Degraff Memorial Hospital-Skilled Nursing Facility

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. One (Skilled Unit 2) of two nursing units reviewed for infection control had an issue involving a glucometer (portable medical device used to calculate blood glucose levels), that was not cleaned and disinfected between resident use. Residents #50 and 135 were involved. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #50 has diagnoses including diabetes mellitus, multiple sclerosis and depression.

Resident #135 has diagnoses including diabetes mellitus, hypertension and depression.

Observation on 9/23/10 at approximately 7:12 AM revealed a Registered Nurse (RN) performed a glucometer (portable medical device used to calculate blood glucose levels) reading on Resident #135. The glucometer was observed to be clean. The RN wore gloves and performed the procedure without any evidence of blood or body fluid contamination.

When the RN finished the blood glucose testing, she discarded the lancet (a pricking needle used to obtain drops of blood for testing) and test strip, removed her gloves, washed her hands and placed the glucometer on the medication cart. The RN did not cleanse the glucometer after it was used for Resident #135.

Continued observation revealed the RN took the glucometer and performed a glucometer reading on Resident #50 on 9/23/10 at approximately 7:24 AM. The RN used a lancet to prick the resident's right middle finger and a small amount of blood was visualized. The RN placed the resident's right arm down toward the floor and compressed his finger using her two gloved hands. The blood started to flow from the resident's finger and small blood smears were observed on the resident's finger. The RN obtained the required amount of blood to perform the reading, and when she was done, the RN discarded the lancet, test strip, removed her gloves, washed her hands and placed the glucometer in the storage base at the nurse's station.

Interview with the RN on 9/30/10 at approximately 7:30 AM, revealed the facility policy it to clean the glucometer with Cavi-wipes (disinfectant wipes) between resident use and she forgot.

Review of a facility policy and procedure entitled Glucose Testing dated 6/1/09 revealed the glucose meter is to be cleaned with a Cavi-wipe if it is visibly dirty. The Cavi-wipe is used to clean the surface of the meter.

415.19(b)(2)

Based on observation, record review and staff interview, the facility did not ensure that all controlled medications were disposed in accordance with State requirements. Two (Residents #68, 96) of six residents reviewed for controlled medications had issues involving the lack of witnesses for the disposal of controlled drugs. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #68 has diagnoses which include hypertension, depression and pain.

Review of Physician's Orders for the period of 5/25/10 through 9/29/10 revealed an order to apply a Fentanyl 25 micrograms (mcg) per hour patch topically every 72 hours for pain - "Controlled Substance".

Review of Medication Administration Records (MARs) dated 6/1/10 through 9/29/10 revealed documentation that:

- The disposal of the Fentanyl Patch was witnessed 4 of 10 times from 6/1/10 to 6/30/10.
- The disposal of the Fentanyl Patch was witnessed 2 of 11 times from 7/1/10 to 7/31/10.
- The disposal of the Fentanyl Patch was witnessed 3 of 9 times from 8/1/10 to 8/31/10 with
no record of patch application or disposal for 8/12/10.
- The disposal of the Fentanyl Patch was witnessed 2 of 8 times from 9/1/10 to 9/28/10.

During an interview on on 9/29/10 at 10:55 AM, the Registered Nurse (RN) Medication Nurse stated "I applied the Fentanyl Patch on 9/28/10. There was no patch in place, I told the desk nurse. I should document that there was no patch in place. I was the desk nurse on 9/22/10 for the 7:00 AM to 3:00 PM shift. The change of the Fentanyl Patch and disposal was not brought to my attention. It is the responsibility of the nurse changing the patch and disposing of it to get a second nurse to witness the disposal. Any nurse working can witness the disposal".

Review of the MAR dated 9/10 revealed the disposal of the Fentanyl Patch was not documented as witnessed on 9/22/10, the 9/25/10 disposal was witnessed and the 9/28/10 disposal was not documented and there was no documentation on the MAR that the patch was missing. During the interview with the RN Medication Nurse on 9/29/10 at 10:55 AM, the RN was observed to document the missing patch on the back of the MAR.

During an interview on 9/29/10 at 11:05 AM, the Unit 2 RN Nurse Manager (NM) stated "Waste is supposed to be initialed. The (time of the) application of the patch was changed to 10:00 AM on 9/22/10. I was not the Desk Nurse on that day, so I can not say what happened. The patch was previously changed at 5:00 PM, during the 3:00 PM to 11:00 PM shift. I cannot say who witnessed the wasting of the patch on the 3:00 PM to 11:00 shift". The RN NM also stated "It was reported that the resident lost the patch in the shower on 9/28/10. We looked for the patch in the laundry and bed but could not find it. Since it was the day for the next scheduled application, we put on the next patch."

Interview on 9/29/10 at 11:21 AM, with the Unit 1 RN NM, who was acting as the Interim Director of Nursing (DON) revealed "the facility expectation is that the disposal of the patches is witnessed. If the (missing) patch is not found, there should be a note documenting that it was not found and there should be a co-signature on the MAR that the patch was missing and looked for".

Review of a facility policy and procedure (P&P) entitled "Corporate Controlled Substances Handling" dated 7/15/02 revealed "Wasting of controlled substances: Every controlled substance that is removed to be administered to a patient must be fully accounted for. Frequently, partial doses of the medication removed are administered; the remainder must be immediately wasted (flushed down a toilet or sink) in the presence of another licensed professional and documented (including the amount wasted and the signature of the witness)". In addition, the P&P documented "Disposing of used/discontinued transdermal (medicated adhesive patch placed on the skin) medication delivery systems: Medications which are delivered using transdermal patches require additional safeguards during their disposal (whether they have been discontinued during a dosing interval or are considered "empty"). If a transdermal delivery system is discontinued, the remaining contents needs to be documented as waste (in terms of approximate days' supply remaining in the patch) and destroyed with a witness. To appropriately destroy a transdermal delivery system (whether discontinued or replaced because it is "empty"), the transdermal patch must be folded in half (adhesive to adhesive) and flushed down a toilet. Transdermal patches should never be cut open during the destruction process."

Interview with the DON, on 10/4/10 at 9:40 AM, revealed it was her understanding "that the wasting of a patch is to be witnessed if there was still dosage left in the patch, as indicated by the policy". The DON stated "I did not think that the disposal of empty patches needed to be witnessed. I now understand that the disposal of all patches should be witnessed, and we have clarified this policy An additional measure I will put into place is to have nursing verify the placement of the patch every shift."

Interview with the Consultant Pharmacist on 10/4/10 at 9:40 AM revealed the facility policy is unclear as to the disposal of the empty patches. The Pharmacist stated "the policy will have to be modified to state that all the patches, whether active or used, will have to be witnessed when disposed of".

2. Resident # 96 has a diagnosis of osteoporosis and a history of pain. The Minimum Data Set (MDS) dated 4/19/10 documented that the resident had severely impaired cognitive skills for decision making. Review of a Physician's Order dated 9/27/10 revealed an order to administer Hydrocodone-APAP (Acetaminophen - Tylenol) 10-500 (narcotic pain medication) via the PEG (percutaneous endoscopic gastrostomy - feeding tube inserted into the stomach) tube QID (four times daily).

During an observation of medication administration on 9/27/10 at 9:30 AM, a Licensed Practical Nurse (LPN) poured Hydrocodone-APAP 10-500 one tablet into a plastic packet and crushed the tablet. The LPN went to the resident's room, dropped the medication packet on the floor and stated she was going to repour the medication. The LPN was observed to pick up the packet and disposed the medication in the toilet. The LPN stated she would have to obtain another dose.

