Van Duyn Center for Rehabilitation and Nursing

Deficiency Details, Certification Survey, March 6, 2012

PFI: 0650
Regional Office: Central New York Regional Office

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F312 483.25(a)(3): ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: April 30, 2012

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.

Citation date: March 7, 2012

Based on observation, staff interview, and record review conducted during the standard survey, it was determined for 4 of 27 residents (Residents #14, 21, 22 and 29), reviewed for ADL concerns and 4 residents outside of the sample (Residents #33, 34, 37 and 38), the facility did not provide necessary care and services regarding activities of daily living (ADLs). Specifically, Residents #14, 21, 22 and 29 did not receive timely assistance at meals to maintain good nutrition without a rationale. Residents #33, 34 and 38 were not provided feeding assistance in a timely manner, and Resident #37 was not provided uninterrupted feeding assistance routinely. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE DECEMBER 14, 2012 SURVEY.

Findings include:

1) Resident #14 had diagnoses including Downs Syndrome, cerebral palsy and end stage dementia.

The comprehensive care plan (CCP) documented on November 21, 2011, the resident received Hospice services. The CCP documented a Hospice aide assisted the resident with activities of daily living (ADLs) 2 hours a day.

The Hospice Home Health Aide Patient Care Plan last updated January 12, 2012 documented the aide was to assist the resident with feeding.

The Minimum Data Set (MDS) assessment dated February 1, 2012 documented the resident was in a vegetative state and required total assistance with activities of daily living (ADLs).

The current, undated, CCP documented the resident was dependent in ADLs and required total assistance with all ADLS including feeding.

On March 1, 2012, breakfast trays were observed on the unit at 8:20 AM. At 10:30 AM, the resident was observed seated in the dining room/community room (Core) being fed her breakfast by the Hospice Home Health Aide. The aide was interviewed immediately after feeding the resident and stated she provided services to the resident from 8:30 AM to 10:30 AM Monday through Friday. The aide said when she arrived, she assisted the resident with her morning care, and after her care needs were met, she brought the resident to the Core. The aide said the resident ate better when she was in the Core.

On March 1, 2012, the resident was observed during lunch at 12:30 PM. The licensed practical nurse (LPN) attempted to feed the resident, the resident sat with her eyes closed and did not eat. The LPN stated to the surveyor at that time she did not know the resident had eaten breakfast between 10:30 AM to 11 AM, and that was most likely the reason the resident was not awake to eat lunch.

On March 5, 2012, the Hospice aide was observed bringing the resident's tray from her room to the Core at 9:55 AM and began feeding the resident at 10:05 AM. The resident was observed at 12:30 PM being assisted by the LPN. The resident had her eyes closed and was not swallowing the food that was placed in her mouth. The LPN said to the surveyor she was not aware the resident received her breakfast tray after 10 AM.

The registered dietitian (RD) and the Acting registered nurse (RN) Manager were interviewed on March 5, 2012 at 1:00 PM. They both stated they were not aware the resident was assisted with her breakfast meal during the week, approximately 1 - 2 hours before receiving her noon meal, and approximately 1.5 - 2 hours after the breakfast trays arrived on the unit.

In summary, the facility did not provide the resident with timely assistance with her breakfast meal, to maintain good nutrition.

2) Resident #29 had diagnoses including Alzheimer's disease.

The February 7, 2012 physician's order documented the resident's diet was pureed consistency with thin liquids.

The February 7, 2012 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required extensive assistance with eating.

The February 14, 2012 registered dietitian's (RD) assessment documented the resident required assistance with eating and received fortified foods with meals for weight maintenance.

In an interview with the registered nurse (RN) Manager on February 29, 2012 between 10:05 AM and 10:25 AM, she stated the resident needed feeding assistance.

The resident was observed on March 2, 2012 between 12:25 PM and 1 PM seated at the table in the dining room/community room (Core). The trays arrived on the unit between 12:26 PM and 12:35 PM (3 carts) and were distributed to all the residents from 4 South. At 12:35 PM Resident #29's tray was removed from the table and the resident remained seated at the table, with no food in front of her until after 1 PM, while the other residents at the table were assisted with their meal.

Immediately following lunch at 1:30 PM on March 2, 2012, the resident's intake documented by the CNA on the meal slip was reviewed. The meal slip documented the resident ate 0% and drank no liquids.

