisted.

On October 25, 2011 between 9:05 AM and 9:40 AM, Resident #18 stated to the surveyor, the scrambled eggs, toast, and hot cereal were always served cold. He was finished with his breakfast and did not eat those foods.

On October 26, 2011 at 7:40 AM, a cart with coffee in air pots was delivered to the A Wing. At 8 AM, a cart with breakfast trays was delivered to the A Wing. At 8:12 AM, the registered nurse (RN) Manager from the B Wing passed the first breakfast tray to a resident on the A Wing. At 8:41 AM, Resident #3 was provided with and assisted with the meal. Staff did not offer to re-heat the food. At 8:42 AM, Resident #19 was assisted, and at 8:43 AM, Resident #12 was served and assisted. Staff did not offer to re-heat the food for Residents #12 and 19.

On October 26, 2011 at 8:43 AM, at the time the last resident was served, a test tray was sampled (43 minutes after the tray was delivered). The eggs tasted cold and were 99 degrees F (Farenheit). The toast tasted luke-warm and was soggy. The surveyor did not taste the coffee as the A Wing ran out of coffee at 8:34 AM and additional coffee was not delivered. The cranberry juice was mostly frozen with 2 blocks of ice in the container.

At 8:45 AM, on October 26, 2011, the registered dietitian (RD), who was present on the A Wing during the breakfast meal, was interviewed. She stated her role during meals included conducting meal rounds and monitoring residents. She did not complete test trays or pass meal trays. She stated she thought it took about 20 minutes to pass meal trays on both of the nursing units.

During the resident group meeting held on October 26, 2011 at 11 AM, 9 out of 13 anonymous residents stated breakfast was often served cold. Five residents stated they often run out of coffee and residents verbalized their toast was often served without butter.

The breakfast meal was observed on the B Wing on October 28, 2011. At 9 AM, there were 5 unidentified residents who had not received breakfast trays. Between 9 AM and 9:25 AM, 3 unidentified residents were served. At 9:25 AM, Residents #8 and 21 were served. Staff did not offer to re-heat or replace the meals served at 9 AM or 9:25 AM.

The Food Service Director stated in an interview on October 28, 2011 at 11:50 AM, the trays were delivered to the B Wing that morning at 8:15 AM. Residents #8 and 21 were served meals an hour and 10 minutes after the trays were delivered. She stated she did not monitor the time trays were delivered to the units or how long it took to pass trays. She completed test trays at lunch only and the pass times times for 2 test trays done in the past week at lunch meals for October 24 and October 25, 2011 for the B Wing was 8 to 10 minutes. No pass times were available for breakfast or dinner meals.

In summary, the facility did not ensure food served to residents was palatable and at proper temperatures.

TASTE CONCERNS:
2) On October 24, 2011 between 6:15 PM and 6:50 PM, the supper meal was observed. The french fries (steak fries) observed in the kitchen at 6:15 PM, appeared overcooked with a dark brown and crusted surface. Residents in the dining room were served received the overcooked french fries. One unidentified resident showed the surveyor a french fry and, as she pulled it apart, stated, see, "they are very rubbery". The residents at the table stated the "dietitian" came to the table and said she knew they were not good.

The evening cook was interviewed on October 24, 2011 at 6:15 PM, and she stated she was aware that the french fries were overcooked, and she has had this problem the last 3 times they were on the menu.

In an interview with the cook and dietary Supervisor on October 24, 2011 at 6:50 PM, the Supervisor stated when he started working at the facility in June 2011, they did not utilize a fryer for making french fries. He stated at that time, he noticed the quality of the french fries was not good when they were baked. The cook stated she also tried different methods of baking the french fries to maintain their taste and appearance as the facility no longer had a deep fryer. They showed the surveyor the box of frozen french fries in the walk-in-freezer. The instructions written on the side of the box were to deep fry the product in a fryer. The Supervisor stated he was not aware the fries should not be baked in an oven. They both stated they told the Food Service Director their concerns in the past. The Supervisor stated he was told that when the facility changed to its winter menu at the end of the month, french fries were not going to be on the menu anymore as they were not an acceptable product.

During the resident group meeting held on October 26, 2011 at 11 AM, 8 of 13 anonymous residents stated the french fries were not good. The residents said they had discussed the french fries at several previous resident council meetings.

The facility's undated recipe for french fries documented the facility prepared french fries by baking them in the oven.

In summary, the facility did not ensure the french fries served were palatable when they did not prepare them in the method recommended by the manufacturer.

3) On October 24, 2011 at 6:50 PM, the kitchen was observed. The surveyors observed the facility had liquid, pasteurized eggs and non-pasteurized shell eggs in the walk-in refrigerator.

The Food Service Director was interviewed on October 25, 2011 at 9 AM, and stated they did not use pasteurized in-the-shell eggs, but they did cook the non-pasteurized eggs to the required temperature. She said they recorded the temperature of poached eggs in the log book at the beginning and end of the tray line. The Food Service Director stated the poached eggs served at breakfast on October 24, 2011 had and internal temperatures of 173 degrees F (Fahrenheit) at the beginning of the tray line.

During the resident group meeting held on October 26, 2011 at 11 AM with 13 anonymous residents present, the residents stated soft boiled eggs and poached eggs were on the menu and the eggs were always served hard. One resident described the poached eggs as eggs "glued together", and another stated the soft boiled eggs "came through as ping pong balls, they bounced".

The cook was interviewed on October 27, 2011 at 9:20 AM, and she stated the recorded temperature for the poached eggs served for breakfast on October 26, 2011 was 165 degrees F at the beginning of the tray line. She stated they stopped buying the pasteurized in-the-shell eggs months ago.

In summary, the facility did not ensure soft boiled and poached eggs were palatable when served to residents.

10 NYCRR 415.14(d)(2)

F312 483.25(a)(3): ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Citation date: October 28, 2011

Based on observations, interviews and record reviews conducted during a standard survey, it was determined the facility did not provide the necessary care and services regarding activities of daily living (ADL's) for 3 of 13 residents (Residents #9, 13 and 14), reviewed for ADL concerns, for 7 of 13 anonymous residents who attended the group meeting and 11 residents outside of the sample (Residents #22, 23, 24, 25, 26, 27, 29, 30, 31, 32 and 33). Specifically, Residents #13, 22, 23, 24 and 25, did not receive timely incontinence care to meet their toileting needs; Residents #13, 26, 27, 29, 30, 31 and 32, did not receive timely assistance to maintain good nutrition; and Residents #9, 13, 14, 27, 32 and 33 did not receive timely morning (AM) care to maintain good grooming or assist them to rise at the planned time. This resulted in no actual harm, with the potential for more than minimal harm, that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF January 20, 2011.

Findings Include:

Toileting Needs
1) Resident #22 had diagnoses including post polio syndrome, anemia, and spinal stenosis (narrowing of the spine).

On October 28, 2011, Resident #22 asked to speak to the surveyor at 8:55 AM. The resident, stated she was very upset as her toileting needs had not been met on the night shift. She said the night shift (11 PM to 7 AM) certified nurse aide (CNA) usually assisted her with morning care at 5:30 AM, which included her toileting needs, per the resident's request. She stated only one CNA worked on the unit "last night", and her toileting needs were not met until the day CNA arrived. She stated she was assisted after 7 AM and, as a result, she was "soaked".

The Minimum Data Set (MDS) assessment dated July 28, 2011 documented the resident was cognitively intact. The MDS recorded the resident required total assistance with toileting needs and was incontinent of bowel and bladder.

The undated resident care card, (used by the CNAs to direct care) documented staff were to offer the resident a fracture pan (bed pan) at night. The care card recorded the resident was on a toileting schedule of every 2 to 4 hours while awake.

At 11:15 AM on October 28, 2011, CNA #1 stated in an interview, "only one" CNA had worked on the night shift and was not able to get everyone up who was assigned to be assisted on the night shift. She said when there was only one CNA working, the CNA was "suppose to" get 4 people up, and if 2 CNAs were working, they were "suppose to" get 8 people up. If not able to get the residents up, CNA #1 stated the aide should "at least have them dry". She stated Resident #22 was incontinent and was "very upset" when she assisted her at 7:30 AM as she usually received care between 5 AM and 5:30 AM.

2) Resident #23 had diagnoses which included dementia, a decrease in function, and diabetes.

On October 28, 2011 at 8:55 AM the resident stated in an interview she was upset as she was not assisted on the night shift as planned, and she was "soaked" when assisted by the CNA on the day shift after 7 AM. She stated she had her call light on at 6:40 AM and did not receive assistance until 8 AM.

The MDS assessment dated September 15, 2011 documented the resident was moderately impaired cognitively, and required extensive assistance with toileting needs.

The undated resident care card (used by the CNAs to direct care) documented the resident was: occasionally incontinent; required extensive assistance of 1 person with toileting needs; was on a toileting program; and was to be offered a bedpan at night.

At 11:15 AM on October 28, 2011, CNA #1 stated in an interview, "only one" CNA worked on the night shift and was not able to get everyone up who was assigned to be assisted on the night shift. She said when there was only one CNA working, the CNA was "suppose to" get 4 people up, and if 2 CNAs were on the unit, they were "suppose to" get 8 people up. If they were not able to get the residents up, CNA #1 stated the aide should "at least have them dry." CNA #1 said the resident was "usually continent", was the "first person" she assisted that morning, and was "a little" wet.

3) Resident #13 had diagnoses which included Parkinson's disease, dementia, and functional quadriplegia (complete immobility).

The Minimum Data Set (MDS) assessment dated July 28, 2011 documented the resident was severly impaired cognitively. The MDS recorded the resident required total assistance with toileting needs and was described as always incontinent.

The undated resident care card (used by the certified nurse aides to direct care) documented the resident wore an incontinence brief and was not on a toileting plan.

At 11:15 AM on October 28, 2011, during an interview, CNA #1 said Residents # 13, 24 and 25 were "ridiculously" wet when she provided care "this morning." CNA #1 stated "only one" CNA worked on the night shift and was not able to get everyone assigned up in the morning. She said when there was only one CNA working the night shift, the CNA was "suppose to" get 4 residents up. CNA #1 stated if the night CNA was not able to get the residents up they should "at least have them dry."

During the resident group meeting held on October 26, 2011 at 11 AM, 7 of 13 residents verbalized they were not having their care needs met in a timely manner. This included: receiving morning (AM) or bedtime (HS) care, toileting needs, and receiving meals in a timely manner.

In summary the facility did not ensure residents received timely assistance with their toileting needs.

Assistance with Morning Care
4) Resident #9 had diagnoses which included depression and hypertension.

The Minimum Data Set (MDS) assessment dated August 25, 2011, documented the resident was cognitively intact. The MDS documented the resident required extensive assistance with transferring, dressing and personal hygiene.

The comprehensive care plan (CCP) dated September 15, 2011, documented the resident required extensive assistance of 1 person for bathing and dressing. The CCP noted the resident transferred with a rolling walker and extensive assistance of 1 person.

On October 24, 2011, the resident stated during an interview at 6:50 PM, she hoped to attend the Resident Council meeting on October 26, 2011 at 11 AM, as staff did not always get her out of bed before 11 AM. She stated she preferred to be up right after breakfast.

On October 28, 2011, at 11:05 AM, CNA #1 was heard informing the social worker that the CNA who was responsible for the resident's care, knew "a half hour ago" the resident wanted to get out of bed. The social worker, was interviewed, immediately after the CNA spoke to her, and stated the resident called her by telephone and told her she was upset and wanted to be up in time for the meeting with the surveyors at 11:30 AM.

The CNA providing care to the resident was unable to be interviewed at that time, as she was busy providing morning care to the residents on her assignment.

At 11:15 AM on October 28, 2011, CNA #1 was interviewed by the surveyor and stated care was late that morning as there was one CNA on the night shift, and that CNA was not able to get all the residents up who were part of the night shift assignment. She stated the resident was in bed waiting for care and was supposed to be up no later than 10:30 AM.

At 11:45 AM, on October 28, 2011, CNA #2 was observed transporting the resident over to speak to the surveyors. The resident was interviewed at that time and stated, after the surveyor told her the resident group meeting was delayed, that she wanted to get out of bed anyway. The resident stated she liked to get up right after breakfast and CNA #3 kept delaying the time she got her up. The resident said CNA #3 would tell her she had to get other residents up before getting her up. The resident stated she had asked to get up at 9:50 AM that morning.

In an interview at 11:45 AM on October 28, 2011, CNA #2, stated the staff usually allow residents to decide what time they get up each day. CNA#2 said "we do put her (Resident #9) off sometimes" as the resident told the CNAs it was OK. CNA#2 stated she had "just 10" residents on her assignment today and 2 residents had not yet been assisted. She said normally, all residents have received their morning care by 11 AM.

5) Resident #14 had diagnoses which included depression, a non-healing surgical wound of the scalp and glaucoma with blindness.

The Minimum Data Set (MDS) assessment dated August 16, 2011 documented the resident was cognitively intact, required extensive assistance with transferring, dressing and personal hygiene.

The comprehensive care plan (CCP) dated September 2, 2011, documented the resident needed assistance with activities of daily living (ADL) due to impaired mobility and blindness. The CCP recorded the resident needed extensive assistance of 1 person for dressing and bathing.

On October 26, 2011, the resident was interviewed 4:40 PM and stated staff assisted him out of bed in the morning and he ate his breakfast in his room, in his wheelchair, between 8:30 AM and 9:30 AM. The resident stated it's "OK" if he got up at that time, and said he then frequently waited until 10 AM or 10:30 AM to receive assistance getting dressed. In speaking to the resident, he verbalized further concern that he had "stubble" as the CNA did not have time to shave him on his shower day (October 24, 2011) and the CNA had not "been able to do it" since. The resident stated the following day (October 27) was a shower day and he had hoped the CNA would have time to shave him then.

During an interview on October 28,2011, at 11:45 AM, CNA #2 stated she "just got him (the resident) up" and he "wasn't too mad" as his family member was not coming to visit. The CNA stated she got residents up but did not get them dressed until "later".

6) Resident #13 had diagnoses which included Parkinson's disease, dementia, and functional quadriplegia (complete immobility).

The Minimum Data Set (MDS) assessment dated July 28, 2011 documented the resident was severly impaired cognitively. The MDS recorded the resident required total assistance with transferring, dressing, eating, and personal hygiene.

The undated resident care card (used by the certified nurse aides to direct care) documented the resident was to eat meals in the dining room.

During the resident group meeting held on October 26, 2011 at 11 AM, 7 of 13 residents verbalized they were not having their care needs met in a timely manner. This included: receiving morning (AM) or bedtime (HS) care, toileting needs, and receiving meals in a timely manner.

At 11:15 AM on October 28, 2011, CNA #1 was interviewed by the surveyor and stated Residents #13, 27, 32 and 33 were fed breakfast in their rooms as they did not receive morning care in time to go to the dining room. She said their normal routine was to have all meals in the dining room.

In an interview on October 28, 2011 at 12:40 PM, the DON stated when shifts were short-staffed it was a "trickle down" problem and all subsequent shifts were trying to catch up. She stated residents should be up and dressed according to their preference and if their preference was not known, residents should be up and dressed "for breakfast."

In summary, the facility did not ensure residents received timely assistance with their AM care needs.

Feeding Assistance
Observations made on October 24, 2011 at 6:15 PM showed:
- Residents #13, 26, 27, 29, 30, 31 and 32 seated at 2 tables (tables #1 and 2) in the dining room. Each of these residents had their dinner in front of them. The 2 tables were identified on the seating chart (posted on the wall) as "Feeder" tables. There was one CNA (CNA #1) assisting the residents at the 2 tables. CNA #1 went from table #1 where she was assisting Residents #26, 27, 31 and 32, to Table #2 where she assisted Residents #29 and #30. The residents at table #1 sat with their food in front of them not eating.
- At 6:20 PM, Resident #26 was heard yelling "can I have some milk please?." A few minutes later, CNA #1 called back to her, "yes (Resident #26), I'll be right back". CNA #1 stopped feeding residents at table #2, returned to Resident #26 and assisted her with her glass of milk.
- At 6:25 a second CNA (CNA #2) entered the dining room and began assisting Resident #13 with her meal.
- At 6:35 PM, Resident #13 was removed from the dining room. CNA #2 was overheard saying the food was just "rolling" out of the resident's mouth so she was unable to feed her.

7) Resident #13 had diagnoses which included Parkinson's disease, dementia, and functional quadriplegia (complete immobility).

The resident's weight record documented a weight loss from 112.6 pounds in January, 2011 to 103.6 pounds in October 2011.

The Minimum Data Set (MDS) assessment dated July 28, 2011 documented the resident required total assistance with eating.

The undated certified nurse aide (CNA) care card (used by the CNAs to direct care) documented the resident required total assistance with eating.