During an interview on 9/27/10 at 10:04 AM, the LPN stated she did not know what the policy was for discarding a narcotic medication. After obtaining a second Hydrocodone-APAP 10-500 tablet, the LPN stated she should have had someone watch her waste the first Hydrocodone - APAP tablet.

415.18(e)(4)

Based on observation, record review, staff and resident interview, the services provided or arranged by the facility did not meet professional standards of quality. Six (Residents #6, 15, 68, 96, 134, 141) of 30 residents reviewed for professional standards had the following issues. There was a lack of physician notification that a medication was not administered as ordered, documentation on the Medication Administration Record (MAR) was falsified, and there was a lack of consistent documentation that a controlled medication was witnessed when disposed in accordance with State requirements. In addition, there was a lack of documented evidence of measures utilized to address the resident's discomfort and physician orders did not include parameters/indications for use or the correct route of administration. 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:

1. Resident #96 has a diagnosis of osteoporosis and a history of pain. The Minimum Data Set (MDS) dated 4/10/10 revealed the resident's cognitive skills for daily decision making are severely impaired.

a). Review of the Physician Order dated 9/27/10 and the Medication Administration Record (MAR) dated 9/1/10 to 9/30/10 revealed an entry for Fentanyl (controlled substance - used to treat pain) 50 micrograms (mcg) per hour patch every 72 hours for pain.

When observed on 9/27/10 at 10:20 AM, the Licensed Practical Nurse (LPN) #1 Medication Nurse removed the Fentanyl patch from the resident's left upper back and reapplied a Fentanyl patch to the resident's right back and left the room with the used patch.

Review of the Medication Administration Record (MAR) dated 9/1/10 to 9/30/10 on 9/27/10 at 10:30 AM, revealed the Fentanyl patch was documented as administered on 9/3/10, 9/9/10, 9/12/10, 9/15/10, 9/18/10, 9/27/10 but there was no documented evidence of a second initial indicating that the patch was witnessed as discarded on those dates.

On 10/1/10 at 9:30 AM, the MAR dated 9/1/10 to 9/30/10 was reviewed again. Documentation revealed a second nurse's initial was below the nurses initials that administered the Fentanyl patch on 9/3/10, 9/9/10, 9/12/10, 9/15/10, 9/18/10, and 9/27/10. These initials were not documented in the MAR on 9/27/10.

During an interview on 10/1/10 at 9:58 AM, Medication LPN #2 stated when she administers a Fentanyl patch she "grabs a nurse" to go with her, removes the Fentanyl patch, and the other nurse witnesses her flush the Fentanyl patch down the toilet. The LPN explained she initials the MAR that she removed the old patch and then applies the new patch. The second nurse initials the MAR as a witness that the Fentanyl patch is disposed of in the toilet.

During an interview on 10/1/10 at 10:00 AM, the Registered Nurse (RN) Nurse Manager (NM) observed the second initials on the 9/1/10 to 9/30/10 MAR on 9/3/10, 9/9/10, 9/12/10, 9/15/10, 9/18/10, 9/27/10 and stated she initialed the MAR after she watched the nurse discard the Fentanyl patch in the resident's bathroom toilet. When the RN observed the copy of the MAR dated 9/1/10 to 9/30/10 that was provided to the surveyor on 9/27/10 with the above dates blank, the NM stated that those were her initials but that she did not initial the MAR on those dates and does not know who wrote her initials in the MAR on those dates. The RN explained that not witnessing the disposal of Fentanyl patches was an issue and one of the staff may have put my initials on the MAR.

b). Additionally, Resident #96 has a PEG tube (percutaneous endoscopic gastrostomy tube - feeding tube inserted into the stomach). The Physician Order dated 9/27/10 and the MAR dated 9/1/10 to 9/30/120 revealed an order for Abilify (medication used to help treat depression) 1 milligram (mg)/milliliter (ml) solution (10 ml =10 mg) po (by mouth) q am (every morning).

When observed on 9/27/10 at 10:20 AM, LPN #1 administered Abilify 10 ml solution through the resident's peg tube.

When interviewed on 9/27/10 at 11:35 AM, the LPN reviewed the MAR 9/1/10 to 9/30/10 Abilify 1 mg/ml solution 10 ml = 10 mg po (by mouth) every am and stated "That is not possible and it should not be by mouth".

2. Resident #6 has diagnoses including diabetes mellitus and history of cerebrovascular accident (stroke). Review of the Minimum Data Set (MDS) dated 8/16/10 revealed the resident has intact short and long term memory, modified independence for daily decision making, understands and is understood. Review of the 8/6/10 Physician's Orders revealed an order for Metformin (diabetic medication) 850 milligrams (mg) orally three times a day with meals.

Review of the Medication Administration Record (MAR) for 8/10 revealed on 8/16/10 at 12:00 PM Metformin was initialed and circled indicating it was not given. Review of the MAR PRN, Stat & Medications Omitted Sheet noted that on 8/16/10 Metformin not given-did not return to floor after cafe lunch.

Review of the Progress Notes from 7/15/10 through 9/24/10 revealed no documented evidence that the nurse attempted to locate the resident, that education was provided regarding the importance of returning to the unit for medication, that the resident's blood sugar was checked upon return or that the Physician was contacted.

During an interview with the Registered Nurse (RN) Nurse Manager on 10/1/10 at 11:00 AM, the RN stated that he would expect the nurse to locate the resident and administer the medication or contact the MD for an order to hold the Metformin. The Medication Nurse who omitted the Metformin was not available for interview.

3. Resident #68 has diagnoses which include hypertension, depression and pain.

Review of Physician's Orders, for the period 5/1/10 to 9/29/10 revealed an order for Prochlorperazine (Compazine - medication used to treat nausea and vomiting) 25 milligrams (mg), insert one suppository every 12 hours as needed. There is no indication for use. Review of the original order, dated 10/7/09, revealed "Compazine 25 mg rectal suppository every 12 hours as needed".

During an interview with the Registered Nurse (RN) Nurse Manager, on 9/29/10 at 12:45 PM, the RN stated "I'm surprised that the indication is not there. Pharmacy always makes us write it in. I found the original order, 10/7/09, but the nurse did not write in the indication. It's supposed to be for nausea. The nurse doesn't work here any more".

During an interview with the Consultant Pharmacist on 9/30/10 at 10:15 AM, the Pharmacist stated "There is no indication for the Prochlorperazine, there should be. It's for nausea and vomiting. I check the orders for indications during the Monthly Regimen Review. I just missed this one".

4. Resident #134 has diagnoses including congestive heart failure, diabetes mellitus, and coronary artery disease. Review of the Minimum Data Set (MDS) dated 9/21/10 revealed the resident has no memory impairment, is independent in cognitive skills for daily decision making, understands and is understood.

Review of Physician's Orders dated 9/7/10 revealed an order for Acetaminophen (Tylenol) 325 tab, 2 tabs (dose = 650 mg) every 4 hours as needed for discomfort/fever). The order did not include temperature parameters for which to administer the Acetaminophen.

