Mayfair Care Center

Based on group, family and individual interviews during the recertification survey, the facility did not ensure that resident and family grievances were promptly resolved. Specifically, 1) In a Group Meeting with 8 alert and lucid residents, 1 family interview and 2 individual resident interviews, complaints that personal clothing was missing were identified; 2) During the group meeting and an individual resident interview, it was determined that the residents were unaware of the New York State (NYS) Department of Health Hot Line Number. This was evident for 5 of 8 group members and 1 of 5 individual resident interviews; 3) 8 of 8 residents during the group interview were unaware of the facility's Grievance Policy and process; 4) During the group meeting, 8 of 8 residents stated that facility staff frequently did not have Identification Badges consistently visible. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

This is a Repeat Deficiency.

The findings are:

1) A Resident Group Meeting was held with 8 alert and lucid residents on 10/27/10 at 10:00 AM.

The entire group of 8 residents complained of frequently missing clothing from the laundry. The residents complained that their clothing was frequently found in other resident's closets. In addition, unlabeled clothing, which did not belong to the residents, was often found in incorrect closets. The residents stated that they often noticed other residents wearing their clothing. The residents further stated that this problem has been reported numerous times to the facility administrative staff, brought to the attention of Housekeeping Department Staff and individually reported to Nursing Staff without improvement.

A confidential, family interview was completed on 10/27/10 at 8:00 AM. The family member stated that unlabeled clothing is often found in their family members closet. In addition, the resident's closet often contains other residents' clothing. The family member stated that the resident's personal clothing is often seen being worn by other residents.

During a confidential, individual resident interview on 10/26/10 at 9:00 AM, a resident stated that his clothing is frequently lost. The resident also stated that sometimes it is found when he complains to the staff, but there are times he never sees the clothing items again. In addition, the resident stated that he finds unlabeled clothing in his closet.

An inspection of Resident #16's closet with the resident's assigned Certified Nursing Assistant (CNA) was conducted on 10/28/10 at 8:00 AM. It was observed that there were 3 unlabeled shirts hanging in the resident's closet. The CNA was interviewed and stated that the shirts should have been labeled by the Housekeeping Department prior to being given to the resident.

The Activity/Recreation Director was interviewed on 10/27/10 at 10:15 AM. The Director stated that family members are told to have the resident's clothing sent to the Activity Department with the resident's name and room number. The Director then added that the resident's clothing will then be sent to the Housekeeping Department for labelling. The resident's clothing is then distributed to the proper unit for the CNA to hang it in the resident's closet.

An observation of an out of sample resident's closet was made on 10/28/10 at 2:00 PM. There were eight items of clothing in the resident's closet that were observed to be unlabeled.

The Housekeeping Director was interviewed on 11/1/10 at 11:30 AM. The Director stated that missing unlabelled or misplaced resident's clothing has been an ongoing problem in the facility. The Director further stated that the residents' clothing is usually distributed at night by the CNA staff when there is little lighting. The distribution at night could add to the clothing being misplaced. The Director also stated that ultimately, the Nursing Department is responsible for the distribution of the clothing into the correct closet.

2) During the group interview on 10/27/10 at 10:00 AM, 5 of the 8 alert residents present verbalized that they were unaware that there was a NYS Department of Health telephone hotline number, what its purpose was or if it was posted.

A review of the Monthly Resident Council Meetings from April 2010 through October 2010 revealed no documented evidence that the NYS Hotline Number was reviewed with the residents.

The Director of Social Work (SW) was interviewed on 10/28/10 at 8:55 AM and was unaware that the residents did not know about the NYS Hot Line Number.

3) During the group interview on 10/27/10 at 10:00 AM 8 of the 8 alert residents interviewed stated that they were unaware of the facility's Grievance Policy and Procedure.

On 11/1/10 at 11:00 AM the SW was interviewed. The SW stated that she was recently employed by the facility and did not know that the residents were unaware of the facility's Grievance Procedure. The SW stated that residents should report problems to the Nursing Staff or the Social Worker and then a grievance report would be generated. The SW further stated the Grievance/Complaint Policy is part of the Admission package however, the SW stated that it should be reviewed with the residents.

The Resident Council Minutes reviewed from April 2010 through October 2010 did not have any documented evidence of the residents being educated regarding the Grievance Procedure.

An undated policy titled Grievance/Complaint Policy stated that ". . . grievances may be filed verbally or in writing to Social Services. . . residents may utilize Resident Council. . .if a grievance is registered or a recommendation is made by Resident Council, it is the responsibility of the Activities Director to initiate the proper procedure. . ."

4) During a group interview on 10/27/10 at 10:00 AM 8 of the 8 residents present stated that facility staff do not regularly wear their ID Tags.

This complaint was documented on the minutes of the facility's Resident Council Meeting dated 10/12/10.

During the recertification survey the following observations were made of staff with their identification badges not visible: 10/26/10 on the 2nd floor, 2 Licensed Practical Nurses; 10/27/10 on the 3rd floor, 1 Registered Nurse and on the 2nd floor, one CNA; 10/28/10 on the 2nd floor, 2 CNAs.

The facility's undated policy titled Grievance/Complaint documented "... If a grievance is registered or a recommendation made at Resident Council, it is the responsibility of the Activities Director to initiate the proper procedure and/or to bring it to the attention of the Administrator..."

415.3 (c) (1) (ii)

Based on record review and staff interview during the recertification survey, the facility did not ensure that a surety bond sufficient to cover all resident's funds was held by the facility. Specifically, the facility's surety bond covered less than the total amount of the residents' funds as of 10/28/10. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

The facility's Surety Bond dated as effective on 12/23/09 and ending on 12/23/10 covered $85,850.00.

The total balance of the residents' funds as of 10/28/10 totaled $108, 374.97.

An interview with the facility Administrator was conducted on 10/28/10 at 10:00 AM. The Administrator stated that he would check into the bond amount and would take care of it.

483.10(c)(7)

Based on observation and staff interview during the recertification survey, it was determined that the facility did not ensure that housekeeping and maintenance services were provided to maintain a sanitary and orderly interior on 3 of 3 floors. Reference is made to peeling and scratched wallpaper, stained wall guards and wall panels, and stained ceiling tiles.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During environmental rounds on 10/26/10 between 10:00am and 1:30pm the following was observed:

1. Peeling and scratched wallpaper were observed in the resident corridor on the 1st floor. Examples include but are not limited to the following areas: in front of the nursing station, by resident rooms 108 and 105.

In addition, the inside entrance in the main dining room was observed with peeling and torn wallpaper at the base of the wall.

2. Stained wall guards were observed in the resident corridors on the 1st floor between rooms 113-114, and in front of rooms 105 and 110.

3. Corridor wall panels were observed with stains on the 3rd floor. Examples include but are not limited to
the following areas: between the shower room and soiled utility room and between rooms 323 and 326 on the South Unit.

4. Stained ceiling tiles were observed in the corridors by room 321, in the 2nd floor tub room, and across room 108.

In an interview on the same day at approximately 11:00am the Director of Maintenance stated that he is in the process of renovating the resident rooms and that the areas identified would be addressed in a timely manner.