At 1:35 PM on March 2, 2012, the CNA and the CNA orientee were interviewed. The CNA stated the CNA orientee fed the resident that day in the Core while the CNA fed another resident in her room. The CNA orientee stated she tried to feed the resident, the resident refused and the tray was removed from the table. The CNA stated when a resident refused a meal, they usually left their food on the table, waited a little while, and then had other staff members try to feed the resident.

On March 5, 2012 at 4:15 PM, the Assistant Administrator stated in an interview, there was currently a project team within the facility working on addressing the residents' dining experience. She stated this included providing timely meal assistance to all residents.

In summary the facility did not ensure the resident was provided with adequate and appropriate meal assistance.

3) Resident #21 had diagnoses including anoxic brain damage, dysphagia, depression, anxiety and hypertension.

The Minimum Data Set (MDS) assessment dated December 9, 2011 documented the resident's cognitive status was severely impaired and she required extensive to total assistance with all activities of daily living (ADL's).

The comprehensive care plan (CCP) printed on March 5, 2012 documented the resident required total assistance with all ADL's.

The certified nurse's aide (CNA) care card used at the time of the survey and printed on March 5, 2012 documented the resident required total assistance of 1 person for eating.

On February 29, 2012, the supper tray cart arrived on the unit at approximately 5:25 PM. At 5:35 PM, the resident was observed seated facing sideways at the table, with her tray uncovered in front of her. The resident remained seated at the table in that position, with no assistance until 5:50 PM. At 5:50 PM, a staff member assisted the resident with the meal (pureed hot dog and baked beans).

On March 1, 2012 at 8:10 AM, residents were observed in the dining room/community room (Core) area awaiting breakfast. A certified nurse aide (CNA) stated, to the surveyor, the trays usually arrived on the unit at approximately 8:15 AM. At 8:19 AM, two tray carts arrived on the unit. At 8:50 AM, Resident #21 was observed laying in bed with her eyes open her breakfast tray was on the overbed table, with the cover on it. At 9:05 AM, a CNA entered the resident's her room and began assisting her with breakfast. The CNA stated, to the surveyor, the resident had pureed Western eggs, a biscuit, cream of wheat and prunes.

On March 5, 2012, the breakfast trays were observed on the unit at 8:25 AM. At 9:05 AM, the CNA entered the room to assist the resident with her meal.

On March 5, 2012 at 9:05 AM, the registered dietitian stated in an interview, resident trays were delayed, on the unit ,as there had been some "medical issues" on the unit staff had to attend to first. She stated the facility was working on a tray schedule as they were aware of the problem.

In summary the facility did not provide the necessary services to maintain good nutrition as the resident did not receive assistance eating a timely.

10 NYCRR 415.12(a)(3)]

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: April 30, 2012

The facility must establish and 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. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Citation date: March 7, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 5 residents (Resident #3), reviewed for tube feedings, 2 of 6 residents (Residents #7 and 20), reviewed for pressure ulcers and 2 residents (Residents #12, 32) observed during meals in the Unit 4 dining room, the facility did not establish and 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. Specifically, there were multiple breeches in infection control practices observed during a tube feeding administration for Resident #3 and pressure ulcer dressing changes for Residents #7 and 20. For Resident's #12, and 32 staff handled their food with bare hands without using a barrier. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS OF December 14, 2010 and November 19, 2009.

Findings include:

1) Resident #20 had diagnoses of intracerebral hemorrhage, aspiration pneumonia and a Stage IV pressure ulcer on the coccyx.

The February 6, 2012 Minimum Data Set (MDS) assessment documented that the resident had a Stage IV pressure ulcer measuring 0.5 centimeters (cm) x 0.5 cm x 2.2 cm in depth.

The March 5, 2012 physician order documented to pack the pressure ulcer on the coccyx with 1/4 inch packing strips with normal saline once daily.

The resident's wound care was observed on March 5, 2012 at 6:30 PM. The licensed practical nurse (LPN #1) removed the foam wedge pillows from the resident's bed and placed them on the floor. LPN #2 washed her hands, then with her bare hands:
- opened the package of gauze;
- removed the gauze;
- placed the gauze in a bowl of normal saline;
- opened the container with the 1/4 inch packing strips;
- pulled the packing out of the container;
- cut what she needed; and
- placed the remainder of the packing strips back into the container.
LPN #2 then donned gloves on, removed the old dressing from the pressure ulcer, removed her gloves, washed her hands, and completed the rest of the wound care, after donning another set of gloves. LPN #1 then picked the wedge pillows up off the floor and placed them back on the bed with the resident.

