Rosewood Heights Health Center

Deficiency Details, Certification Survey, June 18, 2012

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: Isolated

Severity: Actual Harm

Corrected Date: August 17, 2012

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: June 18, 2012

Based on observation, record review, and staff interview conducted during the standard and abbreviated survey (#NY 00114903), it was determined the facility did not ensure 2 of 9 sampled residents (Residents #4 and 23) reviewed for pressure ulcers, received the necessary care and services to prevent the development of pressure ulcers and promote healing. Specifically, for Resident #4 who developed a Stage III pressure ulcer, staff were not aware of the Stage III pressure ulcer and did not implement preventative measures for pressure relief or treatment to prevent further pressure ulcers; For Resident #23, prior to developing a pressure ulcer staff did did not implement pressure relieving devices; and after developing a pressure ulcer staff used an incorrect product for treatments. This resulted in actual harm for Resident #4 and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #23.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF October 14, 2011.

Findings include:

1) Resident #4 was admitted on May 10, 2012, and readmitted from the hospital on May 21, 2012, with diagnoses including Hodgkin's lymphoma, chronic back pain, chronic obstructive pulmonary disease, anxiety and contractures of the legs.

The Skin Condition Monitor form documented the resident returned from the hospital on May 21, 2012 with a Stage II pressure ulcer measuring 0.3 centimeters (cm) x 0.3 cm on the left inner knee.

The readmission assessment, dated May 24, 2012, documented the resident had a pressure ulcer risk score of 18, with a score of 15 or higher meaning very high risk. The assessment documented the resident had a pillow between his legs, and a Gaymar (pressure relieving) overlay was placed on his mattress.

The skin condition Monitor form dated May 24, 2012 documented the pressure ulcer on the resident's left inner knee was a Stage II that measured 0.6 cm x 0.5 cm x 0.1 cm with dry eschar in the woud bed.

A physical therapy (PT) progress note, dated May 28, 2012, documented the resident had severe spasticity and tightness of both hips, which was "causing pressure sores" between both knees. The recommendation was for a pillow to be placed between the resident's thighs and knees.

The Minimum Data Set (MDS) assessment dated June 2, 2012, documented the resident had normal cognition with no behavior issues. The MDS recorded the resident was non-ambulatory and was totally dependent for bed mobility and all other activities of daily living except eating. The MDS documented the resident had worsening of 1 pressure ulcer, was not on a turning and positioning program, and did not have pressure relieving devices for his chair or bed. The MDS recorded no impairment to the resident's range of motion of his legs.

A PT progress note dated June 4, 2012, documented a recommendation, "reiterated to nursing," for the resident to have a pillow between both knees at all times due to "continuing worsening and spread of pressure areas" between both knees and thighs.

The comprehensive care plan (CCP), last updated on June 5, 2012, documented:
- The resident had: potential for impaired skin integrity related to bowel and bladder incontinence; a history of pressure ulcers; limited mobility; poor intake of food and fluids; weight loss; and severe pain.
- On May 10, 2012, the resident had Stage I pressure ulcers on the left inner knee and left hip; a Stage II pressure ulcer on the left knee and an unstageable pressure ulcer on the left hip.
- The CCP did not contain information about the number and stages of the resident's pressure ulcers after May 10, 2012.
- The resident's potential for impaired skin integrity was "resolved" on June 5, 2012.

The Skin condition Monitor form dated June 7, 2012 documented the left inner knee pressure ulcer was a Stage III, and measured 2.0 cm x 1.5 cm x 0.2 cm (depth). The recommendation on the form, documented by the occupational therapist was to use a t-shaped cushion between the resident's legs "for pressure relief while in bed and wheelchair - remove for hygiene."

An occupational therapy (OT) progress note, dated June 11, 2012, documented precautions including; "pillow between legs in bed-skin breakdown." The OT progress note documented a t-shaped cushion for pressure relief between the resident's knees was trialed, and the resident refused it. The new recommendation, for pressure relief, was a Gaymar air (pressure relieving) wheel chair cushion between the legs for "pressure relief-utilizing contour seat cushion for pressure relief and position."

On June 12, 2012 at 9 AM registered nurse (RN) #8 stated the resident had 5 pressure ulcers: Stage II pressure ulcers on the right and left inner knees; an unstaged blister on the right medial thigh; a Stage II pressure ulcer on the lower left knee; and a Stage IV pressure ulcer on the left hip.

The Resident Plan of Care, dated June 12, 2012, did not document the resident was to have a pressure relieving device between his knees, and did not specify the resident was provided with a pressure-relieving mattress or overlay.

At 2:30 PM on June 12, 2012, a surveyor observed the resident sitting in a wheelchair in his room. The resident stated he had 5 open wounds. A 4 inch circle of yellow drainage was observed on his pajamas over his inner left knee. His knees were touching, and there was no pressure relieving device between them. A blue T-cushion was observed on the dresser. The resident's unmade bed contained a standard pressure relieving mattress, without a Gaymar overlay.

At 9:30 AM on June 13, 2012, the resident was observed lying on his right side, eating breakfast. Dressings were observed on both inner knees, and there was no pressure relieving device between his knees. The resident stated the t- shaped cushion (on the dresser) was used "a couple of times," and he did not like it because it was bulky and embarrassing. He stated he was supposed to have a gel pillow between his legs at all times, and he did not know where the pillow was.

During an observation of a dressing change at 11:35 AM on June 13, 2012, the surveyor asked the licensed practical nurse (LPN) to roll the resident for observation of his buttocks. An open area covered by yellow slough (dead tissue) was observed on the resident's left buttock. The LPN stated to the surveyor this new open area had not been reported to her.

At 11:40 AM on June 13, 2012, CNA #12 who was assigned to care for the resident stated the resident had no new open skin areas.

At 11:45 AM on June 13, 2012 RN #8 assessed the open area on the resident's left buttock and stated to the surveyor the area was a Stage III pressure ulcer measuring 4.3 cm x 2.0 cm, with 50% slough in the wound bed.

At 11:50 AM on June 13, 2012, CNA #12, who began work at 7 AM, stated she had not provided incontinence care to the resident that day. The CNA said she was unaware the resident had a new pressure ulcer on his left buttock.

At 12 PM on June 13, 2012 RN #8 stated all of the resident's pressure ulcers should be documented on the CCP, and after reviewing the CCP and Resident Plan of Care (used by the CNAs to direct care), she stated she did not know if the resident was supposed to have a pressure relieving cushion between his knees.

At 12:10 PM on June 13, 2012 RN #8 stated the resident told staff that a Gaymar cushion covered by a pillowcase was supposed to be positioned between his knees.

At 12:15 PM on June 14, 2012, the RN unit manager stated she was unsure about the criteria for provision of pressure relieving mattresses.

At 12:18 PM, the resident stated staff had placed an alternating pressure mattress (APM) on his bed at 5:30 PM on June 13, 2012.

When re-interviewed at 12:20 PM on June 14, 2012, the RN unit manager stated the Assistant Director of Nursing had placed the APM on the resident's bed on the evening of June 13, 2012, and that in view of the resident's multiple open wounds, the APM should have been provided sooner.

During an interview with the occupational therapist/Director of Rehabilitation at 3:15 PM on June 14, 2012, she stated therapy staff recommended use of a (Gaymar) pillow between the resident's knees at skin rounds, and she would have expected this recommendation to be included in the resident's care plan.

In summary, the resident who was at very high risk for development of pressure ulcers, experienced harm as:
- the interdisciplinary team did not provide comprehensive, timely care planning and individualized interventions to prevent worsening of existing pressure ulcers and development of new pressure ulcers;
- the facility did not provide the recommended pressure relieving devices and the resident's wounds continued to worsen;
- staff did not provide incontinence care as planned; and
- the CCP did not accurately document the numbers and stages of the resident's pressure ulcers;

2) Resident #23 had diagnoses including dementia, osteoporosis and degenerative joint disease.

The Minimum Data Set (MDS) assessment dated February 28, 2012 documented the resident:
- had severe cognitive impairment;
- was non-ambulatory;
- used a wheel chair with extensive assistance for transferring and mobility on the unit;
- required extensive assistance with dressing and hygiene needs;
- was always incontinent of bowel and bladder;
- was not identified as being at risk for pressure ulcers; and
- was not documented as having a pressure reducing device for her bed.

The registered nurse (RN) Unit Manager was interviewed on June 18, 2012 at 10 AM and stated a nursing quarterly assessment including a "Pressure Ulcer Risk Assessment and Prevention Measures" should have been completed in February, 2012. Reviewing the resident record, the RN Unit Manager was unable to locate the assessment and stated she did not know if it was ever completed.

The comprehensive care plan (CCP) dated March 12, 2012 documented the resident had potential for impaired skin integrity related to incontinence and limited mobility. The CCP included pressure relieving/reducing devices for the bed and chair as indicated. The CCP did not document if the devices were indicated or what devices would be used.

A nursing progress note dated March 15, 2012 documented the staff reported an area on the resident's buttocks, that was superficial, reddened measuring 0.5 x 0.5 (no unit of measure recorded). The plan included turning and positioning the resident every 2 hours and applying Sensicare (a protective barrier creme).

The registered dietitian (RD) documented on March 19, 2012 review of the skin book revealed the resident had an area on her left buttock "noted as excoriation" versus a Stage I pressure ulcer.

A nursing progress note dated March 21, 2012 documented the resident's excoriated area had resolved and the resident had a new open area on her coccyx measuring 1.5 x 0.5 (no unit of measure recorded) that was a "Stage II." The note documented the skin care protocol "to include prevention" was put in place.

Review of dietary and nursing progress notes, from March 21 - April 10, 2012, documented the resident continued to have a pressure ulcer on her coccyx. The notes recorded the pressure ulcer on the resident's buttocks had reopened and then resolved.

The RN Unit Manager was interviewed on June 18, 2012 at 10 AM and stated the resident was given the APM (alternating pressure mattress) when the pressure ulcer developed in March, 2012. She stated she did not think the facility's regular mattresses were pressure relieving/reducing. The RN Unit Manager said she was unable to find documentation the resident had any type of pressure reducing mattress before developing the pressure ulcer in March 2012. She stated the resident should have been identified as high risk for developing a pressure area as she was unable to change positions independently and required a mechanical (Hoyer) lift for transfers. The RN Unit Manager said the resident had "always been" a Hoyer lift. The RN Unit Manager said the resident should have had a Gaymar (pressure relieving) mattress if assessed to be at risk, but was unable to say if she had one before developing the pressure ulcer on her coccyx in March 2012.

On April 10, 2012, nursing progress notes documented the resident fell and was sent to the emergency room.

The nursing note dated April 12, 2012 documented the resident returned from the hospital and had an open area on the coccyx. The note recorded the facility skin care protocol was to be followed.

The RN's Pressure Ulcer Risk Assessment and Prevention Measures form dated April 12, 2012 documented the pressure ulcer on the resident's coccyx. The assessment documented the resident's risk score for developing pressure ulcers was 17, with 15 or greater being very high risk. Protocols set up by level of risk and preventive measures were documented to include an APM and a Gaymar mattress overlay.

The MDS assessment dated May 22, 2012 documented the resident had an unstageable pressure ulcer. The skin and pressure ulcer treatments included a pressure reducing device for the chair and bed. The MDS recorded the resident was on a turning and repositioning program, nutrition and hydration interventions were in place and the resident was receiving pressure ulcer care.

The nurse practitioner (NP)'s orders dated June 12, 2012 documented the treatment to the pressure ulcer on the resident's coccyx as "cleanse with NS (normal saline), pat dry, and apply Aquacel (used to promote healing) and dry sterile dressing every day."

The June 2012 Treatment Administration Record (TAR) documented the treatment as ordered by the NP.

The licensed practical nurse (LPN) was observed on June 15, 2012 at 9:45 AM as he performed the resident's pressure ulcer treatment. The LPN applied Aquacel Ag (a dressing with an antimicrobial agent).

The LPN, with the RN Unit Manager present, stated during an interview on June 15, 2012 at 10:09 AM, the TAR documented the type of treatment product to be used for the resident's pressure ulcer as Aquacel, not Aquacel Ag.

During an interview with RN Assistant Director of Nursing (ADON), who was the acting Director of Nursing (DON), on June 15, 2012 at 3:40 PM, she stated she provided oversight to the skin program. She stated Aquacel Ag had a silver component, that helped with bacteria, and Aquacel did not. She stated if the physician's order was for Aquacel she expected Aquacel to be used. She was not aware staff used Aquacel Ag for the resident's pressure ulcer treatment when Aquacel was ordered.

In summary the facility:
- did not identify the resident to be at risk for developing pressure ulcers;
- did not document evidence the resident was provided with pressure relieving device in bed, in a timely manner, before developing skin breakdown; and
- did not administer the pressure ulcer treatment as ordered.

10 NYCRR 415.12 (c)(1)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Citation date: June 18, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 3 of 13 residents (Residents #4, 5, and 22), reviewed for activities of daily living (ADLs), the facility did not ensure residents who were unable to carry out ADLs received the necessary services to maintain good nutrition, grooming, and personal hygiene. Specifically, for Resident #4, who was assessed at very high risk to develop pressure ulcers, staff did not consistently provide incontinence care as planned and the resident was observed to be in need of incontinence care when a new Stage III pressure ulcer was discovered. For Resident #5, the interdisciplinary team did not identify the resident's needs for assistance with ADLs related to his right hemiplegia and right hand contracture and staff did not groom the resident's fingernails until brought to their attention. Resident #22 was incontinent and was not assisted with toileting or incontinence care as planned; staff did not attempt to assist the resident with eating when needed. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #4 was admitted on May 10, 2012, and readmitted from the hospital on May 21, 2012, with diagnoses including Hodgkin's lymphoma, chronic back pain, chronic obstructive pulmonary disease, anxiety, and contractures of the lower extremities.

The readmission assessment, dated May 24, 2012, documented the resident had a pressure ulcer risk score of 18, with a score of 15 or higher meaning very high risk.

The 14 day Minimum Data Set (MDS) assessment, dated June 2, 2012, documented the resident had normal cognition; had no behaviors; was non-ambulatory; was totally dependent for bed mobility and all other activities of daily living except eating; was incontinent of bowel and bladder; was not on a toileting program; and had worsening of 1 pressure ulcer. The MDS did not document the resident's leg contractures and documented the resident had no impairment of range of motion in his legs.

The comprehensive care plan (CCP) dated June 5, 2012, documented:
- the resident had the potential for impaired skin integrity related to bowel and bladder incontinence, history of pressure ulcers, limited mobility, poor intake of food and fluids, weight loss, and severe pain; and
- interventions for the resident's bowel and bladder incontinence included toileting every 2-4 hours, with skin care after incontinence episodes and application of barrier cream.

During the initial unit tour at 9 AM on June 12, 2012, the float registered nurse (RN) stated the resident had 5 pressure ulcers: Stage II ulcers on the right and left inner knees; an unstaged blister on the right medial thigh; a Stage II ulcer on the lower left knee; and a Stage IV ulcer on the left hip.

The Resident Plan of Care, dated June 12, 2012, used by certified nurse aides (CNAs) to provide care, documented the resident was to be turned and positioned every 2 hours. The general instructions documented that "incontinent residents receive incontinence care per house policy."

During an interview with the resident at 9:35 AM on June 13, 2012, he stated that he was left in the dining room for 12 hours recently, and staff did not believe him when he told them his "diaper" was wet and soiled for 7 hours.

During observation of a dressing change at 11:35 AM on June 13, 2012, the surveyor asked the licensed practical nurse (LPN) to roll the resident for observation of his buttocks. The resident was observed to be incontinent of stool and urine. An open area covered by yellow slough (dead tissue) was observed on the resident's left buttock. The LPN stated this new open wound had not been reported to her.

At 11:40 AM on June 13, 2012, the resident's assigned CNA stated the resident had no new open skin areas.

At 11:45 AM on June 13, 2012, the float RN assessed the wound on the resident's left buttock as a Stage III pressure ulcer, with 50% slough, measuring 4.3 (centimeters) cm x 2.0 cm.

At 11:50 AM on June 13, 2012, the resident's assigned CNA, who began work at 7 AM, stated she had not performed incontinence care that day, and was unaware the resident had a new open area on his left buttock.

In summary, the facility did not consistently provide the care planned incontinence care as the resident was observed to be in need of incontinence care when a new Stage III pressure ulcer was discovered.

2) Resident #5 was admitted on May 31, 2012 with diagnoses including history of stroke with right hemiplegia (weakness) and expressive aphasia (difficulty communicating), recent transient ischemic attack (TIA; temporary stroke symptoms), heart disease, and peripheral vascular disease (PVD).

The Admission History and Physical, dated May 31, 2012, documented the resident was alert and oriented and had chronic upper and lower extremity weakness.

The nursing Admission Assessment, dated May 31, 2012, did not document the resident's right hemiplegia, and did not specify the resident had a contracture. The assessment incorrectly documented the resident had clear speech; was not oriented; and had no sensory impairment due to PVD.

An occupational therapy assessment, dated May 31, 2012, documented the resident had right elbow and hand contractures, and no strength in his right upper shoulder, elbow, wrist, and fingers.

The comprehensive care plan (CCP), dated May 31, 2012, did not document problems and interventions for the resident's right hemiplegia, right hand contracture, and need for assistance with activities of daily living (ADLs).

The admission Minimum Data Set (MDS) assessment, dated June 6, 2012, documented the resident was able to identify all of his daily and activity preferences; required extensive assistance for all ADLs except eating; and had impaired upper extremity (on one side) functional range of motion that interfered with daily functions or placed the resident at risk of injury. The MDS incorrectly documented the resident had severe cognitive impairment.

The Resident Plan of Care, dated June 12, 2012, used by certified nurse aides (CNAs) to provide care, contained no instructions regarding nail care.

The resident was observed to have a contracted right hand and long fingernails with black material under the nails at 1:10 PM on June 12, 2012; 9:15 AM on June 13, 2012; 2:20 PM on June 14, 2012; and 3:40 PM on June 15, 2012.

At 8 AM on June 18, 2012, a surveyor observed the resident as his assigned CNA transferred him from his bed to a wheelchair. The resident's fingernails were long, with black material under the nails. The CNA stated that residents' nails could be cut at anytime or "if the resident asks."

At 8:45 AM on June 18, 2012, the CNA told the surveyor that she had cut the resident's fingernails.

A surveyor interviewed the RN Unit Manager at 9:25 AM on June 18, 2012. After reviewing the resident's nursing Admission Assessment and CCP, she stated his right hand contracture should have been documented on the Admission Assessment. She stated the CCP should have included care planning for the resident's need for assistance with ADLs, right hemiparesis, and right hand contracture. She stated she was unaware the resident's fingernails were in need of grooming until brought to staff's attention that day. She stated this grooming should be done with care. The CNA Unit Clerk, who was present during the conversation, stated staff were supposed to cut residents' nails on shower day.

In summary, the facility:
- did not identify the resident's needs for assistance with ADLs related to his right hemiplegia and right hand contracture; and
- did not groom the resident's fingernails until brought to their attention during survey.

3) Resident #22 had diagnoses including dementia.

The March 5, 2012 registered dietitian's (RD) assessment documented the resident weighed 122.8 pounds and consumed 37% at meals. The RD documented she questioned the weight of 122.8 pounds as the weight was not confirmed by a re-weight. The RD used a weight of 117 pounds in her assessment of the resident, documented a goal was weight stability, and added donuts to the resident's meal plan.

The May 23, 2012 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, weighed 115 pounds, had no significant weight changes and fed herself after set-up.

The May 24, 2012 RD assessment documented the resident weighed 115.2 pounds in April of 2012 and 114.7 pounds in May of 2012. The resident consumed 36% at meals and the RD made changes to the resident's meal plan to provide her with more calories.

The comprehensive care plan (CCP) reviewed by the interdisciplinary team on June 5, 2012 documented a weight goal for the resident of 115 to 120 pounds. The resident was dependent on staff for all ADLs except eating. The resident's weight documented in the May 24, 2012 RD assessment was below the documented goal weight for the resident.

The Resident Plan of Care (RPOC) (used when providing care) dated June 8, 2012 documented the resident was on a regular unmodified diet with nectar thick liquids. The resident's feeding ability was not documented.

The June 13, 2012 physician's orders documented the resident's diet order was regular with nectar thick liquids.

The resident was observed on June 13, 2012 between 9:15 AM and 9:50 AM in the dining room. The resident received an egg, muffin and grits. Her meal ticket documented she was to receive cold cereal and coffee and she did not receive either. The resident received milk and juice, which were in cartons and not poured into glasses for her. The resident was observed throughout the meal with her head down and eyes closed. A certified nurse aide (CNA) attempted for less than 1 minute to wake her up and was unsuccessful. No other staff members were observed to attempt to wake the resident. The resident did not eat or drink.

The resident was observed on June 13, 2012 from 12:17 PM to 1:40 PM. She woke up for less than 1 minute during the meal and ate 1 bite of ice cream.

On June 13, 2012 at 1:45 PM, the resident's assigned CNA stated in an interview, she tried to wake the resident up for breakfast and lunch and was not successful. She stated the resident did not wake up related to her advanced age. She stated the resident was able to feed herself and staff only set-up her meal for her and did not feed her. The surveyor asked if she attempted to feed the resident when she was lethargic and she stated the resident needed set-up help only.

The RN Manager was not available for interview on June 18, 2012.

In summary the facility did not ensure staff made attempts to assist the resident with eating when needed to ensure the resident maintained good nutrition and maintained her weight within her established goal weight range.

10 NYCRR 415.12(a)(3)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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 observation, record review and interview with staff and family members conducted during the standard survey, it was determined for 3 of 30 sampled residents (Residents #13, 22, and 25), and one resident outside of the sample (Resident #34), the facility did not thoroughly develop, review, and revise comprehensive care plans (CCPs). Specifically, Resident #13's CCP did not accurately reflect the resident's manner of voiding or his tentative discharge plan. For Resident #22, the facility did not provide significant rationale for the use of psychotropic medications, and did not include psychotropic medications in the CCP. For Resident #25, the facility did not provide sufficient rationale for not assisting the resident with dressing or getting out of bed, did not ensure there was documented evidence that the resident's preferences had been assessed to develop a plan of care based on the resident's wishes, and did not provide documentation that the resident had the right to refuse services or treatment and those refusals were monitored by nursing. For Resident #34, the facility did not provide documented rational for not assisting the resident with getting dressed; did not provide documentation that adequate information was provided to the resident in order for her to make an informed decision about not getting dressed and wearing a hospital gown, and did not provide documented evidence in the resident's comprehensive care plan that supported the resident's preferences related to staying in a hospital gown. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF OCTOBER 14, 2011.

Findings include:

1) Resident #22 had diagnoses including dementia and anemia.

The March 13, 2012 social work note documented the resident's daily routine was "stable," the resident yelled at staff, spit at staff, and was easily agitated. The social worker documented the resident was on Haldol (antipsychotic medication) and the medication use was reviewed by the "team."

The nurse practitioner progress note dated April 19, 2012 documented, "...It was found that at this time she has an order for PRN (as needed) Haldol. In reviewing back, in light of her history, it can cause increased amounts of prolonged QT intervals (a measure of heart rate). In light of her age, Haldol would not be warranted for the patient at this time. It is somewhat contraindicated. She has not been utilizing this...There have been no further reports of agitation at this time that required the use of Haldol. Therefore, we will go ahead and discontinue the Haldol..."

A physician progress note dated April 20, 2012 documented, "...She does have a history of agitation and has been placed on Haldol in the past at 2 mg twice daily, and this does appear to be reasonably effective, although at times she does need alprazolam...Psychotropic Medications: Include Haldol and Xanax which has been effective and will be continued at this time..."