10 NYCRR 415.29

Based on observations, record review and staff interviews during the recertification survey, the facility did not ensure that the Minimum Data Set (MDS) Assessments accurately reflected the residents' status for 3 of 7 residents reviewed for Restraints (#4, #14 and #9); for 1 of 12 residents reviewed for Incontinency/Toilet Programs (#5); and for 4 residents (#14, #4, #5 and #18) where the Attestation Statement (Section AA-9) that staff members sign attesting to the accuracy of the portion of the MDS was incomplete and/or missing. Specifically, 1a) Resident #4 had a Mitten Restraint applied to the right hand which restricted movement, 1b) Resident #14 had a seat belt in the wheelchair which prevented the resident from rising and 1c) Resident #9 was positioned in a Geri-Recliner which prevented the resident from rising and there was no documented evidence in the MDS Assessments identifying the Devices as Restraints (Section P-4). 2) Resident #5 MDS Assessments incorrectly documented that the resident was Incontinent of Bladder. 3) Two of the most current MDS Assessments reviewed for Resident #14 were incomplete for sections addressing certification of accuracy completed by various disciplines. This was also evident for Residents #4, #5 and #18. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding are but not limited to:

1a) Resident #4 has diagnoses which include Schizophrenia and Dementia.

The Comprehensive Care Plan Dated 10/31/09 and updated 9/20/10 documented that the resident utilized a right Hand Mitten.

Physician's Orders dated 3/2/10 through 10/12/10 documented that the resident was to have a right Hand Mitten applied and to be released every two hours for hygiene, skin check and daily care.

The Quarterly MDS Assessment dated 3/28/10 documented that the resident had severely impaired cognition and was totally dependant on staff for all activities of daily living. The MDS documented that the resident receives all nourishment through a Gastrostomy Tube (GT-tube placed into the stomach).

A review of the MDS Assessments dated 3/28/10, 6/24/10 and 9/20/10 revealed no documented evidence that identified the resident's Hand Mitten as a Device/Restraint.

The resident was observed on 10/26/10 at 12:04 PM. The resident was in the hallway positioned in a Geri-Recliner with the Right Hand Mitt applied.

The MDS Coordinator was interviewed on 11/1/10 at 12:30 PM. The Coordinator stated that the Hand Mitt should have been documented on the MDS.

The CMS-RAI Version 2.0 Manual, page 3-198 documented that ". . .the assessor should evaluate whether or not the resident can easily remove the device, material or equipment. . .the assessor should not focus on the intent or reason behind the use of the device, but on the effect the device has on the resident.. .". The item should be coded appropriately in that category.

2) Resident #5 has diagnoses which include history of Cerebral Vascular Accident, Depression and Anxiety. The resident was admitted to the facility on 8/9/10.

The facility's Admission Nursing Assessment dated 8/9/10 at 6:05 PM documented that the resident was alert and oriented with "quick" comprehension. The Nursing Assessment also documented that the resident was Continent of Bladder.

The CCP for Continence dated 8/9/10 documented that the resident was incontinent of Bladder.

The Initial MDS Assessment dated 8/19/10 documented that the resident had modified independence with cognitive skills for daily decision making. The MDS also documented that the resident had no memory problems and was able to communicate verbal information without difficulty. The MDS included documentation that the resident was totally Incontinent of Bladder and did not use a urinal (Section H1-b and H-3 f-g).

On 11/01/10 at 10:45 AM the resident was observed to have a Urinal at his bedside. The urinal was observed to have approximately 300 cubic centimeters of urine in the container. During an interview with the resident at that time, the resident stated that he had been using the urinal since his admission to the facility in August 2010.

The Certified Nursing Assistant (CNA) who usually cares for the resident was interviewed on 11/01/10 at 10:50 AM . The CNA stated that the resident has been using the Urinal since he was admitted and notifies her when he is done. The CNA stated that the resident is not incontinent of urine.

The MDS Coordinator was interviewed on 11/01/10 at 12:30 PM. The Coordinator stated that the resident is continent and the MDS and Care Plan were incorrect.

CMS-RAI Version 2.0 Manual page 3-121 documented to ". . .ensure accurate coding . . .assessors must use multiple sources of information to code accurately: resident interview and observation, review of the clinical record and discussions with the direct care staff. . . "

3a) Resident #14 has diagnoses which include Dementia and Schizophrenia.

The MDS Quarterly Assessments dated 3/8/10 and 6/7/10 were incomplete and did not include the sections completed for the attestation of accuracy. There were no sections documented on any of the 4 signatures that were documented on both MDS Assessments.

The MDS Coordinator was interviewed on 10/28/10 at 2:00 PM and stated that the sections should have been filled out and that the disciplines would have to be told to complete their sections.

CMS-RAI Version 2.0 Manual page 1-25 documented " The importance of accurately completing and submitting the MDS cannot be overemphasized. The MDS information is the basis for. . .Medicare Prospective Payment System, State Medicare reimbursement programs, . . .Quality Monitoring... The primary responsibility for accuracy lies with the person selecting the MDS item responses and each person completing a section of the MDS is required to sign the Attestation Statement (AA9...)

415.11(b)

Based on record review and staff interviews during the recertification survey, the facility did not complete a Significant Change Assessment following the placement of a Gastrostomy Tube (GT-tube placed into the stomach in which all nourishment is provided), and the discontinuation of Palliative Care for 1 of 7 residents reviewed for GT in a total of 29 residents reviewed. Specifically, Resident #18 was readmitted from the hospital with a new GT and discontinued from Palliative Care. There was no documented evidence of a Significant Change Assessment completed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #18 has diagnoses which include Multiple Myeloma and Failure to Thrive.

A Comprehensive Care Plan (CCP) dated 9/11/10 documented that the resident was on Palliative Care.

A Significant Change MDS dated 9/11/10 documented that the resident's cognition was severely impaired. The resident was bed bound and had not eaten during the seven day assessment period. The MDS documented that the resident had a significant weight loss and was withdrawn from activities and social interaction.

The resident was admitted to the hospital on 10/3/10 with a diagnosis of Failure To Thrive.

On 10/7/10 the resident was readmitted to the facility with GT in place and new diagnoses of Dysphagia.

The Physician's order dated 10/7/10 documented to discontinue the resident from Palliative Care.

The Nutrition/GT CCP was updated on 10/14/10 and documented that the resident had a significant weight gain of 10.2 pounds since readmission.

There was no Significant Change Assessment completed post readmission from the hospital addressing the GT Placement and subsequent improvement in the resident's general condition. Although the Dietary CCP was updated to include the addition of the GT feeding, there were no Interdisciplinary reviews or revision to the resident's plan of care.

The Registered Nurse (RN)/Unit Manager was interviewed on 11/1/10 at 9:10 AM. The RN stated that the family had withdrawn the request for Palliative Care and had the GT placed. The RN also stated that the resident was improving with the addition of the tube feeding. The RN further described the resident as "doing much better", was getting out of bed into a recliner and being brought to off unit activities.

