Aaron Manor Rehabilitation and Nursing Center

Based on observations, staff interviews, and record reviews, it was determined that for three of three residential units, the facility did not provide for the safe and secure storage of medications. The issues included a lack of accurate accounting of narcotic reconciliation sheets for three of three residential units and a controlled substance (narcotic) cabinet on the first floor. Also, a West 200 Unit medication cart was not double locked. This resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by, but not limited to, the following:

1. Review of the shift-to-shift narcotic sheets for the 500 Unit revealed that for November 2011, 45 nursing signatures were missing; December 2011, 83 nursing signatures were missing; January 2012, 52 nursing signatures were missing; and February 2012, 35 nursing signatures were missing.

Review of the shift-to-shift narcotic sheets for the 600 Unit revealed that for November 2011, 22 nursing signatures were missing; December 2011, 20 nursing signatures were missing; January 2012, 24 nursing signatures were missing; and February 2012, 15 nursing signatures were missing.

The medication room on the second floor, 500 and 600 Units, was inspected on 2/13/12 at 8:50 a.m. Review of the Feburuary 2012 shift-to-shift narcotic count sheet revealed that both day nurses had not signed that they had counted narcotics on 2/13/12 with the night nurse. When interviewed at that time, Licensed Practical Nurse (LPN) #2 stated she does not usually sign the sheet until she uses the first narcotic of the day. She stated she should have signed when she counted with the night nurse but she got busy.

When interviewed on 2/13/12 at 9:35 a.m., the LPN Manager stated the shift-to-shift narcotic sheets should be signed immediately after the count if the count is correct. She also stated that no one checks to see if the sheets are being signed and that there is no reason they would not be signed.

2. Review of the shift-to-shift narcotic sheets for the 100 Unit revealed that for November 2011, 37 nursing signatures were missing; December 2011, 36 nursing signatures were missing; January 2012, 50 nursing signatures were missing; and February 2012, 10 nursing signatures were missing.

Review of the shift-to-shift narcotic sheets for the 200 Unit revealed that for December 2011, 33 nursing signatures were missing; January 2012, 53 nursing signatures were missing; and February 2012, 24 nursing signatures were missing.

The medication rooms on the first floor, 100 and 200 Units, were inspected on 2/13/12 at 10:20 a.m. Review of the February 2012 shift-to-shift narcotic count sheet revealed that both day nurses had signed that they had counted narcotics on 2/13/12 with the night nurse. However, the night nurse's signature was blank. When interviewed at that time, LPN #3 stated she usually signs the sheet when she does the narcotic count, the night nurse should know to sign the sheet also, and she does not know why she did not sign that day.

When interviewed on 2/16/12 at 9:10 a.m., the Director of Nursing stated they used to do audits of the narcotic sheets but had recently stopped. She also stated that she physically checks the medication carts on a regular basis.

Review of the August 2008 facility policy entitled, "Controlled Substances," revealed that the medication cart contains a double lock box and that controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together.

3. During observation of a medication pass on 2/14/12 at 1:45 p.m., LPN #1 was asked to unlock the medication cart so the surveyor could view the narcotic box. The narcotic box was not locked and contained several packets of narcotics including Vicodin (pain). When interviewed at this time, the LPN stated she had forgotten to lock it and should have.

During an interview on 2/15/12 at 3:15 p.m., the Registered Nurse Manager stated the narcotic box should have been locked and that the facility policy is to leave it locked.

[10 NYCRR 415.18(d)]

Based on observations, family and staff interviews, and record reviews, it was determined that for one of three residents reviewed for activities, the facility did not provide activities designed to meet the physical, mental, and psychosocial well-being of cognitively impaired residents. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #110, and is evidenced by the following:

Resident #110 has diagnoses including dementia, cerebral vascular accident (stroke), and depression. The 1/13/12 Minimum Data Set (MDS) Assessment revealed that the resident's cognitive skills for daily decision making are severely impaired and that the resident is totally dependent on staff for all activities of daily living (ADLs) including transportation. Review of the Certified Nursing Assistant (CNA) care card, dated 2/2/12, revealed that the resident is non-verbal, alert and confused, is non-ambulatory, requires staff to propel resident to all locations, and is to be given soft items for tactile stimulation.

