Niagara Rehabilitation and Nursing Center

Based on observation, record review, staff and resident interview the services provided or arranged by the facility did not meet professional standards of quality. Four (Residents #1, 8, 9, 19) of 24 residents reviewed for professional standards had issues involving inaccurate physician orders for a DNR (Do Not Resuscitate - do not revive). In addition, physician orders were not followed to cover a gastrostomy tube (feeding tube inserted into the stomach) site with an abdominal binder, to elevate the left lower extremity when out of bed in a wheelchair or for use of a Duoderm (moisture retentive wound dressing) dressing preventatively. This is a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #1 has diagnoses including senile dementia and hypertension. Review of a current Minimum Data Set (MDS) dated 5/12/10 revealed that the resident has severely impaired cognitive skills for daily decision making with short and long term memory impairment.

Review of the facility face sheet located in the medical record revealed the resident was admitted to the facility on 11/9/09. Affixed to the face sheet is an orange DNR (Do Not Resuscitate) sticker and a yellow Advance Directives sticker marked DO NOT RESUSCITATE.

Review of the resident's DNR CONSENT FORM revealed the Adult Patient Without Capacity with Surrogate section was completed and signed by the Surrogate on 11/11/09.

Review of the Physician's Telephone Orders revealed an order dated 11/11/09, May obtain DNR.

Review of the Physician's Orders dated 11/11/09, 1/20/10, 2/22/10, 3/29/10, 4/20/10 and 6/14/10 revealed the line "DO NOT RESUSCITATE" is checked "NO". The order dated 6/2/10 was documented NO, crossed out and Yes was marked.

Review of a facility policy entitled Advanced Directives-General, Date Revised: 3/31/08, revealed that the Social Worker will initiate the process of having a DNR Order executed.

Interview with the Registered Nurse (RN) Unit Coordinator on 6/15/10 at 10:45 AM revealed that the resident's orders should be checked YES for DNR. The orders should be double checked each month by the nurses before the physician signature and a second time by a different nurse after the physician signature.

2. Resident #19 has diagnoses including atherosclerosis (a disease in which plaque builds up inside your arteries), calf ulcer and septicemia (bacterial infection in the blood). Review of a Minimum Data Set (MDS) dated 3/19/10 revealed the resident is independent with cognitive skills for daily decision making, usually understands, is usually understood, and has intact long term memory and impaired short term memory.

Review of Physician's Telephone Orders dated 6/5/10 revealed the following orders:

- Do not touch dressings on the left thigh and left leg,
- May be out of bed in a wheelchair,
- Must have the left leg elevated.

Review of a Plan of Care identified as current and the Closet Care Plan dated 3/19/10 and identified as current revealed a lack of written instructions to keep the resident's left lower extremity elevated when out of bed in the wheelchair.

Observation on 6/16/10 at 8:15 AM revealed the certified nurse aide (CNA) transferred the resident from the bed to the wheelchair and transported the resident to the dining room for breakfast without elevating the resident's left lower extremity as ordered by the physician. The resident remained in the dining room/lounge after breakfast until 10:30 AM seated in the wheelchair with the left leg dependent. Intermittent observation of the resident between approximately 10:45 AM and 12:15 PM revealed the resident's left leg was not elevated as ordered by the physician. Additional observation on 6/17/10 at approximately 9:30 AM revealed the resident was in the lounge in a wheelchair with her left leg dependent.

Interview with the RN Unit Coordinator on 6/17/10 at approximately 10:15 AM revealed a physician's order for leg elevation was written shortly after the resident had a skin graft on a chronic leg ulcer. The RN explained she thought the order was discontinued. The RN reviewed the resident's medical record including physician orders, nurses' notes and consults and did not find an order to discontinue the leg elevation. Review of a nurse's note dated 6/13/10 revealed the staff documented the LLE (left lower extremity) was elevated on that day. The RN then stated, "I guess the order wasn't discontinued."

3. Resident #8 has diagnoses including dysphagia (difficulty swallowing), organic brain syndrome ((general term that refers to diseases (usually not psychiatric disorders) that cause decreased mental function)) and has a gastrostomy feeding tube (g-tube - feeding tube inserted into the stomach). Review of a Minimum Data Set (MDS) dated 3/23/10 revealed the resident's cognitive skills for daily decision making are severely impaired and short and long term memory is impaired.

Review of a Physician's Order dated 6/1/10 revealed an order for an abdominal binder at all times. Review of an undated, untitled Certified Nurse Aide Closet Care Plan and the Comprehensive Care Plan dated 6/9/10 revealed no documentation involving the use of an abdominal binder.

When the resident was observed during transfer and incontinence care on 6/14/10 at 12:35 PM, the resident's g-tube was observed to be hanging out from under his shirt and the resident did not have an abdominal binder on.

When observed during administration of a tube feeding by Licensed Practical Nurse (LPN) #1 on 6/15/10 at 9:26 AM the resident did not have an abdominal binder on.

When observed on 6/16/10 at 12:00 PM the resident was lying in bed and the CNA pulled up the resident's shirt to reveal the resident did not have an abdominal binder on. The resident was observed to grab onto the g-tube and the CNA had to remove the g-tube from the resident's hand and explained that residents with feeding tubes are supposed to have abdominal binders on. The CNA further explained the resident has had an abdominal binder on in the past but has not had one on for the last three days. At this time the CNA found the abdominal binder in the top drawer of the resident's stand and stated she would apply it now.

Review of a MAR dated 6/1/10 to 6/30/10 revealed an order for abdominal binder at all times and is initialed and circled by the 11:00 PM to 7:00 AM shift, initialed by LPN #1 at 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM on 6/14/10 and 6/15/10. There is no documentation on the back of the MAR.

During an interview on 6/16/10 at 12:02 PM Medication/Treatment LPN #1 revealed the resident is supposed to have an abdominal binder on at all times. She further revealed the signatures on the Medication Administration Record (MAR) indicate the abdominal binder is on and further explained if the binder was not on then the initials would be circled and the reason the binder is not on would be documented on the back of the MAR. In addition, the LPN stated the resident had an abdominal binder on 6/15/10 but not today.

During an interview on 6/16/10 at 12:10 PM, the LPN Unit Coordinator stated the resident is supposed to have an abdominal binder on at all times. The Unit Coordinator explained that if the resident's abdominal binder was soiled there are plenty of binders in the laundry and one can be obtained for the resident.

4. Resident #9 has diagnoses including diabetes mellitus and morbid obesity. Review of a Minimum Data Set (MDS) dated 3/16/10 revealed the resident is independent with cognitive skills for daily decision making, understands and is understood.

Review of Physician's Orders dated 6/1/10 revealed an order for Duoderm 4 x 4 dressing (moisture retentive wound dressing) to left posterior (behind) waist every three days as preventative.

Review of a 5/5/10 Plan of Care revealed the resident has a potential for alteration in skin integrity related to incontinence, sedentary life style and morbid obesity as evidenced by history of multiple chronic decubitus ulcers. The evaluation section noted the resident was seen by the Nurse Practitioner on 6/1/10 re: pressure to left hip/ waist/ upper buttock and ordered Duoderm every three days as a preventative.

While interviewing the resident on 6/16/10 from 9:00 AM through 10:15 AM, the resident was observed to reposition herself off her left side in her wheelchair multiple times. When questioned, the resident explained that she was uncomfortable sitting in the wheelchair due to a sore on her bottom.