The MDS Coordinator was interviewed on 11/1/10 at 9:30 AM. The Coordinator stated that a Significant Change Assessment was not necessary for the placement of a GT. The Coordinator further stated that a Significant Change Assessment had been completed prior to the placement of the GT for the resident's declining condition and Palliative Care status.

415.11(a)(3)(ii)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that one (Resident #17) of 26 sampled records and one (Resident #28) of 3 closed sampled records in a total of 29 sampled resident clinical records was complete and accurately documented. Specifically, 1) Resident #17 had a Physician order for Metoprolol (antihypertensive drug) to be administered after checking and recording the heart rate (HR). The resident's HR was not consistently recorded as evidenced by the absence of 46 signatures on the Medication Administration Record (MAR) from 4/15/10 through 9/1/10. 2) Resident #28 had a Physician order for Lopressor (antihypertensive drug) to be administered after checking and recording the blood pressure (B/P) and HR. The resident's HR was not consistently recorded as evidenced by the absence of 17 signatures on the Medication Administration Record (MAR) from 5/28/10 through 6/24/10. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. (Resident #17 and #28)

The findings include:

1) Resident #17 has diagnoses including Congestive Heart Failure and Hypertension.

The Physician's Orders from April 2010 through September 2010 documented Metoprolol 50 milligram (mg) to give one tablet orally daily and to hold if systolic B/P is less than 110 or HR less than 55.

The resident's MAR of 4/15/10 through 5/12/10 did not document that the resident's HR was obtained for 6 days that the Metoprolol was administered.

The resident's MAR of 5/13/10 through 6/9/10 did not document that the resident's HR was obtained for 2 days that the Metoprolol was administered.

The resident's MAR of 6/9/10 through 7/6/10 did not document that the resident's HR was obtained for 2 days that the Metoprolol was administered.

The resident's MAR of 7/8/10 through 8/4/10 did not document that the resident's HR was obtained for 8 days that the Metoprolol was administered.

The resident's MAR of 8/4/10 through 9/1/10 did not document that the resident's HR was obtained for 28 days that the Metoprolol was administered.

The nurses notes reviewed from 4/15/10 through 9/1/10 revealed no documented evidence that HRs were taken prior to the administration of the Metoprolol.

The Licensed Practical Nurse (LPN)/Medication Nurse that gave the Metoprolol and did not document the HR was not available for interview.

2) Resident #28 has diagnoses including Coronary Artery Disease and Hypertension.

The Physician's Orders dated 5/28/10 documented Lopressor 12.5 mg by mouth daily and to hold for systolic B/P if less than 100 or HR if less than 60 for Hypertension.

The resident's MAR of 5/28/10 through 6/24/10 did not document that the resident's HR was obtained for 17 days that the Lopressor was administered.

The nurses notes reviewed from 6/4/10 through 6/24/10 revealed no documented evidence that HRs were taken prior to the administration of the Lopressor.

The Director of Nursing Services (DNS) was interviewed on 11/1/10 at 11:30 AM. The DNS stated that the licensed nursing staff should have obtained and recorded the resident's HR as ordered by the physician.

The Medical Director was interviewed on 11/1/10 at 11:30 AM. The Medical Director stated that if the Physician ordered to have the HR or B/P taken prior to the medication administration then the HR or B/P should have been obtained and documented prior to the medication administration.

The facility's undated policy #14 titled "Drug Administration" did not address that documentation of B/Ps and HRs as ordered by the Physician was to be completed prior to medication administration.

415.22(a)(1-4)

Based on record review and staff interviews during the recertification survey the facility did not ensure that all Comprehensive Care Plans (CCP) were developed and/or reviewed and revised to meet resident's medical, psychological and safety needs. This was evident for 3 residents in a total of 29 residents reviewed. Specifically, 1) Resident #10 had two documented falls from the bed without new interventions attempted. A third fall from bed was documented on 10/16/10 and on 10/20/10 an X-ray identified Destruction of the Head of the Right Femur; 2) Resident #9 was documented to have received Hypnotic medications as needed 22 times and there was no documented CCP developed for the use of Hypnotic medication; 3) Resident #5 was documented to have received Hypnotic and Antianxiety medications daily since admission and also documented to have had behavioral problems and there was no documented evidence that CCPs were developed addressing the treatment for the behavior problems, Insomnia or Anxiety. This resulted no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #10 was readmitted to the facility on 11/9/09 and had diagnoses including Diabetes Mellitus and Right Acetabulum (cup- shaped cavity in which the ball-shaped head of the head of the Femur bone articulates) Fracture.

The Minimum Data Set (MDS) Assessments dated 6/25/10 and 9/20/10 documented that the resident was moderately impaired with cognitive skills for daily decision making and had both long and short-term memory problems. The MDSs both documented that the the resident had fallen in the past 31-180 days.

A CCP titled Falls dated 10/10/09 documented that the resident had "falls related to" Dementia with Agitation and Psychotropic medications. The goal documented on the CCP included that the resident will have decreased risk of injury from falls for 90 days. The interventions documented on the CCP included: Physical Therapy assessment/recommendations, routine toilet schedule. On 1/8/10 the interventions were revised to include: wheelchair and bed alarms and floor mat.

Facility Incident Reports dated 3/19/10 at 12:00 Noon and 8/5/10 at 7:30 PM documented that Resident #10 had sustained falls from bed.

The CCP titled Falls revealed no documented evidence of new interventions attempted to prevent reoccurrence of falls from the bed for Resident #10 between 3/19/10 through 8/5/10.

An Incident Report dated 10/16/10 at 8:45 PM documented that the resident sustained a fall from bed. A note attached to the report documented on 10/21/10 revealed that on 10/20/10 the resident complained of pain to the right leg. The note further documented that a Right Hip X-ray documented that the resident was noted to have Osteoporosis and Degenerative Joint Disease (DJD) with a Partial Destruction of the Right Femoral Head. The note further documented that the resident was admitted to the hospital for a Magnetic Resonance Imaging for further evaluation.

A Nurse's Note dated 10/25/10 documented that Resident #10 was readmitted to the facility with diagnoses including Destruction of the Right Femur and Urosepsis.

A CCP titled Falls dated 9/21/10 documented that the resident had falls related to History of Dementia with Agitation and Psychotropic medication usage. The interventions on the CCP included bed alarm, floor mat and frequent bed checks for positioning and comfort.

An interview was conducted on 10/28/10 with the Assistant Director of Nursing Services (ADNS). The ADNS stated that it was her responsibility to implement plans of correction for each incident that had occurred. The ADNS stated that new interventions such as a wide bed and a low bed should have been implemented prior to the 10/16/10 incident.

2) Resident #9 has diagnoses including Dementia and Depression.

A Quarterly MDS Assessment dated 8/5/10 documented that the resident had short and long term memory problems and moderately impaired cognitive skills for daily decision-making.

A Nurse's Note dated 9/30/10 documented that the resident complained of insomnia.

A Physician's Order dated 9/30/10 documented Ambien (a hypnotic medication indicated to induce sleep) 5 milligrams (mg) at hour of sleep PRN (as needed).