The May 16, 2012 social work note documented the resident was "easily agitated" and had an order for Haldol which was discontinued on April 19, 2012, and a current order for Xanax (antianxiety medication). The social worker documented the use of psychotropic medications was reviewed by the "team."

The resident's Minimum Data Set (MDS) assessment dated May 23, 2012 documented the resident had moderate cognitive impairment and required extensive assistance with all activities of daily living (ADLs) except eating. The resident did not exhibit behavioral symptoms and did not resist care.

The May 23, 2012 registered nurse's (RN) assessment documented the resident did not exhibit behavioral symptoms.

The resident's comprehensive care plan (CCP) reviewed by the interdisciplinary care planning team on June 5, 2012 documented the resident had anger and agitation over lost roles/status. The CCP did not address the use of psychotropic medication or gradual dose reduction.

The June 13, 2012 physician orders documented the resident had an order for Haldol (2 mg) twice a day and Xanax (0.25 mg) every 8 hours as needed.

The resident was observed at breakfast on June 13, 2012 between 9:15 AM and 9:40 AM. The resident sat in the dining room, asleep in her wheelchair, and did not wake up during the meal. The resident did not eat or drink. At 10:30 AM, the resident was observed sitting in the wheelchair near the nursing station and she called out "help" a few times. The registered dietitian (RD) asked her at that time if she needed anything and the resident said she did not. At 10:56 AM, the resident's head was down and she was observed to be asleep in her wheelchair. She was observed in the same manner until 12:17 PM, when the RN Unit Manager woke her up and wheeled her to the dining room. The resident was observed from 12:17 PM to 1:40 PM in the dining room with her head down, asleep. She woke up briefly during the meal and ate 1 bite of ice cream. The resident did not eat or drink any other items.

At 1:45 PM on June 13, 2012, the resident's CNA stated she tried to wake the resident up at breakfast and lunch. She stated she was not successful and when the resident woke up, she could feed herself.

On June 18, 2012, the RN Unit Manager was not available for interview.

On June 18, 2012, a message was left for the attending physician/Medical Director, and an interview did not occur prior to the survey exit.

In summary, the facility:
- did not provide significant rationale for the use of psychotropic medication;
- did not document the use of psychotropic medications in the CCP; and
- did not document an attempt at gradual dose reduction of a psychotropic medication.

2) Resident #34 had diagnoses that included heart failure, and cerebral vascular accident (CVA; stroke).

The Minimum Data Set (MDS) dated April 20, 2012 documented the resident made self understood and was able to understand others. The resident required total dependence to transfer, get dressed, maintain personal hygiene, use the toilet room, and move between locations.

The comprehensive care plan (CCP) reviewed by the interdisciplinary care planning team on May 3, 2012 did not reflect the resident's preferences to maintain her physical, mental, and psychosocial well-being. There was no documentation on the resident's CCP regarding preferences to stay in her hospital gown, or that the resident's decision to stay in her hospital gown had been assessed.

The certified nursing aide (CNA) care sheet dated June 8, 2012 documented the resident transferred with minimum assistance of one person, required verbal cues, needed stand by assistance and could ambulate in her room. The care sheet documented the resident "likes to be in room" and try to "encourage to come out of room."

During an interview with the resident's son and daughter on June 12, 2012 at 1:10 PM they stated the resident was not dressed and they (the staff) do not get her dressed, and the resident will not ask staff to get dressed.

The resident observations included:
-On June 12, 2012 at 1:10 and 3:00 PM she was in her room wearing a hospital gown.
-On June 13, 2012 at 1:20 PM she was in her room in bed wearing a hospital gown.
-On June 14, 2012 at 12:00 and 3:30 PM she was in her room in bed wearing a hospital gown.
-On June 15, 2012 at 9:05 AM she was in her room in bed wearing a hospital gown. During an interview the resident stated she had not left the room.
-On June 18, 2012 at 9:20 AM the resident was in her room getting in to bed wearing a hospital gown.

During an interview with CNA #3 on June 18, 2012 at 10:25 AM she stated the resident had not gotten out of her room since last week, and would only get dressed if she was coming out of the room. She stated the resident would not come out, and that the resident's children tried and she would not leave room.

In summary, the facility;
- did not provide documented evidence in the resident's CCP supporting the resident's preferences related to staying in a hospital gown;
- did not provide documentation that adequate information was provided to the resident in order for her to make an informed decision about not getting dressed and wearing a hospital gown; and
- did not provide a care plan for the resident hat allows her to maintain her highest practical physical, mental and psychosocial well-being.

3) Resident #25 had diagnoses including cerebral vascular accident (CVA; stroke) with expressive aphasia (inability to speak), morbid obesity, Chronic Obstructive Pulmonary Disease (COPD), and depression.
The Minimum Data Set (MDS) documented on May 18, 2012 the resident's status for daily decision making was independent. The MDS documented the resident required extensive assistance with dressing and personal hygiene.

The nurse practitioner (NP) note on June 8, 2012 documented the resident "is nonverbal... but he does interact with facial movement and hand gestures."

Nursing documented on May 5, 2012 in the interdisciplinary progress notes that the resident communicated by speaking, pointing, gesturing, and nodding head yes or no.

The interdisciplinary progress notes from March 9, 2012 through June 14, 2012 were reviewed and one nursing note documented on June 3, 2012 that the resident was lethargic and did not want to get out of bed.

The comprehensive care plan (CCP) reviewed by the interdisciplinary care planning team on May 31, 2012 documented to let the resident's certified nurses aide (CNA) know when his favorite activities would occur, so that he could be out of bed and dressed in time to attend the activity.

Resident observations and interviews included:
-On June 12, 2012 at 12:47 PM, the resident was in his room in his bed.
-On June 13, 2012 at 12:40 PM, the resident was in the dining room at the dining table dressed with a T-shirt and sweat pants in a manual wheel chair.
-On June 14, 2012 at 12:00 and 1:40 PM, the resident was in his room in his bed wearing a hospital gown.
-On June 14, 2012 at 12:39 PM, the resident was asleep in his room in bed.
-On June 14, 2012 at 3:33 PM, the resident was in his bed wearing a hospital gown on. The resident shrugged when the surveyor asked if he was getting out of bed this day. The resident shook his head yes when the surveyor asked the resident if he was getting dressed this day.
-On June 15, 2012 at 9:07 AM, the resident was in his room in bed wearing a hospital gown and the surveyor asked the resident if he was getting up this day; the resident shook his head yes.
-On June 15, 2012 at 2:55 PM, the resident was in his room in his bed wearing a hospital gown. The resident shook his head yes when the surveyor asked the resident if he still wanted to get dressed this day.
-On June 15, 2012 at 4:45 PM, the resident was in his room in bed wearing a hospital gown.
-On June 18, 2012 at 9:25 AM, the resident was in his room in his bed with a hospital gown on. The resident shook his head yes and shrugged when the surveyor asked if he was getting up this day.

On June 18, 2012 at 10:25 AM, during an interview with CNA #3, she stated the resident was previously getting up every day. She stated she asked the resident three times every day before lunch if he wanted to get up. CNA #3 stated the resident was out of bed June 16 and June 17, 2012. There was no documentation supporting whether the resident was out of bed on these dates.

There was no documentation by the facility that adequate information was provided to the resident in order for him to make an informed decision about staying in his room in bed or not.

There was no documentation on the CNA care sheet that documented nursing developed and reviewed the residents preferences to maintain his physical, mental, and psychosocial well-being.

There is no documentation on the resident's CCP that addresses the resident's wishes or preferences related to getting dressed, getting out of bed or out of his room.

In summary, the facility;
- did not provide documentation that the resident's preferences had been assessed to develop a CCP based on the resident's wishes and preferences to meet the resident's medical, mental, and psychosocial needs, including his preference to get dressed and/or out of bed;
- did not provide documentation that the resident has the right to refuse services or treatment and that nursing attempted to monitor the residents' requests; and
- did not implement objectives that support the resident's wishes and decisions that assist in maintaining his highest level of functioning.

10NYCRR 415.11(a)(2)(xiii)(c)(1)(i)

F241 483.15(a): DIGNITY

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on observation, record review, and staff interview conducted during the standard and abbreviated surveys (#NY00114373), it was determined for 4 of 30 sampled residents (Residents #21, 22, 23 and 25), and all residents who ate in the Units 2, 4, 5, and 6 dining rooms, including Residents #34, and 36-49, the facility did not promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect. Specifically, Resident #23 was observed sitting in a chair in front of the elevator for an extended period of time waiting to be transported to an activity and staff in the area did not address the resident's need. Resident #25 had a sign posted in his room directing his personal care and the resident was unnecessarily exposed by facility staff during an observation. Residents who ate in the Units 2, 4, 5, and 6 dining rooms, including Residents #21, 22, 34, and 36-49, were observed waiting in the dining rooms for extended periods of time prior to meals, without being provided with beverages. Staff in the Units 4 and 5 dining room were observed interacting with each other and not with the residents they were assisting. The clock in the Unit 6 (special care dementia unit) dining room was observed with the incorrect time. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #23 had diagnoses including dementia, depression, osteoarthritis and degenerative joint disease.

The Minimum Data Set (MDS) assessment dated September 14, 2011 identified listening to music as somewhat important to the resident.

The Minimum Data Set (MDS) assessment dated February 28, 2012 documented the resident had severe cognitive impairment. The resident was non ambulatory and required extensive assistance with transferring and mobility on the unit, with the use of a wheelchair.

The comprehensive care plan (CCP) conference note dated June 4, 2012 documented the resident had become a passive participant in group activities. The CCP included encouraging the resident to participate in programs.

On June 14, 2012, the resident was observed being wheeled out of the dining room at 2:30 PM to go to the activity program that was taking place off the unit. The resident was placed in front of the elevators and the staff member walked away. At 2:48 PM, the Activity Leader was observed to exit the elevator on the unit (Unit 6) and transported another resident who was seated next to the resident, on to the elevator and stated she was taking the resident to the activity program. No interaction occurred with the resident. At 3:25 PM, after observing several staff member walk past the resident without interacting with her, the surveyor questioned a certified nurse aide (CNA #6) why the resident was sitting in the hallway by the elevators, with no interaction. The CNA stated she thought the resident was going to the activity program she then transported the resident back into the dining room.

Review of the Activity Calendar for June 14, 2012 revealed a facility wide program occurred at 2:30 PM titled "Flag Day Social Hour" (music program).

The Activity Leader was observed on the elevator on June 14, 2012 at 3:26 PM. When questioned why the resident was not transported to the activity program she stated, they ran out of "cheese doodles" and only had popcorn. She stated the resident did not eat popcorn.

On June 15, 2012 at 3:15 PM, the Activity Leader stated in an interview, the resident was not at the program as they started transporting residents at 2:15 PM and the program started at 2:30 PM; by the time someone would have been able to bring her to the program, the program was almost over.

In summary, the facility did not treat the resident in a manner that maintained or enhanced the resident's self-esteem and self-worth, when she was excluded from attending a program and remained in a community area without any interaction with others.

2) DIGNITY AND DINING CONCERNS:
On June 12, 2012 at 12:30 PM, in the Unit 5 dining room, there were multiple unidentified residents sitting at tables. At that time, a food service staff person stated meal service had not started as the unit did not have any plate covers and they were waiting for some to be sent from the kitchen. All residents had cups in front of them that were empty and turned upside down. At 12:45 PM, the staff began delivering meals to the residents eating in their rooms and not in the dining room. The residents in the dining room remained seated at the tables without beverages, with their cups turned over. At 1:00 PM, staff members started serving the residents in the dining room and when the food was delivered, they provided that resident with a beverage.

On June 13, 2012 at 8:40 AM, in the Unit 5 dining room, multiple unidentified residents were observed siting at tables prior to being served their meal. All residents had drinking cups in front of them that were turned upside down. When the staff member delivered the resident's food, they provided a drink in the overturned cup. At 9 AM, residents at 2 tables were served, and the last resident in the dining room was served at 9:31 AM.

On June 12, 2012 at 12:17 PM, the Food Service Director was asked what the current meal times were as meals were observed to be served later than their posted times. The Food Service Director stated the current meal times for all units was 8:30 AM, 12:30 PM, and 5:15 PM.

On June 12, 2012 at 1:10 PM, the family member of Resident #34 reported the resident did not like to go to the dining room. He stated the facility brought the residents into the dining room early and the resident had to wait for up to an hour in the dining room without being served. He stated during that time period, the resident was not offered with a drink while she was waiting for her meal.

On June 13, 2012 at 1:05 PM, multiple residents were observed in the Unit 5 floor dining room. Residents #21, 22, and 36-44 were seated at the same table. All of those residents had empty, overturned glasses in front of them and Resident #40 had a plastic cup with water in it. At 1:25 PM, the last resident in the dining room was served and assisted with the meal, Resident #40. From 1:30 to 1:45 PM, there were 5 certified nurse aides (CNA) and 1 licensed practical nurse (LPN) assisting residents at the table where Residents #21, 22, and 36-44 were sitting. In that time period, the staff members were heard having loud, personal conversations and they did not interact with or converse with the residents they were assisting.

On June 14, 2012 at 12:10 PM, multiple unidentified residents were observed sitting in the Unit 5 floor dining room prior to the meal. In front of each resident was an overturned drinking glass. At that time, an activities staff person was observed passing drinks to some residents in the dining room. She provided drinks in disposable cups. A CNA was also observed sitting at a table with Residents #21, and 36-44. None of those residents had beverages in front of them and the CNA was observed with a large Styrofoam cup that she was drinking herself. The activities staff person stated in an interview at that time, she gave drinks to residents who were able to feed themselves. She stated the CNAs had to give drinks to residents who could not feed themselves.

On June 18, 2012 at 8:50 AM, the RN Unit Manager for Unit 5 was not available for interview. The covering RN was not able to speak to the surveyor's observations earlier in the week.

In summary, the facility did not ensure residents who are in the dining room, including Residents #21, 22, 34, and 36-44, were provided with a dignified dining experience as the facility:
- did not offer the residents with a beverage prior to the meal when they waited an extended period of time for meal service; and
- did not ensure staff interacted with the residents when they assisted with meals.

3) On June 5, 2012 at 8:53 AM, the clock in the special care dementia unit (Unit 6) dining room was set at 4:35. Thirty seven residents were in the dining room at the time, waiting for their breakfast meal. At 10:00 AM, following the breakfast meal, the clock had not been reset and remained behind by approximately 4 1/4 hours.

On June 12, 2012 at 1:30 PM, the clock in the dining room on the special care dementia unit was set at 9:15. At 4:50 PM, the clock in the dining room read 12:30.

On June 15, 2012, the clock in the special care dementia unit dining room was approximately set 30 minutes behind the actual time when observed at 3:10 PM (the clock was at 2:44).

On June 18, 2012 at 8:45 AM, the clock in the dining room on the special care dementia unit was set at 7:45.

In summary, for residents with cognitive impairments who may need cues to assist with orientation, the facility did not provide an environment that maintained or enhanced their self-esteem and self-worth.

10 NYCRR 415.5(a)

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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

Citation date: June 18, 2012

Based on observation, record review, and staff interview 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 2 of 2 residents (Residents #3 and 19), reviewed for PICC (peripherally inserted central catheters) and for 2 of 6 residents observed for pressure ulcer treatments (Residents #9 and 23). Specifically, for Residents #3 and 19, the facility did not ensure staff followed acceptable infection control procedures when administering medications via PICC line. For Residents #9 and 23, there were breaches in infection control during pressure ulcer treatment observations. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF OCTOBER 14, 2011.

Findings include:

The facility policy, "The Nurses' Infusion Manual for LTC (long term care) Facilities - 2008," documents the use of aseptic (sterile) technique is required for all infusion procedures.

1) Resident #19 had diagnoses including osteomyelitis (bone infection) of the left foot and peripheral vascular disease.

The quarterly Minimum Data Set (MDS) assessment, dated April 13, 2012, documented the resident had normal cognition and required assistance for all activities of daily living except eating.

During the initial unit tour at 9:00 AM on June 12, 2012, the float registered nurse (RN) stated the resident would be going to the hospital that day for insertion of a PICC line (peripherally inserted central catheter) due to the need for intravenous (IV) medications to treat osteomyelitis.

A physician's order, dated June 13, 2012, was for intravenous Vancomycin (antibiotic), 1 gram in 200 cc solution every 12 hours via PICC line, to infuse at 133 ml/hr by pump.

A surveyor observed the registered nurse (RN) Unit Manager at 9:30 AM on June 14, 2012, as the RN Unit manager administered the resident's Vancomycin via PICC line. Supplies used for the medication administration were on the resident's dresser, without a barrier. After washing her hands and applying clean (unsterile) gloves, the RN moved the IV pole closer to the resident, pushed his sleeve up, and moved the cloth covering the PICC line insertion site down toward his wrist. She took an alcohol pad from the dresser, opened it, removed the cap of the IV tubing, wiped it with the alcohol pad, and recapped the tubing. She took a second alcohol pad from the dresser, opened it, and wiped the end of the resident's PICC line. She took a syringe from a package, and used it to flush the PICC line. She then attached the IV tubing to the PICC line and began the infusion.

At 1:15 PM on June 14, 2012, a surveyor interviewed the RN Staff Educator regarding observations of the resident's PICC line infusion that day. She stated the RN should have assembled all supplies needed prior to the treatment, and should not have proceeded with the treatment while wearing gloves that had touched the IV pole and other things in the room, including the resident's clothing.

At 9:50 AM on June 18, 2012, a surveyor interviewed the RN Unit Manager about observations of touching multiple objects prior to starting the resident's PICC line infusion on June 14, 2012. The RN stated staff were not required to perform the procedure using sterile technique.

2) Resident #3 was admitted on April 9, 2012 and readmitted on May 24, 2012. Her diagnoses included total left hip replacement in September 2011, and surgical removal of the left hip components due to joint infection on May 17, 2012.

The facility did not complete a Minimum Data Set (MDS) assessment after the resident was readmitted. The MDS, dated April 15, 2012, documented the resident had normal cognition.

The Admission History and Physical, dated May 24, 2012, documented the resident had a left hip replacement in November 2011; had multiple postoperative complications, including methicillin resistant staphylococcus aureus (MRSA) infection of the left hip; and required removal of the hip replacement hardware due to continuing infection. She was admitted to the facility for long-term intravenous (IV) therapy with Vancomycin (antibiotic).

Physician's orders, dated May 24, 2012, included Vancomycin 1250 mg IV every 12 hours via PICC line (peripherally inserted central catheter) for 6 weeks.

A surveyor observed the registered nurse (RN) Unit Manager at 8:52 AM on June 13, 2012, as she administered the resident's Vancomycin via PICC line. Supplies used for the medication administration were in the RN's pocket. Without first washing her hands, the RN applied unsterile gloves, and reached into her pocket for an alcohol pad. She opened the package, remove the alcohol pad, and used it to clean the end of the resident's PICC line. She reached into her pocket, removed a pre-filled syringe from a package in her pocket, and used the syringe to flush the resident's PICC line. She then attached the IV tubing and began the infusion.

During an interview with the RN Unit Manager at 8:55 AM on June 13, 2012 regarding observations during the resident's PICC line infusion, she stated she should have washed her hands before applying the gloves, and sterile gloves were not required for the procedure.

During an interview with the RN Infection Control Nurse at 2:25 PM on June 18, 2012, she described the proper procedure for administering IV infusions via PICC line:
- the nurse is to wash her hands and apply gloves;
- the nurse places a barrier on a table, and all necessary supplies are placed on the barrier;
- the nurse removes gloves, washes her hands, and reapplies gloves;
- the infusion is completed according to facility protocol; and
- supples used for the infusion should not be accessed from a pocket.

In summary, the facility did not ensure staff followed acceptable infection control procedures when administering medications via PICC line to Residents #3 and 19.

3) Resident #9 had diagnoses of pressure ulcers and end stage renal disease that required dialysis.

The February 4, 2012 Minimum Data Set (MDS) assessment documented the resident had
moderately impaired cognition.

The May 10, 2012 physician's orders documented the resident's sacral wound was to be cleansed with normal saline, the area was to be patted dry, Aqua Cel AG (treatment cream) was to be applied to the wound, the wound was to be covered, and this was to be changed every day and as needed.

The Skin Condition Monitor on June 4, 2012, documented:
- the resident's pressure ulcer on the right leg amputation site was a Stage IV (full thickness loss of skin layers) pressure ulcer. The wound bed was documented as "red beefy with slough edges" and the wound measured 2 cm (centimeters) x 3.5 cm x 0.5cm; and
- the pressure ulcer on the resident's sacrum was a Stage IV pressure ulcer, measured 3 cm x 5.4 cm x 3 cm and was described with a "pink center white edges."

The June 12, 2012 physician's order documented the pressure ulcer on the amputation site was to be cleansed with normal saline and patted dry. The treatment was to be Aquacel and the area was to be covered with a 4x4 (sterile pad) and Kerlix (sterile wrap) and changed daily.

On June 14, 2012 at 10:28 AM, the resident was observed for a pressure ulcer treatment done by the licensed practical nurse (LPN) with the registered nurse (RN) Manager present. The wound on the right stump was uncovered when the surveyor entered the room and the wound was resting on a pillow. Sero-sanguineous (thin, watery fluid with blood) drainage was observed coming from the stump wound. At 10:28 AM, the licensed practical nurse (LPN) stated she removed the dressing from the resident's stump wound 5 or 10 minutes before the surveyor came to the room. The LPN then completed the treatment to the stump wound. At 10:34 AM, the LPN opened the resident's brief to do the treatment on the sacral wound. There was not a dressing on the sacral wound; the wound was in direct contact with the brief. The LPN stated at that time, that she also removed the dressing from the sacral wound 5 to 10 minutes before the surveyor came into the room. The LPN cleansed the wound with normal saline by patting the wound from the outside edges to the inside of the wound.

On June 14, 2012 at 10:43 AM, the RN Manager stated the wound on the sacrum was "open."

On June 14, 2012 at 10:50 AM, the LPN stated in an interview that she removed the resident's dressings and did not place them on sterile surfaces. She stated she cleansed the wound by patting the outside, then inside, then outside of the wound bed.

In summary, the facility did not ensure effective infection control practices were utilized during Resident #9's pressure ulcer treatment.

10 NYCRR 415.19 (a)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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


Surveyor: Belknap, Elizabeth M

Surveyor: Olivo, Rose M.
Based on observation, record review, and staff and resident interview conducted during the standard survey, it was determined the facility did not ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 sampled residents reviewed for falls/fractures (Resident #3) and 3 of 5 sampled residents reviewed for behaviors (Residents #6, 10, and 16). Specifically, for Resident #3 who had multiple risk factors for falling, the facility did not ensure care planning interventions and staff assistance to ensure her safety during showers. For Resident #6, who fell asleep while smoking and burned his chair cushion, the facility did not reassess smoking safety timely, and did not implement measures to prevent future accidents. For Resident #10, the facility did not implement appropriate recommended monitoring (30 minute checks) when the resident initially refused to wear a Wanderguard; did not implement the recommended 1 hour checks after the resident had an elopement incident on May 19, 2012, and did not ensure there was a current plan in place to prevent elopement. For Resident #16, who left the facility without authorization and undetected, the facility did not implement measures to prevent the resident from leaving the facility and did not implement a missing resident protocol once they discovered she was missing. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF OCTOBER 14, 2011.

Findings include:

UNSAFE SMOKING:
1) Resident #6 had diagnoses including atrial fibrillation (irregular heart rate) hypertension (high blood pressure), peripheral neuropathy (numbness and pain in the extremities because of nerve damage), and depression.

