Rosewood Heights Health Center

Deficiency Details, Certification Survey, October 11, 2011

PFI: 0657
Regional Office: Central New York Regional Office

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F314 483.25(c): PROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES

Scope: Pattern

Severity: Actual Harm

Substandard Quality of Care

Corrected Date: December 14, 2011

Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

Citation date: October 14, 2011

Based on observations, record reviews, staff and family interviews conducted during the extended survey, it was determined for 8 of 17 sampled residents (Residents #6, 19, 24, 25, 31, 32, 40, and 42) reviewed for pressure ulcers, the facility did not ensure residents received the necessary care and services to prevent the development of new pressure ulcers and/or to promote the healing of existing pressure ulcers. Specifically, the facility failed to:
- implement pressure relieving devices timely and/or as planned (Residents #6, 19, 24, 25, 31, and 42);
- review/revise the plans of care timely and/or when needed (Residents #6, 19, 24, 25, 31, 32, and 42);
- notify the physician of changes in skin status timely (Residents #6, and 32);
- administer treatments as ordered (Residents #6, and 31);
- assess pressure ulcer risk accurately and/or when needed (Residents #6 and 19); and
- assess or monitor residents' skin status/open areas on a consistent and timely basis (Residents #6, 31, 24, and 25).
This resulted in actual harm and Sub-Standard Quality of Care, that is not immediate jeopardy for Residents #6, 19, 24, 31, and 42, and no actual harm with potential for more that minimal harm that is not immediate jeopardy for Residents #25, 32, and 40.
- Resident #6 was at risk for the development of pressure ulcers and experienced actual harm when interventions to prevent new pressure ulcers from developing were not implemented timely, the resident developed an unstageable pressure ulcer on the coccyx which gradually worsened, interventions to promote healing were not implemented timely; the resident's condition deteriorated he was admitted to the hospital with a diagnosis of sepsis related to the pressure ulcer on the coccyx and died.
- Resident #19 experienced harm when she developed a pressure ulcer on her left hip that gradually worsened and became infected as the facility failed to notify the physician/NP in a timely manner, accurately assess and reassess pressure ulcer risk, reassess and implement changes to the plan of care for pressure relief, and provide turning and positioning as planned
- Resident #31 experienced harm when he developed 3 unstageable pressure ulcers on his feet, as the facility failed to review and revise the plan of care addressing his actual pressure ulcers and prevention of new pressure ulcers, did not develop or implement a specific plan for pressure relief , did not accurately assess the pressure ulcers when they developed and did not complete treatments as ordered.
- Resident #24 experienced harm when the Stage III pressure ulcer on the bottom of his right foot increased in size as the facility did not ensure the specialized boots issued by podiatry were implemented as ordered.
- Resident #42 experienced harm when she developed an unstageable pressure ulcer on the right heel and a Stage II pressure ulcer on the left heel, as the facility did not implement pressure relieving devices at the time of admission. At the time of admission, the resident had a soft right heel and was assessed to be at risk for pressure ulcer development.
Findings include:

1) Resident #6 was admitted to the facility on August 8, 2011 with diagnoses including coronary artery disease.

The "Skin Condition Monitor," initiated on August 8, 2011, documented the resident had the following:
- an unstageable pressure ulcer on the left heel that measured 3 cm (centimeter) x 3 cm, described as a "deep tissue injury, not open." The planned treatment was skin prep (a topical application that toughens skin), Kerlix (a type of gauze wrap) and offloading.
- a deep tissue injury on the coccyx, no measurements were documented. The planned interventions included a Gaymar (pressure reducing) cushion, and turning/positioning the resident every 2 hours.

The August 8, 2011 nurse practitioner's (NP#1) history and physical documented the resident had edema from knees to toes, no palpable pedal pulses, his calves were non-tender and supple with a negative Homan's sign. There was no documentation in the NP#1 note regarding the pressure ulcer on the resident's left foot, the resident's skin status, or the deep tissue injury on his coccyx.

The August 9, 2011 physician's progress note documented the resident had trace amount of edema of his legs and a "dressing in place" on the left heel. The note did not address the deep tissue injury on the coccyx. The physician's plan included monitoring the resident via the wound team.

The resident's "Skin Condition Monitor" form completed by the registered nurse (RN) documented:
- on August 13, 2011, the deep tissue injury on the coccyx was a Stage II pressure ulcer (partial thickness loss of skin layers) that measured 0.5 cm x 1 cm. The treatment was changed to DuoDerm (a moisture retentive wound dressing);
- on August 16, 2011, the pressure ulcer on the left heel had 80% slough (yellow, soft, dead tissue) and measured 2.5 cm x 4 cm. The treatment was changed to Santyl (a sterile ointment to remove dead tissue);
- on August 26, 2011, the pressure ulcer on the left heel was 90% slough with no change in measurements; and
- on August 26, 2011, the pressure ulcer on the coccyx had 80% slough (no slough was previously documented), measured 2.7 cm x 3 cm x 0.1 cm, and the treatment was DuoDerm.

The August 28, 2011 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, was not resistive to care, and needed extensive/total assist with activities of daily living (ADL). The resident was continent of bowel, occasionally incontinent of bladder, had pressure relieving devices for the bed/chair, was on a turning/positioning program, and received nutritional interventions for wound healing.

The resident's "Skin Condition Monitor" form completed by the RN, documented on September 1, 2011, the pressure ulcer on the left heel was 4.5 cm x 3.5 cm. The RN documented the area increased in size as the Santyl exposed "true necrotic area that had been hidden by dry skin."

On September 2, 2011, a comprehensive care plan (CCP) was initiated. The CCP noted the resident had pressure ulcers and the planned interventions included: moderate to maximum assistance with toileting; skin inspections every shift; and pressure relieving devices (specific devices not listed); This CCP documented turn and position every 2 hours; encourage self positioning as appropriate; and treatments as ordered. There was no documented evidence a CCP was initiated prior to September 2, 2011, addressing the resident's risk for pressure ulcers and actual pressure ulcers.

The Resident's Plan of Care (RPOC, used by the certified nurse aides to direct care) was undated, and documented the resident turned and positioned himself, and his heels were to be offloaded, there was no specific method for offloading documented.

The covering RN on Unit 2 (the unit the resident was admitted to) was interviewed on October 7, 2011 at 8:50 AM. She stated she was just learning how to develop a CCP. She stated she understood she had 14 days to develop a CCP.

The September 5, 2011 nursing progress note documented the resident's left heel had foul smelling drainage and would be assessed by the RN in the morning. Review of the medical record revealed no documented evidence the resident's left heel was assessed by an RN on September 6, 2011 as planned.

The nursing progress note dated September 7, 2011 documented the resident moved from Unit 2 to Unit 4.

The resident's "Skin Condition Monitor" completed by the RN documented:
- on September 9, 2011 the pressure ulcer on the left heel was unchanged.
- on September 16 and 21, 2011, the pressure ulcer on the coccyx had a small amount of drainage and remained the same size; and
- on September 16, 2011, the pressure ulcer on the left heel was larger, measuring 5 cm x 6 cm and was described as "necrotic" (dead tissue) with slough.

The September 28, 2011 nursing progress note documented a new "U" (unstageable) pressure ulcer was found on the resident's right heel. The area was blackened and measured 2 cm x 2 cm. The note documented the NP#2 was notified and evaluated the resident. The note included planned interventions of an APM (alternating air) mattress, pressure relieving booties, and a consult with the wound clinic. (The resident was hospitalized before the consult was provided).

The NP#2's order dated September 28, 2011, documented to off load the resident's heels at all times, and requested a consultation with the wound center as soon as possible for evaluation of the resident's heels and coccyx.

The Treatment Administration Record (TAR) dated September 28, 2011, documented to offload the resident's heels at all times. The TAR documented this intervention (offloading) was added to the resident's RPOC certified nurse aides (CNA), on September 28, 2011. The undated RPOC documented the resident could turn and position himself.

In an interview with the covering RN manager on October 4, 20111, at 2:25 PM she stated the resident used blue booties for offloading.

The September 29, 2011 nursing progress note documented the CNA told the nurse the resident "repeatedly wet himself" when he tried to use a urinal in bed.

There was no documented evidence the plan of care was re-assessed, or changes in planned interventions implemented regarding the resident's continence issues in view of the worsening pressure ulcer on the coccyx.

On October 3, 2011, the resident's "Skin Condition Monitor" form was reviewed by the surveyor. This form documented the pressure ulcer on the resident's coccyx was last assessed on September 21, 2011, and measured 2 cm x 3 cm x 0.1 cm, with a wound bed of 80 % slough with granulating edges.

The resident was observed on October 3, 2011 between 12:50 PM and 1:15 PM, sitting in a wheelchair in the dining room. He had slipper socks on both of his feet, his right foot rested directly on the floor, and his left foot rested directly on the foot rest of the wheelchair. He was not wearing the pressure relieving booties, his feet were not offloaded.

The undated RPOC, provided by the covering registered nurse (RN) Manager on October 3, 2011 at 4:15 PM, documented the resident was to get out of bed, have his heels offloaded no-specific device identified), and turned/positioned himself, and wore incontinence briefs.

The resident was observed on October 4, 2011 at 7:50 AM and at 8:45 AM, lying on his back in his bed.

On October 4, 2011 at 8:45 AM, the resident and his spouse were interviewed. The resident's spouse stated 2 of the resident's pressure ulcers started prior to his admission, and he developed a new pressure ulcer at this facility. She said when the resident was at a previous nursing facility, he was out of bed everyday. She stated staff did not get the resident out of bed daily at this facility, and they did not know why.

The resident was observed on October 4, 2011 at 12:20 PM, 12:45 PM, and at 1:05 PM, lying on his back in bed. He had pressure relieving booties on both of his feet.

On October 4, 2011 at 1:35 PM, a licensed practical nurse (LPN) stated in an interview, that the RN Manager was responsible for completing wound rounds. She stated currently there was no RN Manager for the unit and no specific day for wound rounds.

On October 4, 2011 at 1:40 PM, the resident was observed during the pressure ulcer treatments. The resident was lying in his bed. On the bottom of the left heel was a pressure ulcer that was mostly blackened with a stripe of yellow across the top. The "covering" RN Manager measured the area and said it was 5.3 cm x 2.3 cm, with 95% eschar, and 5% slough. On the right, inner heel was a pressure ulcer that was dark and reddened. The RN stated it was 2 cm x 2.4 cm. Prior to observing the resident's buttocks, the nurses positioned the resident on his side. The resident yelled out "let go, ow, ow." The resident needed staff assistance to turn onto his side. The resident had on an incontinence brief that was soiled with loose stool, there was no dressing on the coccyx pressure ulcer. There was no dressing visible in the brief, the LPN stated she did not see a dressing. The resident was observed to be incontinent of liquid stool. When the LPN began cleaning and drying the pressure ulcer, the resident again yelled out "that's sore." The coccyx pressure ulcer measured 4.3 cm x 4 cm, was unstageable, with a wound bed of 80% yellow slough and a rim of red tissue around the edges. The surrounding skin was darkened. Immediately following the treatment observation on October 4, 2011 at 2:10 PM, the RN stated she did not think the resident was in pain, she thought he was one to yell out.

On October 4, 2011 at 2:20 PM, the CNA (who routinely cared for the resident) stated in an interview, the resident turned himself. She said she did not get him out of bed everyday as he was incontinent and had loose stools. The CNA stated the resident had been having loose stools since he came to that unit (September 7, 2011) and nursing staff were aware.

The resident's NIOR (Nutrition Intake and Output Record) which records the residents intake and output, including bowel movements, documented the resident had loose stools on September 14, 24, 28, 2011, and on October 1, 3, 4, and 5, 2011.

There was no documentation in the nursing progress notes regarding the resident's loose stools.

On October 4, 2011 at 2:25 PM, the covering RN Manager stated in an interview, she did not know when the resident got the APM mattress as there would not be an order for it. She reviewed the medical record and stated the pressure relieving booties were ordered on September 28, 2011 and he did not have them prior to that date. She stated the resident did not "look like someone who'd be easy to turn and position." The RN said she was not going to recommend any change to the resident's current treatments.

The resident was observed on October 5, 2011 at 8:35 AM and at 11:55 AM, lying on his back in bed. He had pressure relieving booties on both feet.

On October 7, 2011 between 10:30 and 10:45 AM, an occupational therapist (OT) and physical therapist (PT) were interviewed. They stated residents with pressure ulcers greater than Stage II were issued Roho cushions. They stated the facility's standard cushion was the Gaymar which was a "general, basic cushion." At 10:45 AM, the OT came to the resident's room with the surveyor, and looked at the cushion in the wheelchair. She stated it was a Gaymar cushion. At that time the resident was observed lying on his back in bed and there was a very strong fecal odor in the room.

On October 7, 2011 at 11:40 AM, the Director of Rehabilitation stated in an interview, the Gaymar cushion was used for residents with no pressure ulcers or no serious pressure ulcers. She stated since the resident no longer received restorative therapy, the therapists would not be involved with his care unless requested by nursing. She said at that time OT or PT did not go on wound rounds.

On October 7, 2011 at 2:35 PM, a second LPN stated in an interview, the LPNs did the ordered treatments and saw residents skin status when the CNAs asked them. She said LPNs did not do regular skin inspections of the residents.

On October 7, 2011 at 3 PM, the Director of Nursing (DON) stated in an interview, skin rounds were done weekly by the RNs and RDs and OT or PT attended "sometimes."

On October 10, 2011 at 2:25 PM, the NP#2 was interviewed. She stated her role at the facility was evolving and she had helped out on Unit 4. She said someone had asked her to see the resident on September 28, 2011 as his pressure ulcers worsened and he developed a new pressure ulcer area. She reviewed the medical record and stated she did not see evidence medical had assessed the resident's pressure ulcers prior to September 28, 2011.

On October 10, 2011 at 10:40 PM, a nursing progress note documented the resident was "pale, pupils dilated, low blood pressure, decreased, shallow breathing." The ambulance was called and the resident was sent to the emergency room for evaluation.

The October 11, 2011 hospital's admission note documented the resident was admitted with "apparent septic shock." He had multiple pressure ulcers that were foul-smelling and purulent. The assessment documented the resident had "septic shock secondary to likely his deep tissue injuries and secondary to infection, more from the sacral than from the heel ulcers."

A social work progress note on October 12, 2011 documented the resident expired at the hospital.

In summary, the resident experienced actual harm when the resident developed an unstageable pressure ulcer on the right heel, the pressure ulcers on the left heel and coccyx worsened, was hospitalized for septic shock from the pressure ulcers which resulted in death, as the facility:
- failed to implement pressure relieving devices timely when the resident was admitted with 2 deep tissue injuries;
- failed to evaluate the resident's pressure relieving device (Gaymar cushion) when the pressure ulcer on the coccyx progressed from a Stage II to an area with 80-90% slough;
- failed to ensure a CCP was developed timely to include individualized approaches for pressure ulcer treatment and prevention including a plan for getting out of bed, tuning/positioning, and management of incontinence;
- failed to notify medical timely when the pressure ulcers worsened;
- failed to ensure pressure relieving booties were implemented consistently.

2) Resident #19 had diagnoses including dementia and osteoporosis.

The Minimum Data Set (MDS) assessment dated August 25, 2011 identified the resident with severe cognitive impairment. The resident required assistance with all activities of daily living and utilized a wheelchair for mobility. The MDS documented the resident was at risk for developing pressure ulcers, and did not have pressure ulcers. The assessment recorded the resident had a pressure relieving cushion in her chair (not in bed), and a trunk restraint applied daily. The MDS did not document the resident as being on a turning and positioning program.

The comprehensive care plan (CCP) updated June 7, 2011, documented the resident had potential for impaired skin integrity, limited mobility, and chronic obstructive pulmonary disease. The planned interventions included: utilizing pressure relieving/ reducing devices in bed and chair as indicated; reposition in chair every 2 hours and as needed; turn and position every 2 hours; encourage self-positioning as appropriate; PT/OT evaluation as needed for positioning equipment; and treatment as ordered as needed.

On August 16, 2011 a nursing progress note documented the resident had an open area on the left hip that measured 1 cm (centimeter) x 1 cm, "Tegaderm (a transparent protective wound covering) and pad applied". The resident was positioned on her side to relieve pressure.

A "Skin Condition Monitor" form (skin tracking sheet) completed by the RN was initiated on August 17, 2011. The form documented the resident had a new Stage II pressure ulcer on the left hip, measuring 1.1 cm x 1.1 cm, that was red, open, and superficial. The treatment was to cleanse with normal saline, pat dry, apply DuoDerm spot (moisture retentive wound dressing) and change every 3 days. An occupational therapy (OT) consult was recommended to evaluate the resident for cushions for the side of the wheelchair.

A physician's order dated August 17, 2011 documented to discontinue the Tegaderm cleanse with normal saline, pat dry, and apply DuoDerm spot every 3 days.

A CCP was initiated on August 17, 2011 for the Stage II pressure ulcer on the left hip. The goals identified were to show improvement in 4 to 6 weeks, and be free from infections. The planned interventions included: ordering and evaluating the treatment for effectiveness as needed; measuring and observing weekly for resolution or worsening and documenting on the skin monitoring form; providing pressure reducing devices as identified on the Resident Plan of Care (used by the certified nurse aides); and an undated entry for an OT evaluation for a cushion of the side of the wheelchair.

The undated Resident Plan of Care (RPOC) documented the resident was to use a Gaymar cushion in the chair and wheelchair, and a Gaymar mattress overlay in bed. There was no documentation in the RPOC directing the CNAs to turn and position the resident.

An OT progress note (date not legible) documented the resident was referred to OT on August 17, 2011 for wheelchair positioning. The resident had a small "abrasion" on her left hip that was healing. The note recorded the resident was observed in a narrow wheelchair with a lap buddy in place. The resident was given a Gaymar (pressure reducing) cushion to sit on as "no cushion was placed" in the wheelchair. The resident was observed not to be seated where the open sore was on her left hip. The note documented the OT determined the pressure ulcer area was not in direct contact with the wheelchair when the resident was seated. The OT recommended the Gaymar cushion be in the resident's wheelchair at all times.

On October 7, 2011 at 11:40 AM, the Director of Rehabilitation stated in an interview, the area she documented as pressure was the area nursing described as a pressure ulcer. The Director said Gaymar cushions were used for residents with no pressure ulcers or no serious pressure ulcers. Those with "more serious" pressure ulcers should have Roho cushions. She stated since the resident did not receive restorative therapy, the therapists would not be involved with the care unless requested by nursing. The Director said at this time, none of the therapists attended wound rounds.

On August 24, 2011, the Skin Condition Monitor, signed by team members (initials not identified), documented the pressure ulcer on the left hip was superficial and measured 0.7 by 0.9 (no unit of measurement identified) No changes were made to the treatment.

On August 31, 2011 a dietary progress note documented the resident was seen for skin rounds and the left hip pressure ulcer "was much worse in status". Changes were made to the nutritional assessment and plan of care.

The Skin Condition Monitor documented the team observed the pressure ulcer on the resident's left hip on August 31, 2011. The pressure ulcer was unstageable, measured 1 x 1.2 (no unit of measurement identified) the wound bed was slough (yellow, soft, dead tissue) with serosanguinous drainage and red surrounding tissue. Treatment was changed to Aquacel Ag (a wound healing product) and DuoDerm every 3 days and as needed.

The current comprehensive care plan (CCP) reviewed by the interdisciplinary team on September 6, 2011, documented the resident had potential for impaired skin integrity, limited mobility, and chronic obstructive pulmonary disease. The planned interventions included: utilizing pressure relieving/ reducing devices in bed and chair as indicated; reposition in chair every 2 hours and as needed; turn and position every 2 hours; encourage self-positioning as appropriate; PT/OT evaluation as needed for positioning equipment; and treatment as ordered as needed.

The Skin Condition Monitor documented the team observed the pressure ulcer on the resident's left hip as follows:
- On September 9, 2011 (9 days later), was unstageable, measured 1.5 x 1.2 (no unit of measurement identified), the wound bed was "necrotic area" (dead tissue). There was no change to the treatment.
- On September 14, 2011, was unstageable, measured 1.3 x 2.1 with slough around the edges and yellow drainage. No changes were made to the treatment.
- On September 21, 2011, was unstageable, measured 1.8 x 1.9, the wound bed was yellow slough with red edges, and yellow drainage. The surrounding skin was intact and no changes were made in the treatment.
- On September 30, 2011, was unstageable, measured 1.4 x 2.4, the wound bed was slough with red edges, and no changes were made to the treatment.
- On October 5, 2011, was unstageable, measured 1.4 x 3.0, the wound bed was described as having "lots" of slough and "a lot" of yellow drainage. The treatment was documented as "same".