LPN #1 was interviewed on March 5, 2012 at 6:45 PM and stated he would not have done anything differently. He then stated he probably should not have placed the wedge pillows on the floor.

LPN #2 was interviewed on March 5, 2012 at 7 PM and stated I washed my hands and then took the gauze and packing strips out of their packaging. She stated we were instructed that we didn't need to wear gloves to set up the supplies for a dressing change.

In summary the staff did not follow proper infection control technique during the pressure ulcer dressing change.

2) Resident #3 had diagnoses of left hemiparesis (weakness), and gastrostomy (feeding tube).

The January 19, 2012 MDS (Minimum Data Set) documented the resident required extensive assistance in her activities of daily living (ADL).

The January 19, 2012 physician orders documented the resident received a puree diet with nectar thick liquids at breakfast and lunch and took nothing by mouth at dinner. The orders instructed at 5 PM to administer Jevity 1.2 (liquid food) at full strength through the feeding tube 720 milliliters (ml) at 80 ml per hour.

On March 1, 2012 at 4:15 PM, the surveyor observed the LPN administering the resident's tube feeding. The LPN poured the Jevity 1.2 into the tube feeding bag, put the tip of the tubing connected to the bag in the empty Jevity can. The LPN placed the tubing along the floor and the empty Jevity can containing the end of the tubing onto the floor. The LPN stated to the surveyor at that time that was how she filled the tubing with the Jevity solution. The LPN said that gravity pulled the Jevity through the tubing. After the tubing was filled with Jevity the LPN took the end of the tubing from the can and connected it to the resident's feeding tube.

The LPN was interviewed on March 5, 2012 at 7:30 PM. She stated she did not know she could not put the tubing from the feeding bag on the floor.

In summary, the LPN did not ensure accepted and proper infection control techniques were used when administering tube feedings.

3) During a meal on Unit 4 on March 1, 2012 between 8:15 AM and 8:45 AM, a certified nurse aide (CNA) was observed setting up Residents #12 and 32's meal trays and the following was observed:
- the CNA held the biscuit on Resident #12's meal tray with her bare hands and spread jelly on the biscuit;
- the CNA prepared Resident #32's biscuit in the same manner and after preparing the biscuit, the CNA peeled the resident's banana, held the banana (without a peel) in her bare hands and handed it to the resident; and
- Residents #12 and 32 were observed to eat the foods the CNA touched with her bare hands.

On March 6, 2012 at 9:05 AM, as the CNA was not available for interview.

The Infection Control registered nurse (RN) was interviewed on March 6, 2012 at 9:05 AM. She stated the facility had a protocol that staff were not to touch food with their bare hands; they were to wear gloves or use utensils when touching the residents' food.

In summary the facility did not ensure proper infection control techniques were utilized when a CNA touched the residents food with her bare hands.

10 NYCRR 415.19 (a)(1)

F323 483.25(h): FACILITY IS FREE OF ACCIDENT HAZARDS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: April 30, 2012

The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Citation date: March 7, 2012

Based on observations, staff and resident interviews, and record reviews conducted during the standard survey, it was determined for 3 of 10 residents (Residents #14, 21 and 22), reviewed for positioning concerns and 2 residents outside of the sample (Residents # 35 and 36), the facility did not provide adequate supervision and assistance to prevent accidents Specifically, Residents #14, 21 and 22 were at risk for choking and were not fed in a manner to minimize the risk of choking or aspiration (taking of foreign matter into the lungs). Residents #35 and 36 were not properly positioned when being fed by staff. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #14 had diagnoses including Downs Syndrome, End Stage Dementia, and a history of bilateral hip fractures. The resident was receiving Hospice care.

The current comprehensive care plan (CCP), with an effective date of December 7, 2010, documented to keep the resident's chair reclined at a 60 degree angle at all times and during meals to maintain trunk balance. On December 20, 2010, the CCP documented a swallow evaluation was requested to assess an appropriate food/fluid consistency and to recommend feeding techniques to enhance the resident's intake.

The most recent swallow evaluation by the speech language pathologist's (SLP) was dated December 21, 2010. The evaluation documented the request for a safe and efficient feeding technique. The SLP recorded the resident presented with severe oral dysphagia, and was at risk for choking, aspiration and dehydration. The recommendation included the resident would be seen by the SLP for 2 weeks. The assessment and plan did not address positioning the resident at 60 degrees during meals.

On January 3, 2011, the SLP documented the resident tolerated pureed consistency food with pudding thick liquids.