5. Resident #141 has diagnoses including cerebrovascular accident (CVA - stroke). Review of the Minimum Data Set (MDS) dated 9/6/10 revealed the resident has modified independence for daily decision making skills, is usually understood and usually understands. The resident's long and short term memory is intact. In addition, the resident requires assistance as follows: transfer extensive assistance/2 people, dressing extensive assistance/1 person, eating set-up only, personal hygiene extensive assistance/1 person, and toilet use extensive assistance/2 people. The resident has full loss of voluntary movement of the arm, hand, leg and foot on one side and partial loss of voluntary movement for other limitations.

Review of the Care Planning Report (comprehensive care plan) dated 9/11/10 revealed the resident has cognitive deficits related to the CVA. The resident has impaired mobility related to the CVA, and is non-ambulatory. The resident uses a manual wheelchair, a sit to stand lift with two person assist utilizing a band sling, support left arm during transfer. In addition, the resident must have trunk support at all times while sitting to maintain balance, extensive assistance for bed mobility/2 persons with partial side rails for mobility. For pain the care plan indicates the resident has "general discomfort" with interventions to provide medications as ordered and position for comfort.

Review of the Pain Management Evaluation dated 9/8/10 revealed the resident had a pain score of "0" on the Wong-Baker Faces (child pain scale).

During an interview with the resident on 9/27/10 at approximately 11:00 AM, the resident stated he has pain when some of the staff provide care and added they are not careful with his left arm (arm affected by the stroke).

Observation on 10/1/10 at 6:30 AM revealed the certified nurse aide (CNA) was providing AM (morning) care while the resident was in bed. The resident's lower torso was dressed and a bath blanket was on the resident's upper torso while the CNA was shaving the resident. When the CNA was finished she applied roll-on deodorant to the resident's underarms. When the CNA applied deodorant to the resident's left arm, she instructed the resident to lift his arm (left). The resident raised his left arm approximately 15 degrees and when the CNA picked the resident's left arm up by the elbow, the resident stated "ow, ow, ow". The CNA continued to raise the resident's arm further even though the resident resisted. The CNA then dressed the resident with a Tee shirt without incident. Observation of a stand to lift transfer during the same observation the CNA held the resident by the left arm for balance, the resident stated "ow" 3 times.

Interview with the CNA, who identified herself as the resident's primary CNA, on 10/1/10 at 9:30 AM revealed the resident always has discomfort. The CNA stated she reports the resident's pain to the team nurse and they usually medicate him with Tylenol. After further questioning, the CNA stated the resident usually exhibits pain in the left arm at least 4 times during the week and recalled the resident received Tylenol several times during the month of September. The CNA stated she used the resident's left arm to stabilize him during transport.

Review of the current CCP revealed it is not individualized to assess the level of pain reported by the resident and known by his personal care aide.

Interview with the RN Night Staff Nurse on 10/1/10 at 7:00 AM revealed she has never had staff report that the resident was in pain. Interview with the RN Nurse Manager (NM) on 10/1/10 at approximately 7:00 AM revealed she knew of no reports of pain for the resident.

415.11(3)(c)(i)

Based on observation, record review and staff and resident interview, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. One (Resident #28) of four residents who require staff assistance for activities of daily living (ADLs) did not receive staff assistance with brushing teeth. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #28 has diagnoses including multiple sclerosis (MS), and arthritis. Review of the Minimum Data Set (MDS) dated 8/16/10 revealed the resident has modified independence for daily decision making, understands and is understood. Additional review of the MDS revealed the resident requires extensive assistance for personal hygiene.

Review of a Dental Progress Note signed by the Dentist dated 3/15/10 revealed the resident had a chipped tooth; multiple carious (decayed) and unrestorable teeth; and the resident was undecided about treatment options. Review of a Long Term Care Oral Evaluation Form dated 3/15/10 revealed a recommendation to brush twice daily.

An Oral Evaluation Form dated 4/2/10 documented the resident had "multiple nonrestorable teeth; resident undecided. Treatment Plan: Annual exam. Recommendation: brush/rinse twice daily".

A Dental Progress Note dated 8/9/10 documented the resident was seen for pain in the upper left side of her mouth; on exam multiple nonrestorable teeth and the resident was told she needed extractions.

Review of the Care Planning Report (Comprehensive Care Plan) for Personal Care Regime dated 9/28/10 revealed the resident has general weakness due to MS with interventions for extensive assistance for upper extremities and that the resident is "independent post set up with teeth". The Care Planning Report for "Oral Hygiene" documented the resident "has own teeth, some with multiple caries; history of tooth extractions related to infection". The Care Planning Report documented and intervention for Dentist - Consults as indicated and prn (as needed).

Review of the current Care Guide, used by certified nurse aides (CNAs) to provide care, printed 9/28/10 revealed the resident has her "own teeth" and is "independent post setup with teeth".

Interview with the resident on 9/27/10 at 4:00 PM revealed she knows she needs dental work, but refuses to have her teeth pulled. The resident stated the CNAs brush her teeth once a day, in the morning. The resident stated she'd like her teeth brushed at night but "it doesn't get done". During an interview on 10/1/10 at 11:35 AM, the resident repeated that her teeth do not get brushed in the evening.

When interviewed on 10/1/10 at 2:45 PM the evening shift CNA who is regularly assigned to the resident, stated he doesn't brush the resident's teeth in the evening because the resident snacks all evening.

During an interview on 10/1/10 at 2:55 PM, the Registered Nurse (RN) Nurse Manager stated he was unaware that the resident was not getting her teeth brushed in the evening.

415.12(a)(3)

Based on observation, record review and staff interview, the facility did not develop, review and revise the resident's comprehensive plan of care. Two (Residents #32, 68) of 25 residents reviewed for comprehensive care plans had issues involving the lack of care plan development for treatment of pressure sores and use of a controlled substance for pain. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #32 has diagnoses of diabetes mellitus, multiple sclerosis, depression, and neurogenic bladder. Review of the Minimum Data Set (MDS) dated 8/9/10 revealed that the resident has modified independence in cognitive skills for daily decision making, short term memory problems, and intact long term memory. Review of the Braden Scale dated 8/11/10 revealed the resident was at moderate risk for skin breakdown. Review of the Care Planning Report (Comprehensive Care Plan) for Skin Integrity, dated 9/29/10 revealed the resident has the potential for skin breakdown due to decreased mobility, incontinence, and use of psychotropic medications. The interventions included treatment as ordered, Braden Scale quarterly and as needed (prn), encourage completion of meals, turn and reposition resident every 2 hours and prn, observe skin for changes and report as needed. The Care Planning Report did not include a plan for the treatment of pressure ulcers.

When observed on 9/30/10 at 9:49 AM, Licensed Practical Nurse (LPN) #3 removed the resident's right foot dressing which revealed an approximately 3 centimeters (cm) round pressure sore.

On 9/30/10 at 10:16 AM, as certified nurse aide (CNA) #1 turned the resident onto his right side, an approximately 2 cm length by .5 cm width stage 2 pressure ulcer was observed on the right mid gluteal (buttocks) fold.

When interviewed on 9/30/10 at 3:10 PM, the Registered Nurse (RN) Nurse Manager (NM) said that she is responsible for care plan development and said she had not had time to develop a pressure ulcer care plan.

2. Resident #68 has diagnoses which include hypertension, depression and pain.

Review of the Physician's Orders, for the period 5/25/10 through 9/29/10, revealed an order for Fentanyl 25 micrograms (mcg) per hour patch, apply 1 patch topically every 72 hours for pain. The order included a note that this drug was a controlled substance.