Review of the January 2012 to January 2013 Comprehensive Care Plan goals revealed that the resident will receive three one to one interactions weekly for socialization and stimulation. The approaches included providing frequent one to one visits, using conversation, music, and sensory stimulation, involving in Eucharistic visits, Bingo, sewing, and card games.

Review of the Resident's Activity Log and Integrated Progress notes from September 2011 to February 2012 revealed that for 13 of 22 weeks, the resident did not meet the activities goal of at least 3 activities per week. Review of the Activity calendars for the corresponding time frame revealed that 104 music activities and 5 Eucharistic activities were offered on the first and second floors.

In an observation on 2/13/12 at 12:24 p.m., Resident #110 was in her room sleeping in her geri chair. Other observations during the course of the day revealed there were seven activities offered in the sensory room on the second floor, and five activities on the first floor, including a music program. The resident was not seen in attendance at any of these activities.

When observed on 2/14/12 at 2:40 p.m., the resident was again in her room alone seated in a geri chair facing the television (TV). The TV was showing a program on the Lifetime channel. A stuffed animal sat on the resident's lap. The resident's face was directed toward the ceiling, which did not place the TV or the stuffed animal in her line of sight. Her eyes were open and her legs were moving. The resident's room was located at the far end of the hall, away from the nurses' station. She did not have a roommate. There was no activity calendar posted in the room. At 3:20 p.m., a music program was offered in the main dining room for Valentine's Day. At that time, staff in the dining room said that this activity was for everyone in the facility. Resident #110 did not attend the activity.

Review of the Activity Log, dated 2/14/12, revealed that the resident received one individual activity that day. The Activities calendar for 2/14/12 revealed there were eight activities available in the facility, including two music programs.

When interviewed by telephone on 2/14/12 at 9:47 a.m., the resident's family stated the staff do not encourage the resident to attend activities or provide assistance to attend them.

When observed on 2/15/12 at 6:45 a.m., the resident was in bed awake and alert. The TV was showing a program on the Lifetime channel. The TV was not within the resident's line of sight. At 1:25 p.m., the resident was seated in her geri chair. The resident was alert and looked around but did not speak. The Licensed Practical Nurse entered the room, said hello, washed her hands, and left the room. The TV was playing a program on the Lifetime channel and was not in the resident's line of sight. At 2:30 p.m., the resident was seated in her geri chair by the nurses' desk alone, while all other residents had been taken to a Bingo program.

Interviews conducted on 2/15/12 are as follows:

a. At 1:30 p.m., the CNA stated she usually encourages all residents to go to activities, but she had not taken Resident #110 to activities that day.

b. At 2:30 p.m., the Director of Activities stated that Resident #110 gets more agitated when in large groups, so she mostly gets individual activities. She stated the goal for this resident is three activities per week, an individual activity should last 5 to 15 minutes, and that everyone is responsible to do them.

c. At 2:48 p.m., the Activities Leader stated she does activities with Resident #110 in group settings but cannot remember doing any individual activities or visits with the resident for the last month.

[10 NYCRR 415.5(f)(1)]

Based on observations, resident and staff interviews, and record reviews, it was determined that for one of two residents reviewed for comprehensive care planning, facility staff did not revise the care plan to reflect the residents' current status. Specifically, Resident #114's Comprehensive Care Plan (CCP) did not address the resident's broken teeth and loose fitting dentures. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #114 has diagnoses including anxiety. Review of the CCP, dated 11/8/11, revealed that the resident needs assistance with oral care and care of upper and lower dentures. Approaches include for staff to assist with applying and removing dentures daily. The 12/16/11 Speech Therapy evaluation revealed that the resident's upper denture kept falling out and the lower partial was broken, which has caused prolonged chewing for the resident. The Certified Nursing Assistant (CNA) care card, last modified 1/26/12, includes assisting the resident with placement and care of the upper and lower dentures. The Minimum Data Set Assessment, dated 2/1/12, showed that the resident has moderately impaired cognitive skills for daily decision making and no oral or dental problems. Review of a Dental Consult, dated 2/9/12, revealed the resident has 21 missing teeth, three roots, and an upper partial denture.