The SLP was interviewed on March 6, 2012 at 10:30 AM. She reviewed the resident record and stated she had not seen the resident in over a year. She was not aware of a recommendation for at risk residents to be positioned at 60 degrees during meals. The SLP stated the goal was always for a resident to be as upright as possible when eating.

The current CCP, effective November 21, 2011, documented the resident required total assistance with eating and identified her at high risk for aspiration. The CCP recorded a Hospice aide was to assist with the resident's care 2 hours a day.

The Hospice Home Health Aide Patient Care Plan dated November 21, 2011 and updated on January 12, 2012 documented the aide was to assist the resident with feeding and encourage fluid intake. The resident's special fluid instructions included "aspiration precautions." No specific instructions, or feeding strategies were documented on the care plan to assist the aide with feeding the resident.

The Minimum Data Set (MDS) assessment dated February 1, 2012 documented the resident was in vegetative state and required total assistance with all activities of daily living. The MDS recorded the resident exhibited signs and symptoms of possible swallowing disorder as: she held food in her mouth/cheeks; or had residual food in her mouth after meals; and was observed coughing or choking during meals or when swallowing medications.

The dietary assessment dated February 10, 2012 documented the resident was difficult to feed at times or would not open her mouth. The assessment documented the resident had difficulty chewing and swallowing and specified the resident occasionally held food in her mouth, coughed with meals/medications and lost liquids/solids from her mouth.

The physician's orders dated February 16, 2012 documented the resident was on a pureed diet with pudding thick liquids "per swallow eval done December 22, 2010."

The Resident Nursing Instructions printed on March 5, 2012 and identified as the certified nurse aide (CNA) instructions used at the time of survey, documented as of January 25, 2012: the resident was to be upright for meals and for 30 minutes after meals; liquids and solids were to be alternated; the size of bites offered were to be reduced; liquids were to be fed by spoon; and the resident was to be turned away from the table.

The registered dietitian (RD) was interviewed at 9:35 AM and she stated Hospice usually communicated with nursing if there were any concerns and the interdisciplinary team met daily to discuss any resident concerns. She stated she did not know where the recommendation came from to feed there resident at 60 degrees adding the resident should be fed in an upright position.

The resident was observed on March 1, 2012 at 10:30 AM in the Core with the Hospice aide. The resident was seated in a "tilt in space" chair that was tilted back at approximately 30 degrees. The aide was using plastic spoons while she mixed pureed prunes with cream of wheat cereal. She stated, to the surveyor, sometimes the cereal was too thin so she mixed the two items together, adding it was the only way the resident would eat it.

At 12:30 PM on March 1, 2012, the resident was in the Core seated with hr chair reclined at approximately 30 degrees. A staff member initially started to assist the resident with her meal. The staff member left the table and a second staff member arrived. The second staff member was overheard, by the surveyor, asking how to position the resident's chair more upright, before she started to feed her.

On March 5, 2012 at 10:05 AM, the Hospice aide was observed in the Core, feeding the resident using plastic spoons and keeping the back of the resident's chair in a reclined (approximately 30 degree) position. In an interview at that time the aide stated she always used the plastic spoons when feeding the resident as the resident did not like metal silverware. She said she did not know if anyone else used plastic utensils when feeding the resident and she thought the registered nurse (RN) Manager was aware she used plastic spoons. The aide stated she fed the resident ate in a reclined position because, if she was upright "she was going to bring it (the food) back up" and not be able to keep it down. She stated the resident could swallow best when reclined. The aide said she mixed the prunes with the cereal to make it a little thicker because if the cereal was "too soupy" the resident would not eat it. The aide said she was not specifically trained on how to feed the resident but used "common sense" and said this was the method that worked best for her as the "key is to make sure she eats."

On March 5, 2012 at 12:30 PM, a licensed practical nurse (LPN) was observed attempting to feed the resident using silverware. The resident's the chair was tilted back at approximately 30 degrees. The resident had her eyes closed she did not swallow the food, the LPN removed the food from the resident's mouth.

The registered dietitian (RD) was interviewed again at 12:45 PM on March 5, 2012. She stated she did not know the Hospice aide used plastic utensils to feed the resident or why she would be.

The Acting RN Manager was interviewed at 1:05 PM on March 5, 2012. She stated she was not aware plastic utensils were being used by the Hospice aide to feed the resident and was not aware of a any concerns with the manner in which the aide was feeding the resident. She said she met regularly with the Hospice nurse (every 2 weeks) and no concerns with feeding the resident were discussed. She stated the Hospice aide usually reports to the CNA assigned to the resident for the day and she had not heard about any concerns from the CNAs.