The significant change Minimum Data Set (MDS) assessment, dated November 22, 2011, documented the resident did not smoke. The MDS dated February 15, 2012, documented the resident's cognition was intact, and he felt tired for several days (2-6 days) during the assessment period.

The nursing progress note, dated April 10, 2012, documented the resident had a change in his mentation; he was having a conversation with someone who was not there; he believed his brother was in the hallway; and he "proceeded to babble incoherently."

Review of the "Resident Smoking Contract", dated April 20, 2012, revealed that sleeping in the smoking room was "not" allowed.

The May 10, 2012 social work progress note documented the resident smoked.

The resident's Comprehensive Care Plan (CCP), dated May 23, 2012, documented the resident was deemed a safe smoker, and could smoke independently.

The June 6, 2012 nursing progress note documented the resident was found asleep in the smoking room. He had a lit cigarette in his hand, dropped it, and burnt a hole in his wheel chair cushion. The progress note documented the licensed practical nurse (LPN) had to shake the resident to wake him up.

Physician's orders, dated June 6, 2012, documented the resident's medications included three antihypertensives, two antidepressants and tow narcotic pain medications (OxyContin and oxycodone).

The June 6, 2012 physician's progress note documented "per staff", the resident "does get a little bit oversedated," and "had an episode tonight when he fell asleep in his wheelchair while smoking."

The facility updated the resident's CCP on June 6, 2012, and documented the resident was found asleep in the smoking room with a lit cigarette in his hand. The resident dropped the cigarette and burned a hole in his wheelchair cushion.

The "Resident Plan of Care" (RPOC, used by direct care givers), dated June 11, 2012, documented the resident smoked. The form did not document whether the resident was a safe smoker and could smoke independently.

During an interview with registered nurse (RN) Unit Manager #5 on June 12, 2012 at 8:50 AM, she stated the resident smoked independently. She stated the resident had burnt the wheel chair cushion the "other day."

The annual "Resident Safe Smoking Assessment" dated June 12, 2012 documented the resident was deemed safe to smoke independently. The assessment did not include the resident's neuropathy, narcotic medication usage, and his history of burning holes in furniture.

The updated "Resident Smoking contract" dated June 12, 2012 also continued to specify that sleeping in the smoking room was "not" allowed.

CNA (certified nurse aide) #9 was interviewed on June 18, 2012 at 8:20 AM, and stated she was not aware the resident had any incidents of burning items.

During a second interview with RN Unit Manager #5 on June 18, 2012 at 9:20 AM, she stated:
- the June 6, 2012 "incident report" when the resident fell asleep while smoking and burned the wheel chair was completed on June 12, 2012;
- when the smoking reassessment was done, she observed the resident's smoking abilities, but it was not documented;
- physical therapy and occupational therapy did not participate in the resident's smoking reassessment; and
- she did not consider the reassessment done on June 12, 2012, to be a timely assessment.

In summary, the facility did not:
- ensure the resident's smoking abilities were reassessed in a timely manner after he fell asleep while smoking;
- ensure the smoking assessment was accurate, as the reassessment did not document the resident's neuropathy, narcotic pain medication usage, and the burning of the wheel chair cushion;
- ensure direct care staff were aware of the resident's incident of burning a hole in his wheel chair.

ACCIDENT PREVENTION CONCERNS:
2) Resident #3 was admitted on April 9, 2012 and readmitted on May 24, 2012. Her diagnoses included total left hip replacement in September 2011; surgical removal of the left hip components due to joint infection on May 17, 2012 and depression.

The Minimum Data Set (MDS), dated April 15, 2012, documented the resident had normal cognition. The facility did not complete an MDS assessment after the resident was readmitted.

The comprehensive care plan (CCP) documented the resident had one interdisciplinary team conference and that occurred on April 17, 2012.

The hospital discharge summary, dated May 24, 2012, documented the resident's activity level was partial weight bearing with a walker.

The nursing Re-admission Assessment, dated May 24, 2012, documented the resident's risk to fall score was 6; a score of 10 or more meant a risk to fall. The assessment incorrectly documented that the resident had no weakness or gait difficulties.

The Occupational Therapy Assessment, dated May 25, 2012, documented the resident required assistance for transferring to a bath tub or shower, and had precautions regarding falls and toe-touch weight bearing of her left leg.

On May 25, 2012, the CCP documented the resident's potential for impaired skin integrity related to limited mobility and "recent orthopedic issues." The CCP did not document the resident's needs for assistance with activities of daily living (ADLs), such as showers and ambulation, and did not document whether the resident was at risk to fall.

During an interview with the resident at 1:15 PM on June 12, 2012, she stated she used the shower unassisted in the bathroom within her room. She stated the shower did not contain a shower chair. She said she entered the shower by backing up to it in her wheelchair or, by using a walker; then stepped into the shower; and completed the shower, while leaning against the wall.

The surveyor observed the resident's shower area at 2:15 PM on June 12, 2012. It did not contain a shower chair.

The Resident Plan of Care (RPOC), dated June 15, 2012, documented the resident was showered on the day shift on Wednesdays and on the evening shift on Saturdays; the resident was to receive verbal cues and assistance of 1 for transfers; the resident did toe touch weight bearing of her left leg; and the resident used a wheelchair for mobility.

During an interview with the resident's assigned caregiver, CNA #4, at 10:40 AM on June 18, 2012, she stated the resident was "self care. She does everything on her own," including showers. The CNA stated that other than bringing the resident's meal trays, staff provided no care.

The registered nurse (RN #4 ) Unit Manager was interviewed at 10:45 AM on June 18, 2012. After reviewing the resident's CCP, RN #4 stated the CCP was not updated since April 2012, and should have included care planning for the resident's risk to fall. RN #4 stated she was unaware staff were not providing the resident with shower assistance. She said the resident was at risk to fall related to the lack of a left hip joint, infection in the hip, and pain.

In summary, the facility did not ensure care planning interventions and staff assistance to ensure the resident's safety during showers, in view of her risk for falls and need for ADL assistance.

PREVENTION OF ELOPEMENT:
3) Resident #10 had diagnoses including mild cognitive impairment and a cerebrovascular accident (CVA, stroke).

The comprehensive care plan (CCP), updated on October 14, 2011, documented the resident had difficulty adjusting to the facility, and had packed his belongings. He stated he was going to be leaving. The resident was noted to have mild cognitive impairment, difficulty in new situations, usually understood others, and had the potential to miss out on some part/intent of what was being told to him.

The March 12, 2012 Minimum Data Set (MDS) assessment documented the resident was cognitively intact.

On April 17, 2012, nursing notes documented the resident reported he was being discharged that week and he was told there was not a plan for discharge. The nurse documented the resident "doesn't seem to understand or accept this." An elopement risk assessment was done. The resident was assessed to be at risk for elopement, and agreed to a Wanderguard.

The April 17, 2012 elopement risk assessment completed by registered nurse (RN) #2, documented 2 different elopement risk scores. It was unclear whether the resident was an elopement risk based on the assessment. The assessment documented the resident "always reports when he is going to leave the unit" and that he signed out whenever he left the floor.

At the time of the survey, RN #2, who completed the April 17, 2012 elopement risk assessment, was no longer employed by the facility and was unavailable for interview.

On April 18, 2012, social work progress notes documented the resident called a taxi from the first floor lobby. The resident was found in the first floor lobby, was returned to the unit, and the registered nurse (RN) Supervisor was asked to issue him a Wanderguard. The note did not document whether the resident's Wanderguard that was applied on April 17, 2012, was in place at the time.

On April 22, 2012, nursing notes documented the resident would not wear the Wanderguard; he called a taxi from the main lobby; and was placed on 30 minute visual checks.

The CCP, updated on April 22, 2012, documented the resident left the unit via the stairs. He called a taxi, took off 3 Wanderguards, and was placed on 30 minute visual monitoring.

Review of the medical record from April 23, 2012 through May 8, 2012 revealed no documentation related to the resident's wandering or the 30 minute visual checks that were to be initiated.

On May 9, 2012, nursing notes documented the resident's Wanderguard was discontinued as he no longer had exit seeking behavior. There was no documented evidence an elopement risk re-assessment was conducted at that time and no documentation the 30 minute visual checks were done.

On May 19, 2012 at 6:56 PM, nursing notes by RN #1 documented a certified nurse aide (CNA) saw the resident walking outside and that the resident was then returned to the unit. The resident refused a Wanderguard; the nurse contacted the Assistant Director of Nursing (ADON) who recommended 1 hour checks.

The May 19, 2012 elopement risk re-assessment completed by RN #1 documented the resident was at high risk for elopement. A Wanderguard and 1 hour checks were to be implemented.

The CCP, updated May 19, 2012, documented the resident went down the elevator, went outside, and walked around the block.

The facility's investigation into the resident's May 19, 2012 incident was initiated by RN #1 and included:
- a Resident/Visitor Event Report, initiated on May 19, 2012 which documented at 6:45 PM, the resident went downstairs on his own, went outside, and walked around the block. After the incident, the resident stated his sister was coming for him. The resident was reminded of the need for supervision, the ADON was notified, and the ADON recommended 1 hour checks. The investigation concluded the event was not an elopement, as staff visualized him on the sidewalk and immediately brought him back to the facility. The report was signed by the RN Manager #3 on June 8, 2012, but was not signed by the Administrator, Director of Nursing (DON), or physician/Medical Director;
- A statement obtained from CNA #1 documented he last saw the resident at 5:15 PM on May 19, 2012. He stated the resident wore a Wanderguard, but did not have a Wanderguard on at the time of the incident. CNA #1 documented he looked out the window and saw the resident walking outside;
- CNA #2 documented in a statement that she looked out the window and saw the resident down the hill, walking around the corner. She stated she ran down the stairs to get him;
- review of the Elopement/Attempted Elopement Investigation, initiated on May 19, 2012 by RN #1, had multiple incomplete sections. The investigation did not document when the resident was last seen, the time he was accounted for, whether the missing resident procedure was implemented (Dr. Find), and when he was returned to the unit. This investigation was not signed by the RN Manager, Administrator, DON, or physician/Medical Director;
- the Resident Plan of Care (filed with the investigation) was dated May 15, 2012 and did not document the resident was at risk for elopement.

On May 21, 2012, social work progress notes documented she spoke with the resident about walking around the building over the weekend. The resident stated he was not trying to leave the facility.

The CCP, updated on May 21, 2012, documented the resident refused a Wanderguard.

On May 22, 2012, nursing notes documented the resident refused a Wanderguard and appeared to have insight into why it was unsafe to leave the building.

The June 1, 2012 nursing progress note by RN #3 documented the resident was assessed and was able to give an explanation as to why he left the facility in the past. The resident stated he would not leave the facility again.

The CCP and the elopement reassessment completed by RN #3, both dated June 7, 2012, each documented the resident was not an elopement risk.

The June 8, 2012 RPOC contained no documentation related to wandering behaviors.

During the initial tour of the unit on June 12, 2012 between 8:55 AM and 9:55 AM, RN #3 told the surveyor that the resident had an incident when he left the unit to go for a walk outside. She stated the resident refused to wear a Wanderguard, and "lately" had been showing insight into his past elopement attempt.

The resident was observed on June 12, 2012 at 2:10 PM, sitting in the lobby on the first floor by himself; at 4:15 PM, the resident was observed sitting on the porch by himself.

On June 13, 2012 at 9:50 AM and 10:30 AM, the resident was observed sitting in the lobby on the first floor with an activities staff person and multiple unidentified residents.

On June 14, 2012 at 2:40 PM, the surveyor observed the unit's resident sign-out sheet. The resident signed out at 1:55 PM and noted he was "outside". The was no documentation that the resident had signed back in yet. At 2:45 PM, the surveyor looked for the resident on the porch; he was not there. The surveyor located the resident in the first floor dining room at an activity.

On June 18, 2012 at 9:25 AM, CNA #3 (assigned to care for the resident) stated the resident was forgetful and that she needed to remind him of things. She stated he usually forgot things right after he was told to him. She did not work on May 19, 2012 when the resident went outside for a walk and did not know about that incident. She said at one time, the resident packed up his belongings as he thought he was leaving. She stated he refused a Wanderguard and had not been on any kind of checks or monitoring. She stated sometimes residents were on 15 minute or 1 hour checks and to her knowledge, the resident never was on these visual checks. CNA #3 said when she could not find the resident, she looked for him on the main level or on the porch and she found him.

On June 18, 2012 at 9:35 AM, RN #3 was interviewed. She stated she recently realized that the resident forgot things right after being told something. She stated he needed to be reminded of the rules on a regular basis and said she planned to add that intervention to his CCP. She stated the resident's May 19, 2012 incident happened right around the time she was hired and she did not believe the resident was placed on any formal checks after that incident. RN #3 stated she was not immediately involved with the incident as it happened on an off shift. She reviewed the incident report and stated she signed it on June 8, 2012.

On June 18, 2012 at 9:50 AM, the ADON who was contacted the evening of May 19, 2012, stated an interview that she remembered being called when the resident went outside. She recommended hourly checks until a more formal plan could be implemented. She was not able to provide any documentation related to the hourly checks.

On June 18, 2012 at 10:45 AM, CNA #1 stated in an interview, on May 19, 2012, he was on the nursing unit, looked out the window, and saw the resident walking down the street. He stated he ran down the stairs to get the resident. He did not know what the resident's plan was after the incident.

On June 18, 2012 at 10:55 AM, CNA #2 stated she was on the nursing unit, looked out the window and saw the resident walking down a steep slope directly towards traffic. She stated ran down the back steps to get to the resident. CNA #2 stated the resident did not have a Wanderguard on as he repeatedly took it off. She stated they tried to do 15 minute checks on the resident and it was difficult when there were 4 CNAs working. She stated it was also difficult to do checks on the resident because if you "take your eye off him, he's gone."

In summary, the facility:
- did not implement recommended monitoring (30 minute checks) when the resident initially refused to wear a Wanderguard;
- did not implement the recommended 1 hour checks after the resident had an elopement incident on May 19, 2012; and
- did not ensure there was a current plan in place to prevent elopement.

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

Surveyor: Sczerbaniewicz, Alis

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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: June 18, 2012

Based on record review, staff interview, and resident interview conducted during the standard survey, it was determined for residents on 6 of 6 nursing units, including 10 anonymous residents at the group meeting, 22 of 30 sampled residents (Residents #2-7, 9, 10, 12, 13, 16, 18-23, 25, 27-30), and 6 residents outside of the sample (Residents #31- 35, and 42), the facility did not provide a quality assessment and assurance program (QA) that readily and effectively identified significant issues affecting residents. Specifically, the QA Committee did not monitor, audit and identify areas of concern that were repeated concerns from prior surveys including issues with resolving residents' grievances, investigating abuse/neglect, completing required assessments, updating, revising, and implementing care plans, providing services that met standards of quality of care, preventing and treating pressure ulcers, preventing accidents, elopement, and unsafe smoking practices, and ensuring proper infection control techniques were implemented. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF October 14, 2011 and the ABBREVIATED SURVEY OF June 1, 2012.

Findings include:

Repeat deficiencies were identified in the standard survey with an exit date of June 18, 2012, including:

RESPONSE TO RESIDENTS' GRIEVANCES:
1) During the Resident Group meeting held on June 13, 2012 at 10:40 AM, 10 anonymous residents reported long wait times when they ring their call bells. Interviews conducted during survey with Residents #2, 3, 30, 33, 34, and 35 also revealed residents had concerns with long wait times for call bell response.

Resident Council meeting minutes from March 21 and April 18, 2012 documented residents had concerns with long wait times for call bells. In the March 21, 2012 minutes the action plan was documented as call bell audits.

The Social Work Director was interviewed on June 14, 2012 at 3:15 PM and stated the facility had done audits on timeliness of the response to resident's call bells in the past with the most recent audits done in 2011.

INVESTIGATION AND PREVENTION OF ABUSE:
2) The facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for Residents #21, 25, 29, and 42 to rule out abuse/neglect and that interventions were implemented to prevent future episodes of abuse/neglect.

The Assistant Director of Nursing (ADON) stated in an interview on June 15, 2012 at 11:30 AM, the prior Director of Nursing (DON) and the facility's other ADON (who were not available for interview) were responsible for ensuring investigations into abuse/neglect were complete and thorough.

MAINTAINING A CLEAN, HOMELIKE ENVIRONMENT:
3) The facility did not ensure the resident environment was maintained in clean, comfortable and homelike condition in 6 of 6 resident units in regards to carpeting, solid surface floors, walls, resident furniture, resident equipment, and odors.
The ADON stated in an interview on June 15, 2012 at 12:10 PM, the facility's QA committee was currently conducting environmental audits.
COMPLETING REQUIRED ASSESSMENTS:
4 ) The facility did not ensure all required assessments were completed as Residents #7, 12, 27, 28, 29, 31 and 32 did not have a quarterly Minimum Data Set (MDS) assessments completed as planned.

The ADON who oversaw MDS completion stated in an interview on June 15, 2012 at 12:10 PM, the facility was aware that all MDS assessments were not completed as scheduled. She stated the facility had trained Nurse Managers to complete MDSs.

IMPLEMENTATION AND REVISION OF COMPREHENSIVE CARE PLANS:
5) The facility did not ensure Residents #13, 22, 25, and 34 had comprehensive care plans (CCP) that were implemented as planned and revised when needed.

QUALITY OF CARE:
6) The facility did not provide care and services that met accepted standards of quality of care for Residents #5 and 20. Resident #5's skin was not monitored and his multiple risk factors for skin breakdown were not addressed. Resident #20 was not provided with pressure relieving devices as planned.

The ADON stated in an interview on June 15, 2012 at 12:10 PM, the facility was auditing and monitoring pressure ulcers and prior to survey the QA committee was not aware of any concerns with their management and prevention of pressure ulcers.

PREVENTION AND TREATMENT OF PRESSURE ULCERS:
7) The facility did not ensure pressure ulcers were properly treated and prevention measures were implemented for Residents #4, 9, 18 and 23.
The ADON stated in an interview on June 15, 2012 at 12:10 PM, the facility was auditing and monitoring pressure ulcers and prior to survey the QA committee was not aware of any concerns with their management and prevention of pressure ulcers.

ACCIDENTS:
8) The facility did not implement measures and monitoring to prevent accidents, falls, elopement, and unsafe smoking events for Residents #3, 6, 10, and 16.

The ADON stated in an interview on June 15, 2012 at 12:10 PM, the facility had been auditing falls, elopement and the QA committee was not aware of concerns with either.

INFECTION CONTROL:
9) The facility did not ensure effective infection control practices were implemented for Residents #3, 9, 19, and 23.

The ADON stated in an interview on June 15, 2012 at 12:10 PM that she provided oversight in infection control and she was not aware of any concerns with infection control practices specific to PICC Lines and dressing changes.

For further detail refer to the following citations: F166, F225, F252, F276, F279, F309, F314, F323, and F441.

In summary, the facility's QA program did not audit, identify, and implement measures when needed in regards to significant care areas and to correct identified quality deficiencies.

10NYCRR 415.27(a-c)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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.

Based on observation, review of the Resident Council minutes and staff, resident and family interviews conducted during the standard and abbreviated (complaint #NY00114373) surveys, it was determined for 10 anonymous residents from the group interview, 3 residents out side of the sample (Residents #33, 34 and 35), and 3 of 30 sampled (Residents #2, 3 and 30), the facility did not ensure residents had the right to prompt efforts by the facility to resolve grievances. Specifically, call bells were not being answered in a timely manner for all the above residents, and there was no documented evidence the facility made attempts to resolve the grievances voiced by the residents. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF October 14, 2011.

Resident Council meeting minutes from March 21, 2012 documented "Call bell issues continue: Multiple resident's state concerns that staff don't respond to the call bells. One resident on unit 2 stated the night shift (11 AM-7 PM) is the worst shift for call bells." Action suggested by nursing liaison to do call bell audits.

Resident Council meeting minutes from April 18, 2012 documented call bells continue to be an issue.

In an interview on June 12, 2012 at 1 PM, Resident #2 stated "they don't answer the bell; they walk by and say they have other patients."

In an interview with the family member of Resident #34 on June 12, 2012 at 1:10 PM, they stated when the resident rang her call bell, it took a long time for anyone to respond.

During an interview with Resident #3 at 1:15 PM on June 12, 2012, she stated that she has stopped using her call bell because staff do not answer it. She stated that she noticed call bells for other residents are sometimes on for up to 2.5 hours.

During an interview with Resident #35 on June 12, 2012 at 3 PM she stated staff did not attend to her needs when she asked. She stated when she rang her call bell it either took staff a long time to respond or they did not respond at all.

Residents at the group meeting held on June 13, 2012 at 10:40 AM stated call bells take an extended period of time to be answered. Residents reported their call bells were some times not answered for hours. An anonymous resident that attended the group meeting stated, I "wait so long for the call bell to be answered, 45 minutes on a bed pan, I have no legs, I need help." Another anonymous resident that attended the group meeting stated, "One time I waited all night." A third anonymous resident that attended the group meeting stated "the call bell rings at the desk, they turn it off" from the desk. A fourth anonymous resident stated the "whole building has to wait a long time, if you are a paraplegic you wait a long time." The same resident stated it happened on all shifts,"but 11 PM - 7 AM is bad" and just "forget it."

Resident #33 stated on June 13, 2012 at 1:30 PM he "will put the call bell on and it takes a half hour to answer."

During a interview with Resident #3 at 12:10 PM on June 14, 2012, she stated that when she previously resided on Unit 1, staff slept on the night shift, and removed the phone from the call bell system to avoid having to answer call bells. She showed the surveyor a picture she had taken with her cell phone. The picture showed a staff person asleep at the nurses station, and the call bell phone was lying on the desk. She stated she did not remember what day the picture was taken.

The Social Work Director was interviewed on June 14, 2012 at 3:15 PM. She stated the facility had done audits on timeliness of the response to resident's call bells. Social Service staff had done audits in the past, staff alternated units on which the audits were done, and audits were most recently done in 2011. The results of the audits would be reported at Quality Assurance meetings, and issues identified with the timeliness of responses would be reported to nursing.

In summary, the facility did not make prompt efforts to resolve resident grievances related to timeliness of call bell responses.

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

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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

Citation date: June 18, 2012

F386 483.40(b): PHYSICIAN RESPONSIBILITIES DURING VISITS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The physician must review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; write, sign, and date progress notes at each visit; and sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Citation date: June 18, 2012

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure the attending physicians reviewed the total program of care related to physician's orders and visits for 1 (Resident #18) of 30 sampled residents. Specifically, Resident #18 had a Foley catheter without a physician's order; and the physician's telephone orders were not signed timely. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #18 was admitted to the facility with diagnoses of severe chronic obstructive pulmonary disease (COPD), stage IV b-cell lymphoma and recent pneumonia.

The hospital's Discharge Summary, dated April 18, 2012, documented the resident was retaining urine after a trial discontinuation of the Foley catheter was attempted; the Foley was replaced.

The Admission Assessment, documented the resident was admitted on April 19, 2012, documented the resident had a indwelling Foley urinary catheter.

The resident's medical record contained undated physician's orders "Admission Orders"that were signed by a physician on April 30, 2012. On those 5 page orders, there was no physician order for the resident to have a Foley catheter.

On June 14, 2012 at noon, the registered nurse (RN) was interviewed. The RN stated she spoke with the physician on April 19, 2012 and received the resident's admission orders. The RN said she took admission orders from the discharge summary from the hospital or the report from the hospital. She stated she also checked the admission assessment. She said if the resident had a Foley catheter, the RN or licensed practical nurse (LPN) would document it on that sheet.