The surveyor requested that the resident be transferred into bed for observation of the area. At 10:45 AM a raised reddened closed area was observed on the resident's left posterior waist area approximately 0.5 centimeters (cm) in size.

During an interview with the certified nurse aide (CNA) on 6/16/10 at 10:50 AM, following the observation, the CNA revealed that she provided morning care to the resident from approximately 7:30 AM to 8:00 AM and the Duoderm dressing was not present when she started care. When questioned the CNA further revealed that she did not report the missing Duoderm to a nurse.

An interview with the Licensed Practical Nurse (LPN) Unit Coordinator at 10:50 AM on 6/16/10 revealed the Duoderm is placed on the area to prevent reopening of a resolved pressure sore.

When interviewed on 6/17/10 at 1:00 PM, the Registered Nurse (RN) Assistant Director of Nursing (ADON) revealed she would expect the Duoderm to be replaced if it was not intact even though it had not been three days.

In summary, the Duoderm dressing was not in place according to the physician's order for at least 3 hours.

none 415.11(c)(3)(i)

Based on record review and staff interview, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs and that resident's received gradual dose reductions, unless clinically contraindicated , in an effort to discontinue the drug. One (Resident #3) of two resident's reviewed for medications used to promote sleep had issues involving the lack of documented evidence to support the need for continued use of a psychoactive medication and lack of documented evidence that a gradual dose reduction (GDR) was attempted. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #3 has diagnoses which include dementia and unspecified psychosis. Review of the Minimum Data Set (MDS) dated 5/12/10 revealed the resident has severely impaired cognition with short and long term memory problems.

Review of Physician's Orders, dated 6/17/09 to 6/11/10 revealed orders for Trazodone (antidepressant medication used for insomnia) 25 milligrams (mg) tablet, by mouth at bedtime for insomnia.

Review of Medication Administration Records (MAR), dated 6/1/09 to 6/15/10 revealed Resident #3 received Trazodone 25 mg every night at bedtime for insomnia.

Review of an Interval Note written by a Nurse Practitioner dated 3/8/10 revealed the resident has dementia with behaviors and receives Seroquel (antipsychotic medication) 50 mg twice a day, Trileptal (seizure medication) 150 mg three times a day, and Trazodone 25 mg for sleep at bedtime.

An Initial Psychiatry Consult dated 6/24/09 documented that the resident was unable to participate in the treatment plan with recommendations to continue Trileptal 150 mg po tid, Seroquel 50 mg po bid and Trazodone 25 mg po at bedtime. "We will follow him as recommended by the PMD (Primary Medical Doctor) and maintain safety measures".

Review of a BMARC (behavior modification assessment record committee) Committee Recommendations form dated 4/22/10 revealed the current Psychotropic Medication included: Trileptal 150 mg po TID (three times a day), Seroquel 50 mg BID (twice a day) and Trazodone 50 mg at bedtime. Additional review of the form revealed the sections titled "Diagnosis", "Date Last Changed" and "Effect were blank. Documented Recommendation included "Seen by Psychiatrist 6/09, no changes at this time" and the section for GDR (gradual dose reduction) was blank.

Review of Pharmacy Consultant Reports, dated 6/23/09 to 5/13/10 revealed no documented comments regarding the indication for the use of Trazodone for Insomnia and there were no recommendations to consider an attempt to taper the insomnia medication quarterly.

Interview with the Registered Nurse (RN) Unit Coordinator on 6/16/10 at 10:40 AM, confirmed there is no documentation in the Nurses Notes that the resident has trouble sleeping. The RN Unit Coordinator stated that the Trazodone may have been started back in 10/08 when the resident was singing during the night.

Interview with the Director of Nursing (DON) on 6/16/10 at 10:50 AM revealed that Resident #3 is reviewed by BMARC every 6 months. The DON stated that the last review by BMARC on 4/22/10 referred back to the last Psychiatrist review on 6/09 when he said to continue the Trazodone. The DON stated "we do not look at hypnotics on a quarterly basis but we do try to eliminate hypnotics aggressively on admission".

Further interview with the DON on 6/16/10 at 12:15 PM revealed that the Trazodone was started in 10/08 because the resident was singing during the night.

415.12(l)(1)

Based on observation, record review and staff interview, the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Two (Residents #4, 8) of seven residents observed for personal and/or wound care had issues involving the lack of proper hand hygiene after positioning a resident; removing a soiled dressing; applying a new dressing; providing incontinence care; and handling soiled linen and dressing supplies. In addition, an overbed table was not cleaned and a barrier was not used prior to placing dressing supplies on the table and a wound was not cleansed after the removal of a soiled dressing, prior to the application of a new dressing. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident # 4 has diagnoses of respiratory failure, pneumonia, cerebral palsy and has a a tracheostomy (surgical creation of an opening in the airway). Review of the Minimum Data Set (MDS) dated 4/19/10 revealed the resident has modified independence for daily decision making skills, intact memory, is usually understood, and always understands.

During observation of a bed bath provided by two certified nurse aides (CNAs #1, 2) on 6/15/10 at 9:30 AM, Resident #4 was incontinent of a moderate amount of soft, semi-formed brown stool. Two dressings on the resident's sacrum (area above the tailbone) and left buttock were observed to be loose and heavily soiled with exudate (drainage) from the wounds. CNA #1 removed both the dressings and discarded them in a plastic bag. CNA #1 cleaned the stool from the resident's peri rectum (area around the rectum) with gloved hands and then positioned the resident on his side with the help of CNA #2.

After being positioned, the resident coughed up loose phlegm from his tracheostomy and CNA #1 (who had just provided fecal incontinence care) instructed the resident to cough up the phlegm. CNA #1 then used a tissue to wipe the phlegm from the resident's tracheostomy while wearing the same gloves used during incontinence care.

While positioning the resident, the plastic bag (which was on the foot of the bed) had fallen on the floor. CNA #1 picked up the soiled linens and dressings that fell out of the bag. CNA #1 removed her gloves and washed her hands for 6 seconds and left the room.

After the completion of care, CNA # 2 removed her gloves and washed her hands for 7 seconds. CNA (#2) then put on new gloves and covered the resident's tracheostomy with gloved fingers to allow the resident to talk.

During observation of wound care on 6/15/10 at approximately 10:45 AM, the Registered Nurse (RN) Unit Coordinator assisted the Licensed Practical Nurse (LPN) Treatment Nurse to position the resident and both nurses were wearing gloves. When the treatment was finished, the RN Unit Coordinator removed her gloves, did not wash her hands, and was observed to leave the room.

Interview with the RN Unit Coordinator on 6/17/10 at approximately 12:30 PM revealed staff are to follow the facility policy for handwashing after providing care.

Review of a facility policy entitled "Handwashing" dated 4/6/06 revealed staff are to wash hands well beneath running water for 20 to 25 seconds using a rotary motion and friction.

2. Resident #8 has diagnoses including dysphagia (difficulty swallowing), organic brain syndrome and has a Stage 2 wound at the base of the thumb and second metacarpal (bones in the hand between the wrist and fingers) on the left hand. Review of the Minimum Data Set (MDS) dated 5/10/10 revealed the resident has severe cognitive impairment and short and long term memory problems.

Review of a Physician's Telephone Order dated 6/9/10 revealed an order to apply triple antibiotic ointment (TAO) and a Telfa (non stick dressing) to the Stage 2 wounds at the base of the thumb every day until resolved.