In summary the resident was not fed in a manner that minimized the risk for choking or aspiration.

2) Resident #21 had diagnoses including anoxic brain damage, and "problem with swallowing."

The Minimum Data Set (MDS) dated December 9, 2011 documented the resident had severe cognitive loss and was totally dependent in activities of daily living (ADLs). The MDS recorded the resident had a feeding tube for flushes only and was on a mechanically altered diet.

The current (undated) comprehensive care plan (CCP), documented the resident had impaired chewing and swallowing related to anoxic encephalopathy. The resident was totally weaned off from the tube feeding on August 31, 2011. The CCP recorded the resident was on a pureed diet with nectar thick liquids, was totally assisted with feeding and was to be seated upright for meals and for 60 minutes after eating.

The current Resident Nursing Instructions, the plan of care used by the certified nurse aides (CNAs), printed on March 5, 2012 documented the resident was to be positioned upright for meals and was to eat all meals in the "center core."

The resident was observed being assisted with meals at the following times:
- on February 29, 2012 at 5:50 PM seated semi-reclined in a Broda chair in the dinning room/community room (Core);
- on March 1, 2012 at 9:05 AM being fed in bed with the head of the bed at approximately 30 degrees;
- on March 5, 2012 at 9:25 AM being fed in bed with the head of the bed at approximately 30 degrees.

On March 5, 2012 at 9:25 AM, the registered dietitian (RD) who observed the resident's positioning in bed, entered the resident's room and requested the CNA reposition the resident in a more upright position. The RD stated the resident was to be fed upright.

In summary the facility did not ensure the resident was positioned during meals in a manner that minimized the risk of choking.

3) Resident #22 had diagnoses including multiple sclerosis, generalized pain and depressive disorder.

A speech language therapy Evaluation dated December 1, 2011 and recommended the resident be seated upright as much as possible with a "neck roll" placed behind her neck while eating.

The Minimum Data Set (MDS) assessment dated December 3, 2011 documented the resident was cognitively intact and required total assistance with activities of daily living.

The current comprehensive care plan (CCP) identified the resident at risk for choking and aspiration and documented on November 30, 2011, the resident had an episode of choking and on December 27, 2011 had increased difficulty in swallowing meat.

On January 25, 2012 the Resident Nursing Instructions (plan of care for the certified nurse aides, CNAs) documented the resident "must be positioned properly before feeding."

The resident was interviewed on February 29, 2012 at 6 PM. She stated she is "scared to eat" because she is fearful of choking. She said she had an episode a few months ago, when the staff had to do the "Heimlich" and she was told by the speech language pathologist, the problem was the way the staff had positioned her. The resident said her head tends to go back and she did not think staff were positioning her right. She said she had requested a follow up visit from the speech language pathologist and was told it was not necessary.

The resident was observed at 8:50 AM being fed breakfast in bed with the head of the bed reclined at approximately 60 degrees.

The speech therapist was interviewed on March 6, 2012 at 10:30 AM. After reviewing the resident's status, she stated the resident was to be positioned upright at 90 degrees at all meals.

In summary the facility did not ensure the resident was positioned during meals in a manner that minimized the risk of choking.

10 NYCRR 415.12 (h)(1),(2)

F246 483.15(e)(1): ACCOMMODATION OF NEEDS AND PREFERENCES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 30, 2012

A resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

Citation date: March 7, 2012

Based on observation, record review, and interview with staff and residents conducted during the standard survey, it was determined for 1 of 27 residents (Resident #19), reviewed for choice the facility did not ensure the resident's preference was reasonably accommodated Specifically, Resident #19 requested siderails or a trapeze for her bed to assist with positioning in bed. There was no documented evidence the facility attempted to meet her individual preferences. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #19 had diagnoses including a progressive muscle disease, morbid obesity, depression, and osteoporosis.

The current physician's orders dated November 30, 2011 documented the resident was to have a low bed.

The physician's progress note dated December 14, 2011, documented the resident had slowly worsening stiffness in her back and lower extremities with peripheral edema. The resident asked for a "trapeze-like fixture on her bed, so she could lift herself up and down." The physician documented "I think that is an excellent idea and we'll implement that."

The physician's orders dated December 14, 2011 documented the resident was to have a trapeze on her bed for positioning.

The Minimum Data Set (MDS) assessment dated February 4, 2012, documented the resident's cognition was intact, and she required extensive assistance for bed mobility. The assessment recorded she did not utilize restraints and did not have functional limitations in her upper extremities.

