Central Park Rehabilitation and Nursing Center

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure investigations of injuries of unknown origin, incidents of resident to resident sexual aggression, injuries experienced during care, and resident falls were thoroughly investigated to determine if abuse or neglect occurred. Specifically, thorough investigations were not completed:
- for Resident #3 with sexual aggression towards other residents and had bruising of unknown origin;
- for Resident #17 with a fall from a mechanical lift, and a fall from bed during care.
- for Residents #2, 18, and 23 who experienced falls;
- for Resident #24 with a scrotal laceration from care;
- for Resident #7 with physical aggression toward another resident. 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 November 18, 2009 SURVEY.

Findings include:

1) Resident #3 had diagnoses including advanced Parkinson's disease, anxiety, depression, dementia, personality disorder, and psychosis.

The Minimum Data Set (MDS) assessment dated March 22, 2010 documented the resident had short and long term memory impairment, with moderate cognitive impairment. The assessment recorded the resident had altered perception, disorganized speech, lethargy, restlessness, and his mental function varied. The MDS documented the resident wandered, was verbally abusive, socially inappropriate, resisted care, and had an unsteady gait. The resident was specified to need assistance with ambulation, transferring, bed mobility, hygiene and dressing.

The "Resident to Resident Abuse Assessment", dated March 24, 2010, documented the resident was at high risk to abuse others and be a victim of abuse.

The comprehensive care plan (CCP), dated January 6, 2010, documented the resident was verbally, physically, and sexually abusive at times. The CCPs interventions were:
- observe for signs of agitation, and redirect or remove other residents from the area;
- if agitated, cease activity/interaction, and return after agitation has decreased;
- observe and intervene with resident removing clothing;
- observe for inappropriate touching;
- diversional activities.

The licensed practical nurse (LPN) nursing notes, dated March 3, 2010, documented the resident was found "feeling on" another resident; and was on the floor looking up a female resident's dress. This note documented when the resident was redirected, he started "started putting his hand in the back of her (the female resident's) wheelchair and feeling her buttocks."

The incident investigation dated March 5, 2010, documented the LPN who wrote the nursing note on March 3, 2010, was interviewed and it was determined she did not fully describe the actual events. The investigation included a written statement from the LPN. The LPN documented the resident was found on the floor next to the other resident, looking up while lying on his back. After he was returned to his room, the resident went to the female resident's room, and put his hand through the back of her chair. The investigation concluded the Resident #3 had no physical contact with the other resident. The investigation did not include other documented interviews to support this conclusion.

In an interview with the Director of Nursing (DON) on May 6, 2010 at 9:45 AM, she stated staff look at anything this resident did as sexually motivated. She stated she interviewed staff on duty at the time of the incident, and re-enacted the occurrence. The DON said she did not document the interviews other than the LPN interviews, and did not document the re-enactment.

Nursing notes, dated March 17, 2010, documented the resident came up to another resident and touched her on the leg.

An investigation, dated March 18, 2010, documented staff reported inappropriate contact with another resident. The investigation documented through an interview with the registered nurse (RN) Unit Manager, it was determined the resident's hand "appeared" on another (female) resident's leg; and she was yelling for Resident #3 to leave her alone. Resident #3 was in the other resident's room at the time. The investigation documented the other resident denied any physical or emotional harm.

The certified nurse aide (CNA) statement, dated March 17, 2010, documented the resident was in another resident's room, and they heard the other resident yelling for him to leave her alone. When the CNA responded, Resident #3 had his hand on the other resident's thigh.

The investigation included undated, unsigned notes that Resident #3 had his hand on the other resident's thigh, rubbing it up and down. The other resident was "screaming and yelling to stop." The other resident was quoted as saying she was not harmed, and that some old man bothered her. The conclusion was that it was not clear if he was seeking the other resident out or, if the action was incidental to being told to leave her room.

During observations made on May 4, 2010 at 4:30 PM. the resident was in his room, lying on the bed. There was a large dark purple blue bruise covering most of his forearm, a large blue/green bruise on his right knee, and a yellow/green bruise on his right hip.

In an interview on May 5, 2010, at 11:45 AM, with the CNA assigned to care for the resident, she stated the resident threw himself around and got lots of bruises. The CNA said the resident may have gotten those bruises from the hospital. She stated she reported bruising to the nurses, and they knew about these.

In an interview with the RN Unit Manager on May 4, 2010, at 5:15 PM, she stated she thought the bruise on his arm was from a recent hospitalization (April 28, 2010). She said she was not aware of the other bruises. The RN stated she did not do an investigation for these bruises of unknown origin.

In summary the facility:
- did not provide documented evidence of thorough investigations of two separate incidents to determine if the resident's actions were sexually abusive;
- did not investigate three bruises of unknown origin to make a determination if abuse occurred.

2) Resident #18 had diagnoses including diabetes, end stage renal disease, coronary artery disease, left hip fracture.

The Minimum Data Set (MDS) assessment, dated March 8, 2010, documented the resident had long term memory impairment with moderately impaired cognition. The MDS recorded the resident had repetitive anxious complaints, and persistently sought attention and reassurance. She was resistive to care, required the extensive assistance of 1 for bed mobility and transferring, and noted the resident had dizziness, an unsteady gait, and fell in the past 30 days.

The comprehensive care plan (CCP) dated March 3, 2010, documented the resident had a fall when transferring herself out of bed; the planned intervention was to use a bed/chair alarm. The CCP, dated March 4, 2010, documented the resident fell out of bed; the planned intervention was to place the resident in a gerichair at the nursing station when she was restless.

A nursing note dated March 12, 2010 documented the resident slid out of a gerichair onto the floor. The note documented "earlier in the shift resident had to be repeatedly repositioned in chair" after "multiple attempts to get out of it." "In this instance, although resident had been placed in a common area for observation, she slid out of the chair when all 3 staff members were otherwise involved." The note documented the resident had complaints of moderate to severe pain when pressure was applied to her left hip, and was transferred to the hospital for evaluation.