During an observation on 6/16/10 at 8:55 AM, the Medication/Treatment Licensed Practical Nurse (LPN #1) changed the dressing on the resident's left hand. LPN #1 washed her hands for 4 seconds and applied gloves. Without cleaning or placing a barrier on the over bed table, the LPN cut the Telfa dressing in half and placed each half of the dressing on top of the dressing package then applied TAO to the Telfa dressing. The LPN then removed a Kling (rolled dressing used to wrap around a wound) and the Telfa dressing from the base of the left thumb and index finger and the dressing was observed to have serosanguinous (thin pink) drainage. LPN #1 applied the new Telfa dressing with the TAO to the left thumb wound without cleansing first, applied the Kling wrap, removed her gloves and washed her hands for 5 seconds.

When interviewed on 6/16/10 at 10:05 AM, the Medication/Treatment LPN (#1) stated she should have cleansed the wound after removing the soiled dressing. LPN #1 said "I should have taken my gloves off after removing the dressing because it had drainage on it and then washed my hands, but I did not". LPN #1 stated she should have washed her hands for 30 seconds, but only washed them for about 5 seconds.

During an interview on 6/16/10 at 10:25 AM, the LPN Unit Coordinator stated the over bed table should be cleansed when doing a dressing change and a barrier should be placed on the table under the dressing supplies. The LPN Unit Coordinator stated that during a dressing change, a nurse should wash hands for 30 seconds, apply gloves, remove the soiled dressing, and then remove and reapply gloves. The LPN Unit Coordinator explained that she would cleanse the wound, remove the glove from one hand, apply the new dressing with the remaining gloved hand, then remove the glove and wash her hands.

Review of a facility policy and procedure entitled Aseptic Technique (procedure performed under carefully controlled conditions to minimize contamination) dated 2/2/06 revealed nursing staff are to use aseptic technique during all dressing changes and/or treatments. Staff are to wash hands, ensure the surface of the over bed table is clean, apply clean gloves, remove and then dispose soiled dressings and soiled gloves. After disposal of soiled items, the nurse is to wash hands, open the new dressings, put on gloves, cleanse the wound, apply the new dressing, remove gloves and wash hands.

The facility policy for Handwashing dated 4/6/06 documented that staff are to wash their hands for 20 to 25 seconds using a rotary motion and friction.

415.19(a)(1)(4)

Based on observation, record review and staff interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #7) of five residents observed for wheelchair transport had an issue where the resident's feet were dragging on the floor during the transport. There is no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #7 has diagnoses of dementia and glaucoma. Review of a Minimum Data Set (MDS) dated 5/19/10 revealed that the resident's cognitive skills for daily decision making are severely impaired and short and long term memory is impaired. Review of a Comprehensive Care Plan (CCP) dated 6/1/10 revealed the resident is independent in the wheelchair. Review of an undated Certified Nurse Aide (CNA) Closet Care Plan, undated, revealed total assist for wheelchair mobility.

When observed on 6/14/10 at 11:27 AM, CNA #3 pushed the resident in the wheelchair without leg rests from the resident's room to the nurse's station approximately 90 feet (ft) and on 6/15/10 at 8:35 AM, CNA #3 pushed the resident from the unit dining room to the resident's room in the wheelchair without leg rests, approximately 107 ft. During these transports the resident's sneakers were observed to bounce off the floor and catch pulling her feet back under the wheelchair. The CNA was not observed to instruct the resident to pick up her feet.

When observed again on 6/16/10 at 8:50 AM, the Medication Licensed Practical Nurse (LPN) pulled the resident in the wheelchair without leg rests from the dining room on the unit to the elevators, approximately 49 feet. The resident's feet were observed to catch on the tiled floor, bounce, and were pulled back under the wheelchair. The LPN stated to the resident "pick up your feet". The resident was unable to pick her feet up and the LPN #1 continued to push the resident in the wheelchair another 27 ft. After the surveyor intervened, the LPN stopped pushing the resident and stated she needed wheelchair leg rests. She then obtained assistance from CNA #3 and they pulled the resident up in the chair and the CNA pushed the resident in the wheelchair while the LPN #1 guided it slowly from the side instructing the resident to pick up her feet which the resident was unable to do.

When interviewed on 6/16/10 at 8:50 AM, CNA #3 stated the resident does not have leg rests for the wheelchair. She stated she knows the resident's sneakers catch on the floor and further explained sometimes the resident "plants" her feet on the floor when she propels her in the wheelchair.

When interviewed on 6/16/10 at 10:00 AM, LPN #1 stated she had called Physical Therapy to obtain a leg rests for the resident's wheelchair.

During an interview on 6/16/10 at 10:35 AM, the LPN Unit Coordinator stated the resident is independent in the wheelchair. The Unit Coordinator further explained that leg rests should be on the wheelchair for the instances when the resident is propelled by staff on or off the unit.

Review of a facility policy entitled Resident Special Needs/ Accident/ Incident Prevention dated 1/05 revealed it is imperative during wheelchair transport, residents who require foot rests have them in place to prevent injuries.

415.12(h)(2)

Based on observation, record review and staff interview, the facility did not ensure it is free of medication error rates of five percent or greater. There were three errors for 40 observed medication opportunities involving Residents #15 and #26. This resulted in a medication error rate of 7.5% (percent). The issues involved medications that were not prepared and administered according to the physician's orders. Miralax was not mixed with eight ounces of water, Prilosec was not administered within one hour of the ordered time and the wrong dose of Vitamin D was given. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #26 has diagnoses including gastrointestinal bleeding (bleeding in the digestive tract), gastro esophageal reflux (GERD-backflow of gastric fluids into the food tube) and diverticulosis (sac-like outpouching of the lining of the bowel) of the colon. Review of the Minimum Data Set (MDS) dated 4/27/10 revealed the resident is independent for daily decision making, has intact memory, understands and is understood.

Review of Physician's Orders signed by a Nurse Practitioner dated 6/14/10 revealed orders for Prilosec (medication used to decrease production of stomach acid) 20 mg one tablet by mouth daily at 7:30 AM and Miralax (laxative) powder 17 grams in 8 ounces of water or juice, once daily for bowel management.

During an observation of medication administration on 6/15/10 at 9:55 AM, the Unit #4 Licensed Practical Nurse (LPN) Medication Nurse prepared and administered the resident's medications including Miralax 17 gms and Prilosec 20 mg (ordered to be given at 7:30 AM). The LPN Medication Nurse was observed to mix the Miralax in a four ounce cup of water instead of eight ounces as ordered by the physician.

Review of Medication Administration Record (MAR) dated 6/10 revealed the Prilosec and Miralax were transcribed according to the 6/14/10 Physician's Orders.

During an interview, the LPN Medication Nurse on 6/15/10 at 2:20 PM stated that she didn't catch the resident before he left for the dining room. The LPN Medication Nurse stated that the medication cart contains four ounce drinking cups and she should have divided the Miralax in two 4 ounce cups of water prior to administering it.

Review of a facility policy dated 6/08 entitled Pharmacy Services-Standard Nursing Home Policies revealed medication passes are to be timely. The policy documented that no longer that one (1) hour prior to or more that 1 hour past the indicated time is acceptable.

2. Resident #15 has a diagnosis of chronic osteomyelitis (bone infection). Review of the Minimum Data Set (MDS) dated 4/20/10 revealed the resident has modified independence in cognitive skills for daily decision making and intact memory.