A review of the Medication Administration Record (MAR) documented that from 9/30/10 to 10/25/10, Resident #9 received Ambien 22 times.

A review of the CCPs dated 9/30/10 to 11/1/10 documented that there was no evidence of a CCP developed for Insomnia while the resident had been receiving the hypnotic medication.

The Assistant Director of Nurses (ADNS) was interviewed on 11/1/10 at 10:25 AM. The ADNS stated that a Care Plan should have been developed for Insomnia and the use of the Ambien for Resident # 9.

3) Resident #5 was admitted to the facility on 8/9/10 with diagnoses including Cerebral Vascular Accident and Anxiety.

The 8/19/10 MDS Assessment documented that the resident had modified independence with cognitive skills for daily decision making and had no long or short-term memory problems. The MDS documented that the resident presented with indicators of Depression, Anxiety and Sad Mood: daily expressions of what appear to be unrealistic fears in the past 7 days; daily repetitive anxious complaints/concerns in the past 7 days; and, Insomnia/Change in usual sleep pattern had not been exhibited in the past 30 days. The MDS documented that the resident presented with behavioral symptoms including: verbally abusive daily and the behavior was not easily altered and, socially inappropriate behaviors 4-6 times per week and the behavior was not easily altered.

The Physician's Order's dated 8/9/10 through 10/5/10 documented orders for Ambien 10 mg by mouth at bedtime for Insomnia and Xanax (an Antianxiety medication) 0.25 mg by mouth three times per day for Anxiety.

A review of Resident #5's CCPs revealed no documented evidence of CCP developed for Behaviors or Insomnia.

An interview was conducted on 10/28/10 at 11:55 AM with the both the ADNS and the RN Unit Manager responsible for Resident #5. The ADNS and the RN acknowleged that there should have been CCPs developed for Insomnia and Behaviors for the resident.

415.11(c)(1)

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs. This was evident for one of 15 residents reviewed for psychoactive medications in a total of 30 records reviewed. Specifically, Resident #9 received Ambien (a hypnotic used to induce sleep) for 22 evenings without documented evidence of non-pharmacological interventions attempted prior to administration. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
This is a Repeat Deficiency.

The finding is:

Resident # 9 has diagnoses including Dementia and Depression.

A Quarterly Minimum Data Set (MDS) Assessment dated 8/5/10 documented that the resident had short and long term memory problems and moderately impaired cognitive skills for daily decision making.

A Nurse's Note (N/N) dated 9/30/10 documented that Resident #9 complained of insomnia. A subsequent N/N was dated 10/14/10 and documented that resident stated she is sleeping much better with Ambien and had no further complaints. There was no documented evidence of further N/N's.

A Physicians Order dated 9/30/10 documented Ambien 5 Milligrams (mg.) at hours of sleep PRN (as needed).

A review of the Medication Administration Record (MAR) documented that from 9/30/10 to 10/25/10, Resident #9 received Ambien 22 times.

A review of the behavior sheets and N/N's for the period from 9/30/10 to 10/25/10 documented that there were no non-pharmacological interventions attempted prior to the administration of the Ambien.

The Assistant Director of Nurses (ADNS) was interviewed on 11/1/10 at 10:25AM. The ADNS stated that when resident's receive PRN Hypnotic medications for sleep, there should be documented evidence of some interventions, such as a drink or snack prior to the administration of the medication.

A review of an undated facility policy titled Drug Administration documented that the policy did not address the administration of PRN Hypnotics.

415.12(1)(1)

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that proper infection control techniques were implemented during a wound care treatment to prevent the development and transmission of disease. This was evident for 1 of 29 sampled residents (Resident #7). Specifically, the Licensed Practical Nurse (LPN) was observed to cleanse multiple pressure ulcers and then reposition the resident back onto the adult brief prior to covering each wound with a protective dressing. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
This is a Repeat Deficiency.

The finding is:

Resident #7 has diagnoses including Parkinson's Disease, Stage 2 Sacral Pressure Ulcer and Stage 4 Pressure Ulcers of the Coccyx and Right Buttock.

A Quarterly Minimum Date Set (MDS) Assessment dated 9/06/10 documented that the resident had short and long term memory problems and had moderately impaired cognitive skills for daily decision-making.

Physician's Order's dated 10/12/10 documented to cleanse the Right Buttock with Normal Saline, apply Collagenase to wound and zinc oxide ointment to periwound (around wound) and cover with dry protective dressing.

Physician's Order's dated 10/12/10 documented to cleanse the Coccyx with Normal Saline, then apply silvercell/alginate dressing and cover with dry dressing every day and as needed.

Physician's Order's dated 10/12/10 documented to cleanse the Sacral Pressure Ulcer with Normal Saline, apply Collagenase and cover with dry dressing every day and as needed.

A wound observation was conducted on 10/27/10 at 11AM with the LPN treatment nurse. The LPN was observed to wash her hands, don gloves and remove the right buttock, coccyx and sacral dressings. The coccyx and sacral dressings had scant amounts of serosanguinous drainage and the buttock dressing had no drainage. The LPN then removed her gloves, washed her hands and regloved. The LPN cleansed the buttock pressure ulcer with gauze-soaked normal saline, then repositioned the resident back onto the adult brief. The LPN then washed her hands, donned clean gloves, repositioned the resident and treated the wound with collagenase and the periwound with zinc oxide. The LPN then covered the wound with a dry dressing.

The LPN was observed to remove her gloves, wash her hands and don clean gloves. The LPN cleansed the coccyx pressure ulcer with gauze- soaked normal saline, then repositioned the resident back onto the adult brief. The LPN then removed her gloves, washed her hands, don clean gloves, repositioned the resident and treated the wound with silvercell/alginate and covered it with a dry dressing. The LPN then removed her gloves and washed her hands.

The LPN was observed to don clean gloves, cleanse the sacral pressure ulcer with gauze soaked normal saline,then reposition the resident back onto the adult brief. The LPN then removed her gloves, washed her hands, regloved, repositioned the resident, treated the wound with collagenase and covered it with a dry dressing. The LPN then removed her gloves and washed her hands.

The LPN was interviewed on 10/27/10 at 11:30 AM. The LPN stated that she should have kept the resident positioned up and away from the adult brief after cleansing each wound with normal saline.

The In-Service Director who is responsible for infection control was interviewed on 10/28/10 at 12:15pm. The Inservice Director stated that once a wound is cleansed, it should be kept off bed linens/briefs until covered with a protective dressing.

An undated facility policy and procedure titled dressing change (clean) documented to cleanse wound with prescribed solution, apply prescribed medication if ordered, apply dressings and secure with tape, remove gloves and discard and then assist resident to comfortable position.

415.19(a)(1-3)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that Accident/Incidents (A/I) were thoroughly investigated for 2 of 15 records reviewed for A/I in a total of 29 sampled residents (Residents #24 and #25). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #24 a diagnoses that include Alzheimer's Disease with Dementia.

The Quarterly Minimum Data Set (MDS) Assessment dated 6/5/10 documented that the resident had severely impaired cognitive skills for daily decision making with both short and long term memory problems. The MDS also documented that the resident required two person physical assistance for bed mobility, transferring, personal hygiene, dressing and toilet use.