The accident investigation, dated March 12, 2010, documented the chair alarm was not applied at the time of the fall, as it did not have a battery. The resident statement, dated March 12, 2010, specified "I wasn't going to stay in (the) chair." The investigation did not include documented employee statements regarding the resident being left unattended in the chair, the resident's status prior to the fall, or the chair alarm not being applied as planned.

In an interview with the registered nurse (RN) Unit Manager on May 5, 2010 at 11 AM, she stated the resident was falling from bed. The plan was to use the gerichair to provide a change in position when the resident was restless, and to keep a closer eye on her.

In an interview with the Director of Nursing (DON) on May 6, 2010, at 9:45 AM, she stated accident/incident reports were reviewed by her and the Administrator. She said she was not aware the chair alarm was not applied at the time of the incident.

In summary, there was no documented evidence a thorough investigation was conducted to determine if abuse or neglect occurred, as the resident was left unattended, in a gerichair without the chair alarm applied.

3) Resident #17 had diagnoses including cerebral vascular accident (CVA) with left sided hemiparesis (weakness of 1 side of the body) and dementia.

The Minimum Data Set (MDS) assessment, dated February 8, 2010, documented the resident had long term memory problems with difficulty making decisions in new situations only, and required total assistance for bed mobility, transferring, and personal hygiene.

The comprehensive care plan (CCP), dated February 11, 2010, documented the resident was non-ambulatory and required 2 assist with a mechanical lift for transfers. The CCP documented the resident was at risk for falls related to her hemiparesis and poor vision.

Review of the undated CNA Daily Care Record revealed the resident was to be transferred with 2 assist and a sit to stand lift (a mechanical lift used to assist residents to stand and then transfer between surfaces).

A hand written note on the CCP, dated April 8, 2010, documented the resident "slid - fell out of sling of sit - stand". T he CCP was changed to have the resident transfer with a mechanical lift (Hoyer lift for non-weight bearing transfers) and 2 assist.

An Incident/Accident Report, dated April 8, 2010, documented the resident slid out of the sit-to-stand sling while being transferred and fell on the floor, hitting her head. A statement by the certified nursing aide (CNA) documented he was transferring the resident off the toilet and she leaned back causing her body to "fall free from the sling". The report documented the CCP and CNA Daily Care Record were reviewed and the resident was changed to a mechanical lift (Hoyer) for transfers with 2 assist. There was no documented evidence the CNA was re-educated on how to use a sit-to-stand lift to prevent another fall from bed. There was no documented evidence of a determination of whether abuse or neglect had occurred or whether the NYSDOH (New York State Department of Health) should have been notified.

A second hand-written note on the CCP, dated April 26, 2010, documented the resident "rolled OOB (out of bed) during care".

An Incident /Accident Report, dated April 26, 2010, documented the resident rolled out of bed and lowered to the floor while given care by a CNA. A statement by the CNA documented the resident was asked to roll over on her side for care, and the resident slid out of bed. The CNA documented he lowered the resident to the floor and called for help. The report documented the CCP and CNA Daily Care Report were reviewed, and there were no intervention changes. There was no documented evidence the CNA was re-educated to prevent recurrence of the incident, there was no documented evidence of a determination on whether the care plan was followed, whether abuse or neglect had occurred, or if NYSDOH should have been notified.

During an interview on May 5, 2010 at 4:30 PM with the RN Unit Manager, she stated there should be 2 staff present when a resident was transferred with the sit-to-stand lift. The Unit Manager said the CNA did not follow the plan of care when he used the lift by himself and was not formally re-educated on using the sit-to-stand lift correctly. She stated she counseled the CNA and explained to him what he did wrong. The Unit Manager said the CNA was counseled and reeducated by the Director of Nursing (DON).

During an interview on May 6, 2010 at 9 AM, the registered nurse (RN) Staff Educator stated all CNAs and nurses received training on the proper use of mechanical lifts during orientation. The RN educator said if a staff member did not use a mechanical lift properly, the staff member would be re-educated by either the Staff Educator, or by the Unit Manager. She stated she did not re-educate any CNAs regarding mechanical lifts or care in April 2010.

During an interview on May 6, 2010 at 10 AM, the DON stated the CNAs involved in both incidents did not follow the plan of care. The DON said she thought the CNAs involved in the resident's incidents were counseled by the Unit Manager. The DON stated she thought the CNA involved in the resident's April 8, 2010 incident was re-educated and that the CNA involved in the April 26, 2010 incident was not re-educated at that time. The DON said she did not believe there was any intentional abuse or neglect in either incident; that determination was not documented in the investigation report.

In summary, the facility did not ensure a thorough investigation was completed of 2 falls involving facility staff, to determine if abuse or neglect had occurred, and whether staff were re-educated in a timely manner to prevent a reoccurrence.

10NYCRR 415.4(b)(2-4)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the nurse call system was equipped properly and operating properly in 8 of 33 resident toilet rooms sampled, (room of Residents #29 and 31, and rooms 107, 118, 212, 214, 217, 304), and in 2 of 8 common resident toilet rooms (Unit 3 shower room and Unit 2 bathing suite). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) The nurse call cord in the toilet room of Resident #29 was 2 inches long when observed on May 5, 2010 between 11:45 AM and 12:15 PM and between 4:10 PM and 5 PM.

Resident #29 had diagnoses including schizophrenia and depression. The resident's MDS (Minimum Data Set), dated November 9, 2009, documented the resident's cognitive status was modified independence. The comprehensive care plan (CCP), dated November 6, 2009, documented the resident had an unsteady gait. The intervention was to remind the resident to call for assistance when needed.

When the registered nurse (RN) Unit Manager was interviewed on May 5, 2010 at 8:45 AM, she stated she was not aware of any reason the residents should not have a nurse call cord in the toilet room. She said she was not aware the nurse call cord was 2 inches long, and that there was no current work order to repair the nurse call cord.