Review of Physician's Orders dated 5/18/10 revealed an order for an Os-Cal 500 + D tablet (Oyster Shell Calcium 500 with Vitamin D 200) by mouth three times a day at 9:00 AM, 1:00 PM and 5:00 PM.

During observation of medication administration on 6/14/10 at 12:00 PM the Unit #2 Medication Nurse poured two tablets from a stock bottle labeled Oyster Shell Calcium 250 milligrams (mg) with Vitamin D (Oyster Shell Calcium 250 with Vitamin D 125) and administered it to the resident.

When interviewed on 6/15/10 at 8:10 AM, the Medication LPN #1 stated she gave the resident two tablets of the Calcium 250 mg instead of one tablet of Calcium 500 mg because it is easier for the resident to swallow two smaller pills instead of one big one. At this time, the LPN Medication Nurse removed both Calcium 250 mg with Vitamin D 125 I.U. (international units) and Oyster Shell Calcium 500 mg with Vitamin D 200 I.U. bottles from the medication cart and stated she did not realize that the amount of Vitamin D in the pills was different.

When interviewed again on 6/16/10 at 10:05 AM, the LPN Medication Nurse stated that she could have called the pharmacy or the physician and got the order for the Calcium with Vitamin D changed but she did not.

During an interview on 6/16/10 at 10:20 AM, the LPN Unit Coordinator revealed a physician's order would be required to give one tablet of Calcium 500 mg with Vitamin D 200 I.U. instead of two tablets Calcium 250 mg with Vitamin D 125 I.U. because the Vitamin D dosage is different.

415.12(m)(1)

Based on observation, record review and staff interview, the facility did not ensure that drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the expiration date when applicable. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse. Two (Units 3, 4) of two nursing units reviewed for medication storage had issues involving controlled drugs that were stored in a cabinet that was not double locked, and one open, outdated vial of insulin. Resident #25 was involved. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. During the initial tour of Unit 3, on 6/14/10 at 9:15 AM, one of two Controlled Substance cabinets located in the Unit Medication Room, was observed to have the outside door unlocked and ajar. The inside door was locked.

Observation of the Controlled Substance Cabinet revealed it contained the following medications:

- Two 30 milliliter (ml) bottles of Morphine Sulfate (narcotic pain medication) 20 milligrams (mg)/ml Oral Solution.
- One Fentanyl (narcotic pain medication) 25 micrograms (mcg)/hr Transdermal System.
- One Fentanyl 50 mcg/hr Transdermal System.
- Ninety Alprazolam (anti-anxiety medication) 1 mg tablets.
- Eighteen Hydrocodone/APAP (Acetaminophen) (narcotic pain medication)10/500 tablets.
- Sixty Lorazepam (anti-anxiety medication) 1 mg tablets.
- Forty one Alprazolam .25 mg tablets.

Interview with a Licensed Practical Nurse (LPN) who had the keys to the cabinet, on 6/14/10 at 9:25 AM, revealed that another nurse was helping on the unit. The LPN explained that she counted the narcotics in the cabinet this morning and she must have forgotten to lock the cabinet.

Review of a facility policy entitled Controlled Substance Accountability/ Security/ Re-Ordering/ Obtaining Emergency Supply/Pill Splitting, dated 5/08, revealed the controlled substance keys must be kept in the possession of the nurse responsible for the controlled substance count. The keys must not be given to anyone else.

2. Resident #25 has diagnoses which include diabetes mellitus, congestive heart failure and schizophrenia. Review of Physician's Orders dated 5/11/10 revealed orders to administer 6 units of Novolog (fact acting insulin) insulin before meals and per Rainbow Coverage (the administration of insulin based on blood glucose levels) as directed.

Observation of the Unit 4 medication refrigerator on 6/14/10 at approximately 9:45 AM revealed one open vial of Novolog Insulin labeled for Resident #25. The vial of Novolog was dated as opened on 5/6/10. Interview with the Registered Nurse (RN) Unit Coordinator on 6/14/10 at approximately 9:50 AM revealed the vial of open insulin should be discarded. Interview with the Registered Pharmacist on 6/17/10 at 12:00 PM revealed open vials of insulin should be discarded after 28 days.

Review of a facility policy entitled Labeling and Storing Medications dated 8/08 revealed all medications stored in the medication room or refrigerator must have an expiration date listed, once the medication is opened.

415.18(d)(e)(2)

Based on observation, record review and staff interview, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Two (Residents #5, 8) of seven residents reviewed for pain had issues involving a lack of pain management during range of motion (ROM - normal range of motion to a joint). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #5 has diagnoses of dementia, cerebrovascular disease and hypertension. Review of a Minimum Data Set (MDS) dated 5/17/10 revealed the resident has moderate cognitive impairment for daily decision making skills, usually understands, is usually understood with impaired short term memory and intact long term memory.

Review of a facility form entitled Range of Motion Review dated 2/23/10 revealed the resident has contractures of the right knee, refused to bend her hips, with recommendations for Passive Range of Motion (PROM - exercises performed on the resident by nursing staff) for the bilateral lower extremities once daily, 5 days per week. In addition, the resident exhibited resistiveness with the bilateral upper extremities and recommendations were made for PROM to the bilateral upper extremities twice a day 5 days per week.

Review of a Plan of Care identified as current revealed a care plan for contracture development of the bilateral upper extremities and right knee initiated on 10/2/08. There was no care plan for pain or one which addressed pain.

Review of Physician's Orders signed 6/11/10 revealed orders for Lortab (controlled substance used to treat pain) 5/500 tablet hydrocodone /APAP 5/500 TA give (1) tablet by mouth every six hours if needed for pain and Tylenol 325 milligrams (mg) 2 oral every four hours as needed for pain.

Review of a Medication Administration Record (MAR) for 6/10 revealed the resident received Lortab on 6/1/10, 6/2/10, 6/4/10, 6/5/10, 6/6/10, 6/7/10, 6/12/10, 6/13/10, 6/14/10 and 6/16/10 at 7:30 AM for complaints of right hand pain.

Observation on 6/16/10 at approximately 10:30 AM revealed two ROM CNAs transferred the resident to bed to perform PROM. The CNA started by performing left arm/shoulder flexion (bending of a joint) and extension (straightening movement). When the CNA moved the resident's left arm to perform shoulder abduction (movement away from the body)/ adduction (movement toward the body) the resident stated "ow" for the first two repetitions. The CNA instructed the resident to relax and completed the next 5 repetitions. With left knee PROM the resident stated "ow" once and continued with facial grimacing through the remainder of the 5 repetitions. The right wrist splint was removed and the resident stated "ow" and "oh" with facial grimacing and guarding her hand. When the CNA performed wrist flexion and extension the resident mumbled "I can't stand it" with facial grimacing and the CNA completed 5 repetitions. With the right leg raise the resident stated "oh" with the first repetition with facial grimacing, with right knee flexion/extension the resident stated "oh" for a prolonged period of time and the CNA completed the 5 repetitions. When the CNAs were finished, they placed the right hand splint back on the resident. The CNAs did stop occasionally and instruct the resident to "relax", they never asked the resident if she was in pain or discomfort.

Interview with the Licensed Practical Nurse (LPN) Medication Nurse on 6/16/10 at 3:00 PM revealed the CNAs never reported any pain or discomfort to him. The LPN stated he knew the resident had problems with pain particularly her hands and he premedicated her with pain medication in the morning prior to the ROM. The LPN stated he would want to know if the resident had breakthrough pain.