The resident's Intake Flow Sheet did not document the resident's intake for the dinner meal on October 24, 2011.

8) Resident #26 had diagnoses including cerebral vascular accident (stroke) with paralysis of the left leg, depression, and chronic renal failure.

The Minimum Data Set (MDS) assessment dated August 14, 2011, documented the resident required total assistance with eating.

The undated CNA care card documented the resident required extensive assistance for eating and was on aspiration precautions.

The resident's Intake Flow Sheet did not document the resident's intake for the dinner meal on October 24, 2011.

9) Resident #31 had diagnoses including dementia, hypertension, and seizure disorder.

The resident's weight record dated 2011, documented the resident had a weight loss from 151 pounds in January, 2011, to 133.2 pounds in October, 2011.

The Minimum Data Set (MDS) assessment dated August 25, 2011 documented the resident was severely impaired cognitively and required extensive assistance for eating.

The resident's Intake Flow Sheet did not document the resident's intake for the dinner meal on October 24, 2011.

During an interview on October 24, 2011, at 7 PM, the registered nurse (RN) manager informed the surveyor, residents that needed assistance eating included Residents #13, 26, 27, 29, 30, 31 and 32.

On October 25, 2011 at 1:07 PM, CNA #4 was interviewed as she assisted residents with the lunch meal in the main dining room. She stated she worked at the corporation's other facility and had never worked at this facility before today. She did not know the residents seated at the table with her and was not able to answer questions about them. She would not state what time her shift started or when it was going to end

On October 25, 2011 at 1:10 PM, CNA #5 was interviewed as she assisted residents with the lunch meal in the main dining room. She stated she worked at the corporation's other facility and had never worked at this facility before today. She would not state what her assignment was that day and was not able to tell the surveyor if she had a resident assignment and/or what unit she was working on.

During the resident group meeting held on October 26, 2011 at 11 AM, 7 of 13 residents verbalized they were not having their care needs met in a timely manner. This included: receiving morning (AM) or bedtime (HS) care, toileting needs, and receiving meals in a timely manner.

The Administrator was interviewed on October 27, 2011 at 12:20 PM regarding the facility's quality assurance program for which he was the coordinator. As part of the facility's quality assurance program, he stated the RD (registered dietitian) was responsible for doing diet audits including the orders, and reviewing the weight records for the entire building. He stated she was employed 2 days per week.

In summary, the facility did not ensure residents received timely assistance with meals to maintain good nutrition.

10 NYCRR 415.12(a)(3)]

F319 483.25(f)(1): APPROPRIATE TREATMENT FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

Based on the comprehensive assessment of a resident, the facility must ensure that a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem.

Based on observation, staff interview and record review conducted during the standard survey, it was determined for residents who displayed adjustment difficulty the facility did not ensure the appropriate treatment and services were provided for 4 of 16 sampled residents (Resident's #1, 6, 7, and 12). Specifically, Residents #1, 6 and 7 were seen by the psychologist and there was no documented evidence the recommendations were addressed by the facility. Resident #12 was not provided with a psychological evaluation as ordered. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #1 was admitted on September 30, 2011 with diagnoses including diabetes, hypertension, vascular disease, an infection in his right leg and pain.

The registered nurse (RN) progress note dated October 1, 2011, documented the physician recommended medical treatment to amputate the resident's right leg, and the resident refused. The note recorded the resident stated "I am not going back. I would rather die" than have a procedure done.

The licensed practical nurse (LPN) progress note dated October 1, 2011, documented the resident stated he did not want to go to the hospital and he did not care if he died, "because he doesn't want to put his family through all this".

The October 3, 2011, "Initial Psychosocial Assessment" was completed by the social worker. The assessment documented that the resident had previously lived at home with his family.

The social work progress note dated October 3, 2011, documented the resident stated he was depressed because of his health problems and the hardships this had placed on his family. The note documented a consult was requested with the psychologist and emotional support would be offered as needed.

The comprehensive care plan (CCP) dated October 3, 2011, documented the resident had a strong identification with his past roles, and life status, and expressed sadness over his "lost roles/status". The CCP documented a goal for the resident to establish his own goals, and identify his abilities and strengths.

The admission Minimum Data Set (MDS) assessment dated October 7, 2011 documented the resident's cognition was intact. The MDS documented the resident:
- required limited to extensive assistance with bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene.
- had surgical wounds, received surgical wound care,
- had frequent pain that was rated a 9 out of 10 on a pain scale of 1 to 10 (one being little or no pain, 10 being the worst pain)
- felt little pleasure, or interest, in doing things on most days,
- felt down, depressed, or hopeless nearly every day,
- had sleep problems on most days,
- felt tired, or had little energy on most days, and
- felt bad about himself, that he was a failure, or let himself or his family down on several days.

The CCP dated October 11, 2011 documented the resident:
- expressed little interest in doing things,
- felt down, depressed, or hopeless,
- had sleep problems,
- felt tired, or had little energy,
- felt bad about himself, and
- moved or spoke slowly, and was fidgety or restless.
The goal for the resident was acute changes in the resident's mood would be recognized and treated appropriately. The planned interventions included a psychological evaluation as needed.

The nursing notes dated on October 16, 2011, documented the resident requested to go to the emergency room due to increased pain in the right leg and was sent to the hospital for evaluation.

The nursing notes dated October 20, 2011 documented the resident returned to the facility.

The social work progress note dated October 21, 2011, documented the social worker would continue to offer support.

During an interview with the Director of Social Services on October 26, 2011 at 2:10 PM, she talked to the resident about his family problems a lot. She stated she faxed the referral to the psychologist on October 3, 2011, and was not sure when the psychologist saw the resident. The Director said the results of the consultation were not back as of this date. She stated the psychologist had a new dictation service, there was a problem accessing the reports, and she would expect to get the report back "soon".

During an interview with the Director of Social Services on October 26, 2011 at 2:30 PM, she stated the psychologist saw the resident on October 13, 2011. The social worker stated the psychologist's report was not available.

The resident's "Psychological Consultation/Progress Note" dated October 13, 2011, was provided to the surveyor on October 27, 2011 between 1:30 PM and 2 PM. The note documented the resident:
- had diagnoses including adjustment disorder, with depressed mood, and possible post traumatic stress disorder;
- was experiencing depression associated with recalls of past memories;
- was experiencing depression because of his recent nursing home placement;
- might benefit from medication re-evaluation to help improve his depressed mood,
- would benefit from individual psychotherapy to help focus on symptom management; and
- had flashbacks, and it "might be important" to verify the authenticity of the flashback memory, and help the resident process and talk about this incident to help improve feelings and decrease recurrent crying that was associated with these memories.
The note documented to encourage the resident to interact and participate in programs and activities within the nursing home to help decrease isolation in his room.

In summary, the facility did not provide appropriate treatment and services for this resident's adjustment difficulties as they did not ensure the psychologist's evaluation was available and recommendations were addressed.

2) Resident #7 had diagnoses including depression, and Clostridium difficile (C-Diff, a bacterial infection in the stool).

The nurse practitioner's progress note dated July 1, 2011, documented the resident was seen for recurrent diarrhea. The note recorded a plan to start the resident on Vancomycin (an antibiotic) 250 mg every 6 hours for 10 days, and contact precautions, as the resident had a recent history of C-Diff.

The nursing progress notes dated July 11, 2011 through July 26, 2011 documented:
- On July 11, 2011, the resident expressed wanting to be off precautions stating "it's making me depressed, I miss seeing my family".
- On July 14, 2011 the resident was taken off precautions and moved back to a semi-private room.
- On July 20, 2011, the resident restarted treatment for C-Diff and was placed on precautions and moved back to the private room.

The Minimum Data Set (MDS) assessment dated July 26, 2011 documented the resident was cognitively intact. The MDS documented the resident's mood interview was indicative of moderate depression.

A nursing progress note dated July 28, 2011 documented the resident's family expressed concern that the resident was on isolation precautions and was unable to leave her room. This was discussed with the nurse practitioner and the antibiotic was discontinued as the resident did not have loose stools.

A nurse practitioner progress note dated August 10, 2011 documented the resident developed diarrhea and was restarted on the antibiotic on August 9, 2011 for 14 days.

A nursing progress note dated August 10, 2011 documented the contact precautions were maintained.

A social work progress note dated August 12, 2011 documented she met with the resident to discuss her "declining mood", and documented the isolation was "effecting" the resident.

On August 18, 2011, the social worker documented she "learned" the resident continued to decline in mood and requested a consult with the psychologist.

The psychological consult dated August 18, 2011 documented the resident was seen for a psychological consult because of "increased difficulty adjusting to illness and decrease in functioning." The psychologist's diagnoses included anxiety, depression, adjustment difficulties with nursing home placement, and psychosocial stressors. The recommendations included psychotherapy to help the resident learn coping skills regarding feelings of depression. The note documented an objective of participating in individual therapy "once in three weeks." Recommendations included the resident "might benefit" if taken out of her room to socialize with peers and staff and to participate in programs whenever possible.

There was no further documentation of psychological follow up in the resident record when reviewed on October 27, 2011. The resident remained on contact precautions as noted by the sign outside the resident's door.

The registered nurse (RN) manager was interviewed on October 27, 2011 at 11:55 AM and stated the resident's "restrictions" changed but she did not know when. She said the resident would not longer be isolated in her room once she stopped having loose stools.

The psychologist was interviewed on October 28, 2011 at 9:30 AM. He stated, if he recommended "3 weeks or as needed" it meant he would see the resident in 3 weeks or sooner if needed. No explanation was provided in regards to the resident not being seen since August 18, 2011.

In summary, the facility did not provide psychological follow up as recommended, or document a rationale for not providing it.

3) Resident #6 was admitted to the facility on June 6, 2011 with diagnoses including cardiomyopathy (enlarged heart muscle), aortic stenosis (narrowing of the aortic heart valve), and cerebral vascular accident (CVA, stroke).

The June 7, 2011 psychosocial assessment completed by the social worker documented the resident was alert/oriented and able to follow complex directions.

The June 13, 2011 Minimum Data Set (MDS) assessment documented the resident was cognitively intact. The assessment recorded the resident showed little interest in doing things, felt down/depressed, had little energy, felt bad about himself, and had a poor appetite.

A nursing progress note dated June 21, 20113:30 AM, documented the resident had been awake until that time and stated he was lonely.

The June 21, 2011 physician's progress note documented the resident had anxiety, insomnia, and depression. The physician documented the resident's insomnia was in large part related to anxiety. The note recorded the resident "admitted" he was anxious and fearful of dying. The physician wrote that he was going to start the resident on anti-anxiety and anti-depressant medication.

The June 23, 2011 social worker's progress note documented the social worker spoke with the resident's wife who understood the resdient was dying and requested comfort measures, including no hospitalization, and no feeding tube as the resident was dying.

The June 23, 2011 physician's orders documented the resident was on comfort care and ordered no resuscitation, no hospitalization (except for severe symptoms or pain that could not be controlled), no tube feeding, or intravenous.

Nursing progress notes documented:
- on June 23, 2011, the resident was anxious and restless;
- on June 28, 2011, the physician was notified of the resident's restlessness;
- on June 29, 2011, the resident was awake most of the night, rang his call bell repeatedly when staff left his room, staff provided 1:1 to the resident, and the resident seemed lonely;
- on July 7, 2011, the resident stated "I'm lonely and I'm depressed;"
- on July 8, 2011, the resident repeatedly rang his call bell;
- on July 12, 2011, the resident was awake most of the night ringing his call bell. He told staff he did not want anything except someone to talk to; and,
- on July 16, 2011, the resident was "demanding with care" and asked staff to sit with him.

The psychologist's assessment dated as initiated on July 8, 2011 and concluded on July 16, 2011, documented on July 8, 2011 a psychology evaluation was ordered due to the resident's declining health, pain, and fear of death. The psychologist documented the resident was anxious due to his declining health status and the psychologist discussed anxiety management with the resident. The recommended course of action was documented as "individual therapy" of 2 sessions.

The July 17, 2011 physician's order documented the resident was to have a psychology consult and treatment if needed.

The July 18, 2011 nursing progress note documented the resident was not able to sleep and asked staff for help.

The comprehensive care plan (CCP) was updated on July 27, 2011 and documented the resident openly expressed conflict, anger, anxiety and sadness. The CCP recorded the resident was on comfort care and the plan included psychological evaluations as needed. The CCP did not document the recommendations made by the psychologist or the plan for follow-up psychology sessions.

The July 28, 2011 social worker's progress note documented the resident had been doing well and was stable. The note recorded the resident's condition was terminal and he had been experiencing anxiety related to his decline in health dislike of being alone. The social worker planned to visit with him periodically and recommended a psychology referral.

The August 18, 2011 social work progress note documented the social worker met with the resident to provide emotional support.

The social worker stated in an interview on October 26, 2011 at 12:25 PM, she made the initial contact with the psychologist regarding referrals that were ordered and after that, the psychologist maintained his own schedule. She stated the psychologist came to the facility every other week and saw either newly referred residents or residents receiving ongoing therapy. She stated the resident was referred to the psychologist in the summer as he was dying and was anxious about his medical condition. She stated at that time, the resident was fearful of being alone. She stated she did not keep track of the psychologist's schedule for ongoing appointments and did not know why the resident was not seen for the 2 follow-up sessions as recommended.

On October 27, 2011 at 11:20 AM, the Administrator stated in an interview, he thought the social worker kept track of the psychologist's schedule and monitored to ensure residents were seen as planned.

On October 28, 2011 at 9:30 AM, the psychologist stated in an interview, he worked as a consultant for the facility, saw those residents that were referred to him, and made recommendations. He stated when he recommended follow-up sessions for a resident, he would follow-up with the resident as recommended or if the facility contacted him and told him there was a need, he would see the resident more often.

In summary the facility:
- did not ensure there was documented rationale for not providing follow-up psychological visits as recommended when the resident exhibited difficulty adjusting to his declining medical condition; and,
- did not ensure the resident's CCP was updated to reflect the plan for psychological services.

10 NYCRR 415.12 (f)(1)

F241 483.15(a): DIGNITY

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the facility did not ensure 2 of 16 residents (Residents #7 and 13) reviewed for dignity, and 4 residents outside of the sample (Residents #26, 27, 29, and 30), received care and services that maintained or enhanced their dignity and respect. Specifically, Resident #7 received meals on disposable dishware without a rationale, and Residents #13, 26, 27, 29, and 30 were not provided assistance during meals in a manner that maintained their respect and individuality. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) On October 24, 2011 between 6:15 PM and 7:00 PM, the following was observed in the main dining room:
- At 6:15 PM, a certified nurse aide (CNA) assisting Residents #26 and #27 (seated at table #1) left the table and assisted Residents #29 and #30 (seated at table #2) with Resident #13.
- From 6:15 PM to 6:20 PM, Residents #13, 26 and 27 sat at the tables, not eating, with their meals in front of them, with no one assisting them.
- At 6:20 PM, the CNA left Resident #29 and returned to table #1, and fed Resident #26 while standing. Residents #29 and #13 remained at table #2 unassisted and not eating. The CNA turned from Resident #26 and began assisting Resident #27.
- At 6:25 PM, a second CNA sat down to assist Resident #13 while another staff member, who was standing up, assisted Resident #27.
- At 6:30 PM, 3 staff members were observed in the dining room assisting residents at 4 tables.
- At 6:32 PM, the nursing Supervisor entered the dining room, spoke to a staff member, and left the room.
- At 6:35 PM, Residents #13 and 26 were transported by the staff out of the dining room and back to their units.
- Upside down plate covers with straw wrappers and debris from the meal were observed on the middle of table #2 as Residents #26, 27, 31 and 32 ate their meal.

During an interview with the B Wing licensed practical nurse (LPN) on October 24, 2011 at 6:20 PM, she stated the registered nurse (RN) Supervisor "just left the unit." She stated the RN Supervisor was acting as the Supervisor and passing medications on "West" (part of the B Wing).

At 6:25 PM, the RN Supervisor returned to the B Wing and stated to the surveyor, that she was working as the medication nurse.

At 7:25 PM, the RN Supervisor was observed passing medications and stated to the surveyor, she was unable to assist residents and answer problems when she was administering medications.

In summary, residents were not provided a dignified dining experience when staff:
- assisted the residents with eating while standing;
- left the residents' table to assist other residents without providing complete assistance to individual residents; and
- left debris on the table while residents were eating.

2) Resident #7 had diagnoses including depression, malnutrition and was being treated for chronic Clostridium difficile (C-diff, an intestinal bacteria causing diarrhea).

Review of nursing progress notes revealed the resident had episodes of loose stools from July 1, 2011 through September 26, 2011. From September 27, 2011 through October 26, 2011, no episodes of loose stools were documented.