Review of the Resident's Care Planning Report, Effective Date: 10/4/10 revealed a care plan for pain that included the following interventions:

- medications as ordered,
- position for comfort,
- offer diversional activity,
- note effectiveness of pain control.

The care plan did not include a plan for the use of the Fentanyl patch.

When interviewed on 10/5/10 at 10:30 AM, the RN Charge Nurse said that the Unit Manager is responsible for writing the care plan. She said there should be instructions on the care plan for the use of the patch and to monitor the resident's pain control.

415.11(c)(1)

Based on observation, record review, staff and resident interview, the facility did not ensure that the resident's comprehensive care plan was periodically reviewed and revised by a team of qualified persons after each assessment. Three (Residents #28, 141, 191) of 25 residents' care plans reviewed had issues involving a lack of care plan revisions to address anticipated/actual loss of independent community living, frequency of oral hygiene, and left arm pain. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #191 has diagnoses which include surgical repair of a hip fracture, hypertension, and congestive heart failure. Review of the Minimum Data Set (MDS) dated 7/29/10 revealed the resident is independent in decision making, has intact memory, is always understood and always understands. The MDS documented that the resident had mood indicators present which were easily altered including a depressed, sad or anxious mood. The 7/29/10 MDS documented that the resident's mood status "deteriorated" as compared to status 90 days ago. Review of the Resident Assessment Protocol (RAP) Summary dated 7/29/10 revealed the resident triggered for Psychosocial Well Being and Mood State with a notation that RAP Assessment Documentation was in the Social Work (SW) notes.

Review of the Care Planning Report for Discharge Planning (dated 7/16/10) documented that the resident lives alone and plans to return to her apartment when able. The Care Plan documented a goal for the resident to safety return to the community with the support of the interdisciplinary team. Interventions include weekly interdisciplinary team meetings to discuss progress and any obstacles to discharge.

Review of the Care Planning Report for Behavior (comprehensive care plan) dated 7/24/10 revealed the resident was "pleasant and cooperative" with a goal that the resident will continue to be free of mood and/or behavior problems. Interventions include plans for staff to help the resident with "adjustment to floor and routine changes" and to monitor for any changes in mood/behavior and report to MD at onset.

Review of a SW Progress Note dated 7/16/10 revealed the resident was alert and oriented x (times) 3 (to person, place and time) and able to make her needs known. The Social Worker documented that the resident had been living alone in a one story apartment. An Occupational Therapy (OT) Evaluation dated 7/16/10 documented that the resident stated "I want to be independent again".

Review of Physician Orders dated 7/23/10 revealed an order for Xanax (antianxiety medication) 0.25 milligrams (mg) every 4 hours PRN (as needed) for increased anxiety. Review of the Medication Administration Record (MAR) dated 7/16/10 to 7/30/10 revealed Xanax was not administered.

Review of a SW Progress Note dated 8/2/10 revealed concerns regarding discharging the resident home were discussed with the resident's family. A SW Progress Note dated 8/6/10 revealed a meeting was held with the resident and her family on 8/4/10. The Social Worker documented she discussed the resident's functional limitations, inability to return home alone and provided information for assisted living. The Social Worker documented "Resident was very sad, tearful that she is not able to return to her apartment".

Review of a Physical Therapy (PT) Plan of Care Progress Note dated 8/5/10 revealed the interdisciplinary team decided the resident would be safer in assistive living. The Progress Note documented that the resident stated "I don't understand it, I thought I was doing so well. They say I need to go to an Assistive Living Facility. Why can't I go home?".

A SW Progress Note dated 8/11/10 documented that a discharge planning meeting was held and Adult Day Care information was provided to the family.

Review of the MAR dated 8/1/10 through 8/26/10 revealed Xanax 0.25 mg was administered to the resident due to increased anxiety on 21 of the 26 days with positive effects.

Review of a SW Progress Note dated 8/25/10 revealed a discharge home was planned for 8/28/10.

Review of Care Planning Reports dated 7/24/10, 7/29/10, and 8/27/10 revealed there were no revisions regarding an alternate discharge plan and no revisions to the behavior plan to address the resident's increased weepiness and anxiety.

Interview with the Director of Social Work, on 10/5/10 at 10:45 AM revealed she would have expected the Social Worker to have updated the resident's Care Plan regarding the changes in the discharge destination and the changes in her behavior. The Director explained that the Care Plan is generally updated at the care plan meetings and the discipline responsible for the care area is responsible to update it.

2. Resident #141 has diagnoses of cerebrovascular accident (CVA - stroke). Review of the Minimum Data Set (MDS) dated 9/6/10 revealed the resident has modified independence for daily decision making skills, is usually understood and usually understands. The resident's long and short term memory is intact. In addition, the resident requires assistance as follows: transfer extensive assistance/2 people, dressing extensive assistance/1 person, eating set-up only, personal hygiene extensive assistance/1 person, and toilet use extensive assistance/2 people. The resident has full loss of voluntary movement of the arm, hand, leg and foot on one side and partial loss of voluntary movement for other limitations.

Review of the Care Planning Report (Comprehensive Care Plan (CCP)) dated 9/11/10 revealed the resident has cognitive deficits related to CVA. The resident has impaired mobility related to CVA is non-ambulatory, uses a manual wheelchair, use of a sit to stand lift with two person assist utilizing a band sling (sling with a wide body component for increased support of the upper torso), support left arm during transfer, must have trunk support at all times while sitting to maintain balance, extensive assistance for bed mobility/2 persons with partial side rails for mobility. For pain the care plan indicates the resident has "general discomfort" with interventions to provide medications as ordered and position for comfort.

Review of the Pain Management Evaluation dated 9/8/10 revealed the resident had a pain score of "0" on the Wong-Baker Faces (Child pain scale).

Interview with the resident on 9/27/10 at 11:00 AM revealed the resident has pain when some of the staff provide care and they are not careful with his left arm (arm affected by the stroke).

Observation on 10/1/10 at 6:30 AM revealed the certified nurse aide (CNA) was performing AM care with the resident in bed. The resident's lower torso was dressed and the CNA was in the process of shaving the resident, and a bath blanket was on the resident's upper torso. When the CNA was finished she applied roll-on deodorant to the resident's underarms. When she applied deodorant to the resident's left arm she instructed the resident to lift his arm (left). The resident was observed to raise his arm minimally and the CNA picked the resident's arm up by the elbow. The resident stated "ow, ow, ow" and the CNA continued to raise the arm further despite resistance was visible by the resident. The CNA then dressed the resident with a Tee shirt without incident. Additional observation of a stand to lift transfer revealed the CNA held the resident by his left arm for balance. During the transfer the resident stated "ow" 3 times.

Interview with the CNA, who identified herself as the resident's primary CNA, on 10/1/10 at 9:30 AM revealed the resident always has discomfort, she reports it to the team nurse and they usually medicate him with Tylenol. After further questioning the CNA recalled the resident received Tylenol several times in the month of September. The CNA also recalled the resident usually exhibits pain in the left arm at least 4 times during the week. The CNA stated she used the resident's left arm to stabilize him during transport.

There was no documented evidence that the current Care Planning Report was revised and individualized to address the level of pain reported by the resident and known by his personal care aide

3. Resident #28 has diagnoses including multiple sclerosis, hypertension, and arthritis. Review of the Minimum Data Set (MDS) dated 8/16/10 revealed the resident has modified independence, understands and is understood.