The current undated RPOC, provided on October 3, 2011, documented the resident was to use a Gaymar cushion in the chair and wheelchair, and a Gaymar mattress overlay in bed. There was no direction for turning and positioning the resident documented on the RPOC.

On October 4, 2011, the resident was observed in the dining room at 10:30 AM. Shes was seated in a wheelchair with a pressure reducing cushion and a lap buddy in place.

There was no documentation in the nursing progress notes related to the resident's skin status or pressure ulcer from August 16, 2011 through October 4, 2011.

There was no documented evidence in the resident's medical record, from September 1, 2011 through October 5, 2011, that the treatment to the resident's left hip pressure ulcer was reassessed as the area worsened.

A nursing progress note dated October 5, 2011, identified as a "late entry", documented the staff advised the nurse the resident's left hip wound was "foul smelling" and had "a lot" of slough with moderate yellow drainage. The note recorded the nurse practitioner (NP) was notified and gave an order for an antibiotic on October 4, 2011.

During a wound care observation on October 5, 2011 at 2:20 PM, the licensed practical nurse (LPN), the registered nurse (RN) Unit Manager, and the nurse practitioner (NP) were present in the resident's room. The resident was lying in bed, on her right side, with her left hip exposed. The old dressing on the left hip was removed by the LPN and had light greenish drainage on it. The RN then measured the pressure ulcer area as 1.4 cm (centimeters) x 3 cm. The wound bed was covered with light greenish, foul smelling slough with a reddened rim of tissue surrounding it.

The October 5, 2011 CCP documented the resident's left hip pressure ulcer was "ongoing" The plan included a Roho cushion, an APM (alternating pressure mattress) and a bed wedge for pressure relief .

A nursing progress note dated October 6, 2011 documented the left hip pressure ulcer was observed and continued to have a moderate amount of yellow drainage. "Per policy/procedure" for skin protocol, the resident's treatment was changed.

A physician's order dated October 6, 2011 documented the treatment change to left hip as follows: cleanse with normal saline, pat dry, apply Tegafoam securing with tape daily. A physician's order was written to obtain a bed wedge to relieve pressure off the resident's left hip while in bed, and for an APM mattress (alternating pressure).

The RN manager was interviewed on October 7, 2011 at 3:32 PM. She said a bed wedge was provided "yesterday", as the resident favored her left side, and an APM mattress was provided within the past week. The RN stated that on August 11, 2011, an OT evaluation for positioning was ordered, and no changes were recommended. She said a Roho cushion was provided for the resident's chair approximately 2 to 3 weeks ago. The RN stated she did not date changes made to the CCP.

The NP#2 was interviewed on October 10, 2011 at 1:30 PM. The NP said the RN Manager informed her about the left hip pressure ulcer on October 4, 2011. She stated the nursing staff thought the area was infected. The NP observed the pressure ulcer and started the resident on Levaquin (antibiotic). The NP said she thought the area was "fairly new." She stated the "skin team" reviewed the residents' skin status and if they had concerns, or thought a change in treatment was needed, the RN manager brought the concerns to the NP or the physician. The NP stated she trusted the "wound care team's" recommendation for treatment. After observing the pressure ulcer the NP stated she ordered a different treatment. She said providing special pressure relieving devices was a "nursing judgement" the team decided per facility protocol. The NP stated the first time she saw the resident's left hip pressure ulcer was October 5, 2011 with the RN manager, the LPN, and a surveyor.

In summary, the resident experienced actual harm when she developed an unstageable pressure ulcer that progressively worsened when the facility:
- failed to ensure the physician/NP were notified in a timely manner as the pressure ulcer worsened and became infected;
- failed to re-assess the resident's need for improved pressure relief as the pressure ulcer worsened;
- failed to communicate the plan to turn and position the resident to the direct care staff;
- failed to identify on the nursing assessment the resident was at risk for skin breakdown in June 2011, as she was incontinent, dependent on staff for mobility; and unable to reposition herself due to the use of a trunk restraint (Lapbuddy); and
- failed to complete a skin assessment when the resident had a change in condition (Stage II pressure ulcer).

3) Resident #31 was readmitted to the facility on August 29, 2011 following a hospitalization for respiratory failure and pneumonia. The resident also had a diagnosis of diabetes.

The August 29, 2011 readmission RN's assessment, documented the resident required assistance with bed mobility, needed assistance with transferring/walking, and had a diagnosis of diabetes. The assessment recorded the resident had a "denuded blister" on the plantar aspect of the right foot. There was no documentation regarding the implementation of pressure relieving devices.

The August 29, 2011 readmission orders signed by the NP documented the resident's right heel was to be cleansed daily with normal saline, patted dry and covered with Telfa (dressing) a DSD (dry sterile dressing) daily.

The resident's "Skin Condition Monitor" documented:
- on August 29, 2011, a "denuded" (irritant dermatitis) "blister" was found on the plantar aspect of the right foot. There were no measurements documented and the treatment was a DSD. The form recorded notification of interdisciplinary team as the physician/NP and "NM" (nurse manager);
- on September 9, 2011, (11 days later), the area on the right foot was an "open blister" with a pink base, and a small amount of drainage. The stage was documented as "N/A" (not applicable), no measurements were documented, and the treatment remained DSD;
- on September 16, 2011, the area on the right foot was staged as "N/A", and it had a pink base with macerated edges. No measurements were documented; and,
- on September 16, 2011, a "large denuded hard/dark blister" was found on the resident's left foot (plantar area). The area was intact, no measurements were documented, and the plan included Skin Prep (a topical application that toughens skin) and "offload." The form recorded notification of interdisciplinary team as the physician/NP and "NM".

The undated resident plan of care (RPOC, used by the certified nurse aides (CNA) to provide care) documented to "offload heels" there was no specific direction given or device identified for offloading. There was no documentation on the RPOC regarding the use of the resident's own shoes.

On October 5, 2011 at 2:15 PM the resident was interviewed by the surveyor and stated he was told not to wear his own boots, because of the areas on his feet.

The September 16, 2011 verbal physician's orders documented a treatment of skin prep to the left foot daily.

The September 2011 Treatment Administration Record (TAR) documented the treatment (Telfa and DSD) to resident's the right foot was discontinued on September 22, 2011 as it was "healed."

The resident's "Skin Condition Monitor" form completed by the registered nurse (RN) dated September 22, 2011 documented:
- the area on the left foot was not changed and was "hard/dark." skin prep was applied and the plan was to "offload;" and,
- the area on the right foot was documented as a 1 cm (centimeter) x 1 cm dark area. (The RN did not document the area was healed).

The nurse who completed the skin monitoring form and discontinued the treatment in the September 2011 TAR was not available for interview.

There was no documented evidence on the October 2011 TAR the treatment to the left foot (Skin prep) was administered from October 1 - 3, 2011. There was no documented rationale for the treatment not being provided.

The current comprehensive care plan (CCP) was last reviewed by the interdisciplinary team on July 14, 2011 (prior to the resident's hospitalization and development of pressure ulcers). The CCP recorded the resident was at risk for developing pressure ulcers, had a Gaymar cushion in the wheelchair, and a Gaymar mattress on the bed. The CCP did not document the resident's current pressure ulcers.

The undated RPOC was reviewed by the surveyor on October 3, 2011 at 4:15 PM. The RPOC instructed to "offload heels" and did not document directives regarding positioning, pressure relieving devices, or skin care.

In an interview on October 3, 2011 between 8:45 AM and 10:00 AM, the "covering" RN Manager stated the resident had a facility acquired pressure ulcer that was an intact blister.

The resident's "Skin Condition Monitor" form documented the resident's pressure ulcers were last assessed on September 22, 2011.

On October 4, 2011 at 10:10 AM, the "covering" RN Manager stated her first day in that role was October 3, 2011. She stated it was the responsibility of the RN Manager to do weekly wound rounds. In a second interview, at 1:35 PM, the RN stated she was not aware the resident's pressure ulcers had not been assessed since September 22, 2011.

There was no documentation the skin prep treatment to the pressure ulcer on the resident's left foot was administered on the TAR dated October 4, 2011.

On October 5, 2011 at 2:15 PM, the resident was observed lying in bed, on his back, his heels resting directly on the bed.

On October 5, 2011 at 2:35 PM, during a wound observation the resident was lying in bed on a standard pressure reducing mattress with no Gaymar mattress overlay. There was a round darkened area on the bottom, outer aspect, of the resident's left foot. The RN measured the area and stated it was 4 cm x 4 cm. There were 2 areas on the outer aspect of the resident's right foot. The first area on the right foot was darkened and measured 1.2 cm x 1.5 cm. The second area on the right foot was darkened with a reddened patch at the bottom and measured 1.5 cm x 3 cm. The RN told the LPN to "put Skin Prep on both of them" as they were unstageable areas.

The undated ROPC provided to the surveyor October 5, 2011, did not document directives regarding positioning, pressure relieving devices, or skin care.

The resident was observed on October 7, 2011 at 8:15 AM, sitting in a wheelchair, with slipper socks on both of his feet. The resident's feet rested directly on the foot pedals of the wheelchair. At 9:45 AM the resident was observed in the same position.

On October 7, 2011 at 10:30 AM, a physical therapist (PT) and occupational therapist (OT) were interviewed. They stated nursing was responsible for implementing pressure relieving mattress, and nursing or PT/OT could implement cushions/offloading devices for feet. They stated they were not involved with residents who were not receiving restorative PT/OT unless nursing requested their input.

The Skin Integrity Prevention and Treatment policy dated October 1997, documented if a resident had an area of impaired skin integrity on the feet position heels off bed with the use of pillows. This policy instructed to obtain a physician's order for a PT positioning evaluation "if necessary."

The Skin Care Protocols and Products policy dated November 2009, documented if a resident was at risk for pressure ulcers, heel booties or heel float must be on at all times, when resident is in bed or geri-chair or heels must be suspended off the mattress with a pillow.

On October 7, 2011 at 2:30 PM, the certified nurse aide (CNA) stated in an interview, the resident did not have any devices for offloading his feet when in the bed or the wheelchair. She stated the resident used to wear boots then got blisters so now he wears slipper socks.

On October 7, 2011 at 3:00 PM, the Director of Nursing (DON) stated in an interview, weekly wound rounds should be done by the RN Managers. She said was not aware that pressure ulcers on Unit 4 had not been assessed weekly. The DON stated one of the other RNs in the facility should have done the wound rounds. She stated the facility had established protocols, and the nurses who assessed pressure ulcers should follow the protocols. The DON said the RN would make a recommend treatment to the physicians/NP based on the facility's protocols.

The undated ROPC provided to the surveyor on October 13, 2011 did not document directives regarding positioning, pressure relieving devices, or skin care.

The facility's "Skin Care Protocols and Products" policy dated November 19, 2009, documented "denuded" areas were an irritant dermatitis and can be caused by moisture and were usually irregular in shape and superficial. The recommended treatment was Sensicare Protective Barrier cream.

There was no documentation regarding the RN's assessment of "denuded" when the resident's pressure ulcers did not meet the facility's description of "denuded" and there was no documented rationale regarding the treatment of DSD in place of the recommended treatment for a "denuded" area.

The RN who made the initial assessment and assessed the resident through September 22, 2011 was no longer employed by the facility, therefore was no available for interview.

In summary, the resident experienced actual harm when the resident developed 3 unstageable pressure areas on the feet, as the facility:
- failed to ensure the resident's CCP was reviewed and revised when needed to address the resident's actual pressure ulcers and prevention of further pressure ulcers;
- failed to ensure a plan of care was developed and implemented to "offload" the resident's feet;
- failed to ensure the resident's areas were accurately assessed according to the facility's established protocols; and
- failed to ensure treatments were completed as ordered.

10 NYCRR 415.12(1)(2)


10 NYCRR 415.12(c)(2)

F490 483.75: FACILITY ADMINISTERED EFFECTIVELY TO OBTAIN HIGHEST PRACTICABLE WELL BEING

Scope: Pattern

Severity: Actual Harm

Corrected Date: December 14, 2011

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Citation date: October 14, 2011

Based on observation, record review, and staff interview conducted during the extended survey, it was determined the facility's administration, including the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), failed to administer the facility in a manner that attained or maintained the highest practicable physical well-being for 8 (Residents #6, 19, 24, 25, 31, 32, 40, and 42) of 17 sampled residents reviewed for pressure ulcers. Specifically, the facility's administration:
- failed to ensure residents with pressure ulcers were monitored on a regular and timely basis;
- failed to ensure staff reviewed/revised residents' plans of care timely or when needed;
- failed to ensure the physician was notified of skin changes timely;
- failed to ensure treatments were administered as ordered;
- failed to ensure pressure relieving devices were implemented timely or as planned;
- failed to ensure staff assessed residents' pressure ulcer risk accurately and/or timely. This resulted in actual harm that is Substandard Quality of Care and not Immediate Jeopardy for Residents #6, 19, 24, and 42, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #25, 31, 32, and 40.
Findings include:

1) F314 Pressure Ulcers - The facility's administration, including the Administrator, DON, and ADON failed to have a system in place to monitor the pressure ulcers of Residents #6, 19, 24, 25, 31, 32, 40, and 42 on a regular and timely basis; failed to review/revise plans of care timely or when needed; failed to ensure the physician was notified of skin changes timely to ensure treatments were administered as ordered; failed to ensure pressure relieving devices were implemented timely or as planned; and failed to ensure staff assessed residents' pressure ulcer risk accurately and/or timely.

When the surveyor interviewed the DON on October 7, 2011 at 3:00 PM regarding skin care protocols and pressure ulcers, she stated she was unaware all residents with pressure ulcers were not assessed timely on all the units. She was unaware that: the residents' comprehensive care plans (CCPs) were not updated and that physicians were not notified when needed.

On October 12, 2011 between 11:30 AM and 12:30 PM, the surveyor interviewed the Administrator who stated he was not aware of the facility's problem with pressure ulcer prevention and treatment. He said he attended morning report and gave staff reminders of how to address issues, when he felt his input was helpful. He thought the facility had a good skin program and was only aware the physical therapy/occupational therapy departments struggled to find time to attend skin rounds.

When the surveyor interviewed the Administrator and the ADON on October 14, 2011 at 3:45 PM, the ADON stated the facility did a "good job" with skin breakdown "last year", as there were no problems on the previous survey. She stated they needed to follow the policies as the "policy works". The Administrator stated, due to many staffing changes with registered nurses, consistency seemed to be the concern.

In summary, the facility's administration, including the Administrator, DON, and ADON failed to develop and implement effective systems to prevent and treat pressure ulcers for Residents # 6, 19, 24, 25, 31, 32, 40, and 42.

10 NYCRR 415.26

F520 483.75(o)(1): FACILITY MAINTAINS QA COMMITTEE

Scope: Pattern

Severity: Actual Harm

Corrected Date: December 14, 2011

A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Citation date: October 14, 2011

Based on observations, record reviews, and staff interviews conducted during the extended recertification survey, it was determined the facility failed to provide a Quality Assurance (QA) program that readily identified issues with the potential to cause harm and no actual harm with potential for more than minimal harm that is not immediate jeopardy for 8 of 17 sampled resident reviewed for pressure ulcers. Specifically, the QA program:
- failed to ensure residents with pressure ulcers were monitored on a regular and timely basis;
-failed to ensure staff reviewed/revised residents' plans of care timely or when needed;
- failed to ensure the physician was notified of skin changes timely; - failed to ensure treatments were administered as ordered;
- failed to ensure pressure relieving devices were implemented timely or as planned;
- failed to ensure staff assessed residents' pressure ulcer risk accurately and/or when needed. This resulted in actual harm that is Substandard Quality of Care and not Immediate Jeopardy for Residents #6, 19, 24, and 42.

Additionally, the facility did not have a QA program in place that effectively identified issues to prevent repeat deficiencies and maintain compliance with State and federal regulations in F225, F252, F281, F323, and F441. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #4, 5, 9, 12, 15, 20, 25, 26, 27, 29, 31, 32, 34, 35, 40, 45, 47, 48.
Findings include:

1) During the survey of October 3 through October 13, 2011, 4 residents who had pressure ulcers (Residents #6, 19, 24, and 42) did not receive the necessary care and services to prevent the development of new pressure ulcers and/or to promote the healing of existing pressure ulcers. The facility's QA program failed to:
- assess or monitor resident skin/open areas on a regular and timely basis (Residents #6, and 24),
- review/revise the plans of care/RPOC (Resident Plan of Care) timely or when needed (Residents #6, 19, 24, and 42),
- notify the physician of skin changes timely (Resident #6), administer treatments as ordered (Resident #6),
- implement pressure relieving devices timely or as planned (Residents #6, 19, 24, and 42);
- assess pressure ulcer risk accurately and/or timely for (Residents #6 and 19).

2) The facility did not have a QA program in place that effectively identified issues to prevent repeat deficiencies in:
- F225 - Investigate and Report Possible Neglect - The facility's QA program did not ensure thorough investigations were completed and reported for this repeat deficiency, regarding incidents of unsafe wandering and/or elopement of Residents #27 and 34.
- F252 - Clean, Safe, Homelike Environment - The facility's QA program did not ensure floors, walls, ceilings, doors, windows, furniture and equipment were clean, safe, and well maintained.
- F281 - Professional Standards of Quality - The facility's QA program did not ensure Resident #32 insulin orders were clarified prior to the administration of the insulin, for this repeat deficiency.
- F323 - Accident Supervision and Prevention of Accident Hazards - The facility's QA program did not ensure effective measures were implemented and care plan developed in this repeat deficiency regarding Residents #9 and 12 for falls, regarding unsafe smoking practices of Residents #4, 5, 26, 31, 45, 46, and 47, and regarding unsafe wandering and/or elopement for Residents #27, 34, and 35.
- F441 - Infection Control Program - The facility's QA program did not ensure appropriate infection control standards were maintained for this repeat deficiency during dressing changes of Residents' #5, 19, and 25 wounds; and did not ensure a safe, sanitary environment was maintained during Residents' #15, 20, 24 and 29 care, as appropriate infection control precautions were not implemented.

During an interview with the Administrator on October 11, 2011 at 2:15 PM, he stated members of the QA committee included the two Assistant Directors of Nursing (ADON), the ADON of Operations, and the ADON.

The ADON of Operations was interviewed on October 11, 2011 at 2:21 PM, and stated she was not on the QA committee "as of yet".

The ADON was interviewed on October 11, 2011 at 2:30 PM, and stated internal audits, survey citations, staff suggestions, and plans of correction were used by the committee to select QA topics. The ADON stated topics under review by the QA committee included pressure ulcers, and she was not aware there were problems with pressure ulcers until the current survey was in progress.

In summary, the facility failed to provide a QA program that readily identified issues that had potential to cause serious harm to the health and safety of Residents #6, 19, 24, and 42.

10 NYCRR 415.27 (a-c)

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

Scope: Isolated

Severity: Actual Harm

Corrected Date: December 14, 2011

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: October 14, 2011

Based on observation, staff and resident interview, and record review conducted during the standard survey, it was determined the facility did not ensure residents were provided adequate supervision and assistive devices to prevent accidents for 9 of 18 (Residents #4, 5, 9, 12, 26, 27, 31, 34 and 35) residents reviewed for accidents, and 3 residents outside the sample (Residents #45, 47, and 48). Specifically:
- for Residents #9 and 12, the facility did not
implement planned interventions, did not determine the cause of the residents' falls, did not make changes to the planned interventions, in a timely manner, to minimize the residents' fall risk;
- for Residents #4, 5, 26, 31, 45, 47, and 48, the facility did not provide adequate supervision regarding where residents kept their smoking supplies; and did not provide routine and consistent assessments for safe smoking practices;
- for Residents #27, 34, and 35, the facility did not implement changes to the plan of care, to minimize elopement risk, in a timely manner, and complete a thorough investigation of an elopement and report the incident to the NYSDOH.
This resulted in actual harm for Resident #12, when she fell multiple times resulting in a fractured arm and pelvis; and developed a subdural hematoma (bleeding into the brain) and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #4, 5, 9, 26, 27, 31, 34, 35, 45, 47, and 48.

THIS IS A REPEAT DEFICIENCY FROM THE PREVIOUS 5 RECERTIFICATION SURVEYS: AUGUST 15, 2007, AUGUST 20, 2008, MAY 6, 2009, MARCH 9, 2010, AND JANUARY 14, 2011.