The resident was observed eating her meals on a disposable tray and received dishware on October 24, 2011 during the evening meal, and October 26, 2011 during the noon meal.

The evening Food Service Supervisor was interviewed on October 24, 2011 at 6:35 PM regarding the posted sign observed during kitchen inspection documenting the resident was on precautions for C-diff. He stated the resident must receive disposable trays and utensils because of contact precautions. He stated the resident had been off contact precautions once in the past 3 months.

Resident #7 was interviewed on October 26, 2011 at 1 PM and stated she had received her meals on disposables trays and plates for months and was not sure why she continued to receive them.

A licensed practical nurse (LPN), who brought the resident's tray into her room, on October 26, 2011 at 1 PM was interviewed. She stated she did not know why the resident continued to receive disposable trays and utensils, as she no longer was having a problem related to C-diff.

The Food Service Director was interviewed on October 27, 2011 at 9:15 AM, and stated the resident was placed on contact precautions for C-diff sometime in July 2011. She stated she received a daily list from the Admissions Coordinator, listing the resident with a "C" beside her name. The Food Service Director said the "C" stood for C-diff. She stated that any resident with a "C" next to their name would served on disposable trays, dishes and utensils.

On October 28, 2011, at 2 PM, the Inservice Educator, (a consultant functioning in that position), stated in an interview the use of disposable goods was necessary as the facility's dish solution was not strong enough to kill the active spores of C-diff. He said if the resident was chronic and did not have active symptoms (loose stools) the disposable products should be discontinued.

In summary the facillity didnot provide a dignified dining experience as the resident meals on disposable dishware with no current rationale.

10 NYCRR 415.5(a)

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Citation date: October 28, 2011

Based on observation, record review, and staff interviews conducted during the standard survey, it was determined the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment, and prevent the transmission of infection for 3 of 3 residents (Resident's #5, 17, and 28), with diabetes, observed during the medication administration, 1 of 5 residents (Resident #7), reviewed for infection control, and 1 of 2 units (Unit B), observed during the initial tour. Specifically, for Residents #5, 17, and 28 the facility did not use proper infection control techniques when obtaining blood glucose levels with a glucometer. For Resident #7 staff did not employ consistent infection control techniques during care; and on Unit B soiled soaker pads were observed on the floor in 3 resident rooms. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) The "Census" form dated October 24, 2011, provided to the surveyor the first day of survey, documented Resident #28, had a diagnoses of Methicillin resistant Staphylococcus aureus (MRSA, infection), and Resident #5 had diagnoses of MRSA and Clostridium difficile (C-diff, a bacterial infection in the stool). The form recorded both residents were on contact precautions.

During a medication administration observation on October 25, 2011 at 8:35 AM, the surveyor observed a yellow sign and an isolation cart outside of Resident #28's room. The licensed practical nurse (LPN) stated, during an interview at that time, the yellow sign outside of the resident's room, meant he was on "precautions for MRSA" in his wound, and it was present in his "wound vac" (a device to promote wound healing through negative pressure).

On October 25, 2011 the medication administration observation showed:
- At 11:48 AM, a yellow sign and isolation cart were outside of Resident #28's room. The LPN removed a glucometer (a device that measures blood sugar levels), a bottle of test strips, and a lancet (a small needle used to obtain blood) from the top drawer of the medication cart placing them on top of the medication cart. The LPN entered the resident's room and placed the glucometer on top of the resident's over bed table. After performing a fingerstick glucose test on the resident the LPN placed the glucometer on the over bed table. The LPN then took the glucometer exited the resident's room, and placed the glucometer on top of the medication cart. The LPN wiped the glucometer with an alcohol pad and placed it in the drawer of the medication cart on top of an open box of lancets.
- At 11:54 AM a yellow sign and an isolation cart were outside of Resident #5's room. The LPN removed a glucometer, a container of test strips, and a lancet from the top drawer of the medication cart, placing them on top of the medication cart. The LPN then entered Resident #5's room, and placed the glucometer on top of the over bed table. After performing the fingerstick test on Resident #5, using the glucometer that was previously used on Resident #28, the LPN place it on the over bed table. The LPN then took the glucometer, exited the resident's room, and placed the glucometer on top of the medication cart. The LPN wiped the glucometer with an alcohol pad, and placed it in the drawer of the medication cart on top of an open box of lancets.
- At 11:58 AM, the LPN took the glucometer from the top drawer of the medication cart, placed the glucometer and bottle of glucometer strips on top of the medication cart. The LPN entered Resident #17's room, placed the glucometer on top of the over bed table, performed the fingerstick glucose test on Resident #17 using the same glucometer that was previously used for Residents #28 and 5 then placed it back on the over bed table. The LPN then took the glucometer exited the resident's room, and placed the glucometer on top of the medication cart. The LPN wiped the glucometer with an alcohol pad, and placed it in the drawer of the medication cart, on top of an open box of lancets.

The Director of Nursing (DON) was interviewed on October 26, 2011 at 11:35 AM, and stated the Infection Control Nurse was no longer employed by the facility. She stated she expected staff to use germicidal wipes or alcohol pads to clean the glucometer after using it. The DON stated that if a resident was on precautions, the glucometer would not be brought into the resident's room. It was to stay on top of the medication cart, and the nurse would use a pipette to obtain a sample of blood, then bring the sample to the cart for testing.

During an interview with the LPN on October 26, 2011 at 11:40 AM, she stated she was taught to clean the glucometer between resident's with an alcohol pad.

The Infection Control - Blood Glucose Meter policy dated October 2011, documented to clean the glucometer with "CaviWipes" documented as a "disinfectant/infection control wipe" between residents.

In summary, the facility did not ensure blood glucose fingersticks were performed according to acceptable standards of infection control techniques, as the glucometer was not kept free from potential contamination during storage and was not properly cleansed and disinfected after usage.

2) Resident #7 had diagnoses including depression, malnutrition and Clostridium difficile (C-diff, a bacterial infection in the stool).

Minimum Data Set (MDS) assessment dated November 8, 2010 documented the resident had moderately impaired cognition. The MDS documented the resident had mild depression, required total assistance with mobility, extensive assistance with transferring and dressing, and supervision eating.

On July 1, 2011, the nurse practitioner documented in a progress note, the resident was seen for recurrent diarrhea. The plan included starting the resident on Vancomycin (an antibiotic) 250 mg every 6 hours for 10 days as the resident had a recent history of C-diff colitis. A stool specimen was sent to the laboratory for testing and the resident was placed on contact precautions.

A nursing progress note dated July 1, 2011 documented the resident was transferred to a private room "until confirmed report on stool becomes available."

Nursing progress notes dated July 2 through July 10, 2011 documented the resident had intermittent episodes of loose stools. The note recorded the resident received Vancomycin, and was on "contact precautions." There were no specific limitations related to the contact precautions documented in the note.

The nursing note dated July 11, 2011, documented the resident had received her last dose of Vancomycin. The note recorded the resident was on contact precautions, and expressed wanting to be off "isolation" stating "It's making me depressed, I miss seeing my family."

On July 14, 2011 nursing documented the resident was transferred to a semi-private room and was taken off contact precautions.

The nursing note dated July 16, 2011 documented the resident was having loose stools.

The nursing note dated July 20, 2011 documented Vancomycin was ordered by the nurse practitioner and the resident was transferred back to a private room.

The nursing note dated July 21, 2011 documented "precautions maintained."

A nursing progress note dated July 28, 2011 documented the resident's family expressed concern that the resident was unable to leave her room. The note recorded that this was discussed with the nurse practitioner and the antibiotic was discontinued as the resident was no longer having loose stools.

The nurse practitioner's note dated August 10, 2011 documented the resident developed diarrhea and Vancomycin had been re-started on August 9, 2011 for 14 days.

The comprehensive care plan (CCP) dated August 12, 2011 documented the resident continued to have loose stools after treatment with antibiotics. The plan was to maintain contact precautions which included, assisting the resident to wash her hands with soap and water after toileting, providing good hygiene, and ensuring daily room cleaning especially the areas that were touched frequently when toileting and changing incontinence briefs. There was no documentation related to the resident's need to be isolated in her room.

On August 18, 2011, a nursing note documented the resident continued on Vancomycin, the resident "may come out of her room, and precautions were to be maintained with "meals and care."

On August 20, 2011, the nursing progress note documented "precautions with care."

Nursing progress notes from August 27 through September 9, 2011 documented the resident remained on contact precautions.

The nursing note dated September 11, 2011 documented contact precautions were discontinued.

The nursing notes dated September 17, 18, 19, and 20, 2011 documented the resident had loose stools. The nursing note dated September 20, 2011 recorded the resident was placed back on contact precautions.

Review of nursing progress notes revealed the resident continued to have loose stools through September 26, 2011 and continued on Vancomycin and precautions.

From September 27, 2011 through October 26, 2011, nursing documented the resident continued on the Vancomycin with no loose stools.

The evening Food Service Supervisor was interviewed on October 24, 2011 at 6:35 PM and stated the resident received disposable trays and utensils because she was on contact precautions due to C-diff. He stated the resident had been off contact precautions once in the past 3 months.

On October 24, 2011, the resident was observed at 7:30 PM in her darkened room. A disposable tray and disposable paper goods were observed on the resident's overbed table. A sign outside the resident's door directed visitors to report to the nurses' station.

On October 26, 2011, at 11 AM, the resident was observed out of her room attending a meeting.

The resident and her family member were interviewed by the surveyor at 12:30 PM on October 26, 2011. The resident stated she was no longer on precautions. She stated she had been isolated in her room, but now the problem was considered chronic. The resident stated when she was told "a couple of months ago" the C-diff was no longer active, and she "took it upon myself to go out" of her room. The resident stated she did not care for being isolated. She stated she missed seeing her family. Her family member stated he was initially educated and had to wear a gown and be sure to wash his hands when visiting. He said he no longer wore a gown or washed his hands, and no one had said anything to him. The resident stated her meals continued to be served on disposable paper products and she did not know why.

On October 26, 2011 between 12:30 PM and 1 PM, the licensed practical nurse (LPN) was observed entering the residents room without donning a gown or gloves. The LPN served the resident her lunch on disposable products. She stated to the surveyor, at that time, she did not know why the resident continued to receive her meals on disposables. The LPN said she thought the physician had discontinued the order for contact precautions. She reviewed the resident's menu slip (which was on the lunch tray) and stated the resident was listed as being on precautions.

On October 26, 2011 at 12:35 PM, a certified nurse assistant (CNA) stated in an interview the sign outside of the resident's room meant visitors had to go to the front desk where they would be told to wear a gown, gloves and a mask because the resident had C-diff.

At 2:45 PM on October 26, 2011, the CNA caring for Resident #7 was interviewed and stated the sign meant, if family members toileted the resident, they needed to wear gloves. She said for staff, it meant they had to double bag linen and had to wear gloves for care. The CNA stated the resident was not "actively stooling" and previously, there had been a sign telling staff what they had to do for precautions. She stated if the resident's stool was "splattering" they would have to wear a gown. She said she would learn in "morning report" if the resident was having a problem and if they needed to use more than gloves.

The Food Service Director was interviewed on October 27, 2011 at 9:15 AM, and she stated the resident was placed on contact precautions for C-diff sometime in July 2011. She said she was notified by the Admissions Coordinator of residents who were on precautions. She stated that any resident with C-diff would automatically get served on disposable dishes and utensils.

On October 27, 2011 at 11:45 AM, the resident's unit housekeeper was interviewed and stated the resident was on contact precautions. She said she used gloves, a gown and a mask when she entered the resident's room to clean.

At 11:55 AM on October 27, 2011, the registered nurse (RN) manager stated during an interview staff should always wear a gown and gloves when caring for the resident, although it had been weeks since the resident had loose stools. The RN stated she did not remember when the contact precautions were discontinued or when the resident was able to leave her room. She said if a resident had a diagnosis of C-diff, the resident was placed on contact precautions. The RN stated she thought staff would know from morning report when it was all right for the resident to be out of her room. She stated she would tell visitors they needed to "gown up" when entering the resident's room. The RN said she was not aware the resident's family member was not wearing a gown when in the resident's room.

On October 28, 2011 at 10:40 AM, the resident's physician was interviewed by the surveyor via telephone and stated he did not identify in his orders or notes, specific measures to be used when a resident was on contact precautions, unless he was asked to by the nurse manager.

In summary facility did not consistently identify and follow procedures necessary related to contact precautions as:
- staff were inconsistent in knowing what contact precautions meant for this resident;
- were inconsistent in maintaining precautions when entering the resident's room; and
- visitors were unaware of the procedures to follow when entering the resident's room.

3) During the initial tour of Unit B on October 24, 2011 between 6:15 PM and 7 PM soiled soakers (cloth incontinence pads) were observed on the floors of resident rooms #18 and 21.

During an interview with the licensed practical nurse (LPN) on October 24, 2011 at 6:20 PM, she stated the certified nurse aides (CNA) were not available for an interview because they were feeding residents.

The Director of Nursing (DON) was interviewed on October 26, 2011 at 11:45 AM, and when asked if soiled soaker pads were to be placed on the floor, she stated, "Absolutely not."

The Administrator was interviewed on October 27, 2011 at 12:20 PM regarding the facility's quality assurance program for which he was the coordinator. He stated they currently did not have an infection control nurse as she left about one month ago. Currently, the Director of Nursing (DON) was covering until the new infection control nurse would begin on November 7, 2011. As part of the facility's quality assurance program, they performed periodic chart reviews and looked for patterns and trends in the infection rates, and also looked for problems with infection control techniques. He was not aware of any problems with the facility's infection control practices or techniques.

In summary, soiled soakers were placed and left in direct contact with the floors in resident rooms.

10 NYCRR 415.19

F363 483.35(c): MENUS MEET NUTRITIONAL NEEDS/PREPARATION IN ADVANCE/FOLLOWED

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

Menus must meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences; be prepared in advance; and be followed.

Citation date: October 28, 2011

Based on observation, review of facility documentation, and staff and resident interviews conducted during the standard survey, it was determined for all residents of the facility, including Residents #4, 5, 6, 26, 34 and 5 of 13 anonymous residents at the group meeting, the facility did not ensure menus were planned in advance and followed. Specifically, Residents #4, 5, 6, 26, and 34 did not receive all food items listed on the meal tickets. 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 STANDARD SURVEYS OF January 20, 2011 and October 22, 2009.

Findings include:

Observations and interviews conducted during survey revealed multiple occasions when residents did not receive all items listed on their meal tickets, including:
- on October 25, 2011 at 8:34 AM, Resident #6 was eating the breakfast meal. He did not receive the coffee listed on the meal ticket and received a fried egg instead of the scrambled eggs listed.
- On October 25, 2011 at 11:50 AM, the surveyor observed a sign posted on the B Wing documenting the lunch menu that day was changed. Broccoli was going to be served instead of spinach.
- On October 25, 2011 at 12:30 PM, the Food Service Director stated in an interview, she received a food delivery the previous day and did not receive enough spinach. She stated all residents were going to receive broccoli today instead of spinach and spinach would be served later in the week when they ordered more.
- On October 25, 2011 at 12:40 PM, Resident #5 received broccoli instead of the garlic spinach listed on the meal ticket. The resident received coffee and it was not listed on the meal ticket. He stated at that time to the surveyor, he hoped the coffee was decaffeinated as he could not drink regular coffee and he did not know why he received broccoli instead of spinach as he did not like broccoli, and preferred spinach. He stated he was not offered another option that day.
- On October 25, 2011 at 1:07 PM, Resident #4 was observed eating lunch. She did not receive the soft sandwich listed on the meal ticket. She received pureed pasta with sauce and broccoli instead of the pureed chicken, bread, and cauliflower listed on the meal ticket.
- On October 25, 2011 at 1:20 PM, the cook stated in an interview, she served the food at the lunch meal that day and was to serve what was listed on the meal tickets. She stated the Food Service Director or Supervisor checked her work. The Food Service Director, who was present, stated she checked the meal service that day and was supposed to check every plate. She stated she walked away towards the end of the meal service and did not check all residents' meals as planned. The Food Service Director stated the kitchen did not always serve the residents the sandwiches listed on the meal tickets. She said the kitchen knew what residents wanted them or nursing staff asked for them when the resident requested them.
- On October 25, 2011 at 6:30 PM, Resident #34 was observed in the dining room with her meal in front of her and was not eating. Her family member was with her and stated, the resident was a fussy eater and was waiting to return to her room to eat the dessert he brought her. He stated she often ate a peanut butter and jelly sandwich when they brought it to her and none was provided. The resident's menu slip was observed and included the sandwich. At 6:45 PM, the resident was observed again in the dining room and was eating a sandwich. The resident's family member stated he requested it after his conversation with the surveyor.
- On October 26, 2011 at 8:45 AM, Resident #26 was observed eating breakfast. The meal ticket documented she was to receive cream of rice and super cereal. The resident received super cereal only. The resident received applesauce that was not listed on the meal ticket.
- On October 26, 2011 at 1:10 PM, Resident #4 was observed to receive pureed zucchini instead of the pureed cauliflower listed on the meal ticket.
- On October 26, 2011, Resident #34 was observed in the dining room at 6:30 PM with her meal in front of her, and it included baked fish, the main entree posted for the meal. The alternate for the meal was grilled cheese, and the resident's menu slip documented the grilled cheese. The resident's family member was with her at the time and he stated, the staff brought her the fish and did not ask her what she preferred. He did not know why she received the fish as she did not like fish.

