Westgate Nursing Home

Based on staff interviews, and record reviews, it was determined that the facility did not maintain a Quality Assessment and Assurance (QAA) committee that readily and consistently identifies and corrects quality deficiencies. Specifically, facility staff lack knowledge of the QAA process, which was demonstrated by multiple repeated deficiencies up to four Recertification Survey cycles (F225, F242, F253, F279, F281, F282, F431, and F441. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy and is widespread. This is evidenced by the following:

Deficient practices identified during the survey included the following:

a. F225 - Repeated from the Recertification Survey of 6/17/11. The facility did not complete thorough investigations of incidents of bruises of unknown origin to rule out abuse, neglect, or mistreatment.

b. F242 - Repeated from the Recertification Survey of 6/17/11. The facility did not allow residents to make choices about aspects of their life that is significant to them.

c. F253 - Repeated from the Recertification Surveys of 6/17/11 and 6/10/10. Housekeeping and maintenance services do not provide a sanitary, orderly, and comfortable interior.

d. F279 - Repeated from the Abbreviated Survey of 11/21/11 and the Recertification Survey of 6/17/11. Lack of care planning.

e. F281 - Repeated from the Recertification Survey of 6/17/11. The facility did not follow professional standards for providing care/services to residents.

f. F282 - Repeated from the Recertification Survey of 6/17/11. Lack of revision of care plans.

g. F431 - Repeated from the Recertification Surveys of 6/17/11, 6/10/10, and 8/27/09. Lack of systems to safely store/identify drugs and biologicals.

h. F441 - Repeated from the Recertification Surveys of 6/17/11, 6/10/10, and 8/27/09. Lack of effective management of infection control policies and procedures.

Staff interviews conducted on 4/20/12 between 12:00 p.m. to 1:34 p.m., and on 4/23/12 between 1:41 p.m. to 4:18 p.m. revealed that two of two Licensed Practical Nurses, four of five Certified Nursing Assistants, and one of one Activities Aide were not familiar with the QAA process, activities, or how to bring resident centered care issues to the committee.

During an interview on 4/20/12 at 1:29 p.m., the past QAA Registered Nurse said there is no QAA program, that audits are being done, and there is no director.

During an interview on 4/25/12 at 9:30 a.m., the Director of Nursing said they do not have a formal process for obtaining information from families or residents regarding their concerns. She also said information can be obtained by referring to information obtained during quarterly Minimum Data Set Assessments, but no one tracks or trends this information. She said that staff need to know what the QAA committee does, and they may include a staff member on the committee to help with this. She was unable to provide any example of how the facility identified an area with a quality deficiency, developed an action plan, implemented the plan, and analyzed the result.

[10 NYCRR 415.27(a-c)]

Based on observations, staff interviews, and record reviews, it was determined that for two of eight employee files reviewed for the Criminal History Record Checks (CHRC), the facility did not conduct a CHRC for employees that have direct access to resident areas. 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 the following:

1. On 4/20/12 from 8:25 a.m. to 9:00 a.m. the receptionist provided the surveyor with records of recently hired employees. The records showed that two dietary aides were hired on 3/13/12 and 4/12/12, and no CHRC was conducted. In an interview at that time, the receptionist stated that they do not perform a full CHRC review for dietary aides because they do not go in the resident rooms.

2. Observation on 4/20/12 at 9:12 a.m. revealed a dietary aide delivering a meal cart from the kitchen to the first floor. In an interview at 9:15 a.m., the Dietary Supervisor stated that the dietary aides deliver meal carts to the floors and give the trays or food items to the Certified Nursing Assistants to take to the resident rooms. Additional observations at 9:20 a.m. revealed two dietary aides on the second floor attending to dietary carts near the elevators.

3. On 4/20/12 at 10:00 a.m., the Dietary Supervisor provided the surveyor with job descriptions for the dietary aides. A review of these documents showed that responsibilities include getting food trucks from the units, picking up trays in main dining room, returning trucks from floors, bussing dining room tables, and cleaning dining room tables and chairs.

[10 NYCRR Section 402.6(a), 402.3(i)(1)]

Based on record review, it was determined that for one (Certified Nursing Assistant - CNA) of eight employee files reviewed for the Criminal History Record Checks (CHRC), the facility did not properly supervise a prospective employee. 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 the following:

On 4/20/12 from 8:25 a.m. to 9:00 a.m. the receptionist provided the surveyor with records of recently hired employees. The records showed that a CNA was hired on 7/25/11. A pending denial letter from the CHRC was issued on 9/26/11. The supervision log showed a single date of 7/30/11. No other records were provided to show that this employee was supervised while awaiting the results of the CHRC.

[10 NYCRR Section 402.6(d), 402.4(b)(2)(i)]

Based on observations, staff interviews, and record reviews, it was determined that for two of two residential living areas reviewed for accident hazards, the facility did not ensure that the residents' environment remained as free of accident hazards as possible. The issues included hot water temperatures that exceeded 120 degrees (*) Fahrenheit (F) and the lack of monitoring of hot water temperatures at the point of service (Resident Rooms #101, #104, #108, #110, #203, #206, #208, #212, S-2 tub rooms first and second floor). This resulted in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

On 4/18/12 at 11:09 a.m. the hot water in the bathroom sink of Resident Room #108 measured 124.8*F. Additional water temperatures were taken on 4/18/12 between 11:10 a.m. and 3:30 p.m. The water temperatures were measured using a Taylor digital thermometer model #9842. In Room #101, the water temperature was 123.2*F; Room #104, 123.2*F; Room #110, 124.1*F; Room #203, 122.9*F; Room #206, 122.4*F; Room #208, 122.7*F; Room #212, 125.4*F; first floor S-2 tub room hand sink, 127.1*F; and the second floor S-2 tub room hand sink, 127.6*F.

When interviewed on 4/18/12 at 11:55 a.m., 3:05 p.m., and 5:10 p.m, the Maintenance Director stated that he personally checks water temperatures in the residents' rooms. He said that he was unable to locate his water temperature log, and the last time he took water temperatures was two weeks ago. He said there have been no complaints regarding hot water. He stated that he does not document any readings from the boiler, which controls the water temperatures. When asked about a policy for hot water temperatures, he said that he is told he should have a policy, but he has never seen one and is unable to locate one.

On the morning of 4/19/12 the Maintenance Director provided water temperature logs for residents' rooms. The logs were from October 2011 through 4/2/12 and included water temperatures less than 120*F.

The facility called in a plumber on 4/19/12, and a new part (Aquastat) was installed. When interviewed on 4/19/12 at 11:00 a.m., the Administrator and Maintenance Director said that the Aquastat failed and needed to be replaced. They both said that the expectation would be to try and maintain water temperatures between 115* to 118*F. The Maintenance Director said that if he received hot water readings, he would adjust the Aquastat and then recheck the water temperatures in the residents' rooms.

When interviewed on 4/18/12 at 3:50 p.m., the Administrator said that it would be his expectation that the Maintenance Department visually inspect the water temperatures in the basement daily and log on a weekly basis.

[10 NYCRR 415.12(h)(1)]

Based on observations, staff interviews, and record review, it was determined that on two of two residential units, the facility did not provide for the safe and secure storage of medications. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEYS OF 6/17/11, 6/10/10, and 8/27/09. Specifically, medication carts that also held narcotics were left unlocked and unsupervised. This resulted in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

During an observation on 4/23/12 at 11:55 a.m., medication carts on Unit 1 (North and South hall) were sitting in the hallway unsupervised and unlocked. There were several residents in the vicinity of the North hall cart. One resident went to the cart and took a drink of water with a cup off the top of the cart. Licensed Practical Nurse (LPN) #1 returned to the cart about five minutes later. In an interview at that time, LPN #1 stated he should have locked the North hall cart. There were three residents near the South hall cart. LPN #2 stated she forgot to lock the cart. LPN #2 reported that when the carts are not in use, they are kept by the nursing station, and the wheels are locked.