Findings include:

FALL PREVENTION CONCERNS
1) Resident #12 had diagnoses of dementia, hypertension, and anemia.

The facility policy titled Resident Plan of Care Sheets, revised by the current Director of Nursing in March 2011, had the following policy statement, "To assure all clinical care needs for each resident are addressed and documented, and to provide communication to certified nurse aides (CNA ) and licensed staff regarding the individual plan of care for each resident. The resident plan of care sheet (RPOC) is provided to certified and licensed staff to assure that the resident's needs are known to the front line caregiver."

An unsigned and undated facility policy titled Comprehensive Care Plan (CCP) had the following policy statement, "Each resident will have a comprehensive plan of care that includes measurable goals, approaches and interventions that affect positive resident outcomes." Included under the heading of Guidelines was the statement, "When a resident is transferred from one unit to another, the registered nurse (RN) Unit Managers will sign off on the care plan and interventions during their review of the care plans. This will ensure that all care plans are in place to meet the resident's needs despite where the resident resides in the facility."

The Minimum Data Set (MDS) admission assessment dated July 8, 2011 documented the resident had severely impaired cognition (never or rarely made decisions), needed extensive assistance of 1 person to move in bed, and was totally dependent on staff to move about on the unit. The MDS Functional Status assessment documented the resident had impairment on one side of her upper body, both sides of her lower body, and required a wheelchair for mobility.

The facility's Admission Assessment completed by a registered nurse (RN), dated July 1, 2011, documented the resident had a history of falls. The assessment documented there were no specific safety concerns or special safety equipment needed for this resident. The resident was alert and oriented to person and place, and not oriented to time or situation.

The CCP, dated July 1, 2011, documented the resident was at risk for falls due to her functional status and age. The CCP contained a page addressing "Alteration in psychosocial well-being: related to: placement, separation from family and agitation." There were no individualized interventions related to agitation or behaviors.

A nursing progress note dated July 11, 2011 at 10:45 PM documented the resident was found on the floor in her room by a CNA. The note documented the resident was found undressed, and had been incontinent of stool and urine.

A Resident/Visitor Event Report dated July 11, 2011 documented the resident was found sitting on the floor undressed and had no injuries. The report documented the care plan and RPOC, used by the CNA to direct care, were updated. The report documented an "RN assessment, no injury noted" with "clip alarm initiated." The report recorded "Any resident with history of falling is high risk." The report contained a Post Fall Evaluation tool with two columns titled "Identified issue" and "What was done to modify the environment to prevent further falling" this section was left blank. The use of a clip alarm was not documented on the resident's CCP or the RPOC.

The licensed practical nurse's (LPN) progress note dated August 4, 2011 at 2:30 PM documented the resident was "Very agitated this shift yelling down hall cussing at residents, staff. Very confused, combative."

The RN's progress note dated August 4, 2011, documented the "Resident fell in her room while trying to get up from her wheelchair. No s/s (signs or symptoms) injury, no external rotation, no swelling, denied hitting head and pain." The progress note did not note if the clip alarm had been used prior to the fall.

An untimed and undated LPN's progress note documented "no injury noted from previous fall." There were no further nursing progress notes for this resident until August 7, 2011 at 7:15 AM, written by the LPN, "Late Entry: Day 3 Fall, no injury noted."

There was no documented evidence an investigation was conducted regarding the resident's fall, and there were no documented changes to the planned interventions.

The RN's progress note dated August 21, 2011 at 8:00 AM documented the RN was called to the resident's room and the resident was found "sitting on the floor next to her bed." The resident stated she sat on the floor, she denied pain or discomfort. The note recorded the resident had no injury from the fall. The RN noted the resident was in good spirits, and they would continue to monitor. The progress note did not include any information regarding whether a clip alarm was in use prior to, or after the resident's fall.

A Resident/Visitor Event Report dated August 21, 2011 documented the description of the incident as written by the RN. The report documented the follow up steps taken as "Safety measures are in place including personal alarm (clip alarm) and low bed/mats." The Post Fall Evaluation section of the report documented the resident had a fall risk score of 3 (3 to 4 identifies moderate risk). The report recorded dim lighting was a contributing factor and noted the "resident got out of the bed by herself, unsteady on feet." There was no documentation the clip alarm was in use prior to the fall.

The CCP dated August 21, 2011, documented the resident's fall. There were no new interventions documented on the care plan, including no documentation of the use of a clip alarm, low bed or floor mats.

The physician progress note dated September 2, 2011 documented "There has been no history of falls."

The RN's progress note dated September 8, 2011 at 1:00 PM documented the resident was found on the floor in her room by an activities staff member. "Resident's normal behavior is very anxious and yells out. When assisted her back into bed, yelling that her left shoulder/arm hurt. Left eyebrow ecchymotic (bruised) with swelling noted. Left shoulder appears to be displaced, the (nurse practitioner) to come down to evaluate resident."

The Resident/Visitor Event Report dated September 8, 2011 documented the resident had a fall with injury at 1:00 PM. The report recorded an activities staff member was passing by the resident's room and heard her call out for help. The resident was discovered on her left side on the floor next to the dresser at the foot of the bed. The resident had a developing hematoma above her left eyebrow, and complained of left upper arm and left leg pain. The call bell was not turned on, and the floor was dry and clean. The report noted the resident had a "history of falling" and was at "high risk" for falls. The report did not document environmental factors that could have caused or contributed to the fall. The report did not include any information regarding whether the clip alarm, low bed or floor mat, was in use at the time of the fall and did not document any change in planned interventions to prevent or minimize falls.

The nursing progress note dated September 8, 2011 at 1:15 PM documented the resident was sent to the hospital for evaluation.

Hospital X-ray reports dated September 8, 2011 documented the resident had a fracture of the left upper arm and pelvis. A hospital CT report dated September 8, 2011 documented a very small frontal subdural hematoma.

The Resident/Visitor Event report dated September 9, 2011 documented the type of event was a fall with fractures which included a left arm fracture, a pelvis fracture and a subdural hematoma. The form documented the fall was unavoidable because the resident did not have her call light on, was alert and oriented and needed minimal assistance from 1 person. There was no documentation regarding the use of the clip alarm, low bed or floor mat prior to the fall. The form documented a new plan was developed and did not document what the new plan was. The form was completed by the RN Manager.

The CCP had no new fall prevention interventions documented.

The hospital Orthopedic Consult dated September 9, 2011, documented the resident had fractures of her pelvis, her left upper arm and a small left frontal subdural hematoma. The consult also documented the resident was confused during the physical exam.

The undated RPOC, provided to the surveyor on October 3, 2011, had no fall prevention interventions listed, did not document the use of a clip alarm, low bed or floor mats and did not identify the resident as being at high risk for falls. The RPOC documented the "Patient is pleasant and slightly confused. Will do as she wants at times, takes clothes off at times. Encourage to come out of room." There were no interventions listed on the RPOC for the resident's behaviors.

The CCP dated October 3, 2011 documented the resident had a self-care deficit, related to a decline in physical status and impaired cognition.

On October 3, 2011 at 12:57 PM, the resident was observed eating lunch in the dining room and calling out, "hooray, hooray, hooray". The resident was seated in a tilt in space chair with a clip alarm attached to the back of the chair and the resident's clothing.

On October 5, 2011 at 11:45 AM, the Unit 3 RN Manager was interviewed regarding the resident's falls. She stated the resident resided on Unit 3 when she fell on August 21, 2011 and September 8, 2011. The RN stated she did not make any change in the planned interventions to the resident's CCP or the RPOC after the resident's falls, she did not document the use of a clip alarm, low bed or floor mats. The RN Manager stated the personal alarm was the same as a clip alarm.

On October 5, 2011 at 11:50 AM, the Unit 2 RN Unit Manager was interviewed regarding the resident's falls on July 11, 2011 and August 4, 2011. The RN stated she was not present when the resident fell on July 11, 2011 and was the acting Nurse Manager when the resident fell on August 4, 2011. She stated she was just learning about CCP's, and could not explain when/how interventions would be documented on the resident's CCP.

On October 5, 2011 at 12:45 PM, the Director of Nursing was interviewed and stated, an investigation would be conducted and the plan of care updated in the event of a fall. She stated residents' fall risk were not documented on the RPOC, but planned interventions should be.

On October 6, 2011 a CNA was interviewed and stated, all of the resident's care needs were documented on the RPOC, and that was what she followed.

The undated, current RPOC had no fall prevention interventions and no clip alarm documented for the resident.

On October 7, 2011 at 9:20 AM, the resident's physician was interviewed and stated, "I wasn't here for the first 2 falls, I came to (the facility) in August. You kind of expect that after the first fall that a resident is going to fall again. Perhaps they should have had physical therapy see if she wasn't as strong as we thought or checked her for a UTI (urinary tract infection)."

On October 11, 2011 at 2:15 PM the Medical Director was interviewed and stated, "my expectations would be that the interdisciplinary team would look at root causes for this resident's falls, perform a thorough investigation, implement preventive measures and reassess measures that were in place to see why they failed." She further stated the interdisciplinary team would include the nurses, CNA's, physical therapy, and the resident's family, "The more perspective, the better."

In summary, the resident experienced harm (a fracture arm and pelvis, and a subdural hematoma) when the facility:
- did not include planned interventions (the clip alarm, low bed or floor mats) on the CCP or RPOC;
- did not determine an accurate root cause analysis of each of the resident's falls; and
- did not implement changes to the plan of care in a timely manner to minimize the resident's risk for falls.

ELOPEMENT PREVENTION CONCERNS
2) Resident #27 was admitted to the facility with diagnoses that included vascular dementia, depression, and hypertension.

A social service note dated August 17, 2011 at 11:30 AM documented a referral was made to the Hospital Behavioral Health Unit for a psychiatric evaluation related to delusional behaviors, such as talking to people not present, and attempts to leave the facility without knowing where she was going. The note recorded the resident would be transferred to the Hospital Behavioral Health Unit the following day (August 18, 2011).

The Minimum Data Set (MDS) dated August 18, 2011 documented the resident was cognitively intact. The MDS documented the resident had little interest or pleasure in doing things, was feeling down, depressed, or hopeless, had trouble falling or staying asleep and was feeling tired, having little energy. She required limited assistance in ambulation and transferring, and extensive assistance for toileting and hygiene.

Nursing progress notes documented the resident was re-admitted to the facility on September 2, 2011.

The Hospital discharge summary September 2, 2011 documented the resident had intermittent episodes of confusion, "most likely secondary to her sundowning episodes." The discharge diagnoses included: depressive disorder, psychosis disorder and dementia, "most likely mixed type with vascular and Alzheimer's component with behavioral disturbance."

An elopement risk assessment was completed on September 5, 2011 and identified the resident was at risk for elopement. She was described as disoriented occasionally, with exit seeking behaviors, a history of unsafe wandering or exiting, not accepting of her current residency in the facility, and verbalized a desire to leave.

The Comprehensive Care Plan (CCP) updated September 5, 2011 documented the resident was at risk for elopement, with behaviors placing her at risk for impaired safety. Relocation to a locked unit was indicated and appropriate secondary to her high safety needs, decline in cognition and ADLs (activities of daily living). The resident needed continuous redirection/supervision and visual monitoring. It was documented the resident attempted to leave the unit via elevator unsupervised and via stairway exits. She expressed a plan to leave the facility and wandered on the unit daily in a wheelchair or ambulating, and wandered down the hallway and "found door". The CCP documented the resident "just wants to go home".

A nursing progress note dated September 14, 2011 at 11 AM documented the resident came out of her room fully dressed and tried to get on the elevator and leave the unit. On September 18, 2011 on the 11 PM to 7 AM shift, the resident tried to open the west side door multiple times and tried to leave. There was no documented evidence of a change in planned interventions as the resident was found continuing to engage in exit seeking behavior.

A social services progress note, dated September 20, 2011, documented the resident was "found outside the building" at approximately 8:30 AM. The social worker was called to assist bringing the resident back into the building. The resident was near the curb on "Harrison St" and stated she was waiting for her sister to pick her up. The resident voluntarily reentered the building approximately 45 minutes later, after several staff attempted to bring her back. The social worker remained with her until a new Wanderguard was applied.

A nursing progress note dated September 20, 2011 documented the resident was outside the building "after removing Wanderguard". The resident's daughter was contacted regarding the resident's "frequent attempts to leave" and "requests to go home". The resident was placed on 1 to 1 monitoring following the incident.

The Resident Elopement/Attempted Elopement Investigation dated September 20, 2011 documented the resident was not accounted for at 8:40 AM, was found at 8:40 AM, and returned to the unit at 9:30 AM. The investigation documented the incident did not meet the criteria for elopement as the resident was not in harm's way. The investigation included the following witness statements:
- The Nurse Manager documented upon arriving at the facility at 9 AM she saw staff standing with the resident. The resident was holding a pillowcase with a few of her belongings inside.
- The Director of Social Services documented (no time documented) she witnessed the resident outside the building in the parking lot with staff watching the resident from afar. The resident was agitated, stating that her sister (deceased) was coming to pick her up.

On October 5, 2011 at 10 AM, a surveyor entered the resident's room and observed the resident standing by her bed. She was taking clothes from her closet and folding them on the bed. When asked what she was doing, the resident just looked at the surveyor and did not respond. When the surveyor left the room, the CNA who was sitting outside the door (doing 1:1 monitoring) told the surveyor "the resident does that, she is packing to leave."

During an interview with the unit social worker on October 5, 2011 at 1:10 PM, the social worker said she was sitting at her desk and got a phone call around 8:30 AM from the supervisor saying the resident was outside near the parking lot. She said she joined the staff already there (the Assistant Director of Nursing and Social Work Director). She stated staff were able to talk the resident into coming back into the facility. The social worker was asked to show the surveyor where the resident was standing when she saw her. The social worker pointed to a pole between the curb and the sidewalk on Harrison Street (a busy street) and said the resident was hanging on to the pole with her bag of belongings. The social worker stated the resident said she was waiting for her sister to pick her up.

During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on October 6, 2011 at 4:40 PM, they were asked to describe the incident from September 20, 2011. They were unsure who originally found the resident. There was no investigation as to how the resident left the building, who saw the resident last, and what time the resident was last seen. The DON said she would re-investigate the incident. When asked regarding reporting the incident she stated it was not reported to the New York State Department of Health (NYSDOH), the DON said the resident was never in harm's way. The DON said the resident had been stable since her return from the hospital and she was not aware the resident had made any attempts to leave the building prior to September 20, 2011.

On October 7, 2011 at 9:00 AM, the DON gave the surveyor an updated investigation into the incident which occurred on September 20, 2011. The investigation documented the resident was seen on the unit by the day LPN at 7:30 AM, and was observed in bed by a certified nurse aide (CNA) at 8 AM. At 8:10 AM she was first sighted in the parking lot and at 8:15 AM the Director of Social Work intervened. The DON stated the incident did not need to b reported to the NYSDOH, as the resident was never in harms way.

In summary, the facility did not ensure the resident received adequate supervision to prevent elopement, as the facility:
- implement changes to the plan of care, to minimize elopement risk, in a timely manner, as the resident continued to engage in exit seeking behavior;
- did not complete a thorough investigation of the resident's elopement and report the incident to the NYSDOH.

CONCERNS WITH MANAGEMENT OF SMOKING:
3) The facility's "Smoking" policy revised in August of 2009, documented:
- residents were to be assessed for "safe smoking" upon admission, quarterly, annually, and upon significant change;
- residents were required to lock their cigarettes in their dresser when they were not carrying them;
- lighters were available only in the smoking area;
- residents who were unable to follow the smoking guidelines, and who broke any of the smoking area rules were subject to a progressive system of consequences up to and including total loss of smoking privileges; and,
- residents had to agree with rules for smoking and sign a "Smoking Contract", in order to be permitted to smoke.

The "rules" listed on the "Designated Representative Smoking Contract" form included:
- residents were to use the lighters provided in the smoking area;
- "NO" lighters or matches were permitted in the facility; and,
- smoking supplies must be locked in the drawer in the resident's room.

1) Resident #26's diagnoses included peripheral neuropathy (numbness and pain), chronic obstructive pulmonary disease, and hypertension.

The Minimum Data Set (MDS) assessment dated August 19, 2011, documented the resident's cognition was intact.

The smoking assessment January 21, 2009, documented the resident wanted to continue to smoke. The assessment recorded resident was "automatically deemed unsafe to spoke independently" (may only smoke with family supervision, if available). There was no documented evidence a smoking contact was signed by the resident.

The RN's "Quarterly Assessment" note dated May 25, 2011, documented the resident smoked . The assessment recorded a "Safe Smoking Assessment MUST be completed before" the resident was allowed to smoke. There was no documentation of an assessment after January 21, 2011.

The CCP, dated September 1, 2011, documented the resident smoked and could be irritable and complain when she was not able to smoke. The CCP documented the resident signed a smoking contract and followed the rules of smoking "at this time."

The resident was observed on October 4, 2011 at 12:40 PM in bed. There was a carton of cigarettes in her wheelchair (in her room) and a package of cigarettes on her bedside table.

A full carton of cigarettes were observed in the resident's room on October 5, 2011 at 9:18 AM.

During an interview with the resident on October 5, 2011 at 10:00 AM, she stated she smoked, and could smoke anytime she wanted. the resident said she kept her cigarettes and lighter in her purse. She stated she had her own lighter because she had "neuropathy" (numbness and pain in her fingers).

During an interview with a certified nurse aide (CNA) on October 5, 2011 at 10:33 AM, she stated the resident smoked. She said the resident kept her smoking supplies in the pocket of her jacket.

During an interview with the covering RN Manager for Unit 4 on October 5, 2011 at 10:40 AM, she said smoking reassessments were not done, unless residents violated the smoking policy. She stated the resident smoked independently.

The "covering" RN Manager for Unit 4 was interviewed on October 5, 2011 from 10:50 to 11:15 AM. She stated the did not have cigarettes stored in the medication room. She said the resident buys cigarettes by the pack. The RN stated lighters were chained to the tables in the smoking area. She said she was not aware the resident had a carton of cigarettes in her room, and did not know she had a lighter in her purse.

In summary, the facility did not ensure residents were provided adequate supervision and assistive devices to prevent accidents, as the facility:
- did not ensure safe smoking procedures and supervision were implemented consistently;
- did not ensure staff were aware of where residents kept their smoking supplies;
- did not ensure smoking supplies were stored in secured locations; and
- did not ensure residents were routinely and consistently assessed for safe smoking practices.

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

F159 483.10(c)(2)-(5): FACILITY MANAGEMENT OF RESIDENT FUNDS

Scope: Widespread

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in paragraphs (c)(3)-(8) of this section. The facility must deposit any resident's personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $50 in a non-interest bearing account, interest-bearing account, or petty cash fund. The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative. The facility must notify each resident that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and that, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

Citation date: October 14, 2011

Based upon a review of personal account records, and resident and staff interviews conducted during the standard survey, it was determined for 168 of 169 residents whose personal accounts were managed by the facility, including 9 anonymous residents at the group meeting, the facility did not make residents' individual financial records available through quarterly statements provided to each resident. Specifically, the facility did not offer all residents the right to receive their own quarterly statements and lacked a policy to determine whether to send the quarterly statements to the resident or to their designated representative. 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 October 4, 2011 at 11:00 AM, 9 of 9 residents in attendance stated they never received a written quarterly account statement from the facility and they were not aware they could request a written account statement. Some of the residents stated they would like to receive one.

According to the Trial Balance for Sub-Resident Accounts Receivable provided by the facility, as of October 6, 2011 at 9:21 AM, there were 169 residents with personal accounts managed by the facility.

The Director of Resident Funds/Accounts Payable was interviewed on October 7, 2011 at 10:20 AM. When asked for a list of residents who received written quarterly statements at the facility, she stated there were probably very few residents that did. She said she did not know who or how many residents received their own quarterly statements as the computer software was not designed to print this information out. When asked who or how it was determined which residents received their own quarterly statements, she stated she did not know.

The Director of Social Work was interviewed on October 7, 2011 at 11:00 AM. When asked who or how it was determined which residents received their own written quarterly statements, she stated she was not the one who determined this, and she did not know for certain how this was determined, but she would expect the quarterly statements were sent to the designated representatives or power of attorneys listed on each resident's face sheet. She stated she would try to find out if there was such a policy and how many residents currently received quarterly statements from the facility.

The Director of Social Work was interviewed on October 7, 2011 at 1:50 PM, and stated there was no policy to determine which residents should receive their quarterly statements, and currently, there was 1 resident receiving a quarterly statement from the facility. No rationale was provided for not offering residents who were cognitively intact the choice to receive their statements.