During the resident group meeting held on October 26, 2011 at 11 AM, with 13 anonymous residents present, 5 residents stated they often run out of coffee in the morning, and frequently, at least one a week, they substituted an item that was not on the posted menu.

On October 26, 2011 at 2:15 PM, the registered dietitian (RD) stated in an interview, to her knowledge when a "sandwich" was listed on a meal ticket, the residents were to receive the entree listed and the sandwich. She stated she was not aware the kitchen was not always providing the sandwich as planned.

In summary, the facility did not ensure menus prepared in advance were followed as residents did not receive all items listed on their meal tickets.

10 NYCRR 415.14(c)(1)(3)

F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4): NOT EMPLOY PERSONS GUILTY OF ABUSE

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Citation date: October 28, 2011

Based on review of personnel files and staff interview conducted during the standard survey, it was determined for 5 of 5 newly hired employees (Employees #1, 2, 3, 4 and 5) the facility did not thoroughly screen employees at the time of hire and did not provide abuse training to employees prior to allowing them to provide resident care. Specifically, Employees #1, 2, 4, and 5 did not receive abuse training prior to working in the facility, and there was no documented evidence the status of Employees #2 and 3 was checked against the CNA registry prior to hire. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

On October 27, 2011, the personnel files of 5 newly hired employees were reviewed and documented:
- Employee #1 was hired on September 23, 2011 as a registered nurse (RN) Supervisor and there was no documented evidence she completed abuse training prior to starting work.
- Employee #2 was hired on July 20, 2011 as a dietary employee. There was no documented evidence the employee's status was checked against the CNA registry prior to hire or that the employee received abuse training prior to working in the facility.
- Employee #3 was hired on July 7, 2011 as an activities assistant and there was no documented evidence the employee's status was checked against the CNA registry prior to being hired.
- Employee #4 was hired on August 19, 2011 as a physical therapist (PT) and there was no documented evidence she received abuse training prior to working.
- Employee #5 was hired on July 14, 2011 as a licensed practical nurse (LPN) and there was no documented evidence she attended abuse orientation prior to working in the facility.

On October 27, 2011 at 1:00 PM, the Staff Educator (from the corporation's other facility) stated in an interview, he was asked to come to the facility on October 24, 2011 to complete employee orientation as the facility currently did not have a Staff Educator. He provided documentation that Employee #2 received abuse training on October 24, 2011. He was not able to provide information on how employees were chosen to attend the orientation class as he stated he was not involved in the process and was there solely to conduct orientation classes.

The Administrator was interviewed on October 27, 2011 at 1:10 PM, and stated all of the required information on the CNA registry checks should be contained in the personnel files. He stated he was responsible for completing the paperwork for fingerprinting new employees, and did not answer when asked who was responsible for completing other screening of new employees.

On October 27, 2011 at 3:15 PM, the Administrator stated in an interview, "they found" Employee #1's abuse training and provided the surveyor with a paper signed by Employee #1 documenting she received abuse training. The paper was not dated and did not document who completed the training. He stated Employee #4 worked in the facility for one day, August 18, 2011, when they needed PT coverage. He provided an orientation packet for Employee #4 documenting she received abuse training on September 6, 2011 at the corporation's other facility. He provided undated CNA registry checks for Employees #2 and 3 and was not able to state when the registry checks were done or who did them. There was no additional information provided for Employee #5.

The facility's Employee Hiring Screening Process policy dated December 2010 documented certifications were to be checked with applicable screening agencies and employees would be enrolled in a general orientation, including abuse training "as soon as possible."

In summary, the facility did not ensure the required screening and training of new employees was completed prior to the employees being permitted to provide resident care, as:
- the facility did not have documented evidence Employees #1, 2, 4, and 5 received abuse training prior to working in the facility; and,
- the facility did not have documented evidence the status of Employees #2 and 3 was checked against the CNA registry prior to hire.

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

F309 483.25: PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Citation date: October 28, 2011

Based on observation, staff and resident interview and record review conducted during the standard survey, it was determined for 1 of 1 resident (Resident #5) reviewed for new admission, 1 of 3 residents (Resident #6) reviewed for falls, and 1 of 7 residents (Resident #6) reviewed for weight concerns, the facility did not ensure care and services were provided to attain or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care. Specifically, for Resident #5 the facility did not ensure there was a physician's order for a medical device and did not develop/implement a plan of care to ensure the device was utilized appropriately. For Resident #6 neurological checks were not completed as planned and an investigation was not completed timely after a fall. For Resident #6, the plan to monitor weekly weights with parameters for physician notification was not implemented. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #6 had the diagnoses of cardiomyopathy (enlarged heart muscle), diabetes, aortic stenosis (narrowing of the aortic heart valve) and a previous cerebral vascular accident (CVA, stroke).

The Minimum Data Set (MDS) assessment dated September 2, 2011, documented the resident had moderately impaired cognition, and was dependent on staff for bed mobility/transfers.

The resident's October 18, 2011 physician's orders documented the resident received 81 mg (milligrams) of Aspirin every day.

A registered nurse's (RN) progress note, dated October 19, 2011 at 9:45 AM, documented she was "called to" the residents room "due to a fall", and she observed the resident lying on his left side at the foot of his bed. "Staff reported" to the RN the resident hit the left side of his head. The note recorded the resident was alert and talking properly and vital signs were being obtained. The progress note documented "will start neuro (neurological) checks."

The physician's orders dated October 19, 2011, documented the resident was to have neurological checks, and a chair alarm was to be implemented as he was status post a fall. The order instructed to check the resident's chair alarm every shift when the resident was in the wheelchair.

The facility's 24 Hour Report dated October 19, 2011, documented on the 7 AM to 3 PM (day) shift, the resident fell out of his wheelchair at 10 AM, had a small abrasion to his forehead and the neurological checks were within normal limits. The Supervisor/Unit Manager signature area for the day shift was blank. The 3 PM to 11 PM (evening) shift 24 Hour Report documented the resident's neurological checks were within normal limits, his range of motion was within normal limits, there was a bruise on his forehead and he had no complaints of pain. The section for the evening Supervisor/Unit Manager to sign was blank.

The facility's 24 Hour Report dated October 20, 2011 documented on the day shift, "day 2 Fall, no further injuries noted from fall, no complaints this shift." The section of the report for the shift Supervisor/ Unit Manager to sign was blank.

There was no documented investigation for the resident's fall on October 19, 2011.

On October 25, 2011 at 3 PM, the resident's medical record was reviewed. There were not documented neurological checks after the resident's fall on October 19, 2011.

During an interview on October 25, 2011 at 3:20 PM, LPN #1 was interviewed and stated there was a form used for neurological checks but she did not know where it came from or where it went after it was completed.

During an interview on October 25, 2011 at 3:30 PM, LPN #2 stated after a resident fell, vital signs are done every shift for 7 days. She stated she was not sure what the facility protocol was for neurological checks unless she reviewed the policy. She stated she was caring for the resident that evening and was not told he recently fell. She stated she did not know where his neurological checks would be found.

On October 26, 2011 at 7:35 AM, the RN (who assessed the resident after the fall) stated in an interview, she assessed the resident after the fall. The RN said she did not know his usual orientation, but he answered simple questions at that time. She initiated neurological checks and they were to be performed by the LPN's on the unit. The RN said she did not know where the neurological checks could be found and referred the surveyor to the unit ward clerk. The RN stated she did not know if the resident was on neurological checks currently, as she could not recall the facility's protocol. The RN stated the LPN's should have started an incident report, after she assessed the resident.

On October 26, 2011 at 8:12 AM, the surveyor was given the resident's Neurological Observation Sheet. The sheet was dated October 19, 2011 and documented observations of the resident at 10 AM, 10:15 AM, 10:30 AM, 11 AM, and 12:00 PM. There were no other observations documented. The instructions recorded on the sheet included obtaining a blood pressure, a temperature, a pulse, respirations and neurological observation every 15 minutes for 4 times; every hour for 4 times; every 4 hours twice; and every 8 hours twice.

On October 26, 2011 at 12 PM, the director of nursing (DON) stated in an interview, if a resident fell and hit their head neurological checks were implemented. The RN who assessed the resident obtained the first set of neurological checks and the remainder were obtained by the LPNs. If abnormal results were obtained, the resident would be sent to the emergency room. The DON stated the neurological checks were attached to the accident/incident reports. She stated all department heads and managers meet at a round table to review accident/ incident reports when they were completed. The DON said all department heads signed the accident/incident investigations. She stated neurological checks were reviewed on the 24 Hour Report sheet.

On October 26, 2011 at 1:30 PM, the DON stated she found an accident/incident report for the resident's fall that was started by LPN #3. She stated considered it an incomplete investigation.

The facility's Incident/Accident Report dated October 19, 2011, documented, "resident found lying on floor as he fell out of wheelchair, found by activities lady, reported immediately." The report documented the resident had a 0.1 (no unit of measure) by 0.1 (no unit of measure) bruise on his forehead and "see neuro check sheet." The section "Findings/Conclusions" was left blank and there were no signatures from the department heads of the interdisciplinary team.

On October 26, 2011 at 2 PM the DON stated in an interview, she did not know why the neurological checks were not completed for this resident. She said she had no knowledge of the resident's fall until the surveyor brought it to her attention.

On October 27, 2011 at 9 AM, LPN#3 stated in an interview, she started the accident/incident report and neurological checks after the resident fell. She left the neurological check form on the nurse's station desk attached to the 24 Hour Report and passed the information on to the next shift. She did not know why the resident's neurological checks were not completed as planned.

In summary, the facility:
- did not ensure neurological checks were completed as ordered after the resident fell and hit their head; and,
- did not ensure an investigation regarding the fall was completed in a timely manner.

2) Resident #6 was admitted to the facility on June 6, 2011 with diagnoses including cardiomyopathy (enlarged heart muscle), aortic stenosis (narrowing of the aortic heart valve), a previous cerebral vascular accident (CVA, stroke), and congestive heart failure (CHF).

The June 2011 weight record documented the resident weighed 193.8 pounds on the first week,198.6 pounds the second week, and 186 pounds the third week 3 (no dates specified).

The June 21, 2011 nurse practitioner's (NP) progress note documented the resident had "critical aortic stenosis" and was not a surgical candidate. The plan was to check the residents weights weekly and to notify the physician/NP if the resident gained 5 pounds or more.

The June 21, 2011 physician's orders documented the resident was to be weighed weekly and medical was to be notified if the resident gained 5 pounds or more.

The June 22, 2011 nursing progress note documented the resident had "generalized edema."

The June 23, 2011 nursing progress note documented the resident had 2+ to 3+ edema (fluid retention) in the legs.

The June 23, 2011 NP's progress note documented the resident complained of shortness of breath and was seen by the cardiologist the previous day. There were no changes recommended by the cardiologist.

The June 24 and 25, 2011 nursing progress notes documented staff were to "push fluids" as the resident had an infection.

The weight record documented the resident was not weighed in the fourth or fifth weeks of June 2011 (June 19 - 30, 2011).

The resident's June 2011 Medication Administration Record (MAR) documented weekly weights were ordered June 21, 2011. The MAR did not document a weight was obtained for the last 2 weeks of June 2011.

The July 2011 weight record documented the resident weighed 185.7 pounds in the first week of the month (no date specified).

The July 13, 2011 physician's orders documented the resident was to be weighed weekly and was on "diuretic alert." The instructions related to the "diuretic alert" documented staff were to notify medical if the resident gained or lost 5 or more pounds in one week. The orders included 80 mg (milligrams) of Lasix (a diuretic) twice a day for CHF.

The July 2011 weight record did not document the resident was weighed the second or third week and weighed 170 pounds on the fourth week.

The July 2011 MAR documented the order to contact the physician with weight changes greater than or equal to 5 pounds based on weekly weights. There were no weights documented on the MAR and next to the order was written "FYI" (for your information).

The August 2011 MAR documented the resident weighed 182.6 pounds on August 2, 2011. This was a 12.6 pound increase from the resident's last recorded weight.

There was no documentation in the medical record the physician/NP were notified of the resident's weight change.

The August 2011 weight record documented the resident weighed 171 pounds the first week (no date specified). This weight was 11.6 pounds different from the weight recorded on August 2, 2011 on the resident's MAR.

There was no documentation in the medical record that the physician or NP were notified of the resident's weight change.

The weight record and MAR dated August 2011 did not document any additional weights for the resident during August 2011.

The August 8, 2011 physician's orders documented the same orders related to the weekly weights and "diuretic alert" as documented in the July 13, 2011 physician's orders. The resident remained on Lasix 80 mg twice a day.

The Minimum Data Set (MDS) assessment dated September 2, 2011, documented the resident had moderately impaired cognition

The September 2011 MAR documented the resident weighted 165.4 pounds on September 6, 2011. The weight record documented the same weight. This was a 5.6 pound loss since the last recorded weight, there was no documented evidence the physician or NP were notified of the weight change, and no further weights were documented for the resident during September 2011.

The September 13, 2011 physician's note documented the resident had no weight loss since the last physician's visit (July 13, 2011). The resident complained of shortness of breath, had 1+ pitting edema in the right leg, and 2+ pitting edema in the left leg .

The September 16, 2011 physician's orders documented the resident was on weekly weights, "diuretic alert" and Lasix 80 mg twice a day.

The comprehensive care plan (CCP), dated September 22, 2011, documented the resident received diuretics, had a weight goal of 235 - 245 pounds, and the plan included monitoring weight.

The weight record documented the resident weighed 161.4 pounds in the first week of October 2011. There were no other weights documented on the weight record.

The October 18, 2011 physician's orders documented the resident was on weekly weights, "diuretic alert" and Lasix 80 mg twice a day.

On October 26, 2011 at 11:45 AM, the Director of Nursing (DON) was interviewed and stated she did not know about the resident's order for weekly weights as it was initiated in June 2011 and she did not work at the facility at that time. She stated the weekly weights should be monitored by the registered dietitian (RD).

On October 26, 2011 at 2:15 PM, the RD stated in an interview, when weekly weights were ordered for a medical reason such as for monitoring fluid losses/gains, she did not monitor the weights, nursing did.

On October 27, 2011 at 11:35 AM, the physician stated in an interview, if weekly weights were ordered he expected the resident to be weighed weekly. He stated he and/or the medical staff were in the facility frequently. The physician said if a resident was asymptomatic and had a weight change, nursing staff could notify them (medical staff) at their next visit to the facility. He stated if a resident was symptomatic, nursing staff should call the medical staff sooner.

In summary,the facility:
- did not ensure weekly weights were obtained as ordered; and
- did not ensure medical staff was notified of weight changes as ordered.

3) Resident #5 was admitted to the facility on October 18, 2011 following a hospitalization for a left below the knee amputation as a result of gangrene of the the left foot from a chronic, non-healing wound. The resident also had a diagnosis of end-stage kidney disease requiring dialysis and vascular disease (impaired circulation).

During the initial tour of the facility on October 24, 2011 between 6:15 PM and 6:50 PM, the resident was observed wearing a beige sleeve on his left leg stump.

The hospital discharge summary, dated October 17, 2011, did not document the use of a sleeve on the left leg stump.

The admission physician's orders dated October 18, 2011, did not document an order for a sleeve to be worn on the left leg stump.

The resident's comprehensive care plan (CCP), initiated on October 18, 2011, documented the resident had a recent amputation. The CCP did not document a plan of care related to the sleeve on the resident's left leg stump.

The resident was observed on October 26, 2011 at 7:45 AM. He was wearing the sleeve on the left leg stump at that time. He told the surveyor that he was given the device in the hospital, applied it himself, and wore it "all day every day." He stated he had a spare sleeve so he always had one on.

In an interview on October 26, 2011 at 11:45 AM, the Director of Nursing (DON) stated there was no nurse manager for the unit. She said she was not aware the resident was admitted with any specialized devices. The DON stated she thought therapy would monitor devices for residents with amputations as they helped them obtain prosthetics.

On October 27, 2011 at 8:15 AM, the resident was observed wearing the sleeve on his left leg stump. The resident told the surveyor it was a "pressure sock" used to get his leg ready for a prosthesis. He stated he applied it himself and wore it all times except when bathing.