The A/I Report dated 9/7/10 at 8:00 AM documented that the resident had an "ecchymotic area at the tail of the left breast/left axilla." There were no documented statements from the CNA's that had assisted with the resident's care on the three shifts prior to the incident.

An interview with the Assistant Director of Nursing (ADNS) was conducted on 11/1/10 at 10:35 AM. The ADNS stated that she was responsible for all A/I investigations. The ADNS stated that she never obtains the second CNA statements to complete the investigation for a resident who had an injury of unknown origin if that resident required a two-person assist in ADLs.

2) Resident #25 has diagnoses that include Dementia and Psychosis.

The Annual MDS Assessment dated 7/2/10 documented that the resident was moderately impaired with cognitive skills for daily decision making and had both short and long term memory problems.

The A/I Report dated 8/10/10 at 4:30 PM documented that a CNA noted that the Resident had a "left hand 5th-digit redness and slight swelling." The A/I Report contained a statement of the CNA that worked on 8/10/10 on the 3-11PM shift. There was no documented evidence that statements were obtained from CNAs that cared for the resident on the previous shifts.

An interview with the ADNS was conducted on 11/1/10 at 10:35 AM. The ADNS stated that it was not necessary to obtain statements from other CNAs that cared for the resident from the previous shifts. The ADNS further stated that there is "no logical way to go back and investigate."

The facility's undated policy titled Resident Incidents and Accidents did not address how the investigation process is done for an injury of unknown origin. The policy did not document that required statements of staff from previous shifts as well as other staff who may have assisted during the care of a resident were to be obtained to determine that neglect and mistreatment did not occur. The policy did not address that the investigation had to address the previous 24 hour period if an injury of unknown origin was identified.

415.4(b)(l)(ii)

Based on observations and staff interviews during the recertification survey, the facility did not ensure that a multidose medication vial which was opened and undated was removed from residents' unit. This was evident on two of five nursing units (2 South and 2 North). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) During an observational tour of the 2 South with the Registered Nurse (RN) Charge Nurse and the Licensed Practical Nurse (LPN)/Medication Nurse on 11/1/10 at 10:45 AM, the following were noted:

One (1) opened and undated vial of Novolin R Insulin and one (1) opened and undated vial of Lantus Insulin were observed in the medication refrigerator. (Novolin R and Lantus are Diabetic Insulin injections).

The RN and the LPN were immediately interviewed on 11/1/10 at 10:45 AM. The RN stated that multidose Insulin vials do not need to be dated when opened.

2) During an observational tour of the 2 North with the Licensed Practical Nurse (LPN)/Medication Nurse on 11/1/10 at 11:00 AM, the following were noted:

One (1) opened and undated vial of Novolin R Insulin was observed in the medication refrigerator.

The LPN was immediately interviewed. The LPN stated that multidose Insulin vials should be dated when opened and that the expired Insulin vials should have been discarded.

The Staff Development/Inservice RN was interviewed on 11/1/10 at 11:25 AM. The RN stated that the multidose Insulin vials should be dated once opened and should be discarded after 30 days from opening. The RN further sated that she will start inservicing the licensed staff on multidose medication vials storage.

The facility's undated policy #23 titled, "Storage of Drugs" did not address the storage of multiple dose vials of medications once they are opened.

415.18(d)

Based on observations, record review and resident and staff interviews during the recertification survey the facility did not ensure that all residents received the necessary care and services necessary to attain or maintain their highest practicable wellbeing. This was evident for 2 of 30 sampled residents. Specifically, 1) Resident #13 had ill fitting dentures that had not been reassessed for approximately five months and was also documented to have had a choking incident without documented re-evaluation of the resident's swallowing function; 2) Resident #7 was observed to express pain during a wound treatment observation and there was no evidence that the Nurse had assessed the resident for the possible need of additional pain medication. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #13 is a 55 year old with diagnoses including Schizoaffective Disorder and Depression.

The Minimum Data Set (MDS) Assessment dated 5/8/10 documented that the resident had modified independence with cognitive skills for daily decision making and had no long or short-term memory problems. The MDS also documented in Section L (Oral/Dental Status) that the resident received daily mouth care. Section L1(b) was blank and did not document if the resident had dentures. The MDS also documented that the resident had a chewing problem and received a mechanically altered diet.

The MDS Assessment dated 8/6/10 documented that the resident had no changes in cognitive skills for daily decision making or memory. The MDS documented that the resident continued to have a chewing problem.

Speech Language Pathologist (SLP) evaluations dated 6/22/09 and 10/26/09 revealed that the resident had a total of three choking episodes in 2009.

The Physician's Orders dated 2/9/10 through 9/21/10 documented the following diet order: Puree consistency with thin liquids, supervision at all meals and to maintain aspiration precautions.

A Comprehensive Care Plan (CCP) titled Oral/Dental Care dated 5/18/09 documented that the resident "did not have or does not use dentures". Interventions included: nutritional assessment, dental exam as needed and monitor condition of dentures and refer to dentist as needed. An update to the CCP dated 2/12/10 documented that the resident had been seen by the dentist as requested to process dentures. Another update to the CCP dated 5/8/10 documented that the resident was still being seen by the dentist to have dentures made.

A Dental Consultation (Consult) dated 5/24/10 documented that Full Upper (FU) and a Full Lower (FL) dentures had been delivered to Resident #13 and that the FU/FL dentures "feel most comfortable with denture adhesive". The recommendations documented on the Consult included: please dispense denture adhesive and assist with application to dentures, will evaluate and adjust dentures as needed.

An interview was conducted with Resident #13 on 10/27/10 at 10:25 AM. The resident stated that she did not like eating pureed foods. The resident stated that she had received dentures about 5 months ago and currently has them in her room but, does not wear them because they do not fit anymore. The resident stated that she did not recall the staff ever trying to apply adhesive to the dentures and that it would probably help. The resident also stated that she would have liked to have the dentures repaired and maybe not have to eat pureed foods.

A revised CCP titled Oral/Dental Care dated 5/8/10 documented that Resident #13 "does not use dentures" and was edentulous (without teeth) with a goal to have no oral issues for 90 days. The interventions on the CCP included: nutritional assessment, dental exam as needed. An update to the CCP dated 8/6/10 documented "no c/o (complaint of) oral issues proceed with POC (Plan Of Care)". There was no documented evidence of revisions to the Oral/Dental Care CCP addressing the resident's dentures or the need for adhesive to the dentures as recommended by the dentist.

A CCP titled Behavioral Care Plan dated 5/8/10 documented that the resident was noncompliant with diet restrictions. An intervention on the CCP included to refer to dietary for inappropriate behavior.

A Nurse's Note dated 6/21/10 documented that the resident was observed to be purchasing items from a vending machine. The note also documented that the snack was taken from the resident and that the resident was encouraged to ask for snacks and not go to the vending machine.

