Highfield Gardens Care Center of Great Neck

Based on observation, staff interview, and facility policy during the recertification survey, the facility did not store and prepare food and maintain the kitchen environment under safe and sanitary conditions to prevent food borne illnesses. Reference is made to the following:

1. Undated and unlabeled food items for one of five unit refrigerators.
2. Live and dead insects in the kitchen.
3. Unclean floor surfaces in the kitchen, unclean kitchen equipment, and unclean pantry refrigerators on 4 of 5 units.
4. Unsafe food storage practices in the kitchen and on 2 of 5 units.
5. Undated/unlabelled used food items in the kitchen.
6. A dented food can in the kitchen storage area.
7. Stained ceiling tiles in the food storage areas and in the dishwashing room in the kitchen.

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

The findings are:

1. During tour of the 1 North Unit on 7/26/10 at 6:00 AM, the refrigerator located behind the 1 North Nursing Station was noted to contain multiple resident food items which were undated and/or unlabeled.

The undated/unlabeled food items observed were as follows:
1 undated Styrofoam container containing applesauce
1 undated/unlabeled plastic container containing cheesecake
1 undated/unlabeled Styrofoam container
1 undated brown bag labeled "101"
1 undated plastic bag labeled "101" containing two plastic containers of crabmeat salad and crackers
1 undated plastic bag with fresh fruit items labeled "120W"

The Unit Registered Nurse (RN) was interviewed on 7/26/10 at 6:35 AM and stated that all food items stored in the refrigerator should be labeled and dated.

The facility policy and procedure titled "Storage of Resident's Food", which was revised 10/08, contained policy including but not limited to:
-Food that requires refrigeration must be brought to the attention of the nurse in charge. The food must be in an acceptable closed container labeled with the resident's name
- Perishable items will not be kept greater than 72 hours to preserve freshness.

The policy did not include the need to date the food that required refrigeration. The policy was revised on 7/26/10 to include being dated.

During the recertification survey on 7/26/10 between 6:10am and 12:00pm and on 7/27/10 between 8:30am and 3:00pm the following were observed:

2. (a) Several flies were observed hovering in the following areas :

- next to the dairy pot washing sink
- in the dishwashing room
- over the dairy food preparation area

(b) Dead insects were observed on the surfaces of the light fixture covers. Examples include but are not limited to the following areas: over the dairy steam table and food preparation areas, in the dishwashing room, and over the Hobart food mixer. In addition three dead flies were observed stuck to the ceiling tiles next to the dairy range hood.

In an interview on 7/26/10 at approximately 7:00am the Food Service Director stated that he did not know where the flies were entering the kitchen from and that he would discuss the issue with the head of maintenance and speak to the contracted pest control company.

3. (a) A black and brown substance was observed accumulated on the floor corners next to the two ice cream freezers and on one floor corner in the adjacent area containing the rolling food carts.

(b) A portable window air conditioning unit was observed with a missing front cover and an accumulation of a black substance was observed on the exposed condenser grilles. In addition, lint accumulation was observed on a portion of the vent grille. An approximate 1.5 inch hole was observed on ventilation cover/filter located over the dairy pot washing area.

(c) Lint accumulation was observed on the edges of two baffles (grease filter) under the meat range hood.

(d) Two air filters located next to the dishwasher were observed to be partially discolored (off-white) in appearance on some areas.

(e) A water leak was observed originating from a leaky valve and accumulating on top of the dishwashing machine.

(f) Stains were observed on the floors of the pantry refrigerators on the nursing units as follows:

-3North Unit - brown stains on the door shelf of the refrigeration compartment.
-3South Unit - red stains on the floor of the freezer compartment.
-2North Unit - brown residues on the floor of the refrigeration compartment.
-1North Unit - brown stains on the floor of the freezer compartment.

4. On 7/26/10 at approximately 6:50am one of two reach-in ice cream freezers was observed with thermometers that displayed an internal temperature reading of 28 degrees F and an external temperature reading of 1 degree F. In an interview at this time, the Director of Food Service stated that both thermometers are broken and would be replaced. He also stated that the temperatures are checked on a daily basis but are not recorded.

Unsafe food storage practices were observed as follow:

- 1 bag of partially used breaded egg " pastina " pasta was improperly wrapped and the contents within were exposed in the dry goods storage room.
- 2 of 2 reach-in ice cream freezers were observed without functioning thermometers
- pantry refrigerators were observed without thermometers on the 3North and 3South units

In an interview on 7/26/10 at approximately 10:00am the Director of Maintenance stated that he is responsible for maintaining the thermometers in the pantry refrigerators and that he has no knowledge of the missing thermometers. He further stated that he would discuss the issue with the unit nurses to make sure the thermometers are kept in the refrigerators.

5. Undated and unlabelled food items were observed in the walk-in refrigerator and in the ice cream freezers in the kitchen. Examples include but are not limited to the following:

- 3 plastic bins of raw chicken in the walk-in refrigerator in the kitchen
- 1 plastic spring water bottle each in the two ice cream freezers

6. At approximately 7:20am on 7/26/10 a can of tomato with dents on the hermetic seal and side was observed on a food storage rack in the dry goods storage room. In an interview at this time the Food Service Director stated that the food cans are supposed to be checked before storing on the shelf. He then contacted a dietary employee to check the storage racks for dented cans.

none 7. Stained ceiling tiles were observed in the following areas:

- the emergency food storage room
- the dishwashing room
- the ice cream freezer room
- over the coffee urns in the kitchen

In an interview on 7/26/10 at approximately 7:30am the Food Service Director stated that there are no active leaks in the areas and that the stained ceiling tiles would be brought to the Maintenance Director to be replaced.