Review of a Dental Progress Note dated 3/15/10 and signed by the dentist revealed the resident had a chipped tooth, multiple carious and unrestorable teeth, with the resident undecided about treatment options. Review of a Long Term Care Oral Evaluation Form dated 3/15/10 revealed a recommendation to brush twice daily.

An Oral Evaluation Form dated 4/2/10 documented multiple nonrestorable teeth; resident undecided. Treatment Plan: Annual exam. Recommendation: brush/rinse twice daily. A Dental Progress Note dated 8/9/10 documented the resident was seen for pain in upper left side of her mouth; on exam multiple nonrestorable teeth. Patient was told she needed extraction.

Interview with the resident on 9/27/10 at 4:00 PM revealed she knows she needs dental work, but refuses to have her teeth pulled. The resident also stated the aides brush her teeth once a day, in the morning. The resident stated she'd like her teeth brushed at night but "it doesn't get done".

Review of the Care Planning Report (Comprehensive Care Plan) dated 9/28/10 revealed for "oral hygiene" the identification of "has own teeth, some with multiple caries; history of tooth extractions related to infection", with one approach: dentist--consults as indicated and prn. The "Personal Care Regime" section of the care plan documented "independent post setup with teeth". Review of the Care Guide, used by the CNAs in providing care, revealed the resident has "own teeth" and "independent post setup with teeth". There is no documented evidence that the Care Planning Report and the Care Guide were revised to direct that the resident's teeth are to be brushed twice daily.

On interview 10/1/10 at 2:48 PM, the RN Nurse Manager stated he used to include that in the care plans, until "someone" asked him why he did that since it was facility policy to brush twice daily. When the surveyor asked the RN Nurse Manager, if he thought it was important to include to brush teeth twice daily specifically in the care plan for a resident who has unrestorable teeth and multiple cavities, the RN Nurse Manager responded, "Yes".

415.11(c)(2)(iii)

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 #40) of three residents reviewed for accidents did not have foot pedals attached to the wheelchair during transport and the resident's feet dragged on the floor. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #40 has diagnoses including hypertension, arthritis, dementia, and macular degeneration (medical condition of the eye which results in a loss of vision in the center of the visual field). Review of the Minimum Data Set (MDS) dated 6/14/10 revealed the resident has moderately impaired cognitive skills for daily decision making and short and long term memory problems. Review of the Care Guide, used by certified nurse aides (CNAs) to provide care, dated 9/26/10 revealed the resident needs limited assistance for wheelchair use on the unit, propels the wheelchair on the unit without foot plates and is to be transported with 2 foot plates off the unit.

Observations from 9/27/10 to 9/30/10 revealed the following:

- On 9/27/10 at 11:50 AM, CNA #2 transported the resident in the wheelchair from room #271 to the unit dining room, a distance of approximately 52 feet. There were no foot plates on the wheelchair during the transport and the resident's feet were dragging and her shoes made a scraping sound on the floor.
- On 9/29/10 at 11:30 AM, the resident was transported in the wheelchair without foot plates on by a CNA/Rehab Aide out of the Dining Room /Activities Room into the First Floor Lobby, a distance of approximately 40 feet. At 11:40 AM on 9/29/10, the Activity Director transported the resident in the wheelchair from the First Floor Lobby into the elevator and then to the Second Floor Dining Room, approximately 118 feet, with both of the resident's feet dragging on the floor. The Activity Director did not tell the resident to pick up her feet.
- On 9/29/10 at 5:10 PM revealed the resident's son pushed the resident in the wheelchair without foot plates on and both of the resident's feet were dragging on the floor for a distance of approximately 50 feet. The Registered Nurse (RN) Nurse Manager was observed to accompany the resident and the resident's son during the transport in the hall.
- On 9/30/10 at 11:30 AM, the resident was transported by CNA #3 from the First Floor Dining Room/Activity Room into the elevator, to the Second Floor Dining Room approximately 151 feet without foot plates on. The resident's feet were dragging on the floor.
- On 9/30/10 at 11:32 AM, the resident self propelled the wheelchair on the unit from the Dining Room to the nurses' station, a distance of approximately 75 feet. At 11:39 AM, CNA #3 transported the resident to the Dining Room on the unit, a distance of approximately 82 feet. There were no foot plates on the wheelchair and the resident's feet were dragging on the floor.

During an interview on 9/30/10 at 1:08 PM, CNA #3 stated the resident self propels in the wheelchair. CNA #2 explained that when the resident is pushed in the wheelchair on the unit or to activities on the first floor, the foot plates are not put on. CNA #2 stated "the only time we put the foot plates on is when the resident's son pushes her in the wheelchair".

When interviewed on 9/30/10 at 1:15 PM, the RN Medication/Treatment Nurse stated that the resident self propels the wheelchair on the unit and when the resident is transported by staff on or off the unit, she would expect that staff follow the care plan. The Care Card was reviewed with the RN and the RN stated that the care card directs to put foot plates on the wheelchair when the resident is propelled off the unit and "I would expect them to be put on".

When interviewed on 9/30/10 at 1:29 PM, the RN Nurse Manager (NM) stated the resident self propels on the unit and when the resident is transported by staff, the resident propels the wheelchair with her feet. After reviewing the Care Card, the RN NM stated the resident's care plan is for foot plates and the resident should have them on when transported in the wheelchair off the unit.

415.12(h)(2)

Based on observation, record review, staff and resident interview, the facility did not ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. One (Resident #32) of three residents observed for pressure sores had an issue involving the lack of repositioning a resident with a Stage 2 pressure sore on the buttock every 2 hours as planned. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #32 has diagnoses of diabetes mellitus, multiple sclerosis and history of pressure ulcers. Review of the Minimum Data Set (MDS) dated 8/9/10 revealed the resident has modified independence for daily decision making, intact long term memory and impaired short term memory.

Review of the Care Planning Report (Comprehensive Care Plan (CCP)) dated 9/29/10 for Skin Integrity documents potential for breakdown due to decreased mobility, incontinence, and psychotropic (medications used to treat mental disorders) medications. Interventions include treatment as ordered, turn and reposition resident q 2 h (every 2 hours) and prn (as needed). Review of the Skin Care Record dated 9/28/10 revealed a .7 centimeter (cm) length by .5 cm width stage two pressure ulcer.

When observed intermittently on 9/29/10 from 10:40 AM to 5:15 PM, the resident was out of bed in the wheelchair.

epn Interview on 9/30/10 at 10:15 AM, the Certified Nurse Aide (CNA) stated that the resident has an open area on his buttock and that the nurse puts cream on it. The CNA further explained that the area opens and closes and opens if the resident is not put back to bed in the afternoon.

On 9/30/10 at 10:16 AM, CNA #1 turned the resident onto his right side and an approximate 2 centimeter (cm) length by .5 cm width stage 2 pressure ulcer was observed on the right mid gluteal (buttocks) fold.

During an interview on 9/30/10 at 11:46 AM, the CNA stated she was assigned to the resident yesterday (9/29/10) and after she got the resident up in the AM she did not approach the resident again to ask if he wanted to lie down. The CNA stated the resident was off the unit and she could not find him.

When interviewed on 9/30/10 at 11:55 AM the resident stated he ate lunch with his wife in the lobby. He further stated no staff member approached him to lie down after lunch and stated he needed to lie down and would have if someone had asked him to.