In summary, the facility:
- did not ensure there was a physician's order for a Foley catheter;
- did not ensure the physician's orders were signed timely, as required.

10NYCRR 415.15 (b)(2)(iii)

F226 483.13(c): POLICIES, PROCEDURES PROHIBIT ABUSE, NEGLECT

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Citation date: June 18, 2012

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not operationalize written policies and procedures for resident abuse/neglect reporting and investigation for 5 of 30 sampled resident s (Resident #7, 21, 24, 25, and 29) and, 1 out of sample (Resident # 42) resident. Specifically, Residents #7, 21, 29 and 42 who had incidences of resident to resident abuse, the facility did not complete a thorough investigation of each incident. Resident #24 and 25 incurred injuries of unknown origin and the facility did not conduct an investigation to rule out abuse/neglect. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facilities "Abuse, Neglect, and Mistreatment of Residents" policy, last revised September 2011, documented "... Staff members witnessing or suspecting abuse must notify...RN (registered nurse) unit manager or designee/immediate supervisor will be responsible for notifying the Director of Nursing/designee of the witnessed or suspected incident of abuse. Upon receiving an allegation of abuse, the RN unit manager or designee will insure that the affected resident(s) are safe from future incidents of abuse....RN unit manager or designee will insure that the unit staff has correctly and accurately completed an incident report. RN unit manager or designee...to gather information regarding incident and submit it at the end of the shift to the Director of Nursing....The results of the investigation must be reported to the administrator or his/her designated representative within 5 working days of the incident. If the alleged violation is verified, appropriate corrective action will be taken..."

1) Resident #29 had diagnoses including dementia "with some paranoid features" and depression.

The nursing "Quarterly" assessment form dated March 8, 2012, documented the resident had verbal behavioral symptoms directed towards others (described as threatening, screaming, or cursing at others), was aggressive, angry, and argumentative.

The nursing progress note dated June 11, 2012, documented the resident had a "confrontation" with another resident in the dining room. The event occurred at 5:00 PM, and "became physical" was documented. The resident was "instructed" to sit at a different table during the meal, and there were further "issues" during the shift.

The "Resident/Visitor Event Report" form dated June 11, 2012, documented another resident (Resident #7) held the resident's right wrist because she "was attempting to strike him/pointing her finger" at him. The report documented Resident #29:
- was removed from the area of the incident and placed at another table;
- was agreeable, "although" difficult to redirect; and
- was non-receptive when her "inappropriate behaviors" were discussed with her.

The acting Director of Nursing (DON) was interviewed on June 15, 2012 at 3:40 PM, and she stated she had not reviewed the incident, or CCP, as the RN unit manager "had it upstairs". The acting DON stated direct care staff would know what the resident's behaviors were and how to protect her from victimization verbally, shift to shift report, and the CCP. She stated the CNAs do not have access to the resident's medical record.

The Administrator was not available for an interview.

In summary, the facility did not operationalize written policies and procedures regarding the prevention of abuse/neglect when they did not ensure that the affected resident was safe from future incidents of abuse prior to the completion of the investigation.

2) Resident #42 had diagnoses including dementia, anxiety disorder, atrial fibrillation, hypertension, and peripheral vascular disease.

The Minimum Data Set (MDS) dated April 11, 2012 documented the resident was non-ambulatory, and required extensive assistance with use of the wheelchair.

The Resident/Visitor Event Report dated May 26, 2012 documented Resident #42 had gotten bitten by another resident; the physician was notified; A Registered Nurse (RN) documented an assessment in the resident's chart; the resident was started on an antibiotic, dressing changes to the bite location and to monitor for signs and symptoms of infection. The form was signed as completed by the Nursing Supervisor.

The Nursing Supervisor documented in a Progress note on May 26, 2012, "Resident apparently got bit on the right index finger by another resident while sitting next to each other in the dining room. 3 Teeth marks breaking the skin.

The residents comprehensive care plan (CCP) did not include interventions to monitor Resident #42's index finger for signs or symptoms of infection and did not include interventions to minimize Resident 42's risk of further resident to resident abuse.

In summary, the facility did did not complete a thorough investigation of the incident of resident to resident abuse and did not ensure a plan was in place to prevent further potential abuse to Resident #42.

3)Resident #25 had a diagnoses including cerebro-vascular accident (CVA) with expressive aphasia, hypertension, depression and seizure disorder

The Minimum Data Set (MDS) dated May 18, 2012 documented the resident made independent decisions regarding tasks of daily life.

The resident was observed during wound care by a licensed practical nurse (LPN), assisted by a certified nurse aide (CNA) at 10:26 AM on June 15, 2012. A scabbed area was observed on the resident's right knee.

At 10:27 AM on June 15, 2012 surveyor interviewed the LPN and CNA. They both stated they did not know how the injury to the resident's right knee occurred. The CNA stated, "The resident wheels himself around. He might have bumped into something."

During an interview with the registered nurse (RN) unit manager at 3:15 PM on June 15, 2012, she stated she was not aware that the resident had a scab on his right knee, and staff should have notified her.

The Assistant Director of Nursing (ADON) was interviewed on June 15, 2012 at 11:30 AM and stated there was not an incident for this resident for the injury of unknown origin on his knee. She stated the prior Director of Nursing and the facility's other ADON were responsible for ensuring staff completed incident reports and investigations.

In summary, the facility did not operationalize written policies and procedures regarding the prevention of abuse/neglect when they did not initiate an investigation of an injury of unknown origin.

10NYCRR 415.4 (b)(1)(i)

F322 483.25(g)(2): PROPER CARE & SERVICES FOR RESIDENT W/ NASO-GASTRIC TUBE

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

Based on the comprehensive assessment of a resident, the facility must ensure that a resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.

Based on observations, staff interviews, and record reviews conducted during the standard survey, it was determined the facility did not ensure appropriate treatment and services were provided to 4 of 5 sampled residents (Residents #20, 27, 28 and 30) reviewed with tube feedings to prevent complications related to tube feeding. Specifically, Resident #30's purulent drainage from her gastrostomy tube (G-tube, a feeding tube inserted into the stomach) was not thoroughly evaluated in a timely manner after developing pain with administration of water via her G-tube. For Residents #27 and 28, the facility did not ensure staff verified correct gastrostomy tube placement prior to administering fluids. For Resident #20, the facility did not ensure there was consistent documentation as to what type of feeding tube the resident had as the medical record documented he had both a G-tube and jejunostomy feeding tube (J-tube, a feeding tube inserted into the small intestine). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #30 was admitted to the facility with diagnoses of stroke, respiratory failure and G-tube.

The Minimum Data Set (MDS) dated February 26, 2012 documented the resident usually understood others and sometimes was understood. She had short and long term memory problems and some difficulty making decisions in new situations. She was totally dependant on staff for all activities of daily living, including eating the MDS recorded the resident was on a mechanically altered diet and had a feeding tube.

The nurse practitioner (NP) orders dated March 7, 2012 documented the resident was to receive a regular ground consistency diet with honey thick liquids.

The physician orders dated March 14, 2012 documented a diet change to regular unmodified with thin liquids with a "Proval" cup (a cup that allows only small sips) and nectar thick liquids without the Proval cup.

A physician's progress note dated March 15, 2012 documented the resident had irritation around the G-tube site with some mild yellowish discharge. The resident related she had some mild pain around that site for the last few days. The note recorded the resident was started on an antibiotic and her medications were to be administered by mouth as she had been doing okay with a nectar thick liquid diet. The plan was to continue to monitor the resident closely.

The NP note dated March 17, 2012 documented the resident had increased amounts of abdominal and stomach pain most likely secondary to her G-tube. The NP documented he tried to administer 30 cubic centimeters (cc) of water via the G-tube resulting in causing the resident tremendous discomfort, and stopped immediately. The NP tried to withdraw the fluid and minimal came back. The note recorded the resident had discomfort upon trying to withdraw the fluid. The NP documented the resident had a significant amount of pain at that time. The plan was to obtain a stat (immediate) KUB (abdominal x-ray) to evaluate the placement of the G-tube. The NP recorded no further feedings would be administered through the resident's G-tube until placement was verified.

The KUB report dated March 17, 2012 documented non-obstructive bowel gas pattern. The report did not document placement of the resident's G-tube.

A nursing progress note dated March 17, 2012 at 8 PM, documented "per licensed practical nurse there is no obstruction." The RN documented the resident was evaluated by the NP and had pain when her tube was flushed.

The 24 hour report documented on March 17, 2012 the residents tube feeding was held per order.

The physician order dated March 18, 2012 documented to hold the resident's G-tube feedings.

The 24 hour nursing report documented on March 18, 2012, the resident's tube feeding remained on hold, and to encourage food by mouth.

The 24 hour nursing report documented on March 19, 2012 the resident's tube feeding was held, and check for placement was still ordered. The report documented the resident refused to let the writer check for residual and the supervisor was made aware.

The March 19, 2012 nursing progress note written at 9 PM, documented the tube feeding was held per orders and she notified the Supervisor to see if results were back from the x-ray to check for placement of the resident's G-tube. The note recorded the resident refused to let the nurse check for residual or placement of the G-tube. The plan was to monitor the resident.

The March 17, 2012 x-ray report contained a handwritten note dated March 20, 2012 to have the x-ray "re-read for PEG (G-tube)placement."

The nursing note dated March 20, 2012 at 3:30 PM documented the resident was to be sent to the hospital for displacement of the G-tube.

A computerized tomography (CT scan) of the resident's abdomen and pelvis report dated March 20, 2012 documented a displaced G-tube with the balloon within the anterior abdominal wall. Surrounding inflammatory changes were noted. Superimposed infection could not be excluded.

On June 15, 2012 at 11:15 AM, the NP stated in a telephone interview, he always checked for placement before flushing a G-tube. He said he did not send the resident to the emergency room, as he ordered and x-ray and wanted to see the results first. The NP said when the x-ray report came back as no obstruction, not for G-tube placement it had to be re-read. He said he still did not send the resident to the emergency room as he did not want to "jump to any conclusions" he would get the x-ray results first.

During an interview on June 15, 2012 at 4 PM the NP stated the appropriate thing was done for the resident as one of their goals was to reduce the amount of hospitalizations. The NP said he would not transfer the resident to the emergency room until the x-ray report came back. The NP said he did not communicate with the attending physician regarding each patient and he would expect nursing to follow up when needed.

On June 18, 2012 at 10:20 AM a phone interview was done with the RN working on March 17, 2012. She said she remembered the resident, she was having pain at the tube site and she had the NP see the resident. She said he ordered a KUB and she did not know what the result was. He did order the flushes to be held. When asked what monitoring the resident would mean to her she said she would expect vital signs every shift, a nursing note every shift and the resident would be put on the 24 hour report.

During a phone interview with the attending physician on June 18, 2012 at 10:45 AM, the physician said he would expect to be notified if the resident was not getting better. If she was in a lot of discomfort he would send her to the emergency room for evaluation.

In summary the facility did not ensure the resident was thoroughly evaluated in a timely manner when experiencing abdominal pain and questionable displaced gastrostomy tube.

2) Resident #28 had a G-tube and diagnoses including laryngeal cancer, tracheostomy and esophageal stricture.

The Minimum Data Set (MDS) assessment dated March 8, 2012 documented the resident had moderately impaired cognition and received nutrition/hydration via a feeding tube.

Physician orders dated May 3, 2012 included:
- Give 100/100/100 cubic centimeters (cc) water via PEG tube (feeding tube) with each medication pass.
- Give extra 240 cc water BID (twice a day) via PEG tube
- Jevity 1.2 (a type of tube feeding) 500 cc TID (three times a day) at 300 cc/hour.

On June 14, 2012 at 2:10 PM the surveyor observed licensed practical nurse (LPN) #2 as he administered 240 cc of water, to the resident, via the G-tube. LPN #2 did not aspirate the resident's stomach contents, and did not verify G-tube placement. During an interview following the medication administration, LPN #2 stated it was not necessary to check the feeding tube for placement every time there was a flush (water). The G-tube was checked for placement in the morning and in the afternoon when medications were administered.

On June 14, 2012 at 2:30 PM, the surveyor interviewed the nurse manager and she stated she was not aware staff were not checking G-tube placement prior to administering flushes. She stated that placement of the G-tube should be checked before and after flushes. The nurse manager said to verify G-tube placement, stomach contents were aspirated. She believed there were G-tube competencies that staff completed during orientation

On June 15, 2012 at 9:30 AM the Staff Educator was interviewed. She stated she has been in the position of Staff Educator for 10 months. She stated that orientation for licensed staff included reviewing the tube feeding policies in general. The policy instructed before administering medications, feedings or flushes, the residual should be checked by aspirating stomach contents. She said she did not instruct nurses to inject air thru the tube and listen for air movement; that was not the policy. The Staff Educator said during orientation she may have observed a medication pass via a feeding tube. If she did not cover feeding tubes with the orientee she told them to be sure to go over it with their preceptor. She stated she decides who will be a preceptor by choosing who would be a good role model.

Review of the "Medication Pass Observation," and "LPN Orientation to Procedure Checklist," forms, both of which had a section for feeding tube competency, showed 8 of 15 nurses did not demonstrate competency with tube feedings/medication pass via a tube feeding.

At 11:20 AM on June 15, 2012, the Staff Educator gave the surveyor "Preceptors 2012." Review of the document showed LPN#2 was a preceptor.

On June 15, 2012 at 11:55 AM The acting Director of Nursing (DON) was interviewed. She stated G-tube placement should be verified prior to administering anything via the G-tube. She was not aware of any concerns related to G-tube feedings or G-tube care. She would have to defer to the Staff Educator regarding education/training with tube feedings. The DON said she was not aware of any discrepancies between policies and did not know the Staff Educator was teaching from policies that were not the facilities current policy. She stated the policy "Enteral Tube Feeding" dated March, 2011 was the current policy. It documented G-tubes were checked for residual prior to feedings.

The facility's policy "Enteral (Tube) Feedings - Administration," dated July, 2009, which instructed staff to aspirate a G-tube or a J-tube for residual feedings before administering a feeding.

The facility policy "Enteral Nutrition Teaching Tool (Gastrostomy Tube)," dated November, 2008, instructed staff to always check tube placement prior to initiation of any feeding or administration of a medication. This was done by aspirating to check for gastric contents, using a stethoscope to listen, over the left upper quadrant of the abdomen, for "whoosh" caused by placement of 10 milliliters (ml) - 20 ml of air.

In summary the facility did not ensure appropriate treatment and services to prevent complications related to tube feeding, as staff did not ensure correct G-tube placement before administering fluids and the facility's training/competency of licensed staff on feeding tubes was inconsistent and incomplete.

3) Resident #27 had a G-tube and had diagnoses including dementia and aspiration (inhaling of foreign material into the lungs)pneumonia.

The quarterly Minimum Data Set (MDS) assessment, dated March 15, 2012, documented the resident had severe cognitive impairment and received all of her nutrition/hydration needs via a feeding tube.

The physician orders dated April 19, 2012 included:
- 300 cubic centimeters (cc) of water via G-tube at 2400, 0300, 0600, 1500 and 2100;
- 100/100/100 cc water every medication pass;
- full strength Promote with fiber (a type of tube feeding) at 90 cc an hour for 17 hours; and
- check for residual prior to starting the tube feeding.

The Medication Administration Record (MAR) dated June 2012 documented to check for residual prior to starting the resident's tube feeding at 5 PM. The MAR documented the resident had a G-tube.

At 2 PM on June 13, 2012, a surveyor observed licensed practical nurse (LPN)#2 administer 300 cc of water via the resident's G-tube. The LPN did not aspirate the resident's stomach contents or verify correct G-tube placement.

During an interview following the administration of the water, the LPN #2 stated it was not necessary to check the feeding tube for placement; as the feeding tube was a J-tube.

During an interview at 3:30 PM on April 13, 2012, the Nurse Manager of unit 3 told the surveyor the resident had a G-tube.

During an interview at 2:30 PM on June 14, 2012 the nurse manager of unit 3 stated G-tube placement should be verified prior to administering anything via the G-tube.

During an interview on June 15, 2012 at 1:15 PM with the nurse manager of unit 3, she stated she was in the process of educating staff regarding checking feeding tubes for placement.

During interview of the Staff Educator on June 15, 2012 she stated feeding tube policies were reviewed during orientation. She said G-tube placement was verified by aspirating stomach contents, and J-tubes do not need to be checked for placement. When asked if these differences between G-tubes and J-tubes were included in orientation education she stated, "I think so." The Staff Educator said she was not aware of any resident having a J-tube.

In summary, the facility did not ensure staff verified G-tube placement, before administering fluids to the resident.

10NYCRR 415.12(g)(2)

F276 483.20(c): QUARTERLY REVIEW OF ASSESSMENTS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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: June 18, 2012

Based on record review and staff interview conducted during the standard survey the facility did not ensure 5 of 28 residents (Resident #7, 12, 27, 28 and 29), 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 #7, 12, 27, 28, and 29, did not have a quarterly Minimum Data Set (MDS) assessments completed timely. 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 OCTOBER 14, 2011 SURVEY.

Findings include:

The facility's "Timely Completion of MDS" policy dated November 2011 stated, "The Interdisciplinary Team will complete all MDS assessments based on Federal Regulatory requirements."

1) Resident #12 had diagnoses including chronic airway obstruction, hypertension and diabetes.

At the start of the standard survey on June 12, 2012, the resident's last quarterly MDS was completed March 9, 2012. There was no documented evidence an MDS assessment was completed since March 9, 2012.

2) Resident #28 had diagnoses including laryngeal cancer, tracheostomy, esophageal stricture and Gastrostomy tube (G-tube).

At the start of the standard survey on June 12, 2012, the resident's last quarterly MDS was completed March 8, 2012. There was no documented evidence an MDS assessment was completed since March 8, 2012.

3) Resident #29 had diagnoses including dementia "with some paranoid features" and depression.

At the start of the standard survey on June 12, 2012, the resident's last quarterly MDS was completed March 8, 2012. There was no documented evidence an MDS assessment was completed since March 8, 2012.

During an interview with the Nurse Manager of unit 3 on June 12, 2012, she stated she has not been able to catch up on the MDSs; she has not had enough training; and administration was aware that not all MDS assessments have been completed.

The MDS Coordinator was interviewed on June 14, 2012 at 1:05 PM, and stated the Unit Managers were recently trained to complete MDSs. No competencies of the Unit Managers proficiency in completing MDSs were conducted. She was aware that the Unit Manager on Unit 3 was "adamant" she had not had enough training in completing MDS assessments. She stated support was offered. She was aware that many residents were behind in the MDS assessments and those MDSs have not been submitted.

During an interview with the Assistant Director of Nursing (ADON) who oversaw the MDS Department, on June 15, 2012 between 11:30 - 12:10 PM, she stated she was aware the MDSs were not up to date on Unit 3.

In summary, the facility did not ensure MDS assessments were completed timely for Residents #12, 28 and 29.

10 NYCRR415.11(a)(4)

F333 483.25(m)(2): RESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The facility must ensure that residents are free of any significant medication errors.

Citation date: June 18, 2012

Based on observation, record reviews, and staff interview conducted during the standard survey, it was determined for 6 residents observed during medication administration (Residents #50, 51, 52, 53, 54, and 55), the facility did not ensure residents were free from significant medication errors. Specifically, Residents #50-55 were administered medications more than 1 hour after the scheduled time. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #50 had diagnoses including, diabetes, arthritis, and degenerative joint disease.

The physician's orders, dated April 22, 2012, documented the resident was to receive the following medications:
-Protonix one tablet every morning for gastroesophageal reflux disease (GERD);
-norvasc one tablet every day for hypertension;
-potassium one tablet daily for hypotassemia;
-vitamin B one tablet daily.
The following medications were to be administered more than daily:
-Lyrica, one capsule twice daily for lumbar stenosis; and
-ferrous sulfate one tablet three times a day for anemia.

Review of the resident's medication administration record (MAR) revealed the resident was scheduled to receive all of the above medications at 9 AM.

During a morning medication administration by the licensed practical nurse (LPN) on June 13, 2012 at 10:05 AM the surveyor observed that that resident had not yet received her 9:00 AM medications.

When interviewed at 10:05 AM on June 13, 2012, the LPN Medication nurse stated that 9:00 AM medication pass is a "heavy medication pass" and there were still 6 more residents (including Resident #50) that she still needed to pass 9:00 AM medications to.

In summary, the facility did not ensure the resident was free from significant medication errors as 6 medications were administered more than 1 hour after the scheduled time.

2) Resident #54 had diagnoses including hypertension, diabetes, coronary artery disease, chronic obstructive pulmonary disease, depression, and GERD.

Physician's orders dated May 31, 2012, documented the resident was to receive the following medications daily:
- Protonix one tablet every day.
The following medications were to be administered more than daily:
-Risperdal twice daily (2mg every morning and 3mg every evening);
-ferrous sulfate one tablet twice daily;
-colace one tablet twice daily;
-glucophage 2 tablets twice daily;
-metoprolol one tablet twice daily;
-diabetic tussin 5ml three times daily; and
-nystatin 5ml three times daily.

Review of the resident's medication administration record (MAR) revealed the resident was scheduled to receive all of the above medications at 9 AM.

During morning medication administration by a licensed practical nurse (LPN) on June 13, 2012, at 10:36 AM the resident had not yet received his 9 AM morning medications.

When interviewed at 10:36 AM on June 13, 2012, the LPN Medication nurse stated that the resident had not yet received his 9 AM medications. When interviewed again at 12:06 PM the LPN Medication nurse stated that the resident received his 9 AM medications at 11:45 AM.

In summary, the facility did not ensure the resident was free from significant medication errors as 8 medications were administered more than 2 hours after the scheduled time.

3) Resident #55 had diagnoses including dementia, chronic kidney disease, hypertension, and benign prostatic hyperplasia.

Physician orders, dated May 23, 2012, documented the resident was to receive the following medications daily:
-Proscar one tablet daily; and
-vitamin D one tablet daily;
The following medications were to be administered more than daily:
-Fergon one tablet twice daily;
-lopressor one tablet twice daily; and
-hydralazine one tablet three times daily.

Review of the resident's medication administration record (MAR) revealed the resident was scheduled to receive all of the above medications at 9 AM.

When interviewed at 10:36 AM on June 13, 2012, the LPN Medication nurse stated that the resident had not yet received his 9 AM medications. When interviewed again at 12:06 PM the LPN Medication nurse stated that the resident received his 9 AM medications at 11:45 AM.

In summary, the facility did not ensure the resident was free from significant medication errors as 5 medications were administered more than 2 hours after the scheduled time.


10 NYCRR 415.12(m)(2)

F371 483.35(i): STORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Citation date: June 18, 2012

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure food was stored under sanitary conditions in 2 of 6 unit refrigerators, the unit refrigerators in Units 4 and 6. Specifically, food in the 2 unit refrigerators was not maintained at or below 45 degrees F. as required. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) The door gasket for the Unit 6 refrigerator was observed to be in poor condition on June 12, 2012 between 1:30 PM and 2:30 PM and again at 4:10 PM.

A surveyor observed the Unit 6 refrigerator on June 12, 2012 at 4:10 PM; the air temperature was 52 degrees F. per the facility thermometer inside the refrigerator. Food stored in the refrigerator included fruit juices, applesauce, soda, and 2 chocolate shakes. The surveyor determined food temperatures between 4:10 PM and 4:20 using the surveyor's thermometer and the food service contract company's thermometer.
Food temperatures were determined to be (surveyor thermometer temperature/food service contract company thermometer temperature in degrees F.):
- cranberry juice 50/50;
- orange juice 49/49;
- applesauce 50/50;
- gingerale 46/46;
- cranberry juice 47/47 (from another container);
- thickened apple juice 48/48.