NYCRR 415.14(h)
Chapter 1 SSC Subpart 14-1

Based on observation, staff interviews, and record reviews during the recertification survey, the facility did not ensure that acceptable procedures and techniques were used by staff to minimize the potential for the development and spread of infection for two of two residents (Resident #14 and Resident #1) observed for wound care and for one of five residents (Resident #34) observed for a medication pass in a total sample of twenty-nine . This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #14 has diagnoses that include an infected (Methicillin Resistant Staphylococcus Aureus) Stage III Pressure Ulcer.

The Minimum Data Set (MDS) assessment dated 6/8/10 documented that the resident had severely impaired cognitive skills for daily decision-making and had a Stage IV Pressure Ulcer.

On 7/27/10 at 10:45 AM a wound care observation was completed. The Licensed Practical Nurse (LPN) Treatment Nurse was observed to wash her hands using very little friction and rinsed the soap off her hands after turning the faucet on. The LPN donned gloves and removed the old dressing that contained with dark yellow drainage. The LPN removed her gloves, applied soap to her hands, turned on the faucet, rinsed the soap off, and used very little friction to complete washing her hands. The LPN donned gloves again, cleansed the wound, removed her gloves, applied soap to her hands, turned on the faucet, rinsed the soap off, and used very little friction to wash her hands. The LPN donned gloves, applied Santyl Ointment (a debriding agent), and a clean dressing. The LPN removed her gloves and washed her hands using very little soap and friction.

The LPN Treatment Nurse was interviewed on 7/27/10 at 11:00 AM and stated that she was nervous and did not realize that she had not washed her hands with enough friction or soap.

The Director of Nursing (DON) was interviewed on 7/28/10 at 9:00 AM and stated that hand washing should be completed in a twenty second time line with friction and soap.

2) Resident #1 has diagnoses including Pressure Ulcers, Kyphoscoliosis (curvature of the spine), and a Pelvic Fracture.

The admission Minimum Data Set (MDS) assessment dated 5/23/10 documented that the resident had one Stage I Pressure Ulcer, one Stage II Pressure Ulcer, one Stage III Pressure Ulcer, and one Stage IV Pressure Ulcer.

An observation of Resident #1's Pressure Ulcer treatments were made on 7/28/10 at 9:00 AM. The Licensed Practical Nurse (LPN) was observed to wash her hands for twenty-five seconds, however was not creating friction for more than five seconds. The LPN rinsed her hands under running water for twenty seconds then touched the doorknob and removed a box of gloves from the top of the treatment cart before donning gloves.

A treatment tray was placed on the overbed table, however items were removed from the tray, placed on the unwashed table, then placed back on the treatment tray.

The LPN was observed to complete a treatment to the right side of the resident's back. The LPN then proceeded to remove the bandage from the resident's right heel without removing the gloves utilized for treatment to the resident's back. After the treatment was completed to the resident's right heel, the LPN proceeded to remove the dressing from the resident's left heel without removing the gloves utilized during the treatment to the resident's right heel.

The LPN was observed washing her hands several times throughout the treatment to the resident's right back and both heels. On six occasions, the LPN was observed washing her hands with very little friction.

The LPN was observed to not place a barrier between the resident's heels and the bedding. Normal Saline was utilized to cleanse both heels and was observed dripping onto the sheet and pillow placed under the resident's heel.

After the treatment observation to the resident's right heel, the LPN was observed placing her gloved hand into her pocket to retrieve a pen to date and initial the dressing. The gloves had been worn to treat the right heel.

An interview was held on 7/28/10 at 10:50 AM with the LPN who was observed rendering the pressure ulcer treatments to Resident #1. The LPN stated that she had been instructed to wash her hands for 15-30 seconds. The LPN stated that she was instructed to wash or use a clean drape on the overbed table as a barrier. The LPN could not recall touching the doorknob or the box of gloves after washing her hands, but stated that she was instructed to don gloves right after washing her hands. The LPN stated she was instructed to complete treatment to one area, wash her hands, and apply new gloves before initiating treatment to a new area. The LPN acknowledged that she did not place a barrier under the resident's heels and that she had been educated to do so to prevent contamination. The LPN acknowledged that she was wearing gloves that were worn at the completion of a treatment to the right heel when she placed her hand into her pocket to retrieve her pen. The LPN further stated that she forgot to date and initial the dressing to the right heel, that the dressing should have been labeled before the treatment, not done afterwards.

An interview was held on 7/30/10 at 1:45 PM with the Registered Nurse (RN) who was the Inservice/Wound Care Nurse. The RN stated that staff was instructed to wash their hands for at least 20 seconds, clean under their nails, and create friction. The RN stated that it was good practice to use a barrier between an extremity and the bed linens if there was a lot of drainage. The RN stated that each area should have been treated in completion before moving onto another area. The RN stated that the LPN should not have touched the doorknob after washing her hands. The RN stated that treatment dressings should be labeled before a treatment was initiated and that the LPN should not have placed her gloved hand into her pocket.

3) A medication pass observation was held on 7/27/10 at 9:00 AM. The Licensed Practical Nurse (LPN) was observed to utilize a sani hand towel to clean her hands, then utilized the same sani towel to wipe the top of her medication cart.

The LPN was interviewed on 7/27/10 at 9:00 AM and had no comment.