During an interview on 9/30/10 at 3:10 PM, the Registered Nurse (RN) Nurse Manager stated she measured the pressure ulcer on the gluteal fold today and stated she was shocked because the pressure ulcer was bigger and had increased to a length of 2 cm (centimeters) and width of .5 cm. The RN further explained she had instructed the CNA to put the resident back to bed after lunch. It is on the Skin Care Record for naps after lunch. When a resident "breaks down" on the buttock area we normally put the resident back in bed after lunch.

Review of the Skin Care Record dated 9/30/10 revealed a 2 centimeter (cm) length by .5 cm width stage two pressure ulcer.

415.12(c)(1)

Based on observation, record review, staff and resident interview, the facility did not ensure that each resident is given the appropriate treatment and services to maintain or improve his or her abilities. One (Resident #28) of eight residents reviewed for activities of daily living did not receive staff assistance to maintain and or improve the resident's ability to brush her teeth to ensure oral health. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #28 has diagnoses including multiple sclerosis (MS), and arthritis. Review of the Minimum Data Set (MDS) dated 8/16/10 revealed the resident has modified independence for daily decision making, understands and is understood. Additional review of the MDS revealed the resident requires extensive assistance for personal hygiene.

Review of a Dental Progress Note signed by the Dentist dated 3/15/10 revealed the resident had a chipped tooth; multiple carious (decayed) and unrestorable teeth; and the resident was undecided about treatment options. Review of a Long Term Care Oral Evaluation Form dated 3/15/10 revealed a recommendation to brush twice daily.

An Oral Evaluation Form dated 4/2/10 documented the resident had "multiple nonrestorable teeth; resident undecided. Treatment Plan: Annual exam. Recommendation: brush/rinse twice daily".

A Dental Progress Note dated 8/9/10 documented the resident was seen for pain in the upper left side of her mouth; on exam multiple nonrestorable teeth and the resident was told she needed extractions.

Review of an Occupational Therapy (OT) Progress Note dated 8/16/10 documented the resident is "independent post setup with teeth".

Review of the Care Planning Report (Comprehensive Care Plan) for Personal Care Regime dated 9/28/10 revealed the resident has general weakness due to MS with interventions for extensive assistance for upper extremities and that the resident is "independent post set up with teeth". The Care Planning Report for "Oral Hygiene" documented the resident "has own teeth, some with multiple caries; history of tooth extractions related to infection". The Care Planning Report documented an intervention for Dentist - Consults as indicated and prn (as needed).

Interview with the resident on 9/27/10 at 4:00 PM revealed she knows she needs dental work, but refuses to have her teeth pulled. The resident stated the CNAs brush her teeth once a day, in the morning.

During an interview on 9/30/10 at 1:25 PM, CNA #4 stated, "I brush her teeth myself. I don't encourage her because she says she can't put any pressure to her teeth. I brushed her teeth this morning for her. When the CNA was asked if she had reported to nursing staff that the resident has been unable to brush her own teeth as documented in the Care Planning Report and Care Guide, the CNA responded, "No".

When interviewed on 10/1/10 at 9:35 AM, CNA #5 stated, "I brush her teeth after she is out of bed and sitting up. She doesn't brush her own teeth at all". When the CNA was asked if she was aware that the care plan directed that the resident be set up to brush her own teeth, the CNA responded, "I am not her regular aide. I didn't know that". CNA #5 stated she did not tell nursing staff that the resident was not brushing her own teeth.

During an interview on 10/1/10 at 9:40 AM, the Registered Nurse (RN) Nurse Manager stated he was unaware that the resident needs more assist with teeth brushing than is care planned.

Observation of an Occupational Therapy Evaluation on 10/1/10 at 11:30 AM revealed the Occupational Therapist (OT) set the resident up to brush her own teeth as care planned. The Occupational Therapist put toothpaste on the brush and provided the resident with a cup of water and a basin to spit in. The resident attempted to brush her teeth, commenting after approximately 1 minute, "This is hard". The OT responded, "Well it's important that you try to brush. You know what they say: Use it or lose it". The resident laughed and agreed and attempted for an additional minute. The resident then stated, "I can really only brush my front teeth". The resident stated, and the OT confirmed that the resident was not able to apply pressure and the proper angle to brush the rest of her teeth. The OT informed the resident she would change the care plan to have the CNAs set the resident up, have the resident brush her own front teeth, and have the CNAs brush all other teeth.

Review of the Care Guide and Care Planning Report on 10/1/10 at 3:00 PM revealed they were revised to include, "independent post setup for front teeth, extensive assist for molars and side teeth".

415.12(a)(2)

Based on observation, record review, staff and resident interview, the facility did not ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections. Two (Residents #40, 134) of seven residents reviewed for urinary incontinence and catheters had issues involving the lack of a clinical indication for the use of an indwelling catheter and improper cleansing technique during incontinence care. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #134 has diagnoses including congestive heart failure, diabetes mellitus, and coronary artery disease. Review of the Minimum Data Set (MDS) dated 9/21/10 revealed the resident has independent cognitive skills for daily decision making, intact memory, understands and is understood. The MDS documented the resident is usually continent of bowel, and has an indwelling Foley catheter (tube inserted into the bladder to drain urine).

Review of Skin Care Records dated 1/20/10 through 5/11/10 revealed the resident had six pressure sores on the left inner buttock which healed on 5/11/10. Review of Skin Care Records dated 1/20/10 through 8/11/10 revealed the resident had three pressure sores on the right buttock. Additional review of the Skin Care Records revealed the pressure sores were identified as Stage 3 however there was no measurable depth documented for the pressure sores.

Review of the Skin Care records with the Registered Nurse (RN) Nurse Manager on 10/5/10 revealed with no depth, the pressure sores would be Stage 2's not Stage 3's. Review of the MDS dated 1/27/10, with a 7 day look back period, revealed documentation of three Stage 2 stasis ulcers and no pressure sores.

Review of a Progress Note written by an RN dated 2/12/10 at 10:30 AM revealed the resident requested to have a Foley catheter inserted due to increased incontinence of urine and stool. The Note documented that the resident had positive C-diff (Clostridium Difficile - bacteria in the bowel that may cause diarrhea) in stool, was on Flagyl (medication used to treat bacterial infection), and the resident's sacrum was "very excoriated".

Review of SNF (Skilled Nursing Facility) Physician Telephone Orders revealed an order dated 2/12/10 to insert a Foley catheter 16 French, with a 5 cubic centimeters (cc) bulb due to excoriation of the sacrum, incontinence of urine and stool positive for C-diff.

Review of the Care Planning Report (Comprehensive Care Plan) dated 7/15/10 and confirmed by the Registered Nurse (RN) Nurse Manager as the most current, revealed the resident has a "Foley catheter to gravity. At risk for UTI (urinary tract infection) resulting from Foley catheter". The care plan did not document the reason for the use of the Foley catheter.

Review of a Physician Order Form dated 9/7/10 revealed orders for a Foley catheter (16 French (diameter size)/5 milliliters (ml) balloon (inflatable balloon used to secure placement), Foley care every shift, and change the Foley every month and prn (as needed) for plugging and leaking.

Review of Progress Notes written by the Physician and Long Term Care Physician Evaluation/Progress Notes dated 2/7/10 to 9/7/10 (confirmed with the Interim Administrator on 10/5/10 as all physician documentation for that time period) revealed there was no documentation of a rationale for the use of the Foley catheter.