A Nurse's Note dated 10/6/10 at 6:40 AM completed by a Registered Nurse (RN) documented that the Nursing Supervisor was called to the unit and that it was reported that the unit nurse found the resident with a donut and the resident was gagging on part of the donut. The note documented that the unit nurse reported that she had performed the Heimlich Maneuver until the resident's airway was clear. The note further documented that the resident was sent to the hospital.

A subsequent Nurse's Note dated 10/6/10 at 12:45 PM documented that the resident had returned to the facility with no signs/symptoms of aspiration.

There was no documented evidence in the resident's medical record between 5/8/10 through 10/26/10 that an investigation had been completed regarding the 10/6/10 choking episode, that the resident's CCP had been revised for the behaviors documented on 6/21/10 or the choking episode, that the facility Dietitian had been notified of the choking episode, or that the resident had been reassessed by the facility after the choking episode.

An interview was conducted on 10/27/10 at 10:30 AM with the Certified Nursing Assistant (CNA) responsible for Resident #13. The CNA stated that she had been working with the resident for over six months. The CNA stated that the resident refused to wear her dentures and that she had never asked the resident why she did not want to wear the dentures. The CNA stated that she had never tried to use adhesive on the resident's dentures.

An interview was conducted on 10/27/10 at 10:50 AM with the Licensed Practical Nurse (LPN) responsible for Resident #13. The LPN stated that she recalled that when the dentures arrived they fit the resident well. The LPN stated that she was aware that the resident refused to wear the dentures and that she had not asked the resident why she did not want to wear them. The LPN further stated that a follow-up dental consult should have been suggested for the resident since she had been refusing to wear them for about 4 months.

An interview was conducted on 10/28/10 at 12:40 PM with the Assistant Director of Nursing Services (ADNS). The ADNS stated that she was responsible for ensuring completion and accuracy of facility investigations. The ADNS stated that she was unable to locate an investigation for the 10/6/10 choking incident for Resident #13 and there should have been one developed. The ADNS also stated that a dental consult should have been completed for the resident who had been refusing to wear the dentures.

An interview was conducted on 10/28/10 at 1:20 PM with the facility SLP. The SLP stated that she is usually notified to evaluate all residents that have had choking incidents to assess if the current diet and liquid consistency provided are still appropriate for the resident. The SLP stated that she was aware of Resident #13's history of choking and that she would have at least screened the resident had she been notified.

2) Resident #7 has diagnoses including Parkinson's Disease, Stage II Sacral Pressure Ulcer (P/U) and Stage IV Pressure Ulcers of the Coccyx and Right Buttock.

A Physician's Order dated 10/12/10 documented Oxycodone-APAP-5/325 (Percocet) (a narcotic pain reliever) 1 tablet every six hours.

A wound observation was conducted on 10/27/10 at 11:00 AM with the Licensed Practical Nurse (LPN) Treatment Nurse who was assisted by a Certified Nursing Assistant (CNA). The LPN and CNA were observed to position the resident. The resident was observed to yell "OW". T he LPN was observed to wash her hands, don gloves and remove the buttock, coccyx and sacral dressings. The resident was observed to yell "OW". The LPN then removed her gloves, washed her hands and regloved. The LPN cleansed the buttock P/U with gauze soaked with normal saline and the resident was observed to yell "OW'' and pulled away from the gauze. The LPN then washed her hands, regloved, repositioned the resident and treated the wound with collagenase and surrounding wound area with zinc oxide. The resident was observed to yell "OW why do you have to do that?" The LPN then covered the wound with a dry dressing. The LPN was observed to have removed her gloves again, wash her hands and donned new gloves. The LPN cleansed the coccyx P/U with gauze soaked with normal saline and the resident was observed to yell "OW". The LPN then washed her hands and treated the wound. The resident was observed to yell "OW" during the treatment. The LPN covered the wound with a dry dressing. The LPN then removed her gloves and washed her hands. The LPN then donned clean gloves. The LPN cleansed the sacral P/U with gauze soaked with normal saline and the resident was observed to yell "OW, Please". The LPN responded "almost done". The LPN then washed her hands, regloved, repositioned the resident and treated the wound with collagenase. The resident was observed to yell "OW, OW". The LPN then covered the wound with a dry dressing. The LPN then removed her gloves and washed her hands.

The LPN was interviewed on 10/27/10 at 11:30 AM. The LPN stated that the resident yells when you just touch him and she felt that he was not in pain, as he was actually better today than on previous days. The LPN further stated that if she felt the resident was in pain, she would stop the treatment, inform the Unit Manager Registered Nurse and get an order for additional pain medication.

The Physician was interviewed by telephone on 10/27/10 at 12:00 PM. The Physician stated that if a resident was having pain during a wound care treatment, he would expect that the nurse would inform him so that pain medication could be increased or adjusted.

The RN Inservice Director was interviewed on 10/28/10 at 1:30 PM. The RN stated that if a resident was having pain during a wound care treatment, the Unit Manager should be informed so that the Physician could be called for an adjustment in pain medication.

An undated facility policy and procedure titled Pain Management documented that the medication nurse should report to the Nurse Manager/Supervisor any change in resident's condition.

415.12

Based on observations, record review and staff interviews during the recertification survey, the facility did not ensure that a resident was assessed for the least restrictive restraint. This was evident for 1 of 8 residents reviewed for restraints in a total of 29 sampled residents. Specifically, Resident #9 was observed in a Geri-recliner that prevented the resident from rising and there was no documented evidence that quarterly assessments were completed for consideration of a lesser restrictive device. This resulted in no actual harm with the potential for more than minimal harm that is no immediate jeopardy.

The finding is:

Resident #9 has diagnoses which include Dementia and Depression.

The Minimum Data Set (MDS) Assessments dated 2/8/10 and 8/5/10 documented that the resident had long and short term memory problems and had moderately impaired cognitive skills for daily decision making. The MDS documented that the resident's had no limitations in voluntary movement of any extremities. The MDS documented that the resident did not use a chair that prevented rising and was not physically restrained.

A Physician's Order dated 2/2010 through 10/2010 documented to position the resident in a Geri-recliner when Out Of Bed (OOB) in an Upright Position for Mobility.

A Comprehensive Care Plan (CCP) dated 2/8/10 and updated on 8/5/10 titled Physical Restraints/Safety Devices was circled for safety devices, and indicated that the Geri-recliner was not utilized as a restraint. The CCP documented that the resident had impaired physical function and used a reclining Geri-recliner daily for safety, comfort and mobility.

A review of the Physical Rehabilitation Notes dated 2/10/09 through 8/10/10 documented that there were no further recommendations or assessments of alternative devices attempted for positioning the resident when OOB. Additionally, there were no Occupational Therapy (OT) Quarterly Screening Forms completed between 2/10/09 through 8/10/10.

An observation was conducted on 10/26/10 at 9:30 AM Resident #9 on the 2 South Unit hallway. Resident #9 was observed to be sleeping, seated in a Geri-recliner with the head of the recliner tilted back. The resident appeared to be sliding down in the Geri-recliner and her left leg was hanging over the foot of the Geri-recliner.