415.19(a)(1-3)

Based on record review, observation, and staff interview during the recertification survey, the facility did not ensure that 1) adequate supervision to prevent resident to resident altercations was provided for one of twenty-nine sampled residents (Resident #25); 2) cleaning supplies on 1 nursing unit were secured and kept out of reach of residents; 3) freestanding wardrobes in resident rooms on 5 of 5 units were provided with restraints to prevent them from accidentally tipping over.

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

The findings are:

1) Resident #25 has diagnoses which include Dementia with Behavioral Disturbances and Depressive Disorder.

The quarterly Minimum Data Set (MDS) assessment dated 5/20/10 revealed that the resident had moderately impaired cognitive skills for daily decision-making with short and long-term memory problems. The resident was usually understood and could usually understand others. The resident was also able to ambulate independently on the unit.

The Accident/Incident (A/I) Report dated 4/27/10 at 12:35 PM revealed that as the resident was pacing on the 2 South Unit, she suddenly stopped in front of a resident who was seated in a geri chair, grabbed his right hand and attempted to twist it. The intervention implemented in an attempt to prevent further occurrence was to place the resident on 15 minute checks, order a psychiatric consult, and review the resident's medication.

The A/I Report dated 7/2/10 at 1:00 PM revealed that the resident went over to another resident and pulled her hair in the 2nd floor dining room. The intervention was to send the resident to the emergency room for an evaluation secondary to agitation with physical aggression.

The A/I Report dated 7/8/10 at 5:30 PM revealed that the resident had slapped another resident in the face in the 2 South small dining room. The intervention was to put the resident on 15 minute checks and to send the resident to the emergency room for an evaluation.

The A/I Report dated 7/12/10 at 9:45 AM revealed that the resident had gone into another resident's room on the 2 South Unit and hit that resident in her chest. The intervention was to have the resident under constant supervision, remove her from the Unit to the Nursing Office on a one to one, and transfer her to the emergency room.

A subsequent A/I Report dated 7/12/10 at 10:00 AM revealed that the resident had gone into the 2 South small dining room and squeezed another resident's arm. The intervention was to have the resident taken to the Nurse's Station away from other residents and then to the Nursing Office on a on to one before being sent to the emergency room.

The Director of Nursing was interviewed on 7/30/10 at 2:05 PM and stated that the resident had two incidents of aggressive behavior within 15 minutes of each other on 7/12/10 because after the first occurrence, the staff was meeting on the Unit to determine what to do with the resident and before anyone knew it, the resident had walked into the 2 South small dining room and squeezed another resident's arm.

Despite the interventions put into place by the facility after each incident of resident to resident altercation, the resident's behavior continued.

2) Observation on 7/29/10 at 11:40 AM on the 1 North Nursing Unit revealed that keys were found hanging from the lock of the Porter's closet door. No housekeeping staff members were observed in the vicinity of the closet. The Porter's closet was located in a high traffic area; near a dining room, elevator and main hallway to the rehabilitation department. Multiple residents, staff members and visitors were observed passing by the Porter's closet.

An interview was held on 7/29/10 at 11:50 AM with the Director of Maintenance Services. The Maintenance Director stated that the Poster's closet should be locked and that keys should not be hanging from the doorknob. The Maintenance Director and surveyor entered the Porter's Closet and the following chemical products were found:

- two cartons of PH7Q Ultra Disinfectant- utilized to clean toilet seats and floors
- four cartons of AF79 concentrate- utilized to clean toilet bowls
- one carton of glass cleaner
- one jug of pine disinfectant - utilized as a cleanser/disinfectant/Deoderant
- one jug of multi-purpose rejuvenator- utilized on floors
- total bath shower cleaning soap- utilized in shower dispensers
- floor finish
-lavender cleaner and Deoderant- utilized as a carpet cleaner

After observation of the contents of the Porter's closet with the Maintenance Director, the Maintenance Director stated that the products stored in the Porter's closet should always be locked. He further stated that he would re-inservice the porter who left the keys in the Porter's closet regarding safety, removing keys from the closet, and ensuring that the door was locked before leaving the Porter's closet.

3) During the recertification survey on 7/26/10 between 6:10 AM and 12:00 PM and on 7/27/10 between 8:30 AM and 3:00 PM, observation of the freestanding wardrobes in the resident rooms revealed that they were not provided with restraints or anchors to prevent them from accidentally tipping over. A check of one of the wardrobes in a resident room revealed that it could be tipped forward or sideways if someone pulled on the doors in the open position.

In an interview at this time, the Director of Maintenance stated that all of the resident rooms on all of the units were provided with the same type of freestanding wardrobes and that they were equipped with stilts that could be adjusted to prevent them from tipping over. He further stated that restraining removable hooks or brackets would be installed to prevent them from accidentally tipping over.

415.12(h)(1)

(j) Housekeeping

(1) The entire nursing home, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment and furnishings, shall be clean. The facility shall be maintained in good repair including, but not limited to buildings, utilities, fixed equipment, resident care equipment and furnishings.

Based on observation and staff interview, it was determined that the facility did not ensure that light fixtures, ceilings, handrails and vent grilles were maintained clean and in good repair in 1 of 2 buildings.

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

The findings include:

During the recertification survey on 7/26/10 between 6:10am and 12:00pm and on 7/27/10 between 8:30am and 3:00pm, the following were observed:

1. The sconce lighting in the corridor was not maintained in good repair. Examples include the following:
- taped light fixture with missing light bulbs and shades on the 3rd and 2nd floor elevator lobbies
- a light shade with a hole and brown spot in front of room 322

2. Brown stained ceiling tiles were observed in the 3South unit common shower room, and in the recreation room on the 1st floor .