The surveyor telephoned the Food Service Director at 4:20 PM. A Dietary Supervisor arrived later and check the temperature of applesauce and orange juice (with another thermometer) and the food temperatures were above 45 degrees F.

The facility removed the food from the Unit 6 refrigerator after the Dietary Supervisor checked food temperatures at 4:35 PM.

2) A surveyor observed the Unit 4 refrigerator on June 12, 2012 at 4:40 PM; the air temperature was 46 degrees F. per the facility thermometer inside the refrigerator. Food stored in the refrigerator included fruit juices and chocolate milk. The surveyor determined food temperatures at 4:45 PM using the surveyor's thermometer and the food service contract company's thermometer. Food temperatures were determined to be (surveyor thermometer temperature/food service contract company thermometer temperature in degrees F.):
- cranberry juice 50/51;
- chocolate milk 53/53;
- yogurt 52/52.

The surveyor telephoned the Food Service Director to let him know the Unit 4 refrigerator was not operating properly.

Per the daily Temperature Logs for June 1 through June 11 (dated June 1 through June 11, 2012, the air temperature of each unit refrigerator was checked and recorded daily. No temperatures above 45 degrees F. were documented. Very low temperatures (20 to 26 degrees F.) were documented for the refrigerators on Units 3, 4, and 5 on June 8, 2012.

The Food Service Director was interviewed on June 14, 2012 at 2:50 PM. He stated Dietary Supervisor checked each refrigerator temperature once daily, and he was not aware the 2 unit refrigerators were not maintaining food at or below 45 degrees F.

In summary, the facility did not ensure 2 of 6 unit refrigerators maintained food at or below 45 degrees F. as required.

10YCRR 415.14(h), 14-1.40(a)

F310 483.25(a)(1): ADLS DO NOT DECLINE UNLESS UNAVOIDABLE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

Based on the comprehensive assessment of a resident, the facility must ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to bathe, dress, and groom; transfer and ambulate; toilet; eat; and use speech, language, or other functional communication systems.

Citation date: June 18, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 13 residents (Resident #8) reviewed for ADL decline/concerns. the facility did not ensure the ability to perform activities of daily living (ADLs) did not diminish unless unavoidable. Specifically, staff did not ensure Resident #8 was evaluated after a decline in ambulation and transfer status. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #8 had diagnoses including dementia, hypertension, a mood disorder, and he was legally blind.

The admission orders dated February 6, 2012, signed by the nurse practitioner (NP), documented physical therapy was to evaluate the resident.

The nurse practitioner (NP) progress note dated February 7, 2012, documented the resident had degenerative joint disease, and was unable to walk.

The Minimum Data Set (MDS) assessment dated February 12, 2012, documented the resident had moderately impaired cognition, required limited assistance with bed mobility, transferring in and out of bed, and he did not walk. He used a wheelchair, and required extensive assistance for locomotion on and off the unit. The MDS documented the resident did not have functional limitations in his range of motion, and he had not participated in a physical therapy program within the 7 days prior to the assessment period.

Review of the most current MDS showed it had not yet been completed.

The physical therapy weekly note dated March 13, 2012 through March 20, 2012, documented the resident was progressing. He ambulated with moderate assistance of 1, with a wheelchair to follow, and verbal cues.

The physical therapy discharge summary form dated March 27, 2012, documented the resident was discharged from restorative physical therapy. He required the assistance of 1 person for transfers. He walked 16 feet with a wheeled walker, and 1 person moderate assistance, with wheelchair follow. Verbal cues were needed to keep the resident's posture upright. The resident was discharged with the recommendations including transfer with 1 person moderate assistance from wheelchair to bed.

The resident's comprehensive care plan (CCP) dated May 16, 2012, documented the resident required assist of 1 for bathing, grooming, and dressing. The CCP documented the resident required the assistance of 2 persons for transfers, Assistive devices were not documented and ambulation documented "PT" (physical therapy)/OT (occupational therapy)."

The physician progress note dated June 6, 2012, documented the resident had "some" arthritic changes in his knees, hands, and feet, and he had "not had any decline mobility."

The Resident Plan of Care (used to provide care) form dated June 11, 2012, had a column titled "Transfer weight bearing Lifts/Ambulation", and documentation included an the assistance of 1 person.

During an interview with certified nurse aide (CNA) #8 on June 14, 2012 at 1:20 PM, she stated the resident's transfer ability required the assistance of 1 - 2 people, depending upon how much weight he bore.

CNA #10 was interviewed on June 14, 2012 at 1:25 PM, and she identified herself as the resident's primary CNA. She stated the resident transferred with stand-pivot and the assistance of 2 persons, he could bear weight with minimal assistance.

June 14, 2012 at 2:15 PM, CNA #'s 8 and 11 were observed transferring the resident from his wheelchair to his bed. CNA #8 held the resident's left arm, CNA #11 held the resident's right arm, they both held the waist of the resident's pants, stood him, and transferred the resident to bed. They stated they pivoted the resident to bed.

During an interview with CNA #9 on June 18, 2012 at 8:15 AM, she stated she transferred the resident with the assistance of 2 and a gait belt, and this information should be on the resident's plan of care. She stated she did not know if the resident had a decline in his ambulation or transfer status.

Licensed practical nurse (LPN) #5 was interviewed on June 18, 2012 at 8:15 AM, and stated there was no change in the resident, and she did not remember the resident walking.

During an interview with the registered nurse (RN) Unit Manager on June 18, 2012 at 9:20 AM, she stated:
- the resident transferred with maximum assistance of 1 person;
- the resident was to was to ambulate with the assistance of 1 person;
- the PT evaluation dated March 27, 2012, documented the resident transferred with moderate assistance of 1 person;
- she was not aware the resident was transferred with the assistance of 2 persons until the surveyor discussed the observations, and the resident did not walk, "probably" because staff were not walking him; and
- PT evaluations "don't always come my way."

During an interview with the Director of Rehabilitation Services on June 18, 2012 at 12:45 PM, she stated moderate assistance was required for the resident, as he participated "at least" 50% of the time, as he needed assistance with his hand placement because of blindness. She said at the time the resident was discharged from therapy he ambulated 10 feet with a wheeled walker with moderate assistance of 1 person. The Director stated if the resident had a decline in transfer or ambulation status she would expect to receive a referral.

In summary, the facility did not ensure the resident's abilities in activities of daily living did not diminish, and the facility did not refer the resident for an evaluation after the resident had a decline in transfer and ambulation status.

10NYCRR 415.12(a)(1)(i-v)

F319 483.25(f)(1): APPROPRIATE TREATMENT FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

Based on the comprehensive assessment of a resident, the facility must ensure that a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem.

Citation date: June 18, 2012

Based on observation, record review, and staff and resident interview conducted during the standard survey, it was determined for 2 of 27 sampled residents (Residents #9 and 13), the facility did not ensure residents who displayed mental or psychosocial adjustment difficulty received appropriate treatment and services to correct assessed problems. Specifically, for Resident #9 the facility:
- did not ensure the resident's adjustment issues/concerns were addressed following multiple hospitalizations;
- did not ensure the resident was assisted with psychosocial adjustment issues he experienced over the loss of his home and his belongings,
- as staff did not assist the resident in obtaining his personal belongings and personalizing his room, and
- did not ensure the resident's psychosocial needs were met as he worked through the decision to permanently stop dialysis.
Resident #13 transferred from one unit to another and there was:
- no documentation rationale for the transfer:
- no documentation staff assisted the resident with adjusting to the new unit;
- no documented specific discharge plan; and
- no plan to assist the resident with potential adjustment difficulties related to discharge out of state.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #9 had multiple medical diagnoses including end-stage renal disease requiring dialysis, following a failed kidney transplant, depression, a pressure ulcer on the coccyx, and status post right below the knee amputation.

The Social Work Discharge Plan of Care initiated on November 10, 2010, documented the resident was initially admitted to the facility for short-term rehabilitation with a plan to be discharged home. The resident had a supportive family member who was involved in his care. The plan of care was updated in 2010 and was last updated on August 16, 2011. On August 16, 2011, the plan of care documented the resident was transferred to a long-term care unit within the facility and he no longer had a plan to be discharged form the facility.

The February 4, 2012 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition; was understood by others; understood others; exhibited no indicators of altered mood state; exhibited no behavior symptoms; and participated in his own assessment and goal setting. The MDS documented the resident did not have a discharge plan and expected to remain in the facility.

The resident's March 2, 2012 readmission form, completed by the social worker, documented the resident was readmitted following a hospitalization related to a "bone infection." The resident's mood or psychosocial information was left blank and there was no documented evidence the social worker assessed the resident's adjustment to the facility following the hospitalization.

Review of the interdisciplinary progress notes from March 3 through 26, 2012 revealed no documentation related to the resident's adjustment to the facility after the hospitalization and no documentation related to his adjustment to his multiple medical diagnoses.

The March 27, 2012 nursing assessment documented the resident did not exhibit behavioral symptoms. The resident's mood was not assessed at that time.

Review of the medical record from March 28 - May 8, 2012 revealed no documentation related to the resident's mood state, adjustment to placement, adjustment to medical condition or psychological status.

The May 9, 2012 readmission form completed by the social worker documented the resident was readmitted to the facility after a hypoglycemic episode. The social worker documented the resident's mood was "pleasant" and psychosocial status was "stable."

The physician's orders dated May, 2012 documented the resident was to receive Wellbutrin XL (an antidepressant) 300 mg daily.

The comprehensive care plan (CCP), updated by the social worker on May 11, 2012, documented the resident had an "alternation in psychosocial well-being" as he "expresses sadness/anger/empty feelings over lost roles/status related to health changes, functional limitations, verbalizations of feelings, and DNR (do not resuscitate, allow natural death in the event the heart stopped)" status. Goals included adjustment to placement and acceptance of health changes/condition. Approaches included 1:1 emotional support as needed, encouraging activities, involving the resident in decision making, and assisting the resident in developing relationships.

The resident's May 16, 2012 MDS assessment was not completed as scheduled. The resident's cognition, mood, behavior, and goal setting/assessment were not assessed.

The May 31, 2012 nursing progress note documented the resident did not complete his scheduled dialysis treatment that day and was sent to the hospital as his fistula (dialysis access site) was plugged. The resident returned to the facility on the same day.

The June 3, 2012 nursing progress note documented the resident was lethargic and his family member visited and noticed a change in the resident. The note recorded the resident stated he realized he was a little confused.

The resident's room was observed on June 12, 2012 at 12:40 PM and minimal personal items were in the room. The walls of the room had no decorations or personal items except for 1 very small stuffed animal pinned to the wall. The resident's bed did not have personal blankets or a bedspread. the dresser contained only a television and the nightstand contained a radio.

The admission and discharge "Complete History Report" printed on June 13, 2012, documented the resident was admitted to the hospital on 12 occasions from June 2011 to June 13, 2012 .

On June 13, 2012 at 8:40 AM, the resident was observed lying in bed and a certified nurse aide (CAN) was in his room. The CAN asked the resident if he wanted his television turned on and the resident said his television did not work.

On June 13, 2012 at 8:45 AM, the resident was interviewed while he was lying in bed in his room. The resident's room was observed with minimal personal items. The walls contained no pictures or decorations except for 1 very small stuffed animal pinned to the wall. The resident's bed contained the facility's white sheets and did not contain a personal blanket or bedspread. On the dresser was a television and on the nightstand was a radio. The resident stated he was struggling with the decision of whether to stop dialysis. He said his nephrologist spoke to him about this option and he was "thinking about it." He stated he would "rather be dead then here" and he knew he was not going to ever go home again. He stated he was thinking about this on his own and he did not know if the facility had a social worker available. He said before he was admitted, he had a home and lived alone. The resident began tearing up and told the surveyor that he "lost" his home. He stated he had "beautiful stuff" that he made or found over the years. He stated his belongings had no value to anyone else but were important to him. He said when people came to his house they would say "oh my god, how beautiful." He described his home as a "profoundly personal statement on my part." He said a family member was storing all of his belongings and he did not know if anyone told him he could bring his things to the facility. He stated his family member was coming tomorrow to take him out for a few hours and he was happy as he needed "a break from this." He stated he had a television in his room and it was broken. He said he told staff a few times that it did not work.

On June 18, 2012, the registered nurse (RN) Unit Manager was not available for interview.

The comprehensive care plan (undated) documented the resident does not care to participate in any activities because he is often tired after dialysis and/or mental condition and that he prefers to keep to himself. It documented the resident shows no interest in the therapeutic recreation calendar. The approaches included therapeutic recreation was to provide materials for leisure activity and encourage resident to share his feelings.

On June 18, 2012 the social worker was interviewed from 9:15 - 9:45 AM. She stated the resident had been in and out of the hospital several times since his admission to the facility and he was "hard to read" but thought he was accepting of his situation. She said he never told her he ever thought about stopping his dialysis, and said the dialysis center would notify the facility if they ever heard anything. When asked about the resident's room lacking personal items, the social worker stated the family knew they could bring his belongings to the facility as it was part of the information given to them upon the resident's admission. She said with the resident's frequent hospitalizations and readmission's, she did not recall if he ever had any of his personal items at the facility.

In summary the facility:
- did not ensure the resident's adjustment issues/concerns were addressed following multiple hospitalizations;
- did not ensure the resident was assisted with psychosocial adjustment issues he experienced over the loss of his home and his belongings, as staff did not assist the resident in obtaining his personal belongings and personalizing his room; and
- did not ensure the resident's psychosocial needs were met as he worked through the decision to stop dialysis permanently.

2) Resident #13 was admitted to the facility from the hospital in January 2012 with diagnoses including dementia, and depression.

A nursing progress note dated January 30, 2012 documented the resident was transferred from Unit 2 to Unit 5. The resident was confused and a wanderguard was placed on the resident's right ankle. There were no progress notes in the resident record providing a rationale for the resident's transfer and no documented evidence the resident and/or family was informed and/or involved in the decision for the transfer.

Review of the interdisciplinary progress notes from January 30, 2012 through February 27, 2012 documented the resident's behavior as confused, restless, wandering in and out of rooms, and aggressive and combative toward staff. There were no social service progress notes during this time period.

On February 27, 2012 the registered dietitian (RD) documented the resident with "recent transfer to Unit 6". There were no other interdisciplinary progress notes during this time period documenting the resident's transfer from unit 5 to unit 6.

The registered nurse (RN) Unit Manager was interviewed on June 13, 2012 at 2:20 PM and stated there were no progress notes related to the resident's unit transfer as the facility charts by exception and the resident did not have any problems with the transfer. She stated the date of the transfer would be documented on the 24 hour report and she would obtain the information for the surveyor.

Review of the 24 hour reports provided by the registered nurse (RN) Manager on June 13, 2012 revealed the resident's name was added to the Unit 6 report on February 23, 2012, with no notations regarding the resident on February 23 or February 24, 2012. On February 25, 2012, the night shift documented the resident was awake most of the shift. There were no notations related to the resident's adjustment to the unit.

Review of the comprehensive care plan (CCP) revealed the CCP was reviewed by the interdisciplinary team on February 21, 2012 and there was no evidence the resident's adjustment to the facility, or changes in room placement within the facility were addressed. There were no additions to the CCP following the resident's unit/room change on February 23, 2012.

On March 2, 2012, the social worker documented she met with the resident's son and he wanted to know how the resident was doing and if placement was going to be long term. The social worker documented the resident's son resided out of state and was considering moving the resident closer to him.

A Room Change Progress Note dated March 8, 2012 was completed by the social worker and documented the resident "moved rms (rooms) prior" and the resident/family response to the room change was documented as "okay" with change and the resident was "doing well". There was no further documentation related to the rationale for the change in units, and the documentation did not clarify if the response to the room change referred to the resident or the family member.

On March 21, 2012, the social worker documented medical information was faxed to a facility near the resident's son, as requested by the family. There was no documented evidence of social work involvement prior to or following the resident's room transfers, and no documented evidence the social worker discussed a possible move out of state, with the resident.

On April 30, 2012, the social work quarterly note documented the resident wandered on the unit and was easily confused. The discharge plan was reviewed and documented the resident required long term care and the family was working to transfer the resident to a nursing home out of state, near them. The note was signed by the social worker on May 1, 2012.

On May 7, 2012, the social worker documented in the CCP Care Conference notes, they were working on the resident's discharge out of state and documented the resident was on a waiting list.

On June 13, 2012 at 10 AM, when asked by the surveyor where the resident was, the RN Unit Manager stated he was often in his room waiting for his significant other to visit or, if not in his room, he was attempting to contact her by phone.

At 10:05 AM on June 13, 2012, the resident was interviewed in his room . He stated he often had problems with his memory and if he waited about 30 seconds, "it comes back." When talking about placement at the facility he stated "I have to accept what's handed to me." The resident said it was difficult for him, as many times he found them (residents) in his room or in his bed and he got "chewed out" if he attempted to do anything about it. He informed the surveyor he had a "lady friend" locally and family in Pennsylvania. He stated he did not want to stay here "forever" and said he may go to be with his family in Pennsylvania. The resident then became very teary and stated "but they won't take my lady friend." He stated if she could not go "I'm done." The resident stated he did not think his family was going to help find a place for her, and if she did not go he wanted "no part of it." The resident spoke about his previous hobbies, including coin and stamp collections and said at that time (other than his lady friend) he had nothing to enjoy. At the end of the conversation, the resident accompanied the surveyor out to the nurses desk and requested assistance calling his "lady friend" on the phone.

On June 18, 2012, the social worker and RN Unit Manager were interviewed between 9:15 AM and 10 AM. The social worker explained the resident was transferred to the special care dementia unit (Unit 6) because of his wandering behavior. She stated the family was "usually called' the day of the move. The social worker said the resident was transferred on February 24, 2012. She stated there had been changes in the social work department and that may have been why there was no documentation related to the resident's room transfers or adjustment. The social worker said the family was looking for a lateral transfer and she was not aware of a specific plan to discharge the resident. She did not recall if the resident was on a waiting list for a specific facility, and was not aware of the concern related to the resident's significant other. The RN Unit Manager stated she did not know about the plan for the resident to be discharged from the facility.

In summary the facility did not ensure appropriate treatment and services were provided to meet the resident's needs regarding unit transfer, adjustment and discharge planning.

10NYCRR 415.12(f)(1)

F274 483.20(b)(2)(ii): ASSESSMENT AFTER A SIGNIFICANT CHANGE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

A facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a significant change means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)

Citation date: June 18, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not conduct a comprehensive assessment within 14 days after a significant change occurred for 1 of 30 sampled residents (Resident #15) with a significant change in behavioral and physical status. Specifically, for Resident #15, the facility did not complete a comprehensive assessment within 14 days after the resident experienced a significant decline in activities of daily living (ADLs) including a decline in the ambulation, transferring, bed mobility, eating and bathing and a significant change in behaviors.
Findings include:

Resident #15 had diagnoses including Alzheimer's Disease, Dementia, Hypertension and Parkinson's Disease.

The resident's Minimum Data Set (MDS) dated March 6, 2012 documented the resident's cognitive skills for daily decision making as severely impaired. The MDS documented the resident did not have a Wanderguard; had not exhibited rejection of care, and had not exhibited behavioral symptoms. The MDS documented the resident was independent and required no set up or physical help from staff with activities of daily living (ADLs) including; bed mobility, transfers, walking in the room/corridor, locomotion on the unit and dressing. The resident required extensive assistance from 1 person with toilet use, required physical help in part of bathing, needed supervision with personal hygiene, and was independent with eating after set-up. The MDS documented the resident was steady at all times when moving from seated to standing position, walking, turning around, moving on and off toilet, surface to surface transfers and the resident had no impairment with range of motion and used a walker.

The March 25, 2012 nursing progress note documented the resident "was seen pushing a tray table, when licensed practical nurse (LPN) went to get the wheel chair the resident fell."

On March 26, 2012 a nursing progress note documented the "resident attempted to ambulate independently, staff redirect several times, also certified nurses assistant (CNA) reports resident is increasingly aggressive with cane and combative."

On March 27, 2012, a nursing progress note documented the "resident continues to attempt to get out of wheel chair, occupational therapy (OT) ordered for a change in condition and the CNA reports the resident is abusive with cane making care given, difficult."

The physician progress note dated March 29, 2012 documented the resident was seen on routine and also related to a complaint of increased agitation. The note documented the resident had become very combative throughout care. He had aggression towards staff. The progress note documented that the resident has become more aggressive and agitated and the resident "has had decreased stability with standing and walking although he does ambulate with his walker. He does have a difficult time standing and has been much more shaky." The note documented a "decline in bed mobility, transferring, toileting and eating has occurred." The note documented "generalized weakness with episodes of falling:" Additionally, the note documented "the patient will be monitored closely. Apparently this is a significant change for this patient."

On March 31, 2012 at 11:30 AM, nursing documented the resident was "ambulating in hall with his rolling walker. He keeps running in to residents and is aggressive...the resident lost balance and fell backwards."

Nursing progress notes between April 1 and 20, 2012 documented the resident was medicated for increased agitation, was "grabbing and squeezing his daughter hard," was found on the floor on April 9, 2012, fell out of bed on April 11, 2012, needed to be fed on April 12, 2012, fell on April 16, 2012, and utilized a lap buddy on April 17, 2012.

The physician's progress note dated April 20, 2012 documented "the patient continues to be agitated and aggressive toward both nursing and other residents."

The interdisciplinary physical restrictive device/restraint evaluation form dated April 24, 2012 documented the resident had a significant change and was at increased fall risk. A lap buddy was evaluated to maintain the resident's safety related to multiple falls.

Nursing progress notes documented:
-On April 24, 2012, the resident was very agitated and difficult to assess. He was found out of bed on his mat;
-On April 25, 2012, "staff report decreased appetite and change in transfer status;" and
-On April 26, 2012, nursing had "conversation with daughter related to decreased appetite and increase in falls."

On April 26, 2012, the registered dietitian (RD) progress note documented the resident's diet was downgraded to puree with honey thickened liquids.

On April 26, 2012 on the 3-11 PM shift, nursing progress notes documented the resident was agitated and grabbed at his daughter and that the "family was upset about a change in the resident."

On April 27, 2012, the RD documented the "resident presents with a recent significant decline in status."

On April 29, 2012, nursing documented the CNA "noticed the resident was on the floor and off the fall mat ...the resident was kicking and flailing arms with fist formed."

On April 30, 2012 the RD documented a voicemail was left for social work to discuss medical orders for life sustaining treatment (MOLST) and family's desire in terms of artificial nutrition or hydration."

On April 30, 2012, social work documented she met with the resident's daughter to discuss MOLST.

On May 2, 2012, the RD documented "staff report the resident is taking a little longer to eat than he did in the past."

The resident's comprehensive care plan (CCP) dated May 15, 2012 documented the resident utilized a lap buddy and needed total assist with routine transfers. Staff were to observe the resident for changes in gait/balance, observe for changes in and mentation and use a Broda chair when out of bed.

On May 16, 2012 at 7:45 PM nursing documented the resident took off the lap buddy and fell to the floor.

The physician's progress note dated May 22, 2012 documented "over the last several months, he has experienced extreme agitation and aggressiveness towards other patients and towards staff." The note documented "he has had 2 falls" and "he continues to be agitated and aggressive," "the patient remains to be a total assist with all of the above," and "we will get a consult for further advice to control this man's agitation."

On May 24, 2012 the RD documented the resident was at high risk and had a "recent decline in status."

The resident was observed on June 13, 2012 at 12:52 PM seated in a wheelchair in the dining room, with his chin to his chest and his eyes closed. At 1:04 PM, the resident's tray was served and the resident's eyes remained shut. A few minutes later, a staff member sat down next to the resident, woke him up and began feeding the resident. The resident received total assistance.