The physician's orders dated February 21, 2012 documented the resident was to have a low bed.

The resident's current comprehensive care plan (CCP), printed by the facility on March 6, 2012, documented the resident was at risk for falls, and the plan included "no siderails, low bed." The CCP did not address a plan for the resident to have increased independence with bed mobility.

The resident was interviewed on March 1, 2012 between 8:30 AM and 8:40 AM. The resident was in her bed and stated she wanted siderails or a trapeze on the bed to help her change positions when in bed. She said she received assistance from staff to turn and position and felt having either one top side rail or a trapeze would allow her to help reposition herself. The resident said she spoke to the registered nurse (RN) and asked for the positioning devices, and had not received a response.

On March 5, 2012, the resident was observed being assisted by the certified nurse aide (CNA) with morning care at 10:30 AM. When the CNA rolled the resident onto her side, the resident could not assist with turning and positioning.

On March 6, 2012, at 12:15 PM, the Director of Nursing (DON) stated in an interview they were unable to use a trapeze or side rails on the resident's low bed.

In summary, the facility did not ensure attempts were made to accommodate the resident's individual preference for siderails and a bed trapeze to promote increased independence in bed mobility.

10 NYCRR 415.5(e)(1)

F280 483.20(d)(3), 483.10(k)(2): DEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 30, 2012

The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

Citation date: March 7, 2012

Based on resident and staff interviews, and record reviews, it was determined for 1 of 30 residents (Resident #24), reviewed for care planning the facility did not provide the resident the right to participate in changes to his plan of care. Specifically, Resident #24 was not provided the right to participate in his care planning when the decision was made that his care needs would be provided by 2 caregivers. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #24 had diagnoses including quadriplegia and depression.

The Minimum Data Set (MDS) assessment dated January 7, 2012 documented the resident was cognitively intact. The MDS recorded the resident required total assistance with activities of daily living and resisted care form 1 to 3 days of 7 days.

The comprehensive care plan (CCP) documented on January 24, 2012, the resident refused to use the SLIPP (a pad to assist the resident when being repositioned in bed) after being educated on the benefits of its use. The plan included encouraging the resident to avoid being pulled up and down in bed too much to minimize shearing and further documented the resident refused to use the SLIPP.

Review of nursing progress notes from January 24, 2012 through February 12, 2012 revealed the resident continued to refuse to utilize the SLIPP.

An Incident Report was initiated on February 13, 2012 related to an incident on February 12, 2012. The report documented the resident stated he had refused to use the SLIPP as requested by the certified nurse aide (CNA), and the CNA left, without providing care. Per the resident's statement, he was left in an unsafe situation. The report documented the resident had made allegations regarding care in the past. The outcome summary documented the "CNA will receive discipline for not following facility standards of care."

A nursing progress note dated February 14, 2012 documented the registered nurse (RN) manager met with the resident and informed him about the need for 2 CNAs to provide care related to issues he "recently had regarding standards of care not being met." The note recorded the RN assured the resident this was for his benefit and for his safety. The resident "got very upset" and informed the RN he was going to refuse care. The note documented the resident was informed this was not an option and she (RN) would share his concerns with the administration. The note recorded resident stated he felt he was being singled out.

The CCP documented on February 14, 2012, the resident was to have two CNAs for care related to "frequent allegations."

The resident was interviewed on March 1, 2012 at 10:30 AM. He stated that approximately two weeks earlier, he had a problem with a CNA, who did not provide assistance to meet his needs and the resident reported the concern to the Director of Nursing (DON). The resident stated the DON interviewed the CNA and had a meeting with the (RN) Manager, the unit social worker, and the Assistant Administrator. The resident said as a result of the meeting, he was informed, by the RN Manager, that he was to have 2 CNAs present when care was being provided. The resident stated he was not involved in this decision and felt it was very "degrading."

On March 6, 2012 at 9:10 AM, the RN Manager stated in an interview, the interdisciplinary team and administration met, and the decision was made that the resident required 2 CNAs for care as care was not being met "the way he wanted it to." The RN said the resident had made several accusations and some had been founded and others had not. She stated the resident was not involved in the decision to have 2 staff present during care and he was not informed of this until "after the fact." She stated initially, the resident was resistant to the plan, but she did not think it continued to be a problem for him.

In summary the facility did not provide the resident the right to participate in the plan when the decision was made to have 2 caregivers present to provide all of his care needs.