3. Two registers (vent grilles) were observed with lint accumulation on their interior and exterior surfaces in the 3North common shower room.

In interview an interview on 7/26/10, at approximately 8:45am, the Director of Maintenance stated that the sconce lights were damaged and that they would be repaired or replaced. In a separate interview on the same day at approximately 10:30am he stated that there are no active leaks in the facility as he can recall and further contacted a maintenance employee to replace the stained ceiling tiles and the housekeeping department to clean the vent grilles.

415.29 (j)(1)

Based on observations and resident and staff interviews during the recertification survey, the facility did not ensure that one of twenty-nine sampled residents had a call bell placed within reach to access staff members for personal needs. Specifically, Resident #7 was observed on three occasions to have the call bell placed out of reach. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #7 has diagnoses including Constipation, Generalized Pain, and a Pressure Ulcer of the Left Heel.

Observation on 7/28/10 at 11:00 AM in Resident #7's room revealed that the resident's call bell was clipped to the privacy curtain between the resident's bed and the bed parallel to the resident's bed. Resident #7 was lying supine in bed and the call bell was placed approximately five feet off the floor, out of the resident's reach.

An interview was held on 7/28/10 at 11:00 AM with Resident #7. The resident stated that the call bell was not always located within her reach and that she often calls out for staff when she requires assistance. Additionally, Resident #7 stated that, on occasion, staff does not respond to her call bell and that she often waits a long time for help.

Observation on 7/29/10 at 10:30 AM in Resident #7's room revealed that the resident's call bell was placed on the floor. Resident #7 was lying supine in bed and was unable to utilize the call bell.

Observation on 7/29/10 at 12:45 PM in Resident #7's room revealed that her call bell was tied to the upper portion of the left half side rail of her bed. The resident was lying supine in bed and was unable to locate the call bell. When the resident was informed where the call bell was located, the resident attempted to access the call bell but was unable to do so. The Licensed Practical Nurse (LPN) Charge Nurse was present during the observation when the resident was unable to access the call bell. The LPN relocated the call bell within the resident's reach. Resident #7 was observed activating the call bell successfully once the call bell was within her reach.

415.5(e)(1)

Based on interview and record review during the recertification survey the facility did not ensure that for one of twenty nine sampled residents with a permanent pacemaker, the nursing staff properly identified the pacemaker during the initial skin assessment. Specifically, although Resident #2 had documentation in the medical record from the transferring hospital which identified the permanent pacemaker, the nursing home staff did not identify the same. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. (Resident #2)

The finding is:

Resident #2 has diagnoses that include Congestive Heart Failure.

The Minimum Data Set (MDS) assessment dated 7/12/10 documented that the resident had moderately impaired cognitive skills for daily decision-making.

Resident #2 was admitted to the facility on 7/1/10. A hospital History and Physical dated 6/13/10 documented that the resident had a permanent pacemaker.

The Resident Assessment-Data Collection Form dated 7/1/10 and signed by a Registered Nurse (RN) did not document that the resident had a permanent pacemaker.

An interview with the unit RN Charge Nurse on 7/30/10 at 10:00 AM revealed that she was unaware that Resident #2 had a permanent pacemaker.

The RN Supervisor was interviewed on 7/30/10 at 3:55 PM and stated that not documenting that the resident had a pacemaker was an oversight.

The Director of Nursing (DON) was interviewed on 7/30/10 at 4:00 PM and stated that the pacemaker information should have been included in the resident's initial assessment.

415.11(a)(2)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that one out of sample resident and two of twenty-nine sampled residents' dignity was maintained. Specifically, 1) Resident #33 was observed lying in bed undressed in full view of residents and staff as they passed the resident's room. The privacy curtain was not closed around the resident's bed and the door to the hallway was open. 2) Resident #34 was observed during a medication pass with the door to his room open. The privacy curtain was not closed around the resident's bed and the resident's brief could be seen by the other residents in his room. 3) Resident #1 was not properly draped during a wound care observation. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1) Resident #38 has diagnoses which include Dementia.

The Minimum Data Set (MDS) assessment dated 6/1/10 documented that the resident had moderately impaired cognitive skills for daily decision-making and was totally dependent on staff for bed mobility.

On 7/27/10 at 8:15 AM, the resident was observed lying in bed on his back undressed with his bed curtain and the door leading to the hallway open. The Certified Nursing Assistant (CNA) was heard calling out to another CNA that was located two rooms away.

An interview was held on 7/27/10 at 8:20 AM with the resident's CNA (Certified Nursing Assistant) #1. CNA #1 stated that she should have closed the resident's bed curtain.

2) Resident #34 has diagnoses that include Dementia and Bipolar Disease.

The Minimum Data Set (MDS) assessment dated 6/18/10 documented that the resident had severely impaired cognitive skills for daily decision-making and required staff assistance for turning and positioning in bed.

On 7/27/10 Resident #34 was observed in bed with his brief exposed, the curtain around his bed open, and the door leading to the hallway open at 8:20 AM and again at 9:00 AM.

The resident's primary CNA was interviewed on 7/27/10 at 9:00 AM and stated that the resident did not like to be covered with a sheet. The CNA additionally stated that she should have closed the privacy curtain around the resident's bed.

The Director of Nursing (DON) was interviewed on 7/23/10 at 3:00 PM and stated that the residents should have been covered.

3) Resident #1 has diagnoses including Pelvic Fracture, Kyphoscoliosis (curvature of the spine), and Breast Cancer.