Interview with the resident on 10/5/10 at 12:00 PM revealed she did not know why she had the Foley catheter. The resident stated that "Many, many months ago I had a problem with a lot of open areas and irritation and one of the aides said urine has a lot of acid in it and I would heal better with the tube (Foley) in". The resident stated "I don't know why it's still in, because I am healed up".

During an interview on 10/5/10 at 12:15 PM, the Registered Nurse (RN) Nurse Manager stated he was not sure why the resident had a Foley catheter in. The RN Nurse Manager stated that the Foley was inserted on another unit when "the resident had had some skin breakdown". The RN Nurse Manager stated that the resident has not had any open areas on the buttocks or sacrum (area above the tailbone) "in a while".

During a telephone interview on 10/5/10 at 12:30 PM, the Attending Physician stated he could not recall the reason for the Foley order. The surveyor read the order dated 2/12/10 to insert the Foley catheter to the Physician and the Physician responded, "Isn't that a reason for a Foley?" When asked to clarify, the Physician responded he thought a Foley was justified to "clear the excoriation". When asked why he discontinued the Foley catheter this day (10/5/10) the Physician responded, "the nurse said there was no indication for the Foley so I gave the order to remove it".

During an interview on 10/5/10 at 12:50 PM, the Interim Administrator stated there were no other skin records and no documentation in the medical record to justify the use of a Foley catheter. The Interim Administrator provided a copy of a form entitled, "Rationale for Indwelling Urethral Catheter", dated 11/2/07, and stated, "The physician is supposed to complete this for residents who have a Foley cathter inserted, but there wasn't one for this resident". During the interview, the Interim Administrator first stated there was no policy for rationale for inserting a Foley catheter. On 10/5/10 at 1:30 PM, the Interim Administrator provided a copy of a Policy and Procedure (P&P) entitled, "Urinary Catheterization Insertion and Maintenance for the Acute Adult and Pediatric Patient", dated as last revised 7/10. The P&P documented "Urinary catheters are used to collect sterile specimens, relieve urinary retention, measure residual urine, maintain urinary drainage during a major operative procedure, maintain an accurate record of urine output, acute episode, comfort care, and stage multiple 2, 3, and 4 pressure ulcers".

In summary, there was no documented evidence for use of an indwelling urinary catheter for approximately 7 months.

2. Resident #40 has diagnoses including arthritis, dementia, macular degeneration (medical condition of the eye which results in a loss of vision in the center of the visual field) and a history of urinary tract infection (UTI). Review of the Minimum Data Set (MDS) dated 3/22/10 revealed the resident has moderately impaired cognitive skills for daily decision making and short and long term memory problems.

Review of a Care Planning Report (comprehensive care plan) for Elimination dated 9/16/10 revealed the resident is incontinent of bladder. The Care Guide, used by certified nurse aides (CNAs) to provide care, dated 9/26/10 documented the resident is often incontinent of bladder and bowel with a plan to provide extensive assistance for hygiene. Review of a Physician Telephone Order dated 9/2/10 revealed an order for Septra (antibiotic) DS (double strength) one BID (twice a day) for 5 days for a UTI (urinary tract infection).

During an observation of incontinence care on 9/29/10 at 12:51 PM, CNA #3 stood the resident after toileting and cleansed and dried the resident's peri area by wiping repeatedly from front to back and back to front, then rectal area front to back. While wearing the same gloves, CNA #3 applied barrier cream, removed the gloves and pulled the resident's brief up.

When interviewed on 9/29/10 at 1:13 PM, CNA #3 stated when doing incontinence care, the resident's peri area should be washed from front to back and then the rectal area. The CNA stated she thought she had washed the resident's peri area from front to back and did not realize she washed the resident's peri area from front to back and back to front.

During an interview on 10/4/10 at 9:40 AM, the Medication Licensed Practical Nurse (LPN #4) stated when doing peri rectal care, staff are to cleanse the peri area from front to back "so you do not drag the bacteria up". Staff are to rinse the same way, change the water and wash the rectal area front to back.

Review of a facility policy and procedure entitled Incontinent Care dated 12/1/01 revealed that CNAs will perform incontinence care with every episode of incontinence with the use of facility designated cleaner, as per manufacturer, front to back to avoid infection and/or cross contamination.

415.12(d)(1,2)

Based on record review and staff and resident interview, the facility did not ensure that residents had appropriate access to their personal funds. Five (Residents G, I, J, K, L) of six residents reviewed for availability of funds, had limitations placed on the amount and days available for withdrawals from their personal funds. This was a pattern with no actual harm with potential for minimal harm.

The findings are:

1. During resident interviews over the course of the recertification survey, from 9/27/10 through 10/5/10, Residents G, I, J, K and L said that access to their personal funds was not available on the weekends and that only $25 at a time was available for withdrawal. Resident J stated she was told by the Social Worker at a Resident Council Meeting that residents cannot get money out of their accounts on weekends and that residents would have to get money out of their account before the weekend if they wanted it. The resident said the residents were not given a choice and had to accept the rules.

When interviewed on 10/1/10 at 2:29 PM, the Social Worker revealed that residents' funds are available through the cashier's office of the hospital, between 8:00 AM and 4:00 PM, on Monday through Friday. She said that in order to make a withdrawal, a resident must sign a withdrawal slip, which is available from the Social Worker, from 8:00 AM to 4:00 PM, on Monday through Friday. The slip must be signed by the resident and the Social Worker. The Social Worker also said that when a Social Worker is not in the building, there is not a plan in place for a resident to access their personal funds. She said the facility policy limits withdrawals to $25.00 per day, but allowances can be made to increase the limit on a case by case basis with the Administrator's approval, for larger needs, such as paying a bill.

Review of the facility policy entitled "Resident Trust Fund Accounts", effective date 5/15/07, revealed that petty cash fund will be kept available in the Facility Business Office and/or Cashier's Office for the convenience of residents maintaining Trust Fund Accounts. There was no further information regarding the availability of resident funds on evenings or weekends.

Review of the Resident Council Meeting Minutes dated 8/10/10 revealed Banking Hours are Monday through Friday and that residents are in agreement with no weekend banking hours.

When interviewed on 9/30/10 at 5:15 PM, the Activities Director stated that there were 12 residents at the 8/10/10 Resident Council meeting and four of them frequently take money out of their accounts. She explained that there are 64 other residents in the Skilled Nursing Facility (SNF) who were not asked if it was ok that there was no banking hours on weekends.

415.26(h)(5)

Based on record review and staff and resident interview, the facility did not ensure that each resident promptly received mail. One (Resident #J) of one residents reviewed for mail delivery had issues regarding no weekend mail delivery. This was a pattern with no actual harm with potential for minimal harm.

The finding is:

1. Resident J has diagnoses including cerebral vascular accident (CVA - stroke). Review of the Minimum Data Set (MDS) dated 8/9/10 revealed that the resident has modified independence in cognitive skills for daily decision making, a short term memory problem, and intact long term memory

During a resident interview conducted during the survey, Resident J stated that mail is not delivered on Saturdays.

When interviewed on 10/4/10 at 9:00 AM, the Activities Assistant stated that all mail is delivered to the hospital then brought to the SNF (Skilled Nursing Facility) but there is no mail delivery on the weekends.