When the Environmental Services Director was interviewed on May 5, 2010 between 9:05 and 10 AM, he stated a work order for the nurse call cord in Resident #29's toilet room was turned in on May 5, 2010.

In summary, the facility did not ensure Resident #29's toilet room was equipped with an appropriate nurse call cord.

2) When Unit 3's shower room was observed on May 4, 2010 at 11:05 AM, there was no pull cord at the nurse call station adjacent to the toilet. The call station was designed to have a cord to initiate the nurse call signal, and the call station was inoperable without the cord, leaving no way to call staff for assistance.

In summary, the facility did not ensure the nurse call system in Unit 3's shower room was equipped properly.

3) The nurse call pull cords in several resident toilet rooms were wrapped multiple times around the grab bar adjacent to the toilet, and did not operate properly when tested:
- Resident #31's room on Unit 4 was observed on May 3, 2010 between 2:15 and 3 PM.
- in room 304's toilet room, a nurse call cord was wrapped 4 times around the grab bar on May 4, 2010 between 9:50 and and 10:50 AM.
- resident rooms 212, 214, and 217, and the Unit 2 bathing suite were observed on May 5, 2010 between 9:45 and and 10:15 AM.
- resident rooms 107 and 118 were observed on May 5, 2010 between 11:45 AM and and 12:15 PM.

Resident #31 had diagnoses including encephalopathy (a brain disorder). The resident's MDS (Minimum Data Set) dated March 11, 2010 documented his cognitive status was moderately impaired. The comprehensive care plan (CCP), updated April 26, 2010, documented the resident was at risk for falls, with an intervention to remind him to call for assistance when needed.

When Unit 4's registered nurse (RN) Manager was interviewed on May 4, 2010 between 5:15 PM and 5:30 PM, she stated she did not know why the nurse call cords were wrapped around grab bars in some resident toilet rooms.

When Unit 3's RN Manager was interviewed on May 4, 2010 between 5:45 PM and 6 PM, she stated she did not know why the nurse call cords were wrapped around grab bars in some resident toilet rooms.

When Unit 1's RN Manager was interviewed on May 5, 2010 at 8:45 AM, she was not aware of any reason the nurse call cords were wrapped around the grab bars in some resident toilet rooms.

The Environmental Services Director was interviewed on May 5, 2010 between 9:05 AM and 10 AM, and stated the facility did random resident room audits, which included checking the nurse call system. He said checks for nurse call cords wrapped around grab bars were done at that time.

In summary, the facility did not ensure the nurse call system was operating properly in 7 resident toilet rooms and 1 bathing suite.

10NYCRR 415.29(b)

Based on observation, record review, and staff interview during the standard survey, it was determined the facility did not develop, review, and revise the comprehensive care plan (CCP) for 2 of 24 residents reviewed for care plan concerns (Residents #9 and 10). Specifically, the facility did not ensure Resident #9's CCP was accurate and complete regarding the type of chair used by the resident. For Resident #10, the facility did not ensure the CCP was accurate and complete regarding the discontinuation of isolation precautions. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #10 had diagnoses including Parkinson's disease and dementia with psychosis.

The comprehensive care plan (CCP), dated January 15, 2010, documented the resident was placed on contact precautions for Clostridium difficile (a bacterial infection causing diarrhea). The CCP documented the care plan would be reviewed in April 2010.

The resident's current CNA (certified nurse aide) Daily Care Record (guidance for direct care staff), dated January 15, 2010, documented the resident was on precautions for Clostridium difficile.

The resident's Minimum Data Set (MDS) assessment, dated February 15, 2010, documented the resident had some difficulty with daily decision making, in new situations only. The MDS assessment did not document the resident had Clostridium difficile.

Physician renewal orders, dated April 2, 2010, documented the physician discontinued the resident's Clostridium difficile precautions.

On May 4, 2010 at 8:45 AM, there was no isolation precaution signage or isolation cart for supplies observed outside the resident's room.

During an interview on May 5, 2010 at 11:10 AM, the registered nurse (RN) Unit Manager stated she should have updated the CCP when the physician discontinued the resident's contact precautions.

In summary, the facility did not ensure the CCP was revised when the physician discontinued the resident's contact precautions.

2) Resident #9, who was readmitted to the facility April 20, 2010, had diagnoses including diabetic neuropathy (nerve pain) and Parkinson's disease.

The resident's Minimum Data Set (MDS) assessment, dated December 25, 2009, documented the resident did not walk in his room or the hallway, and was able to move from location to location in his chair with limited assistance of one person. The MDS assessment did not document a chair prevented the resident from standing.

Review of the physician renewal orders dated April 20, 2010 and interim orders revealed there was no order for the resident to use a gerichair when out of bed.

The comprehensive care plan (CCP), dated April 20, 2010, documented the resident was to use a high back wheelchair, with the correct size wheelchair and raised pedals, and the resident should be assisted with wheelchair mobility. The CCP documented staff should monitor the resident for correct fit of the "w/c, g-chair". The CCP did not specify which chair the resident was given.

The resident's current (undated) CNA (certified nurse aide) Daily Care Record (guidance for direct care staff) documented the resident used a wheelchair with foot pedals.

During an observation in the resident's room on May 3, 2010 at 1:55 PM, the resident was in bed, there was a gerichair on his side of the room, and there was no wheelchair in his room.

On May 3, 2010 at 12:40 PM and on May 4, 2010 at 12:40 PM, the resident was observed in a gerichair, eating lunch in the unit dining room.

When interviewed on May 5, 2010 at 1:50 PM, the registered nurse (RN) Unit Manager stated she "automatically" documented on the CCP that the resident used a wheelchair. The RN said the resident used a high back wheelchair before he went to the hospital and said the resident was not comfortable in the wheelchair after he returned. She stated physical therapy staff recommended a gerichair for the resident.