The admission Minimum Data Set (MDS) assessment dated 5/23/10 documented that the resident had both short and long-term memory impairment and modified independence regarding daily decision-making skills. The resident required extensive assistance of one person for positional changes in bed and extensive assistance of two people to transfer out of bed/chair.

Prior to the initiation of treatment to the resident's pressure ulcers on 7/28/10 at 8:55AM, the Licensed Practical Nurse (LPN) reviewed the Electronic Medical Record (EMR) and was heard in the hallway stating the treatments out loud. This was in the near vicinity of two other residents.

The resident was observed for pressure ulcer treatments to the right side of the back and both heels on 7/28/10 at 9:00 AM. The resident was observed lying on her left side, wearing an open-backed gown, and noted with two bandages on the right upper back region. The Licensed Practical Nurse (LPN) who performed the treatments was observed pulling the open backed gown down to the resident's waist and then removed two bandages from the resident's back. No drape was placed over the resident's anterior body from the neck to the waist throughout the treatment to the resident's back and both heels.

The LPN observed during the treatments was interviewed on 7/28/10 at 10:50 AM and stated that she did not realize that the resident was exposed and that the resident should not have been exposed. The LPN further stated that she was verifying the resident's treatment orders to the surveyor and that she had been instructed during inservice education not to discuss resident issues in the hallway.

An interview was held on 7/30/10 at 1:45 PM with the Registered Nurse (RN) who was the Inservice/Wound Care Nurse. The RN stated that the LPN should have kept the resident's front (anterior surface) covered while rendering treatment to the resident's back. The RN further stated that privacy issues are included during inservice education.

The Director of Nursing (DON) was interviewed on 7/30/10 at 2:15 PM and stated that the staff was inserviced regarding proper positioning of residents during wound care and that the resident should not have been exposed during the treatment.

415.5(a)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that one of twenty-nine sampled residents had two Accident/Incidents (A/Is) thoroughly investigated. Specifically, A) Resident #10 was found on the floor on 5/20/10 and the A/I Report did not address if the bed alarm sounded. Additionally, B) the resident was found with an unwitnessed skin tear on the left cheek on 7/24/10 and the A/I Report did not contain statements from the staff who rendered care to the resident prior to the identification of the skin tear. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #10 has diagnoses including Dementia, Status/Post Hip Fracture, and Purpura.

The admission Minimum Data Set (MDS) dated 5/29/10 documented that the resident had severely impaired cognitive skills for daily decision-making with long and short-term memory problems. The resident required extensive assistance of two people for transfers out of bed/chair and was non-ambulatory.

A) A Nurse's Progress Note dated 5/20/10 at 6:34 AM documented that the resident fell at 1:15 AM and that an A/I Report was completed. There was no visible injury observed related to the fall. The resident was placed at the nursing station because the resident attempted to come out of bed frequently.

The A/I Report dated 5/20/10 at 1:15 AM documented that the Nurse was called to the resident's room by the roommate because Resident #10 was on the floor. The resident was unable to give an explanation of the incident due to confusion. A statement was taken from the Certified Nursing Assistant (CNA) rendering care for the resident. The CNA documented that Resident #10's "roommate called us, the resident was lying on the floor". The Registered Nurse (RN) Supervisor documented that the resident had a bed alarm in place, however did not address if the bed alarm sounded.

An interview was held on 7/30/10 at 11:30 AM with the RN Supervisor who signed the A/I Report as the Risk Manager. The RN stated that she was not sure if the alarm sounded and that the A/I Report did not address whether or not the alarm sounded.

B) A Nurse's Progress Note dated 7/24/10 at 3:03 PM documented that the resident was found with an abrasion on their left cheek measuring approximately 1.0 cm (centimeter) by a CNA.

The A/I Report dated 7/24/10 at 7:15 AM documented that the resident was found by a CNA to have an unwitnessed skin tear to the left cheek. The resident was unable to give an account of the incident due to the diagnosis of Dementia. The statement from the CNA documented that the CNA went to do morning rounds and noticed the skin tear which was then reported to the Nurse. The statement from the RN Supervisor documented that the resident was observed lying on her left side with a 1 cm skin tear to the left cheek. The resident had fragile skin and was noted with her short nails in contact with the left cheek. The resident's nails were trimmed and filed. There were no statements taken from the staff who had rendered care to the resident on the previous nursing shifts.

An interview was held on 7/30/10 at 10:45 AM with the RN Risk Manager. The RN Risk Manager stated that for incidents of unknown origin, the facility obtains statements going back at least three nursing shifts from staff who rendered care. The RN stated that she believed the incident occurred when the resident was in bed and she thought the resident scratched herself. On 7/30/10 the RN Risk Manager then provided an additional statement from the CNA who found the skin tear, which documented that the resident was found with dried blood under her nails.

415.4(b)(1)(ii)

Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that procedures for labeling a gastrostomy tube feeding were followed for one sampled resident observed being tube fed. Specifically, Resident #23 was observed with a Gastrostomy tube feed running at 50 milliliters (ml) per hour. The container was not labeled with the resident's name, date, and or flow rate. This resulted in no actual harm with the potential for more than minimal harm.

Resident #23 has diagnoses that include Dementia and Failure to Thrive.

The Minimum Data Set assessment dated 7/18/10 documented that the resident had modified independence in cognitive skills for daily decision making and required the use of a GT for feedings and hydration.

On 7/26/10 at 6:00 AM an initial tour of the facility was conducted. Resident #23 was noted to have a GT feeding running at 50 ml per hour. The feeding container was not labelled with the resident's name, date, flow rate, or the time it was hung.