During an interview on 4/24/12 at 8:30 a.m., LPN #3 working on Unit 2, said that she had narcotics in the medication cart. When observed at that time, the narcotics drawer was locked within the cart and contained two cards of Oxycodone (narcotic pain medication) with greater than 21 tablets and additional narcotics. LPN #3 said she keeps the narcotics in the medication cart throughout the day if residents receive narcotics more than once per day.

The second floor North hall medication cart was observed unattended in front of the nurses' station from 8:15 a.m. until 9:00 a.m. on 4/24/12. In an interview at 9:05 a.m. that day, LPN #4 stated that she keeps the narcotics locked in her medication cart until she is finished with them at the end of the day. At that time, LPN #4 unlocked the medication narcotic drawer which held six cards of narcotics, including greater than 20 doses of Ativan (anti-anxiety) and Oxycodone.

When interviewed on 4/24/12 at 12:58 p.m., the LPN/Nurse Manager stated that the nurses know that the medication carts should be locked.

[10 NYCRR 415.18(d)]

Based on observations, resident and staff interviews, and record reviews, it was determined that for three of four residents reviewed for telephone use, the facility did not provide reasonable access to the use of a telephone where calls can be made without being overheard. Specifically, residents were being offered the telephone at the nursing station to make personal phone calls. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #12, #41, and #78, and is evidenced by the following:

1. Resident #12 has diagnoses including cancer of the bowel. Review of the Minimum Data Set (MDS) Assessment, dated 2/16/12, revealed that the resident is cognitively intact.

During an observation on 4/23/12 at 3:39 p.m., the resident was brought to the nursing station to a telephone that was dialed for him. The resident was overheard to have a conversation with a family member about very personal matters. The evening supervisor was seated in the nursing station, the Social Worker (SW) was standing at the desk, and three residents seated in wheelchairs were within hearing distance of the resident. When the resident concluded his conversation, staff asked him if he was all set. The resident said, "yes." When interviewed at 3:51 p.m. that day, the resident said that he would have liked to have privacy when speaking on the telephone.

2. Resident #41 has diagnoses including cerebral vascular accident (stroke). Review of the MDS Assessment, dated 11/15/11, revealed that the resident's cognitive skills for daily decision making are moderately impaired.

During a family interview on 4/18/12 at 10:32 a.m., a family member stated that the SW told him that he needed to pay for a telephone to be placed in his mother's room because she was yelling on the phone and everyone could hear her. The family member reported that the resident speaks to her husband a few minutes a day. She does raise her voice because of her stroke.

3. Resident #78 has diagnoses including bipolar disorder (severe depression). Review of the MDS Assessment, dated 3/14/12, revealed that the resident is cognitively intact.

During an observation on 4/19/12 at 12:02 p.m., the resident walked to the nursing station, where staff dialed a phone number for him. The resident spoke for several minutes on the telephone. A Licensed Practical Nurse was in the hall, and three residents were seated in wheelchairs nearby. When interviewed immediately after the phone call, the resident said that he is able to use the phone whenever he wants, and there is no other phone that he can use.

Interviews are as follows:

a. On 4/23/12 at 1:41 p.m., the Activities Aide and at 4:00 p.m., the evening Certified Nursing Assistant (CNA) #1, and at 4:18 p.m., evening CNA #2 all said the only place for a resident to use the phone is at the nursing station.

b. On 4/24/12 at 9:45 a.m., the SW said residents can use the phone in the nursing station, and they could accommodate a private phone. At 9:55 a.m. that day, the Consultant Administrator said a resident could use the phone in his office.

[10 NYCRR 415.3(d)(3)]

Based on observations, resident and staff interviews, and record reviews conducted during the Recertification Survey and complaint investigation(#NY00113727, Resident #21), it was determined that the facility did not reasonably accommodate the individual needs of five of five residents (Residents #6, #9, #76, #95, and #21) reviewed for accommodation of needs. Specifically, Resident #21 was not offered the opportunity to regain the ability to use an electric wheelchair, Resident #9 was not provided an appropriate sized mattress, Resident #95 was not provided with an appropriate sized chair/commode, and Residents #6, #9, #21, #76, and #95 did not have call bells in reach. This resulted in 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. Resident #21 was admitted on 4/27/10 with diagnoses including cerebral palsy and paraplegia. Review of the Minimum Data Set (MDS) Assessment, dated 1/18/12, revealed that the resident was cognitively intact, was independent in locomotion on and off the unit, and had no behaviors for the time period. An undated Personal Mobility Device Skills Test indicated the resident had failed safe use of the electric wheelchair. Review of nursing progress notes, dated 3/9/12, showed that the resident lost access to use the electric wheelchair for safety reasons.

During an observation on 3/26/12 at 10:40 a.m., the resident was transferred to a manual wheelchair via a mechanical lift.

Interviews conducted on 3/26/12 are as follows:

a. At 8:26 a.m. and again at 9:30 a.m., the Administrator stated that staff felt the resident was no longer safe in the electric wheelchair. There was no plan to return the electric wheelchair.

b. At 9:30 a.m., the Physical Therapist stated that she has not recently evaluated the resident for safety in the electric wheelchair.

c. At 9:50 a.m., the resident reported that he understood there were safety issues but was still upset about losing privileges to use his electric wheelchair.

d. At 4:45 p.m., the Administrator and the Director of Nursing stated that the resident had several instances of safety concerns that were discussed in morning report but were not documented. They thought the resident had been re-evaluated by Physical Therapy more recently.

There was no documented plan to show the resident was offered the opportunity for safety reassessment of and therapy training to allow for the use of the electric wheelchair.

2. Resident #9 has diagnoses including morbid obesity. A Patient Review Instrument completed by the hospital, dated 7/18/10, and sent to the facility revealed that the resident was 6 feet 2 inches tall and weighed 376 pounds. Review of the MDS Assessment, dated 9/28/11, revealed that the resident's cognitive skills for daily decision making are intact.

During an interview on 4/20/12 at 1:13 p.m. and 1:59 p.m., the resident stated that his bed is too short and not wide enough. He reported that facility staff know his bed is too small and had seen his feet hanging off the end of the bed. The resident's bed was observed at that time. There was a gap between the foot of the bed and end of the mattress that measured 8 inches. The mattress measured 6 feet long and was 37 inches wide.

During interviews on 4/23/12 at 4:00 p.m. and 4:18 p.m., two different Certified Nursing Assistants (CNA) said they have seen the resident with his feet hanging off of the end of the bed.

During an interview on 4/24/12 at 2:33 p.m., the Occupational Therapist said the resident needs a longer mattress and the bed should fit the resident.

During an interview on 4/24/12 at 3:00 p.m., the Licensed Practical Nurse Manager (LPNM) said she was not aware the bed was too small for the resident. On 4/25/12 at 10:02 a.m., the LPNM reported that the resident's bed frame was a correct size for the resident but the mattress that was on the bed was not, and they have replaced it.

When interviewed on 4/25/12 at 1:30 p.m., the resident reported that he has a new mattress on the bed, neither his feet nor arms hang off the bed any more.

3. Resident #6 has diagnoses including weight loss, macular degeneration with right eye blindness, and constipation. Review of the MDS Assessment, dated 2/15/12, revealed that the resident has moderately impaired cognitive skills for daily decision making and requires extensive assistance for activities of daily living. A 4/1/12 Personal Care Profile revealed the resident is blind in her right eye, to encourage and assist at meals or total feed as tolerated, and to provide total assist with dental/mouth care every morning and evening.

During an observation on 4/18/12 at 10:47 a.m., Resident #6 was in bed and was calling out for water. Her mouth was open and there were flakes of skin visible in the mouth and hanging from her upper lip. There was a container of water on the overbed table located approximately 8 feet away, out of her reach.