During an interview with the physical therapist on May 5, 2010 at 2 PM, he stated he requested a gerichair for the resident, and nursing was made aware the resident was to use a gerichair. The therapist could not provide documentation of this recommendation for the gerichair.

In summary, the facility did not ensure the resident's CCP was revised to include the resident was to use a gerichair, and not a wheelchair.

10NYCRR 415.11(c)(1)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure aseptic (sanitary) technique was used by staff to prevent or minimize the development and transmission of disease and infection for 1 of 2 residents observed during treatment observations (Residents #9). Specifically for Resident #9, aseptic technique was not maintained while cleansing the pressure ulcer. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #9 had diagnoses including a Stage III pressure ulcer and methicillin resistant Staphylococcus aureus (MRSA, an antibiotic resistant bacterial infection).

The comprehensive care plan (CCP), dated April 20, 2010, documented pressure ulcer treatments were to be done as ordered.

On April 26, 2010, the facility nurse practitioner ordered resident's coccyx pressure ulcer should be cleaned with normal saline, nurses were to "pat" the wound dry, apply Skin Prep to the intact skin around the wound, use Santyl (a type of ointment) in the wound, and then cover with Allevyn adhesive (a type of dressing). The order documented the dressing change was to be done every day.

The resident's Skin Condition Monitor form, dated May 4, 2010, documented the resident's Stage III coccyx area pressure ulcer, measured 5.0 centimeters (cm) x 11.0 cm. The form documented the pressure ulcer's wound bed was 80% covered with slough (yellow opaque drainage). The form documented a second area, next to the large area and separated by healed skin, measured 1.5 cm x 1.0 cm, and had a moist and clean wound bed.

During an observation on May 5, 2010 at 8 AM, the licensed practical nurse (LPN), after spraying the wound with normal saline, used a 4 x 4 gauze to wipe the wound in a circular motion, from the slough area at the center of the wound, out to the clean, red wound beds to the left, and then to the right, of the slough area. After the LPN wiped the wound, a small amount of slough was observed in the right side of the wound bed, which had been clean. The LPN repeated the process, cleansing the wound with a second 4 x 4 gauze in a circular motion, from the slough area of the wound to the clean areas of the wound.

When interviewed on May 5, 2010 at 9:35 AM, the treatment LPN stated she cleansed the wound in a circular motion from the inside of the wound to the outside. The LPN could not explain the wound technique that should be used, when the inside of the wound was covered with slough and the outside of the wound bed was clean.

In summary, the facility did not ensure acceptable standards of quality were maintained, as aseptic technique was not followed while the cleansing the pressure ulcer, during the dressing change observation.

10NYCRR 415.19

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure the environment remained as free from accident hazards as possible, and adequate supervision and assistance devices were provided to prevent accidents for 2 of 21 residents reviewed for accident concerns (Residents #3 and 20), and for 1 of 8 sampled resident rooms observed in Unit 3 (Resident #28's room). Specifically for Resident #3, the chair and bed alarms were not consistently applied as planned, and were not maintained in functioning order. For Residents #3 and 20, the 15 minute monitoring checks were not signed as being done, as planned. For Resident #28, a throw rug without a non-slip backing or pad (accident hazard) was observed in the room. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #3 had diagnoses which included advanced Parkinson's disease, anxiety, dementia, personality disorder, and psychosis.

The Minimum Data Set (MDS) assessment dated March 22, 2010 documented the resident had short and long term memory impairment, with moderate cognitive impairment, had altered perception, disorganized speech, lethargy, restlessness, and varied mental function. The MDS documented the resident wandered, was verbally abusive, socially inappropriate, resisted care, and had an unsteady gait. The assessment recorded the resident needed assistance with ambulation, transfer, and bed mobility, and fell within the past 30 to 180 days.

The Fall Assessment Tool and Guidelines dated January 6, 2010, documented the resident was at high risk for falls.

The current comprehensive care plan (CCP), dated January 6, 2010, documented the resident was at risk for falls related to a history of cataracts, medications, self- transferring, unsteady gait, a history of falls, Parkinson's disease, and behavior. The planned interventions included a bed/chair alarm, the bed in a low position with floor mats, and hourly checks.

The Fall Assessment Tool and Guidelines dated April 24, 2010, documented the resident remained at high risk for falls.

The current undated CNA (certified nurse aide) Daily Care Record documented the resident was to have a chair alarm, and was on 15 minute checks.

On May 4, 2010, from 4:30 PM to 5:06 PM, the resident was observed in his room, lying on his low bed with a floor mat next to it. There was a bed alarm on the bed next to his pillow that was not attached to him. The licensed practical nurse (LPN) came into the resident's room and gave him his medications. When doing so, she moved the floor mat across the room. The LPN exited the room, without putting the mat back next to the resident's bed. As the resident moved in the bed, his bed alarm fell onto the floor. He was holding the string with the metal tab, the alarm box was on the floor and did not sound. At 5:06 PM, a CNA came into the room. She started to reattach the bed alarm box after seeing it on the floor. When the surveyor asked the CNA about the alarm's functioning, she checked and saw there were no batteries in the box. The CNA started to leave the room, taking the alarm box with her to get new batteries. The floor mat was remained across the room, not near the resident's bed. Upon inquiry by the surveyor, the CNA stated the mat should be next to the resident's bed when he was in it. The CNA then placed the mat next to the bed.

The resident was observed on May 5, 2010, at 11:45 AM, lying in his bed. The bed alarm was on the bed and not attached to the resident.

In an interview with the day shift CNA on May 5, 2010 at 11:45 AM, she stated when she went into the resident's room that same morning, only the metal tab with the string attached was in the room. There was no alarm box. The CNA said she replaced the alarm box and said the resident removed the bed alarm.

The LPN was not available for interview.