On October 27, 2011 at 8:50 AM with the surveyor present the Director of Rehabilitation observed the resident's left leg sleeve and stated it was used to prevent blood clots. She stated her department did not monitor those devices as they were monitored by nursing or medical. The licensed practical nurse (LPN), who was present, stated to the surveyor, she was not aware the resident wore sleeve and said it was not documented on the resident's Treatment Administration Record (TAR). She stated the certified nurse aides (CNA) would put the sleeve on the resident and it should be listed on the CNA's care card (used to direct care).

On October 27, 2011 at 8:55 AM, the CNA assigned to care for the resident for the day, stated she had never taken care of the resident before. The CNA said the resident had the sleeve on when she came in that morning and she thought he put it on himself. She stated she was not told to apply or remove the sleeve. The CNA said she was not told anything about the sleeve in report.

The attending physician stated during an interview on October 27, 2011 at 11:35 AM, he had not yet seen the resident as he was a new admission. The physician said the resident was at dialysis on the 2 occasions he had tried to see him. He stated if a sleeve was used, he would expect that it was recommended by the surgeon and the facility should follow the directions of the surgeon.

The resident's undated CNA care card did not document the use of the sleeve on the left leg stump.

In summary the facility:
- did not ensure there was an order for the sleeve on the resident's left leg stump;
- did not specify a wearing schedule; and
- did not ensure a plan of care was developed and implemented to ensure the device was utilized as planned.

10 NYCRR 415.12

F325 483.25(i): RESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.

Citation date: October 28, 2011

Based on observation, record review, and staff and resident interviews conducted during the standard survey, it was determined for 6 of 7 residents (Residents #2, 3, 4, 6, 12, and 14), reviewed for weight concerns, the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, Resident #4 was provided with a therapeutic diet without a physician's order and had a significant weight loss without timely changes to the planned interventions. Resident #14 had weight loss and interventions were not individualized or implemented timely. Residents #2, 3, 6, and 12 had weight loss without timely reassessments of their plans of care. During the resident group meeting 13 anonymous residents stated they did not routinely receive bedtime (HS) snacks. 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 STANDARD SURVEY OF January 20, 2011.

Findings include:

1) Resident #4 was admitted to the facility on April 19, 2011 with diagnoses including chronic renal insufficiency and dementia.

The April 20, 2011 registered dietitian's (RD) admission note documented the resident weighed 155 pounds and her ideal body weight (IBW) was 108 - 132 pounds. The RD documented she "questioned" the resident's admission weight and planned to re-weigh the resident. The nutritional needs were assessed using the IBW of 132 pounds and the diet was no added salt (NAS), no concentrated sweets (NCS). The RD did not document a planned weight loss and did not document a rationale for assessing nutrition needs based on a weight that was 23 pounds less than the resident's actual weight.

The weight record did not document the resident was re-weighed as requested in April 2011.

The April 26, 2011 Minimum Data Set (MDS) assessment noted the resident had moderately impaired cognition, required extensive assistance for eating, and had 2 Stage II pressure ulcers (partial thickness loss of skin layers).

The April 29, 2011 RD's assessment documented the resident's albumin (measure of protein stores) on April 26, 2011, was 2.6 g/dl (grams per deciliter), normal = 3.5-5 g/dl; the resident had a pressure ulcer, and weighed 155 pounds. The RD assessed the resident's nutritional needs using the adjusted body weight of 138 pounds (17 pounds less than the actual weight). The RD documented the resident was at risk for weight loss, had pressure ulcers and a low albumin. The resident's diet consistency was changed to puree and the RD recommended Resource (a supplement) 3 times a day.

The comprehensive care plan (CCP), updated on April 29, 2011, documented the resident was at risk for weight loss/gain related to poor intake and advanced age. The plan included Resource supplement, the diet as ordered, and extensive assistance for meals.

The weight record documented the resident weighed:
- 162 pounds in the first week of May 2011;
- 158 pounds in the first week of June 2011; and
- 150.4 pounds in the first week of July 2011.
The weight record showed the resident was re-weighed the first week of of July 2011 to confirm the weight of 150.4 pounds. The resident lost 11.2 pounds (7%) in 2 months.

The RD's July 12, 2011 progress note documented the resident's pressure ulcer was resolved the month prior. The note recorded the resident had weight loss, received Resource 3 times a day, and consumed 25 - 50% at meals. The RD recommended Resource be increased from 3 to 4 times a day.

The RD's July 15, 2011 assessment documented the goal was to maintain the resident's weight above 150 pounds as weight loss was "unfavorable."

The July 29, 2011 physician's progress note documented the resident lost 7.6 pounds in one month and a re-weigh was requested. On the same date the physician wrote an order to re-weigh the resident.

There was no documented re-weigh on the weight record for the fourth week of July 2011.

The weight record documented the resident weighed 146.6 pounds the first week of August 2011, which was a 3.8 pound weight loss in one month (2.5%) and a 15.4 pound weight loss in two months (9.5%).

The August 2011 Medication Administration Record (MAR) documented the resident received Resource at 8 AM, 12 PM, 5 PM, and 8 PM. The August 2011 MAR recorded the resident refused the Resource on 27 occasions. Review of the medical record revealed no documented rationale for providing the Resource supplement immediately prior to meals.

The weight record documented the resident weighed 143 pounds the first week of September 2011.

The RD's September 22, 2011 progress note documented the resident left 50% of meals uneaten, had weight loss, and received Resource 4 times a day. There was no documented evidence the RD assessed the resident's acceptance of the Resource and there was no rationale provided for the decision to provide Resource just before meals times.

The September 27, 2011 physician's orders documented the resident's diet was NAS, NCS, puree consistency with an option of soft sandwiches.

The resident's September 2011 Intake Flowsheet documented the resident was offered between meal drinks and was not offered solids. The record did not document the resident was offered an HS (evening) snack.

The weight record documented the resident weighed 138.6 pounds in the first week of October 2011 and 136 pounds in the second week of October 2011.

The RD's October 20, 2011 note documented the resident's intake was poor (0 - 50% at meals). The resident received Resource and the RD's plan was to change milk at lunch and supper to Glucose Control Boost (a supplement).

The undated CNA care card documented the resident required extensive assistance at meals.

The October 1 - 24, 2011 Intake Flowsheet documented the resident was offered drinks between meals daily and was not offered solids. There was no documentation the resident was offered HS snacks.

On October 25, 2011 at 1:07 PM the resident was observed at lunch. The resident's meal ticket documented a diet of NCS, low potassium. The resident fed herself pureed pasta, broccoli, fruit, milk, water, and coffee. The meal ticket documented the resident was to receive a soft sandwich which was not provided. The resident ate 25% of the meal. The meal ticket did not include Glucose Control Boost as planned and the resident did not receive it. There was a certified nurse aide (CNA) at the same table as the resident and the resident was not provided with extensive assistance.

The CNA that was assisting other residents seated with the resident was interviewed on October 25, 2011 at 1:10 PM. The CNA stated she did not work at this facility, she said she was from the corporation's other facility, and had never worked at this facility before. The CNA said she did not know the resident and did not, when asked by the surveyor, answer questions related to her assignment or her job duties for the day.

On October 25, 2011 at 1:20 PM, the Food Service Director was interviewed. She stated the kitchen did not always give the residents a soft sandwich when it was listed on the meal ticket. She stated they either knew which residents wanted the sandwich or the CNAs would asked for one. She stated the resident must not have wanted the sandwich that day or the CNA would have asked for it. The cook who was present during the interview then stated they "have this down to a science."

On October 26, 2011 at 1:10 PM, the resident was observed feeding herself lunch without staff assistance. She ate bites of the pureed food, and did not eat the soft sandwich.

On October 26, 2011 at 2:15 PM the RD was interviewed and said the resident was the only one currently on a low potassium diet, which was the facility's most restrictive diet. The RD was asked the reason for the diet and stated she had to review the medical record. After reviewing the record, the RD stated there was no order for a low potassium diet. She said the resident was provided with a low potassium diet since April 2011, without a physician's order or a rationale. The RD stated the resident received Resource and a soft sandwich at lunch and supper which provided 1000 calories. She said the resident needed 1600 calories a day, therefore the resident almost met her calorie need daily.

The resident's meal profile dated October 26, 2011 at 3:17 PM, listed a low potassium, NCS, pureed diet. The profile documented the resident was to receive a soft sandwich daily at lunch and supper in addition to the planned entree. The profile did not document Glucose Control Boost at lunch and supper as planned. The profile did not document to provide food between meals or at HS.

In summary the facility:
- did not ensure there was an order and therapeutic need for a low potassium diet which the resident received for 6 months:
- did not ensure timely changes to the plan of care when the resident exhibited weight loss, and:
- did not ensure nutrition interventions were consistently implemented as planned.

2) Resident #14 had diagnoses including atrial fibrillation (irregular heartbeat), hypertension, depression and glaucoma.

The January 2011, wight record documented the resident weighed 233.6 pounds.

The Minimum Data Set (MDS) assessment dated May 18, 2011 documented the resident was cognitively intact and required supervision/set up for meals. The assessment documented resident's weight as 228 pounds.

The registered dietitian's (RD) note dated August 5, 2011 documented the resident ate well, 100% at meals. The resident's weight was documented as stable at 226 to 229.8 pounds for the past 4 months, with a July weight of 224.4 pounds. The note recorded the resident had a cold in July 2100 and accepted lower calorie and fat items. The note documented the current weight was within proximity to the resident's normal weight and no significant change was noted. The RD's note recorded the resident's care plan was assessed as appropriate and no change was necessary.

The MDS assessment dated August 16, 2011 documented there was no change in the resident's cognition or activities of daily living (ADLs). The assessment recorded the resident's weight was 220 pounds and was not a concern. (This was a weight loss of 13 pounds in 7 months).

The comprehensive care plan (CCP) dated August 17, 2011, documented the resident was at risk for weight loss. The goal was changed from 228 pounds, plus or minus 3 pounds to 224 pounds, plus or minus 3 pounds. The CCP documented the goal was then changed to 220 pounds, plus or minus 3 pounds. There were no dates written to identify when the weight goal was changed, and no documented rationale on the CCP for changing the resident's weight goal. The CCP did not document a weight reducing plan. The planned interventions included: monitoring the resident's weight and intakes; providing an adequate diet; providing encouragement; providing the resident's favorite fluids; and providing the necessary adaptive equipment. The RD note documented the resident had a gradual, non-significant weight loss within 6 months. The CCP recorded the resident's usual meal intake as 100%. There was no documented changes in interventions on the CCP.

The Intake Flow Record dated September, 2011 documented the resident's intake of solids at breakfast and lunch was 75 to 100 %. The documentation was completed for 16 of 30 days of the month for supper. "Any sandwich" was documented for the bedtime snack (HS) and the amount eaten was not recorded on the flow record.

The weight record for October, 2011 documented the resident's weight as 203.8 pounds with a reweigh of 202.4 pounds.

A RD progress note dated October 11, 2011, recorded the resident's weight as 203.8 pounds, and noted this was a loss of 16.6 pounds (7.5%) in a month. The RD documented the resident's weight had been in the 220s over the past 6 months and, "as reported by nursing", the resident's intake was 75 to 100% of meals. The note recorded the resident received a sandwich at bedtime (HS) which he ate 50% of the time. The RD documented the resident was having some "head congestion" that "may effect" his intake. The plan was for the RD to "follow" the resident's status.

On October 25, 2011, the RD documented the resident continued to be treated for congestion while intakes remained at 75 to 100% at meals. The RD noted the resident's weight of 202.4 pounds and recommended starting the resident on 4 ounces (oz) of Resource 2.0 twice a day to prevent further weight loss.

At 4:40 PM on October 26, 2011, the surveyor met with the resident at the resident's request. The resident spoke about his weight loss. The resident stated, his wife used to visit and bring him cookies and drinks prior to her recent placement in a facility. The resident said he now was receiving Resource, and never received an afternoon or evening snack from the staff. The resident then clarified the statement stating the evening shift certified nurse aide (CNA) brought him a half a sandwich (liverwurst) "the other night", and occasionally staff offered him a sandwich in the evening. The resident explained the sandwich provided was often a meat sandwich (turkey, liverwurst, bologna), and he did not care for these items. He said he liked egg salad, tuna or peanut butter and jelly. The resident stated he could not see and was not aware there was a cart, at the nursing desk in the evening with snacks, until residents mentioned it at the group meeting earlier today.

The resident's Intake Flow Record for October, 2011, recorded a HS snack of "any sandwich". The record was completed for fluid intake on the 11 to 7 shift from October 1 through October 27, 2011 and documented the resident's meal intake for breakfast and lunch. Documentation for dinner was sporadic and documentation of the resident's HS snack was recorded for October 2, 4, 6 and 8, 2011. There was no documented evidence of the resident's acceptance of the HS snack through October 27, 2011.

When the registered dietitian (RD) was interviewed on October 27, 2011 at 9:55 AM and 11:10 AM, she stated the resident was assessed in August and was now eating well. When asked about the resident's gradual weight loss, she stated it was all "non-significant" weight loss. The RD said the resident was on low fat, low calorie items and weight was not a concern. She did not know if the resident's weight loss was planned. The RD stated stated the resident's intake was 75 % to 100 %, and he ate a sandwich at HS 50% of the time. She said she did not work evenings and never observed residents' intake directly during supper or HS snack time. The RD said she did not know if there were any weights recorded between the monthly weights of August and September 2011. She stated she added Resource in October 2011 as a result of the resident's weight loss. The RD said she did not speak to the resident directly regarding his meal plan, or HS sandwich. She stated the HS snack cart was on the unit at 7 PM included: tuna, egg salad, peanut butter and jelly, turkey, ham, bologna, and occasionally liverwurst sandwiches. She said the resident's meal ticket documented "any sandwich", and she was not aware he had any dislikes. The RD said "lots of people did not take" the HS snacks as they were in bed before they were provided. If snack consumption was not documented, she asked staff verbally, for the information.

The Resident Profile dated October 27, 2011 documented the resident's specific dietary plan and included his dislike of bologna, pork, liverwurst and turkey sandwiches.

In summary the facility did not reassess, re- evaluate, and address the resident's nutritional needs in a timely manner.

3) Resident #3 had diagnoses including chronic obstructive pulmonary disease (COPD, lung disease), anxiety and macular degeneration (eye disorder/blindness).

The registered dietitian's (RD) admission progress note dated July 19, 2011, documented the resident weighed 102.4 pounds, and had "severely depleted" albumin levels. The RD documented the resident's oral intake would be monitored to determine if supplementation was necessary.

The July 21, 2011 RD's assessment documented the resident's albumin (measure of protein stores) on July 12, 2011, was 1.8 g/dl (grams per deciliter), norm=3.5-5 g/dl. The resident was at risk for weight loss, and the RD recommended Resource 2.0 (a supplement) as the resident left greater than 25 percent of her meal uneaten and she had increased protein needs.

The resident's Comprehensive Care Plan (CCP) dated July 21, 2011, documented 2 ounces of Resource 2.0 four times a day as an approach, with a goal weight, for the resident, of 105 pounds (plus or minus 5 pounds).

The resident's Minimum Data Set (MDS) assessment dated July 26, 2011, documented the resident had moderately impaired cognition, needed extensive assistance with eating, and weighed 102 pounds.

The CCP dated August 10, 2011, documented the resident continued to receive 2 ounces of Resource 2.0 four times a day.

The MDS assessment dated August 14, 2011, documented the resident needed supervision for eating after her tray was set up, and she weighed 101 pounds.

The physician's orders dated August 17, 2011, documented the resident was to receive 4 ounces of Resource 2.0 twice a day.

The RD's progress note dated September 15, 2011, documented the resident had an 8 pound (8 %) weight loss over the past month, and a 10 pound weight loss since admission. The note documented the resident was given 4 ounces of Resource 2.0 twice a day, and she would recommend increasing this to three times a day. The resident agreed to have a "few extra" items added to her menu pattern (cottage cheese, yogurt pudding, and ice cream). The resident's care plan was not updated to reflect the resident's weight loss.

The physician's orders dated September 15, 2011, documented a change in the Resource 2.0 to 4 ounces three times a day.

The resident's September 2011, Medication Administration Record (MAR) documented the resident was to receive 4 ounces of Resource 2.0 three times a day. The MAR from September 19 to September 30, 2100 documented the resident refused the Resource on 5 occasions, and was given and did not consume the Resource on 14 occasions.

The October 2011, Activities of Daily Living Tracking Sheet documented the resident required supervision for eating.

The RD's progress note dated October 11, 2011, documented the resident was "comfort care status." The resident's current weight was 84.6 pounds, an 8 % loss in one month. The note recorded adjustments were made to the resident's menu to incorporate her food preferences.

On October 25, 2011 at 12:45 PM, the resident was observed at lunch being fed by the licensed practical nurse (LPN).