When interviewed on 10/4/10 at 10:30 AM, the office worker responsible for the facility's mail revealed she is the sole person responsible to sort mail and she is off on Saturdays. She said that Saturday's mail is held in a post office box in the post office.

415.3(d)(2)(i)

Based on record review, staff and resident interviews, the facility did not inform residents before the residents' room or roommate in the facility was changed. Three (Residents A, B, C) of three residents reviewed for notification of roommate change had issues involving the lack of notification prior to a roommate change. This was a pattern with no actual harm with potential for minimal harm.

The finding is:

1. When interviewed during the course of the survey, Residents A, B and C stated that they were not given notice before a change of roommate.

When interviewed on 10/1/10 at 3:43 PM, the Social Worker on the long term care unit said that they do a very good job of informing residents on roommate changes and that information is also given by the admission staff. She said she did not think that the facility is actively informing Rehab Unit residents when a new roommate is coming in.

When interviewed on 10/1/10 at 3:55 PM, the Social Worker on the Rehab Unit said she did not specifically speak to the Rehab residents about roommate changes.

Review of the facility policy entitled "Room Changes, Long Term Care" dated 5/17/10 revealed no information on notifying a resident before their roommate is changed.

When interviewed again on 10/1/10 at 4:45 PM, the Social Worker of the long term care unit confirmed that the policy does not talk about notifying the person staying in the room of a roommate change and only addresses notifying the resident who is changing rooms."

415.5(e)(2)

Based on observation during a Life Safety Code survey, hazardous area doors on two (Skilled Units 1, 2) of two resident units were not properly maintained. Issues included hazardous area doors that were held open by devices that were not arranged to automatically close the doors upon activation of the fire alarm system, smoke detectors and/or the automatic sprinkler system. 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 the Second floor on Skilled Unit 2 on 9/29/10 at approximately 2:16 PM revealed an approximate three foot tall by two foot long by two foot wide cart was stored directly against and obstructing the door to the Linen room, room #230, from closing. Also at this time, observation revealed this room contained four, approximately five foot tall by five foot long by two foot wide carts full of sheets, towels, gowns and disposable briefs and one approximately five foot tall by four foot long by two foot wide cart full of cloth bed pads. Further observation at this time revealed this room is approximately 15 feet long by 10 feet wide.

2. Observations on the First floor on Skilled Unit 1 on 9/29/10 at approximately 2:26 PM and 3:00 PM and on 9/30/10 at approximately 8:00 AM, 9:58 AM, 10:14 AM and 11:18 AM revealed the door to the storage room (that was formerly a Bath room) located near resident room #165 was obstructed from closing by a shower chair that was wedged between the door and its frame. Also at these times, observations revealed this room contained four wheelchairs, two upholstered geri-style chairs and two plastic shower chairs and that the tub and associated plumbing pipes and fixtures had been removed from the room. Further observations at these times revealed the door to this room lacked a self-closing mechanism and that the room was approximately 10 feet long by 10 feet wide.

epn 10NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA: 13-2.2.2.6
2000 NFPA: 19.2.2.2.6

Based on observation during a Life Safety Code survey, electrical outlets were not properly maintained. Issues included electrical outlet covers that were broken, cracked and/or partially missing and electrical outlets that were cracked. This affected two (Skilled Units 1, 2) of two resident units. 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 the Second floor on Skilled Unit 2 on 9/27/10 at approximately 1:27 PM revealed two approximately one inch cracks and an approximate one half inch crack in the plastic outlet cover for a television outlet installed in the corridor wall near resident room #267.

2. Observation on the Second floor on Skilled Unit 2 on 9/27/10 at approximately 1:28 PM revealed that three quarters of the plastic electrical cover was broken-off and missing from the duplex outlet installed in the corridor wall near resident room #267.

3. Observation on the Second floor on Skilled Unit 2 on 9/27/10 at approximately 1:36 PM revealed an approximate two inch by one inch area of the top left corner of the plastic electrical cover was broken-off and missing from the duplex electrical outlet installed in the corridor wall near resident room #263.

4. Observation on the Second floor on Skilled Unit 2 on 9/27/10 at approximately 1:39 PM revealed an approximate one inch crack in the plastic electrical cover for a duplex outlet installed in the wall of the Pantry.

5. Observation on the First floor on Skilled Unit 1 on 9/27/10 at approximately 1:49 PM revealed an approximate two inch by one inch piece of the upper-right corner of the plastic electrical cover was broken-off and missing from an electrical outlet for a computer touch screen installed in the corridor wall across from resident room #167.

6. Observation on the First floor on Skilled Unit 1 on 9/27/10 at approximately 2:07 PM revealed two of the 10 electrical outlets installed in the corridor wall across from the elevator near resident room #155 were cracked.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 1997 NFPA 101: 7.1.2
2000 NFPA 101: 9.1.2
1999 NFPA 70: Article 370-25

Based on observation during a Life Safety Code survey, a manual oxygen shut off valve was not properly maintained. Issues involved one of two observed manual oxygen shut off valves on Skilled Unit 1 that was not accessible at all times. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observations on 9/27/10 at 1:12 PM, 1:48 PM, 2:00 PM and 2:16 PM revealed an approximate three foot tall by one foot wide patient monitor cart was stored in front of and obstructing the manual oxygen shut off valve located on the First floor on Skilled Unit 1 near resident room #162. Further observation at this time revealed this valve was the manual shut off valve for the West corridor rooms located on the First floor on Skilled Unit 1. Observations on the First floor on Skilled Unit 1 on 9/29/10 at approximately 2:11 PM, 2:43 PM and 2:58 PM revealed a mechanical lift was stored in front of and obstructing the manual oxygen shut off valve located near resident room #162.

10NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101:13-3.2.4
2000 NFPA 101: 19.3.2.4
1999 NFPA 99: 4-3.1.2.3(i)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 10/22/09.

Based on observation, record review and staff interview during a Life Safety Code survey, a smoke barrier was not properly maintained. Issues included a smoke barrier on one (Skilled Unit 2) of two resident units that was not complete from floor to ceiling. 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 the Second floor of the Skilled Unit 2 smoke barrier wall that runs through the Pantry on 9/27/10 at approximately 1:41 PM revealed an approximate 14 inch long by eight inch wide area of the wall lacked gypsum board. Also at this time, observation revealed that this area that lacked gypsum board was located in an open area below the Pantry's sink. Further observation at this time revealed the section of the Skilled Unit 2 smoke barrier wall runs between the Pantry and the Soiled Utility room. Review of the facility provided floor plan at this time revealed that this wall is part of the Skilled Unit 2 smoke barrier wall.

Interview with the Maintenance Manager on 9/27/10 at approximately 2:23 PM confirmed that the Pantry wall that had the area that lacked gypsum board was part of the Skilled Unit 2 smoke barrier wall. Further interview with the Maintenance Manager at this time revealed the gypsum board was removed from this area of the Second floor Pantry wall approximately two weeks ago while maintenance staff was checking on a plumbing leak.

2. Observation above the ceiling tiles on the Second floor of the Skilled Unit 2 smoke barrier wall on 9/28/10 at approximately 3:11 PM revealed an open, unsealed circular penetration around an approximate three inch pipe that runs through the Skilled Unit 2 smoke barrier wall. Further observation at this time revealed this open, unsealed circular penetration ranged from approximately one half inch to one inch in diameter and was located above the Skilled Unit 2 smoke barrier doors located near resident room #263.

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