In summary, the facility did not offer residents the right to receive their own written quarterly statements, and lacked a policy to determine whether to send the quarterly statements to the resident or their designated representative.

10 NYCRR 415.26(h)(5)(iii)

F469 483.70(h)(4): MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

Scope: Widespread

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

The facility must maintain an effective pest control program so that the facility is free of pests and rodents.

Citation date: October 14, 2011

Based upon observations, record review, and resident interviews conducted during the standard survey and abbreviated surveys complaints (#NY00106069 & #NY00103378), it was determined the facility did not maintain an effective pest control program to keep the facility free of pests. Specifically, sufficient measures were not implemented to eliminate all sources of potential insect harborage/shelter thus preventing infestation of pests in the kitchen and on the resident units. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the initial kitchen inspection on October 3, 2011 at 9:05 AM, 2 small roaches were observed crawling on the wall above the pot wash sink. Other environmental factors observed in the kitchen that would allow for shelter and harborage of pests included:
- loose floor molding in the retherm (Unitron) room;
- hole in the wall in the retherm room;
- cracked wall tiles near dishmachine room and cartwash room;
- holes and duct taped wall panels in cartwash room; and
- buckled ceramic wall tiles near pot wash sink.

The Regional Food Service Director was interviewed on October 3, 2011 at 9:45 AM, and he stated the pest control company treated the kitchen last week. They were aware of the wall problems in the kitchen and one wall in the cartwash room had been replaced. He stated the loose floor molding and the wall problems have been that way for a long time, about two years, and were not immediately addressed because they were expecting to build a new facility at one time, which is no longer the case.

During the building inspection conducted on October 3, 2011 between 1:00 PM - 4:30 PM, and October 4, 2011 between 9:00 AM - 3:00 PM, one roach was observed crawling on the floor in the shower area on Unit #4, and one roach was observed hiding on the floor beneath a cardboard box containing Styrofoam cups in the Unit #4 pantry. Other environmental factors observed on the nursing units that would allow for shelter and harborage of pests included:
- excessive dust and debris beneath the metal staff lockers on Units #3, 4, and 5;
- hole around ceramic wall tile of Unit #6 shower handle;
- hole around pipe penetration through the wall of the Unit #6 tub room;
- hole in wall of resident room #513;
- hole through rusted hollow metal door frame to Unit #4 scale room in the bathing area;
- hole in rusted metal door frame to Unit #3 tub room in the bathing area;
- hole in Unit #3 dining room wall near radiators beneath an electrical outlet;
- hole in wall of Unit #2 janitor's closet;
- hole in wall of resident room #221;
- hole along door frame of janitor's closet in S-level laundry; and
- holes in wall of S-level clean linen storage room.

The Director of Maintenance was interviewed on October 3, 2011 at 2:00 PM, and stated the pest control company has been coming to the facility on a weekly basis for the past 2 months due to increased roach activity. They kept a list of roach sightings in the kitchen and on the floors for the pest control company to follow-up on and treat. They had to change their pest control company after they did not show up as scheduled and the facility was not pleased with the company's performance.

The Unit #4 Ward Clerk was interviewed on October 4, 2011 at 9:55 AM, and she stated she saw roaches in the bath area, but not recently.

At the group resident interview held on October 4, 2011 at 11:00 AM, 6 of 9 residents stated they saw cockroaches in the facility including in the Unit #4 dining room and in the elevators. A review of the Resident Council Meeting minutes for 2011 revealed there were concerns about roaches mentioned in the January 19, 2011 meeting, and in the September 21, 2011 meeting at which residents stated they had spotted roaches in the Unit #2 kitchen, the Unit #5 kitchen and dining room, and on Unit #3.

The Director of Maintenance was interviewed on October 4, 2011 at 11:55 AM, and he stated he was not aware of the hole in the wall in room #221.

The Director of Maintenance was interviewed on October 4, 2011 at 2:45 PM, and he stated he would provide copies of the bug sightings and bug audits from June 2011 - September 2011.

A review of the facility's Pest Control Sighting Log from June 2011 - September 2011, provided by the Director of Maintenance, revealed there were 9 roach sightings in June 2011 including 50 bugs observed on June 7, 2011 in the pot wash area; 14 roach sightings in July 2011; 16 roach sightings in August 2011; and 21 roach sightings in September 2011. The listed sightings occurred throughout the building in the kitchen, staff cafeteria, compactor room, beauty shop, staff bathrooms, staff locker rooms, elevators, resident rooms, central bathing areas, dining rooms, and resident unit pantries.

A review of the pest control company's inspection report dated August 23, 2011 documented in large capital letters that the "kitchen was filthy - food everywhere."

A review of the pest control company's inspection report dated August 30, 2011 documented in large capital letters that the kitchen floor must be cleaned.

In summary, facility did not eliminate all sources of potential insect harborage/shelter.

10 NYCRR 415.29(j)(5)

F164 483.10(e), 483.75(l)(4): PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

Scope: Widespread

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility. The resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution; or record release is required by law. The facility must keep confidential all information contained in the resident's records, regardless of the form or storage methods, except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident.

Citation date: October 14, 2011

Based on a review of personal account records and staff interviews conducted during the standard survey, it was determined for all 169 residents with personal accounts managed by the facility, the facility did not ensure the confidentiality of each resident's financial records. Specifically, the facility did not ensure that the account balances for each resident account managed by the facility were not unnecessarily disclosed and made available to unauthorized personnel. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
Findings include:

According to the Trial Balance for Sub-Resident Accounts Receivable provided by the facility, as of October 6, 2011 at 9:21 AM, there were 169 residents with personal accounts managed by the facility.

The Director of Resident Funds/Accounts Payable was interviewed on October 7, 2011 at 10:20 AM. When asked how residents would find out how much money they had in their personal accounts, she stated the residents could ask her between 9 AM - 12 PM (the banking hours), and she would tell them. Between 12 PM - 3 PM, a small box of money was kept at the front reception desk, and the receptionist was provided daily with an alphabetized list kept on a clipboard at the front desk with the trial balances for each resident. Residents could withdraw up to $5 for personal use if they had enough money in their account. After 3 PM, residents could request up to $5 at any time from the security guard, who was also provided with the trial balance list after the receptionist left for the day. When she was asked why it was necessary to print out the exact amount each resident had in their account and not provide a list of residents who had over $5 in their accounts, she stated she did not believe the software could do that.

In summary, the facility did not ensure the trial account balances for each resident account managed by the facility was not unnecessarily disclosed and made available to unauthorized personnel.

10 NYCRR 415.3(d)(1)

F354 483.30(b): USE OF CHARGE NURSE AND REGISTERED NURSE

Scope: Widespread

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

Except when waived under paragraph (c) or (d) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Except when waived under paragraph (c) or (d) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

Citation date: October 14, 2011

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure the Director of Nursing (DON) of the 242-bed facility functioned as the DON on a full-time basis. Specifically, the facility functioned with the DON serving as the Infection Control Nurse at the same time. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The review of the facility's FSR (Facility Survey Report), signed on October 3, 2011, by the "CEO/Administrator", revealed the DON worked in the facility on a full-time basis as the DON.

On October 5, 2011 at 2:55 PM, the DON stated to a surveyor, "I've always been the Infection Control Nurse, since the day I came in here (the facility)."

When the surveyor interviewed the DON on October 7, 2011 at 3:05 PM, she stated she functioned both as the DON and Infection Control Nurse in the facility.

In summary, the facility did not ensure the Director of Nursing (DON) served as the DON on a full-time basis.

10 NYCRR 415.13(b)(1)

F500 483.75(h): USE OF OUTSIDE PROFESSIONAL RESOURCES

Scope: Widespread

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (h)(2) of this section. Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and the timeliness of the services.

Citation date: October 14, 2011

Based on review of the Facility Survey Report (FSR) and staff interview conducted during the standard survey, it was determined for all residents, the facility did not obtain necessary services, that were not provided by facility employees, from a person or agency outside of the facility when needed. Specifically, the facility did not employee a master's level social worker on staff and there was no documented evidence the facility obtained those services from an outside resource. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The Facility Survey Report (FSR) signed by the Administrator on October 3, 2011, documented the facility employed a full-time Social Worker who was not a master's level, licensed social worker. The facility had a contract with a licensed master's level social worker (LMSW) who worked as a "consultant." The LMSW's contract was last renewed on January 2, 2006.

On October 7, 2011 at 1:50 PM, a unit social worker stated in an interview, she worked at the facility since March 2011, and she had not seen the LMSW. She stated "it would be nice" to meet with the consultant as they "could use one."

On October 7, 2011 at 2:30 PM, the Director of Social Services stated in an interview, she did not remember the last time the LMSW consultant was in the building.

On October 7, 2011 at 3:15 PM, the Administrator was asked for a copy of the LMSW's contract with the facility.

On October 11, 2011 at 3:30 PM, the Administrator was asked a second time for the LMSW's contract. He stated the facility had a book with contracts in it, and hers was not in there. A contract was not provided to the survey team prior to exit.

In summary, there was no documented evidence the facility obtained the services of a LMSW to consult with the facility's social workers on a regular basis and as needed.

10NYCRR 415.26(e)(i-iv)

F160 483.10(c)(6): CONVEYANCE OF RESIDENT FUNDS UPON DEATH

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

Upon the death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate.

Citation date: October 14, 2011

Based upon a review of personal account records, facility policies, and staff interviews conducted during the standard survey, it was determined for 308 of 321 discharged/expired residents with personal accounts managed by the facility, the facility did not ensure these funds were distributed to the appropriate persons or agencies in a timely manner. Specifically, the facility did not ensure the balances/funds for 110 of 115 expired residents were conveyed within 30 days to the individual or probate jurisdiction administering the resident's estate, or to the county Department of Social Services, and did not ensure the balances/funds for 198 of 206 discharged residents were conveyed to the resident's estate, and if unclaimed, to the appropriate agency within the time frames prescribed by law. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
Findings include:

According to the Trial Balance for Sub-Resident Accounts Receivable provided by the facility, as of October 6, 2011 at 9:21 AM, there were 308 of 321 expired or discharged residents with personal accounts managed by the facility that were not distributed within 30 days, including 110 of 115 expired residents and 198 of 206 discharged residents no longer residing in the facility. Of the 308 personal accounts that were not distributed within 30 days, 93 of these accounts were over 5 years old and dated as far back as January 28, 1999. There were 9 accounts with balances over $1000, ranging from $1128 - $4323.

The Director of Resident Funds/Accounts Payable was interviewed on October 7, 2011 at 12:30 PM. When asked what happens to the money in the personal accounts when a resident died, she stated it depended on whether the resident was on Medicaid. If the resident was on Medicaid, it was supposed to go to Onondaga County. If the resident was not on Medicaid, the families would contact the facility or the social worker could contact the family.

The Director of Social Work was interviewed on October 7, 2011 at 12:32 PM, and she stated she had never been contacted by families, and she would have to check to see what the facility's policy stated about this.

The Director of Resident Funds/Accounts Payable was interviewed on October 7, 2011 at 1:45 PM. She stated she had worked here 3 years, and took over her current title about 18 months ago. She was never told what to do about the long list of residents who had expired or transferred and still had balances in their accounts. She stated that she did try once to clean up some of these accounts, but there currently was no plan to remedy this.

The Chief Financial Officer (CFO) was interviewed on October 11, 2011 at 3:15 PM. He stated it was a complicated situation. For discharged residents, a check is supposed to be written for the amount in the account or the facility sends out the balance statements, and waits to be contacted. For deceased residents, the money is supposed to be turned over to the surviving spouse, family, or funeral home or otherwise, to Onondaga County. This process underwent changes about 5 years ago by Onondaga County. The facility received two letters in 2010 from the Public Administrator of Onondaga County regarding the process for release of funds in personal accounts for deceased residents. The second letter advising the facility as of December 1, 2010, the policy of release of personal accounts had not changed, and requested the facility to release all personal account funds to them. He stated the facility did not do this because the letters were misplaced and the facility just recently discovered them.

In summary, the facility did not ensure the balances/funds for 110 of 115 expired residents were conveyed within 30 days to the individual or probate jurisdiction administering the resident's estate, or to the county Department of Social Services, and did not ensure the balances/funds for 198 of 206 discharged residents were conveyed to the resident's estate, and if unclaimed, to the appropriate agency within the time frames prescribed by law (Abandoned Property Law).

10 NYCRR 415.26(h)(5)(iv)

F279 483.20(d), 483.20(k)(1): DEVELOP COMPREHENSIVE CARE PLANS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4).

Based on record review, observation and staff interview conducted during the standard survey, extended survey, and abbreviated survey (complaint #NY00106114), it was determined that for 6 of 35 sampled residents (Residents #2, 9, 16, 20, 32, and 35),
the facility did not thoroughly develop, review, and revise comprehensive care plans (CCP) to ensure they were current, accurate, and included the services provided to maintain the residents' highest practicable physical, mental and psychosocial well-being. Specifically: Resident's #2, 9, 20, 32, and 35 the care plans were not developed to include the resident's specific care needs; Resident 16's care plan included care for a medical condition the resident did not have. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #9 had diagnoses including diabetes, end stage renal disease, chronic obstructive pulmonary disease (COPD, lung disease), and MRSA (Methicillin resistant Staphylococcus aureus) infection.

The hospital discharge summary dated September 30, 2011, documented the resident was on hemodialysis.

The physician orders, dated September 30, 2011, documented the resident had food and fluid restrictions, used oxygen, and had an open area on her sacrum (the area above the tail bone on the right and left buttocks).

There was no documented evidence a plan of care was developed to address these medical concerns.

The "Skin Condition Monitor" forms dated September 30, 2011, documented the resident was admitted to the facility with a Stage II pressure ulcer on her sacrum, and 3 surgical incisions.

There was no documented evidence a plan of care was developed to address these concerns.

The admission assessment dated October 1, 2011, documented the resident had food and medication allergies, impaired vision, usually understood others, and used oxygen. The assessment recorded the resident needed limited assistance for activities of daily living, and was at risk for falls. The assessment documented the resident was incontinent, a Stage II pressure ulcer on her sacrum, 2 surgical incisions with staples on her right inner arm, and a 25 centimeter surgical incision with staples, on her left inner calf. The assessment documented preventative measures of a bed wedge, blue booties, and a Gaymar (pressure reducing ) cushion for the wheelchair.

There was no documented evidence a plan of care was developed to direct the resident's care, including the preventative measures as on the admission assessment.

The nursing progress note dated October 3, 2011, at 6:30 AM, documented the resident "rolled off the bed onto the floor".

There was no documented evidence a plan of care was developed to prevent further falls.

The Unit 2 "Resident Plan of Care" form (RPOC, used by the certified nurse aides to provide care) was reviewed by the surveyor on October 3, 2011 at 9:07 AM. The form included the resident's name and room number and the words "Tues & Fri Eve." There was no other documentation on the RPOC, there was no documented evidence the form provided a plan of care to guide staff in caring for the resident.

The resident was observed on October 3, 2011 at 1:20 PM, in bed, lying on her back. There were pillows, under a fitted sheet, placed length-wise on both sides of the resident There was no documented plan of care for the resident to have pillows underneath the fitted sheet.

On October 3, 2011 at 12:45 PM, as the surveyor reviewed the resident's medical record there was no documented evidence a plan of care had been developed. At that time the Ward Clerk stated that when developed a plan of care would be in the resident's medical record. The registered dietician (RD) added to the interview at this time, if the resident was a new admission, a care plan would not be done for 7 days after the admission. The RD stated most of the residents who were admitted to the facility on September 30, 2011 were admitted "late" in the day.

On October 3, 2011 at 2:30 PM, The Assistant Director of Nursing "acting Unit Manager", approached the surveyor and stated the care plans were kept in the residents' medical records. The surveyor inquired about residents who were admitted on September 30, 2011, and the Assistant Director of Nursing, acting Unit Manager, stated "we technically have 14 days".

The RPOC for resident Unit 2 was reviewed by the surveyor on October 4, 2011 at 1:00 PM. There was no documentation regarding the use of blue booties, or pillows along each side of the resident's body.

The resident was observed on October 7, 2011 at 7:58 AM, lying in bed on her back with a pillow on each side under a fitted sheet. During an interview with the licensed practical nurse (LPN) at that time she stated the pillows "should be a wedge cushion". The LPN said the resident used them since her admission for positioning and so she did not fall out of bed.

During an interview with the certified nurse aide (CNA) on October 7, 2011 at 8:00 AM, she stated the 2 pillows were placed under the sheet "because" the resident "might crawl out of bed. She stated that if the RPOC was blank the nurse would tell staff how to care for the resident.

During an interview with the registered nurse (RN) charge nurse on October 7, 2011 at 8:50 AM, the resident's "Skin Condition Monitor" forms were reviewed. A care plan "Actual alteration in skin integrity" dated October 1, 2011, was kept with the skin monitoring forms. The RN charge nurse was asked about this care plan during the interview stated "I just did it". She said she dated the care plan October 1, 2011, because she "just started" doing care plans, and thought this was okay, since it was what "we've been doing it all along".

During an interview with the Assistant Director of Nursing on October 11, 2011 at 2:55 PM, she stated the care plans should not be back dated. When asked if she was aware that care plans were back dated, she stated it was not my expectation for nursing to back date care plans.

In summary the facility did not ensure a plan of care was developed and implemented which included the care and services to be rendered to the resident to maintain the resident's highest practicable physical well being.

2) Resident #2 had diagnoses including diabetes. The resident had a tracheostomy tube (small tube inserted into the wind pipe).

The facility's "Interdisciplinary Care Planning" policy dated February 2011 (day not specified) documented the care plan was the "blueprint" for the resident's entire care needs which directed the actions of all health care team members. Care plans were essential for residents to ensure that facility staff directly involved with the resident's care knew the plan and provided care to the resident, based on the resident's needs.

The resident's Comprehensive Care Plan (CCP) dated June 22, 2011, identified the resident had "potential" for alteration in her respiratory function because of a tracheostomy tube. The CCP did not document the size of the tracheostomy tube, or emergency procedures to implement if the tracheostomy tube became dislodged.

The registered nurse (RN) progress note dated July 22, 2011, documented tracheostomy care (care of the tracheostomy tube) was done to remove dried mucous, and the tracheostomy tie (holds the tracheostomy tube in place) was changed because of soiling. Face masks were placed in the resident's room, and the resident was instructed on how to secure the mask behind her ears and cover the opening of the her tracheostomy. The progress note documented the face masks were to be used because of sputum production when the resident coughed, for the resident's dignity, and to decrease the risk of infection. A #4 cuffless Shiley tracheostomy tube (size and brand name), with an inner cannula (removable inner tube of the tracheostomy tube), was taped to the resident's wall above her bed. The resident's CCP did not provide documentation regarding the tracheostomy tube at the resident's bedside, or the use of face masks to cover the tracheostomy.

The resident's Minimum Data Set (MDS) assessment dated July 2, 2011, documented the resident's cognition was intact. The resident was independent with bed mobility, transfers, walking in her room, dressing, toileting, and personal hygiene. She required supervision for ambulation in the hall and bathing.

The nursing progress note dated July 25, 2011 at 9:45 PM, documented the resident's tracheostomy tube "came out", and a new tracheostomy tube was inserted. There was no documented evidence the resident's CCP was updated to reflect that her tracheostomy tube came out.

The resident's CCP reviewed August 2011 (date unspecified) documented the resident had a tracheostomy tube. The CCP did not provide guidance for the care of the resident's tracheostomy tube, the size of the tracheostomy tube, emergency procedures for if the tracheostomy tube became dislodged, a tracheostomy tube was at the resident's bedside, or the use of face masks by the resident.

The physician orders, dated August 26, 2011, documented the resident was to have routine tracheostomy care performed daily, and as needed, was to wear a humidified 28% (oxygen) trach collar at bedtime and as needed. The resident was to be suctioned orally and/or nasopharyngeally as needed. There was no documentation regarding the size and type of trach tube or the emergency measure to implement if the tube came out.

The physician orders, written by the nurse practitioner (NP) on September 1, 2011, included "Trach Care": clean inner canula, suction as needed, change trach ties, and change drain sponge. There was no documentation regarding the size and type of trach tube or the emergency measure to implement if the tube came out.

The nursing progress note dated September 10, 2011, at 10 PM, documented the resident's tracheostomy tube "popped out". A new tracheostomy tube was on the wall, at the head of the resident's bed, with her name on it, and it was inserted into the tracheostomy stoma (hole). The writer of the progress note documented an "identifying" size for the tracheostomy tube was not found, and the "day shift" would be asked to find the information.