The Visual Monitoring Sheet dated May 5, 2010, documented the resident was on 15 minute monitoring. This sheet was reviewed by the surveyor on May 5, 2010 at 2 PM. There were no signatures for the 15 minute checks May 5, 2010 from 11:30 AM until 2 PM. In an interview at that time with the CNA responsible for the monitoring, she stated she had not signed the monitoring sheet yet, but had been with the resident. In an interview with the RN unit manager at that time she said the 15 monitoring checks were visual checks and anyone could do them. She stated there were no specific times to be signed. The RN then said there was a sheet for the CNA assigned to monitor to sign, and that the CNAs did not always sign every 15 minutes. The RN stated the CNAs usually signed at the end of their shift.

In an interview with the RN unit manager on May 6, 2010 at 10:10 AM, she stated the resident was on 15 minute checks. She said the plan for 15 minute checks did not get put onto the current CCP, and that the 15 minute checks were on the previous CCP.

In summary, the facility did not ensure the resident's environment was as free of hazards as possible, and did not provide adequate supervision and assistance devices to prevent accidents, as the facility:
- did not ensure the bed alarm was applied and functioning;
- did not ensure the floor mat was in place next to the resident's bed;
- did not ensure planned interventions on the CNA care card and the CCP matched;
- did not ensure the 15 minute monitoring checks were documented when completed to ensure accuracy and compliance.

2) Resident #20 had diagnoses which included Alzheimer's disease, anxiety, agitation, and paranoid ideations.

The Minimum Data Set (MDS) dated January 6, 201 documented the resident had short and long term memory impairment, with moderately impaired cognition. This assessment recorded the resident had altered perception, episodes of disorganized speech, restlessness, and was easily distracted. This MDS documented the resident wandered and resisted care.

The current comprehensive care plan (CC) dated January 13, 2010, documented the resident the resident was at risk for elopement, related to a history of elopement attempts, wandering without purpose, impaired safety awareness, poor impulse control, the ability to learn the door code, and diagnoses of dementia with anxiety and agitation. The planned interventions included 15 minute safety checks.

Nursing notes dated February 28, 2010 through May 4, 2010 documented the resident was maintained on hourly visual checks.

The current, undated CNA (certified nurse aide) Care Record documented the resident was at risk for elopement, with no documentation of visual monitoring.

The Visual Monitoring Sheet dated May 5, 2010, documented the resident was on hourly monitoring checks. The sheet was reviewed by the surveyor on May 5, 2010 at 2 PM, and revealed it had not been signed as being done since 6 AM on May 5, 2010.

In an interview with the RN Unit Manager on May 5, 2010 at 2 PM, she said the monitoring checks were visual checks and anyone could do them. She stated there were no specific times to be signed. The RN then said there was a sheet for the CNA assigned to monitor to sign; the CNAs did not always sign every hour; they usually signed at the end of their shift.

In an interview with the RN Unit Manager on May 6, 2010 at 10:10 AM, she stated the resident was on hourly checks. She said the checks did not get put onto the current CCP, or CNA Care Card. The hourly checks had been documented on the previous CCP and CNA Care Card.

In summary the facility did not ensure the resident's environment was as free of hazards as possible, and did not provide adequate supervision and assistance devices to prevent accidents, as the facility:
- did not ensure there were no discrepancies in planned interventions on the CNA care card and the CCP contained no discrepancies in planned interventions; and
- did not ensure the hourly monitoring checks were documented when completed to ensure accuracy and compliance.

3) Resident #28 had diagnoses including dementia and personality disorder.

Resident #28's MDS dated March 12, 2010 documented her cognitive status was moderately impaired, and she walked in both her room and the corridor with supervision, without physical assistance from staff.

Resident #28 's comprehensive care plan dated March 19, 2010 documented she was at risk for falls related to impaired vision, confusion with impaired judgement, and poor safety awareness. Goals in the comprehensive care plan included decrease risk of falls through modification of environment.

When Resident #28's room was observed on May 4, 2010 between 9:50 AM and 10:50 AM, May 4, 2010 between 4:10 and 5:15 PM, and May 5, 2010 between 8:15 AM and 8:45 AM, a small throw rug was under the foot end of the resident's bed, without a non-slip pad or non-slip backing.

When the registered nurse (RN) Unit Manager was interviewed on May 4, 2010 between 5:45 PM and 6 PM, she stated she was not aware of the facility policy regarding throw rugs.

When the Environmental Services Director was interviewed on May 5, 2010 between 9 AM and 10 AM, he stated the facility did not allow throw rugs.

In summary, the facility did not ensure Resident #28's environment was free of accident hazards.

10NYCRR 415.12(h)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure 1 of 4 residents reviewed for pressure ulcers (Resident #4) received the necessary treatment and services to promote healing and prevent new pressure ulcers from developing. Specifically, the physician was not notified of Resident #4's newly developed pressure ulcer, and no treatment was ordered until 6 days after it was found, when it had drainage. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #4 had diagnoses which included peripheral edema, coronary artery disease, Alzheimer's disease, and peripheral vascular disease (PVD).

The Braden Scale for Predicting Pressure Sore Risk, dated January 8, 2010, documented the resident was at high risk for skin breakdown.

The Minimum Data Set (MDS) assessment, dated January 11, 2010, documented the resident had short and long term memory impairment with moderately impaired cognition. This MDS documented the resident needed total assistance with bed mobility, transfer, activities of daily living (ADLs), had edema, had no pressure ulcers, was on a turning schedule, and had pressure relieving devices for the bed and chair.

The 24 hour nursing report for the 7 AM to 3 PM shift dated January 28, 2010, documented the resident had a "pressure area on right ankle" that remained intact and needed evaluation.

A nursing note, dated January 28, 2010, documented the resident had no change in the pressure area on his right ankle, and the surrounding area was intact. A nursing note dated January 29, 2010 documented the resident had no change in the pressure area.