During an observation on 2/13/12 at 12:20 p.m., staff assisted the resident in putting in her top denture.

During an interview on 2/13/12 at 12:25 p.m., the resident said she has some of her own teeth on the bottom and some are broken and showed the surveyor. She also said that her top denture is too big and loose. At 12:35 p.m., the resident was observed to remove the top denture, which she showed the surveyor was moving up and down, and gave them to the CNA that entered the room.

During an interview on 2/14/12 at 1:41 p.m., the resident said she did not use her dentures that day because "they keep slipping." At that time, the upper denture was observed to be in a container with water on the bedside stand.

In an interview on 2/15/12 at 8:50 a.m., the assigned CNA said that the resident does use the upper denture but it keeps falling out. The CNA said she did not believe that the resident had a lower denture. At 3:11 p.m. that day, the Registered Nurse Manager said the resident has loose fitting upper partials, and the care plan should have been updated.

The facility's policy regarding comprehensive care planning, dated September 2008, directs staff to review and revise CCPs on a quarterly, annually, and on an as needed basis, as the care plan changes.

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

Based on observations and staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not did properly maintain an emergency generator. The issue was related to unlocked access panels on an emergency generator located outside. This affected two of two resident use floors and one of one basement, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy and is widespread. The findings are:

Observation on 2/17/12 at 11:45 a.m. revealed the emergency standby generator located outside on the south west side of the building was observed to have access panels that were unlocked. These included a panel covering the main switch, as well as one covering the main instrument panel board. Additionally, a wooden enclosure with a gate surrounding the generator was observed to be open with a padlock that was not secured. The Director of Maintenance stated in an interview at that time that the gate was always left unlocked, and he was not sure where the keys were for the generator access panels.

The 1999 edition of NFPA 110, Standard for Emergency and Standby Power Systems, states that consideration shall be given to the location of the Level 1 and Level 2 Emergency Power Supply Systems (EPSS) equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by vandalism, sabotage, and other similar occurrences.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.5.1, 9.1.3; 1999 NFPA 110: 5-2.4(b)]

Based on observations, record reviews, and staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain the fire alarm system. The issues were related to incomplete testing and documentation of audio/visual signaling devices and electromagnetic door holders that are tied in to the fire alarm system. This affected two of two resident use floors and one of one basement, and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy and is widespread. The findings are:

1. Observations during the initial tour of the building on 2/16/12 from 8:30 a.m. to 1:20 p.m. revealed the facility has visual strobes and audible devices affixed to the wall throughout the building, including the basement. Additionally, there are electromagnetic door hold open devices throughout the facility on smoke barrier doors and various doors to hazardous areas in the basement.

2. On 2/16/12 at 1:45 p.m. records of recent fire alarm inspections were provided to the surveyor for review. For the inspections completed 8/11/11 and 2/13/12, there was no documentation to show that the audio/visual signaling devices or the magnetic door releases had been tested. The Director of Maintenance stated at that time that the devices were looked at during fire drills but they were not officially documented. A review of fire drill reports on 2/16/12 at 2:25 p.m. revealed that there was no documentation of the aforementioned devices being tested.