During an interview and observation on 4/18/12 at 11:53 a.m., a LPN reported that for the past few weeks the resident has been declining and a hospice referral has been sent. The LPN stated that the resident's appetite is poor. She is always thirsty and when she asks for something to drink it it usually water. At that time, the LPN asked the resident if she wanted something to drink, and the resident replied she wanted water. She was given water through a straw and drank about one ounce. The LPN provided oral care and described the resident's mouth as dry, her tongue was coated with a yellow colored substance, and there were visible flakes of skin around her lips.

During an observation on 4/19/12 at 10:01 a.m., the resident was in bed. The call bell was located behind the headboard and out of her reach.

[10 NYCRR 415.5(e)(1)]

Based on observations, resident and staff interviews, and record reviews, it was determined that for one of three residents reviewed for activities, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well being of each resident. Specifically, Resident #111 remained in her room following a hospitalization and was not provided with activities. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #111 was readmitted on 3/30/12 with diagnoses including coronary artery disease and Clostridium difficile (bowel infection). Review of the Minimum Data Set (MDS) Assessment, dated 2/15/12, revealed that it is very important to the resident to have books, magazines and newspapers provided, to listen to music, visit with animals, and keep up with the news.

Review of the Comprehensive Care Plan, dated 4/3/12, for activities revealed that the resident follows an activity program in her room. She likes to read, play cards, do crossword puzzles, listen to country music, watch television, and to have pet and family visits. The goal is for her to attend group activities as much as possible and continue in room activities. Interventions include providing materials to maintain in room activity program, for example, puzzle books. The current Certified Nursing Assistant (CNA) Personal Profile sheet does not include any information regarding activities. The MDS Assessment, dated 4/16/12, revealed that the resident is cognitively intact.

Review of an activities progress note, dated 4/20/12, revealed that the resident has refused invitations to activities and follows an independent activity program, which includes family visits, television, and reading.

Documentation on the April 2012 activities log showed that the resident had three 1:1 visits with family, however, was unavailable for pet and musical entertainment.

During intermittent observations made on 4/20/12 between 12:48 p.m. to 1:58 p.m., on 4/23/12 from 8:25 a.m. to 3:55 p.m., on 4/24/12 from 8:30 a.m. to 12:18 p.m., and on 4/25/12 at 8:00 a.m. and 1:30 p.m., the resident was lying in bed. The television was not on during any of these observations.

During interviews on 4/19/12 at 10:48 a.m. and on 4/25/12 at 8:00 a.m., the resident said that she does not attend activities because she has been staying in bed since she returned from the hospital. She also said she has not been offered any books, magazines, or music, nor has the staff brought in any pets.

During an interview on 4/24/12 at 12:11 p.m., the CNA said she regularly cares for the resident and does not know what the resident likes to do for activities.

When interviewed on 4/25/12 at 8:09 a.m., the Activities Aide said the resident does not come to the group activities. She also said the resident gets some pet visits, as they have dogs that come in once a week.

During an interview on 4/25/12 at 8:15 a.m., the Activities Director said the resident "doesn't like a whole lot" and does not want to come out of her room. She said that staff made 1:1 visits but she did not know who or what was done. She also said they could offer her music and magazines.

[10 NYCRR 415.5(f)(1)]

Based on resident and staff interviews, and record reviews conducted during the Recertification Survey and complaint investigations (#NY00113404 and #NY00113727), it was determined that for 2 of 32 residents reviewed for care planning, the facility did not have care plans in place consistent with the residents' current needs. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 6/17/11 AND THE ABBREVIATED SURVEY OF 11/21/11. Issues involved lack of care planning related to nutrition/hydration (Resident #36) and seating equipment for mobility (Resident #21). 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:

1. Resident #36 was admitted to the facility on 1/31/12 with diagnoses including a subarachnoid hemorrhage (bleeding in the brain) following a fall, kidney disease, and clostridium difficile (C-diff) colitis (infection of the bowel).

Review of the medical record included the following:

a. Review of a Care Area Assessment Summary, dated 2/7/12, following a comprehensive Minimum Data Set (MDS) Assessment showed the resident triggered as at risk of dehydration, fluid maintenance, and nutritional status.

b. A nutritional assessment, dated 2/10/12, included that the resident had loose stools positive for C-diff infection, a history of urinary tract infection, impaired skin integrity, and was receiving a diuretic (fluid medication). It also indicated that increased nutritional needs were to be further evaluated after the results of labs drawn on 2/7/12 were available and that a care plan was initiated. There were no other nutrition notes found in the record.

c. The resident's weight records revealed an admitting weight of 150 pounds (lbs.), and a 3/5/12 weight (last on record) of 133 lbs.

d. A physician note, dated 3/6/12, included that the resident's weight was down 14 lbs. since admission, her renal function had worsened, and blood work was ordered. A Physician Acute Visit Note, dated 3/13/12, revealed that the resident had increasing episodes of diarrhea, a fever, and was not drinking much. The resident was sent to the hospital for concern of a recurrent C-diff infection.

f. A Comprehensive Care Plan, dated 3/15/12, did not address the resident's nutrition/hydration status.

Interviews conducted on 3/26/12 include the following:

a. At 2:00 p.m., the Licensed Practical Nurse (LPN) said that she did not recall discussing the resident's weight loss with the Dietary Consultant. The LPN reported that the resident did have some edema which nursing thought was contributing to the weight loss. Also, they did not have a care plan for this resident's nutritional or hydration status.

b. At 3:15 p.m., the Director of Nursing (DON) stated that she called the dietary consultant on this date regarding the nutritional care plan, and the dietitian said that she had 21 days from admission to complete the care plan, which would have been due on 2/21/12.

2. Resident #21 has diagnoses including cerebral palsy, paraplegia, bi-polar disease and depression. Review of the MDS Assessment, dated 1/18/12, revealed that the resident was cognitively intact and independent in locomotion on and off the unit.

Review of nursing progress notes, dated 3/9/12, revealed that the resident lost access to use of an electric wheelchair for safety reasons. He now uses a manual wheelchair that he is unable to independently manage.

During an observation on 3/26/12 at 10:40 a.m., the resident was transferred to a manual wheelchair via a mechanical lift. There was no headrest or bath support attached to this wheelchair.

Interviews conducted on 3/26/12 are as follows:

a. At 8:26 a.m. and again at 9:30 a.m., the Administrator said that the resident would no longer be allowed to use the electric wheelchair because his safety in the electric wheelchair had deteriorated.

b. At 9:50 a.m., the resident stated that his new chair is very uncomfortable and hurts his back. He knew why the electric wheelchair was taken but wanted a chance to use it again, and if he had to use a manual wheelchair, wanted it to be comfortable.

c. At 9:35 a.m., the Physical Therapist stated that she had ordered a headrest for the manual wheelchair but has not recently evaluated the resident for safety in the electric wheelchair.

d. At 4:45 p.m., the Administrator and the DON said that the resident's safety issues had been discussed several times in morning report but were not documented. They thought the resident had been re-evaluated by the Physical Therapist.

[10 NYCRR 415.11(c)(1)]

Based on observations, staff interviews, and record reviews, it was determined that for one of three residents and one of one main kitchen reviewed for infection control practices, facility staff did not use appropriate infection control techniques. THIS IS A REPEAT DEFICIENCY FROM THE PAST THREE RECERTIFICATION SURVEYS OF 6/17/11, 6/10/10, AND 8/27/09. Specifically, the issues involved not wearing gowns and gloves during provision of personal care and hygiene, lack of availability of hand soap in the kitchen, and not using an effective germicidal floor cleaner. This affected Resident #14 and the main kitchen, resulting in no actual harm with the potential for minimal harm that is not immediate jeopardy, and is evidenced by, but not limited to, the following:

1. Resident #14 has diagnoses including cardiac artery disease and chronic renal insufficiency. Review of a microbiology report, dated 4/14/12, revealed that the resident was positive for Clostridium Difficile toxin (C-diff, bowel infection). On 4/19/12 nursing documented that the resident remains on isolation precautions.