2. Resident #8 has diagnoses of arthritis, organic brain syndrome and has a Stage 2 wound at base of left thumb and second metacarpal (bones of the hand). Review of a Minimum Data Set (MDS) dated 5/10/10 revealed the resident's cognitive skills for daily decision making are severely impaired and short and long term memory is impaired.

Review of a Physician Order dated 6/9/10 revealed an order for Physical Therapy assessment as needed. Review of a Physical Therapy (PT) Evaluation dated 3/15/10 is bilateral lower extremity passive range of motion (PROM - exercised performed on the resident by nursing staff) 5 times a week once a day. Review of an Occupational Therapy (OT) Evaluation dated 3/15/10 is PROM to bilateral upper extremities 5 times a week. Review of a Comprehensive Care Plan dated 6/9/10 indicates PROM to bilateral upper and lower extremities twice a day.

When observed on 6/17/10 at 9:15 AM, during ROM (range of motion - normal range of motion for a joint), the resident was assisted back to bed and the right side of the bed was moved away from the wall, ROM Aide #2 extended the resident's right arm towards the resident's head and the resident called out "ouch". ROM Aide #2 asked the resident not to resist and after completing 3 repetitions (reps) the resident pulled his arm away. ROM Aide #2 stated that they are supposed to do 5 reps on each (joint).

ROM Aide #1 then extended the resident's left arm upward towards the resident's head for 3 reps and stated the resident is resisting.

ROM Aide #2 then performed 2 reps of ROM extension (straightening movement) and flexion (bending of a joint) of the resident's left elbow and 2 reps of abduction (movement away from the body) and adduction (movement toward the body) when the resident called out "ouch" and the CNA stopped. CNA #2 then performed right leg ROM consisting of 2 reps of abduction and adduction and flexion and extension to the resident's left lower leg and stated the resident is resisting and stopped.

ROM Aide #1 then performed left leg extension 5 reps, left knee flexion and extension 4 reps and abduction and adduction for 2 reps.

ROM Aide #2 then walked around the end of the bed and pushed the right side of the bed against the wall and stated she had completed ROM and that the resident was resistive so she would come back later. When this surveyor asked if she was going to perform ROM on the resident hands and feet, ROM Aide #2 said "oh, yes" and did ROM to the resident's right hand and bilateral ankles and the resident tolerated this without calling out. ROM Aide #2 stated she does not perform ROM on the resident's left hand because of the dressing on the hand.

When interviewed on 6/17/10 at 9:30 AM, ROM Aide #2 revealed that the resident says ouch when he has ROM. She further revealed that she has not told the nurse about the resident's pain during ROM.

When interviewed on 6/17/10 at 9:40 AM, the Licensed Practical Nurse (LPN) Unit Coordinator revealed that she would expect the ROM Aides to report to her if the resident was resisting, refusing or having pain and they had not.

Review of a ROM Flow Sheet/Calender dated 6/10 revealed the resident had refused ROM from 6/1/10 to 6/15/10.

During an interview on 6/17/10 at 10:00 AM the LPN Medication Nurse stated the resident gets Tylenol for pain and has not had any this month. She further explained it has not been reported to her by the ROM Aide that the resident is having pain.

Review of a Medication Administration Record dated 6/1/10 to 6/30/10 revealed an order for Tylenol 650 milligrams (mg) every four hours through the peg tube as needed for pain. Further review of the same MAR revealed no documented evidence Tylenol had been administered during this time period.

When interviewed on 6/17/10 at 10:03 AM, the PT Director stated she was not aware that the resident was refusing ROM for the last three weeks and that the ROM Aide had not reported to her that the resident was having pain during ROM.

During an interview on 6/17/10 at 10:05 AM, ROM #1 stated the resident has pain during ROM but she assumed that all resident's got something for pain and did not tell anyone.

415.12

Based on observation, record review and staff interview, a resident with a limited range of motion (ROM) did not receive appropriate treatment and services to increase range of motion and/or prevent further decease in ROM. One (Resident #14) of three residents reviewed for ROM had an issue with ROM not provided per Occupational Therapy recommendations. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #14 has diagnoses which include hypertension, idiopathic scoliosis (abnormal curvature of the spine), and osteoporosis. Review of a Minimum Data Set (MDS) dated 3/14/10 revealed the resident has modified independence for decision making, sometimes understood, and sometimes understands.

Review of a Physical Therapy Evaluation dated 3/2/10 revealed the resident has multiple contractures of both lower extremities with recommendations for Passive Range of Motion (PROM - exercises performed on the resident by nursing staff) to both lower extremities 5 times a week. Review of an Occupational Therapy Evaluation dated 3/1/10 revealed the resident has contractures of both shoulders, left wrist, and severe kyphosis (outward curvature of the spine) with recommendations for PROM to both upper extremities 5 times a week.

The Range of Motion (ROM) Aide #1 was observed on 6/17/10 at 9:45 AM completing ROM on the resident's lower extremities only. The ROM Aide did not attempt to range the resident's upper extremities.

Interview with the Licensed Practical Nurse (LPN) Unit Coordinator (UC) on 6/17/10 at 10:00 AM stated the resident should be getting ROM to both upper and lower extremities. In addition, the LPN UC stated therapy is responsible for updating the ROM Aide worksheet. During an interview with ROM Aide #1 on 6/17/10 at 10:10 AM the ROM Aide stated the resident does not receive ROM to the upper extremities and she hasn't completed any ROM to the resident's upper extremities.

Review of the Range of Motion and Walking Club work sheet utilized by the ROM Aides dated 6/17/10 page 1 revealed the resident received PROM to both lower extremities every day with no documented directives to complete ROM on the upper extremities. Review of page 2 on the worksheet documented the resident should receive PROM to both upper extremities every day.

Interview with ROM Aide #2 on 6/17/10 at 10:20 AM revealed the work sheet did have directives to complete upper extremity ROM on page 2. ROM Aide #2 stated she does complete upper extremity ROM.

Review of the ROM Flow Sheet/Calendar for 4/10 to 6/17/10 revealed ROM Aide #1 was responsible for the resident's ROM 26 of 50 opportunities.

415.12(e)(2)

Based on record review and staff interview, the pharmacist did not report drug regimen irregularities to the attending physician and the director of nursing. One (Resident #3) of 21 resident's reviewed for drug regimen reviews had an issue involving the lack of Pharmacist identification and recommendation for a gradual dose reduction for a medication used for insomnia. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #3 has diagnoses which include dementia and unspecified psychosis. Review of the Minimum Data Set (MDS) dated 5/12/10 revealed the resident has severely impaired cognition with short and long term memory problems.

Review of Physician's Orders, dated 6/17/09 to 6/11/10 revealed orders for Trazodone (antidepressant medication used for insomnia) 25 milligrams (mg) tablet, by mouth at bedtime for insomnia.

Review of Medication Administration Records (MAR), dated 6/1/09 to 6/15/10 revealed Resident #3 received Trazodone 25 mg every night at bedtime for insomnia.

Review of an Interval Note written by a Nurse Practitioner dated 3/8/10 revealed the resident has dementia and receives Seroquel (antipsychotic medication) 50 mg twice a day, Trileptal (seizure medication) 150 mg three times a day, and Trazodone 25 mg for sleep at bedtime.