The undated "Resident Plan of Care" (RPOC, used to provide care) documented the resident was independent in her activities of daily living.

The resident was observed on October 3, 2011 at 9:45 AM, in bed and had dried mucous on her gown. The resident was able to talk, and stated she was suctioned "once in awhile".

During a second interview with the resident on October 4, 2011 at 1:05 PM, the resident stated she was suctioned "every now and then" and she did not leave her room often because she was embarrassed that she had mucous on her clothes. The resident said it was the staff's idea to put a mask over the tracheostomy tube to "catch the mucous"

The Director of Nursing (DON) and the Assistant DON, present were interviewed on October 6, 2011 at 3 PM. The DON stated she would expect the size of the trach, and the emergency measure to implement if the trach came out to be on the CCP. The assistant director of Nursing (ADON) stated that she began the resident's tracheostomy care plan and the unit registered nurse (RN) should have completed it.

In summary the facility did not ensure a comprehensive care plan for the resident's trach was developed including the care and services to be furnished to maintain the resident's highest practicable physical well being.

3) Review of the policy titled "Standard and Contact Precautions, and Resistant Organisms", updated March 2008 and provided as the policy currently in use, revealed residents with Clostridium difficile (C-diff, an intestinal infection causing diarrhea) infection, continuing to have diarrhea, would be on Contact Precautions. The procedure included:
- If the resident was incontinent and had diarrhea, gloves, handwashing; and wearing a gown were required.
- If the resident was assessed by the Infection Control Nurse as safe to come out of the room, the resident's hands were to be washed, and staff in other departments were to be made aware of the precaution techniques needed.
- Common equipment (such as commode) would not be shared between residents unless unavoidable, and if unavoidable, it must be adequately cleaned and disinfected before using it for another resident.
- Signs were to be placed by the resident's name outside the door and would read "VISITORS WASH HANDS BEFORE AND AFTER VISITING" - if intending to do personal care see nurse first".
- For residents with C. Diff, a waste container would be in the room with a foot-operated step lid and a clear plastic bag in it for briefs and other waste related to feces.

The "Resident Plan of Care Sheets" policy revised by the facility March 2011 (date unspecified), documented the resident plan of care (RPOC) sheet was to assure all clinical care needs for residents were addressed and documented, and provide communication to the certified nurse aide (CNA) and licensed staff regarding the individual plan of care for each resident. The RPOC was provided to assure that the resident's needs were known to the front line care giver. The policy documented any temporary care needs staff needed to be aware of would be documented on the RPOC sheet. The "special considerations" would be documented under the "Customary Routine" column with an asterisk.

The undated "Comprehensive Care Plan" policy documented the resident would have an individualized comprehensive plan of care and the interventions were to be noted on the RPOC form "so that front-line staff know how to provide the right level of care for the resident".

Resident #20 had diagnoses including dementia and C-diff.

The resident's Minimum Data Set (MDS) assessment dated July 1, 2011, documented the resident had severe cognitive impairment.

The resident's Comprehensive Care Plan (CCP) dated July 12, 2011, documented the resident was incontinent of bowel.

The nursing progress notes dated September 25, 2011, documented the resident had a "large loose stool this shift".

The physician's order dated September 26, 2011, documented the resident's stool was to be sent to laboratory for C-diff testing. There was no documented evidence the resident's care plan was updated to reflect the resident's loose stools, or the stool specimen sent for C-diff testing.

The resident's laboratory results dated September 28, 2011, documented the resident was positive for "Clostridium difficile Toxin B Gene" and "Positive for the 027 NAP1 BI strain".
The laboratory results documented "Epidemic 027 Nap1 BI strains of Clostridium difficile produce excessive amounts of Toxin B that potentially may cause more serious disease and increased amount of spores that may contribute to a higher incidence of patient relapse or nosocomial infection in the healthcare environment". There was no documented evidence the resident's care plan was updated to reflect the resident's C-diff infection.

The physician's order dated September 28, 2011, documented to give the resident 500 mg (milligram) Flagyl (antibiotic used to treat C-diff) 3 times a day for 14 days. There was no documented evidence the resident's care plan was updated to reflect the resident's C-diff infection, or planned interventions for their care.

The nursing progress notes dated September 29 and 30, 2011, and October 1 and 2, 2011, documented the resident had loose stools.

During the initial tour on October 3, 2011, between 9 AM and 10 AM, the registered nurse (RN) unit manager stated the resident was on "precautions" for C- diff.

The current"Resident Plan of Care" (RPOC, used to direct the resident's care) provided to the surveyor on October 3, 2011 at 10 AM contained no documented evidence the resident had a C- diff infection, was on precautions, or if any special precautions were necessary when caring for the resident.

The resident's care plan, reviewed by the facility on October 3, 2011, documented the resident was incontinent of bowel, and the outcome was "ongoing". There was no documented evidence the resident's care plan was updated to reflect the resident's C-diff infection and precautions to implement.

The nursing progress note dated October 4, 2011, documented the resident had loose stools.

During an interview on October 5, 2011 at 1:50 PM, a CNA who was working on the resident's unit, stated this was her "usual floor", and no residents on the unit were "currently" on contact precautions. She stated if a resident was on contact precautions, it would be documented on the RPOC.

On October 5, 2011 at 2:45 PM, the unit clerk stated during an interview she updated the information on the RPOC She said contact precautions were not documented on the form because "anyone could look at the CNA care card and it was confidential information".

In summary the facility did not ensure a comprehensive care plan was developed and implemented, including the care and services to be furnished to the resident to maintain the resident's highest practicable physical well being.

10 NYCRR 415.11(c)(1)

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

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: October 14, 2011

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the facility did not establish and maintain an infection control program designed to provide a safe, sanitary environment , and to prevent the development and transmission of infection for 7 of 16 residents (Residents #5, 15, 19, 20, 24, 25 and 29), reviewed for infection control concerns. Specifically, there were breaches in infection control standards during observed dressing changes for Residents #5, 19, and 25. For Residents #15, 20, 24 and 29, staff did not provide a safe, sanitary environment while providing care, as appropriate infection control precautions were not followed. 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 JANUARY 10, 2011 SURVEY.

Findings include:

1) Resident #15 had diagnoses including dementia, osteoarthritis and cardiac disease.

The Minimum Data Set (MDS) assessment dated July 23, 2011 identified the resident with severe cognitive impairment. The resident required supervision and/or assistance with all activities of daily living (ADLs).

Review of nursing progress notes revealed the following:
- On September 2, and 9, 2011, staff reported the resident had loose stools.
- On September 11, 2011, a stool sample for laboratory testing for Clostridium difficile (C-diff, an intestinal infection), sent to the lab.
- On September 12, 2011, the laboratory report documented the resident's stool was positive for C-diff and the nurse manager was notified.
- At 10:30 PM on September 12, 2011, the resident received the first dose of Flagyl (an antibiotic) at 10:00 PM;
- On September 13 and 15, 16, and 17, 2011 the resident continued to have loose stools.
- On September 19, 21, 24, and 25, 2011, the resident had loose stools.

On September 27, 2011, the NP documented the resident was "quite dehydrated" and was "SP" (status post) C-diff. The resident appeared lethargic and confused and the family requested he be evaluated in the Emergency Room.

The nursing notes dated September 27, 2011, documented the resident was sent to the hospital upon the request of the family, as a result of an overall decline in function.

The readmission history and physical completed by the NP documented the resident was admitted to the hospital and returned to the facility on September 29, 2011. The document did not address the resident's recent history of C-diff with loose stools.

On October 1 and 2, 2011, nursing notes documented the resident had 3 episodes of loose stools each day.

When the registered nurse (RN) manager was interviewed on October 3, 2011 between 9:30 AM and 10:15 AM, she stated the resident did not have any symptoms and was on "precautions" for C-diff.

The resident's room was observed between 9:00 AM to 10:15 AM on October 3, 2011 and there was no signage or evidence in the resident's room, that the resident was on contact precautions.

A nursing progress note dated October 5, 2011 6 AM, documented the resident had a "large loose stool this AM". A note later the same day, documented the resident continued with loose stools (times 3) throughout the shift (7 AM to 3 PM).

A physician's order written on October 5, 2011 documented an order for Flagyl 500 mg three times a day for 3 weeks to "retreat C-diff".

On October 5, 2011 at 1:50 PM, a certified nurse aide (CNA) who worked on the resident's unit stated this was her "usual floor" and she was familiar with the resident. She stated no residents on the unit were "currently" on contact precautions. She stated signs were not posted outside resident rooms and no isolation cart was placed outside the room as it would be a " HIPAA (Health Information Portability and Accountability Act) violation. She stated if a resident was on contact precautions, it would be documented on the resident plan of care (RPOC). The CNA stated she would use a mask, gown and gloves for anyone on contact precautions. She said these supplies were on a cart in the alcove on the unit. She stated some residents were recently treated for C-diff and universal precautions were used.

On October 5, 2011 at 2:45 PM, the Unit clerk stated in an interview that she updated the information on the RPOC. She said contact precautions were not documented on the RPOCs as anyone could look them and that was confidential information. She stated the information was communicated to staff verbally through daily report. She was not aware of anyone on contact precautions "recently" and said they were only on "universal precautions". After thinking about it further, she stated a sign may be posted outside the resident's door if they were on contact precautions and said a green dot was placed on the binder of the residents' records if they had a "communicable disease."

On October 6, 2011, nursing documented in a progress note the resident was restarted on Flagyl on October 5, 2011 for "another bout" due to signs and symptoms of C-diff.

The resident's family was observed visiting on October 6, 2011 at 11:50 AM. When interviewed at that time, the family member stated they were informed "yesterday" the resident was started on an antibiotic for C-diff, and were not told any special precautions needed when visiting the resident.

On October 7, 2011 at 11:45 AM, the resident was observed sitting in a wheelchair in the hallway by the nursing station. The resident was heard asking the RN manager if he could use the bathroom. The RN manager and a licensed practical nurse (LPN) were observed taking the resident into the community bathroom across from the nursing station and assisted him onto the toilet. The resident was observed to have a loose stool. The the RN manager and LPN stood the resident up when he finished, and re-applied his briefs. The RN and LPN both washed their hands, and did not wash the resident's hands or clean the toilet.

During an interview on October 7, 2011 at 2:10 PM, the LPN was asked if she was aware the resident had a diagnosis of C-diff. She said she was a float to the unit, and at the time she was helping the nurse manager toilet the resident, she was not aware of the diagnosis.

Review of the policy titled "Standard and Contact Precautions, and Resistant Organisms", updated March 2008 and provided as the policy currently in use, revealed residents with C-diff continuing to have diarrhea, would be on Contact Precautions. The procedure included:
- If the resident was incontinent and had diarrhea, gloves, handwashing; and wearing a gown were required.
- If the resident was assessed by the Infection Control Nurse as safe to come out of the room, the resident's hands were to be washed, and staff in other departments were to be made aware of the precaution techniques needed.
- Common equipment (such as commode) would not be shared between residents unless unavoidable, and if unavoidable, it must be adequately cleaned and disinfected before using it for another resident.
- Signs were to be placed by the resident's name outside the door and would read "VISITORS WASH HANDS BEFORE AND AFTER VISITING" - if intending to do personal care see nurse first".
- For residents with C-Diff, a waste container would be in the room with a foot-operated step lid and a clear plastic bag in it for briefs and other waste related to feces.

On October 14, 2011, between 12:30 PM and 1 PM, the Medical Director stated in an interview, she was involved in the development of the facility policies and reviewed them prior to signing off on each policy, including the infection control policy. She stated when resident was infectious and required precautions, she expected the resident would be treated for the infection; would use one bathroom (if the infection was C-difficile) keeping it clean and other residents from using it; appropriate signage be posted to ensure awareness by all; and, appropriate protection be used by direct care staff.

In summary the facility did not maintain an infection control program to provide a safe and sanitary environment to help prevent the transmission of infection when contact precautions were not employed as indicated when the facility:
- did not ensure direct care staff were aware of residents on contact precautions;
- did not ensure staff knew how to implement contact precautions;
- did not ensure personal protective equipment was readily available;
- did not provide appropriate waste containers for contaminated articles; and
- did not ensure the resident was assisted with toileting in a manner that would not expose others to the infection.

2) Resident #29 was admitted to the facility with diagnoses which included a recurrent infection left knee, hypertension and atrial fibrillation.

The Minimum Data Set (MDS) dated July 3, 2011 documented the resident had no cognitive impairment, was understood and could understand others. The MDS assessment documented the resident was non-ambulatory and required limited assistance from staff with activities of daily living (ADLs).

The laboratory report dated September 30, 2011 documented drainage from the wound on the right knee tested positive for MRSA (methicillin resistant staphylococcus aureus, an antibiotic resistant infection).

The Interdisciplinary Plan of Care dated October 4, 2011 documented the resident's right knee was red with serous drainage with chronic MRSA.

On October 5, 2011 at 9:35 AM, the resident was observed sitting outside the nursing station there was a dressing on the right knee saturated with yellow drainage. The ward clerk gave the resident a bath towel to wrap around his knee and the clear yellow drainage was observed on the bath towel. The resident was heard saying there was drainage on the floor in his room and asked a housekeeper to clean it up. The licensed practical nurse (LPN) was observed down the hallway passing medications. The surveyor asked the resident if the LPN was aware his right knee was draining, the resident said she saw me, but was passing medications. He then said, "It seems she doesn't want to help me." The resident said he has been waiting since 7:30 AM to get his dressing changed. He stated sometimes, the dressing is dry and sometimes it leaks, like now. The LPN was observed telling the resident, "I have to pass my pills, I only have one hour before and one hour after to get them done." She then told the resident to go to his room and she would change his dressing.

During an interview on October 5, 2011 at 10:50 AM, the LPN said wanted to finish her medication pass, before changing the resident's dressing. She stated to the surveyor the resident's dressing had been changed around 9 AM. The surveyor said she was talking with the resident at 9:30 AM and the dressing was saturated at that time. The LPN said the wound was not draining on the floor, and did not offer a rationale for the bath towel around the resident's leg with yellow drainage on it.

On October 5, 2011 at 11 AM, the housekeeper on Unit 5 was interviewed said she cleaned the resident's private room. The housekeeper stated there was a trail of fluid on the floor, which the resident said came form his knee. The housekeeper said she cleaned the resident's room the way she cleaned all the rooms, there was no special cleaning method employed.

On October 7, 2011 at 11 AM, the resident was observed in the hallway, his right knee dressing was saturated and draining, there was a bath towel wrapped around his right knee. The resident said the dressing was changed last evening. He said it did not leak during the night when he was in bed, but it starts to drain when he gets up and moves around.

A review of the list of residents with MRSA, which the facility compiled and gave to the survey team, documented the resident had MRSA "Active, not being treated, still has hardware in leg per nurse practitioner, not treat."

During an interview on October 7, 2011 at 12:52 PM with Assistant Director of Nurses (ADON) for operations, MDS co-coordinator and registered nurse (RN) educator the RN educator said infection control was going to be her department responsibility now. When asked about wound drainage on the floor, the RN educator said it should be treated like a blood spill. Staff should wear gloves and other appropriate personal protective equipment. For a little spill. they need to pick it up right away so no one walks in it; put in red bag in the soiled utility room; it needs to be done before housekeeping can clean. If there is a huge spill, staff need to wear gown, booties, gloves, goggles and mask.

During an interview on October 7, 2011 at 1:43 PM, the Housekeeping Supervisor was asked about drainage such as body fluids on the floor and how it would be cleaned. The Housekeeping Supervisor said the certified nurses aides (CNA) and nurses would clean the area of the spill. There was a kit kept in the dirty utility room that is used for all spills. The nurses or CNAs would clean the area using the kit and the housekeeper would mop afterwards with Virex. Housekeeping did not clean blood, urine, feces, wound drainage or any drainage. Housekeeping staff were instructed to say "no" if asked to do it by nursing staff.

In summary, the facility did not ensure acceptable standards of infection control practices were followed to prevent the spread of infection for a resident with an active MRSA infection.

3) Resident #19 had the diagnoses of dementia and osteoporosis.

The nursing notes dated August 16, 2011 documented the resident had a Stage II pressure ulcer on the left hip that measured 1 centimeter (cm) x 1 cm open area on the left hip.

The Minimum Data Set (MDS) assessment dated August 25, 2011 documented the resident had severe cognitive impairment, required assistance with activities of daily living and used a wheelchair for mobility.

The Physician's order sheet dated September 1, 2011 documented the following order for the left hip pressure ulcer:
- cleanse with normal saline;
- pat dry;
- apply Aquacel Ag (an antimicrobial wound dressing) cover with a DuoDerm (a moisture retaining wound dressing for wounds with little to no drainage); and,
- change every 3 days and as needed.

The Physician's order sheet dated October 4, 2011 documented an order for Levaquin (an antibiotic) 250 milligrams (mg) by mouth every day for 10 days for a wound infection.

The Skin Condition Monitor sheet dated October 5, 2011 documented the resident had an unstageable pressure ulcer on her left hip which measured 1.4 centimeters (cm) by 3.0 cm with "Lots of slough (yellowish, soft, dead tissue), a lot of yellow drainage."

On October , 2011 at 2:20 PM, the resident's wound care was observed. The registered nurse (RN) unit manager and a licensed practical nurse (LPN) brought the treatment cart to the resident's room. The LPN removed scissors and a package of Aquacel Ag from the treatment cart drawer. The Aquacel Ag package was open on three sides with the dressing sandwiched inside. Without cleaning the scissors before or after use, washing her hands or donning gloves, the LPN cut a small piece of Aquacel Ag, placed the cut piece back into the opened package and returned the scissors to the drawer. The LPN brought the wound care supplies, including the open package of Aquacel Ag into the resident's room and placed them in direct contact with the dresser. The LPN washed her hands at the bathroom sink, donned clean gloves, placed a barrier on the overbed table and opened the wound care supplies onto the barrier. The cut piece of Aquacel Ag was removed from the opened package and placed directly onto the barrier. The resident was lying on her right side on the bed with her left hip exposed. The old dressing on the left hip wound was removed by the LPN and was observed to have light greenish drainage on it. The RN then measured the pressure ulcer area as 1.4 cm (centimeters) by 3.0 cm. The wound bed was covered with light greenish, foul smelling slough and surrounded by a rim of reddened tissue. The LPN moistened a 4 x 4 gauze with normal saline, cleansed the wound and patted the wound bed dry with another 4 x 4 gauze. While wearing the same gloves, the LPN picked up the Aquacel Ag and placed it into the wound bed and applied the DuoDerm dressing.

On October 5, 2011 at 2:50 PM the RN Unit Manager was interviewed and stated, "I didn't know that the Aquacel Ag dressing couldn't be left open in the cart. We always do that."

On October 5, 2011 at 2:50 PM the LPN was interviewed regarding the dressing change and stated they always re-used the same package of Aquacel Ag as only a small amount was needed for the dressing. She said she did not know the sterile Aquacel Ag dressing needed to be sealed when it was stored in the treatment cart drawer. The LPN offered no explanation for not cleaning the scissors before using them to cut the dressing; and offered no explanation for not changing gloves or performing hand hygiene after cleaning the infected drainage, and before handling the dressing.

On October 5, 2011 at 2:55 PM, the Director of Nursing was interviewed and stated, "I've always been the Infection Control nurse since the day I came in here (the facility)." When interviewed regarding the dressing change observation, she stated, " That's not the standard for infection control practices here."

In summary, the facility did not ensure an infection control program was maintained when they:
- did not clean scissors prior to cutting a dressing;
- did not properly handle dressings;
- did not store dressing in an aseptic manner; and
- did not perform hand hygiene during a dressing change of an infected wound after contact with drainage and prior to applying a dressing.

10 NYCRR 415.19(a)(2)(3)(b)


F166 483.10(f)(2): FACILITY RESOLVES RESIDENT GRIEVANCES

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

A resident has the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.

Citation date: October 14, 2011

Based on observation, review of the Resident Council minutes, and interviews with staff and residents conducted during the standard survey, it was determined for residents on all 6 nursing units, including Residents #7, 16, 46, 49, and 50, and 9 anonymous residents at the group meeting, the facility did not ensure residents had the right to prompt efforts by the facility to resolve grievances. Specifically, residents voiced grievances about the quality/taste of food at Resident Council meetings and there was no documented evidence the facility made attempts to resolve the grievances voided by the residents. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

On October 3, 2011 at 9 :00 AM, on Unit 4, Resident #46 was observed sitting in the dining room eating breakfast. She told the surveyor the toast was usually burnt and she could not eat it as it was very hard and dry. The toast was observed and was very burnt. She stated the food at the facility used to be better and now it was not good. She said vegetables were also mushy and overcooked.