When observed on 4/19/12 at 8:28 a.m., the Certified Occupational Therapy Assistant (COTA) was sitting on the resident's bed helping her to eat. The COTA was not wearing gloves or a gown. The sign on the door read, "Please check with nurse before entering." In an interview that day at 10:21 a.m., the COTA stated that she was not aware that the resident she was feeding was on precautions and did not know that she needed to don a gown and gloves for a resident on C-diff precautions just to feed breakfast.

2. When observed on 4/23/12 at 2:00 p.m., the housekeeper was cleaning all the resident rooms, including rooms where residents had C-diff infections, with the same broom and mop.

Review of the product information sheet located on the container of floor cleaner revealed that the solution is not effective to kill the C-diff toxin.

In interviews regarding infection control practices on 4/24/12 at 2:45 p.m., the Registered Nurse (RN) reported that, currently, three residents are on contact precautions for C-diff and that gowns and gloves should be worn when entering the resident rooms, sitting on furniture, or providing cares. She said that a 10 percent bleach solution is used to clean these rooms, bathrooms, and floors. She said that the housekeeper cannot use the same broom in the C-diff room as the rest of the facility. At 3:00 p.m., the Director of Nursing (DON) also said that staff should be using bleach to clean C-diff rooms, including the floors. She said that all staff should be wearing gowns and gloves when entering the C-diff rooms.

3. During a tour of the main kitchen on 4/18/12 at 8:22 a.m., it was observed that there was no hand soap available at the handwashing sink. The Director of Food Service (DFS) stated at that time, that the hand soap dispenser was not working, and he sent a work request last week. The DFS stated that they do have liquid dish soap in the office just in case people need soap to wash their hands. He showed the surveyor a bottle of Ajax liquid dish detergent kept in the diet office behind the door.

On 4/19/12 at 3:00 p.m., the wall mount soap dispenser had been removed. The DFS said he had placed liquid hand soap on the sink. There was a bottle of Aloe Vera liquid hand soap on the sink.

[10 NYCRR 415.19(a)(1-3)]

Based on staff interviews and record reviews, it was determined that for one of ten residents (Resident #7) reviewed for physician visits, the facility did not ensure that the resident was seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. 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 was readmitted to the facility on 12/21/11 with diagnoses including dementia with behaviors. Record review revealed a 51-day span (12/21/11 to 2/14/12) and minimally a 46-day span (2/14/12 to 3/31/12) where physician orders were not signed by a physician. Review of the record revealed a lack of documentation to show that the physician visits were made once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.

In an interview on 4/23/12 at 12:40 p.m., the Director of Nursing (DON) said that when a resident is readmitted from the hospital, they should be seen by the physician and have orders signed every 30 days for 90 days.

When interviewed on 4/23/12 at 12:55 p.m., the primary physician said that she saw the resident on 2/14/12 because there is a note in the chart indicating that she dictated. The facility was unable to find the 2/14/12 physician note. The physician said that when a resident returns from the hospital, she continues with the every 60 day visits.

During an interview on 4/25/12 at 9:30 a.m., the Medical Records Coordinator reported that she schedules the physician visits as follows: new admissions are seen by the physician every 30, 60, and 90 days; readmissions are seen every 60 day schedule. The Medical Records Coordinator also said that the physician had instructed her to adjust the physician schedule based on the readmission date. She does not monitor/track the signing of physician orders.

In an interview on 4/25/12 at 11:30 a.m., the DON stated that the facility does not have a written policy to describe the frequency and timing of physician visits.

[10 NYCRR 415.15(b)(2)(ii)]

Based on observations, and resident and staff interviews, it was determined that the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two of two residential units and the laundry room. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEYS OF 6/17/11 and 6/10/10. The issues included unclean resident tub rooms, floors and furniture, light not working, and bathroom door not installed properly. This resulted in no actual harm with the potential for minimal harm that is not immediate jeopardy, and is evidenced by, but not limited to, the following:

1. On 4/25/12 at 9:07 a.m., there were dark brown/black stained towels, a large accumulation of dust, broken ceiling tiles, paper, plastic gloves, a large plastic funnel with dirty brown colored towels stuffed in it, and a pool of water on the floor behind and in between the four washing machines in the laundry room.

Interviews on 4/25/12 include the following:

a. At 9:18 a.m., the two laundry assistants could not state when the area behind the washer had been cleaned last or who was responsible for cleaning it.

b. At 9:19 a.m., the Consulting Administrator said he was not aware if anyone was responsible for maintaining the area behind the washer.

2. When observed on 4/18/12 at 10:35 a.m., Resident Room #116's bathroom contained a wooden bi-fold door. The small circular wooden handle was located on the outside of the door. When the door was shut, the only way to open the door from inside the bathroom was to place fingers between the door and the door frame. When interviewed at that time, the resident said she is able to independently use the bathroom but said she does not shut the bathroom door all the way,as she is unable to open the door.

During an interview on 4/23/12 at 3:45 p.m., a Certified Nursing Assistant (CNA) said that the resident does use the bathroom independently. When asked, the CNA entered the bathroom and shut the door. When asked to open the door, the CNA said she could not except by placing her hand between the door and the door frame. She stated that the door needed to have a handle on the inside or else the resident might not be able to get out. The CNA was unsure how long the door had been installed this way and would request a maintenance work order to fix it.

During an interview on 4/24/12 at 10:55 a.m., a Maintenance Worker said he has worked for the facility for approximately two years. He did not know when the door had been installed.

3. Observations made during a tour of the environment on 4/20/12 from 12:50 p.m. to 1:20 p.m. include the following:

a. In the first floor dining room, there was a significant amount of bird food and feathers underneath the bird cage, heavily stained carpet by the television, and multiple brown stains on the pink upholstered couches and the two green upholstered chairs.

b. In the South 1 tub room, there was a discarded brief sitting on the center stall chair, a used razor and soaked glove in the soap dish above the tub, a pink bed pan partially full of a cloudy liquid with a white towel soaking inside of it, and a discarded soiled white towel on the floor next to it. Additionally, there was a 6-inch x 8-inch circular brown/black stained ceiling tile near the supply room next to the S-2 tub room.

c. In the second floor South S-1 tub room, the center stall had discarded gloves on the seat of the toilet chair and a wheelchair seat, and a high back chair had a small cup of an unknown pink substance. The light in the back shower stall did not work.

[10 NYCRR 415.5(h)(2)]

Based on observations, resident and staff interviews, and record reviews, it was determined that for three of eight employee files reviewed for the nurse aide registry, the facility did not conduct a review prior to the onset of employment. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 6/17/11. Additionally, it was determined that for two of six residents reviewed for injuries of unknown origin, the facility did not complete a thorough investigation in a timely manner to rule out abuse, neglect, or mistreatment (Residents #28 and #34). 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:

1. During a review of Nurse Aide Registry Checks on 4/20/12 from 8:25 a.m. to 9:00 a.m., the receptionist provided records of recently hired employees. The records showed that for a Certified Nursing Assistant (CNA) hired on 1/30/12, registry check was done on 2/27/12; a dietary aide hired on 3/13/12, registry check was done on 3/21/12; and, an Occupational Therapist hired on 12/14/11, registry check was done on 12/23/11. In an interview during this review, the receptionist stated that she was not sure why the checks were not conducted earlier.

2. Resident #28 has diagnoses including chronic obstructive pulmonary disease and morbid obesity. A 7/27/11 Personal Care Profile revealed to transfer the resident with two assist and to turn and position her every two to three hours. Review of the Minimum Data Set (MDS) Assessment, dated 3/21/12, revealed that the resident's cognitive skills for daily decision making are moderately impaired and the resident requires extensive physical assistance for bed mobility, transfer, toileting, and bathing.

