Lakeside - Beikirch Care Center, Inc

Based on record review and staff interview, the facility did not immediately remove an employee (Employee #1) from direct care or supervision of residents upon receipt of a negative determination letter for that employee. This resulted in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is:

Record review of the Criminal History Record Check for Employee #1 revealed the facility was sent a Pending Denial letter from the New York State Department of Health Criminal History Record Check Legal Review Unit for this employee. An interview with the Director of Nursing and the Staff Development Coordinator on 8/23/11 at approximately 12:07 p.m. revealed that Employee #1 worked at the facility in a capacity that allowed the employee contact with residents for two days after the Pending Denial letter had been received by the facility. Record review of the employee Time Sheets for Employee #1 on 8/23/11 at approximately 12:10 p.m. confirmed that Employee #1 continued to work at the facility in a capacity that allowed the employee contact with residents for two days after the Pending Denial letter had been received by the facility.

[402.7(a)(3)(i)]
none

Based on observations, staff interviews, and record reviews, it was determined that for two of four residents observed for care, proper infection control techniques were not followed. The issues involved improper glove changes and handwashing for Residents #7 and #24. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #7 has diagnoses including cerebral vascular accident. Review of the master care card revealed that the resident is incontinent of bowel and bladder and wears incontinence briefs.

The resident was observed receiving morning care on 8/23/11 at 11:00 a.m. The primary Certified Nursing Assistant (CNA) applied gloves and washed the resident's buttocks and peri area. The resident had defecated soft brown stool in the collecting device over the toilet. While wearing the same gloves, the CNA then applied the resident's t-shirt, pants, sneakers, and a new incontinence brief. She then washed the water basin, shaved the resident's face with an electric razor, and washed and applied clean glasses. The CNA combed the resident's hair, applied the clip alarm and the resident's sweater before removing gloves and washing hands.

When interviewed on 8/23/11 at 11:30 a.m., the primary CNA stated that she should have changed her gloves after giving care. At 12:15 p.m. that day, the Registered Nurse Manager (RNM) stated that the CNA should have changed her gloves after providing care.

2. Resident #24 has diagnoses including dementia and recurrent urinary tract infections (UTIs). The Minimum Data Set Assessment, dated 7/27/11, the CNA care card, dated 8/22/11, both included that the resident is incontinent of bowel and bladder and requires total care.

During an observation of cares on 8/23/11 at 10:37 a.m., the CNA donned gloves and cleansed the resident's rectal area of feces. Without removing gloves or washing hands, the CNA touched the resident's incontinence brief, clothing and bedding, as well as the mechanical lift sling, bed controls, overbed table, wash basin, hygiene items, and floor mat before removing the gloves and washing hands.

When interviewed on 8/23/11 at 11:27 a.m., the CNA stated she usually removes her gloves after cleansing the resident and before touching anything on the resident or in the environment but forgot to this time.

During an interview on 8/25/11 at 10:10 a.m., the RNM stated she expects staff will remove gloves and wash hands after rectal care and before touching items on the resident or in the environment.

The facility's policy entitled, "Handwashing/Hand Hygiene," dated June 2011, included to "decontaminate hands when moving from a contaminated site to a clean site on the same patient."

[10 NYCRR 415.19(b)(4)]

Based on observations, staff interviews, and record review, it was determined that for 1of 23 residents reviewed for care plan implementation, the resident did not receive services in accordance with their written plan of care. Specifically, Collagenase Santyl (a prescription skin care ointment used to break down dead skin) was used for Resident #7 without a physician's order. 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 #7 has diagnoses including cerebral vascular accident and a history of a heel pressure ulcer. The Minimum Data Set Assessment, dated 5/6/11, revealed that the resident's cognitive skills for daily decision making are moderately impaired. Review of wound care flow sheets revealed that the heel pressure ulcer was healed on 7/26/11. Review of the master care card in use on 8/22/11 revealed no reference to use of prescription skin care products.

During observations and interviews on 8/23/11 at 10:43 a.m., the resident was being bathed while seated on the toilet. The resident stated several times that his bottom was so sore he could hardly stand it. After personal cares were completed, the resident complained that his back was "itchy." The primary Certified Nursing Assistant (CNA) went into the bedside stand, brought back a tube of ointment, and then put the ointment on the resident's back. Review of the label on the tube of ointment at this time revealed that the ointment was Collagenase Santyl, which had been prescribed for use on a heel pressure ulcer. The surveyor instructed the CNA to inform the nurse about the ointment that she had applied.

When interviewed on 8/23/11 at 12:15 p.m., the Registered Nurse Manager (RNM) stated that the resident is not to have Collagenase Santyl on his back and did not know where the tube came from, as it was not ordered in the facility.