The 1999 edition of NFPA 72, National Fire Alarm Code, requires that audible and visible devices to be tested annually.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.3.4, 9.6.1.4; NFPA 72 1999: 7-3.2]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not maintain corridor walls. The issue was related to openings through corridor walls above a suspended ceiling that was not smoke resistant. This affected two (first and second) of two resident use floors, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

Observations above the suspended ceiling on 2/17/12 from 8:40 a.m. to 11:00 a.m. revealed the following:

1. On the second floor, there were two approximately 12 x 12-inch square openings through the corridor wall between the hall outside the activities room and the Nurse Manager's office. The suspended ceilings, both in the hall outside the Nurse Manager's office (near the elevators) and within the Nurse Manager's office, have 2 x 2-foot air transfer grates. Additionally, the Nurse Manager's office lacks electrically supervised smoke detection.

2. On the first floor, there were two approximately 12 x 12-inch square openings through the corridor walls between the hall outside the consulting room and Social Work/Nurse Manager's office. The suspended ceilings, both in the hall outside the nurses' station and within these offices, have 2 x 2-foot air transfer grates. Additionally, the consulting room and the Social Work/Nurse Manager office lack electrically supervised smoke detection.

3. On the first floor, there were openings through the corridor wall in the Director of Human Resources (HR) office, which is located across from staff dining. The openings are described as follows: a 5 x 5-inch cutout for an electrical conduit and wires, two unsealed conduit sleeves with wires running through, and two small openings surrounding steel I-beams that pass through the corridor wall. The suspended ceilings, both in the HR office and the corridor, were compromised by air transfer grates that were approximately 12 x 12-inches in size (two in the corridor, one in the HR office). Additionally, the HR office lacked electrically supervised smoke detection.

4. The Centers for Medicare & Medicaid Services recognizes the 2001 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety, (also known as the Fire Safety Equivalent System or FSES). This standard provides alternative approaches to life safety based on equivalent safety concepts. A building determined to have equivalent safety to the requirements of the NFPA 101, Life Safety Code, is deemed to be compliant for the identified deficient requirement. The facility completed an FSES as of 6/29/11 and has submitted the document to the Regional Office; however, the review process has not yet been completed. If the report is found to be valid, the facility will be deemed to be compliant for this deficient issue based on the equivalency system. Please include your Plan of Correction or your request for continuation of the FSES.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.3.6.1, 19.3.6.2.1]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not properly maintain exit access. The issue was related to a required exit pathway that extended through an intervening room. This affected one (first floor) of two resident use floors, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

1. Observation on 2/16/12 at 11:05 a.m. revealed the first floor corridor located outside the Admissions Parlor has an exit pathway with an illuminated exit sign that directs occupants to travel through the Therapy Suite. The exit discharges through a door at the south east corner of the building.

2. The Centers for Medicare & Medicaid Services recognizes the 2001 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety, (also known as the Fire Safety Equivalent System or FSES). This standard provides alternative approaches to life safety based on equivalent safety concepts. A building determined to have equivalent safety to the requirements of the NFPA 101, Life Safety Code, is deemed to be compliant for the identified deficient requirement. The facility completed an FSES as of 6/29/11 and has submitted the document to the Regional Office; however, the review process has not yet been completed. If the report is found to be valid, the facility will be deemed to be compliant for this deficient issue based on the equivalency system. Please include your Plan of Correction or your request for continuation of the FSES.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.2.1, 19.2.5.9, 7.5.1.2]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not maintain hazardous areas. The issues were related to doors with improper hold open devices, trash receptacles greater than 32-gallons, a room door that lacked a self-closing device, and a malfunctioning door coordinator. This affected one (first floor) of two resident use floors and one of one basement, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

1. Observation on 2/16/12 at 10:40 a.m. revealed the main kitchen (first floor) has two doors that open directly into the main dining room that are not smoke tight, fire rated, or positive latching. The corridor doors to the main dining room are held open by friction catches at the base of each door and only release manually.

2. Observation on 2/16/12 at 10:50 a.m. revealed the corridor door to the first floor Therapy Suite was held open by a friction catch located at the base of the door. Within the Therapy Suite was a trash receptacle that was determined to be 35-gallons in volume.