During an observation and resident interview on 4/18/12 at 10:16 a.m., there was a bright purple-red bruise in a fold of skin near the right elbow, approximately 4 centimeters (cm) x 2.5 cm, a pale purple bruise at the right wrist approximately 3 cm x 1.5 cm, and a dark purple bruise on the outer aspect of the right hand approximately 5.5 cm x 3 cm, extending down from the fourth and little fingers to the middle of the hand. The resident said she was not sure how the bruises occurred.

Review of Incident/Accident (I&A) Reports from April 2012 and the 24-hour report sheets, dated from 4/11/12 to 4/22/12, revealed no reported bruising.

Interviews on 4/23/12 included:

a. At 9:13 a.m., two CNAs said that the resident transfers with one assist and a rolling walker. Both CNAs said that they had not worked with the resident recently but had noticed the bruises on her right elbow, arm, and hand.

b. At 1:30 p.m., Licensed Practical Nurse/Assistant Nurse Manager (LPN/ANM) #1 said she had noticed some bruising on the resident's hands that morning that had not been reported.

c. At 3:53 p.m., LPN/ANM #2 said no one had reported any bruising to her.

d. At 4:11 p.m., LPN/ANM #1 said that she thought the bruises had been caused by the siderails and that she would be placing a towel over the rails.

3. Resident #34 has diagnoses including diabetes and gait instability. Review of an I&A Report, dated 10/1/11, revealed that a 4 cm circular bruise on the right upper arm was discovered at 5:00 a.m. on the night shift by a CNA. The report noted that the resident did not know how the bruise occurred. Two CNAs interviewed on 10/1/11 and 10/2/11 had no knowledge of the bruise located on the resident's right upper arm. No other statements were included with this investigation.

When interviewed on 4/25/12 at 10:45 a.m., the Director of Nursing (DON) stated that the process for investigating an injury of unknown origin includes interviewing staff from the previous three days and evaluating these statements to determine a possible root cause. The DON stated this injury of unknown origin was not thoroughly investigated.

[10 NYCRR 415.4(b)(1)(ii)(3)]

Based on observations, staff interviews, and record reviews, it was determined that for one of one resident, the facility did not ensure that a resident remained free of significant medication errors. Specifically, Resident #91 received additional doses of insulin for seven days, which was not consistent with the current standing physician's orders. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #41 has diagnoses including diabetes. Physician orders, dated 4/17/12, include to administer Novolog insulin 3 units, subcutaneous (under the skin) if blood glucose is greater than 350, check with breakfast, call the physician if under 90 or greater than 400; Lantus insulin 50 units subcutaneous every morning if blood glucose is over 120; Lantus insulin 25 units subcutaneously if blood glucose is 90 to 120; call the physician if blood glucose is under 90.

The Novolog insulin is signed off on the Medication Adminsitration Record as being given on 4/18/12 - 4/23/12. On all of the days the resident's blood glucose was recorded below 350 (92-142). In addition, the Lantus insulin is signed off for both the 25 unit and 50 unit dose.

When interviewed on 4/24/12 at 8:30 a.m., the Licensed Practical Nurse (LPN) said for the past several days, the resident should not have received the Novolog insulin because her blood glucose was not over 350. She also said the Lantus orders were confusing, and it was difficult to determine what amount of Lantus the resident received. At 9:18 a.m. that day, the LPN/Nurse Manager said the orders were confusing, the nurses should not be giving the Novolog, and it was hard to tell what they were giving with the Lantus.

The facility's policy regarding, "Administration of Insulin," currently in use, includes to check the physician order prior to administering insulin.

[10 NYCRR 415.12(m)(2)]

Based on resident and staff interviews, and record reviews, it was determined that for 1 of 26 residents reviewed for residents rights, the facility did not allow a resident to refuse treatment. Specifically, Resident #111, who requested to be returned to bed, was not put back into bed in a timely manner. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #111 has diagnoses including morbid obesity. The Minimum Data Set Assessment, dated 4/6/12, and the undated Personal Care Profile both show that the resident is cognitively intact and is totally dependent upon two staff for transfers.

Review of a note written by a Certified Occupational Therapy Assistant (COTA), dated 4/17/12, revealed that the resident refuses to sit up in a chair again because she was left in a chair for four hours on 4/16/12.

During an interview on 4/19/12 at 10:48 a.m., the resident said the last time she was out of bed was 4/16/12 when staff left her up for four hours. She was told by the therapy person that this was "the order." The resident reported that she asked staff to put her in bed several times because she was very uncomfortable.

Interviews conducted on 4/24/12 are as follows:

a. At 12:11 p.m. and on 4/25/12 at 8:45 a.m., the Certified Nursing Assistant (CNA) #1, who worked with the resident on 4/16/12, reported that the Occupational Therapist (OT) and COTA got the resident out of bed that day at 10:00 a.m. She stated that the resident cried, was anxious, began to dry heave, and stated she wanted to go back to bed. She and CNA #2 put the resident back to bed at 1:30 p.m. CNA #1 stated that the resident has refused to get out of bed since that day.

b. At 12:18 p.m., the resident said if the staff would put her back to bed when she asks, she would get out of bed.

c. At 2:22 p.m., the OT said he and the COTA did get the resident up into a chair on 4/16/12 at approximately 10:00 a.m., and she could have been up for four hours. From a therapy point of view they were looking for a toleration point. After this, the resident refused therapy for several days and then was discharged from therapy. The OT did not know the resident did not want to get up because she was left in the chair for such a long time, and if he had known, he would have put her in bed right away.

d. At 3:12 p.m., the Licensed Practical Nurse Manager (LPNM) confirmed that the resident is in bed because she refuses to get up. The LPNM reported that the last time (4/16/12 at 10:00 a.m.) the resident got up, she complained bitterly the entire time and wanted to go back to bed. She was put back in bed at 1:00 p.m., three hours later.

During an interview with the Director of Nursing on 4/25/12 at 10:15 a.m., she said that residents should be put back to bed whenever they ask. At 1:39 p.m. that day, the resident said that she sat up that day for 2.5 hours and "it felt good."

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

Based on observations, resident and staff interviews, and record reviews, it was determined that for 4 of 26 residents reviewed for care plan implementation, the facility did not provide services in accordance with the resident's written plan of care. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 6/17/11. Specifically, Resident #27's dialysis access site was not monitored, Resident #25's fall preventions were not followed, Resident #7 did not receive a physician ordered treatment for a pressure ulcer, and Resident #76 did not have compression stockings applied. 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:

1. Resident #27 has diagnoses including end stage renal failure and receives hemodialysis three times a week. Review of the Comprehensive Care Plan (CCP), dated 9/6/11, and the dialysis communication sheets revealed that the dialysis access site should be monitored for signs and symptoms of infection. After dialysis, the dialysis site should be monitored for bleeding.

Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) for March and April 2012, and nursing progress notes from February 2012 through April 2012 revealed a lack of documentation to show that nursing had been monitoring the dialysis access site.

When interviewed on 4/23/12 at 1:50 p.m., the Licensed Practical Nurse/Nurse Manager (LPN/NM) said that the resident's dialysis access site should be checked for signs of infection around the bandage and for bleeding, and this would be documented on the TAR every shift. The LPN/NM then reviewed the TAR and said this documentation was not on this treatment sheet, but should be.

In an interview on 4/24/12 at 8:45 a.m., the staff LPN said that the resident has a central line for access for dialysis in her chest. She said that she does not need to do anything with the site; dialysis is responsible for changing the resident's dressing.

During an interview on 4/24/12 at 9:00 a.m., the Director of Nursing said that she would expect that the nurses check the dialysis access site (central line) for bleeding or signs of infection for one shift after the resident returns from dialysis and document this in the progress notes.

The facility's policy regarding hemodialysis, dated 3/27/12, does not address the care of the dialysis access site.

2. Resident #25 has diagnoses including syncope and macular degeneration. Review of the Minimum Data Set (MDS) Assessment, dated 3/14/12, revealed that the resident's cognitive skills for daily decision making are moderately impaired.