During an interview with the RD on October 27, 2011 at 10:15 AM, she stated she would not have seen the resident from July to August 8, 2011 unless the resident had a significant weight loss. She stated she saw the resident on September 6, 2011, and reassessed the resident's fluid needs because she had an urinary tract infection. The RD said she documented a change in Resource 2.0 on September 15, 2011. The RD stated she did not re-evaluate changes to the resident's care plan because she "only worked" 2 days per week. She stated resident weights were done the first of the month and she was not aware the resident was not consuming the Resource 2.0.

The Administrator was interviewed on October 27, 2011 at 12:20 PM and as part of the facility's quality assurance program, he stated the RD was responsible for doing diet audits including physician's orders, and weight records for all residents. He stated the RD worked 2 days a week.

In summary, the facility did not ensure the resident's significant weight loss was re-evaluated and re-addressed in a timely manner.

10 NYCRR 415.12(i)(1)

F252 483.15(h)(1): SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

The facility must provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

Citation date: October 28, 2011

Based upon observations and staff interviews conducted during the standard survey, it was determined the facility did not provide effective housekeeping and maintenance services to maintain a sanitary, orderly, and odor free environment on 2 of 2 nursing units (A-wing and B-wing), including a sampling of 16 resident rooms. Specifically, the facility did not keep resident areas free from persistent odors; and did not maintain the building in good repair in regard to resident room furniture. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) ODORS:
During the survey, disinfectant spray odors were detected in the following areas at the following times:
- On October 25, 2011 at 8:30 AM, there was a strong disinfectant odor in the main dining room while multiple unidentified residents were sitting at tables waiting for their meals.
- On October 25, 2011 at 9:40 AM, a strong disinfectant odor was detected on B-wing.
- On October 25, 2011 at 11:40 AM, a strong disinfectant odor was detected on B-wing.

The housekeeper on B-wing was interviewed on October 25, 2011 at 11:50 AM, and stated she sprayed Lysol disinfectant into the air in every resident room (if they were not in the room) and she sprayed all residents' privacy curtains.

The Director of Maintenance was interviewed on October 24, 2011 at 1:15 PM, and he stated he talked to the housekeeper again, and she told him it was true she used to spray the Lysol directly into the air, but now she only sprays the Lysol directly onto the curtains.

During the survey, other foul odors were detected in the following areas at the following times:
- On October 25, 2011 at 8:30 AM, there was a strong fecal odor detected in the main dining room, the hallway leading to the A-wing, and in the corridors of the A-wing.
- On October 25, 2011 at 9:00 AM, there was a strong urine odor detected in the hallway of B-wing.
- On October 26, 2011 at 2:10 PM and 2:15 PM, a strong urine odor was noticed in the hallway of A-wing.
- On October 28, 2011 at 9 AM, a strong urine odor was noticed in the hallway of B-wing, and the odor remained and was still evident at 9:25 AM and 11:00 AM.

In summary, the facility did not keep resident areas free from persistent chemical (disinfectant sprays) and other foul odors (urine/fecal) and the facility did not employ cleaning methods that conformed to the guidelines of the Centers for Disease Control (CDC) Recommendations for Disinfection and Sterilization in Healthcare Facilities published in 2008, which recommends against the use of disinfectant fogging for routine purposes in patient-care areas.

2) RESIDENT ROOM FURNITURE:
During the building inspection conducted on October 25, 2011 between 1:15 PM and 4:15 PM, the bedside tables in resident rooms were observed in poor condition (taped, worn or scraped) in 6 of 16 resident rooms sampled (Rooms #A10, A13, A25, B3, B7, and B10).

The Director of Maintenance was interviewed on October 25, 2011 at 1:30 PM, and he stated he expected the facility would purchase new bedside tables in about one year.

In summary, the facility did not keep the building in good repair in regards to bedside tables.

10 NYCRR 415.5(h)(1), 415.29(j)(1), 415.5(h)(1), and 415.29(i)(3)

F353 483.30(a): SUFFICIENT NURSING STAFF ON A 24-HOUR BASIS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: Except when waived under paragraph (c) of this section, licensed nurses and other nursing personnel. Except when waived under paragraph (c) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Based on observations, staff and resident interviews and record reviews conducted during the standard survey, it was determined the facility did not ensure there was sufficient nursing staffing levels to maintain the highest practicable level of well-being. The facility did not ensure sufficient staff to provide the necessary care and services regarding activities of daily living (ADL's) for 6 of 13 residents (Residents #3, 8, 9, 12, 13 and 14), reviewed for ADL concerns, for 7 of 13 anonymous residents who attended the group meeting and 13 residents outside of the sample (Residents #19, 21, 22, 23, 24, 25, 26, 27, 29, 30, 31, 32 and 33). Specifically, the lack of sufficient staff on duty affected multiple areas of resident care and quality of life, and adversely affected the staff's ability to provide care in a safe and time manner. Specifically, for Residents #13, 22, 23, 24 and 25, nursing staff did not provide timely incontinence care to meet their toileting needs; for Residents #13, 26, 27, 29, 30, 31 and 32, nursing staff did not provide timely assistance during meals to maintain good nutrition; for Residents #9, 13, 14, 27, 32 and 33 nursing staff did not provide timely morning (AM) care to maintain good grooming or assist them to rise at the planned time; and Residents #3, 8, 12, 19 and 21 were served food that was out of temperature. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Toileting Needs
1) Resident #22 had diagnoses including post polio syndrome, anemia, and spinal stenosis (narrowing of the spine).

On October 28, 2011, Resident #22 asked to speak to the surveyor at 8:55 AM. The resident, stated she was very upset as her toileting needs had not been met on the night shift. She said the night shift (11 PM to 7 AM) certified nurse aide (CNA) usually assisted her with morning care at 5:30 AM, which included her toileting needs, per the resident's request. She stated only one CNA worked on the unit "last night", and her toileting needs were not met until the day CNA arrived. She stated she was assisted after 7 AM and, as a result, she was "soaked".

The Minimum Data Set (MDS) assessment dated July 28, 2011 documented the resident was cognitively intact. The MDS recorded the resident required total assistance with toileting needs and was incontinent of bowel and bladder.

The undated resident care card, (used by the CNAs to direct care) documented staff were to offer the resident a fracture pan (bed pan) at night. The care card recorded the resident was on a toileting schedule of every 2 to 4 hours while awake.

At 11:15 AM on October 28, 2011, CNA #1 stated in an interview, "only one" CNA had worked on the night shift and was not able to get everyone up who was assigned to be assisted on the night shift. She said when there was only one CNA working, the CNA was "suppose to" get 4 people up, and if 2 CNAs were working, they were "suppose to" get 8 people up. If not able to get the residents up, CNA #1 stated the aide should "at least have them dry". She stated Resident #22 was incontinent and was "very upset" when she assisted her at 7:30 AM as she usually received care between 5 AM and 5:30 AM.

2) Resident #23 had diagnoses which included dementia, a decrease in function, and diabetes.

On October 28, 2011 at 8:55 AM the resident stated in an interview she was upset as she was not assisted on the night shift as planned, and she was "soaked" when assisted by the CNA on the day shift after 7 AM. She stated she had her call light on at 6:40 AM and did not receive assistance until 8 AM.

The MDS assessment dated September 15, 2011 documented the resident was moderately impaired cognitively, and required extensive assistance with toileting needs.

The undated resident care card (used by the CNAs to direct care) documented the resident was: occasionally incontinent; required extensive assistance of 1 person with toileting needs; was on a toileting program; and was to be offered a bedpan at night.

At 11:15 AM on October 28, 2011, CNA #1 stated in an interview, "only one" CNA worked on the night shift and was not able to get everyone up who was assigned to be assisted on the night shift. She said when there was only one CNA working, the CNA was "suppose to" get 4 people up, and if 2 CNAs were on the unit, they were "suppose to" get 8 people up. If they were not able to get the residents up, CNA #1 stated the aide should "at least have them dry." CNA #1 said the resident was "usually continent", was the "first person" she assisted that morning, and was "a little" wet.

3) Resident #13 had diagnoses which included Parkinson's disease, dementia, and functional quadriplegia (complete immobility).

The Minimum Data Set (MDS) assessment dated July 28, 2011 documented the resident was severly impaired cognitively. The MDS recorded the resident required total assistance with toileting needs and was described as always incontinent.

The undated resident care card (used by the certified nurse aides to direct care) documented the resident wore an incontinence brief and was not on a toileting plan.

At 11:15 AM on October 28, 2011, during an interview, CNA #1 said Residents # 13, 24 and 25 were "ridiculously" wet when she provided care "this morning." CNA #1 stated "only one" CNA worked on the night shift and was not able to get everyone assigned up in the morning. She said when there was only one CNA working the night shift, the CNA was "suppose to" get 4 residents up. CNA #1 stated if the night CNA was not able to get the residents up they should "at least have them dry."

During the resident group meeting held on October 26, 2011 at 11 AM, 7 of 13 residents verbalized they were not having their care needs met in a timely manner. This included: receiving morning (AM) or bedtime (HS) care, toileting needs, and receiving meals in a timely manner.

In summary the facility did not ensure sufficient staff to provide timely assistance to meet the toileting needs of the residents.

Assistance with Morning Care
4) Resident #9 had diagnoses which included depression and hypertension.

The Minimum Data Set (MDS) assessment dated August 25, 2011, documented the resident was cognitively intact. The MDS documented the resident required extensive assistance with transferring, dressing and personal hygiene.

The comprehensive care plan (CCP) dated September 15, 2011, documented the resident required extensive assistance of 1 person for bathing and dressing. The CCP noted the resident transferred with a rolling walker and extensive assistance of 1 person.

On October 24, 2011, the resident stated during an interview at 6:50 PM, she hoped to attend the Resident Council meeting on October 26, 2011 at 11 AM, as staff did not always get her out of bed before 11 AM. She stated she preferred to be up right after breakfast.

On October 28, 2011, at 11:05 AM, CNA #1 was heard informing the social worker that the CNA who was responsible for the resident's care, knew "a half hour ago" the resident wanted to get out of bed. The social worker, was interviewed, immediately after the CNA spoke to her, and stated the resident called her by telephone and told her she was upset and wanted to be up in time for the meeting with the surveyors at 11:30 AM.

The CNA providing care to the resident was unable to be interviewed at that time, as she was busy providing morning care to the residents on her assignment.

At 11:15 AM on October 28, 2011, CNA #1 was interviewed by the surveyor and stated care was late that morning as there was one CNA on the night shift, and that CNA was not able to get all the residents up who were part of the night shift assignment. She stated the resident was in bed waiting for care and was supposed to be up no later than 10:30 AM.

At 11:45 AM, on October 28, 2011, CNA #2 was observed transporting the resident over to speak to the surveyors. The resident was interviewed at that time and stated, after the surveyor told her the resident group meeting was delayed, that she wanted to get out of bed anyway. The resident stated she liked to get up right after breakfast and CNA #3 kept delaying the time she got her up. The resident said CNA #3 would tell her she had to get other residents up before getting her up. The resident stated she had asked to get up at 9:50 AM that morning.

In an interview at 11:45 AM on October 28, 2011, CNA #2, stated the staff usually allow residents to decide what time they get up each day. CNA#2 said "we do put her (Resident #9) off sometimes" as the resident told the CNAs it was OK. CNA#2 stated she had "just 10" residents on her assignment today and 2 residents had not yet been assisted. She said normally, all residents have received their morning care by 11 AM.

5) Resident #14 had diagnoses which included depression, a non-healing surgical wound of the scalp and glaucoma with blindness.

The Minimum Data Set (MDS) assessment dated August 16, 2011 documented the resident was cognitively intact, required extensive assistance with transferring, dressing and personal hygiene.

The comprehensive care plan (CCP) dated September 2, 2011, documented the resident needed assistance with activities of daily living (ADL) due to impaired mobility and blindness. The CCP recorded the resident needed extensive assistance of 1 person for dressing and bathing.

On October 26, 2011, the resident was interviewed 4:40 PM and stated staff assisted him out of bed in the morning and he ate his breakfast in his room, in his wheelchair, between 8:30 AM and 9:30 AM. The resident stated it's "OK" if he got up at that time, and said he then frequently waited until 10 AM or 10:30 AM to receive assistance getting dressed. In speaking to the resident, he verbalized further concern that he had "stubble" as the CNA did not have time to shave him on his shower day (October 24, 2011) and the CNA had not "been able to do it" since. The resident stated the following day (October 27) was a shower day and he had hoped the CNA would have time to shave him then.

During an interview on October 28,2011, at 11:45 AM, CNA #2 stated she "just got him (the resident) up" and he "wasn't too mad" as his family member was not coming to visit. The CNA stated she got residents up but did not get them dressed until "later".

6) Resident #13 had diagnoses which included Parkinson's disease, dementia, and functional quadriplegia (complete immobility).

The Minimum Data Set (MDS) assessment dated July 28, 2011 documented the resident was severly impaired cognitively. The MDS recorded the resident required total assistance with transferring, dressing, eating, and personal hygiene.

The undated resident care card (used by the certified nurse aides to direct care) documented the resident was to eat meals in the dining room.

During the resident group meeting held on October 26, 2011 at 11 AM, 7 of 13 residents verbalized they were not having their care needs met in a timely manner. This included: receiving morning (AM) or bedtime (HS) care, toileting needs, and receiving meals in a timely manner.

At 11:15 AM on October 28, 2011, CNA #1 was interviewed by the surveyor and stated Residents #13, 27, 32 and 33 were fed breakfast in their rooms as they did not receive morning care in time to go to the dining room. She said their normal routine was to have all meals in the dining room.

In an interview on October 28, 2011 at 12:40 PM, the DON stated when shifts were short-staffed it was a "trickle down" problem and all subsequent shifts were trying to catch up. She stated residents should be up and dressed according to their preference and if their preference was not known, residents should be up and dressed "for breakfast."

In summary, the facility did not ensure sufficient staff to provide the necessary services in a timely manner to meet residents's AM care needs.

Feeding Assistance
Observations made on October 24, 2011 at 6:15 PM showed:
- Residents #13, 26, 27, 29, 30, 31 and 32 seated at 2 tables (tables #1 and 2) in the dining room. Each of these residents had their dinner in front of them. The 2 tables were identified on the seating chart (posted on the wall) as "Feeder" tables. There was one CNA (CNA #1) assisting the residents at the 2 tables. CNA #1 went from table #1 where she was assisting Residents #26, 27, 31 and 32, to Table #2 where she assisted Residents #29 and #30. The residents at table #1 sat with their food in front of them not eating.
- At 6:20 PM, Resident #26 was heard yelling "can I have some milk please?." A few minutes later, CNA #1 called back to her, "yes (Resident #26), I'll be right back". CNA #1 stopped feeding residents at table #2, returned to Resident #26 and assisted her with her glass of milk.
- At 6:25 a second CNA (CNA #2) entered the dining room and began assisting Resident #13 with her meal.
- At 6:35 PM, Resident #13 was removed from the dining room. CNA #2 was overheard saying the food was just "rolling" out of the resident's mouth so she was unable to feed her.

7) Resident #13 had diagnoses which included Parkinson's disease, dementia, and functional quadriplegia (complete immobility).

The resident's weight record documented a weight loss from 112.6 pounds in January, 2011 to 103.6 pounds in October 2011.

The Minimum Data Set (MDS) assessment dated July 28, 2011 documented the resident required total assistance with eating.

The undated certified nurse aide (CNA) care card (used by the CNAs to direct care) documented the resident required total assistance with eating.

The resident's Intake Flow Sheet did not document the resident's intake for the dinner meal on October 24, 2011.

8) Resident #26 had diagnoses including cerebral vascular accident (stroke) with paralysis of the left leg, depression, and chronic renal failure.

The Minimum Data Set (MDS) assessment dated August 14, 2011, documented the resident required total assistance with eating.

The undated CNA care card documented the resident required extensive assistance for eating and was on aspiration precautions.

The resident's Intake Flow Sheet did not document the resident's intake for the dinner meal on October 24, 2011.

9) Resident #31 had diagnoses including dementia, hypertension, and seizure disorder.

The resident's weight record dated 2011, documented the resident had a weight loss from 151 pounds in January, 2011, to 133.2 pounds in October, 2011.

The Minimum Data Set (MDS) assessment dated August 25, 2011 documented the resident was severely impaired cognitively and required extensive assistance for eating.

The resident's Intake Flow Sheet did not document the resident's intake for the dinner meal on October 24, 2011.

During an interview on October 24, 2011, at 7 PM, the registered nurse (RN) manager informed the surveyor, residents that needed assistance eating included Residents #13, 26, 27, 29, 30, 31 and 32.