An Initial Psychiatry Consult dated 6/24/09 documented that the resident was unable to participate in the treatment plan with recommendations to continue Trileptal 150 mg po tid, Seroquel 50 mg po bid and Trazodone 25 mg po at bedtime. "We will follow him as recommended by the PMD (Primary Medical Doctor) and maintain safety measures".

Review of a BMARC (behavior modification assessment record committee) Committee Recommendations form dated 4/22/10 revealed the current Psychotropic Medication included: Trileptal 150 mg po TID (three times a day), Seroquel 50 mg BID (twice a day) and Trazodone 50 mg at bedtime. Additional review of the form revealed the sections titled "Diagnosis", "Date Last Changed" and "Effect were blank. Documented Recommendation included "Seen by Psychiatrist 6/09, no changes at this time" and the section for GRD (gradual dose reduction) was blank.

Review of Pharmacy Consultant Reports, dated 6/23/09 to 5/13/10 revealed no documented comments regarding the indication for the use of Trazodone for Insomnia and there were no recommendations to consider an attempt to taper the insomnia medication quarterly.

Interview with the Registered Nurse (RN) Unit Coordinator on 6/16/10 at 10:40 AM, confirmed there is no documentation in the Nurses Notes that the resident has trouble sleeping. The RN Unit Coordinator stated that the Trazodone may have been started back in 10/08 when the resident was singing during the night.

Interview with the Director of Nursing (DON) on 6/16/10 at 10:50 AM revealed that Resident #3 is reviewed by BMARC every 6 months. The DON stated that the last review by BMARC on 4/22/10 referred back to the last Psychiatrist review on 6/09 when he said to continue the Trazodone. The DON stated "we do not look at hypnotics on a quarterly basis but we do try to eliminate hypnotics aggressively on admission".

Further interview with the DON on 6/16/10 at 12:15 PM revealed that the Trazodone was started in 10/08 because the resident was singing during the night.

Interview with the Pharmacy Consultant on 6/17/10 at 12:00 PM revealed he did not recommend a quarterly GDR for the Trazodone because he knew it was originally used for behaviors and not for insomnia. The Pharmacy Consultant stated "I should have made a recommendation to change the insomnia indication on the orders to behavior. When I review I look at the Psych Consult and the BMARC reviews and both of those recommended a continuation of the Trazodone".

415.18(c)(2)

Based on observation, record review and staff interview, the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated that this was not possible. Two (Residents #14, 22) of seven residents reviewed for weight loss had issues involving the lack of timely documentation by dietary to address residents' weight loss and/or gain, lack of evaluation of actual intake following a significant weight loss and dietary interventions were not revised to address significant and continuing weight loss. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #14 has diagnoses which include hypertension, scoliosis (curvature of the spine), and osteoporosis. Review of the Minimum Data Set (MDS) dated 3/14/10 revealed the resident has modified independence for decision making, sometimes understands, and is sometimes understood. Review of the admission face sheet revealed the resident was readmitted to the facility on 3/1/10.

A Dietary Progress Note dated 3/2/10 documented the resident was readmitted with a weight of 85 pounds (#).

Review of the Weight Sheet revealed the resident's weekly weights were as follows:

- 3/1/10 - 85 pounds (#)
- 3/8/10 - 80#
- 3/15/10 - 79#
- 3/22/10 - 76#
- 3/24/10 - 90#

A Nutritional Assessment dated 3/16/10 documented that the resident weighed 85#, had an ideal body weight (IBW) range of 94 to 122#, had a 7 percent (%) weight loss over the last three months, and a plan to monitor weight every week. Additional review revealed the resident's Health Care Proxy would be honored with no feeding tube placement and weight loss is to be expected due to poor intake. "Will continue to monitor". The 3/16/10 Nutritional Assessment did not document the resident's weekly weight loss on 3/8/10 and 3/15/10.

Review of the Dietary section of the medical record revealed there was no documentation regarding the resident's continued weight loss on 3/22/10. Additional review of the Weight Sheet revealed the resident had a significant weight loss of more than 10% from 3/1/10 to 3/22/10.

Review of a facility policy entitled Intake Studies with a revision date of 6/09 revealed an intake study will be conducted when a significant weight loss occurs. An evaluation of calories, fluids, and protein intake will be performed, calculated and meal plan changes will be made as needed. Review of the medical record including Dietary documentation revealed no evidence that an intake study was done.

Review of a facility policy entitled Significant Weight Loss revised 6/09 revealed when a resident has a significant weight loss a reweight should be obtained, the resident placed on weekly weights, a 3 day intake study obtained, the meal pattern evaluated, the RD (Registered Dietitian) consulted for suggestions, and nutritional supplements utilized. Interview with the Registered Dietitian on 6/16/10 at approximately 10:30 AM revealed Resident #14 is followed by the Diet Technician and the RD was not consulted regarding the resident. Interview with the Diet Technician on 6/17/10 at 1:00 PM revealed she doesn't ask for reweights when someone is on weekly weight because by the time she requests the reweight, its the next week.

Additional review of the Weight Sheet revealed the resident weighed 90# on 3/24/10, representing a 14# increase. Review of the medical record on 6/14/10 revealed there was no documentation by dietary regarding the weight gain.

Review of a facility policy revised 5/25/05 revealed any documented weight loss of 5% in 30 days or 10% in 189 days requires a change in care planning, including weekly weights until the problem is resolved. Additionally, a weight gain of 8 pounds in 6 months and a weight of 85 pounds or less should be reported to the physician and to the RD and the Comprehensive Care Plan is to be updated. Additional review of the medical record lacked documentation that the physician, RD or Diet Technician were aware of the resident's weight status.

Additional review of the Weight Sheet revealed the following weekly weights for 4/10:

- 4/5/10 - 85#
- 4/12/10 - 82#
- 4/19/10 - 84#
- 4/20/10 - 72#

The Weight Sheet documented the resident's weight was 84# on 5/3/10 and 83# on 6/1/10. There was no documentation of weekly weights in 5/10 and 6/10. Interview with the Licensed Practical Nurse (LPN) Unit Coordinator (UC) who spoke to the Diet Technician (DT) by phone on 6/15/10 at approximately 10:15 AM revealed the weekly weights were discontinued because the DT felt the resident's weights were stable.

Interview with the Registered Dietitian on 6/16/10 at approximately 10:30 AM revealed the Diet Technician usually completes an intake for residents after hospitalization but she just didn't and she would have obtained reweights on the resident to verify the weights.

The resident was observed being fed by staff on 6/14/10 at the lunch meal and on 6/17/10 at the breakfast meal. Review of the Meal Consumption Log revealed the resident ate approximately 25% of her meals during the week of 6/13/10.

Observation on 6/16/10 revealed the resident was weighed after lunch using a Hoyer scale (mechanical lift scale) with a weight of 79#. Interview with the RD on 6/16/10 at approximately 4:00 PM revealed they usually weigh the resident in a chair scale and it was difficult to get an accurate weight. The RD stated a Hoyer scale will be used from now on.

Review of a Dietary Progress Note dated 6/16/10 revealed 4 ounces of 2 Cal HN (high nitrogen - liquid nutritional supplement) twice a day was added to medication passes, weekly weights will be reinstated to attain a base weight using the Hoyer scale, and a 3 day intake study will be initiated to assess the resident's actual caloric intake.

In summary, there was a lack of timely documentation by dietary to address the resident's weight loss and subsequent weight increase. There was no evaluation of the resident's actual intake following a significant weight loss, and dietary interventions were not revised to address the weight loss.