The Director of Nursing was interviewed on 7/30/10 at 9:00 AM and stated that the GT feeding bottle should have had the resident's name, date, flow rate, and the time that it was hung.

415.12(g)(2)

Based on observation and staff interview during the recertification survey, the facility did not ensure that 1 of 5 nursing unit's (1 North Unit) medication refrigerator was locked. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

During tour of the 1 North Unit on 7/26/10 at 6:00 AM, the medication refrigerator was observed to be unlocked. The Registered Nurse (RN) Unit Charge Nurse was interviewed on 7/26/10 at 6:35 AM. The RN verified that the observed refrigerator was unlocked and stated that it should have been locked.

The following items were found in the refrigerator at the time of the observation:
a) multiple bottles of Pneumovax Vaccine
b) one container of Acidophilous prescribed for a resident
c) one medication for one resident.

415.18(c)(1-4)

Based on observation, record review, and resident and staff interviews during the recertification survey, the facility did not ensure that one of twenty-nine sampled residents received the necessary care and services to maintain the highest practicable physical, mental and psychosocial well being. Specifically, the facility did not ensure that Resident #7 was assessed, monitored, or treated for constipation in a timely manner. This resulted in an emergency room visit at the resident's request, to address an episode of constipation. This resulted in no actual harm, with the potential for mare than minimal harm, that is not immediate jeopardy.

The finding is:

Resident #7 has diagnoses including Constipation, Generalized Pain, and a Left Heel Pressure Ulcer.

The admission Minimum Data Set (MDS) assessment dated 5/23/10 documented that the resident exhibited short-term memory problems, had intact long-term memory, and exhibited modified independence with daily decision making skills. Resident #7 required extensive assistance of one person for transfers out of bed/chair and for toileting needs. The resident was incontinent of both bowel and bladder. The resident had two Stage II and one Stage IV pressure ulcers. Additionally, the resident exhibited mild pain less than daily of the back, hip, and soft tissue.

An interview was held on 7/28/10 at 11:00 AM with Resident #7. The resident stated that there were occasions when she called for staff with the use of her call bell and/or called into the hallway for assistance for toileting and did not receive timely assistance. The resident stated that she would "hold her bowels" to prevent having a bowel movement in her incontinent garment. Additionally, the resident stated that when she was first admitted to the facility the staff would take her to the bathroom and place her on the toilet, however since the pressure ulcer on her left heel had deteriorated, the staff did not take her to the bathroom and she used an incontinent garment for her toileting needs.

The CCP for Pain Management dated 5/12/10 documented interventions including, but not limited to: monitor side effects and adverse reactions from interventions rendered.

The Comprehensive Care Plan (CCP) for Constipation dated 5/14/10 documented that the resident was at risk for constipation due to poor food intake, decreased mobility and medication use. The goal was for the resident to remain free of signs and symptoms of constipation. The interventions included, but are not limited to: monitor bowel output for frequency, consistency and color; observe for episodes of constipation; and monitor for adverse medication effects.

The Resident Certified Nursing Assistant (CNA) Documentation Record for May 2010 documented that the resident had a small formed bowel movement on 5/22/10 on the 11:00 PM-7:00 AM nursing shift. Although the Nurse's Progress Note dated 5/29/10 at 4:33 AM documented that the resident had a small bowel movement, the next recorded bowel movement on the CNA Documentation Record was a large loose bowel movement on the 11 PM-7 AM nursing shift after returning from the hospital on 5/30/10.

The resident's Medication Administration Record (MAR) for May 2010 documented that the resident was prescribed Percocet (a pain medication which may cause constipation) 5 mg-325 mg tablet every six hours as needed for pain on 5/11/10. This order was changed to every four hours as needed for pain on 5/13/10. Percocet was administered at least once daily and up to four times daily between 5/13/10 and 5/29/10. The MAR documented that no bowel medications were prescribed for the resident until 5/27/10, five days after the last recorded bowel movement on 5/22/10.

A Nurse's Progress Note dated 5/27/10 documented that the resident complained of difficulty moving her bowels. The Physician was made aware and ordered Senna 8.6 milligrams (mg) two tablets daily and Colace 100 mg two caplets daily. This call was made to the Physician five days after the resident's last recorded bowel movement on 5/22/10.

A Nurse's Progress Note dated 5/28/10 at 6:53 AM documented that the resident did not have a bowel movement during the night. Nurse's Progress Notes dated 5/28/10 (3 PM-11 PM shift) documented no bowel movements. The 9:25 PM 5/28/10 Nurse's Note documented that the resident refused an abdominal assessment. This was six days after the last recorded bowel movement.

A Nurse's Note dated 5/29/10 at 4:33 AM documented that the resident was incontinent of bowels with one small bowel movement noted. A Nurse's Note dated 5/29/10 at 7:20 PM documented that the resident complained of difficulty defecating. The resident stated, "I have to strain and it doesn't want to come out". The Physician was contacted and ordered Milk of Magnesia (MOM) 30 cc daily as needed and a Fleet Enema daily as needed. A subsequent Nurse's Note dated 5/29/10 at 7:35 PM documented that the resident stated that she wanted to go to the hospital, that the things given to the resident were not working. The resident refused to take MOM and the Fleet Enema. The Physician was contacted and ordered the resident to be transferred to the hospital.