A fall assessment, dated 2/17/12, documented a high risk of falling. Review of Incident and Accident reports and nursing progress notes for 2/19/12, 2/24/12, and 3/4/12 all show that the resident had fallen on the floor. A nursing note, dated 3/8/12, shows that a care conference was held with the resident and family. The resident's falls were discussed, and it was decided that the resident would be care planned to be put to bed after breakfast and lunch.

Review of the Comprehensive Care Plan, dated 3/15/12, revealed a history of actual falls and alterations in safety. Approaches include a nap in the morning and afternoon to help decrease the risk of falls. The current Certified Nursing Assistant (CNA) personal care profile does not include this information.

In observations made on 4/20/12 at 9:00 a.m., 10:00 a.m., 11:00 a.m., 12:30 p.m., on 4/23/12 at 8:38 a.m., 9:00 a.m., 9:39 a.m., 10:10 a.m., 10:15 a.m., 10:48 a.m., 1:06 p.m., 2:00 p.m., 3:00 p.m., 3:30 p.m., and on 4/24/12 at 9:20 a.m., 9:40 a.m., and 10:38 a.m., the resident was out of bed and seated in a wheelchair.

During an interview on 4/24/12 at 10:41 a.m., the assigned CNA said they would not know to put the resident to bed unless it was on the CNA care plan. At 12:34 p.m. that day, the LPN/NM said the information needs to be on the personal care profile so the CNAs know what to do.

3. Resident #7 has diagnosis including a Stage III sacral pressure ulcer. A physician order, dated 3/14/12, included to apply Santyl (enzyme used to help with healing ulcers) to the outer edge of the right side of the wound with every sacral dressing change. This order was not written on the April 2012 TAR. A physician order, dated 4/11/12, included to discontinue the use of Santyl on the wound.

When interviewed on 4/23/12 at 1:00 p.m., the LPN/NM reviewed the chart and did not comment. When questioned about carrying over physician orders from month to month, she replied that there is a three nurse check system in place for checking the monthly orders.

When interviewed on 4/23/12 at 1:15 p.m., the Physician Assistant said that he was not aware that the Santyl was not used from 4/1 to 4/11/12. He confirmed that the order for Santyl was discontinued on 4/11/12.

4. Resident #76 has diagnoses including hypertension and edema. A Personal Care Profile card, dated 7/9/11, directs to apply compression stockings every morning and remove at bedtime. Review of the MDS Assessment, dated 1/18/12, revealed that the resident's cognitive skills for daily decision making are moderately impaired. Physician notes, dated 12/6/11 and 2/7/12, identify edema (fluid accumulation) in the extremities and to continue to wear compression stockings. Physician orders, dated 4/3/12, include to apply compression stockings to both lower extremities every morning and remove at night.

In an interview and observation on 4/23/12 at 1:26 p.m., Resident #76 said that she did not have her stockings on and did not know where they were. She was wearing ankle socks. Her ankles were visibly swollen above the top of the socks.

Observation and interviews on 4/23/12 at 2:12 p.m. are as follows:

a. When LPN #1 looked at the resident's lower legs, she remarked that there were marks in her legs and then asked the LPN/NM if the resident should be wearing compression stockings. The LPN/NM called out, "Yes, she is!"

b. CNA #1 said, "I usually work evenings, and she has TEDs (compression stockings) on when I come to work. Let me check her room for the stockings." CNA #1 checked the room and said, "They aren't here."

c. CNA #2 reported that she took care of the resident that morning and did not put compression stockings on the resident and did not tell a nurse.

In an interview on 4/23/12 at 2:19 p.m., LPN #2 said that she would expect a CNA to notify her if compression stockings were not available so that a nurse could get some.

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

Based on staff interviews and record reviews, it was determined that for 2 of 26 residents reviewed for professional standards, the facility did not provide services that met professional standards of quality. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 6/17/11. Issues involved inaccurate transcription of a medication order (Resident #6) and lack of neurological checks after a resident sustained a fall with head injury (Resident #25). 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 #6 has diagnoses including osteoarthritis, a history of hip fracture, and pressure ulcers. Review of the Minimum Data Set (MDS) Assessment, dated 2/15/12, revealed that the resident had moderately impaired cognitive skills for daily decision making.

Review of a physician order, dated 4/23/12, revealed that Roxanol (morphine narcotic analgesic, pain medication) was increased to 10 milligrams (mgs), change as needed Roxanol to every two hours (was every three hours).

Interviews on 4/24/12 are as follows:

a. At 11:16 a.m., a Licensed Practical Nurse (LPN)/Medication Nurse said she was not aware that the resident's pain medication had been increased.

b. At 11:23 a.m. and 11:30 a.m., both LPN/Assistant Nurse Managers (ANM) #1 and #2 said they did not know why the orders were not transcribed.

c. At 11:34 a.m., LPN/ANM #1 stated that an evening nurse should have taken those orders off, and a night nurse should have rechecked those same orders.

d. At 12:48 p.m., a LPN/Medication Nurse said, "The resident wants some pain medicine now but I can't give her anything because she does not have a PRN ordered." After surveyor intervention, the LPN/Medication Nurse checked the medical record and said, "Oh, yes, there is a PRN ordered. LPN/ANM#1 transcribed the order and left off the PRN order."

e. At 1:12 p.m., the Medical Director said the resident should have received the increased dose of pain medicine beginning 4/23/12.

2. Resident #25 has a diagnosis of syncope. Review of the fall assessment, dated 2/17/12, revealed that the resident is at risk for falling.

Review of a nursing note, dated 3/4/12 from the 3:00 p.m. to 11:30 p.m. shift, revealed that the resident was found on the floor with bleeding from the laceration on the forehead. This note did not include any neurological checks. An undated physician order includes to transfer the resident to the hospital for fall with head injury.

Nursing notes, dated 3/5/12, revealed the resident was readmitted from the Emergency Room with diagnoses that include fall with scalp hematoma (blood blister) and redness on the forehead that measured 2 centimeters (cm) x 12 cm. Review of the 24-hour report sheets, nursing notes, and an Incident/Accident Report, dated 3/4/12, revealed no reference to any performed neurological checks.

Review of the Comprehensive Care Plan, dated 3/5/12, revealed that the resident is at risk for falling. Approaches include to complete neurological checks as needed.

During an interview on 4/24/12 at 12:34 p.m., the LPN/NM reported that neurological checks should have been done before the resident left and upon readmission to the facility. She provided a neurological check sheet that directs staff to perform neurological checks after a fall involving a head injury, every 15 minutes for one hour, then every hour for four hours, then every shift for 72 hours.

The facility's policy, dated 3/13/12, regarding neurological checks includes that neurological checks are to be performed when a resident has a fall with a head injury. These should be done every 15 minutes for one hour, then every hour for four hours, then every shift for twenty four hours. The policy requires nursing to document results on a neurological check sheet.

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

Based on observation, staff interviews, and record reviews, the facility did not ensure that essential equipment was maintained in a safe operating condition. The issue involved the juice dispensing machine that was not cleaned or maintained in a proper working order. This resulted in no actual harm with the potential for minimal harm and is widespread. This is evidenced by the following:

During a tour of the kitchen on 4/24/12 at 9:40 a.m., the nozzle of the juice machine was removed and was observed to have a brown colored build-up around the entire circumference of the nozzle. The Director of Food Service (DFS) took a plastic spoon and was able to scrape away some of the accumulation. Additionally, there was a visible accumulation of a dark colored substance in the circuit lines (carry juice concentrate into the nozzle) of the dispenser. Both the DFS and FSW said that the nozzle should be cleaned daily and added that there was no cleaning log to direct or document cleaning. The DFS added that he thought that the nozzle was flushed once a week but did not have a record of this. The DFS said that all juice used at the facility was poured through the dispenser.

On 4/24/12 at 2:20 p.m., the DFS provided instructions for cleaning the Wunder-Bar II Dispenser nozzle, sheathing, and post mix system (lines coming from bag-in-box syrup containers through the nozzle). The DFS said that he would immediately in-service staff on how to clean the dispenser and have staff document the cleaning.