A subsequent observation was conducted on 10/27/10 at 1:00 PM of Resident #9 in the 2 South Dining Room during the lunch meal. The resident was observed in a Geri-recliner with the head of the recliner leaning back. The resident was sliding down in the Geri-recliner, sleeping with her lunch tray in front of her. An interview was conducted with a Certified Nursing Assistant (CNA) during the observation. The CNA stated that the resident feeds herself. The Registered Nurse (RN) approached the resident, woke her up and the resident started to feed herself by raising her head. The resident continued to feed herself while the Geri-recliner was in the reclining position.

An observation was made of Resident #9 on 10/28/10 at 10:00 AM on the 2 South Unit hallway. Resident #9 was observed to be sleeping, seated in a Geri-recliner with the head of the recliner leaning back, and appeared to be sliding down in the chair. The resident was observed with her legs in a crossed position while in the recliner.

Subsequent observations of Resident #9 were conducted in the 2 South hallway on 10/27/10 at 2:15 PM and on 10/28/10 at 9:45 AM, 11:30 AM and 2:15 PM. The resident was asleep in the Geri Recliner with the head of the recliner leaning back and the resident sliding down in the chair.

The RN MDS Coordinator was interviewed on 10/28/10 at 1:00 PM. The RN stated that Resident #9 was at one time in a reclining wheelchair but, she would throw her legs over the chair and the decision was made by OT and Nursing to place the resident in a Geri-recliner. The RN stated that the Geri-recliner was not coded as a restraint as the resident does not attempt to get out of it. The RN further stated that she is responsible for documenting restraints on the MDS and she obtains the information from the Rehabilitation Screening Form. The RN stated that quarterly updates of seating are completed by Occupational Therapist (OT).

The RN who completed the MDS for Resident #9 on 8/5/10 was interviewed on 10/28/10 at 2:00 PM. The RN stated that she did not test the resident for balance and range of motion when she completed the MDS but, she had obtained the information from the most recent Rehabilitation Screening Form dated 2/9/09. The RN stated that testing for Resident #9 to assess seating requirements could have been completed more recently, and this would be looked into.

The OT was interviewed on 10/28/10 at 1:45 PM. The OT stated that residents could be referred for seating problems by Nurses or CNA's but, she did not recall receiving a referral for Resident # 9. The OT further stated that prior to placing a resident in a Geri-recliner, alternate safety interventions should be attempted. The OT also stated that she could have attempted a foot rest on a regular wheelchair or an anti-sliding cushion for the resident but, had not received a referral. The OT stated that quarterly reassessments by OT and PT of seating requirements should have been documented.

The undated facility Policy and Procedure titled Residents Physical Restraints documented that before physical restraints are ordered the Physical Therapist or the OT must evaluate the residents need for and the appropriateness of the restraint and suggest adaptive devices as alternatives. The policy also documented that a Geri-recliner was acceptable for use as a restraint in the facility.

There is no documented evidence in the medical record that the resident had been assessed for a lesser restrictive device since 2/2010.

415.4 (a) (2-7)

Based on observations, staff interviews and record review during the recertification survey the facility did not ensure that all resident's rooms and equipment were kept in a clean and homelike environment. This was evident for 1 resident in a total of 29 residents reviewed. Specifically, two observations of Resident #8's room were conducted and revealed soiled care equipment, a soiled floor and soiled walls. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #8 was readmitted to the facility on 1/9/10 and had diagnoses including Failure to Thrive and Dysphagia (difficulty swallowing). Resident #8 was fed via a Gastrostomy Tube (GT) (tube surgically inserted in the abdomen to provide nutrition and hydration).

An observation of Resident #8 was conducted on 10/28/10 at 2:00 PM. The resident was observed in his room and was lying in a recliner, was verbal, pleasant and answered appropriately to simple direct questioning. A GT feeding pump was observed to be behind the head of the recliner. Dried yellow/brownish drip marks were observed on the top of the GT feeding pump and on the base of the GT feeding pump pole. The wall adjacent to the resident's bed was observed to be scattered with dried yellow/brownish drip and splatter marks. The floor behind the head of the resident's bed contained three circular spots approximately 2-3 inches in diameter that appeared to be dried yellowish debris.

A subsequent observation of Resident #8 was conducted on 11/1/10 at 8:30 AM. The Resident was in his room and was observed to be awake, verbal, pleasant and was lying in bed. The room's cleanliness was observed to be unchanged from the 10/28/10 observation.

An interview was conducted on 11/1/10 at 8:45 AM with the Registered Nurse (RN) Unit Manager. The RN stated that the drip marks on the wall, the dried spots on the floor and the droplets on the top of the feeding pump and on the base of the feeding pump appeared to be soiled with milk products. The RN stated that she was not aware of the room's condition prior to 11/1/10 and that the room needed to be cleaned and should have been cleaned by 10/29/10.

An interview was conducted on 11/1/10 at 8:50 AM with a Housekeeper that had been assigned to Resident #8's room. The Housekeeper stated that he was not the regular Housekeeper on the unit and acknowledged that the room should have been cleaned by whoever had been assigned to the room last week. The Housekeeper stated that the Housekeepers have a special solution specifically to clean the type of soil identified in Resident #8's room.

An interview was conducted on 11/1/10 at 11:00 AM with the Director of Housekeeping. The Director stated that the room should have been cleaned by 10/29/10.

415.5 (h) (1)

Based on observation, staff interview, and record review during the recertification survey, the facility did not ensure that sanitary conditions were being maintained in the kitchen. Reference is made to the inappropriate final rinse (sanitizing) temperatures for two of two dishwashing machines, and portions of the kitchen not maintained clean and in good repair.

The findings are:

During the kitchen inspection on 10/26/10 between 8:15am and 9:45am the following was observed:

1. At approximately 8:45am, testing of the dairy dish washing machine final rinse temperature revealed temperature readings between 110-120 degrees Fahrenheit (F) (as indicated on the final rinse temperature gauge) for three consecutive test runs. This temperature is lower than the required 180 degrees F for heat sanitization. The Food Service Supervisor stated that the final rinse temperature properly functioned the day before and that he would call the outside servicing company to address the issue. He also stated that both dish washing machines are not equipped with back-up chemical sanitizers.

Documentation review of the " dish machine temperatures " for October 2010 on the same day at approximately 9:30am further revealed inappropriate sanitizing temperatures for both dish washing machines. Examples include but are not limited to the following final rinse temperatures that were recorded by the facility:ne
Lunch meal rinse temperatures:

10/04/10 - 175 degrees F
10/11/10- 160 degrees F
10/12/10- 160 degrees F

Supper meal rinse temperatures:

10/01/10 - 147 degrees F
10/07/10 - 140 degrees F
10/13/10 - 160 degrees F

In addition, the wash and rinse temperatures were not consecutively documented for both dish washing machines. Examples include but are not limited to the following dates:
10/2/10, 10/3/10, and 10/09/10.

Furthermore, the " standard temperatures " or targeted temperature for the rinse cycle was indicated at 160 F on the temperature log. The Food Service Supervisor stated that the standard rinse temperature for the rinse cycle should have indicated 180F instead of 160F. He further stated that he would change the temperature requirement for the rinse cycle on the log and in-service the kitchen employees. He also stated that he would make sure the dishwashing machine temperatures are logged at all times.