On October 25, 2011 at 1:07 PM, CNA #4 was interviewed as she assisted residents with the lunch meal in the main dining room. She stated she worked at the corporation's other facility and had never worked at this facility before today. She did not know the residents seated at the table with her and was not able to answer questions about them. She would not state what time her shift started or when it was going to end

On October 25, 2011 at 1:10 PM, CNA #5 was interviewed as she assisted residents with the lunch meal in the main dining room. She stated she worked at the corporation's other facility and had never worked at this facility before today. She would not state what her assignment was that day and was not able to tell the surveyor if she had a resident assignment and/or what unit she was working on.

During the resident group meeting held on October 26, 2011 at 11 AM, 7 of 13 residents verbalized they were not having their care needs met in a timely manner. This included: receiving morning (AM) or bedtime (HS) care, toileting needs, and receiving meals in a timely manner.

The Administrator was interviewed on October 27, 2011 at 12:20 PM regarding the facility's quality assurance program for which he was the coordinator. As part of the facility's quality assurance program, he stated the RD (registered dietitian) was responsible for doing diet audits including the orders, and reviewing the weight records for the entire building. He stated she was employed 2 days per week.

In summary, for these residents who require encouragement and/ or assistance eating, the facility did not ensure sufficient staff to provide the necessary services for good nutrition in a timely manner.

Food Issues
1) During a supper observation on October 24, 2011 between 6 PM and 7:20 PM, the following interviews were conducted:
- Resident #5 stated his supper meal was usually cold when he received it.
- Resident #17 said the food was "always cold" and the coffee was served "warm," not hot.
- Resident #20 stated she always ate in her room, and the hot food served at supper was usually cold and not well-seasoned.

Observations of breakfast on October 26, 2011 showed the following:
- At 7:40 AM, a cart with coffee in air pots was delivered to the A Wing.
- At 8 AM, a cart with breakfast trays was delivered to the A Wing.
- At 8:12 AM, the registered nurse (RN) Manager from the B Wing passed the first breakfast tray to a resident.
- At 8:41 AM, Resident #3 was provided breakfast and assisted with their meal. Staff did not offer to re-heat the food.
- At 8:42 AM, Resident #19 was assisted with the meal, and staff did not offer to re-heat the food and
- at 8:43 AM, Resident #12 was served and assisted. Staff did not offer to re-heat the food.

On October 26, 2011 at 8:43 AM, at the time the last resident was served, a test tray was sampled. The eggs tasted cold and were 99 degrees F (Farenheit). The toast tasted luke-warm and was soggy. The surveyor did not taste the coffee as the A Wing ran out of coffee at 8:34 AM and additional coffee was not delivered. The cranberry juice was mostly frozen with 2 blocks of ice in the container.

At 8:45 AM, on October 26, 2011, the registered dietitian (RD), who was present on the A Wing during the breakfast meal, was interviewed. She stated her role during meals included conducting meal rounds and monitoring residents. She did not complete test trays or pass meal trays. She stated she thought it took about 20 minutes to pass meal trays on both of the nursing units.

On October 26, 2011 at 8:58 AM, the Administrator stated he was not aware there was an issue with getting meal trays passed timely to residents. He stated meal trays were usually passed in "12 minutes" and he was surprised it took longer than that to pass trays that morning.

During the resident group meeting on October 26, 2011 at 11 AM, 7 of 13 residents verbalized they were not having their care needs met in a timely manner. This included morning (AM) or bedtime (HS) care, toileting needs, and receiving meals in a timely manner. During the meeting 9 out of 13 anonymous residents stated breakfast was often served cold and 5 residents stated they often run out of coffee, multiple residents verbalized their toast was often served without butter.

The breakfast meal was observed on the B Wing on October 28, 2011. At 9 AM, there were 5 unidentified residents who had not received breakfast trays. Between 9 AM and 9:25 AM, 3 unidentified residents were served. At 9:25 AM, Residents #8 and 21 were served. Staff did not offer to re-heat or replace the meals served at 9 AM or 9:25 AM.

CNA #6 interviewed on October 28, 2011 at 11 AM, stated there should be 4 CNAs available to pass trays on the unit. Two CNAs pass trays on the unit and 2 CNAs go to the dining room. She stated if there was enough help, it usually took about 30 minutes to pass trays, and if there was not enough help, it took about 45 minutes.

LPN #1 (licensed practical nurse) interviewed on October 28, 2011 at 11:05 AM, stated there were supposed to be 4 CNAs available to pass breakfast trays, but sometimes there were only 3 CNAs. The carts arrived on the unit about 8:15 AM, and if there were 4 CNAs, 2 were assigned to the dining room, and 2 were assigned to pass trays on the unit. It usually took about 40 minutes. She stated if there were two carts instead of one, it would take less time.

CNA #7 interviewed on October 28, 2011 at 11:20 AM, stated there were usually 3 - 4 CNAs, and sometimes only 2 CNAs were available for passing trays at breakfast on the A-wing. The trays arrived on the unit between 8 - 8:15 AM, and at 8:15 AM, if there were 4 CNAs, 1 CNA went to the main dining room, and the other CNAs passed the trays on the unit. After the trays were passed to the residents on the unit, another aide would go to the dining room. She stated the earliest the trays were passed to residents would be 8:50 AM, and at the latest by 9:05 AM (40 - 65 minutes after the trays arrived on the unit).

The Food Service Director stated in an interview on October 28, 2011 at 11:50 AM, the trays were delivered to the B Wing that morning at 8:15 AM. She stated she did not monitor the time trays were delivered to the units or how long it took to pass trays. The Food Service Director said completed test trays at lunch only and the pass times times for 2 test trays done in the past week at lunch meals for October 24, 2011 and October 25, 2011 for the B Wing was 8 -10 minutes. There were no tray pass times available for breakfast or dinner meals.

On October 28, 2011 at 12:40 PM, the DON stated in an interview, she was aware of residents' concerns regarding long wait times for call bells to be answered and the length of time it took to pass meal trays, She she was aware it took 45 minute to an hour to pass meal trays and she felt that length of time was not acceptable and was related to staffing. She stated the plan was to hire more CNAs, LPNs, and RNs. She stated the prior night (11 PM-7 AM), the facility had 1.5 CNAs per unit and the goal was to have 2 CNAs on each unit.

In summary the facility did not ensure sufficient staff to provide residents with meals that were palatable and served in a timely manner.

Pertinent interviews
On October 24, 2011 at 7:25 PM, the RN Supervisor was observed passing medications on the B unit. She stated she was passing medications because an LPN called in (for the evening shift) and she was unable to address any problems in the facility when she was in the middle of passing medications.

On October 25, 2011 at 8:50 AM, the DON stated in an interview, the A Wing did not have a RN Manager for the past 2 months. She stated the ADON was covering the A Wing until she left the facility approximately 2 weeks ago. AT this time, herself and the RN Manger from the B Wing were covering the A Wing. She stated the A Wing was the "rehab unit."

On October 26, 2011 at 11:45 AM, the DON stated in an interview that for the past 3 weeks she had been filling in as the A Wing RN, the Staff Educator and and Infection Control RN. She stated prior to that, an ADON filled those roles.

The Administrator was interviewed on October 27, 2011 at 12:20 PM regarding the facility's quality assurance program for which he was the coordinator. He stated they currently did not have an infection control nurse as she left about one month ago. Currently, the Director of Nursing (DON) was covering until the newly hired infection control nurse began on November 7, 2011.

10 NYCRR 415.12(a)(3)]

F310 483.25(a)(1): ADLS DO NOT DECLINE UNLESS UNAVOIDABLE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

Based on the comprehensive assessment of a resident, the facility must ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to bathe, dress, and groom; transfer and ambulate; toilet; eat; and use speech, language, or other functional communication systems.

Citation date: October 28, 2011

Based on observation, staff and resident interview and record review conducted during the standard survey, it was determined the facility did not ensure resident's the ability to perform activities of daily living (ADL), did not diminish unless unavoidable for 2 of 3 residents (Resident's #11 and 14) reviewed for ADL decline/concerns. Specifically, Residents #11 and 14 experienced a decline in their ability to ambulate as these residents were not provided the amount of assistance required for ambulation. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #11 had diagnoses including arthritis.

The nursing note date June 30, 2011 documented a new physician order for the resident to receive physical therapy (PT) 5 times a week for 4 weeks.

The Plan of Treatment For Rehabilitation form dated June 30, 2011, documented the resident would receive therapy 5 times per week for 4 weeks. The treatment goals included the resident would be able to transfer (sit to stand, and bed to chair) with distant supervision, and ambulate 300 feet with a rolling walker and distant supervision.

The resident's Minimum Data Set (MDS) assessment dated July 15, 2011, documented the resident's cognition was intact. The MDS recorded the resident required extensive assistance of one person for ambulation, and limited assistance of one for transferring.

The physical therapy (PT) discharge summary dated July 18, 2011, documented the resident made improvement since her evaluation dated June 29, 2011. The summary documented the resident met the established goals to maximize her functional independence, and was appropriate for discharge from "skilled PT" at that time. The recommended follow up was "HEP" (home exercise program).

The comprehensive (CCP) care plan dated July 18, 2011 documented the resident was discharged from PT. The CCP recorded the resident used a rolling walker, and did not document the level of assistance/supervision needed or the distance the resident ambulated. The CCP did not document the recommendation for HEP or instructions for implementing the program.

The undated certified nurse aide (CNA) care card (used by the CNA to direct care) documented the resident ambulated 150 feet with a rolling walker and extensive assistance of one person. There was no documentation regarding HEP on the care card.

The July 2011, CNA ADL Sheet documented the resident walked inconsistently form July 19 through July 31, 2011. The distance varied from 30 to 200 feet. The ADL Sheet, under ambulation, was left blank on the following dates:
- July 19, and 24, 2011 on the evening (3 PM - 11 PM) shift; and
- July 28 and 29, 2011, on the day (7 AM - 3 PM) shift.

The August 2011, "CNA ADL Sheet" documented the resident walked inconsistently from August 1 through August 30, 2011. The ADL sheet, under ambulation, was left blank on the following dates:
- August 5, 6, 14, 17, and 30, 2011 on the day shift; and
- August 16, 18, 19, 20, 22, 25, 27, 28, 29 and 30, 2011 on the evening shift.

The nursing progress note dated August 23, 2011, documented a new physician's order that the resident "may" ambulate with a rolling walker in the hallway (no more than 150 feet), with distant supervision. The note recorded the resident was aware of her limitations and would rest as needed.

There was no entry on the CCP regarding the resident's ability to ambulate with the rolling walker and distant supervision.

The undated CNA care card documented the resident needed extensive assistance of 1 person to ambulate with the rolling walker. There was no documentation on the care card regarding the resident's ability to ambulate with distant supervision.

The September 16, 2011 nurse practitioner's note documented the resident was stable with no changes since her last physician visit. The note did not address the resident's functional status regarding ADLs and ambulation/transfer.

The September 2011, "CNA ADL Sheet" documented the resident walked inconsistently from September 1 through September 30, 2011. The ADL sheet, under ambulation, was left blank on the following dates:
- September 1, 3, 4, 7, and 12, 2011 on the evening shift;
- September 22, 2011, on the day shift; and
- September 24, 25, and 30, on the evening shift.

The October 2011, "CNA ADL Sheet" documented the resident walked inconsistently between October 1 through October 26, 2011. The ADL Sheet was blank under ambulation for the following dates:
- October 1, 6, 9, 10, 16, 20 and 21, 2011 on the day shift, and
- October 3, 8, 14, and 17, 2011 on the evening shift.

The Rehabilitation Referral form dated October 20, 2011, signed by the director of nursing (DON) documented an evaluation was requested due to the resident's decrease function in ADLs and ambulation.

The Physical/Occupational Therapy screen form dated October 20, 2011, documented the resident required increased supervision for transferring, toileting and ambulation. The screen recorded the resident required extensive assistance of 1 person for transferring, and extensive assistance of 1 - 2 persons for ambulating. The recommendation was for restorative PT and occupational therapy (OT) 5 times a week, for 4 weeks, to increase the resident's ADL and ambulation abilities.

On October 26, 2011 at 2:10 PM, the Director of Rehabilitation Services (OTR), stated in an interview the therapy department no longer offered a maintenance therapy program. She stated If a resident was discharged from restorative therapy, nursing would update the resident's CNA care card regarding the resident's ambulation status/plan.

During an interview on October 27, 2011 at 8:30 AM, the resident stated staff "on the unit would walk me to the dining room, but they are short staffed, and busy." The resident stated because of the unit being short staffed, "I don't ask to walk anymore."

During an interview with the DON on October 27, 2011 at 10:20 AM, she stated she was not aware of the the resident's decline in ambulation until she was informed by the resident on October 20, 2011.

During an interview with the OTR on October 27, 2011 at 12:30 PM, she stated the resident's cognition was intact, and the resident was aware of her own functional decline. She stated the resident came to the PT department and told them she was weaker, and informed the therapist, that "staff were busy" and did not always have time to walk with her. The OTR stated the resident had previously been on maintenance therapy which was was discontinued facility wide on May 16, 2011. The OTR said when evaluated (on October 20, 2011), the resident required increased assistance including, 2 persons for toileting, and moderate assistance to go from a sitting to a standing position. She stated previously the resident required assistance of 1 for toileting, close supervision for transfers and ambulated with close supervision approximately 500 feet, 5 days a week. The OTR said when the resident returned to the PT program (October 2011), she walked half that distance, and became tired at approximately 150 feet. She stated the current goal for the resident was to walk without assistance, and since starting the program her ambulation improved.

In summary, the facility did not provide the necessary services to maintain the resident at her highest level of functioning.

2) Resident #14 had diagnoses including atrial fibrillation (irregular heart beat) with peripheral neuropathy, glaucoma and blindness.

The Minimum Data Set (MDS) assessment dated August 16, 2011 documented the resident was cognitively intact and required limited assistance with walking in his room or in the corridor. The MDS recorded the resident had no falls since the previous MDS assessment (May 18, 2011).

A registered nurse's (RN) progress note dated August 25, 2011 documented the resident had a fall.

A Rehabilitation Referral to evaluate the resident's ambulation status dated August 30, 2011 documented the resident fell on August 25, 2011 while ambulating with staff in the hallway before lunch. The referral noted the resident's right leg "gave out."

The comprehensive care plan (CCP) dated August 25, 2011 documented the resident's fall and the need to provide assistance with ambulation. The CCP documented the resident was started in physical therapy as a result of the recent fall.

The physical therapist (PT) screen dated August 31, 2011 documented the resident was previously able to ambulate 150 feet with a rolling walker and limited assistance. The screen noted the resident's current ambulation status was 75 feet with a rolling walker and contact guard assistance. The recommendation was for skilled PT to return the resident to his previous level of functioning.

The Plan of Treatment For Rehabilitation form dated August 31, 2011 documented the goal stated by the resident was to strengthen his legs and walk more. The PT documented a short term goal to increase the resident's ambulation to 150 feet with a rolling walker and contact guard assistance/supervision, with a long term goal to maximize the resident's independence with functional mobility. The plan was for the resident to receive physical therapy 5 times a week for 4 weeks.

The CCP dated September 2, 2011 documented the resident required assistance with activities of daily living (ADLs) due to impaired mobility and blindness. The CCP recorded the resident required extensive assistance with transfers and ambulated with a wheeled walker and limited assistance of 150 feet or as tolerated.

The PT progress notes dated September 28, 2011, documented the resident had made good progress, and was working toward therapy goals. This note recorded the resident would benefit from continued therapy.

The physical therapy discharge summary dated October 7, 2011 documented the resident met his maximum functional level. The resident's current status was documented as walking 200 feet with a rolling walker and contact supervision.

The Director of Rehabilitation Therapy (OTR) was interviewed on October 26, 2011 at 2:10 PM. She stated when residents were discontinued from maintenance therapy, there was a decline in function nursing referred the resident to physical/occupational therapy for re-evaluation. She stated the certified nurse aides (CNAs) were to ambulate the residents and do range of motion daily with the residents. The Activity Department was also doing gross motor activities with the residents who had previously been involved in maintenance therapy. The OTR stated the resident was to be walked on the unit by the CNAs. She said that when the resident was in maintenance therapy, he ambulated from the physical therapy room to his room at least daily which was approximately 150 to 200 feet.

The CNA ADL Sheet documented the resident's "ambulation by nursing". The September sheet documented the resident ambulated on the day shift (7 AM to 3 PM) 20 of 30 days, and the evening (3 PM to 11 PM) shift documented the resident ambulated 11 of 30 days.

The CNA ADL Sheet for October, documented the resident ambulated on the day shift 23 of the 25 days and 2 of 25 days on the evening shift.

A CNA was interviewed on October 26, 2011 at 2:45 PM. She stated the resident was to be walked two times a day, once on the day shift and once on the evening shift. She stated it was not written on the CNA ADL sheet specifically, but staff knew that was what they were supposed to do.