3. Observation on 2/16/12 at 10:55 a.m. revealed the door to the storage room located on the first floor next to the conference room was not self (automatic) closing. The room is greater than 50 square feet in size and contained a significant amount of combustible material including, but not limited to, dozens of cardboard boxes, crafts, papers, and decorations.

4. Observation on 2/16/12 at 12:35 p.m. revealed the corridor door to the soiled linen side of the basement laundry room was held open by a friction catch at the base of the door that only released manually. Additionally, the double doors that open to the clean linen side of the laundry room would not close properly. When pulled from their electro-magnetic releases, one of the two doors stopped short of full closure and became hung up on the door coordinator, leaving an approximately 6-inch opening along the meeting edge of the doors.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.3.2.1, 19.7.5.5]

Based on observations and staff interview conducted during the Life Safety Code Survey, it was determined that the facility was not in compliance with heating, ventilation, and air conditioning (HVAC) requirements. THIS IS A REPEATED DEFICIENCY FROM THE LIFE SAFETY CODE SURVEY OF 2/4/11. The issues were related to the presence of a return air plenum in egress corridors. This affected three of three smoke compartments on the second floor and five of six smoke compartments on the first floor, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

Previous Life Safety Code Surveys conducted on 2/8/08, 1/9/09, 2/19/10, and 2/4/11 have identified concerns related to corridor plenums.

1. On 2/17/12 from 8:40 a.m. to 11:00 a.m. the area above the suspended ceiling was observed. A potential ceiling plenum was observed in the corridor outside Resident Rooms #616, #314 and #315, #214 and #211, and in the corridor outside #114 and #115. Specifically, there is a centralized air duct system that appears to draw air from inside the resident rooms and then discharge the air out the end of the main ventilation duct into the area above the suspended ceiling. At the terminus of each vent, spring dampers were observed to have been added to the terminus of each ventilation duct to restrict the flow of air into the area above the suspended ceiling in each corridor. Approximately 12-inches from where the spring dampers were observed in the main ventilation duct, a small separate air handling unit was observed in the area above the suspended ceiling with a discharge vent into the corridor. There are also multiple openings in the corridor suspended ceiling, which compromise the smoke resistance of the ceiling, including 2 x 3-inch openings in canned light fixtures and air transfer grates. The Director of Maintenance stated in an interview at that time that the air handling units at the end of each hall were actually heating units and that the spring dampers had been added over the summer to correct the plenum issue as a result of a recommendation from an individual who performed an assessment of the building.

2. Upon completion of the survey of 2/19/10, the facility was issued a Time Limited Waiver for this Life Safety Code requirement, in order to have the corridor plenum issue assessed. The waiver terminated 5/5/11. Throughout the course of the survey of 2/17/12, there was no documentation to show that the corridor ceiling plenum issue had been resolved or that the modifications to the HVAC system (installation of the spring dampers) resulted in compliance with NFPA 90A.

The 1999 edition of NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, states that egress corridors in health care occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.5.2.1, 9.2.1; NFPA 90A 1999: 2-3.11]

Based on observations, record review, and a staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not provide compliant interior finish. The issue was related to a newly installed interior wall finish that lacked a proper flame spread rating. This affected one (first floor) of two resident use floors, and resulted in a pattern of no actual harm with the potential for minimal harm. The findings are:

1. Observation on 2/16/12 at 10:30 a.m. revealed a white rigid paneling measuring approximately 6-feet tall x 12-feet long was installed on the kitchen wall behind the three-bay sink. The Maintenance Director stated in an interview at that time, that it had recently been installed to protect the wall from deterioration.

2. On 2/16/12 at 12:50 p.m., the Director of Maintenance provided the surveyor with a specification sheet for the kitchen wall paneling. The specification sheet showed the wall covering to be to be a "FRP" material that can be a Class C general purpose or Class A fire retardant material with regard to flame spread.

3. On 2/17/12 at 8:30 a.m., the Director of Maintenance stated in an interview that the material in question was a Class C material.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.3.3.2]