When the MDS Coordinator was interviewed at 3:35 PM on June 14, 2012, she stated if the resident had a change in status, it would be discussed at morning report and if it was documented in that report, they "would do a significant change".

The RN Manager was interviewed on June 18, 2012 at 10:15 AM regarding the resident's change in condition, and she stated a significant change MDS would be done when it was scheduled by the MDS Coordinator.

The MDS quarterly assessment dated May 29, 2012 documented the resident's cognitive skills for daily decision making as severely impaired. The MDS documented the resident had physical behavioral symptoms directed towards others daily and the resident had not exhibited behavior with rejection of care or wandering. The MDS documented the resident's as requiring total dependence for ADLS including; bed mobility, dressing, eating, toilet use, personal hygiene and bathing with one person total assist. The MDS documented the resident required extensive assistance for locomotion on the unit with one person physical assist. The MDS documented the resident was not steady and only able to stabilize with staff assistance in order to move from seated to standing position, move on and off toilet and surface to surface transfers. The MDS documented the resident used a wheel chair and used a daily trunk restraint.

In summary, the facility did not complete a comprehensive assessment within 14 days after the resident experienced a significant change in behaviors and a significant decline in ADLs.

10 NYCRR 415.11(a)(3)(ii)

F272 483.20(b)(1): COMPREHENSIVE ASSESSMENTS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. A facility must make a comprehensive assessment of a resident's needs, using the resident assessment instrument (RAI) specified by the State. The assessment must include at least the following: Identification and demographic information; Customary routine; Cognitive patterns; Communication; Vision; Mood and behavior patterns; Psychosocial well-being; Physical functioning and structural problems; Continence; Disease diagnosis and health conditions; Dental and nutritional status; Skin conditions; Activity pursuit; Medications; Special treatments and procedures; Discharge potential; Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS); and Documentation of participation in assessment.

Based on record review and staff interview conducted during the standard survey, it was determined for 1 of 30 sampled residents (Resident #9), the facility did not conduct a comprehensive, accurate, reproducible assessment of the resident's functional capacity. Specifically, Resident #9's comprehensive initial assessment was not completed timely. This resulted in no actual harm with potential for more then minimal harm that is not immediate jeopardy. Findings include:

Resident #9 was readmitted to the facility on May 9 2012 from the hospital with diagnoses including end stage renal disease requiring dialysis and a pressure ulcer.

At the start of the standard survey, on June 12, 2012, the resident's Minimum Data Set (MDS) assessments were reviewed. The resident had a quarterly MDS assessment completed on February 4, 2012 and no further assessments were submitted for the resident.

The resident's admissions and discharges history report, printed on June 13, 2012, documented the resident was admitted to the hospital on March 27, 2012 and was readmitted to the facility on May 9, 2012.

Per request, on June 14, 2012 at 11:15 AM, the MDS Coordinator provided the surveyor with the resident's May 16, 2012 assessment. The sections assessing hearing, speech, vision,
cognition, mood, behaviors, functional status, bladder/bowel, active diagnoses, health conditions, skin conditions, medications, special treatments, and participation in assessment and goal setting were not completed. The MDS documented CAA (care area assessments) were completed for the resident for nutrition and therapeutic recreation. At that time, the MDS Coordinator stated in an interview, the MDS was not submitted as nursing had not completed their portions.

The Assistant Director of Nursing (ADON) who oversaw the MDS department stated in an interview on June 14, 2012 at 11:20 AM, the MDS should have been done and she would have someone complete it as soon as possible. She stated she did not know why it was not completed timely.

The MDS Coordinator was interviewed on June 14, 2012 at 1:05 PM, and stated the registered nurse (RN) Managers had been trained to complete MDS assessments. She was aware that some of the RN Managers were not completing their assessments timely and stated some of them did not feel they had adequate training to complete MDS assessments.

The RN Manager was no longer employed by the facility on June 18, 2012.

The covering RN Manager stated in an interview on June 18, 2012 at 8:50 AM, she was aware there were many MDS assessments in the facility that were not completed timely. She stated the RN Managers were trained and were supposed to be completing them for their units. She stated the MDS directed the care planning process and the resident's care and she did not know how that was carried out when an MDS assessment was not completed.

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

10NYCRR 415.11(a)(2)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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

Based on record review and staff interview conducted during the standard survey, it was determined for 2 of 30 sampled residents (Residents #5 and 27) , the facility did not ensure that the care plans were reviewed and revised to reflect the residents current status and care planning needs. Specifically, for Resident #5 the facility did not ensure accurate completion of the MDS and Admission assessments; conduct an interdisciplinary assessment of the resident's needs; develop a comprehensive care plan; and provide direct care staff with appropriate instructions regarding the resident's care needs. For Resident #27's the facility did not conduct an interdisciplinary assessment of the resident's needs or re-evaluate the comprehensive care plan timely.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy
Findings include :

The facility's "Interdisciplinary Care Planning" policy dated February, 2011 stated, "...The residents needs will be assessed with care plan development at the time of admission and throughout the residents stay in the facility. The Interdisciplinary Team is responsible for the development of a resident plan of care that is comprehensive and includes measurable objectives and timetables to meet the resident's physical and psychosocial needs...Upon admission the Interdisciplinary Care Team (ICT) will develop the resident's plan of care. The therapeutic Recreation and Social Services departments will have care plans completed by day 14 of admission. The Nursing Plan of Care will be developed within 24 hours of admission...Care planning meeting will be facilitated by the Registered Nurse (RN). The MDS schedule will be used to designate which resident is to be reviewed at the meeting..."

1) Resident #5 was admitted on May 31, 2012 with diagnoses including history of stroke with right hemiplegia (weakness) and expressive aphasia (difficulty communicating), recent transient ischemic attack (TIA; temporary stroke symptoms), heart disease, hypertension, hyperlipidemia, peripheral vascular disease (PVD), recent methicillin resistant staphylococcus aureus (MRSA) urine infection, suprapubic catheter, urinary incontinence, carotid stenosis (narrowing of artery in the neck), depression, insomnia, history of right leg deep vein thrombosis (DVT; blood clot), and gastroesophageal reflux disease (GERD).

The Admission History and Physical, dated May 31, 2012, documented the resident was alert and oriented; had chronic upper and lower extremity weakness; had urinary incontinence as well as a urinary catheter; told the physician he smoked 1/2 pack of cigarettes/day for many years; and was to continue antibiotic treatment for a MRSA urinary infection until June 14, 2012.

The nursing Admission Assessment, dated May 31, 2012, documented information inconsistent to the History and Physical including: the resident had clear speech; was not oriented; did not smoke; did not have elongated, mycotic (fungal infected) toenails; had no sensory impairment due to PVD; did not require preventive measures to prevent skin breakdown; was ambulatory with assistance of 2 persons; was not at risk to fall; and required limited assistance to transfer or walk. The resident's medications were not included on the assessment, and the resident's right elbow and hand contractures were not documented.

Rehabilitation department records, dated May 31, 2012, documented the resident was alert and oriented; had slurred speech; followed multiple complex commands; was non-ambulatory; had contractures of his right elbow and wrist; and was at risk for falls.

The admission Minimum Data Set (MDS) assessment, dated June 6, 2012, documented information inconsistent to the History and Physical, nursing assessment, and rehabilitation documentation including: the resident had severe cognitive impairment; had clear speech; and was a non-smoker. The MDS documented the resident was able to communicate his daily preferences and activity preferences; he required assistance of 1-2 persons for most activities of daily living; had impaired range of motion of the the upper and lower extremities on one side of his body; had signs of muscle disuse; had an indwelling urinary catheter; had a urinary tract infection in the last 30 days; had moderate pain that caused insomnia and caused him to limit his daily activities; and received medications including antidepressants, hypnotics, anticoagulants, antibiotics, and diuretics.

A physical therapy progress note, dated June 7, 2012, documented the resident remained non-ambulatory and was unable to stand.

The Resident Plan of Care (RPOC), dated June 12, 2012, used by certified nurse aides (CNAs) to provide care, incorrectly documented the resident was capable of full weight bearing, and did not document how staff were to transfer the resident.

The comprehensive care plan (CCP), initiated on May 31, 2012, and reviewed by the surveyor on June 18, 2012, included the resident's problems of alteration in psychosocial well-being related to health changes; "the resident/designated representative does not want to be asked about discharge planning every 90 days;" and included care planning for nutrition and hydration. The CCP contained no information regarding the resident's multiple medical problems and care needs.

At 8:00 AM on June 18, 2012, a surveyor observed the resident as his assigned CNA transferred him from his bed to a wheelchair by use of a slide board.

At 9:00 AM on June 18, 2012, a surveyor observed the resident's feet with his assigned CNA. His feet were dry; his toenails were mycotic and in need of cutting; and there was an area of black eschar (dead tissue) on the tip of his right great toe.

At 9:25 AM, a surveyor interviewed the RN Unit Manager, who stated the resident's Admission Assessment was incorrect and/or incomplete in the following areas:
- the resident's speech was unclear due to aphasia, rather than clear as documented;
- the resident needed extensive assistance with ADLs, rather than limited assistance;
- the skin assessment was incorrect - the resident's sensory perception was limited due to PVD. The RN said she did not know whether the resident was incontinent;
- the resident should have been provided with a wheelchair cushion and Gaymar (pressure relieving) mattress overlay;
- the resident's medications were not listed;
- the fall risk assessment was incorrect;
- a smoking assessment was not completed; and
- the resident's contractures were not documented.
The RN Unit Manager then reviewed the resident's CCP, and stated care planning should have commenced with the Admission Assessment, and should have been completed by the 14 th day following the resident's admission. She stated the interdisciplinary team had not met to discuss care planning for the resident since the day of his admission, and she did not know who was responsible for care planning. She stated care planning should have been initiated for the resident's problems of ADL needs, hemiparesis, cardiac status, history of DVT, hyperlipidemia, aphasia, risk for skin breakdown related to history of stroke, PVD, limited mobility, dry skin, mycotic toenails, MRSA urinary infection, incontinence, suprapubic catheter, pain, upper and lower extremity weakness, smoking, contractures; cognitive status, decreased appetite, constipation, depression, insomnia, psychotropic medications, and code (resuscitation) status.

In summary, for Resident #5, who had multiple medical problems, the facility did not:
- ensure accurate completion of the MDS and Admission assessments;
- conduct an interdisciplinary assessment of the resident's needs;
- develop a comprehensive care plan; and
- provide direct care staff with appropriate instructions regarding the resident's care needs.

2) Resident #27 had diagnoses including diabetes, dementia, anxiety disorder, status post fractured right hip and aspiration pneumonia.

The quarterly Minimum Data Set (MDS) assessment, dated December 22, 2012 documented the resident was severely impaired cognitively, was totally dependent with all activities of daily living (ADLs), was non-ambulatory, was incontinent and required a feeding tube for hydration/nutrition.

Review of the Care Plan Face Sheet documents the last interdisciplinary team meeting was held on January 4, 2012.

The quarterly Minimum Data Set (MDS) assessment, dated March 15, 2012, documented the resident had severe cognitive impairment was totally dependent with all activities of daily living (ADLs), was non-ambulatory, was incontinent and required a feeding tube for hydration/nutrition.

There was no documentation on the Care Plan Face Sheet that an interdisciplinary care planning meeting was scheduled or held following the MDS assessment.

On June 14, 2012 at 2:30 PM the registered nurse (RN) Unit Manager was interviewed. She stated that she was behind in the care planning process. The care plan drives the MDS, and she is behind in those as well.

In summary, for Resident #27, who had multiple medical problems, the facility did not:
conduct an interdisciplinary assessment of the resident's needs or re-evaluate the comprehensive care plan timely.

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

F224 483.13(c): FACILITY PROHIBITS ABUSE, NEGLECT

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Citation date: June 18, 2012

Based on observation, staff interview, and record review conducted during the standard survey, it was determined for 1 of 12 residents (Resident #24), observed seated in a congested area without supervision, the facility did not provide services necessary to avoid physical harm . Specifically, Resident #24, who was at risk for injury when observed in a congested area with other residents, and developed a skin tear, the facility did not assess the resident or identify interventions to prevent occurrences. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #24 was admitted to the facility on May 29, 2012 with diagnoses including Alzheimer's disease.

The admission Skin Assessment Tool dated May 29, 2012 documented the resident had bruises on both arms, with no further skin conditions identified.

The physician progress note date May 31, 2012 documented the resident was clinically stable.

The physician orders dated May 31, 2012 documented the resident's skin treatment was "per policy and protocol". There were no specific treatment orders related to the resident's skin status.

The Minimum Data Set (MDS) assessment dated June 10, 2012 identified the resident with severe cognitive impairment, with no behavior concerns documented. The resident was non ambulatory and required extensive assistance with mobility, and utilized a wheelchair. The MDS documented the resident had no skin problems.

The comprehensive care plan (CCP) reviewed by the interdisciplinary team on June 11, 2012 documented the resident's skin was intact. The resident had a potential for impaired skin integrity. The plan included inspecting the resident's skin every shift for evidence of redness, excoriation, breakdown, and to treat as needed.

On June 13, 2012, at 6:30 PM,12 residents, including Resident #24, were observed seated across from the nurse station following the evening meal: the residents were wheeled out of the dining room by staff and were left in their wheelchairs between the nurse station and the elevator area. The residents were in close proximity to one another and were observed wheeling themselves into one another. No staff were in the area at 6:32 PM when Resident #24 was seen facing the wall, and a dark red spot, approximately 1/2 inch in size, was observed on his left lower pant leg. When the surveyor asked the resident to lift his pant leg, a skin tear was observed with blood dripping down the side of his left lower leg.

On June 14, 2012 at 2:15 PM, review of the resident's medical record and the unit skin book revealed no evidence of any documentation related to a skin tear.

On June 15, 2012, at 4:50 PM, a certified nurse aide (CNA) familiar with Resident #24 stated in an interview, the resident required total assistance with dressing and HS (bedtime) care. The CNA had not cared for the resident on this date and was not aware of any skin concerns with the resident. She stated if she saw a skin tear, she would report it to the "Charge Nurse".

At 4:55 PM on June 15, 2012, a licensed practical nurse LPN #3 on the resident's unit observed the resident's lower left leg at the request of the surveyor. She observed the "injury" and stated she did not work on the resident's side of the unit and was not aware of the area. LPN #4 who was working on Resident #24's side of the unit verified she worked on June 13, 2012 and stated she was not aware of any skin injury. She stated staff were to notify the nurse if they observed any skin concerns. If it had occurred on a previous previous shift, she would have been informed in report. LPN #3 reviewed all possible locations the skin tear would be documented, (for example, the Treatment Record, the CNA Pocket guide, the skin book, and the shift report),and was unable to find any documentation of the skin tear.

At 5:06 PM on June 15, 2012, the registered nurse (RN) Manager was interviewed and stated she was not aware of the skin tear. She stated residents were all removed from the dining room after the meal as housekeeping needed to clean the room. She was aware there was congestion out by the nurses station and said there was no other place to take the residents after the meal.

At 1:30 PM on June 18, 2012, the resident's assigned CNA #6 told a surveyor the resident had no open skin areas.

Review of the interdisciplinary notes at 1:33 PM on June 18, 2012, revealed the most recent note was written by the registered dietitian (RD), and the note did not specify that the resident had open skin areas.

At 1:35 PM on June 18, 2012, a surveyor observed the resident's lower legs with CNA #7. Three scabs were observed on the resident's left lower leg.

At 1:40 PM on June 18, 2012, the RN Unit Manager stated she initiated a Skin Condition Monitoring form on June 15, 2012, after a surveyor told her that blood was observed on the resident's pants. The RN stated she was unaware of the 2 additional open areas on the resident's left lower leg.

At 1:42 PM, the RN Unit Manager measured the 2 new open skin areas on the resident's lower left leg, and stated the lower one measured 0.2 centimeters (cm) x 0.7 cm, and the upper one measured 0.6 cm x 0.4 cm. She stated she did not know how the injuries occurred.

In summary, the facility did not provide the necessary services to avoid physical harm as:
- the resident had injuries not identified by staff, resulting in the lack of interventions to prevent reoccurrence; and
- the resident, as well as other residents on the special care dementia unit were left unattended in congested areas, increasing their risk for being abused by one another.

10NYCRR 415.4(b)

F327 483.25(j): FACILITY PROVIDES SUFFICIENT FLUID INTAKE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.

Citation date: June 18, 2012

Based on record review and staff interview conducted during the standard and abbreviated surveys (complaint #NY00115025), it was determined for 1 of 6 residents reviewed for hydration (Resident #17), the facility did not ensure the resident was provided with sufficient fluid intake to maintain proper hydration. Specifically, the facility did not assess and monitor Resident #17's actual fluid intake; did not ensure the plan of care was revised when the resident consumed insufficient fluids, and did not ensure ordered laboratory work was obtained (help in the evaluation of resident's hydration status). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facility policy titled "Nursing Nutrition Monitoring (intake documentation form, HS (bedtime) Snack, Fluids)" revised April 12, 2011, documented all residents' intake was to be documented on the intake form and documentation of the cc (cubic centimeters) consumed was to be done by the licensed practical nurses (LPN) or certified nurse aides (CNA). Before the end of each shift, the LPN was to review the "NIOR" documentation to ensure all information on the document had been completed. The Unit Manager or designee was to review the completed "NIOR" forms.

Resident #17 had diagnoses including end-stage COPD (chronic obstructive pulmonary disease) and diabetes.

The March 29, 2012 physician's orders documented the resident was to have a BMP (Basic Metabolic Panel (a blood test useful in evaluating the resident's hydration status and kidney function) weekly for 2 weeks, and then monthly. The resident's diet was ordered to be "no concentrated sweets".

The BMP results dated March 29, 2012, included: sodium was 145 mmol/l (milimol per liter) (norm = 136-145 mmol/l); potassium was 4.3 mmol/l (norm = 3.6-5.2 mmol/l); chloride was elevated at 112 mmol/l (norm = 100-108 mmol/l); BUN (blood urea nitrogen) was 15 mg/dl (milligrams per deciliter), (norm = 7-24 mg/dl); and creatinine was 1.0 mg/dl (norm = 0.6-1.0 mg/dl).

The resident's intake form documented:
- incomplete data for March 29, 2012, with a total recorded intake of 840 cc (cubic centimeters) of fluid;
- 1320 cc of fluid consumed on March 30, 2012;
- incomplete data for March 31, 2012, with a total recorded intake of 840 cc; and
- incomplete data for April 1, 2012 with a total recorded intake of 1320 cc.

The registered dietitian's (RD) "Nutritional Evaluation", dated April 2, 2012, documented the resident's fluid requirements were assessed to be 1620-1890 cc, based on the calculation "30-35 cc per kilogram of weight, related to high caloric osmolarity (measure of hydration status)." The RD documented the resident had inadequate beverage intake;was less than recommended, as evidenced by high caloric osmolarity. The RD documented she educated the resident on increasing her intake and her preferences were obtained. The RD did not document the amount of fluid provided to the resident with the meal plan.

The resident's re-admission comprehensive care plan (CCP) dated April 2, 2012 documented the resident was an risk for altered hydration status as her fluid intakes were less than 75% of assessed needs; her intake was less than 1500 cc per day; her diuretic usage; her recent hospitalization; and her increased caloric osmolarity. There was no specific, individualized interventions on the CCP that documented when and how much fluids would be provided to the resident.

The intake form dated April 2-5, 2012 contained incomplete data. The form documented a total intake of 480cc to 1920 cc/day, with no fluid intake recorded on April 3, 2012.

The resident's medical record did not provide documented evidence the BMP blood test was done on April 5, 2012 as ordered.

The resident's intake form dated April 6-9, 2012 was incomplete. This intake form documented the resident consumed a total of 360 cc on April 6, 2012; had 1660cc on April 7, 2012; had 1680 cc on April 8, 2012; and consumed 720 cc on April 9, 2012.

Review of the resident's Minimum Data Set (MDS) assessment, dated April 9, 2012, documented the resident's cognition was moderately impaired, and ate independently after tray set up.

The RD's progress note dated April 10, 2012, documented the resident's "current intake" dated April 4-9, 2012 was reviewed and data was recorded for 13 of 18 meals. The resident consumed 1800-1920 cc of fluid per day and meeting 79% of fluid needs. It was unclear how the RD made the assessment of the resident's actual fluid intake due ot the incomplete intake data for 2 of the resident's intake.

The resident's medical record did not provide documented evidence a BMP was done on April 12, 2012 as ordered.

The intake form contained incomplete documentation of the resident's intake from April 16- 21, 2012, with intakes ranging from 120 cc/day to 2040cc/day. The resident's intake for 9 of 10 days were recorded as less than 1500 cc/day; and intake on 4 of 10 days was recorded as less than 1000 cc/day.

The "Transfer Communication Form" dated April 26, 2012, documented the resident had an acute change in status, and was transferred to the hospital.

The hospital admission note dated, April 26, 2012, documented at the time of admission the resident's temperature was 104.3 F (elevated), creatinine was elevated at 2.3 mg/dl and the BUN level was elevated at 52 mg/dl.

The Clinical Nutrition Manager was interviewed on May 10, 2012 at 9:10 AM and stated:
- she could not "assume" what the unsigned boxes on the intake form meant;
- she did "a lot of meal rounds", and if there were "blanks" on the intake form, she would notify the Nurse Manager, and the interdisciplinary team at the 9:00 AM meeting;
- the intake form was a "small part" of the assessment of the resident's fluid intake; and said
- when the residnet's fluid needs were assessed, she would use the resident's most recent labs, specifically the BUN; and look at the resident's skin and weight.

The RD was interview on May 11, 2012 at 1:12 PM and stated when the resident was admitted on March 28, 2012, she had been recently discharged from the facility and returned. From March 28 through April 2, 2012, she stated she continued with the plan of care prior to the resident's discharge. She said when she assessed the resident's fluid intake, she took an average from the information that was completed on the intake form.

The registered nurse (RN) Manager at the time the resident was in the facility was called and did not return the surveyor's phone call.

The "Fax Cover Letter" form dated May 11, 2012, signed by the Director of Nursing (DON) documented "no further labs past" March 29, 2012, were obtained "despite order".

An acting unit RN Manager was interviewed on May 14, 2012 at 3:00PM and stated the certified nurse aides (CNA) were to fill out the meal consumption records, the charge nurse was to oversee the records, and the CNA was to notify the Unit Manger if there was a problem.

In summary, for Resident #17, the facility:
- did not ensure the resident's actual fluid intake was routinely monitored and assessed;
- did not ensure the plan of care was updated when the RD documented she was not meeting her assessed fluid needs;
- did not ensure ordered labs were obtained.

10NYCRR 415.12(j)

F309 483.25: PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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: June 18, 2012

Based on observation, record review, and staff and resident interview conducted during the standard survey, it was determined for 3 of 30 sampled residents (Residents #5, 8, and 20), the facility did not provide the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive plan of care. Specifically, for Resident #5, the interdisciplinary team did not identify the resident's multiple risk factors for skin breakdown and did not initiate appropriate care planning; staff did not identify and provide interventions for the resident's dry skin and mycotic toenails, and the facility was unaware of an unstageable foot ulcer until brought to their attention during survey. For Resident #20, the facility did not ensure the planned sheepskin booties were applied to the resident and did not ensure the plan of care addressed whether the short or longer sheepskin boot was to be applied to a specific foot. For Resident #8, the facility did not ensure medicated creams were consistently applied, as they did not clarify a physician's order. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF October 14, 2011.