In a follow-up interview on 8/24/11, the RNM reported that she had discovered that a family member had brought the Collagenase Santyl in from home.

[10 NYCRR 415.11(c)(3)(ii)]

Based on observations, resident and staff interviews, and record review, it was determined that for 1 of 23 residents reviewed for professional standards, the facility did not provide services in a manner consistent with accepted standards of quality. The issue involved a physician's order for a specific diet for Resident #8 that was not provided. 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 #8 was admitted to the facility on 8/11/11 with diagnoses including hemi-colectomy, ulcerative colitis, and malignant neoplasm.

Review of a physician's order revealed that on 8/17/11 a clear liquid diet was ordered for 24 hours; on 8/18/11, an order to add yogurt to the clear liquid diet as long as no increased abdominal distention or discomfort; and on 8/19/11, to discontinue the yogurt, continue clear liquid diet only.

Record review revealed a nutrition note, dated 8/17/11, documented that the resident would receive clear liquids for 24 hours. On 8/19/11, nursing noted that the resident would receive clear fluids without yogurt until further notice. A nursing note, dated 8/20/11, revealed that the resident received solid food and complained of stomach pain. A nursing note, dated 8/21/11, documented that the resident had chicken nuggets and ice cream. A physician note, dated 8/21/11, acknowledged that the resident ate a solid food meal at supper and that the clear liquid diet was to be continued.

The resident was observed on 8/22/11 at 12:45 p.m. eating lunch. Lunch included an egg salad plate, fruit cocktail, spinach, Ensure (protein drink), and coffee. The resident stated that he would finish the fruit cocktail, the Ensure, and the coffee. The meal ticket was marked low residue diet with no acid, peas, or pork. When interviewed at this time, the resident stated that he does not usually eat much lunch. He eats more at breakfast and dinner. He stated that he had scrambled eggs, Rice Krispies, and chocolate Ensure for breakfast. He also said that he continues to have stomach pain and that the staff know about it.

Interviews conducted on 8/22/11 are as follows:

a. At 12:55 p.m., the rehabilitation Registered Nurse (RN) stated that the resident was supposed to be on a clear liquid diet.

b. At 12:56 p.m., the primary Certified Nursing Assistant (CNA) stated that the resident was on clear liquids on Friday (the 19th). She said she did serve him breakfast that day and gave him two sugars for his coffee.

c. After reviewing the 8/22/11 breakfast and lunch slips at 1:50 p.m., the RN Manager (RNM) stated that the resident is to be on a clear liquid diet. She had no further input on how the resident continued to get the incorrect diet.

A physician's order, dated 8/22/11 at 3:15 p.m., included clear liquid diet x 24 hours, then full liquid x 24 hours, then low residue.

During an interview on 8/24/11 at 12:55 p.m., the Registered Dietitian (RD) reported that nursing can communicate changes in diet orders by calling the kitchen, completing a Dietogram, or by sending her an e-mail. The RD said she was not aware of a new diet order for this resident. At 1:20 p.m. that day, the RNM documented in progress notes that the resident received the wrong diet on 8/21/11. This note did not show that dietary was notified that the resident received the wrong diet.

In a follow-up interview on 8/25/11 at 8:05 a.m., the RNM stated that she did not know why the resident continued to receive the incorrect diet on 8/22/11 after the prior error had been entered on the computer generated supervisor's log reporting that the resident received the wrong diet.

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

Based on record review and staff interview, it was determined that for two of two closed records reviewed, the facility did not manage resident funds according to regulations. Specifically, the facility did not disburse the personal funds of deceased residents (Residents #30 and #31) within 30 days after death. This resulted in a pattern of no actual harm with potential for minimal harm, and is evidenced by the following:

1. Resident #30 was admitted to the facility on 12/10/09 and expired on 1/21/11. Documentation revealed that a check for return of personal funds to the appropriate legal representative in the amount of $109.00 was issued on 4/14/11.

2. Resident #31 was admitted to the facility on 7/6/09 and expired on 5/5/11. Documentation revealed that a check for return of personal funds to the appropriate legal representative in the amount of $100.30 was issued on 6/23/11.

In an interview on 8/25/11 at 7:30 a.m., the Fiscal Service Assistant stated that she was not aware of the 30-day regulation regarding return of personal funds.