10 NYCRR 415.11(c)(2)(iii)

F364 483.35(d)(1)-(2): FOOD PROPERLY PREPARED, PALATABLE, ETC.

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 30, 2012

Each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; and food that is palatable, attractive, and at the proper temperature.

Citation date: March 7, 2012

Based upon observations resident and staff interview conducted during the standard survey, it was determined the facility did not ensure foods served were palatable and at the proper temperature for 16 of 33 residents interviewed at the resident group interview and for 1 of the 1 sampled meals on 1 of 9 resident units (Unit 7). Specifically, 16 of 33 residents stated food was not served hot and food sampled at breakfast on Unit 7, was not served at a palatable temperature. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

At the Resident Group Interview held on March 1, 2012 at 2 PM, 16 of 33 residents stated the hot food was too cold.

During a breakfast meal observation on Unit 7 on March 5, 2012, trays were observed being passed at 8:25 AM. At 9:05 AM, a certified nursing aide (CNA) entered the room of Resident #21 to provide feeding assistance. Due to the length of time the tray had been observed by the surveyor in the resident's room, the resident's tray was used as a test tray (another tray was requested by the surveyor for the resident). The results of the tray tested at 9:05 AM were:
- milk was 56 degrees F (Fahrenheit) and tasted lukewarm;
- pureed breakfast sausage was 84 degrees F and tasted cold;
- pureed oatmeal cereal was 105 degrees F and tasted cold: and
- pureed blueberry muffin was 62 degrees F and tasted cold.

The registered dietitian (RD), who was present during the test tray, was interviewed on March 5, 2012 at 9:07 AM, and stated she did not know why the food was so cold.

The Regional Food Service Director was interviewed on March 5, 2012 at 11:30 AM, and stated they did test trays on the resident units 2 - 3 times per week. He said they took the food temperatures at the time the last resident was served and did not take them at the time the last resident was assisted with eating.

In summary, the facility did not ensure food served was palatable and at the proper temperature.

10 NYCRR 415.14(d)(1)(2)

F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4): NOT EMPLOY PERSONS GUILTY OF ABUSE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 30, 2012

The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Citation date: March 7, 2012

Based on record review and staff interview conducted during the standard survey, it was determined for 2 of 5 newly hired employees (Employees #1 and 3), the facility did not ensure all required pre-employment screening was completed. Specifically, for Employees #1 and 3, the facility did not verify the employees' status with the State nurse aide registry prior to hire. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Review of personnel files during survey revealed:
- Employee #1 was hired by the facility on January 30, 2012 in the Activities department. There was no documented evidence the facility verified the employee's status with the certified nurse aide (CNA) registry at the time of hire; and
- Employee #3 was hired by the facility on November 7, 2011 as a switchboard operator. There was no documented evidence the facility verified the employee's status with the CNA registry at the time of hire.

In an interview on March 6, 2012 at 9:30 AM, the Personnel Administrator stated the facility did not check Employees #1 or 3 against the CNA registry as they were not CNAs. She stated the facility recently reviewed their personnel files and procedures and thought they no longer needed to check the CNA registry on the unlicensed staff who were subject to criminal history record checks (CHRC).

In summary, the facility did not complete required pre-employment screening for Employees #1 and 3 as their status was not verified with the CNA registry at the time of hire.

10 NYCRR 415.4(b)(1)(ii)
10NYCRR 415.13(c)(2)(ii)

F328 483.25(k): PROPER TREATMENT/CARE FOR SPECIAL CARE NEEDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 30, 2012

The facility must ensure that residents receive proper treatment and care for the following special services: Injections; Parenteral and enteral fluids; Colostomy, ureterostomy, or ileostomy care; Tracheostomy care; Tracheal suctioning; Respiratory care; Foot care; and Prostheses.

Citation date: March 7, 2012

Based on observation, record review and staff interview conducted during the standard survey, it was determined for 1 of 2 residents (Resident #12), reviewed with tracheostomies (an opening through the neck into the trachea), the facility did not ensure the resident received the proper respiratory care. Specifically, for Resident #12, the facility did not ensure all necessary respiratory equipment was readily available. This resulted in no actual harm with potential for more than minimal harm that was not immediate jeopardy.
Findings include:

Resident #12 was admitted to the facility on February 28, 2012 with diagnoses including Down's Syndrome. The resident was admitted from the hospital where she had a tracheostomy placed.

The February 28, 2012 physician's order documented the resident was to have 10 L (liters) of oxygen and wear a 50% trach (tracheostomy) collar.