[10 NYCRR 415.29(b)]

Based on staff interviews and record reviews, it was determined that for three of three resident records (Residents #6, #25, and #113) reviewed for resident rights, the facility did not have a process in place to inform Medicare beneficiaries of his/her potential liability for payment of non-covered services when limitation of liability applies. Specifically, the facility did not provide the beneficiaries with either a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or a denial letter at the termination of Medicare Part A benefits. This resulted in no actual harm with potential for minimal harm that is widespread, and is evidenced by the following:

1. Record review for Resident #6 revealed that the resident was discontinued from Medicare Part A services, effective 12/9/11. The resident received a generic notice of non-coverage on 12/9/11.

2. Record review for Resident #25 revealed that the resident was discontinued from Medicare Part A services, effective 3/30/12. The resident received a generic notice of non-coverage on 3/28/12.

3. Record review for Resident #113 revealed that the resident was discontinued from Medicare Part A services, effective 4/13/12. The resident received a generic notice of non-coverage on 4/11/12.

Residents #6, #25, and #113 all continue to reside in the facility receiving custodial care. There was no documentation to show that a SNFABN or denial letter was given to residents or their representatives informing them of their potential liability for payment.

When interviewed on 4/23/12 at 11:06 a.m., the Account Receivable Specialist said she only provides the SNFABN to residents whose Medicare A has been exhausted. She thought that residents whose Medicare A was cut for skilled services did not need to receive the SNFABN or denial letter, as they no longer received skilled services and that the Medicare non-coverage letter took the place of the letters.

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

Based on observations and staff interview, it was determined that the facility did not post daily nurse staffing information at the beginning of each shift in a prominent place readily accessible to the public for review. This resulted in a pattern of no actual harm with potential for minimal harm, and is evidenced by the following:

In observations made from 4/18/12 to 4/24/12 between the hours of 8:00 a.m. and 3:00 p.m., the daily nurse staffing information was not posted.

When asked about the nurse staffing posting on 4/24/12 at 3:00 p.m., the Director of Nursing said that it is her responsibility to post the staffing. She said it is usually posted on the first floor across from the elevator. She said it has not been posted because she has been too busy.

Based on resident and staff interviews, and record reviews, it was determined that for one of three residents reviewed for quality of life, the facility did not allow a resident to make choices about an aspect of her life that was significant to her. THIS IS A REPEAT DEFICIENCY FROM THE RECERTFICATION SURVEY OF 6/17/11. Specifically, Resident #76 was not offered the opportunity to have a tub bath. This resulted in a pattern of no actual harm with potential for more than minimal harm, and is evidenced by the following:

Resident #76 was re-admitted to the facility on 1/5/09 with diagnoses including diabetes and degenerative joint disease.

A review of the Personal Care Profile, dated 7/9/11, revealed that the resident received a shower once a week. Additionally, "Allow Choices" was written at the top of the card. The Minimum Data Set (MDS) Assessment interview for daily preferences, dated 7/20/11, indicated it was very important to the resident to choose a method of bathing. The MDS Assessment, dated 1/18/12, revealed the resident had moderately impaired cognitive skills for daily decision making and required physical assistance of two for bathing. The Care Plan for Activities of Daily Living, dated 1/24/12, directed staff to provide a shower per policy. The facility Day/Evening Assignment Sheet, dated 4/19/12, included to shower the resident on Monday evening.

During an interview on 4/19/12 at 11:06 a.m., the resident said she wanted to have an occasional bath and had told staff about this. She said it was not acceptable to be told she could not have a bath. She added she had not received a bath since she was admitted and thought there were no tubs available.

Interviews conducted on 4/23/12 included the following:

a. At 9:56 a.m., a Certified Nursing Assistant (CNA) caring for the resident said she did not know if the tub worked and that the resident had not told her she wanted a bath. At the same time, the Licensed Practical Nurse/Assistant Nurse Manager (LPN/ANM) said that "There are no tubs in the facility."

b. At 10:21 a.m., the Director of Nursing (DON) said, "The tubs have not worked in forever."

c. At 10:28 a.m., the Director of Maintenance checked the whirlpool tub in the second floor bathing suite and said the water and tub chair both worked.

d. At 1:49 p.m., the DON said that the resident would get a bath in the morning.

e. At 3:45 p.m. and 4:00 p.m., the Activities Director said she reviewed the customary routine assessment with the resident and knew that having a choice for type of bathing was very important to her. She said she thought that nursing would take that information, ask the resident what she preferred, and put it into place.

In an interview on 4/24/12 at 10:00 a.m., the resident said, "I had a bath, and it was wonderful!"

[10 NYCRR 415.5(b)(3)]

713-1.9 Mechanical requirements.

(i) All handwashing fixtures used by medical and nursing staff and food handlers shall be trimmed with valves that can be operated without the use of hands. Hand operated faucets may be fitted on lavatories in residents' rooms and residents' toilets.

Based on observations, it was determined that the facility did not maintain compliance with Subpart 713-1, Standards For Nursing Home Construction Projects Completed or Approved Prior To August 25, 1975. The issue was related to hand wash sinks that were not trimmed with valves that can be operated without the use of hands. This affected two (first and second) of three resident sleeping floors, resulting in a pattern of no actual harm with the potential for minimal harm. The findings are:

1. Observation on 4/18/12 at 9:45 a.m. revealed the handwashing sink in the first floor clean utility room lacked valves that can be operated without the use of hands.

2. Observations on 4/19/12 at 12:13 p.m. revealed the sinks in the first floor clean utility room and the first floor S-2 tub room lacked valves that can be operated without the use of hands.

All handwashing fixtures used by medical and nursing staff and food handlers shall be trimmed with valves that can be operated without the use of hands.

[10 NYCRR 713-1.9(i)]

During a review of employee files for CHRC on 4/20/11 from 8:25 a.m. to 9:00 a.m., documentation showed that a Certified Nursing Assistant trainee was hired on 7/25/11 and received a pending denial letter on 9/26/11. The documentation showed that the employee was issued a formal notice of termination from the facility, dated 11/8/11, and the CHRC 105 termination form was submitted on 1/6/12.

A provider must immediately, but within no later than 30 calendar days after the event, notify the Department, and document such notification occurred, when any employee who was subject to, and underwent, a criminal history record check is no longer employed by the provider.

[10 NYCRR 402.9(b)(2)]

Based on observations and document review conducted during the Life Safety Code Survey, it was determined that the facility did not meet an acceptable building construction type. The issues were related to a non-fire rated ceiling assembly and unprotected structural supports. This affected three (first, second and third) of three resident sleeping floors, resulting in no actual harm with the potential for more than minimal harm that is not immediate jeopardy and is widespread. The findings are:

A review of the facility's Fire Safety Evaluation System (FSES), dated 6/18/08, revealed the building construction type was determined to be Type II (000). Per the 2000 edition of NFPA 101 Life Safety Code, this construction type is only acceptable if the facility is not over two stories with a complete automatic sprinkler system. Westgate Nursing Home is equipped with a complete sprinkler system, but is three stories. In order to comply prescriptively with an acceptable building construction type, structural support members must be protected from fire by a rated material or rated system with a fire resistance rating of at least one hour.

Observations above the suspended ceiling tile system on 4/19/12 from 10:05 a.m. to 11:10 a.m. revealed that steel structural support members, including some beams and trusses, were not encased in a fire resistive material or system. Additionally, many of the ceiling tiles on the first, second, and third floors were not clipped to the ceiling system grid. Recessed lighting fixtures are present throughout the building in resident rooms, soiled and clean utility rooms, the main lobby, and Lounge/Dining rooms. These recessed lighting fixtures were only partially encased in acoustical material. Documentation was not provided by the facility to show that the ceiling tile system, complete with lighting fixtures, had the required one-hour fire resistance rating to protect the structural supports.