[10 NYCRR 415.26(h)(5)(iv)]

Based on record review and staff interview, it was determined that for three of four residents reviewed for resident rights, the facility did not have a consistent process in place to notify Medicare beneficiaries of appropriate liability notices, and for one of four residents the facility did not inform the resident of her right to an expedited appeal. Specifically, the facility did not issue Advanced Beneficiary Notices (ABN) or Denial Letters to residents whom the facility determined that Medicare would not pay for skilled services any longer and continued to stay in the facility receiving care under private pay. In one instance, the facility did not give a resident a Notice of Medicare Noncoverage advanced notice to notify her of her Medicare coverage ending. This affected Residents #25, #27, #28, and #29, resulting in a pattern of no actual harm with potential for minimal harm. This is evidenced by, but not limited to, the following:

1. Resident #28 was admitted to the facility on 4/7/11 under Medicare benefits. The resident was issued a Notice of Medicare Provider Noncoverage letter on 4/20/11 indicating that Medicare coverage was ending effective 4/22/11. There was no documentation or evidence that either the resident or legal representative were issued an ABN or Denial Letter notifying them of their potential liability for their noncovered stay and/or request a demand bill. The resident was private pay effective 4/23/11.

2. Resident #29 was admitted to the facility on 6/6/11 under Medicare benefits. The resident was issued a Notice of Medicare Provider Noncoverage letter on 6/28/11 indicating that Medicare coverage was ending effective 7/1/11. There was no documentation or evidence that either the resident and/or legal representative was issued an ABN or Denial Letter notifying them of their potential liability for their noncovered stay and/or request a demand bill. The resident was private pay effective 7/2/11.

3. Resident #27 was admitted to the facility on 5/5/11 under Medicare benefits. The resident was issued an ABN notifying her of Medicare noncoverage and liability for services on 5/27/11 indicating that Medicare coverage was ending effective 5/27/11. There was no documentation or evidence that either resident and/or legal representative was issued a Notice of Medicare Provider Noncoverage letter notifying them of their right to an expedited appeal at this time.

In an interview on 8/25/11 at 7:30 a.m., the Fiscal Service assistant stated that she was not aware that both notices were required and that she does not routinely give out the ABN letters. She said she had not found any evidence that the Notice of Medicare Provider Noncoverage letter was issued for the 5/27/11 Medicare cut.

The resident became private pay effective 5/28/11.

[10 NYCRR 415.3(g)(2)(i)]

Based on observations, resident and staff interviews, and record review, it was determined that the facility did not ensure that the New York State Department of Health (NYSDOH) survey results were available to the residents for examination. Specifically, deficient practice statements, pages 2-21 of the Health Care Survey (form CMS 2567- F tags) and 2 of 3 pages of the Life Safety Code Survey (K tags) from the 7/10/10 Recertification Survey were not kept with the copy that was posted for public review. This affected all alert and oriented residents residing in the facility, and resulted in a pattern of no actual harm with potential for minimal harm. This is evidenced by the following:

Six of six residents attending the special meeting of the Resident Council held on 8/22/11 from 1:40 p.m. to 2:20 p.m. reported that the survey results are located in a maroon three ring binder in the lobby area.

During an observation on 8/23/11 at 1:30 p.m., it was determined that the copy of the survey results available for public review was located in a maroon three ring binder in the lobby area. This copy was missing pages 2 through 21 of the Health Care Survey results and pages 2 and 3 of the Life Safety Code results from the 7/10/10 survey.

When interviewed on 8/24/11 at 2:45 p.m., the Administrative Assistant stated that she has been responsible for ensuring that the binder with the survey results is available since January 2011 but does not know what is kept in this binder. At 3:02 p.m. that day, the Administrator stated he was not aware there were pages missing from the binder.

[10 NYCRR 415.3(1)(c)(1)(v)]

Based on observation and staff interview conducted during the Life Safety Code Survey, corridor doors were obstructed from closing. This affected two (second and fourth floors) of three floors containing resident units. This 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 the fourth floor on 8/22/11 at approximately 10:32 a.m. revealed a walker was stored directly in front of and against the door to Resident Room #402 obstructing it from closing.

2. Observation on the second floor on 8/22/11 at approximately 10:59 a.m. revealed a metal wreath-style hanger was hung from the tops of each of the doors to Hamlin Homestead (resident day room) obstructing the doors from closing and latching in their frames. Also, this room is located near Resident Room #205, and these doors could not be physically latched into their frames.

3. Observation on the second floor on 8/22/11 at approximately 11:02 a.m. revealed a soiled linen receptacle was stored directly in front of and against the door to Resident Room #201 obstructing it from closing.

4. Observation on the second floor on 8/22/11 at approximately 11:06 a.m. revealed that a metal wreath-style hanger was hung from the top of one of the doors of Clarkson Corner (resident day room) obstructing the door from closing and latching into its frame. Also at this time, this door could not be physically latched into its frame, and this door was located closest to Resident Room #218.

5. Observation on 8/23/11 at approximately 10:09 a.m. revealed a wheelchair was stored in front of and obstructing the door to Resident Room #218 from closing.