An interview was held on 7/27/10 at 2:30 PM with the Licensed Practical Nurse (LPN) Administrative Nurse, whose responsibilities include assisting staff with the Electronic Medical Records (EMR). The LPN verified that the resident's bowel record documented that the resident had a recorded bowel movement on 5/22/10 on the 11 PM-7 AM nursing shift. The next documented bowel movement on this record was eight days later on the 11 PM-7 AM nursing shift on 5/30/10. The LPN stated that if nine shifts (72 hours) transpire without a bowel movement, the resident was triggered by a report that was run every night in the EMR for the 11 PM-7 AM Registered Nurse (RN) Supervisor. The Registered Nurse (RN) Supervisor was responsible to contact the unit Nurse, who was responsible to contact the Physician. The LPN further stated that the facility did not have a specific bowel protocol to follow, that each Physician prescribed bowel medications based on individual residents.

An interview was held on 7/30/10 at 10:50 AM with the Registered Dietitian (RD). The resident was placed on a No Added Salt (NAS) Chopped diet when first admitted to the facility. The resident was to receive prune juice at breakfast and a fiber additive to hot cereal and soup, which is given to all residents. The RD stated that nursing staff does not routinely inform the dietary department when a resident is placed on Narcotic pain medications to address constipation. The RD stated that she attends morning meeting and could not recall if Resident #7's lack of bowel movements was discussed prior to her emergency room visit on 5/29/10. Additionally, the RD stated that there were no additional dietary interventions to address the resident's constipation until 7/28/10 when stewed prunes were added to the resident's diet.

An interview was held on 7/30/10 at 11:45 AM with the 7 AM-3 PM RN Supervisor. The RN stated that the 5/25/10 11 PM-7 AM RN Supervisor should have informed the 11 PM-7 AM unit Nurse and 7 AM-3 PM RN Supervisor that nine shifts had lapsed without a recorded bowel movement for the resident. The 7 AM-3 PM RN should have determined if bowel medications were in place, should have called the Physician, and should have documented an abdominal assessment.

The Physician was interviewed on 7/30/10 at 12:30 PM and stated that he does not routinely order bowel medications or stool softeners when a resident is placed on pain medication. The Physician stated that he responded to the resident's constipation concern when he was contacted by the Nurse.

The facility's Bowel Protocol, which was revised March 2010, documented that the 11 PM-7 AM Nursing Supervisor will advise the nurse on the unit to medicate any residents who have not had a bowel movement in 72 hours and have a Physician order for bowel medication. The 7 AM-3 PM Nursing Supervisor is to verify the bowel documentation in the Electronic Medical Record (EMR) and assesses the resident as needed, notifies the Physician and follows up as per the Physician's Order.

415.12

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that for one of twenty-nine sampled residents that one resident was seen in a timely manner for a consultant follow-up appointment. Specifically, Resident #10 had a Physician's Order dated 5/31/10 for an Ear/Nose/Throat (ENT) consult due to the resident being Hard of Hearing (HOH). The ENT Physician recommended a treatment and a follow-up appointment in three to four weeks. This follow up appointment was not completed.

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

The finding is:

Resident #10 has diagnoses including Dementia, Esophageal Reflux, and Impacted Cerumen.

Resident #10 was observed on 7/29/10 at 3:30 PM sitting in a wheelchair in the hallway. The Surveyor spoke to the resident in a normal volume and the resident did not respond. The Surveyor repeated a question and the resident looked at the Surveyor, but did not respond verbally.

A Physician's Order dated 5/31/10 documented a request for a ENT Consultation secondary to the resident being HOH.

The ENT consult dated 5/31/10 documented that the resident was seen due to being HOH. The examination revealed deep dry wax and debris. The ENT Physician performed partial removal of ear wax of both ears, the right ear greater than the left (R>L). The ENT Physician documented that the resident would not tolerate full removal of the dried wax and debris. The recommendations included Cortisporin drops to both ears twice a day for ten days and a follow up-appointment in three to four weeks.

A Nurse's Progress Note dated 5/31/10 documented that the resident had been seen by the ENT Physician who recommended ear drops to both ears and a follow-up appointment in 3-4 weeks.

Review of the Treatment Administration Record (TAR) revealed that the resident received the Cortisporin ear drops to both ears between 6/01/10 and 6/10/10.

Review of the resident's Medical Record on 7/29/10 at 3:45 PM with the Licensed Practical Nurse (LPN) present revealed that no ENT consult after the 5/31/10 consult could be found.

The LPN Administrative Nursing Manager was interviewed on 7/30/10 at 9:55 AM and stated that the ENT Physician comes into the facility to see residents rather than the residents going out of the facility for appointments. The LPN stated that the ENT Physician was responsible to keep track of his appointments and that he usually comes in automatically when a resident needs to be seen.

An interview was held on 7/30/10 at 10:30 AM with the Registered Nurse (RN) Supervisor for the 3 North Unit where the resident resides. The RN stated that the ENT Physician usually comes to the facility every Thursday or on weekends if he does not come in on a Thursday. The RN stated that she called the ENT Physician who stated that he had not seen the resident for the follow-up appointment as documented as a plan on the 5/31/10 consultation. The RN stated that the ENT Physician stated that he does not keep track of when he was to see a resident, that it was the responsibility of the nursing staff in the facility to track when he needed to see a resident. The RN further stated that the ENT Physician stated that he would come in later today (7/30/10) or on the weekend to see the resident.