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.

Based on a review of the facility's FSES, dated 6/18/08, and following observations conducted on 4/19/12, it has been confirmed that the facility has provided an equivalent level of safety and is therefore considered to be compliant with the Life Safety Code for the identified deficiency.

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: 19.1.6.2]

Based on observations and record review conducted during the Life Safety Code Survey, it was determined that the facility did not maintain ventilation ducts. THIS IS A REPEAT DEFICIENCY FROM THE LIFE SAFETY CODE SURVEY OF 6/17/11. The issue was related to vertical ducts that were not enclosed with fire rated construction. This affected three of three resident use floors, resulting in no actual harm with potential for more than minimal harm that is not immediate jeopardy and is widespread. The findings are:

Observations conducted on 4/19/12 from 10:05 a.m. to 11:10 a.m. revealed the exhaust system for the three resident room floors uses vertical metal ducts that pass through the floor decks before gathering into "clusters" at the third floor, which are then ducted through the roof. The locations of the vertical ducts are as follows: inside a closet at all three nurses' stations, inside all three clean and soiled utility rooms, inside linen closets, the Assistant Director of Nursing office, the beauty shop, and the common vertical path for the exhaust of resident toilet rooms, including but not limited to: 114/116 to 214/216 to 314/316, 117/119 to 217/219 to 317/319, 121/123 to 221/223 to 321/323, and 102/104 to 202/204 to 302/304. In total there are 14 vertical ducts. No documentation was provided to show that they are enclosed with at least one-hour fire rated construction.

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.

Based on a review of the facility's FSES, dated 6/18/08, and following observations conducted from 4/18/12 through 4/19/12, it has been confirmed that the facility has provided an equivalent level of safety and is therefore considered to be compliant with the Life Safety Code for the identified deficiency.

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: 19.5.2.1, 9.2.1; NFPA 90A 1999: 3-3.4.1]

Based on observations conducted during the Life Safety Code Survey, it was determined that the facility did not maintain egress pathways. The issues were related to exit discharge areas and an obstructed egress corridor. This affected three (first, second, and third) of three resident sleeping floors, resulting in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

1. Observations on 4/18/12 from 9:20 a.m. 9:40 a.m. revealed the exit stairwells that connect the first, second, and third floors discharge through a door to the outside at the North and South ends of the building. The step down from the exit discharge door to the outside consists of an immediate vertical drop of 9 to 10 inches.

2. Observation on 4/18/12 at 10:35 a.m. revealed the egress corridor leading to the exit on the North side of the basement was obstructed by three wheeled flat bed carts, which reduced the width of the hallway to approximately 2-feet for a distance of approximately 20 feet.

In existing buildings where the door discharges to the outside or to an exterior balcony or exterior exit access, the floor level outside the door shall be permitted to be one step lower than the inside, but shall not be in excess of 8 inches (20.3 cm) lower.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.2.1, 7.1.10.2.1, 7.2.1.3]

Based on observations and document review conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain exit stairwell enclosures. The issues were related to openings through stairwell enclosures that were not filled with a fire stopping system capable of resisting fire for at least one hour. This affected three (first, second, and third) of three resident sleeping floors, resulting 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 4/19/12 from 10:05 a.m. to 11:10 a.m. revealed the following openings:

1. There was an approximately 3 x 6-inch opening around a 1-inch electrical conduit located above the exit stairwell door in the hall by Room #301 and extending into the exit stairwell. The areas around the electrical conduit were filled with a yellow mineral wool material only.

2. There was an approximately 2-inch square opening around a 1-inch electrical conduit located above the exit stairwell door in the hall by Rooms #201 and #223 extending into the exit stairwell. The areas around the electrical conduit were filled with a yellow mineral wool material only.

3. There were three approximately 2-inch square openings around 1-inch electrical conduits located above the exit stairwell doors in the hall by Room #101 and extending into the exit stairwell. The areas around the electrical conduit were filled with a yellow mineral wool material only.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.3.1.1, 8.2.5.2]

Based on document review made during the Life Safety Code Survey, it was determined that the facility did not properly conduct fire drills. The issue was related to fire drills that were not conducted quarterly on each shift. This affected two (night, evening) of three employee work shifts, resulting in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

On 4/18/12, the Maintenance Director provided the surveyor with fire drill reports from 7/29/11 to 4/5/12. The reports showed that for the first quarter of 2012 (January, February, March) there was no evening shift (3:00 p.m. to 11:00 p.m.) or night shift (11:00 p.m. to 7:00 a.m.) fire drills conducted. For the fourth quarter (October, November, December) of 2011 there was no evening or night shift fire drills conducted. For the third quarter (July, August, September) of 2011 there was no night shift fire drills conducted.

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.7.1.2]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not protect hazardous areas. The issues were related to noncompliant doors and openings in walls. This affected one (first) of three resident sleeping floors and one of one basement, resulting in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

Observations made on 4/18/12 are as follows:

1. At 9:30 a.m. the door to the first floor activities room was propped open by a black rubber door wedge. The activities room is larger than 50 square feet and contains a significant amount of combustible material.

2. At 10:15 a.m. the wall that separates the first floor maintenance shop from the exit hallway near the dumbwaiter was not smoke tight. At the top of the wall was an approximately 1/4 to 2-inch x 10-foot opening through the wall.

3. At 10:45 a.m. the door to the basement electrical/storage room was propped open by a metal bar. The room is greater than 50 square feet and contained three 55-gallon trash receptacles.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.2.2.2.6, 19.3.2.1, 19.7.5.5]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not provide a fire safe laundry area. THIS IS A REPEAT DEFICIENCY FROM THE LIFE SAFETY CODE SURVEY OF 6/17/11. The issue was related to a build-up of lint behind the laundry dryers. 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:

Observations conducted in the basement on 4/18/12 at 10:30 a.m. revealed the area behind the natural gas powered dryers had an approximately 1/8 to 1/4-inch build-up of lint on the backs of the units, the floors, and electrical conduits. The surveyor was able to peel away large sheets of lint from the top of each unit. The heating flames for these dryers are partially enclosed within the back of each unit which was less than 1-foot away from the lint accumulation.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.1.1.3]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not maintain vertical openings. The issues were related to vertical openings between floors that were not properly enclosed with one hour fire rated construction. This affected three (first, second, and third) of three resident sleeping floors and one of one basement, resulting in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

Observations made on 4/18/12 are as follows:

1. At 8:35 a.m., there was an approximately 3-inch diameter metal sleeve extending through the floor of the third floor electrical room. The sleeve had wires extending down to the second floor and was not filled at either level with a material capable of resisting fire for at least one hour.

2. At 10:25 a.m., there was an approximately 3 x 6-inch and 4 x 10-inch opening through the ceiling of the boiler room and extending at least up through the first and second floors. The openings were located adjacent to the boiler exhaust stack and surrounding water pipes for the shower/tub rooms above.

3. At 10:50 a.m. the door to the dumbwaiter at the basement level had a self-closing device that had been disconnected, and, therefore, would not automatically close. At the first floor level the door to the dumbwaiter was not smoke tight or automatic closing.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.3.1.1, 8.2.5.1, 8.2.5.2, 8.2.5.3, 8.2.5.10, 7.2.1.8.1]

Based on observations and document review conducted during the Life Safety Code Survey, it was determined that the facility did not provide compliant building service equipment. The issue was related to the use of a portable space heater. This affected one of one kitchen, resulting in no actual harm with the potential for more than minimal harm that is not immediate jeopardy and is isolated. The findings are:

Observation on 4/18/12 at 10:00 a.m. revealed a DuraCraft brand portable space heating device was located in a dietary office space within the main kitchen. The facility did not provide any documentation to show that the space heater heating element did not exceed 212 degrees (*) Fahrenheit (F).

Portable space-heating devices shall be prohibited in all health care occupancies.

Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 *F (100 * Celsius).

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.7.8]