2. Resident #22 has diagnoses which include volume depletion, protein calorie malnutrition, and anemia. Review of a Minimum Data Set (MDS) dated 11/25/09 revealed the resident was independent in decision making, always understood, and always understands. Review of the admission face sheet revealed the resident was admitted from the hospital on 11/25/09 with bilateral lower leg fractures following a fall at home.

Review of an Initial Nutritional Assessment dated 11/30/09 revealed the resident weighed 130 pounds (#), had an ideal body weight (IBW) range of 99 to 128#, a goal weight of 125 to 135# and received a regular diet. The Nutritional Assessment documented that the resident had variable intake, good tolerance, weight was above IBW, and skin was intact. The Assessment documented that the resident had a low albumin and prealbumin levels (blood tests to measure protein levels in the blood, used to determine nutritional deficiency). Additional review of the 11/30/09 Nutritional Assessment revealed the resident's estimated daily calorie need was 1475 to 1770 calories, intake was 25 percent (%) to 75% and the resident received Ensure Plus (liquid nutritional supplement) at breakfast.

Review of the Meal Consumption Logs dated 11/25/09 through 12/7/09 revealed the resident consumed an average of 33.33% at meals.

Review of the Weight Sheet dated 12/7/09 revealed the resident weighed 112#. Review of a Dietary Progress Note dated 12/7/09 revealed the weekly weight was down, the resident had casts on both legs removed and will continue to monitor. There was no documentation regarding the resident's low intake at meals, a visual assessment of the resident, a request for a reweight or of a plan to assess actual intake.

The Weight Sheet documented that the resident's weekly weight was 112# on 12/14/09. A Dietary Progress Note dated 12/18/09 documented the resident's intake was 25 to 50%, weights are down due to cast removal from both legs, multiple skin areas noted, and the resident was receiving Ensure Plus at all meals. Additional review revealed no documented evidence of an assessment of the resident's actual intake to assure nutritional needs were being met.

Review of the Weight Sheet revealed the resident weighed 116# on 12/26/09, 118# on 1/4/10, and 106# on 1/11/10. Interview with the Diet Technician on 6/17/10 at 1:10 PM revealed she had initiated an intake study at that point.

Review of a Dietary Progress Note dated 1/15/10 revealed a three day intake study showed the following:

- Day #1 - Total daily calorie intake was 486
- Day #2 - 485 calories
- Day #3 - 230 calories

The Dietary Progress note dated 1/15/10 documented that the intake study revealed that the resident was not meeting her estimated needs and dietary changes included the addition of fortified cereal at breakfast and fortified potatoes at lunch. The Dietary Progress Note documented that the Ensure Plus was not being taken, with a plan to change to milkshakes with meals. Interview with the Registered Dietitian (RD) on 6/16/10 at approximately 10:00 AM revealed the fortifying agents used were butter and milk as opposed to just water.

Additional review of the Weight Sheet revealed the resident weighed 105# on 1/18/10, 104# on 1/25/10, and 103# on 2/1/10. Review of Dietary Progress Notes revealed no documented evidence that dietary was aware of the continued weight loss and no meal plan changes were made. The next Dietary Progress Note was dated 2/2/10 and revealed a Swallowing Evaluation was completed with recommendations to continue a regular diet and a plan to continue to monitor. The 2/2/10 Dietary Progress Note did not document the resident's continued weight loss.

A Dietary Progress Note dated 2/4/10 documented "Resident noted to be making self throw up at meal times, will continue to monitor." The Note did not document any change or planned dietary intervention.

On 2/8/10, the Weight Sheet documented the resident's weight decreased to 97#. Review of a Dietary Progress Note dated 2/11/10 revealed the resident had slightly improved intake and was consuming 25 to 50% of meals. The Note did not document the resident's weekly weight loss and did not identify planned interventions to prevent further loss.

Review of the Weight Sheet revealed the resident's weight on 2/15/10 was 102# with no indication a reweight was requested. The Weight Sheet documented subsequent weekly weights of 97# on 2/22/10 and 96# on 3/1/10. A Dietary Progress Note dated 3/5/10 documented the resident continues with multiple open areas, variable intake, and a plan to continue to monitor. There was no documentation regarding the continued weight loss or whether dietary interventions were revised to prevent further weight loss.

Further review of the Weight Sheet revealed the the resident weighed 90# on 3/8/10, representing a 16# weight loss since 1/15/10 when the last time a meal plan change was implemented.

Review of a Physician's Order dated 3/8/10 revealed the resident was placed on Comfort Care (conservative, supportive measures provided at the end of life) on 3/8/10.

Interview with the Diet Technician (DT) on 6/17/10 at 1:10 PM revealed she does Intake Studies only if there is a significant weight change. The Diet Technician explained that she spoke with the resident frequently to get preferences and provided alternate items for consumption but didn't document those actions.

In summary, there was lack of documented evidence that nutrition interventions were revised to address the resident's continued weight loss.

415.12(i)(1)

Based on record review and staff interview, the facility did not ensure that a signed, informed consent was obtained before submitting requests for a criminal history record check for new employees. Four of four new employee files reviewed for criminal history record checks (CHRC) did not have documented evidence that signed CHRC consents were obtained. This was a pattern of no actual harm with potential for minimal harm.

The findings are:

1. Review of four new employee files for compliance with the Criminal History Record Check (CHRC) requirements revealed that all four files lacked a CHRC Consent Form (#102) that was signed by the employee.

Interview with the facility's primary current Authorized Person (AP) for CHRC on 6/16/10 at 1:35 PM confirmed there were no consent forms on file. During the interview, the AP explained that the consent forms are attached to the CHRC request forms. The AP stated "I have the employee fill out the request form and then submit electronically. I have the employee read the consent, verbally agree to be finger printed, fill out the request form information and throw out the consent form".

Review of a facility policy entitled State Mandated Criminal History Record Check (CHRC) dated 6/09 revealed "Upon successfully completing the interview process, the prospective employee will complete CHRC Form 102 (Acknowledgement and Consent Form for Fingerprinting and Disclosure of Criminal History Record Information) ...The Human Resource Specialist will be responsible for ensuring that the aforementioned form is completed....All completed forms will become a permanent part of an employee's record. CHRC documentation will be retained for six (6) years after the person ceases to be employed or used by this facility".

402.5(c)(1-4)

Based on observation and record review during a Life Safety Code survey, structural components of the facility were not properly protected from fire. Issues include structural steel trusses/joists and beams, located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction type II (222). This affected four (1, 2, 3, 4) of four resident use floors. This was widespread with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Per NFPA 101 Life Safety Code, 2000 edition, the minimum acceptable construction type for this four story building is type II (222). Per NFPA 220 Standard on Types of Building Construction, 1999 Edition, Construction type II (222) requires that structural components (Exterior load bearing walls, Structural Framing (columns, girders, beams, etc.) and Floor construction) are protected with at least a two-hour fire resistive barrier. This can be accomplished by some type of physical two-hour fire rated protective covering on the structural steel components or by maintaining a two-hour fire rated ceiling assembly.