On October 3 , 2011 at 12:55 PM on Unit 2, Resident # 7 was observed with a fried egg on his lunch plate. He showed the egg to the surveyor, and stated it looked and tasted like "rubber." He said the hard boiled eggs were also rubbery and had a poor taste.

On October 3, 2011 at 1 PM, on Unit 2, Resident #49 was observed at lunch. He had a piece of chicken on his plate. He said the chicken was so tough you "couldn't cut it with a chain saw." At 1:12 PM, a licensed practical nurse (LPN) cut the chicken for the resident, stated it was tough to cut, and that she had to apply pressure to it. She stated if the chicken was warmer, it probably would be easier to cut.

Immediately following the lunch meal on October 3, at 1:15 PM, a fried egg was sampled by the surveyor. It had a rubbery texture and was difficult to cut.

On October 4, 2011, at 9:50 AM, during the breakfast meal observation on Unit 6, omelets with visibly burnt edges were served to Residents #16 and 50.

On October 4, 2011 at 11 AM, 9 anonymous residents at the resident group meeting stated the omelets were routinely served burnt.

On October 5, 2011 at 8:55 AM, a hard boiled egg was tasted by 2 surveyors. It had a rubbery texture and the taste was not palatable.

The registered dietitian (RD) and the Regional Food Service Director were interviewed on October 5, 2011 at 1:35 PM. The RD stated she was not aware of resident complaints regarding eggs or chicken. The Regional Food Service Director, who was filling in as the facility's Food Service Director, also was not aware of residents' complaints.

Review of Resident Council meeting minutes from February 16, 2011 to present revealed:
- a representative from Food Service was present at every meeting;
- on February 16, 2011, residents complained about burnt omelets;
- on March 16, 2011, the residents complained about burnt toast;
- on April 20, 2011, the residents complained about burnt omelets;
- on July 20, 2011, the residents complained the food was always overcooked;
- on August 24, 2011, residents reported toast was hard and unappetizing; and
- on each set of minutes there was a place for "action/outcome" to be documented and there was no documented evidence of the corrective measures instituted by the facility to resolve these complaints.

In summary, the facility did not make prompt efforts to resolve resident grievances related to food.

10 NYCRR 415.3 (c)(1)(ii)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

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: October 14, 2011

Based on observation, Resident Council minutes, and interviews with staff and residents conducted during the standard and abbreviated survey (NY00103378) it was determined for residents on all nursing units, including 9 anonymous residents at the group meeting, the facility did not ensure each resident received food that was palatable and at the proper temperature. Specifically, residents at the group meeting reported food temperatures was not served at the proper temperature. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The registered dietitian (RD) stated in an interview on October 3, 2011 at 9:05 AM, the facility performed about 4 test trays a month to test for proper temperature and taste. She stated they considered acceptable temperatures to be above 140 degrees F (Fahrenheit) for hot foods and below 50 degrees F for cold foods/drinks.

During the breakfast meal on October 4, 2011 at 9:50 AM, the coffee on Unit 6 was tested. It was 133 degrees Farenheit (F).

On October 5, 2011 at 8:55 AM, on Unit 4 a test tray was sampled at the same time the last resident was served their meal. The scrambled eggs tasted cold and were 106 degrees F. There were 2 air pots (hot water and coffee) and 1 uncovered carafe of coffee on a table being used by staff throughout the meal to serve residents hot beverages. The hot beverages were tasted at the time of the test tray. The hot water tasted cold and was 95 degrees F. The coffee in the air pot was 107 degrees F and tasted cold. The coffee in the carafe was 135 degrees F and tasted luke warm. After the surveyor completed the test tray, nursing staff were observed to pour additional cups of coffee for unidentified residents in the dining room from the uncovered carafe.

The RD and the Regional Food Service Director were interviewed on October 5, 2011 at 1:35 PM. The RD stated the test trays were not necessarily done at the time of the last person served. The Regional Food Service Director stated they try to pour the coffee immediately into carafes after coffee was made on the units as the heating bases to the coffee machines had been disabled for safety reasons. A review by the surveyor of the last 9 test trays conducted within the past 12 weeks, provided at this time by the RD, revealed 3 of the 9 test trays were conducted at the time of the last resident served. One test tray performed on August 22, 2011 at lunch on Unit #2, documented the coffee was 125 degrees F and there were no further comments on the form about the low coffee temperature.

Review of Resident Council meeting minutes from February 16, 2011 through September 21, 2011, revealed:
- a representative from dietary was present at every meeting;
- on February 16, 2011, residents reported the food on Unit 1 was cold;
- on June 22, 2011, residents stated Unit 3 "needs hot coffee" and in general, food was served cold;
- on July 20, 2011, residents reported the "temperature of food still not adequate;" and
- on August 24, 2011, residents reported "toast is always cold."

In summary, for residents on all nursing units, including 9 anonymous residents at the group meeting, the facility did not serve food that was palatable at the proper temperature.

10 NYCRR 415.14(d)(2)

F157 483.10(b)(11): INFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in 483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in 483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member.

Citation date: October 14, 2011

Based upon record review and family and staff interview conducted during the standard and abbreviated surveys (Complaint #NY00104243), it was determined for 4 residents reviewed for issues related to notification of change in condition (Residents #1, 15, 16, and 20), the facility did not ensure the resident's right, or the right of the resident's legal representative to be fully informed in advance about care and treatment, and of any changes to that care and treatment that may affect the resident's well-being; participate in changes to planned treatment; be notified of a significant improvement or decline in the resident's physical, mental, or psychosocial status; and be notified of the need to alter treatment significantly. Specifically:
- For Resident #1, the facility did not ensure the right of the resident's legal representative to be informed in advance of changes to the resident's care and treatment; to participate in changes to planned treatment; be notified of a significant decline in the resident's medical status; and to be notified of the need to alter treatment significantly, as a non-designated person was allowed these functions.
- For Resident #16, the designated representative was not clearly documented, nor was the person who would make decisions regarding the resident's advance directives.
- For Resident #20, the facility did not ensure the resident designated a representative and a designated representative was not notified of changes in the resident's medications related to inappropriate behaviors and change in medical condition.
- For Resident #15, who did not have a designated representative, the facility did not consistently contact an appointed person regarding changes in the resident's condition. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #1 was admitted on May 13, 2010 with diagnoses including dementia, diabetes mellitus, stroke, and PVD (peripheral vascular disease).

Review of the resident's medical record revealed she designated a health care proxy (HCP) on October 13, 1998.

The resident's Face Sheet (record of personal information), dated December 3, 2010, documented the names and telephone numbers of 2 additional family members not listed on the resident's HCP record. The medical record contained no documented evidence the resident's HCP designated the 2 family members to receive information about the resident.

The quarterly Minimum Data Set (MDS) assessment, dated July 02, 2011, documented the resident had severe cognitive impairment and required assistance for all activities of daily living (ADL).

A nurse practitioner (NP) note, dated July 12, 2011, documented the resident had necrotic (dead tissue) areas on her toes, and she planned to order an appointment for consultation by a vascular physician.

A consultation note from the vascular surgeon affiliated with hospital #1, dated July 15, 2011, documented the resident was seen in his office that day, and was diagnosed with PVD. The recommendation was for the resident to have an aortogram (diagnostic procedure).

A consultation form, dated July 25, 2011, documented the resident was brought to hospital #1 for an aortogram, and the procedure was cancelled due to the resident's blood pressure.

A facility investigation, dated July 25, 2011, documented:
- the decision was made to send the resident to a vascular surgeon without informing the HCP about the decision and the rationale;
- a family member was allowed to accompany the resident to the appointment without the HCP's knowledge; and
- contact information for non-designated persons was added to the resident's medical record without discussing it with the HCP.

A late entry nurse's note, dated July 27, 2011, documented on July 26, 2011, the nurse spoke to the resident's HCP about her vascular surgeon consultation on July 15, 2011. The HCP stated she did not want the resident to be seen by that vascular surgeon again, and requested the resident be taken to hospital #2 for any future procedures. The note documented the HCP wanted to be informed of any medical concerns or problems related to the resident's care and quality of life.

A nurse's note, dated July 28, 2011, documented the resident's HCP did not want anyone in the family to take the resident out of the facility for any reason, and all phone calls regarding the resident were to be directed to the HCP.

A surveyor interviewed the Director of Social Services at 2:00 PM on October 3, 2011. She stated a visitor noticed the resident was in the facility, and told the resident's family member. The family member then gave her contact information to staff, who later saw her visiting the resident. Staff called the family member regarding the resident's medical appointment instead of the HCP. The Director of Social Services stated staff should not have done this. She stated the facility did not have a policy and procedure for accuracy of Face Sheet information, nor was there a current policy for family notification of resident change in condition.

In summary, the facility did not ensure the right of the resident's legal representative to be informed in advance of changes to the resident's care and treatment; to participate in changes to planned treatment; be notified of a significant decline in the resident's medical status; and to be notified of the need to alter treatment significantly, as a non-designated person was allowed these functions.

2) Resident #20 had diagnoses including dementia, arthritis and a history of falls with a hip fracture, and a history of inappropriate behavior.

The Face Sheet (identifying admission information) in the resident record identified one of the resident's daughter's as the person financially responsible, and another daughter and son as the "relatives/friends". The person financially responsible was listed above the relatives/friends on the Face sheet. Both daughters were documented as Power of Attorney and Health Care Proxy.

Review of the resident's nursing progress notes revealed the following:
- On August 4, 2011, the resident was "caught" touching female residents and was "caught" biting another resident's hand. There was no documented evidence a interested family member (designated representative) was notified of the behavior.
- On August 7, 2011, the resident fell and a message was left with the daughter listed as financially responsible.
- On August 30, 2011, the resident exhibited inappropriate behavior toward female residents. Changes were made to the resident's psychotropic medication regime. There was no documented evidence a designated family member was notified of the behavior or changes in medications.
- On September 2, 2011, the resident displayed extreme agitated behavior and received an antipsychotic medication intramuscularly (IM). There was no evidence a designated representative was notified.
- On September 12, 2011, the resident exhibited cold symptoms with a fever, and was started on medications. There was no documented evidence a designated representative was notified.
- On September 14, 2011, an antibiotic was ordered as the resident had a fever, with no documented evidence an interested family member was informed.
- On September 19, 2011, the resident fell and a message was left for the resident's daughter, listed as the person financially responsible, and a message left for the resident's son. There was no documented evidence the resident's other HCP/POA (daughter) was notified or a rationale why the one daughter and son were the ones chosen to be notified.
- On September 22, 2011, a lap buddy was discussed with the physician and "family". There was no documented evidence identifying the family member involved.
- On September 23, 2011, the resident was given Haldol (an antipsychotic) IM, with no evidence a designated family member was notified of any changes in the resident's behavior.
- On September 29, 2011, the resident was started on an antibiotic for Clostridium difficile (an intestinal infection). There was no documented evidence a designated representative was notified.

The Director of Social Services was interviewed by the surveyor on October 7, 2011 at 12:05 PM. She stated the problem was brought to her attention by another surveyor and she was going to write a new policy related to notification of change in condition. She stated the second person (relatives/friends) would be the person to be notified. She stated the policy was not completed yet and she needed to educate staff on the changes.

The unit social worker was interviewed on October 7, 2011 at 1:50 PM by the surveyor. She stated she would use the Face Sheet in the resident's record and contact the person listed first on the sheet. If there was a health care proxy (HCP), she would first contact the HCP. She was unaware of changes being made to the policy.

In summary, the facility did not have a system in place to identify a designated representative for notification of changes, and did not promptly notify a designated representative/interested family member when changes occurred that required physician intervention or when a change occurred in the resident's mental status.

3) Resident #16 was admitted to the facility in August 2011 with diagnoses including dementia, malnutrition and osteoporosis.

On August 18, 2011, the nursing progress note documented the resident was admitted to the facility via wheelchair cab, with no documented evidence a relative/friend accompanied the resident. There was no social work documentation on the day of admission to identify the resident's support system.

The Face Sheet in the resident record documented the resident's date of admission. The financially responsible party was listed first and was documented to be the power of attorney (POA) and health care proxy (HCP). The relationship to this person was listed as "attorney". The section below the financially responsible party and documented as "relatives/friends, listed the resident's nephew and identified this person as the POA and HCP. The Face Sheet did not specify the person to be notified for changes in the resident's condition.

On August 22, 2011, a social work admission progress note documented the name of a family/friend contact with a phone number. The form did not include the relationship of this contact to the resident.

On August 24, 2011, a nursing progress note documented the resident attempted to get on the elevator without knowing where she was going, and a Wanderguard was applied. The nephew was contacted and informed of this change in the resident's plan of care. There was no rationale why the nephew was contacted when both the attorney and the nephew were listed as the HCP.

On August 29, 2011,a nursing progress note documented the resident had an unresponsive episode and was sent to the hospital. The note recorded the family was notified. The note did not document who specifically was notified or now the decision was made to notify the "family" and not the attorney.

When the Director of Social Services was interviewed on October 7, 2011 at 12:05 PM and the unit social worker was interviewed on October 7, 2011 at 1:50 PM, they were not able to provide an explanation for who to contact on behalf of the resident. No policy was in place to explain the facility procedure.

In summary, the facility did not identify a designated representative as the person to be contacted when the resident experienced a change in condition or significant change in the plan of care.

10NYCRR 415.3(e)(2)(ii)(b)

F252 483.15(h)(1): SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

The facility must provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

Citation date: October 14, 2011

Based upon observation and staff interview conducted during the standard survey and as part of an abbreviated surveys complaint (#NY00103470 and #NY00106114), it was determined for 6 of 6 nursing units (Units #1, 2, 3, 4, 5, and 6), which included a sampling of 41 resident rooms, the facility did not provide a safe, clean, homelike environment, including effective housekeeping and maintenance services. Specifically, the facility did not maintain the building in good repair/condition in regard to floors, walls, ceilings, doors, windows, furniture and equipment. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the building inspection conducted on October 3, 2011 between 1 PM - 4:30 PM, and October 4, 2011 between 9 AM - 3 PM, which included a sampling of 41 resident rooms on 6 nursing units, the following environmental concerns were observed:

FLOORS
- the corridor floors were streaked or spotty and in need of stripping and waxing on Units #2, 3, 5, and 6;
- the resident room floors were streaked or spotty and in need of stripping and waxing in rooms #204, 306, 316, 402, 406, 412, 416, 510, 519, 603, 608, and 626;
- the floors in the staff locker rooms on Units #3, 4, and 5 were not kept clean and free of debris;
- the floors in the central bathing areas on Units #5 and 6 were not kept clean and free of debris;
- the floor in the clean linen room on the S-level was not kept clean and free of dust and debris; and
- the carpeting in the OT room was worn/frayed and duct taped.

WALLS
- the wall carpeting around the nursing stations on Units #3, 4, 5, and 6 were frayed and stained;
- the walls and radiator panels in the dining rooms/pantries on Units 1, 2, 3, 4, 5, and 6 were scraped;
- the walls in resident rooms or bathrooms were scraped or damaged in rooms #103, 108, 326, 328, 409, 513, 526, 528, and 614; and
- the wall paper in the central tub room on Unit #3 was discolored.

CEILINGS
- the ceilings had water stains in the S-level corridor by the conference room and by the social work office, the S-level beauty shop shower stall, the Unit #2 shower room right stall, the Unit #2 tub room, the Unit #3 tub room, the Unit #6 corridor by an exit door, and resident rooms #309, 402, 528, and 603.

DOORS
- the doors in resident rooms and bathrooms were scraped or damaged in rooms #108, 201, 204, 216, 316, 409, 417, 430, 603, and 614.

WINDOWS
- the windows were foggy-looking on the Unit #6 dining room (sliding glass doors to the patio), and resident rooms #511 and 522;
- the window curtains were stained in resident rooms #314 and 614; and
- the curtains were missing to the sliding glass doors in the Unit #6 dining room.

FURNITURE/EQUIPMENT
- the tables in the dining rooms had chipped or missing molding along the edges in Units #2 (1 table, 3 (1 table), 4 (2 tables), and 5 (2 tables);
- the cabinets in the dining room pantries on Units #1, 2, 3, 4, 5, and 6 were not kept in good repair as the interiors were no longer in easily-cleanable condition, especially to the base cabinets beneath the sinks;
- the countertop in the Unit #6 dining room pantry was permanently stained;
- the closets in resident rooms were bent, rusted, or scraped in rooms #213, 226, 306, 326, and 410;
- the cubicle curtains were not kept clean and free of stains in resident room #416;
- the shower curtains were not kept clean and free of stains in one of the Unit #5's shower stall;
- the interior of the microwave in the dining room pantry on Unit #6 was not kept clean and free of food encrustation;
- the arm rests to a wheelchair in resident room #309 was not kept in good repair as the material was cracked and crazed;
- the base to an electric wheelchair/scooter parked in the corridor outside room #528 was not kept clean;
- the wood to the footboard and dresser in resident room #326 was chipped;
- the beauty shop was not kept in a clean and sanitary condition as used combs and brushes were left in the sink when not in use; splatter was present on the wall; a dirty stool was placed on top of a chair; a stained pillow was placed on top of a chair; a drip pan was stored in the ceiling of the shower stall to catch leaks and mildew was present in the base of the shower stall;
- the lap buddies belonging to 2 unidentified residents eating in the Unit #6 dining room were not stored in sanitary manner as they were placed in direct contact with the floor; and
- the sling to a mechanical lift was not stored in a sanitary manner as it hung from the safety rails of one shower stall on Unit #5 in direct contact with the shower room floor.

The Director of Housekeeping was interviewed on October 3, 2011 at 1:05 PM, and stated she was not certain what department was currently responsible for cleaning the interior of the microwave ovens in the nursing unit pantries, but as of 2-3 weeks ago, dietary was made responsible for cleaning the refrigerators. She stated the countertop in the Unit #6 pantry was no longer cleanable as it was permanently stained.

The Director of Housekeeping was interviewed on October 3, 2011 at 1:05 PM, and stated the curtains to the sliding doors in the Unit #6 dining room were missing because a resident pulled them down within the past 3 weeks.

The Director of Housekeeping was interviewed on October 3, 2011 at 1:15 PM, and she stated there was no set schedule for stripping and waxing floors, the housekeepers just pick the worst ones to do, but all the dining room floors were stripped and waxed within the past 3 weeks.

The Unit #6 RN (registered nurse) manager was interviewed on October 3, 2011 at 1:17 PM and stated she had worked at the facility for more than 1 year, and did not know where the lap buddies were supposed to be kept after they removed from the residents during meals, but they should not be kept on the floor, and she did not normally see the lap buddies on the floor. A CNA (certified nurse aide) immediately responded they were supposed to be kept on top of the piano or the dresser in the dining room.

The Director of Maintenance was interviewed on October 3, 2011 at 2:45 PM, and he stated the old soap dispensers have been removed and replaced in the resident bathrooms about 9-12 months ago, but the walls have not been painted after patching over the screw holes.

The Director of Housekeeping was interviewed on October 3, 2011 at 2:50 PM, and stated the bathroom floors are cleaned by housekeeping, but the tubs are cleaned by nursing.

The Director of Housekeeping was interviewed on October 3, 2011 at 3 PM, and stated they did not have extra window curtains available and none were ordered yet.

A CNA on Unit #5 was interviewed on October 3, 2011 at 3:35 PM. She stated the Hoyer (a mechanical lift) slings were supposed to be washed in the laundry on S-level every Monday or Thursday or as needed, and were hung to dry in the shower rooms, but should not be hanging and contacting the floor.

The Director of Housekeeping was interviewed on October 3, 2011 at 3:45 PM, and stated the housekeepers were supposed to clean halls, dining rooms, and staff lockers, but they were short on housekeepers last week. Normally they have 2 housekeepers per floor, but only had 6 for the entire building.

The Director of Maintenance was interviewed on October 3, 2011 at 3:50 PM, and he stated the base to the electric wheelchair in the hallway outside room #528 was supposed to be cleaned periodically by maintenance and as needed by nursing staff.

The Director of Maintenance was interviewed on October 3, 2011 at 4:30 PM, and he stated the ceiling leak in room #328 was probably due to condensate dripping from the air conditioning system. He had no idea how long ago this occurred, but stated the ceiling needed to be repainted.

The Director of Maintenance was interviewed on October 4, 2011 at 9:30 AM, and he stated the large brown stain in the ceiling of room #402 was due to condensate dripping from the air conditioning system. He was not sure if it had been fixed.