Findings include:

1) Resident #5 was admitted on May 31, 2012 with diagnoses including history of stroke with right hemiplegia (weakness) and expressive aphasia (difficulty communicating), recent transient ischemic attack (TIA; temporary stroke symptoms), heart disease, peripheral vascular disease (PVD), and history of right leg deep vein thrombosis (DVT; blood clot).

The Admission History and Physical, dated May 31, 2012, documented the resident was alert and oriented and had chronic upper and lower extremity weakness.

The nursing Admission Assessment, dated May 31, 2012, documented the resident had no open skin areas; did not have elongated, mycotic (fungal infected) toenails; was at high risk for skin breakdown; and did not require preventive measures to prevent skin breakdown. The assessment incorrectly documented the resident had clear speech; was not oriented; and had no sensory impairment due to PVD.

The comprehensive care plan, initiated on May 31, 2012, did not document the resident was at risk for skin breakdown and had PVD. No interventions for prevention of skin breakdown and monitoring for complications of PVD were identified.

The admission Minimum Data Set (MDS) assessment, dated June 6, 2012, documented the resident was able to identify all of his daily and activity preferences; was non-ambulatory; required extensive assistance for all activities of daily living except eating; was at risk of developing pressure ulcers; had no pressure ulcers; and had no other ulcers, wounds, or skin problems. The MDS incorrectly documented the resident had severe cognitive impairment.

The Resident Plan of Care, dated June 12, 2012, used by certified nurse aides (CNAs) to provide care, contained no instructions regarding pressure relief and skin care.

During an interview with the resident at 9:15 AM on June 13, 2012, he stated his toenails had not been cut in 3 months.

At 9 AM on June 18, 2012, a surveyor observed the resident's feet with his assigned CNA. His feet were dry, with long, mycotic toenails. Black eschar (dead tissue) was observed on the tip of his right great toe.

During an observation of the resident's feet with the registered nurse (RN) Unit Manager at 9:10 AM on June 18, 2012, the resident stated he had the open skin area on his right great toe before he was admitted to the facility. The RN assessed the area as an unstageable ulcer measuring 1.6 centimeters (cm) x 0.8 cm. The RN said that after reviewing the resident's medical record and the Skin Condition Monitoring Forms, neither contained information regarding the open skin area on the resident's right great toe.

In summary, the facility:
- did not identify the resident's multiple risk factors for skin breakdown and did not initiate appropriate care planning;
- did not identify and provide interventions for the resident's dry skin and mycotic toenails; and
- did not identify the resident's unstageable foot ulcer until brought to their attention during survey.

2) Resident #20 had diagnoses including end-stage kidney disease and peripheral vascular disease (PVD).

The May 9, 2012 Minimum Data Set (MDS) assessment documented the resident was cognitively intact.

The April 6, 2012 skin assessment documented the resident had several scabbed areas on his right lower leg, small, open scabbed areas on his left lower leg, and had several black areas on his toes. The resident was assessed at "very high" risk for developing pressure ulcers and had fleece booties for his feet.

The nursing progress notes from April 6 through May 9, 2012 contained no documentation related to the fleece booties.

The May 9, 2012 skin assessment documented the resident had a diagnosis of PVD, "black necrotic toes," and was at "very high" risk for developing pressure ulcers. The assessment documented the resident had fleece booties for his feet.

The comprehensive care plan (CCP) reviewed by the interdisciplinary team on May 22, 2012 documented the resident was at risk for impaired skin integrity related to incontinence, altered mental state, and medical diagnoses. The resident had sustained abrasions to his lower extremities in the past. The approaches did not document the use of fleece booties and documented "see RPOC for specific protection protocol."

The May 29, 2012 nursing progress note documented the resident sustained a skin tear/abrasion to the right shin after bumping his leg on a doorway.

The May 29, 2012 Skin Condition Monitor documented the resident had an injury of an abrasion/skin tear on the right lower shin. The area was 0.5cm (centimeters) x 0.6 cm. The form documented when the area was assessed on June 4, 2012, it was resolved.

The June 6, 2012 nurse practitioner note documented the resident had small, broken scab wounds on the bilateral lower shins.

The June 8, 2012 RPOC documented the resident had sheepskin booties.

The resident was observed on June 13, 2012 at 8:40 AM and 1:51 PM. He had a sheepskin bootie on the left leg and did not have one on the right leg.

On June 14, 2012 at 4 PM, the resident was observed lying in bed. He had on a sheepskin bootie on the right leg that was a long boot that extended from his foot to just below his knee. On the left foot, the resident had a short sheepskin boot that covered his foot and ankle.

On June 18, 2012 the resident was observed at 8:35 AM. He had a sheepskin bootie on the left foot that was long and extended to just below his knee. He did not have a boot on the right foot.

On June 18, 2012, the registered nurse (RN) Manager was not available for interview.

On June 18, 2012 at 8:50 AM, the covering RN stated she did not know what the plan was for the resident's booties and she did not think he currently had skin breakdown.

On June 18, 2012 at 9:10 AM, the resident's CNA stated in an interview, the resident had a long and a short sheepskin bootie and he was to wear both boots when he was in bed. She stated she was not aware whether the different size booties were planned to be worn on specific feet. She stated he had the boots as he hit his legs into things and developed injuries on his legs.

The resident was observed on June 18, 2012 at 9:15 AM and he had a sheepskin boot on his left foot and no boot on the right foot.

In summary the facility:
- did not ensure the sheepskin booties were applied to the resident's feet as planned; and
- did not ensure the CCP addressed which sheepskin boot (short or long) was to be worn on which of the resident's feet.

3) Resident #8 was admitted to the facility on February 6, 2012, and had diagnoses including dementia, hypertension, seizures, mood disorder and diabetic retinopathy.

The Minimum Data Set (MDS) assessment, dated February 12, 2012, documented the resident had moderately impaired cognition, was occasionally incontinent of bowel and bladder, and had "ointments/medications" applied to areas other than his feet.

The February 2012 TAR (treatment administration record) documented the resident received hydrocortisone cream 1% to his face as ordered on February 8, 2012. According to the February 2012 TAR, the hydrocortisone cream was not applied on February 9, 2012 as the "order needed clarification"; and was not applied on February 22, 2012, as it was not available and needed to be re-ordered. There was no other documentation on the TAR as to why the hydrocortisone cream was not applied on 12 other days, as ordered (February 10, 13-17, 20, 21, 23-25, and 28, 2012).

Review of the February 2012 TAR ordered also revealed that on February 8, 2012, Clotrimazole Cream was ordered to be applied to the resident's scrotum. The TAR documented Clotrimazole:
- was not applied on February 9, 2012, as the "order needs clarification";
- was not applied on February 17, 2012, as the resident was out of bed;
- was not applied on February 21, 2012, as the resident refused;
- and was not applied on February 22 and 27, 2012 as it was not available.
There was no other documentation on the February TAR why the resident did not receive the lotrimazole Cream on 9 other days in February as ordered (February 10, 13, 14, 15, 16, 18, 20, 24, 25, and 26, 2012).

The March 2012 TARs dated March 1, 2012 through March 13, 2012, documented the resident was to receive hydrocortisone cream 1% topically twice a day, and Clotrimazole (over the counter) 1% cream topically (to the skin) every 12 hours. The TARs did not specify where to apply the creams. Review of the March 2012 TARs revealed the creams were not consistently applied. Documentation on the back of the TARs describing reasons not applying the creams included:
- on March 8, 2012, "clarification needed as to where to apply creams;"
- on March 9, 2012, "no site for creams not applied"; and
- on March 13, 2012 "No site, treatment still needs site."

The physician's orders, dated March 13, 2012, documented: hydrocortisone cream 1% was to be applied topically to the resident twice a day, and Clotrimazole (over the counter) 1% cream was to be applied topically to the resident every 12 hours. The physician's orders did not specify where to apply the creams.

The March 2012 TARs from March 13, 2012 through March 30, 2012, documented the creams were not consistently applied. Documentation on the back of the TARs describing reasons not applying the creams included:
- on March 14, 2012 "Site of application not given;"
- on March 20, 2012" Clarification needed for lotions;" and
- on March 30, 2012 "Site of application of lotions not specified."

The May 2012 TARs dated May 1, 2012 through May 31, 2012, documented the resident was to receive hydrocortisone cream 1% topically twice a day, and Clotrimazole (over the counter) 1% cream topically every 12 hours. The TARs documented the creams were not consistently applied. Documentation on the back of the TARs describing reasons not applying the creams included:
- on May 1, 2012 "Site not specified;"
- on May 11, 2012 "Still don't know where to apply;"
- on May 12, 2012 "Used for May 11, 2012 note;"
- on May 14, 2012 "Needs clarification, left copy for nurse managers;" and
- on May 18, 2012 "Order needs clarification. Site not specified."

The May 2012 TARs dated June 1, 2012 through June 6, 2012, documented the creams were not consistently applied. Documentation on the back of the TARs describing reasons not applying the creams included:
- June 1, 2012 "No area indicated to apply these creams to."
- June 2, 2012 "No sites specified."
- June 7, 2012 "Cream re-ordered!"

During an interview with the registered nurse (RN) Manager (RN #5) on June 18, 2012 at 9:10 AM, she stated it was "not acceptable" for facility staff not to understand an ordered treatment; she said staff could call the physician for clarification. At 9:37 AM, the RN reviewed the resident's medical record and stated she thought she was told the order for the application of the creams needed to be clarified.

In summary, the facility did not ensure Resident #8 consistently received medicated creams and did not obtain clarification of the physician orders specifying the sites to apply these creams.

10NYCRR 415.12

F463 483.70(f): RESIDENT CALL SYSTEM

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The nurses' station must be equipped to receive resident calls through a communication system from resident rooms; and toilet and bathing facilities.

Citation date: June 18, 2012

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the nurse call system operated properly in 10 of 44 sampled resident rooms (rooms #108, 219, 310, 430, 502, 515, 604, 612, 616, 630, and the resident men's toilet room in the lobby area). Specifically, the cords for the nurse call system in resident toilet rooms were tied or wrapped around the grab bars and would not turn on the nurse call system when the end of the cord was pulled; the bedside nurse call system in some resident rooms was not fully plugged into the call station and not operating; and the bedside nurse call cord was not operating, or the nurse call pull cord was missing. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) On June 12, 2012 between 9:15 AM and 9:50 AM, a surveyor observed resident room 502 with the nurse call cord in the toilet room wrapped 3 times around the grab bar adjacent to the toilet; it did not turn on the nurse call system when the cord was pulled.

Between 1:30 PM and 2:45 PM on June 12, 2012, a surveyor observed the nurse call cords in the toilet rooms of rooms 604, 612, and 630 were wrapped around the grab bar 3 times; they did not turn on the nurse call system when the cord was pulled. The nurse call cord in the room 616 toilet room seemed to be stuck and did not turn on the nurse call system when the cord was pulled.

On June 12, 2012 between 2:45 PM and 3:50 PM, a surveyor observed the nurse call cord, in the toilet room of room 515, was wrapped around the grab bar adjacent to the toilet; it did not turn on the nurse call system when the end of the cord was pulled.

A surveyor observed resident room 219 on June 13, 2012 between 1:35 PM and 2:30 PM, and on June 14, 2012 at 1:10 PM. The nurse call cord in the toilet room was tied around the grab bar adjacent to the toilet, and only turned on the nurse call system on 2 of 4 attempts when the cord was pulled on June 14.

A surveyor observed resident room 108 on June 13, 2012 between 2:40 PM and 3:20 PM. The nurse call cord in the toilet room was tied around the grab bar adjacent to the toilet and did not turn on the nurse call system when the cord was pulled.

2) On June 13, 2012 between 10:10 AM and 10:30 AM, a surveyor observed resident room 430A with the bedside nurse call cord not fully plugged into the call station; this call cord did not turn on the nurse call system when the button was pushed.

On June 13, 2012 between 11:20 AM and 12:20 PM, a surveyor observed the bedside nurse call cord in 310A did not operate properly, as when the button was pushed, the nurse call system did not turn on.

3) On June 13, 2012 between 3 PM and 3:20 PM, a surveyor observed that the nurse call pull cord was missing from the resident men's toilet room, near the lobby/elevators.

The Maintenance Director was interviewed on June 14, 2012 at 11:45 AM. He stated the maintenance staff audited the nurse call system operability normally twice annually.

The Unit 2 Registered Nurse Unit Manager was interviewed on June 14, 2012 at 1:10 PM. She was not aware why the nurse call cord was tied to the grab bar in room 219.

In summary, the facility did not ensure the nurse call system was operating properly throughout the facility.

10NYCRR 415.29(b)

F221 483.13(a): RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS NOT REQUIRED FOR TREATMENT

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.

Citation date: June 18, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 3 sampled residents reviewed for restraints (Resident #22), the facility did not ensure a resident had a right to be free from physical restraints that were not required to treat a resident's medical symptoms. Specifically, Resident #22 had a lap buddy without an order for its use, without documentation of a medical symptom requiring the use of the restraint, without documented evidence the restraint was assessed to be the least restrictive, and without an individualized plan of care as to when the restraint was to be released. This resulted in no actual harm with potential for ore than minimal harm that is not immediate jeopardy.
Findings include:

Resident #22 had diagnoses including previous hip fracture and dementia.

A Restrictive Device/Restraint Risk Education Form dated November 28, 2011 documented the resident had a lap buddy. The medical symptom requiring the use of a lap buddy was not documented.

The comprehensive care plan (CCP) documented on November 28, 2011, the resident had a lap buddy. The reason or medical symptom requiring the use of a lap buddy was not documented. The plan included releasing the restraint "per policy" and re-evaluating the use of the restraint to determine if a lesser restrictive device could be used.

The January 11, 2012 occupational therapy progress note documented the resident had a lap buddy that was "issued by nursing." The note did not address the use of the lap buddy further.

The February 29, 2012 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, did not exhibit behavioral symptoms, required extensive assistance for all activities of daily living (ADL) except eating, had 1 fall with no injury since the last assessment, and did not have a restraint.

The March 13, 2012 nursing assessment completed by the registered nurse (RN ) Manager documented the resident was at risk for falls. The section of the assessment addressing restraint use was not completed. The RN did not assess the resident as having a restraint.

The CCP was signed as reviewed and the restraint was documented as "ongoing" on March 13, 2012.

The May 23, 2012 RN's assessment documented the resident had a lap buddy that was a restraint. The RN did not document the reason for the use of the lap buddy and/or safety concerns with the use of the restraint.

The May 23, 2012 MDS assessment documented the resident had moderately impaired cognition, dd not exhibit behavioral symptoms, required extensive assistance for all ADLs except eating, had 1 fall with no injury since the last assessment, and did not have a restraint.

The CCP was reviewed on June 5, 2012, and the restraint was documented as "ongoing."

The June 8, 2012 Resident Plan of Care (RPOC, used when providing care) documented the resident had a lap buddy. A plan for the release of the restraint was not documented.

On June 12, 2012 the RN Manager stated in an interview, there were no residents on the unit who had a restraint.

The June 13, 2012 physician's orders did not document the resident had an order for a restraint.

The resident was observed sitting in a wheelchair near the nurse';s station with a lap buddy on the wheelchair on June 13, 2012 from 10:30 AM until 12:17 PM and on June 14, 2012 at 7:45 AM and from 12:56 PM to 1:25 PM.

On June 14, 2012 at 1:40 PM, the resident's certified nurse aide (CNA) stated in an interview, when she arrived at the facility at 7:00 AM, the resident was out of bed, in the wheelchair and had the lap buddy on. She stated the lap buddy was released after breakfast for toileting and the resident was toileted again at 2:30 PM if needed. She stated she thought the resident went back to bed after supper and the lap buddy was not used at that time.

On June 18, 2012 the RN Manager was not available for interview.

On June 18, 2012 at 8:50 AM, the covering RN stated the resident had a lap buddy as she had severe dementia and had tried to get up unassisted in the past. She stated the prior RN Manager would have assessed the resident's restraint and ensured it was the least restrictive device. She stated the whole team would have signed off on the CCP as reviewing the plan for the restraint. She stated she thought the resident's restraint was to be released every 2 hours and she did not know what the resident's specific plan was for using the restraint during meals.

The facility's policy Release of Restraints dated April 12, 2011 documented all residents' restraints were to be released at 8 AM, 10 AM, 12 PM, 2 PM 4 PM, 5 PM, and 7 PM. If the restraint was used after 7 PM, resident's were to be released every 2 hours. The RN was to update the RPOC to document the release schedule.

The policy Restraints and Restrictive devices dated April 12, 2011, documented restraints would be used to treat medical symptoms and restraints would be assessed and the least restrictive restraint would be determined and utilized.

In summary, for Resident #22, the facility:
- did not ensure the resident had an order for the use of a lap buddy;
- did not ensure the lap buddy was used to treat a medical symptom;
- did not ensure the restraint was assessed to be the least restrictive; and,
- did not ensure an individualized plan of care was developed and implemented in regards to the use and release of the restraint.

10 NYCRR 415.4 (a)(2)(iv),(3)(i-iii)

F176 483.10(n): SELF-ADMINISTRATION OF DRUGS IF DEEMED SAFE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

An individual resident may self-administer drugs if the interdisciplinary team, as defined by 483.20(d)(2)(ii), has determined that this practice is safe.

Citation date: June 18, 2012

Based on observation, record review, and staff and resident interview conducted during the standard survey, it was determined for 2 of 18 sampled residents (Resident #3 and 13), the interdisciplinary team did not assess residents to determine if they could safely self-administer medications. Specifically, the facility did not ensure Resident #3 safely self administered a medication, as the interdisciplinary team did not assess the resident for the ability to administer a topical cream; the physician did not provide an order for medication self administration; the treatment administration record (TAR) documented the resident missed multiple doses of the medication; and staff allowed the resident to self administer medication without ensuring the medication was applied properly, and did not document the results of the treatment. For Resident #13, who resided on the special care dementia unit and had periods of confusion and wandering, the resident self administered a prescription cream
without a determination that it was safe for the resident to self-administer drugs; without a plan for the storage of the medication,when other residents with dementia wandered into the resident's room; without evidence the use of the medication was being monitored, or addressed by the interdisciplinary team in the comprehensive care plan; and without a physician's order for the appropriateness of a self administration program for the resident.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #3 was admitted on April 9, 2012 and readmitted on May 24, 2012, and had diagnoses including left hip infection, fibromyalgia, and depression.

The facility did not complete a Minimum Data Set (MDS) assessment after the resident was readmitted. The MDS, dated April 15, 2012, documented the resident had normal cognition.

The comprehensive care plan (CCP) documented the resident's potential for impaired skin integrity was last updated on May 25, 2012, and did not specify the resident had a rash.

A physician's progress note, dated May 31, 2012, documented the resident noticed an itchy rash on her lower back and buttock area for "the last few days." The physician's examination documented a rash with mild peeling in the areas described by the resident. The plan was to apply a medicated cream to the resident's skin, and "encouraged watching this area and continue to monitor this closely."

On May 31, 2012, the physician ordered Lotrisone (anti-infective, anti-inflammatory) cream to be applied to the affected area of dermatitis (skin inflammation) BID (twice daily) until resolved. Review of the physician's orders between May 24 and June 11, 2012, revealed no order for the resident to self-administer her medications.

The June 1-12 2012 treatment administration record (TAR) documented the Lotrisone cream was not applied to the resident 5 times on the day shift, 5 times on the evening shift, and was unavailable (not received from the pharmacy) on 3 occasions.

During an interview with the resident at 1:15 PM on June 12, 2012, she stated she had to keep her prescription skin cream in her bathroom, or staff would not apply it. She stated the nurses were supposed to apply it, and sometimes they asked her if she had applied it, or if she wanted the nurse to apply it. She stated she had a "hard time reaching" to her mid back area. She stated, "Only 2 nurses ask if I put the cream on. The rest don't know if I put it on or not."

At 1:45 PM on June 12, 2012, a surveyor observed 2 tubes of Lotrisone cream in the resident's bathroom. One of the tubes was empty.

At 2:25 PM on June 12, 2012, a surveyor interviewed the medication licensed practical nurse (LPN) in the presence of the resident. The LPN stated Lotrisone cream is applied to the resident's back, buttocks, and the back of her legs twice daily. She stated the resident applied the cream to areas below her waist, and the nurses applied the cream to her back. The resident's skin was observed during the interview, and she had red, scaly, peeling skin up to her mid back, and down to her right hip.

Review of nurses' notes between May 31 and June 18, 2012, revealed no documentation regarding the resident's dermatitis.

During an interview with the registered nurse (RN) Unit Manager at 9:50 AM on June 18, 2012, she stated she was unaware that the resident was applying prescription cream to her back.

In summary, the facility did not ensure Resident #3 self administered medications safely and appropriately as:
- the interdisciplinary team did not assess the resident for the ability to administer a topical cream;
- the physician did not provide an order for medication self administration;
- the TAR documented the resident missed multiple doses of the medication; and
- staff allowed the resident to self administer medication without ensuring the medication was applied properly, and did not document the results of the treatment.

2) Resident #13 had diagnoses including dementia, depression and osteoporosis.

The Minimum Data Set (MDS) assessment dated April 24, 2012 documented the resident had severe cognitive impairment and required limited assistance with transferring and ambulation, and wandered daily.

The comprehensive care plan (CCP) reviewed by the interdisciplinary team on May 7, 2012 documented the resident wandered on the unit and required continuous redirection and exhibited alteration in mood state related to increased confusion. The resident's vision was described as poor, and he exhibited increased weakness and confusion related to dementia and required assistance and supervision with activities of daily living. The CCP did not document the resident was assessed and/or able to self-administer medications.

A physician's progress note dated June 5, 2012 documented the resident was evaluated for a rash on his scrotal area that had become irritated and the resident stated was painful at times. The physician documented the resident had redness and added "it could be an early fungal infection from moisture versus just contact from chronic urine in the area". As a result, the physician ordered A&D ointment and Lotrisone cream to be applied daily. The resident was to be monitored, with adjustments made based on the response to this therapy. The documentation did not address the resident self administering the treatment.

Review of a physician order dated June 5, 2012 documented the resident was to have A and D ointment to scrotal irritation every shift; and Lotrisone cream to apply sparingly to a scrotal rash at bedtime (hs) for 5 days.

The Treatment Administration Record (TAR) for June 2012 documented the use of the ointment and the cream, initiated on June 5, 2012. The Lotrisone cream was documented for June 5 through 8 (4 days) and instructions on the back of the TAR documented the Lotrisone was applied by the resident himself. There was no further explanation regarding the self administration of the cream.

On June 12, 2012 at 9:30 AM, the resident approached the nurse's station desk and handed the Unit Clerk a tube of cream stating, "it was only for 5 days." The Unit Clerk was observed reading the information on the tube, placed the tube on the desk and thanked the resident.

When the medical record was reviewed on June 12, 2012, there were no nursing progress notes written since March 17, 2012 and no notes addressing the resident administering his own cream.

On June 13, 2012, the resident was interviewed at 10:05 AM. The resident stated he knew he had a problem with his memory and said, sometimes when talking, he forgot what he was talking about. The resident stated "I lose my memory in the middle and 30 seconds it comes back." The resident was pacing in his room during the interview and was concerned about other residents frequently entering his room uninvited and getting into his bed. He stated staff became upset with him when he tried to remove the uninvited residents from his room. When asked about the rash, the resident showed the surveyor an over-the counter cream (protective ointment) he had on top of his nightstand and stated he had another one that was a doctor's prescription. He stated the rash was improved and said no one had looked at it to see if it was okay.