Observation made in the facility at the First, Second, Third and Fourth floors on 6/15/10 from 9:00 AM until 3:00 PM revealed this building is protected by a complete automatic sprinkler system. Observation made on 6/15/10 from approximately 9:30 AM until approximately 10:50 AM revealed the ceiling assembly located throughout facility corridors and select resident use rooms are comprised of lay in ceiling tiles. Resident room ceilings are monolithic (solid) ceilings. It could not be determined from a review of facility blueprints on 6/16/10 the fire resistance rating of these ceilings. Furthermore, the facility could not provide documentation of a two-hour fire resistive rated ceiling assembly. Observation made above the ceiling tiles at these same times revealed unprotected structural steel trusses/joists throughout all four floors of the facility.

Steel structural I-beams were protected with a spray on fire resistive coating in some areas of the building. Because the steel I-beams are not protected by a spray on fire resistive coating or protected by a two-hour fire rated ceiling assembly, the building is not compliant per NFPA 101 2000 edition and NFPA 220.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 1997 NFPA 101: 13-1.6.2, 13-3.5.1, 1-3.6, 13-1.1.4.1
2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1

Based on observation during a Life Safety Code survey, corridor doors were not properly maintained. Issues include corridor doors that lacked latching mechanisms. This affected one (First Floor) of four resident use floors. This is a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 6/14/10 at approximately 9:20 AM revealed two pairs of double corridor doors, that open to the first floor Dining Room, lacked latching mechanisms that will positively latch and hold the doors in a closed position.

epn 1997 NFPA 101: 13.3.6.3, 13.3.6.3.2
2000 NFPA 101: 19.3.6.3, 19.3.6.3.2
10 NYCRR 415.29(a)(2), 711.2(a)(1)

Based on observation, record review and staff interview during a Life Safety Code survey, two of two elevators were not equipped with Fire Fighters Service Phase II emergency in-car key operation. This affected four (First, Second, Third, Fourth) of four resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 6/14/10 at approximately 9:30 AM revealed there are two elevators in this facility that serve the First, Second, Third and Fourth Floors. Further observation on 6/15/10 at approximately 12:55 PM revealed the travel distance for the elevators is approximately 30 feet. This was determined by counting the steps in the rear stairwell from the ground floor landing to the fourth floor landing. There were 48 steps. The height of each stair riser was 7.5 inches high. When the number of steps was multiplied by the height of the risers the final number is 360 inches (30 feet). Elevators with a travel distance of 25 feet or more are required to be equipped with both Phase I and Phase II elevator recall per NFPA 101 Life Safety Code 2000 edition.

Record review on 6/14/10 at approximately 2:15 PM revealed an independent outside elevator inspection company performs monthly operating inspections of the elevators fire fighter recall features.

Observation inside the elevator cabin on 6/17/10 at approximately 10:20 AM revealed there was no evidence (by way of buttons or labeled key operation features) of Phase II emergency in-car key operation.

An interview with the facility's Environmental Services Director on 6/18/10 at approximately 1:40 PM revealed he had a phone conversation with the elevator technician responsible for the inspection of the facilities elevators. Based on this conversation the elevators are not equipped with Phase II emergency in-car key operation.

epn 1997 NFPA 101: 13-5.3, 7-4
2000 NFPA 101: 19.5.3, 9.4
10 NYCRR 415.29(a)(2), 711.2(a)(1)

Based on observation during a Life Safety Code survey, means of egress were not continuously maintained free of all obstructions. This affected three (Unit Two, Unit Three, Unit Four) of three resident units. The issue includes passable space in the corridor limited to less than four feet due to storage of Soiled Linen trash receptacles and wheelchairs stored in the corridor. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to the following:

1. Observation on 6/15/10 from 1:16 PM until 1:24 PM revealed the Unit Four corridor is six feet wide. The corridor was observed obstructed to less than four feet (48 inches) in the following location by the following items:

a). 44 inches at Room #414 corridor, by a Soiled linen/trash receptacle
b). 49 inches at Room #419 corridor, by a Soiled linen/trash receptacle
c). 42 inches at Room #427 corridor, by a Soiled linen/trash receptacle
d). 45 inches at Room #429 corridor, by an open, unoccupied wheelchair

2. Observation on 6/15/10 from 1:25 PM until 1:29 PM revealed the Unit Three corridor is six feet wide. The corridor was observed obstructed to less than four feet (48 inches) in the following location by the following items:

e). 44 inches at Room #329 corridor, by a Soiled linen/trash receptacle
f). 44 inches at Room #328 corridor, by a Soiled linen/trash receptacle
g). 44 inches at Room #319 corridor, by a Soiled linen/trash receptacle
h). 36 inches at Room #316 corridor, by an open, unoccupied wheelchair
i). 46 inches at Room #319 corridor, by a Soiled linen/trash receptacle

3. Observation on 6/15/10 from 1:30 PM until 1:38 PM revealed the Unit Two corridor is six feet wide. The corridor was observed obstructed to less than four feet (48 inches) in the following location by the following items:

j). 44 inches at Room #212 corridor, by a Soiled linen/trash receptacle
k). 37 inches at Room #213 corridor, by an open, unoccupied wheelchair
l). 45 inches at Room #215 corridor, by a Soiled linen/trash receptacle
m). 44 inches at Room #216 corridor, by an open, unoccupied wheelchair
n). 38 inches at Room #217 corridor, by an open, unoccupied wheelchair
o). 38 inches at Room #218 corridor, by an open , unoccupied wheelchair

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 5-1.10
2000 NFPA 101: 7.1.10

Based on observation during a Life Safety Code survey, oxygen was improperly stored in one of one Main Oxygen storage room. This affected the Service Corridor on the First Floor. Issues include unsecured oxygen cylinders stored within this room. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy

The findings are:

1. Observation on 6/14/10 at approximately 11:55 AM revealed two of six E-sized oxygen cylinders and one of three D-sized oxygen cylinders were stored unsecured, freestanding in the Main Oxygen Storage room located in the First Floor Service Corridor Oxygen Storage room.

10 NYCRR 415.29(a), 711.2(a)(1)
1997 NFPA 101: 13-3.2.4
2000 NFPA 101; 19.3.2.4
1999 NFPA 99: 4.3.1.1.1

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 6/18/09.

Based on observation during a Life Safety Code survey, smoke barriers on two (Second, Third floors) of four resident use floors were not completed from floor to roof deck. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation above the ceiling tiles on 6/15/10 at approximately 10:03 AM revealed an approximate three inch by four foot penetration between the ceiling deck and the Third Floor smoke barrier wall that runs through the Linen room.

2. Observation above the ceiling tiles on 6/15/10 at approximately 10:20 AM revealed an approximate two inch by ten inch penetration and a two inch by three foot penetration through the Second Floor smoke barrier wall that runs through the Shower room.

The Environmental Services Director was present during the above observations.

2000 NFPA 101: 19.3.7.3, 8.3.2
1997 NFPA 101: 13-3.7.3, 6-3.2
10 NYCRR 415.29(a)(2), 711.2(a)(1)

Based on observation during a Life Safety Code survey, stairwell doors were not properly maintained. This affected the First Floor Power Plant room and three (Unit Two, Unit Three, Unit Four) of three resident units that are served by this stairwell. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 6/14/10 at approximately 12:10 PM revealed the stairwell door that opens into the First Floor Power Plant room did not self latch when closed. This stairwell serves Unit 2, 3 and 4. The door did self close but would not latch. When physically pulled shut, the door would not latch.

10 NYCRR 415.29(a), 711.2(a)(1)
1997 NFPA 101: 13-3.6.1, 5-2.1.8
2000 NFPA 101: 19.3.6.1, 7.2.1.8