The Director of Housekeeping was interviewed on October 4, 2011 at 10 AM, and she stated she keeps a list of badly stained cubicle curtains, and she was a little behind schedule in keeping up with them. There were no extra cubicle curtains available to replace them when they need to be washed, and none have been ordered.

The Director of Housekeeping was interviewed on October 4, 2011 at 10 AM, and she stated the sound panels on the walls in the dining rooms are stained and no longer cleanable, and the cabinets in the pantries should be replaced as the wood is deteriorated.

The Director of Maintenance was interviewed on October 4, 2011 at 11:20 AM, and he stated the water stained ceiling tiles in the Unit #2 tub room were not due to current leaks. He began replacing water stained ceiling tiles 2 weeks ago, but ran out of ceiling tiles on Unit #3.

The Director of Housekeeping was interviewed on October 4, 2011 at 2:25 PM, and she stated the clean linen room is supposed to be cleaned by the contract company that launders their linens.

In summary, the facility did not maintain the building in good repair/condition in regard to floors, walls, ceilings, doors, windows, furniture and equipment.

10 NYCRR 415.5(h)(2)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

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: October 14, 2011

Based on observation, record review, and interview with staff and residents conducted during the standard survey, it was determined for 1 of 1 residents (Resident #23), reviewed who required special accommodations when showering/bathing, the facility did not ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of his individual needs. Specifically, Resident #23 required special accommodations for showering/bathing and there was no documented evidence the facility attempted to meet his needs. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #23 was admitted to the facility on August 12, 2009 with diagnoses including end-stage renal disease requiring dialysis.

The July 8, 2011 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, scoring a 15 out of 15 on the BIMS (Brief Interview for Mental Status). The resident did not resist care, required physical help with bathing, and weighed 345 pounds.

The comprehensive care plan (CCP), last reviewed by the interdisciplinary team on July 21, 2011, documented the resident had an alteration in activities of daily living (ADL) and had difficulty transferring. The resident was to be transferred with a mechanical lift and staff were to monitor his ability to perform ADLs. The CCP did not address a plan for the resident to shower/bathe.

On October 3, 2011 at 2:40 PM, the surveyor overheard a conversation that occurred at and around the nurse's station. The covering registered nurse (RN) Manager stated to the social worker she just received a call from "downstairs" and she had to make sure the resident was showered. The social worker told the RN she knew the resident and he refused the bariatric shower stretcher as he was "fearful" of it. A few minutes later, the RN took the resident into the shower room. When the RN came out of the shower room, she told staff in the area, the resident was too large for the stretcher and did not want to use it.

The undated RPOC (Resident Plan of Care) provided by the covering RN Manager on October 3, 2011 at 4:15 PM, documented the resident was to have a bed bath daily.

On October 4, 2011 at 11:00 AM, the resident stated in an interview, he had 1 shower since admission because the facility did not have a shower stretcher large enough for him. He wanted to take a shower and was told yesterday "they are ordering one for me."

On October 5, 2011 at 10:25 AM, a certified nurse aide (CNA) showed the surveyor the bariatric shower stretcher. She stated she never used it and was told it was for residents over 300 pounds. She stated to her knowledge, the resident had never had a shower at the facility.

On October 7, 2011 at 10:55 AM, the Purchasing Director stated in an interview, the facility had both bariatric shower chairs and stretchers. He stated he thought those pieces of equipment were being used by residents who needed them and he had not been told of any residents having an issues or concerns with the equipment.

On October 7, 2011 at 11:30 AM, the covering RN Manager stated the resident would not use a shower chair and was "terrified" of the facility's shower stretcher as it was "not bariatric enough." She said at this time, the resident received bed baths and it was important for him to be clean. She described him as a "a very clean man." When asked if the facility was pursuing other options for shower stretchers, she provided 2 contradictory answers. She first stated the Purchasing Director was aware of the problem and was working on it. The RN then stated "that's all we have here, he would need to be measured and something would have to be ordered." She stated since that would be costly, she did not know if anyone was working on it.

In summary, the facility did not ensure attempts were made to accommodate the resident's needs when they did not provide him with regular showers.

10 NYCRR 415.5(e)(1)


E702 402.6(a): CRIMINAL HISTORY RECORD CHECK NOT PERFORMED PROVIDER SHALL SUBMIT REQUEST FOR CHECK

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

Section 402.6 Criminal History Record Check Process. (a) The provider shall ensure the submission of a request for a criminal history record check for each prospective employee. If a permanent record does not exist for the prospective employee, the Department shall be authorized to request and receive criminal history information from the Division concerning the prospective employee in accordance with the provisions of section 845-b of the Executive Law. Access to and the use of such information shall be governed by the provisions of such section of the Executive Law. The Division is authorized to submit fingerprints to the FBI for a national criminal history record check.

Citation date: October 14, 2011

Based on a review of personnel files and policies, and staff interviews conducted during the recertification survey, it was determined the facility did not ensure the submission and receipt of a Criminal History Record Check (CHRC) was completed for 1 of 5 newly hired staff required to undergo a CHRC screening (Employee #5). Specifically, the facility did not ensure the submission and receipt of a Criminal History Record Check (CHRC) was completed for a contracted food service worker who had access to residents and/or residents' property. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the survey which began on October 3, 2011, a surveyor reviewed the personnel files of 5 newly hired employees (within the past 4 months). There was no documented evidence, Employee #5, a contract dietary food service worker, hired on September 26, 2011, had a CHRC completed.

The job description (undated) for the contracted food service worker listed the job responsibilities as including:
- "Assist with serving meals on a timely basis. Including cook serve, traylines and family style dining rooms"; and
- "Takes tray carts or food carts to assigned floors. Notifies Nursing of tray arrival and, in conjunction with the nursing staff, delivers trays and/or food to individual residents in room and common dining areas."

The facility's Pre-employment Screening and Background Check Policy and Procedure (revised on July 31, 2011), documented the individuals covered by the statute includes "unlicensed direct care or supervision staff used or employed by a nursing home that has physical access to residents or resident's personal property or provide face-to-face care in accordance with the resident's plan of care" and "If the person's only interaction with a resident occurs in the nursing home common areas and not on the nursing unit, they are not subject to CHRC." For unlicensed resident care/contact workers, the list of titles subject to CHRC included "Dining Room Server."

The Administrator was interviewed on October 6, 2011 at 8:30 AM. He stated the contract agency who supplied the Food Service Worker felt that the CHRC was not required for food service workers on the nursing units because they did not provide direct care and were not left alone with residents.

In summary, the facility did not ensure the submission and receipt of a Criminal History Record Check (CHRC) was completed for a contracted food service worker who had access to residents and/or residents' property.

10 NYCRR 402.6(a)

F329 483.25(l): DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Citation date: October 14, 2011

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 13 residents (Resident #20), reviewed for psychoactive medications, the facility did not ensure the resident was free from unnecessary drugs. Specifically, for Resident #20, the facility: did not ensure there was sufficient and specific documentation of the behaviors exhibited by the resident warranting the use of Haldol (an antipsychotic medication); did not develop and implement a plan of care that incorporated non-pharmacological interventions to use before administering Haldol; and did not provide a rationale for the ongoing order for the Haldol. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #20 had diagnoses including dementia, depression, and aphasia.

The comprehensive care plan (CCP) undated and printed May 4, 2010, documented the resident had a history of inappropriate behavior at times. The behavior included a few occasions of touching female staff, and was documented as behavior that "did not seem to have any malice intent." The social worker was to remain available for support and reassurance as needed, and the resident was to be monitored for inappropriate behaviors toward females.

The most recent social work documentation when reviewed during survey, was in April, 2011 and did not identify inappropriate behavior.

The Minimum Data Set (MDS) assessment dated July 1, 2011, identified the resident with severe cognitive impairment. The resident exhibited disorganized thinking and was inattentive. No inappropriate behaviors were identified on the MDS assessment. The resident was non-ambulatory, dependent on staff for all activities of daily living (ADLs), and used a wheelchair for mobility.

On August 4, 2011, a nursing progress note, written on the evening shift, documented the resident was caught "touching numerous female residents" and had to be redirected "multiple times." The note documented at dinner, the resident was "caught biting" another female resident's hand. The plan was to continue monitoring the resident.

A nursing progress note dated August 18, 2011, on the night shift (11:30 PM), documented the resident was increasingly aggressive towards "everyone" including staff, other residents and visitors. The behavior was described as "excessive grabbing." The note recorded the resident could not be redirected and the plan was to "continue to monitor."

A nursing note dated August 30, 2011, at 6:30 PM documented the resident was very restless. The resident "approached 2 female residents attempting to touch them inappropriately" and was very difficult to redirect. The note recorded the resident received a second dose of Zyprexa (anti-psychotic medication) at 3:45 PM. The nurse practitioner (NP) was called and increased the resident's routine order of Zyprexa.

The NP acute medical visit note dated August 30, 2011 documented the resident was seen for inappropriate behavior. The resident was on 5 mg twice daily of Zyprexa and the plan was to increase the Zyprexa to 15 mg daily. An addendum was added to the note and documented that approximately one hour after giving the resident Zyprexa, he was given Haldol 2 mg (antipsychotic) IM (intramuscular) one time as he continued to be "very aggressive".

The resident's continued aggressive behavior on August 30, 2011, and administration of Haldol IM, was not documented by nursing in the progress notes.

The medication administration record (MAR) on August 31, 2011, documented the resident could receive Haldol 2 mg IM every 8 hours as needed (PRN) for extreme agitation. Extreme was underlined and there was no further description of the type of behavior that may require administration of Haldol.

On September 2, 21011, a nursing progress note on the evening shift, documented the resident had "extreme agitation" and Haldol was given once. The plan was to continue to monitor. There was no documentation related to: the resident's behavior requiring the Haldol; interventions attempted prior to the use of the medication; or the effect of the medication once administered.

The MAR documented the resident received Haldol on September 5, 2011. There was no documentation on the MAR or the progress notes related to: the resident's behavior requiring the Haldol; interventions attempted prior to the use of the medication; or the effect of the medication once administered.

The NP documented on September 9, 2011, the resident was seen to "check" the resident's "aggressive behavior towards patients and staff." The increase in the Zyprexa was documented as helpful in lessening the resident's aggression and was working "somewhat." The Zyprexa was to continue as ordered at 20 mg daily, and the resident was to be monitored weekly. The note did not address the use of the Haldol.

The NP saw the resident on September 13, 2011 for an acute visit related to the resident's cold symptoms. The note did not address any inappropriate behaviors.

The MAR documented the resident received PRN Haldol on September 17, 2011.

Nursing progress notes dated September 17, 2011 documented the resident's vital signs and concerns related to cold symptoms and did not address the use of the PRN Haldol documented as administered on MAR on that date.

Nursing progress notes dated September 19, 2011 documented the resent was sent to the emergency room and returned with a diagnosis of pneumonia. There was no documentation regarding the resident's behavior.

The physician "interval" note dated September 20, 2011 addressed the resident's acute upper respiratory symptoms, and the "worsening aggression along with his psychosis of dementia." The note documented a review of the resident's psychoactive medications, noting the resident required a "stat injection IM Haldol 2 mg" on August 30, 2011. The physician documented the Zyprexa was increased and noted it was controlling the resident's behavior "much better." The plan included continuing Zyprexa at 20 mg daily because of "increasing physical aggression." The note recorded the resident was "well managed." There was no documentation related to the continued use of the PRN Haldol following the one dosage administered on August 30, 2011.

On September 21, 2011, the resident was given Haldol, as documented on the MAR. There was no documentation describing the reason for the administration of the medication, interventions attempted prior to the administration, or the effectiveness of the medication.

On September 22, 2011 a nursing progress note documented the resident had been wandering into other resident's rooms, spitting on the floors. There were no interventions were documented.

On September 22, 2011, the resident was seen by the MD for anemia. The note did not address the resident's behavior or administration of the PRN Haldol.

A nursing progress note dated September 23, 2011 documented the resident was given Haldol in the "AM" as ordered, with positive effect. The MAR documented the administration of the Haldol. There was no documentation related to the reason the medication was administered, or any interventions attempted prior to the use of the medication.

The CCP updated on October 3, 2011 related to the resident's history of inappropriate behavior and documented "ongoing." As no dates were provided regarding changes to the problem or approaches, there was no documented evidence changes were made to the CCP when the resident exhibited inappropriate behavior in August and September 2011.

The Resident Plan of Care (RPOC, used by the direct care staff) was provided to the surveyor on October 3, 2011. The plan documented to keep the resident in visible areas and to approach in a calm voice as he can be combative at times.

The resident was observed on October 3, 2011, at 6:10 PM in the dining room seated at the table in a wheelchair. The resident attempted several times to get up out of the chair. A certified nurse aide (CNA) assisted him to sit back down in the chair, then brought a drink to the table and placed it in front of him to distract the behavior.

On October 7, 2011, at 1:50 PM the unit social worker was interviewed, and stated she had been the social worker on the unit for approximately 2 weeks. She said the resident had been stable, and was "very nice, pleasant". The social worker reviewed the social work progress notes and stated the most recent social work note was April 6, 2011, which documented the resident was combative at times. The social worker said she was not aware of the resident's recent inappropriate behavior toward female residents. She stated 2 other social workers had covered the unit in the past 7 months.

The Director of Social Services was interviewed on October 7, 2011 at 2:15 PM. She stated she was the previous "covering" social worker from April through September 2011. She said she was aware of the resident's behavior toward staff and "believed" there were a couple of incidents with other residents. She said she did not recall being notified of the incident with the resident on August 30, 2011. The Director stated social services' role was minimal related to the resident's behavior. She said if she was aware of the incident, she would have documented it in the CCP and in the care plan. The Director said the social workers were not involved with residents psychotropic medications stating that was "mostly nursing". She stated she did not see any reason for the resident to be seen for psychological services as the resident had dementia, and she was not aware the resident had a physician's order for the PRN Haldol IM.

The NP was interviewed at 2:50 PM on October 7, 2011 via telephone. She stated the resident was given the Haldol as a result of the resident's increased physical behaviors toward other residents. She said the medication was to be given when the resident was physically aggressive toward staff or other residents, after trying to redirect the resident. She stated she expected nursing would document the behavior and interventions attempted before the medication was given. She stated the resident was very strong, and it "took a couple of people" to get the resident to his room to administer the Haldol.

In summary, the resident received Haldol IM without adequate indications for its use when the facility:
- did not document evidence non-pharmacological behavioral interventions were identified or implemented prior to the use of the drug;
- did not document a rationale for the use of the IM medication;
- did not assess the effectiveness of the medication;
- did not document the need for the continued use of the medication; and
- did not document social work involvement in determining non-pharmacological psychosocial interventions to implement prior to the use of the medication.

10NYCRR 415.12(1)(1)

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: December 14, 2011

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: October 14, 2011

Based on record review and staff interview conducted during the standard survey, it was determined for 2 of 17 sampled residents (Resident #27 and 34), reviewed for accidents, the facility did not ensure all alleged violations involving elopement were thoroughly investigated, and reported in conformance with state law. Specifically, for Resident #27 the facility did not ensure a thorough investigation was completed after the resident exited the nursing unit, and did not report elopement incidents involving Residents #27 and 34 to the New York State Department of Health (NYSDOH), as required. 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 MARCH 9, 2010 AND JANUARY 14, 2011 SURVEYS.

Findings include:

1) Resident #27 had diagnoses including vascular dementia, depression and hypertension.

A "Resident/Visitor Event Report" dated August 10, 2011 documented per a witness statement, the resident was observed, before 8 AM, unaccompanied on the service level (one level below the main level) of the facility and was not wearing a Wanderguard device, as per the resident's plan of care. The report documented follow up steps taken including: the resident's room was searched, her wheelchair was removed and taken off the unit, 30 minute visual checks were initiated, and a check of the Wanderguard device. There was no documented evidence an investigation was done to determine how the resident got to the service level undetected.

The resident's Minimum Data Set (MDS) assessment dated August 18, 2011, documented the resident's cognition was intact, and she required limited assistance with transferring and walking. The resident had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble falling or staying asleep and felt tired, having little energy.

A social services progress note, dated September 20, 2011, documented the resident was "found outside the building" at approximately 8:30 AM. The social worker was called to assist bringing the resident back into the building. The resident was near the curb on "Harrison St" and stated she was waiting for her sister to pick her up. The resident voluntarily reentered the building approximately 45 minutes later, after several staff attempted to bring her back. The social worker remained with her until a new Wanderguard was applied.

The Resident Elopement/Attempted Elopement Investigation dated September 20, 2011 documented the resident was not accounted for at 8:40 AM, was found at 8:40 AM, and returned to the unit at 9:30 AM. The investigation documented the incident did not meet the criteria for elopement as the resident was not in harm's way. The investigation included the following witness statements:
- The Nurse Manager documented upon arriving at the facility at 9 AM she saw staff standing with the resident. The resident was holding a pillowcase with a few of her belongings inside.
- The Director of Social Services documented (no time documented) she witnessed the resident outside the building in the parking lot with staff watching the resident from afar. The resident was agitated, stating that her sister (deceased) was coming to pick her up. The investigation did not provide documented evidence of how the resident exited the facility, or how long the facility had been out of the facility.

During an interview with the social worker on October 5, 2011 at 1:10 PM, the social worker said she was sitting at her desk and got a phone call around 8:30 AM from the supervisor stating the resident was outside, near parking lot. She said she joined the staff already there (Assistant Director of Nursing, DON, and Social Work Director), and were were able to talk her into coming back into the facility. The social worker was asked to show the surveyor where the resident was standing when she saw her. The social worker pointed to a pole between the curb and the sidewalk on a busy street, and said the resident was hanging on to the pole with her bag of belongings. The resident said she was waiting for her sister to pick her up.

During an interview with the Director of Nursing (DON) on October 6, 2011 at 4:40 PM, the DON was asked about the investigation for the September 20, 2011 incident of elopement. The DON said she would reinvestigate the incident. When the DON was asked regarding reporting the incident to NYSDOH (New York State Department of Health), the DON said it was not reported as the resident was never in harm's way.

In summary, the facility:
- did not conduct a complete and through investigation as investigation to determine how th resident exited undetected, or how long she was gone; and
- did not report the incident to the NYSDOH as required.

2) Resident #34 had diagnoses including dementia (small vessel ischemia/atrophy) and depression with anxiety.

The comprehensive care plan (CCP), updated June 15, 2011, most recently reviewed by the interdisciplinary team on August 18, 2011, identified the resident was at risk for elopement, as evidenced by successful attempts to leave the facility without proper notification of staff, and failing to provide a destination in the sign out book. The resident frequently stated she wanted to leave. The plan included the resident was only to leave the unit when accompanied by a responsible adult, the use of a Wanderguard bracelet, and redirection as needed.

The Minimum Data Set (MDS) assessment, dated August 7, 2011, described the resident as being alert, oriented and cognitively intact. The resident exhibited delusional behavior, and rejected care on a daily basis. The MDS recorded the resident was independent in activities of daily living (ADLs).

On August 10, 2011 a nursing progress note documented the resident was observed signing herself out in the sign out book on the unit. The resident stated she was going downstairs to buy snacks. Staff were able to convince her to remain on the unit, although she was "very angry". The note documented the resident continued to refuse to wear a Wanderguard bracelet and had previously cut it off. The resident was identified to be at high risk for elopement "due to her impaired cognition, recall, lack of judgment/insight and poor safety awareness."

A Resident Event Report dated August 14, 2011 documented the resident had an elopement event. The resident was observed sitting (outside) on the front patio reading the paper. The report documented the resident stated "I walked to CVS (a pharmacy that is approximately a block away, on the other side of the street from the facility) to get the paper." The resident refused to return to the unit and required encouragement to do so. The investigation documented there were no witnesses to the incident, and the incident met the criteria for elopement, as the resident left the facility without permission or staff knowledge. The report documented the resident was last observed in the dining room between 9:00 AM and 9:15 AM, and was on hourly checks.

Review of the nursing progress notes revealed no documented evidence of the incident on August 14, 2011. The next nursing progress note after August 10, 2011 was dated August 27, 2011.

On October 7, 2011 at 9:50 AM, the Administrator was interviewed. He stated he was aware of each incident of elopement as they were discussed in morning report. He said he signed off on all incident investigations. The administrator stated he was aware elopement was a great concern at this facility due to its location (in the city). He stated two residents were currently on 1 to 1 supervision, due to their elopement risk.

There was no documented evidence the New York State Department of Health (NYSDOH) had been notified of the resident's elopement incident as of October 6, 2011.