415.26(e)(i-iv)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that all sections of the residents' Electronic Medical Records (EMRs) were readily accessible and available to be independently reviewed by the Survey Team on two of five Nursing Units (Unit 2 South and 2 North). Additionally, the staff on one unit could not successfully access all files in the EMR. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. (Resident #9, #17, and #4)

The findings are:

1) On 7/29/10 at 10:50 AM on Unit 2 South , the Surveyor attempted to access the Immunization Record EMR document for Resident #9, but was unable to do so and a notification box on the computer screen displayed, "You do not have permission to perform this action."

The Registered Nurse (RN) Supervisor was interviewed on 7/29/10 at 10:50 AM and stated that she did not know how to access that information on the computer. Additionally, the RN stated that she would have to call the Licensed Practical Nurse Administrative Nurse Manager to access that information.

2) On 7/29/10 at 10:55 AM on Unit 2 South, the Surveyor attempted to access the Immunization Record EMR document for Resident #17, but was unable to do so and a notification box on the computer screen displayed, "You do not have permission to perform this action."

The Registered Nurse (RN) Supervisor was interviewed on 7/29/10 at 11:00 AM and stated that she did not know how to access that information on the computer. Additionally, the RN stated that she would have to call the Licensed Practical Nurse Administrative Nurse Manager to access that information.

3) On 7/28/10 at 11:00 AM, the Surveyor was attempting to access Resident #4's Weight Record, however the information could not be found in the EMR. At this time, the Licensed Practical Nurse (LPN) Charge Nurse was asked to access the information in the EMR. The LPN stated that he did not know how to access the information in the computer and that he would have to call the LPN Administrative Nurse Manager to access the information for him.

415.22(a)(1-4)

Based on observation and staff interview, the facility did not ensure that doors located within the smoke barrier are self-closing or automatic-closing and is capable of resisting the passage of smoke on 1 of 3 resident use floors.

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

The findings are:

During the recertification survey on 7/27/10 at approximately 9:00am, inspections of the smoke barriers in the vicinity of the recreation department on the 1st floor revealed that the doors to the staff and resident only bathrooms are incorporated into the smoke barrier and are not provided with self-closing or automatic-closing devices. In addition, the door to the staff restroom could not completely close when tested. There was an approximately inch gap between that door and door frame.

In an interview at this time the Director of Maintenance stated that this area was renovated and that the door closures may have been removed. He immediately contacted a maintenance employee to adjust and install the self closing devices on the doors.

NFPA 101-2000
711.2(a)(1)

NFPA99 Section 11-5.3.5* Logistics.
Contingency planning for disasters shall include as a minimum stockpiling or ensuring immediate or at least uninterrupted access to critical materials such as the following:

(a) Pharmaceuticals
(b) Medical supplies
(c) Food supplies
(d) Linen supplies
(e) Industrial and potable (drinking) waters

Based on observation and staff interview the facility did not ensure that stockpiling of emergency water supply was maintained to provide an uninterrupted supply.

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

The findings are:

During the recertification survey on 7/26/10 at approximately 7:15am, inspection of the emergency food supply room revealed 5 boxes spring water that was crushed. The individual one gallon plastic containers of water in two cartons were observed partially empty and holes on the side of the containers.

In an interview at this time the Food Service Director stated that the water may have been delivered damaged. He further stated that he would immediately reorder and replenish the emergency water supply. He further stated that he would make sure that the dietary employees check the cases for damages when they are delivered.

NFPA 101-2000
711.2(a)(26)

Based on observation and staff interview the facility did not ensure that metal containers with self closing cover devices were provided in the resident smoking area.

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

The findings are:

During recertification survey on 7/27/10 at approximately 9:50am it was observed that the resident smoking area located next to the 2nd floor dayroom was not provided with metal containers with self closing cover devices.

Metal containers with self-closing cover devices into which the ashtrays can be emptied are required where smoking is permitted.

In an interview at this time the Director of Maintenance stated that a code compliant metal container with a self-closing cover device would be provided.

NFPA 101-2000
711.2(a)(1)

Based on observation and staff interview, the facility did not ensure that the fire resistance rating for the dumbwaiter vertical opening is maintained intact.

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

The findings are:

During the recertification survey on 7/26/10 at approximately 6:10am it was observed that there was an approximate 5 inch opening/space between the dumbwaiter doors in the kitchen. The dumbwaiter was observed decommissioned and enclosed in a vertical opening that extends from the lobby level through 1-3 resident use floors.

In an interview on the same day at approximately 9:00am, the Director of Maintenance stated and confirmed that the vertical shaft for the dumbwaiter is sealed shut on the resident floors and on the lobby level. He further stated that the dumbwaiter is no longer in service and that it would be sealed shut in the kitchen.

NFPA 101-2000
711.2(a)(1)

NFPA 99-1999 Section 8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Based on observation and staff interview the facility did not ensure that small oxygen cylinders (e-tanks) were properly stored on 3 of 5 units. Reference is made to the storage of e-tanks in plastic crates and not properly restrained from tipping over.

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

The findings are:

During the recertification survey on 7/26/10 between 6:10am and 12:00pm and on 7/27/10 between 8:30am and 3:00pm, portable small oxygen tanks (e-tanks) were observed stored in plastic crates (combustible material) in the oxygen storage closets on the 1 North, 2North, and 3 North units. In addition, 3 freestanding e-tanks were not properly restrained from tipping over in the oxygen storage closet on the 2North unit. The restraining chain was observed to be loosely strapped around the e-tanks.

In an interview on 7/26/10 at approximately 10:15am the Director of Maintenance stated that the plastic crates would be removed and replaced with the right kind of storage racks. He immediately adjusted the restraining chain around the tanks.

NFPA 101-2000
NYCRR 711.2(a)(1)
NYCRR 711.2(a)(26)