The Skin Condition record, dated January 29, 2010, documented the resident had a purple-blue area on his right outer ankle which measured 1.5 centimeters (cm) x 1.0 cm; the treatment was to "monitor".

There was no documented evidence in the resident's medical record the physician was notified of the resident's pressure ulcer, or that a treatment was ordered.

The Skin Condition record, dated February 4, 2010, documented the right outer ankle area was 1.0 cm x 0.8 cm, with scant serous drainage; the surrounding skin was dark pink and cool.

A nurse practitioner (NP) order dated February 4, 2010 was to treat the resident's right ankle area with wound gel to the base, Skin Prep around the open area, cover with a dry dressing, and wrap with Kerlix gauze.

In an interview with the registered nurse (RN) Unit Manager on May 5, 2010 at 12 PM, she stated the wound care nurse at the facility when the resident developed the pressure ulcer, was no longer employed by the facility.

In an interview on May 5, 2010 at 4:30 PM, a licensed practical nurse (LPN) stated she documented on the resident's pressure ulcer on January 28 and 29, 2010, because she was told about the area in report at the beginning of her shifts. She said she did not tell any one about the pressure ulcer, as it was already on the report.

The resident was observed in bed at 12:30 PM on May 4, 2010. He had blue booties on both feet, a pillow between his legs, and a foot cradle in place.

The surveyor requested on May 4, 2010 to observe the resident's pressure ulcer during the dressing change the next morning (May 5, 2010). The surveyor did not have an opportunity to observe the pressure ulcer, as a dressing change was performed at the time of a physician visit on May 5, 2010. (This was earlier than staff told the surveyor that the resident's dressing would be changed.)

In summary, the facility did not ensure the resident received the necessary treatment and services to promote healing, when they did not notify the physician of the newly developed pressure ulcer until 6 days later, when it became open with drainage.

10NYCRR 415.12(c)(2)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not complete Minimum Data Set (MDS) assessments in a timely manner, as required for 2 of 30 residents in the sample (Residents #4 and 20). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #4 had diagnoses which included bipolar disorder, dementia, depression, coronary artery disease and osteoarthritis.

An annual MDS (Minimum Date Set) assessment was completed on January 11, 2010. There was no documented evidence a quarterly MDS assessment (due in April 2010) was completed and signed by the registered nurse (RN).

In an interview with the RN MDS coordinator on May 6, 2010 at 10:20 AM, she stated she was new in that role. The RN MDS coordinator said it was a time of transition, and she was "playing catch up."

In summary, the facility did not complete the resident's quarterly MDS assessment within 3 months following the previous assessment, as required.

2) Resident #20 had diagnoses including Alzheimer's disease, anxiety, agitation, depression, and paranoid ideation.

A quarterly MDS (Minimum Data Set) assessment was completed on January 6, 2010. There was no documented evidence a quarterly MDS assessment (due in April 2010) was completed and signed by the registered nurse.

In an interview with the RN MDS coordinator on May 6, 2010 at 10:20 AM she stated she was new in that role. The RN MDS coordinator said it was a time of transition, and she was "playing catch up."

In summary, the facility did not complete the resident's MDS assessment within 3 months following the previous assessment, as required.

10NYCRR 415.11(3) and (4)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure significant medication errors did not occur for 1 of 7 residents (Residents #26) observed during a medication pass. Specifically, Resident #19 was administered insulin beyond its expiration date; the licensed practical nurse (LPN) prepared to administer the wrong dose of a second type of insulin for this resident. 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 November 18, 2009 SURVEY.

Findings include:

Resident #26 had diagnoses including diabetes mellitus.

The resident's Minimum Data Set (MDS) assessment, dated March 8, 2010, documented the resident's cognitive skills for daily decision making were moderately impaired, her decisions were poor, and she required cues/supervision.

The comprehensive care plan (CCP), dated March 10, 2010, documented the resident had diabetes mellitus, blood sugar values were to be maintained in a therapeutic range, and medications were to be administered as ordered.

The physician renewal orders, dated April 9, 2010, documented the resident was to be administered Lantus insulin (long acting) 24 units subcutaneously (injection under the skin) daily and Novolin-R insulin (short acting) 6 units at 5 PM.

The resident's May 2010 Medication Administration Record (MAR) documented the resident was to be administered Lantus insulin 24 units subcutaneously daily at 5 PM. In the MAR, both Lantus and 24 Units were underlined. The resident's MAR documented the resident was administered Lantus insulin 24 units subcutaneously in her right arm and Novolin-R insulin 6 units in her left arm on May 3, 2010 at 5 PM.

During a medication pass observation on May 3, 2010 at 5:15 PM, the LPN drew up 16 units of Lantus insulin into a insulin syringe. After the LPN stated she was ready to administer the resident's medications, the surveyor requested that the LPN review the resident's MAR for the correct dosage of the Lantus insulin. The LPN then rechecked the amount of Lantus insulin in the syringe, which had 16 units in it. The LPN said she did not have the correct dosage, and added 8 units of Lantus to the syringe.

During the same medication pass observation, the resident's bottle of Novolin-R insulin was observed to be dated March 18, 2010, as the date it was opened.

During an interview on May 3, 2010 at 5:30 PM, the LPN checked the date on the resident's Novolin-R insulin bottle, stated the opened insulin bottles can be used for 30 days, and stated she would get a new one.

In summary, the facility did not ensure the resident was free from significant medication errors, as:
- an LPN was prepared to administer the incorrect dosage of one type of insulin;
- administered another type of insulin after its expiration date.

10NYCRR 415.12(m)(2)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined during the medication pass observation, the facility did not ensure 1 of 7 residents (Resident #25), reviewed for self-administration of medications, was assessed for the ability to safely and accurately self-administer medications. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #25 had diagnoses including sleep apnea (interrupted breathing), seasonal allergies, and sinusitis.