The February 29, 2012 physician's order documented the resident was to have trach care every day and as needed.

The comprehensive care plan (CCP) initiated on February 29, 2012 documented the resident had a tracheostomy. The plan included keeping suction equipment and a back-up tracheostomy at the bedside.

The resident's room was observed without an Ambu bag (medical device used to provide assisted breathing) on February 29, 2012 at 2:45 PM, and March 1, 2012 at 9 AM and 11:40 AM.

The March 1, 2012 physician's order documented the resident was to have tracheostomy care 3 times a day and as needed.

On March 2, 2012 between 12:10 and 12:54 PM, the licensed practical nurse (LPN) stated in an interview, the resident did not have an Ambu bag in her room and there was not one on the unit. She stated the Ambu bag was kept with the crash cart on the first floor.

On March 2, 2012 between 12:10 and 12:54 PM, the registered nurse (RN) stated in an interview, there was not an Ambu bag on the unit. He stated there was an Ambu bag with the crash cart on the first floor.

On March 5, 2012 at 2:40 PM, the RN Staff Educator stated in an interview, prior to the resident being admitted, she went to the unit and made sure all of the needed equipment was in the room. She stated she ensured there was a back-up trach and Ambu bag in the room and she did not know where the Ambu bag went. She stated she replaced the Ambu bag on March 2, 2012 and the resident was to have one in the room.

In summary the facility did not ensure all necessary tracheostomy equipment was readily available.

10 NYCRR 415.12 (k)(7)

F318 483.25(e)(2): RANGE OF MOTION TREATMENT AND SERVICES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 30, 2012

Based on the comprehensive assessment of a resident, the facility must ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

Citation date: March 7, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 4 residents (Resident #11) reviewed for range of motion (ROM)/contractures, the facility did not ensure that a resident with limited ROM received appropriate treatment and services to increase ROM and/or prevent further decreases in ROM. Specifically, for Resident #11, who had limitations in ROM in both hands, the facility did not ensure the planned devices were consistently applied and did not ensure there was a clear plan in place in regards to the devices. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #11 had diagnoses including Alzheimer's disease and dementia.

The comprehensive care plan (CCP) dated December 1, 2011 documented the resident was dependent on staff for all activities of daily living (ADL) and had contractures in both hands. The resident was to wear splints according to the wearing schedule, which was not specified and "bilateral palm protectors to be worn at all times per MD (physician) orders." The CCP documented the splints were to be monitored during unit splint checks.

The January 11, 2012 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance for ADLs, and had impairments on both sides of her upper extremities.

The resident was readmitted to the facility from the hospital on February 13, 2012 and the readmission physician's orders did not include splints or devices for the resident's hands.

The February 14, 2012 occupational therapy (OT) progress note documented the resident had muscular tightness and decreased range of motion (ROM) in both hands and the right elbow/wrist. The recommendation was for the resident to wear palm protectors in both hands, with rolled washcloths within the palm protectors.

The resident was observed without palm protectors or washcloths in her hands on March 1, 2012 at 9 AM and 11:30 AM.

The resident was observed on March 2, 2012 between 9:10 AM and 9:20 AM. She had a rolled up washcloth in her right hand and nothing in her left hand. The resident did not have palm protectors in either hand.

On March 5, 2012 at 8:45 AM and 9:15 AM, the resident was observed lying in bed without palm protectors or washcloths in her hands.

The CNA assigned to care for the resident stated in an interview on March 5, 2012 at 9:15 AM, the resident did not have devices in her hands right now. He stated she had rolled up washcloths in her hands when his shift started, but they were soiled, so he removed them. The CNA said he could have replaced them with clean washcloths. He stated the washcloths were not the same as the palm protectors and the resident used to have palm protectors. The CNA said he had not seen the resident's palm protectors for a while.

The registered nurse (RN) Manager stated in an interview on March 5, 2012 at 11:57 AM, the palm protectors were recommended by OT who should have provided them for the resident. She stated prior to the resident's hospitalization, she fed herself so the palm protectors were removed during meals. The RN said now staff fed the resident so she could wear the palm protectors during meals.
She stated the palm protectors would be removed when they clean the resident and to give her a break.

On March 5, 2012 at 12:09 PM, the RN Manager stated the resident was to have palm protectors applied in the morning and removed at HS (evening).

In summary the facility:
- did not ensure the resident's palm protectors with rolled washcloths were applied as planned; and
- did not ensure there was a specific schedule for when the resident was to wear the paln protectors.

10 NYCRR 415.12 (f)(1)