When the resident was interviewed on October 26, 2011 at 4:40 PM, he stated he missed going to therapy. The resident said he walked from the therapy room almost back to his room everyday (approximately 150 feet to 200 feet) when in therapy. The resident stated since his discharge from therapy he walked on the unit with nursing staff from his room to the nurses station (approximately 100 feet), because they said they "couldn't do anything more for me."

The Director of Rehabilitation (OTR) interviewed on October 27, 2011 at 12:30 PM and stated the maintenance therapy program was stopped May 16, 2011. She said the resident had been involved in the program walking everyday from therapy to his room. She stated the resident was re-evaluated for restorative therapy after he fell in August, and was in the program from August 31, 2011 until October 7, 2011 for strengthening to return to his previous level of ambulation. She said when the resident was discharged, he was walking 200 feet with a rolling walker and contact supervision. Her expectation was for nursing to continue walking the resident 200 feet.

In summary the facility did not provide the necessary services to maintain the resident at his highest level of functioning for ambulation.

10 NYCRR 415.12(a)(1)(i-v)

F323 483.25(h): FACILITY IS FREE OF ACCIDENT HAZARDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Citation date: October 28, 2011

Based on record reviews and staff interviews conducted during the standard survey, it was determined for 1 of 3 residents (Resident #5), reviewed for falls, the facility did not ensure the environment was as free of accident hazards as possible and residents received adequate supervision and assistance devices to prevent accidents. Specifically, for Resident #5, interventions were not implemented timely for fall prevention and the resident experienced a fall. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #5 had diagnosis including a recent left below the knee amputation and a previous coronary artery bypass graft (heart surgery).

The hospital's discharge summary dated October 17, 2011 documented "fall precautions" were to be maintained for the resident.

The Hospital Discharge and Referral orders dated October 17, 2011, documented "fall precautions."

The nursing note, written by the Director of Nursing (DON), on October 18, 2011 at 1:50 PM, documented the resident was admitted form the hospital. The note recorded the DON received the transfer report from the hospital registered nurse (RN) via telephone. The DON documented the resident was non-ambulatory and transferred with a slide board.

The fall risk assessment dated October 18, 2011, by the RN Supervisor (RN#1) documented the resident was at high risk for falls related to being "chair bound," concerns with gait/balance, medications with possible side-effects that may increase fall risk, his disease processes including the loss of a limb, poor vision, and a history of 3 or more falls in the past 3 months.

The comprehensive care plan (CCP), dated October 18, 2011, documented the resident was alert/oriented and needed assistance with activities of daily living (ADL). The CCP noted the resident was at risk for falls, was non-ambulatory, transferred with 1 assist and a slide board, was at increased risk for bleeding due to anticoagulant therapy (blood thinning medication). Interventions for fall prevention included counseling the resident on safety, keeping the call bell within reach, providing assistance with ADLs and monitoring changes in the resident's status.

The October 18, 2011 admission physician's orders documented the resident was to receive Coumadin (a blood thinner) 4 milligrams (mg) on Tuesday and Thursday evenings and 5 mg on Monday, Wednesday, Friday, Saturday, and Sunday.

The October 19, 2011 nursing progress note written at 2:20 AM by the RN Supervisor (RN #2), documented the resident fell on the floor and hit his head on the bed frame and floor. The note reported the resident sustained skin tears, was on a blood thinner, and was sent to the hospital emergency room.

The Fall Analysis report dated October 19, 2011 at 2:20 AM, documented the resident rolled off the bed. The report included a statement from the certified nurse aide (CNA) who found the resident. The CNA statement documented the resident was found on the floor bleeding, and the nurse and Supervisor were notified. The report included documentation from RN #2, that the resident sustained a skin tear on the arm and complained of a headache.

The CCP dated on October 19, 2011 documented at 2:20 AM, the resident fell and went to the emergency room. New interventions implemented at that time were a bed alarm and fall mats.

The emergency room report dated October 19, 2011 documented the resident reported he hit his head on the tray table and the "tray table actually went flying." He was seen for a closed head injury with no acute findings and returned to the nursing facility the same day.

The October 19, 2011 nursing progress note written at 3 AM documented a bed alarm and floor mat were implemented for the resident.

The current (undated) CNA care card did not document the planned interventions for fall prevention.

On October 26, 2011 at 11:45 AM, the DON stated in an interview, the resident was not here long when he was sent out to the emergency room following a fall. She stated Interventions were implemented after the resident fell. The DON said she "assumed" the resident had alarms initiated prior to the fall but was not sure. She stated she did not see a progress note written by RN #1 after the fall risk assessment was completed.

RN #1 was not available for interview.

In summary the facility did not ensure interventions for fall prevention were implemented timely.

10NYCRR 415.12(h)(1)(2)

F365 483.35(d)(3): FOOD IS PREPARED TO MEET INDIVIDUAL NEEDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

Each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Citation date: October 28, 2011

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 2 residents (Resident #6), reviewed for thickened liquids, the facility did not provide liquids in a form to meet individual needs. Specifically, Resident #6 had an order for honey thick liquids and received regular (thin) consistency Boost (supplement). This resulted in no actual harm with potential for more than minimal harm that in not immediate jeopardy.
Findings include:

Resident #6 had diagnoses including dysphagia (difficulty swallowing) and cerebrovascular accident (CVA, stroke).

The September 2, 2011 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required extensive assistance for eating.

The resident's comprehensive care plan (CCP), dated September 22, 2011, documented the resident had a swallowing problem and was to receive honey thick liquids. The CCP recorded the resident was at risk for weight loss and would receive Boost at meals and between meals.

The October 4, 2011 Modified Barium Swallow (test of swallowing ability) report documented the resident presented with mild to moderate oropharyngeal dysphagia resulting in aspiration (taking foreign matter into the lungs) with thin and nectar thick liquids. The recommendations included honey thick liquids.

The October 18, 2011 physician's orders documented the resident was to receive honey thick liquids and be on aspiration precautions.

Observations made at breakfast on October 25, 2011 at 8:34 AM, at breakfast on October 26, 2011 at 8:25 AM and at lunch on October 26, 2011 at 1:10 PM showed the resident was given thin consistency Boost. At all 3 meals, the resident was observed feeding himself without staff assistance. He fed himself his drinks, including the thin consistency Boost with a spoon. At all 3 meals, the surveyor observed the thin consistency Boost run off the spoon as the resident fed himself.

On October 26, 2011 at 2:15 PM, the registered dietitian (RD) stated in an interview, Boost was considered by the facility to be nectar thick consistency and the kitchen should be thickening the resident's Boost to honey thick prior to serving it to the resident.

On October 27, 2011 at 9:30 AM, the RD stated in an interview, she checked with the kitchen on the procedure for thickening the Boost. She stated the Boost may have appeared to be thin consistency as it is prepared 20 hours in advance of residents receiving it. She stated in those 20 hours, the thickener may settle to the bottom and the top of the product may appear to be thin consistency.

In summary, the facility did not provide honey thick liquids to the resident as ordered.

10 NYCRR 415.14 (d)(3)

F318 483.25(e)(2): RANGE OF MOTION TREATMENT AND SERVICES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

Based on the comprehensive assessment of a resident, the facility must ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

Citation date: October 28, 2011

Based on observations, staff interviews and record review conducted during the standard survey, it was determined for 1 of 1 residents (Resident #6) reviewed for range of motion (ROM), the facility did not provide the appropriate treatment and services to prevent a decrease in ROM. Specifically, for Resident #6, the facility did not ensure that a left hand roll splint was worn at all times as ordered. This resulted in no actual harm, with the potential for more than minimal harm, that is not immediate jeopardy.
Findings Include:

Resident #6 had diagnoses including a past cerebrovascular accident (CVA, stroke), diabetes mellitus and coronary artery disease.

An Admission Skin Check, dated June 6, 2011, signed by a registered nurse (RN), documented the resident's left arm and hand were contracted (loss of joint function), and the left hand "mid-finger crease" was pink and moist.

A nursing progress note dated June 6, 2011 at 7 PM, documented the resident had a "hand roll to the left hand, dry hand roll at all times."

The comprehensive care plan (CCP), dated June 6, 2011, had no documentation for the use of a hand roll splint for the resident's left hand.

The physicians orders, dated June 7, 2011, documented an order for the resident to have a hand roll to the left hand contracture.

The Minimum Data Set (MDS) assessment, dated June 13, 2011, documented the resident was cognitively intact, required extensive assistance for bed mobility, personal hygiene, and eating. The functional limitation in ROM assessment, for limitations that interfered with daily functions or placed the resident at risk of injury, documented the resident had impairment on one side of the upper body and one side of the lower body.

The physician's orders dated October 18, 2011 documented an order for a left hand roll splint to be worn at all times.

The Splint Sheets form dated October 19, 2011 documented the resident was to wear a left hand roll "AAT - OOB &Bathing" (at all times, out of bed and bathing).

The current undated certified nurse assistant (CNA) care card documented the resident was to wear a left hand roll splint at all times.

On October 25, 2011, the resident was observed at 8:29 AM, 9:05 AM, and 11:55 AM, with hand roll splint in his left hand.

The resident was observed on October 26, 2011 at 8:25 AM with hand roll splint in his left hand.

On October 26, 2011 at 8:55 AM, the Director of Rehabilitation was observed as she put a rolled washcloth into the residents left hand. She stated to the surveyor at that time, the hand roll splint helped promote skin integrity.

On October 27, 2011 at 8:50 AM, the Director of Rehabilitation was interviewed and stated a rolled washcloth was used for the hand roll splint and was to be worn by the resident at all times while out of bed. She stated she checked all splints when she came in to work on Monday through Friday at 9 AM, and applied the devices when residents did not have them in place. She stated the resident's hand was contracted when he was admitted to the facility and due to the severity of the contracture, the plan was to use the washcloth. She stated the hand roll was used to prevent skin breakdown from occurring.

On October 27, 2011 at 11:55 AM, the resident's CNA was interviewed and stated the resident was to have a rolled washcloth in his hand at all times except while bathing or sleeping at night. If he was napping during the day, he was to have the washcloth in place. She stated it was difficult to get the hand roll into his hand due to the contracture.

In summary, the facility did not ensure the resident received the appropriate treatment and services to prevent a decrease in ROM when they did not provide the resident with a hand roll splint at all times as ordered.

10 NYCRR 415.12(e)(2)

F155 483.10(b)(4): RIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section.

Citation date: October 28, 2011

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure 1 of 16 residents (Resident #8) reviewed for advanced directives/choice had the right to formulate advance directives. Specifically, Resident #8's advance directives were completed by a surrogate without documentation the resident lacked decision-making capacity. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #8 was admitted to the facility in September 2011 with diagnoses including dementia.

The resident was admitted with a health care proxy (HCP) dated November 12, 2001.

A physician's progress note dated September 14, 2011 documented the resident had advanced dementia and the family would "most likely" be involved in any decision making process. The progress note did not address the resident's advanced directives or code status.

On September 14, 2011, the Medical Orders for Life-Sustaining Treatment (MOLST) was signed by two witnesses concurring a verbal consent for a Do Not Resuscitate (DNR) order was obtained from the resident's HCP.

On September 19, 2011, the attending physician signed the orders on the MOLST form for DNR. There was no documented evidence in the resident's medical record a determination was made regarding the resident's capacity to make decisions before obtaining consent for DNR from the HCP.

On October 27, 2011 at 12:10 PM, the Director of Social Services stated in an interview, she was not aware statements from the attending physician and a concurring physician were needed for determination of capacity when using the MOLST. She said a previous supplement had included this information and was no longer part of the MOLST. She stated this was the current format used by the facility when completing the MOLST. The Director said there was no formal process for determining a resident's capacity to make decisions.

The Medical Director was interviewed on October 27, 2011 at 3:00 PM and stated, if a person clearly could not make a decision, he would go to the HCP or the power of attorney for the decision.

In an interview on October 28, 2011 at 10:40 AM the Medical Director stated he discussed the New York State law regarding DNR orders with other health care professionals, and understands the facility needs to change their current procedure for determining capacity when completing orders for a DNR.

In summary the facility did not ensure the resident's ability to make decisions regarding advance directives was determined by the attending physician and a concurring physician prior to having the HCP give consent for DNR.

10 NYCRR 415.3(e)(1)(ii)

F281 483.20(k)(3)(i): SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 27, 2011

The services provided or arranged by the facility must meet professional standards of quality.

Citation date: October 28, 2011

Based on observation, staff interview, and record review conducted during the standard survey, it was determined for 1 of 3 residents (Resident #1) reviewed for infections, 1 of 2 residents (Resident #21) observed during medication administration, and 1 of 3 residents (Resident #8) reviewed for falls, the facility did not ensure professional standards of quality were met. Specifically, for Resident #1, the admission skin assessment was not performed by a qualified professional (a registered nurse). Resident #21, received medication which was documented as an allergy. Resident #8, was not assessed by a qualified professional after being found on the floor. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #1 was admitted to the facility on September 30, 2011, and had diagnoses including diabetes and an infection of the right leg.

The "Admission Skin Check" form dated October 1, 2011, completed by a licensed practical nurse (LPN), documented the resident had a surgical incision site with a wound vac (a mechanical device to assist in healing) on the right thigh, an 8 inch surgical scar on the left thigh, a PICC (peripherally inserted central catheter) line site on the right arm, and old surgical scars on the abdomen and feet. There was no documented evidence a qualified professional (registered nurse) assessed the resident's skin upon admission.

The Admission Nursing Evaluation form dated October 5, 2011, signed by the LPN documented under the section "skin condition" "scabby dry area" on the right buttock. There was no documented evidence a registered nurse (RN) assessed the resident's skin upon admission.

The LPN who completed the resident's Admission Skin Check was not available for interview.

During an interview with the RN "helping out" on Unit A on June 26, 2011 at 2:50 PM, she stated an LPN did the resident's nursing admission paperwork including the nursing assessment. When asked by the surveyor, who was responsible for admission paperwork, she stated, "We all pitch in."

During an interview with a LPN who worked Unit A on October 26, 2011 at 3 PM, she stated, when an LPN completed the new admission paperwork it was placed in the resident's medical record for the RN to sign. She stated the RN, who should have done the resident's admission skin assessment no longer worked at the facility.

The Director of Nursing (DON) was interviewed on October 27, 2011 at 9:10 AM, and stated data collection was done by the LPN, and an RN would cosign the paperwork. The DON said a "head to toe" assessment of newly admitted residents was done by the RN. She stated she was not aware the resident's admission skin assessment was done by the LPN.

In summary, the facility did not ensure accepted standards of quality were met when the resident's admission skin assessment was not completed by a qualified professional.

2) During an observation of the medication administration observation on October 25, 2011 at 9:18 AM, the licensed practical nurse (LPN) dispensed medications for Resident #21, including a tablet of Percocet (a narcotic pain reliever). The LPN stated to the surveyor she was going to administer the medications to the resident. The surveyor stopped the medication administration, and asked the LPN if the resident had any allergies. The LPN stated the resident had an allergy to Bactrim (an antibiotic). When the surveyor asked if the resident had an allergy to Percocet the LPN stated she did not know.

The resident's October 2011 medication administration record (MAR) documented the resident was allergic to Percocet.

On October 25, 2011, at 9:18 AM the LPN, after looking at the resident's MAR, stated she had not noticed the documentation of the resident's allergy to Percocet.

In summary the facility did not ensure professional standards of quality were met when they did not know the resident had an allergy to a prescribed medication.

3) Resident #8 was admitted to the facility in September, 2011 with diagnoses including dementia with agitation, muscle weakness, and seizure disorder.

A fall risk assessment dated September 14, 2011 documented the resident was at high risk for falls.

The Minimum Data Set (MDS) assessment dated September 26, 2011 documented the resident had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADLs).

On October 28, 2011 at 11:00 AM, the resident was observed by the surveyor lying on the floor in the hallway of the B Wing. Her head was on the floor and her eyes were closed. The surveyor immediately notified 2 licensed practical nurse (LPNs) who were working on the unit. LPN#1 stated to the surveyor that the resident told her she was tired and put herself on the floor to go to sleep. The in an interview at that time surveyor asked LPN#1 if she saw the resident put herself on the floor. LPN#1 stated she did not see the resident put herself on the floor, and said the resident would usually lie on the floor and go to sleep. The surveyor observed the 2 LPNs assist the resident to her feet and walk with her to her room.

On October 28, 2011 at 12:35 PM, the Director of Nursing (DON) stated in an interview, nursing staff should not have moved the resident without an assessment by a registered nurse (RN) or other qualified professional. She stated they would not know if the resident was injured without an assessment.

In summary, the facility did not ensure accepted standards of quality were met when the resident was not assessed by a qualified professional after being found on the floor.

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