The resident's Minimum Data Set (MDS) assessment, dated March 3, 2010, documented the resident was independent in daily decision making, as her decisions were consistent and reasonable.

On April 8, 2010, the physician renewed the order for Flonase 0.06% (chronic sinusitis medication) nasal spray, 2 sprays in each nostril every day.

On April 26, 2010, the nurse practitioner ordered normal saline nasal spray, 2 sprays in each nostril every day.

The comprehensive care plan (CCP), dated May 4, 2010, documented the resident wanted to be as independent as possible, and included no documented evidence the facility care planned for the resident to self-administer medications.

During a medication pass observation on May 4, 2010 at 8:55 AM, the licensed practical nurse (LPN) reviewed the resident's Medication Administration Record (MAR), stated the resident's Flonase nasal spray, (scheduled at 9 AM), and her normal saline nasal spray, (scheduled at 10 AM), in her room. The resident's MAR included no documented evidence these medications were to be self-administered by the resident.

During the same above medication pass observation, the LPN went in the resident's room, and the resident was observed on her telephone. The LPN administered the resident's oral medications, reminded the resident to take her nasal sprays when she got off the telephone, and left the room.

During an interview on May 5, 2010 at 9:50 AM, the LPN (who was observed on the May 4, 2010 medication pass) stated she knew the concern was there was no documented order for the resident to self-administer her nasal sprays. The LPN could not provided documented evidence of a physician order for the medications to be self- administered.

When interviewed on May 5, 2010 at 10 AM, the registered nurse (RN) Unit Manager just realized the resident did not have an order to self-administer her nasal sprays. The RN manager was not able to provide documentation of a physician order for the resident to self-administer medications, or of any education on the self-administration of medications.

In summary, the facility did not ensure the resident was assessed to determine if she could safely and accurately self-administer medications prior to allowing resident to self-administer 2 medications.

10NYCRR 415.3(e)(1)(vi)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined for 2 of 7 residents (Residents #26 and 27) observed for medication administration, and for 1 of 4 sampled residents reviewed with pressure ulcers (Resident #6), the facility did not ensure professional standards of quality were maintained. Specifically for Resident #26, the medication administration site was the same for 2 injections; and the medical record documentation did not accurately reflect the sites of these 2 insulin injections. For Resident #27, the LPN (licensed practical nurse) was not prepared to administer the resident's medication as ordered by the attending physician. For Resident #6, a planned pressure relieving intervention was not implemented during the survey. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #26 had diagnoses including diabetes mellitus.

The resident's Minimum Data Set (MDS) assessment, dated March 8, 2010, documented the residents cognitive skills for daily decision making were moderately impaired, her decisions were poor, and she required cues/supervision.

The comprehensive care plan (CCP), dated March 10, 2010, documented the resident had diabetes mellitus, blood sugars were to be maintained in a therapeutic range, and medications were to be administered as ordered.

The physician renewal orders, dated April 9, 2010, documented the resident was to be administered Novolin-R insulin (short acting insulin) 6 units and Lantus 24 units subcutaneously (injection under the skin) daily at 5 PM.

The resident's May 2010 Medication Administration Record (MAR) documented the resident was administered Lantus insulin 24 units subcutaneously in her right arm and Novolin-R insulin 6 units in her left arm on May 3, 2010 at 5 PM.

During a medication pass observation on May 3, 2010 at 5:15 PM, the LPN (licensed practical nurse) administered both the resident's Lantus and Novolin-R insulins in the same area of her right arm. The injections were 3 to 4 millimeters apart.

When interviewed on May 6, 2010 at 8:45 AM, the medication LPN stated she administered the resident's insulin in the same area of her arm, and thought the injections were 3 to 4 inches apart. When asked, she stated she documented the injections sites on the resident's MAR.

During an interview on May 5, 2010 at 11:55 AM, the registered nurse (RN) Unit Manager stated if a resident received 2 injections at the same time, she expected the sites to be rotated, 1 injection in 1 arm, and 1 injection in the other arm, for example.

In summary, the facility did not ensure acceptable standards of quality were met when:
- the resident was administered 2 injections at the same time in the same area of her right arm;
- the LPN did not accurately document the injection site of the resident's insulin.

2) Resident #27 had diagnoses including dementia and cerebrovascular accident (CVA, stroke).

The comprehensive care plan (CCP), dated April 21, 2010, documented the resident's daily decision making skills were poor, and cues/supervision was needed. The CCP documented the resident's short term memory was impaired.

The physician renewal orders, dated April 21, 2010, documented an order for Refresh artificial tears (for dry eyes), 1 drop in each eye, 3 times a day and as needed.

The resident's May 2010 Medication Administration Record (MAR) documented the resident was to be administered Refresh artificial tears, 1 drop in each eye, 3 times a day at 9 AM, 1 PM, and 5 PM, and as needed.

During a medication pass observation on May 4, 2010 at 8:55 AM, the licensed practical nurse (LPN) was observed administering the resident's oral medications, and then stated she was done passing medication to the resident. When asked by the surveyor, the LPN reviewed the resident's MARs, and stated "oh, I forgot" to give the resident her eye drops. The LPN was unable to locate the eye drops in the medication cart, or in the unit medication room. The LPN left a telephone message with the central supply staff that she needed a bottle of Refresh artificial tears.

During an interview on May 4, 2010 at 9:15 AM, the LPN stated she would have realized that she forgot the resident's eye drops when she reviewed the resident's MARs at the end of the medication pass.

In summary, the facility did not ensure acceptable standards of quality were met when the resident's eye drops were not administered as ordered.

3) Resident #6 had diagnoses including Parkinson's disease, COPD (chronic obstructive pulmonary disease), and osteoarthritis.

The Minimum Data Set (MDS) assessment, dated February 8, 2010, documented the resident did not have any memory problems, had difficulty with decision making in new situations only, and required total assistance with bed mobility, transferring, personal hygiene, and toileting.