In summary, the facility did not ensure an incident of elopement was reported in a timely manner to the NYSDOH.

10NYCRR 415.4(b)(3 & 4)

F309 483.25: PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Citation date: October 14, 2011

Based on observations, record reviews, and interviews with residents and staff conducted during the standard survey, it was determined the facility did not ensure 3 of 27 residents reviewed for quality of care (Residents #1, 8, and 28) received the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically, the facility did not ensure Residents #1 and #28, had appropriate pressure relieving devices in the wheelchair. Resident #8 was readmitted to the facility without a timely assessment of his skin. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #28 was admitted to the facility with diagnoses including metastatic cervical cancer, hypertension and anemia.

The Minimum Data Set (MDS) dated July 12, 2011 documented the resident was cognitively intact, required extensive assistance for dressing, transferring, toileting and personal hygiene. The MDS documented the resident was at risk for developing pressure ulcers and had a pressure reducing device for the chair and the bed.

The Interdisciplinary Plan of Care dated July 25, 2011 documented the resident had a Gaymar (pressure reducing) cushion in the wheelchair and an APM (alternating pressure mattress) on the bed.

On October 5, 2011 at 11:10 AM, the resident was observed sitting in her wheelchair in the hallway. The resident said her bottom hurt her. The surveyor asked the resident if she had a cushion in her chair and she said, "No, I have a pillow."

On October 5, 2011 at 3:10 PM, the surveyor and the registered nurse (RN) manager, with the resident's permission, observed the resident's buttocks. The resident's buttocks were red but were blanchable. When asked why the resident did not have a pressure relieving device in the wheelchair, the RN manager said she was not aware the resident did not have one and was using a pillow. The resident said they threw her cushion out months ago and she was using a pillow ever since.

In summary, the facility did not ensure a resident at risk for skin breakdown had a pressure relieving device in the wheelchair.

2) Resident #1 was admitted on May 13, 2010 with diagnoses including dementia, diabetes mellitus, stroke, and PVD (peripheral vascular disease).

The quarterly Minimum Data Set (MDS) assessment, dated July 2, 2011, documented the resident had severe cognitive impairment; required assistance for all activities of daily living; was non-ambulatory; and utilized a wheelchair for mobility.

The comprehensive care plan (CCP) documented the resident had a pressure ulcer on July 29, 2011, and that was healed on September 9, 2011. Interventions included "pressure reducing devices: see Resident Plan of Care sheet."

At 9:30 AM on October 3, 2011, when a surveyor observed the resident eating breakfast in the dining room, there was no pressure reducing cushion her wheelchair.

At 1:45 PM on October 3, 2011, a surveyor observed the resident being transferred by 2 certified nurse aides (CNAs) from her wheelchair to her bed. There was no pressure-reducing cushion in the wheelchair.

In an interview on October 3, 2011, at 1:45 Pm the CNA stated the cushion was not in the resident's wheelchair because she removed the cushion and threw it on the floor. The CNA stated the cushion was kept in the utility room.

During an interview with the registered nurse (RN) Unit Manager at 4:30 PM on October 6, 2011, she stated the resident should have a pressure relieving cushion in her chair, and she was unaware the cushion was not being used.

The Resident Plan of Care (RPOC, used by CNAs to provide care) was provided by the RN Unit manager at 6:30 PM on October 6, 2011. The RPOC documented the resident had a Gaymar (pressure reducing) cushion for the wheel chair.

In summary, the facility did not ensure direct care staff provided the pressure reducing cushion as planned.

3) Resident #8 had diagnoses including peripheral artery disease.

The facility policy title "Nursing Assessment" dated April 2010, documented the registered nurse (RN) "must" do the initial skin assessment, and document in the progress note. A skin assessment was required for all residents after admission, readmission, and/or return from bed hold.

The resident's Minimum Data Set (MDS) assessment dated August 9, 2011, documented the resident had moderately impaired cognition. The assessment documented the resident was at risk for the development of pressure ulcers, and had an unstageable pressure ulcer.

The "Skin Condition Monitor" form documented the resident developed a Stage II pressure ulcer on his left heel September 12, 2011, that measured 1.0 cm (centimeter) x 1.5 cm.

The "Skin Condition Monitor" form dated September 16, 2011, documented the pressure ulcer on the resident's left heel was a Stage II, and measured 0.7 cm x 0.9 cm x 0.1 cm.

The "Skin Condition Monitor" form dated September 28, 2011, documented the pressure ulcer on the resident's left heel was a Stage II, and measured 0.7 cm x 0.8 cm x 0. 1cm, and had 25% slough (dead tissue) present. There was no documented evidence the resident's pressure ulcer was assessed from September 16, 2011 until September 28, 2011.

The acting Nurse Manager was not available for an interview on October 3, 2011,

The assistant Director of Nursing was interviewed on October 3, 2011, at 10:00 AM, and she was unable to provide information pertaining to the resident's skin.

On October 4, 2011 at 11:45 AM, the resident was not in his room. At 1:30 PM, the ward clerk (unit secretary) stated the resident was at a doctor's appointment, and at 2:30 PM, she stated the resident may be admitted to the hospital.

The "Skin Condition Monitor" form dated October 4, 2011, documented the resident was in the hospital.

The hospital discharge summary dated October 6, 2011, documented the resident had a nonhealing ischemic (lack of blood flow) ulcer on his left heel for some time, and would "most likely" have an amputation of his left leg in the future. The discharge instructions included a dry sterile dressing to the left heel, to be changed once per day.

The resident's "Readmission Assessment" form dated October 6, 2011, documented the resident had a pressure ulcer. The form documented a dry sterile dressing was on the resident's left heel, and did not document if the resident's heels were observed. The form did not provide documented evidence the resident's left heel was assessed.

The nursing progress note dated October 6, 2011, documented the registered nurse (RN) did the resident's assessment, and the resident would be monitored. The progress note did not provide documented evidence the resident's left heel was assessed.

The "Medicare Skilled Nursing Observation Charting" forms documented:
- October 7, 2011, 7 AM - 3 PM shift, the resident did not have any stasis or pressure ulcers, had the application of dressings to his feet, and did not have circulatory compromise. It was unclear if the resident's skin was intact. The form did not contain documentation for the 11 PM - 7 AM shift or 3 PM - 11 PM shift.
- October 8, 2011, 11 PM - 7 AM shift, the resident did not have any stasis or pressure ulcers, had the application of dressings to his feet, and did not have circulatory compromise. The form did not contain not documentation for the 7 AM - 3 PM shift or the 3 PM - 11 PM shift.
- October 9, 2011, 11 PM - 7 AM shift, the resident did not have any stasis or pressure ulcers, had the application of dressings to his feet, and did not have circulatory compromise. The form did not contain not documentation for the 7 AM - 3 PM shift or the 3 PM - 11 PM shift.
- October 10, 2011, 11 PM - 7 AM shift, the resident did not have any stasis or pressure ulcers, had the application of dressings to his feet, and did not have circulatory compromise. The form did not contain not documentation for the 7 AM - 3 PM shift or the 3 PM - 11 PM shift.

The "Skin Condition Monitor" form, for the pressure ulcer that developed September 12, 2011, was updated October 11, 2011, and documented the pressure ulcer on the resident's left heel measured 1.0 cm x 1.2 cm x 0.2 cm. The pressure ulcer was not staged, and was described as "red base" with "yellow slough".

In summary, the facility did not ensure there was a timely assessment of the resident's left heel pressure ulcer upon readmission to the facility.

10 NYCRR 415.12

F276 483.20(c): QUARTERLY REVIEW OF ASSESSMENTS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Citation date: October 14, 2011

Based on record review and staff interview conducted during the standard survey the facility did not ensure 1 of 17 residents (Resident #32) reviewed for pressure ulcers were assessed using the quarterly review instrument approved by New York State and federal agencies not less frequently than once every 3 months. Specifically, Resident # 32 did not have a Minimum Data Set (MDS) assessment completed timely. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #32 had diagnoses including hypertension, chronic obstructive pulmonary disease (COPD, lung disease), diabetes, congestive heart failure, Stage III chronic kidney diease, dysphagia (difficulty swallowing), and aphasia (difficulty speaking).

The resident was readmitted to the facility on August 8, 2011 and the readmission physician's orders documented the resident was:
- on a specialized diet;
- required blood work for laboratory testing;
- was non-weight bearing;
- transferred via a mechanical lift with assistance of 2 - 3 persons; and
- the resident's bladder function was to be monitored, and if the resident had not voided in 16 hours the physician or nurse practitioner was to be notified.

The physician's progress note dated August 12, 2011, documented the resident had been admitted to the hospital for right lower leg cellulitis (skin infection), which improved. The resident had an "unstageable" ulcer on his right heel, and an episode of urinary retention.

The surveyor reviewed the resident's medical record on October 3, 2011. The record included an annual MDS assessment dated March 21,2011, and a quarterly MDS assessment dated June 15, 2011. There was no documented evidence an MDS assessment was completed since June 15, 2011.

During an interview with the "covering" registered nurse (RN) Manager for Unit 4 on October 5, 2011 at 10:40 AM, she stated prior to October 3, 2011 she was doing the MDS assessments for 3 weeks, because she was "catching up".

The "Assistant Director of Nursing/Nursing Operations" was interviewed on October 11, 2011 at 2:53 PM, and stated she expected the MDS assessment to be done 92 days after that last assessment, and was not aware this resident's were not completed according to that schedule.

In summary, the facility did not ensure the resident's MDS assessment was completed timely.

10 NYCRR415.11(a)(4)

F325 483.25(i): RESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.

Citation date: October 14, 2011

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 1 residents (Resident #16) reviewed for weight loss, the facility did not ensure the resident maintained acceptable parameters of nutritional status. Specifically, for Resident #16 the facility did not assess and implement interventions in a timely manner, to prevent weight loss. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #16 was admitted to the facility on August 18, 2011 had diagnoses including dementia, GERD (gastroesophageal reflux disease), and a recent hospitalization for a diagnosis of mild malnutrition.

The admission nursing assessment dated August 18, 2011 did not document the resident's weight.

The nutritional evaluation dated August 19, 2011 documented the resident's admission weight was pending and the resident's weight goal was determined to be 130 to 140 pounds based on the resident's stated usual body weight. The registered dietitian (RD) documented the resident's nutritional needs were increased related to a low albumin (measure of protein stores) in the hospital (date not specified) of 2.9g/dl (grams per deciliter), norm =
3.5-5g/dl. The plan included providing the "standard" meal plan, which the RD documented met the resident's needs, and monitoring intake.

The RD's August 22, 2011 progress note documented the resident's weight was 123.2 pounds. The RD documented she did not know if the resident lost weight or if the resident did not accurately report her usual body weight. The resident's percent of consumption based on the average of 6 meals was 63%. The RD documented it may be too early to determine the resident's intake as only 6 meals were available at that time. The plan included providing juice at dinner and supper for additional calories, monitor intakes, and monitoring weights.

On August 22, 2011 the resident's weight was recorded on the monthly weight worksheet as 122.5 pounds "standing".

The RD's August 23, 2011 progress note documented the resident's albumin on August 22, 2011 was decreased from the prior lab draw at 2.8g/dl. The RD noted the resident's assessed protein needs were appropriate and no changes were needed to the plan of care.

On August 26, 2011, the RD's progress note documented the resident's weight as 122.5 and established the resident's weight goal as 120 to 130 pounds. The plan was to continue with the nutritional plan of care.

The comprehensive care plan (CCP), written on August 25, 2011, documented the resident was at risk nutritional risk related to her leaving 25% or more uneaten at some meals, medical diagnoses, and a low albumin. The resident's weight goal (added on August 26, 2011) was 120 to 130 pounds. The plan included monitoring the resident's intakes, weighing the resident weekly, and providing chocolate milk at lunch and supper and whole milk at breakfast.

Nursing noted the resident was hospitalized on August 29, 2011 following an unresponsive episode while in the dining room.

The readmission nursing assessment documented on August 31, 2011, the resident weighed 122.9 pounds.

The preadmission nutrition screen dated August 31, 2011 documented the resident's weight as 122.5 prior to the hospitalization.

The resident weekly weight record for September 1, 2011, documented the resident was in the hospital and a weight was not obtained.

On September 6, 2011 the resident's weight was documented in the weekly weight worksheet as 122.9 pounds "standing".

The Minimum Data Set (MDS) assessment dated September 10, 2011 documented the resident had severe cognitive impairment, and required assistance with all activities of daily living. The resident's weight was recorded as 123 pounds.

The weekly weight worksheet for September 12, 2011 documented the resident's weight was 115.4 pounds. This was a 7.5 pound (6%) weight loss since the resident was readmitted on August 31, 2011 and there was no documented evidence a reweigh was obtained.

Nursing and nutrition progress notes were reviewed from September 12 through 20, 2011 and contained no documented evidence the resident's weight loss was addressed.

The resident's monthly weight worksheet for September, with no specific date listed, documented the resident's weight of 115.4 pounds.

A physician's note dated September 20, 2011 documented the resident was initially admitted to the facility on August 18, 2011 following a brief hospitalization for acute confusion, mild chronic anemia and malnutrition. The note documented the resident had not exhibited any weight loss at the time of the review.

The resident was observed on October 3, 2011 between 5:45 PM and 6:00 PM sitting in the dining room with her head on the table. She was not eating and pointed to the main entree (chipped beef ) and said "don't tell me this isn't a big dish." The resident's meal consisted of chicken noodle soup, wheat bread, collard greens, chipped beef, fresh orange wedges, juice, chocolate milk, and coffee. The resident cut her bread in half and dipped it in her coffee. At 6:30 PM, the resident was observed giving her oranges to another resident sitting at the table. The resident had eaten 25% of the chipped beef, and none of the collard greens or soup.

On October 3, 2011, the monthly weight record documented the resident weighed 120.2 pounds and the weight was obtained when the resident was in a wheelchair. The record recorded the wheelchair weight was subtracted from the combined weights of wheel chair and resident.

On October 4, 2011, the resident was observed at 10:00 AM in the dining room staring at the table with her breakfast in front of her and at 1:10 PM with her lunch in front of her. the observation showed her meal consumption of solids was less than 50% at each meal. The resident was observed at 6:40 PM seated by the elevators. When asked how her supper was, she replied "too big".

When the RD was interviewed on October 5, 2011 at 6:20 PM, she stated she was not concerned if someone's weight fluctuated, if it was "relatively stable". When the RD reviewed the weight book and the resident's weight change, she stated she was not aware of the weight loss, and said nursing did the re-weighs. She was not sure of the re-weigh policy and suggested the surveyor ask the Director of Nursing (DON) for the information.

The registered nurse (RN) Manager was interviewed at 6:35 PM on October 5, 2011 by the surveyor and stated she was not sure of the policy for reweighs as it was a new policy. At 6:45 PM, she provided the surveyor with the policy.

Review of the "Monitoring Resident Weights" policy updated March 2011, revealed:
- all residents were to be weighed upon admission/readmission within 24 hours of admission;
- weights would be obtained the first week of each month;
- if a resident had a 5 pound or greater weight gain or loss, the resident was to be re-weighed on the following day. The licensed practical nurse (LPN) was to alert the certified nurse aide (CNA) when a re-weigh was required; and,
- the LPN was to notify the RN Manager following the reweigh when a loss had been determined. The RN was then to e-mail nutrition staff to inform them of the change in weight.

In summary, for this resident admitted on August 18, 2011, readmitted on August 31, 2011 the facility:
- did not assess the resident's significant weight loss (7.5 pound, 6%) in a timely manner; and
- did not obtain a re-weigh to assess the resident's actual nutritional status.

10 NYCRR 415.12(i)(1)

F281 483.20(k)(3)(i): SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

The services provided or arranged by the facility must meet professional standards of quality.

Citation date: October 14, 2011

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure professional standards of quality were met for 1 of 35 sampled residents (Resident #32), and for 1 of 6 resident units (Unit 3). Specifically, Resident #32 had unclear insulin orders which were not clarified by the nurse prior to administering the insulin. The Unit 3 the nurses did not reconcile controlled medications before passing the keys from one nurse to another. 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 JANUARY 14, 2011 SURVEY.

Findings include:

1) Resident #32 had diagnoses including diabetes, chronic kidney disease, and hypertension (high blood pressure), and a history of cerebrovascular accident (CVA, stroke).

The physician's orders dated August 8, 2011, documented the resident was to receive Lantus (insulin) 82 units subcutaneously every morning, and 20 units every evening.

The physician progress note dated August 12, 2011, documented the resident's diabetes was "still" uncontrolled.

The physician's orders dated September 23, 2011, documented the Lantus was to be increased to 85 units every morning and 25 units every morning.

Review of the resident's September 2011, Medication Administration Records (MARs) revealed the resident received:
- 25 units Lantus every morning at "1700" (5:00 PM), between September 23 and September 30, 2011, and
- 85 units Lantus every morning at 8:00 AM, between September 24 and September 30, 2011.

During an interview with a licensed practical nurse (LPN #3) on October 7, 2011 at 10:20 AM, she stated, "I thought it was for AM and PM, I signed it off. There was no clarification of that order."

During an interview with LPN #4 on October 7, 2011 at 10:25 AM, he stated, " I did the second check, it means that I checked that order and there was no clarification of that order."

The registered nurse (RN) Unit Manager was interviewed on October 7, 2011 at 10:40 AM, and stated the order was written wrong by the physician, but the nurses gave it right.

The director of nurses was interviewed on October 7, 2011 at 2:30 PM and stated the physicians orders in question should be clarified prior to being transcribed and carried out by the nurses.

In summary, the facility did not ensure accepted standards of quality were met, when they did not clarify a physician's order before implementing it.

2) On October 4, 2011 at 11:50 AM, the surveyor observed licensed practical nurse (LPN) #1 give LPN #2 a set of keys. During an interview at this time LPN #2 stated the keys were the keys to the medication cart, and the medication cart contained controlled drugs. The LPN stated a reconciliation of the controlled drugs was not done, when the keys to the medication cart were passed from nurse to nurse at their lunch break. The LPN said this was "true" on all units.

Observation of the controlled drug storage drawer on the medication cart on October 4, 2011 between 11:50 AM and 12:00 PM showed the following:
- 15 tablets of Percocet (pain medication), 5/325 milligrams (mg);
- 4 tablets of Valium (anxiety medication), 10 mg;
- 16 tablets of Lortab (pain medication), 10/500 mg;
- 5 tablets of Ativan (anxiety medication), 0.5 mg;
- 28 tablets of Xanax (anxiety medication), 0.25 mg;
- 24 tablets of MS Contin (morphine), 15 mg;
- 18 tablets of Lyrica (pain medication), 150 mg; and
- and unknown quantity of Lortab, 5/500 mg.

The registered nurse (RN) Interim Nurse Manager was interviewed on October 4, 2011 at 12:05 PM, and stated a reconciliation of the controlled drugs in the medication cart should be done before the keys were given to another nurse. The RN stated she was not aware the keys were passed from nurse to nurse, without reconciliation of the drugs.

In summary, the facility did not ensure professional standards of quality when they did not ensure an accurate reconciliation controlled drugs was conducted before the keys to the drugs were passed from nurse to nurse.

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

K29 NFPA 101: HAZARDOUS AREAS - SEPARATION

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 14, 2011

One hour fire rated construction (with hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Citation date: October 11, 2011

Based upon observations and staff interviews conducted during the standard survey, it was determined the facility did not ensure doors to hazardous areas continued to function as designed for 1 of 8 floor levels (S- level). Specifically, the door to the medical records room lacked a self-closing device and the door to the soiled linen room was missing the latching mechanism. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
Findings include:

During the building inspection conducted on October 3, 2011 between 1 PM - 4:30 PM, and October 4, 2011 between 9 AM - 3 PM, the following life safety violations were observed:
- the door to the medical records room on the S-level lacked a self-closing device; and
- the door to the soiled linen holding room on the S-level did not have a latching mechanism.

The Director of Maintenance was interviewed on October 4 at 2 PM, and he stated he was not aware the self-closing device to the medical records room was missing. The Director of Medical Records, who was present, stated they were having a problem with the door about 6 months ago, and the closer was removed.

The Director of Maintenance was interviewed on October 4 at 2:10 PM, and he stated he was not sure how long the door to the soiled linen holding room had been missing. He did not have these on a routine preventive maintenance schedule to check, and believed they should be checked during routine fire drills.

In summary, the door to the medical records room lacked a self-closing device and the door to the soiled linen room was missing the latching mechanism.

2000 LSC 19.3.2.1