2. Areas of the kitchen were not maintained clean and in good repair. Examples include the following:
a) An overflowing drain pipe was observed for the dairy pot washing sink. Water was observed overflowing from the sanitizing drain pipe catch basin and accumulating on the floor areas beneath the pot and pans storage rack, and beneath the pot sink. In addition, there was an approximate 2ft. by 1ft. square hole on the wall beneath the same sink.
b) Lint accumulation was observed on the surfaces of two ventilation grilles in the dish washing machine room.
c) A dark brown stained ceiling tile was observed in the corridor near the kitchen entrance that is located across the dish washing machine room.

In an interview on the same day at approximately 8:45am the Food Service Supervisor stated that the issue with the sink and the hole in the wall would be brought to the attention of the Maintenance Department in order to be addressed. At approximately 9:00am, he stated that the maintenance department cleans the vents as scheduled and that he would make sure that the vents are cleaned as needed.

415.14(h)

Chapter 1 SSC Subpart 14-1

Based on record reviews and staff interview, the facility did not ensure that the provider implemented the supervision requirements identified in section 402.4 of this Part (Section 402.6 Criminal History Record Check [CHRC] Process), applicable to the provider, during the period of temporary employment. This was evident for two (Staff #3 and #4) of 5 sampled employees hired by the facility in the past four months. There was no documented evidence of supervision until the final CHRC results were received by the facility for these two staff. Failure to document supervision while awaiting the results of the CHRC places residents at risk of receiving unsafe care from potentially unqualified employees. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Staff #3, a dietary personnel, was hired on 9/22/10. The facility received the CHRC response letter dated 9/27/10.

2) Staff #4, a central supply personnel, was hired on 9/19/10. The facility received the CHRC response letter dated 9/22/10.

There was no documented evidence of supervision for these two staff members prior to receiving the CHRC final response letter.

An interview with the Administrator, CHRC Authorized Person (AP) #1, was conducted on 11/1/10 at 11:00 AM. The AP #1 stated that the facility did not have to do the supervision since the requirement was weekly supervision.

402.6 (d)

Based on record review and staff interview during the recertification survey, the facility did not ensure that a discharge summary included a recapitulation of the resident's stay, and that a final summary of the resident's status at the time of the discharge was completed. This was evident for 3 of 3 closed records reviewed in a total of 29 sampled residents (Resident #27, #28, and #29). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #27 had diagnoses including Diabetes Mellitus, Hypertension and Alzheimer's Disease.

The resident was discharged to the community on 9/25/10.

Review of the medical record revealed that the Physician had not completed a discharge summary.

2) Resident #28 had diagnoses including Diabetes Mellitus and Spinal Stenosis.

The resident was discharged to home on 6/25/10.

Review of the medical record revealed that the Physician had not completed a discharge summary.

3) Resident #29 had diagnoses including Atrial Fibrillation, Seizure Disorder and Hypertension.

The Resident expired in the facility on 3/21/10 at 6:30 AM.

Review of the medical record revealed that the Physician had not completed a discharge summary.

The Medical Director was interviewed on 11/1/10 at 10:30 AM. The Medical Director stated that the resident's discharge summary should have been completed.

The facility's undated policy titled Discharge Planning documented " ... a Discharge Summary form is placed in the medical record for all disciplines to summarize recommendations upon discharge ..."

415.11(d)(1)(2)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that the Preadmission Screening and Resident Review (PASRR) forms were completed as required for 1 (Residents #27) of 1 resident reviewed for PASRR Screen accuracy in a total of 29 sampled residents. Specifically, Resident #27's PASRR Screen did not have a 10 digit Screener Identification Number as required. The 10 digit Screener Identification Number certifies the person as trained and qualified as a Screener. This resulted in no actual harm with a potential for more than minimal harm that is not an immediate jeopardy.

The finding is:

Resident #27 was admitted on 7/27/10 and has diagnoses including Diabetes Mellitus, Hypertension and Alzheimer's Disease.

The resident's Patient Review Instrument (PRI) was completed on 7/23/10. The Screen was completed on 7/27/10.

The completed PASRR Screen filed in the resident's medical record documented a blank Screener Identification Number instead of the required 10-digit number.

The Social Worker (SW) Director was interviewed on 10/28/10 at 12:35 PM. The SW and stated that Admission Department checks the residents' pre-admission PASRR Screen for completeness and accuracy.

The Admission Director was interviewed on 10/28/10 at 12:40 PM. The Admission Director stated that he checks the resident's admission documents including the Screen. The Director also stated that the Screen should have the required 10-digit Screen number.

The facility's undated policy titled Admission Process-PASSR Screen documented "All individuals applying for new admission to a nursing facility mus be screened to identify serious mental illness or mental retardation/development disability. Regulations mandate this preliminary screening and refer to it as Level I Screening..."

483.20(e)

415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public.

(i) Grounds and building. Grounds and buildings shall be maintained:

(1) in a clean condition free of safety hazards;

(2) in such manner as will prevent standing water, flooding or leakage; and

(3) free of excessive noise, odors, pollens, dusts or other environmental pollutants and such nuisances as may adversely affect the health or welfare of residents.

These requirements are not MET as evidenced by:

Based on observation and staff interview, it was determined that the facility did not maintain the grounds in a clean condition in that trash/garbage were observed on the ground next to the compacter and the delivery area.

This resulted in no actual harm with potential for mimimal harm.

The findings are:

On 10/26/10 at approximately 12:30pm, a visit to the exterior of the facility revealed the following:

1. Pieces of plastic wrapper and paper napkins, disposable paper plates and cups were observed littering the ground in the vicinity of the loading area. In addition, a full trash/garbage can was observed in the area.

2. Three disposable latex gloves and pieces of paper were observed littering the ground next to the compactor.

At the exit conference at approximately 2:00pm the Administrator stated that the trash receptacle is provided in the area to prevent the scattering of trash.

Based on observation and staff interview during the recertification survey, the facility did not ensure that means of egress are continuously maintained free of all obstructions or impediments to full use in the case of fire or other emergency. This was evidenced by the storage of resident supplies congesting exit access corridors 1 of 4 floors.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The findings are:

During life safety rounds on 10/26/10 at approximately 11:30am, the basement exit access corridor in the vicinity of the emergency linen storage area was observed congested with the storage of various items that included six mattresses and three cardboard boxes containing new mattresses that left an approximate 3.5 ft. clearance in the corridor.

In interview at this time the Director of Maintenance stated that there is a shortage of storage space in the facility and that the items would be removed from the corridor and placed in an appropriate storage area.
2000 NFPA 101
NYCRR 711.2(a)(1)

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued.

Include your request for renewal of this waiver, or plan of correction in the space provided on this form.

K-33

One of the exit stairs from the basement runs along the exterior wall, which contains a vent from the oxygen storeroom and a plain glass window to a resident room.
483.70(a), 711.2(a)(1), NFPA 101-2000: 19-3.1.1