The resident's comprehensive care plan (CCP), dated February 11, 2010, documented the resident was non-ambulatory, and was transferred with a Hoyer lift (a mechanical lift). The CCP documented the resident was at risk for developing a pressure ulcer, secondary to her immobility, incontinence, and disease process. Interventions included pressure reduction mattress, a gel cushion in the reclining gerichair, and repositioning every 2 hours and as needed.

A Skin Condition Monitor sheet, dated April 19, 2010, documented the resident had a Stage II open blister behind her right knee. The interventions included a daily treatment to the area, and to monitor placement of the Hoyer pad behind the resident's knees to prevent irritation. A hand written entry, dated May 3, 2010, documented the resident's wound was resolved.

The undated CNA (certified nursing assistant) Daily Care Record (used by the CNAs as a care guide) documented the Hoyer pad was to be removed from under the resident's legs while she was in the reclining gerichair.

On May 4, 2010 12:30 PM, Resident #6 was observed seated in the dining room in a gerichair with a Hoyer pad under her knees, waiting for the lunch meal.

At 4:45 PM on May 4, 2010, Resident #6 was observed in her room in a reclining gerichair, with the Hoyer pad under her knees. The resident was being transferred from the gerichair to the bed by 2 CNAs, using the Hoyer lift. After the CNAs provided incontinence care to the resident, they transferred the resident back into the gerichair using the Hoyer lift. The Hoyer pad remained under the resident's knees after she was transferred back into the gerichair.

During an interview on May 5, 2010 at 5 PM with one of the CNAs who provided the resident with care on May 4, 2010, she stated she did not usually take care of the resident and was aware the resident used to have a blister behind her knees that healed. She said she was not aware the resident's care plan was to remove the Hoyer pad from under the resident's knees when she was in the gerichair. She said she "did not remember anyone saying anything about removing the Hoyer pad."

The second CNA who helped with the resident's transfer was not available for interview on May 5, 2010.

On May 5, 2010 at 5:15 PM, the registered nurse (RN) Unit Manager was interviewed and stated the Hoyer pad was supposed to be pushed back from under the resident's knees, when she was in the gerichair. She said the information was on the CNA care card, and should have been discussed with staff in shift report.

In summary, the facility did not ensure the resident's plan of care was followed to prevent the reoccurrence of a pressure ulcer.

10NYCRR 415.11(c)(3)(i)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure the environment was maintained in a sanitary and orderly manner in 14 of 33 resident rooms sampled during the survey, (rooms 101 , 104,106, 209, 218, 301, 304, 310, 315, 320, 321, 404, 417, and 418). Specific concerns included a broken chair not repaired in a timely manner, lights not working, furniture/fixtures not well maintained, and stained/soiled environmental surfaces. This resulted in no actual harm with potential for more than minimum harm.
Findings include:

1) Unit 4 was observed on May 3, 2010 between 2:15 PM and 3 PM. In resident room 418, at least 5 hooks were missing from the cubicle curtain, 1 dresser drawer pull was missing, and a dark brown stain was on the floor. In resident room 417, several hooks were missing from the cubicle curtain. In resident room 406, the clear plastic light cover was cracked in the toilet room.

2) Unit 3 was observed on May 4, 2010 between 9:50 and 10:50 AM. The overbed light in room 321 did not work. Room 315 had a black spot with a tarry appearance on the floor. The nurse call cord was soiled in room 310's toilet room. There was a colored stain on the floor of room 304. At least 5 hooks were missing from cubicle curtains in resident rooms 301 and 320.

3) In resident room 209 on Unit 2, the window was inoperable when observed on May 4, 2009 between 6:40 and 7 PM and on May 5, 2010 at 1:05 PM. The overbed light in room 218 did not work during the May 5, 2010 inspection between 9:45 AM and 10:15 AM.

4) Unit 1 was observed on May 5, 2010 between 11:45 AM and 12:15 PM. Resident room 116's toilet seat was loose and not firmly attached to the toilet. The toilet seat in the Unit 1 shower room had multiple deep scratches and was not easily cleanable. The overbed light in resident room 104 did not work; there was no toilet paper in room 104's dispenser.

There was a work order dated April 1, 2010 to remove the toilet paper dispenser from room 104, due to sharp edges.

When the Environmental Services Director was interviewed on May 5, 2010 between 9:05 AM and 10 AM, he stated the facility did 3 random resident room audits per unit per week to check the condition of the environment.

5) On May 4, 2010 at 4:30 PM, a surveyor received an anonymous complaint from a visitor that the arm of a chair in room 101 was broken. The visitor stated the concern was reported twice to facility staff, and the broken chair remained in the resident's room.

On May 5, 2010 at 8:20 AM, a surveyor observed the broken arm of a chair in resident room 101.

When interviewed on May 5, 2010 at 8:30 AM, the Environmental Services Director stated he did not receive a work order for the chair in resident room 101.

In summary, the resident environment in the 4 nursing units was not maintained in a sanitary and orderly manner.

10NYCRR 415.5(h)(2), 415.29(j)(1)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the corridor was separated from use areas on 1 of 5 floors of the building, the basement. The basement corridor was utilized as a storage area for flammable mattresses and pads during the survey. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the initial tour of the basement corridor on May 3, 2010 between 9:10 and 9:25 AM, there were 10 mattresses and 7 pads observed near the south end of the basement in the corridor. The mattresses and pads remained in the corridor when observed on May 4, 2010 at 7:30 PM, and on May 5, 2010 at 9:50 AM.

When the Environmental Services Director was interviewed on May 5, 2010 between 9 AM and 10 AM, he stated the mattresses and pads were being discarded. He stated he received conflicting information in the past about whether storage was allowed in the corridor, and he did not have a clear understanding regulations related to corridor storage.

In summary, the facility did not ensure the basement corridor was separated from the flammable trash storage area with partitions.

10NYCRR 415.29(a)(1&2), 711.2(a)(1)