An interview with the Administrator and the Director of Nursing on 8/25/11 at approximately 1:16 p.m. revealed the metal wreath-style hangers on the resident day room doors had only been in place for the last two months.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.3.6.3, 19.3.6.3.3]

Based on observation and staff interview conducted during the Life Safety Code Survey, hazardous area doors did not self-close and latch into their frames. This affected one of one kitchen, 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 8/22/11 at approximately 9:14 a.m. revealed that one of the double doors that lead from the first floor corridor to the kitchen would not self-close and latch into its frame. Also, the left door, as you look into the kitchen from the first floor corridor, would not self-close and latch into its frame. Further observation at this time, revealed that this door was hung up on the right door. Interview with the Dietitian revealed that she was not aware that the door would not self-close and latch into its frame.

2. Observation on 8/22/11 at approximately 9:18 a.m. revealed that one of the doors that separated the first floor kitchen from the Lakeside Caf would not self-close and latch into its frame. Also, this door could not be physically latched into its frame and was located next to the fire shutter. Interview with the Dietitian at this time revealed she was not aware that the door would not self-close and latch into its frame.

During record review on 8/25/11 at approximately 8:00 a.m. of the Full Building Evacuation Plan provided by the Administrator, revision date 12/21/09, revealed the Lakeside Caf is used as an alternate holding area in case of a full building evacuation.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 9.3.2.1]

Based on observation and staff interview conducted during the Life Safety Code Survey, the laundry room was not maintained to minimize the possibility of a fire emergency requiring the evacuation of occupants. Issues included excessive amounts of lint and/or dust on the tops of dryers and a ventilation duct and pipes located around the dryers. This affected one of one basement laundry room, 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:

Observation in the basement laundry room on 8/22/11 at approximately 11:50 a.m. revealed the tops of two dryers were covered with at least an approximately 1/4-inch thick layer of lint and/or dust. Interview with the Housekeeping Supervisor at this time revealed that the tops of the dryers and the area around them was supposed to be cleaned one to two times per week and that the facility did not have any logs for the cleaning of the tops of the dryers or the areas around them.

Observation in the basement laundry room on 8/23/11 at approximately 1:09 p.m. revealed that the top of the ventilation duct and piping located around the dryers were covered with at least an approximately 1/4-inch thick layer of lint and/or dust.

none [10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.1.1.3]

Based on observations and staff interviews conducted during the Life Safety Code Survey, sprinkler piping was exposed to external loads. This affected 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 8/22/11 at approximately 11:28 a.m. revealed the four-wheeled base of a chair, an approximately 3-foot long section of an IV pole, two approximately 4-foot long metal bars that appeared to be part of a medical device, and an approximately 6-foot long metal bar that appeared to be part of the base of a medical device were hung from a sprinkler pipe in the storage room located in the basement Maintenance Shop. An interview with the Senior Vice President Physical Plant at this time revealed he was not aware that the items had been hung on the sprinkler pipe and that they should not have been.

2. Observation on 8/22/11 at approximately 11:30 a.m. revealed electrical lines were attached to and hung from sprinkler piping in the mechanical room located in the basement.

3. Observation on 8/22/11 at approximately 11:56 a.m. revealed an approximately 12-inch diameter speaker was attached to and hung from sprinkler piping in the materials management room located in the basement.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 9.7.5; 1998 NFPA 25: 2-2.2]

Based on observations and staff interviews conducted during the Life Safety Code Survey, manual fire alarm pull stations were obstructed. This affected two (third and fourth floors) of three floors containing resident units. This 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 8/23/11 at approximately 1:28 p.m. revealed a chair and a stool were stored in front of and obstructing the manual fire alarm pull station located in the Lakeview room (resident dining room) on the fourth floor.

2. Observation on 8/23/11 at approximately 1:36 p.m. revealed two chairs and a walker were stored in front of and obstructing the manual fire alarm pull station in the Tree Top Inn room (resident dining room) on the third floor. Interview with the Administrator and the Senior Vice President of Physical Plant at this time revealed that the chairs in the dining rooms were new, that they were larger than the chairs that used to be in the dining rooms, and that staff must not be used to the larger sized chairs.

3. Observation on 8/24/11 at approximately 7:46 a.m. revealed a chair and a clean linen cart partially full of sheets and towels were stored in front of and obstructing the manual fire alarm pull station located near Resident Room #323 on the third floor.

4. Observation on 8/25/11 at approximately 7:38 a.m. revealed two partially full soiled linen receptacles were stored directly in front of and obstructing the manual fire alarm pull station located near Resident Room #303 on the third floor.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 2-8.2.1]