At 10:42 AM on June 13, 2012, the licensed practical nurse (LPN) was interviewed and stated she watched the resident use the Lotrisone, stating "he can forget." The LPN stated the TAR said the resident could apply it himself and the LPN did not know who wrote it on the TAR.

At 10:45 AM on June 13, 2012, the Unit Clerk was interviewed and stated she left the cream on the desk for the nurses and did not know who took it off the desk.

The registered nurse (RN) Unit Manager was interviewed at 2:00 PM on June 13, 2012 and stated the resident initially informed her he had the rash. The RN and the LPN observed the resident at the time and the RN said they "did not see" any redness or rash. The RN requested the attending physician examine the resident and on June 5, 2012, the resident was seen and the cream and lotion were ordered as a result of his visit. The RN stated she did not document as she did not see a problem when she assessed the resident's skin.

At 2:20 PM on June 13, 2012, the RN Manager stated the facility charted by exception and as she did not observe any redness, she did not document any concern and did not need to follow up and monitor the effect of the treatment. She stated her documentation was in the communication book to the physician when she was initially informed by the resident of the area. She stated she did not know the cream was left in the resident's room. If the resident was self-administering the cream, the RN stated there should have been a physician's order to do so and there was no order.

In summary, for this resident who resided on the special care dementia unit and had periods of confusion and wandering, the resident self administered a prescription cream:
- without a determination that it was safe for the resident to self-administer drugs;
- without a plan for the storage of the medication,when other residents with dementia wandered into the resident's room;
- without evidence the use of the medication was being monitored, or addressed by the interdisciplinary team in the comprehensive care plan; and
- without a physician's order for the appropriateness of a self administration program for the resident.

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

F242 483.15(b): SELF-DETERMINATION - RESIDENT MAKES CHOICES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

The resident has the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; interact with members of the community both inside and outside the facility; and make choices about aspects of his or her life in the facility that are significant to the resident.

Citation date: June 18, 2012

Based on observation, record review and interviews with residents and staff conducted during the standard survey, it was determined the facility did not ensure 1 of 30 sampled residents (Resident #26) was given items of choice. Specifically, staff were not observed to assist Resident #26 with getting out of bed or out of his room; and the facility did not provide Resident #26 with specific food items he requested without sufficient rationale. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #26 had diagnoses including paraplegia, multiple sclerosis, dysphagia and depressive disorder.

The Minimum Data Set (MDS) dated April 20, 2012 documented the resident's cognitive skills for daily decision making as moderately impaired. The MDS documented the resident's short term and long term memory were ok and he was able to recall current season, location of own room and that he was in a nursing home.

The physician progress note dated April 17, 2012 documented "the patient is nonverbal, although he is able to respond with nodding" and he "appears to be being fed through his PEG tube for his calories...dietary is monitoring him."

The comprehensive care plan (CCP) reviewed by the interdisciplinary care team on May 3, 2012 , documented the resident was at "nutritional risk due to relies on feeding tube to meet nutritional needs."The CCP documented "staff to ask resident if he would like to eat at each meal, and if he chooses to, staff to provide him a tray," and the CCP described the resident's diet as; "regular, pureed for recreational feeding." The CCP also documented staff are to ask the resident if he wanted food/fluids during/between meals and to provide items per resident's request based on his diet order. The CCP documented the "resident is at risk for altered hydration due to: Relies on feeding tube as primary source of hydration...update preferences of fluid PRN (as needed) and redistribute fluids based on resident's intake/wishes." The CCP documented the resident requires total assist with feeding and activities of daily living (ADLs). The CCP documented, "Fred has alteration in ADL function due to progressive spasticity paraplegia with decreased mobility" and "Involve resident in decision making process." The CCP documented staff should "encourage the resident to get out of bed for socialization" and that the resident "prefers to spend time in his room."

The CNA care sheet printed June 8, 2012 documented the resident requires total assistance with activities of daily living (ADLs) and is to get out of bed as tolerated.

A enteral feeding evaluation note completed by the registered dietician (RD) on June 13, 2012 documented the resident "has consumed a chocolate pudding on occasion." The note documented "staff have noted resident will occasionally request a snickers bar, however note diet: regular puree for pleasure: candy bar would not be appropriate for current diet. Resident appears to like chocolate, will add chocolate pudding" to dinner and supper meals. "Resident frequently is NPO, refusing meals. Staff to continue to offer in case resident wishes to eat his meal."

During an interview with the resident on June 14, 2012 at 12:25 PM the surveyor asked the resident if he wanted to get out of his room and he nodded yes.

During an interview with certified nurses assistant (CNA) #5 on June 14, 2012 at 12:45 PM she stated "we get him up twice per week."

During an interview with the Unit 4 unit clerk on June 14, 2012 at 1:15 PM she stated the resident "never wants to leave that room, we try he just stays in there."

On June 14, 2012 at 1:40 PM, CNA #5 brought the resident's meal tray to the resident's room. The CNA stated, "just juice?" and did not offer to review meal ticket or items on entree. The CNA then offered pudding and the resident nodded yes. The resident did begin to eat pudding with assistance of spoon feeding from the CNA. The CNA stated the resident doesn't ever want to eat and he must be "showing off for the surveyor." The resident ate the whole bowl of pudding with assistance from the CNA feeding. The CNA then offered gingerale, the resident shook his head no and stated "coke." The CNA stated "oh, we don't have that." The CNA did not leave the room to check or request coke and did not offer an alternative. The CNA lifted the top to the entree and asked the resident if he wanted spaghetti and meatballs (that were of pureed consistency), the resident declined these items. The CNA did not show the resident the meal ticket and did not offer an alternate meal choice.

On June 14, 2012 at 3:45 PM during an interview with the resident; the resident shook his head no when asked if he received a coke, and shook his head no when asked if staff requested the coke.

Resident observations included:
-On June 12, 2012 at 9:45 AM and 3:00 PM the resident was in his room in his bed.
-On June 14, 2012 at 12:25 to 12:40 PM and 3:45 to 4:00 PM the resident was in his room in bed.
-On June 15, 2012 at 9:10 AM and 2:55 PM the resident was in his room in bed.

During an interview on June 15, 2012 at 3:45 PM with the registered nurse (RN) Unit Manager she stated she did not know how often the resident left the room.

During an interview on June 15, 2012 at 3:45 PM CNA #3 stated the resident got out of bed every other day.

On June 15, 2012 at 4:05 PM during an interview with the RD she stated the resident "will nod yes or no to likes and dislikes, he's more nonverbal." The RD stated chocolate pudding was added to the residents meals. She stated the facility would not be able to accommodate a candy bar, they would not know the consistency and it would be too "smushy." The RD did not look in to other alternatives or offer items or snacks other than pudding. The RD stated the facility does not have coke/cola. Surveyor observed cola in the first floor conference room on the same date. The RD stated, we don't have for the residents, "all the time." The RD did not check to see if cola could be offered to the resident. The RD stated she would meet with the resident every month and he did not express a desire to eat. The RD stated the CNAs would let her know if the resident wanted items and they haven't "voiced any other requests. They let me know."

There is no documented rationale on the resident's care card when the resident should get out of bed, how often the CNAs should approach the resident regarding getting out of bed. There is no documentation supporting the CNAs statements that the resident has gotten out of bed or out of his room, why the resident chooses not to get out of his bed or out of his room, or that the resident has been offered to get out of bed.

In summary, the facility;
-Did not assist the resident in providing for choices he made that benefited his nutritional preferences;
-Did not provide documented rationale on not getting the resident out of his room or out of his bed; and
-Did not provide documentation the the resident was offered to get out of his room, out of bed and that staff was actively seeking information from the resident that allowed him to voice his choices to benefit his environment.

10 NYCRR 415.5 (b)(1-3)

F253 483.15(h)(2): HOUSEKEEPING AND MAINTENANCE SERVICES

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: August 17, 2012

The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Citation date: June 18, 2012

Based on observation and staff interview conducted during the standard survey, it ws determined the facility did not ensure the resident environment was maintained in sanitary and orderly manner in 6 of 6 resident units, Units 1, 2, 3, 4, 5, and 6. Specifically, concerns included veneer on furniture and other surfaces in poor condition, closet doors out of the tracks and/or not operating properly, drawers in resident furniture out of tracks and/or not operating properly, and other areas in resident rooms needing repair. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Observation of resident rooms was done during environmental rounds as follows:
- Units 1 and 2 on June 13, 2012 between 1:30 PM and 3:30 PM;
- Units 3 and 4 on June 13, 2012 between 10:10 AM and 12:20 PM;
- Units 5 and 6 on June 12, 2012 between 1:40 PM and 3:50 PM.

1) Furniture and other surfaces were in poor condition in multiple resident rooms, including:
- Room 518B had a 1 inch strip of very dark glue residue of the side of the door from top to bottom;
- Room 414 veneer missing from nightstand;
- Room 403 chipped veneer on dresser;
- Room 316 the door veneer was chipped;
- Room 316 the veneer on the nightstand and both dressers was peeling off or chipped;
- Room 307 nightstand the veneer was missing from the left edge of the door;
- Room 319 the nightstand door was taped with a 4 inch piece of first aid tape;
- Room 310 the veneer on both dressers was chipped;
- Room 325 the veneer on the dresser was chipped; and
- Room 228 both nightstand were missing veneer;
- Room 212B the nightstand door was missing veneer;
- Room 229 some of the veneer was missing from the dresser and nightstand;

2) Closet doors were out of track and not operating properly in multiple resident rooms, including:
- Room 612 both closet doors;
- Room 631 closet door was stuck open;
- Room 620 closet door;
- Room 619 closet door was too narrow/not sizes to fit the closet opening;
- Room 424A, Room 424B the door was loose;
- Rooms 408, 409, 417 and 414; room 409 the closet door had at least 10 pieces of old tape on the surface;
- Room 330 both closet doors;
- Rooms 228 and 229; and
- Room 106B.

3) Drawers in resident room furniture in multiple resident rooms were not seated properly in the tracks and in some cases not in good operating condition (difficult to open/close) in multiple resident rooms, as follows:
- Room 616B nightstand top drawer was askew;
- Room 604B the top dresser drawer was askew and there was a screw loose;
- Room 620 the top and bottom dresser drawers were not operating properly;
- Room 518A the middle dresser drawer was askew;
- Room 430 the nightstand drawer;
- Room 422 the nightstand drawer was out of the track;
- Room 218A (door side) the bottom dresser drawer was hard to open;
- Room 212B the nightstand door would not stay closed;

4) Miscellaneous concerns were:
- Room 609 the lampshade on the dresser was damaged;
- Room 403 the grab bar adjacent to the toilet was loose;
- Room 616B (window side) overbed light bottom bulb not working;
- On June 13, 2012 at 9:00 AM the surveyor observed a hole in the sheetrock above the electrical outlet behind the coffee maker in the kitchen of unit 3.
- On June 12, 2012 at 12:00 PM the surveyor observed that the wall tiles in the whirlpool room were chipped, had fallen off and were lying on the floor.

The Maintenance Director was interviewed on June 14, 2012 at 1:45 AM. He stated the facility maintenance staff did environmental rounds on the units. Rounds were normally conducted on weekends, staff would do rounds on one unit and normally the checks would be for a specific issue, for example lights or formica (veneer) surfaces.

In summary, the facility did not ensure the resident environment was maintained in a sanitary and orderly manner.

10NYCRR 415.5(h)(2)

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

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: August 17, 2012

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: June 18, 2012

Based on observation and staff interview conducted during the standard survey and abbreviated survey #NY00114903, it was determined the facility did not ensure the resident environment was maintained in clean, comfortable and homelike condition in 6 of 6 resident units, Units 1, 2, 3, 4, 5, and 6. Specifically, carpeting, solid surface floors, walls, and resident furniture and equipment was not maintained in clean condition; resident furniture in unit dining rooms was not comfortable and homelike and persistent, foul odors were detected on Unit 5. This resulted in no actual harm with potential for minimum harm.

THIS IS A REPEAT DEFICIENCY FROM THE OCTOBER 14, 2011, AND JANUARY 14, 2011 SURVEYS.

Findings include:

Soiled resident toilet call bell cords
1) The nurse call cords in these areas were soiled/stained as follows:
- the Unit 5 bathing suite toilet cord was heavily stained brown when observed on June 12, 2012 between 2:45 PM and 3:50 PM; the Maintenance Director was interviewed during the observation and stated there was no work order to replace the soiled (and uncleanable) call bell cord.
- in Resident room 424, the toilet call bell cord was stained when observed June 13, 20112 between 10:10 AM and 10:30 AM;
- the Unit 3 bathing suite nurse call cords in the tub room and at the toilet were soiled/stained;
- in Resident room 108, the toilet call bell cord was stained brown when observed on June 13, 2012 between 2:40 PM and 3:20 PM.

Soiled floors, walls, and ceilings
2)The floor of the Unit 2 clean utility room was soiled with at least 10 pieces of debris, including a bedpan, empty glove box, gauze when observed on June 13, 2012 between 1:35 PM and 2:30 PM. The floor of the staff locker room on Unit 2 was soiled with debris at the same time.

The Unit 3 Nurse Manager's office had a carpeted surfaced that was heavily stained and soiled on June 13, 2012 between 11:20 AM and 12:20 PM.

The floor of resident room 322 was observed on June 13, 2012 between 11:20 AM and 12:20 PM; debris was scattered on the floor including 4 disposable gloves near the door the corridor, and sealed packaged supplies, including a surgical sponge, Foley catheter, and an unsealed plastic tray with a povidone iodine (disinfectant) swab.

Resident rooms 403, 408, 424, and 430 were observed on June 13, 2012 between 10:10 AM and 11:20 AM. Resident room 403 had a dried on tube feeding formula spill on the floor and many dark spots of unidentified foreign matter between the bed and the south wall; the closet floor surface was soiled with dust. The ceiling of resident room 408 had 2 large yellowish stains on the ceiling, one above the bed that was approximately 2 feet by 2 feet; the other above the heat/AC unit that was approximately 1 foot by 2 feet. The wall of resident room above the bed in room 424 was soiled with brown foreign matter. Resident room 430 had 4 disposable gloves on floor.

Soiled resident equipment & furniture
3) The front surface of the nightstand in resident room 312 was soiled with a dried on food spill when observed on June 13, 2012 between 11:20 AM and 12:20 PM. A surveyor observed the dried on foreign matter came off easily using a moist paper towel.

The IV pole (used to hang tube feeding formula) in resident room 322 was observed on June 13, 2012 between 11:20 AM and 12:20 AM. The steel base of the IV pole was encrusted with old, dried on yellow tube feeding formula covering most of the steel base. There was no change in the condition of the soiled IV pole when observed a second time on June 14, 2012 at 1:05 PM.

On June 13, 2012 at 12:30 PM the surveyor observed that the privacy curtain in room #322B was soiled with dried crusty brown matter.

The Unit 3 Registered Nurse Unit Manager was interviewed on June 14, 2012 at 1:30 PM. She stated she expected it was nursing staff's responsibility to clean up spilled tube feeding formula.

Resident rooms 408 and 409 were observed on June 13, 2012 between 10:10 AM and 11:20 AM. In room 408, there was a 4 inch long dried on food spill on the front of the nightstand. In room 409, there was a dried on food spill on the front of the dresser; a surveyor observed the dried on spill came off easily with a moist paper towel.

A housekeeper in Unit 4 was interviewed on June 13, 2012 at 11:10 AM. She stated she was not the regular housekeeper. Her routine included mopping resident room floors daily, cleaning any food spills in resident rooms. She stated in the event of a spill of bodily fluids, housekeeping cleaned after the initial cleaning was done by nursing.

Dining room sliding glass doors
4)The Unit 6 dining room sliding glass doors to the balcony were soiled/fogged on June 12, 2012 between 2 PM and 2:45 PM.

The Maintenance Director was interviewed on June 12, 2012 between 2 PM and 2:45 PM; he stated there were no plans to replace the sliding glass doors.

The Unit 5 dining room sliding glass doors to the balcony were soiled/fogged on June 12, 2012 between 2:45 PM and 3:50 PM.

The Unit 4 dining room sliding glass doors to the balcony were soiled/fogged on June 13, 2012 between 10:10 AM and 11:20 AM.

5) On June 12, 2012 at 2:35 PM, dining room chairs in the Unit 6 dining room were observed with deflated cushions. As the surveyor sat in one of the chairs, the woodframe of the chair created pressure on the back of the surveyor's legs.

On June 13, 2012 at 1:20 PM, a cushioned arm chair (similar to the chairs in the Unit 6 dining room) was observed in Resident #13's room. The cushion was deflated, causing pressure from the woodframe, when seated in the chair.

In summary, the facility did not maintain the resident's furniture in a, comfortable, homelike condition.

Persistent foul odors
6) On June 12, 2012 at 3:40 PM and on June 14, 2012 at 7:45 AM, a very strong, air freshener smell was detected throughout Unit 5. On June 14, 2012 between 1:35 PM and 2:40 PM, the air freshener smell was detected throughout Unit 5 and was a very strong odor.

In summary, the facility did not ensure Unit 5 was free from a persistent, foul odor.

10NYCRR 415.5(h)(1)

K18 NFPA 101: CORRIDOR DOORS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities.

Citation date: June 18, 2012

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure corridor doors were provided with a suitable means to keep the doors closed, and that corridor doors were equivalent to 20 minute fire rated doors, for 22 out of 55 sampled resident rooms observed (rooms 101, 103, 106, 107, 108, 209, 219, 220, 303, 310, 325, 413, 417, 505, 508, 518, 521, 525, 529, 603, 620, and 631) plus 2 additional rooms, the basement dietary office suite and the basement garbage/storage room. Specifically, concerns affecting corridor doors included doors that did not latch into side leaves (small doors) or door frames, side leaves that did not latch to door frames/floors, and small holes through resident room doors from previous locking hardware which remained unsealed. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The resident rooms doors in the facility, which open into the corridor, consisted of 2 parts, a door approximately 36 inches wide, and a side leaf (small door) approximately 8 inches wide. The side leaf had a latch at the top, which would latch into the door frame when operating properly, and a latch at the bottom, which would latch into the floor when operating properly. The 36 inch wide door would latch into the side leaf when operating properly.

Observation of corridor doors to resident rooms was done during environmental rounds as follows:
- Units 1 and 2 on June 13, 2012 between 1:30 PM and 3:30 PM;
- Units 3 and 4 on June 13, 2012 between 10:10 AM and 12:20 PM;
- Units 5 and 6 on June 12, 2012 between 1:40 PM and 3:50 PM.

Resident room corridor doors not latching to inactive leaf:
1) The following resident room doors did not latch to the inactive leave when tested (each door was tested at least 3 times and consistently did not latch):
Rooms 220, 303, 310, 505, 508, 521, 603, 620, and 631.
The strike plate on the inactive leaf of several resident room doors was bent outward (projected out into the path of travel of the active door), and obstructing the door and prevented the doors from closing for some resident room doors, for example rooms 603 and 631).

Inactive leaf not latching to door frame/floor:
2) The following corridor doors to resident rooms had an inactive leaf that did not latch as required to the door frame/floor: Rooms 106, 108, 219, 310, 325, and 518.

Other corridor doors not latching:
3) During environmental rounds in the basement on June 14, 2012 between 11:30 AM and 12 PM, a surveyor observed the south corridor door to the dietary office suite/cart storage room could not be closed after more than 3 attempts. The corridor door to the garbage room/storage room did not have a latch, and had no other means to ensure the door remained closed.

The Maintenance Director was interviewed on June 14, 2012 between 11:30 AM and 12 PM; he stated he did realize the door to the dietary office suite was not operating properly.

Resident room doors with unsealed holes from previous latching hardware:
4) The following corridor doors to resident rooms had 2 pencil diameter size holes (one above, one below the door knob/hardware):
Rooms 101, 103, 107, 209, 413, 417, 525, and 529.

The Maintenance Director was interviewed on June 12, 2012 between 1:30 PM and 2:15 PM; he stated maintenance staff audited door latching on weekends.

The Maintenance Director was interviewed on June 14, 2012 between 10:30 AM and 12 PM. He stated the holes through the resident room doors were left from former door hardware used to keep doors locked when a resident was on leave or at the hospital to keep the resident's possessions secure.

The Maintenance Director was interviewed on June 14, 2012 at 11:45 AM. He stated the maintenance staff had done audits of door latching, he was not sure which units were done, and audits had not been done in 2012.

In summary, the facility did not ensure all corridor doors were equivalent to 20 minute fire rated doors, and that all corridor doors had operable hardware to keep the doors closed.

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

K12 NFPA 101: CONSTRUCTION TYPE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

Citation date: June 18, 2012

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the building met applicable construction standards, as the integrity of the fire rated floor deck for the first floor was not maintained. Specifically, there was an unsealed opening through the concrete first floor deck. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facility occupies a partially sprinklered seven story building with resident units on floors 1 through 6.

A surveyor observed the Unit 1 large dining room "club lounge" closet on June 13, 2012 between 3:00 PM and 3:20 PM. There was an unsealed opening through the concrete floor deck into the room below in the Service Level (the floor below the first floor) approximately 15 inches long by 3 to 4 inches wide with electrical conduits passing through it.

The Maintenance Director was interviewed on June 13, 2012 at 3:20 PM; he stated he was unaware the opening through the floor was unsealed.

The unsealed opening through the floor of the Unit 1 large dining room closet was observed with a flashlight on June 14, 2012 at 10:30 AM.

In summary, the facility did not ensure the building construction met required standards, as the integrity of the fire rated floor deck on the first floor was not maintained.

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

K17 NFPA 101: CORRIDOR WALLS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

Corridors are separated from use areas by walls constructed with at least hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.) 19.3.6.1, 19.3.6.2.1, 19.3.6.5

Citation date: June 18, 2012

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the corridor in one of 8 floors, the basement, was separated from use areas with partitions. Specifically, the basement corridor was utilized as a storage area for a large quantity of flammable material. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

A surveyor observed the basement corridor on June 12, 2012 between 8:45 AM and 9:15 AM. There were multiple resident beds in the corridor between the kitchen and the west exit and 16 mattresses. During subsequent observations, at 10 AM, 12 PM, and 5 PM, the mattresses remained in the corridor, and a dietary trash cart; size, at least 50 gallons, was parked in the corridor and contained cardboard trash. The trash cart projected into the corridor from an alcove, adjacent to the west kitchen door, and the storage of the cart and beds effectively reduced the width of the 8 foot corridor to 3 feet.

On June 13, 2012 at 12:30 PM, 13 mattresses and the partially full dietary trash cart remained stored in the basement corridor.

The Maintenance Director was interviewed on June 14, 2012 between 11:30 AM and 12 PM. He stated he was aware the corridors should not be loaded with flammable material. He stated the storage space in the building was extremely limited.

In summary, the facility did not ensure the basement corridor was separated from use areas with partitions.

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

K29 NFPA 101: HAZARDOUS AREAS - SEPARATION

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

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: June 18, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure the fire resistance rating for 1 of 13 hazardous areas was intact, the Service Level paper storage/ventilation room (labeled general storage on the floor plan). Specifically, the one hour fire rating of the storage room was not maintained due to the missing section of the west wall of the storage room adjacent to the men's locker room. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

A surveyor observed the Service Level, labeled general storage room on the floor plan, and the adjacent men's locker room on June 14, 2012 between 11 AM and 11:30 AM. After the Maintenance Director moved a ceiling tile in the men's locker room directly west of the general storage room, the surveyor observed there was no wall above the suspended ceiling between the general storage room and the men's locker room. The general storage room was over 1000 square feet in area, and a large volume of flammable storage (paper and boxed goods) was stored in the room.

The Maintenance Director was interviewed on June 14, 2012 between 11 AM and 11:30 AM; He stated he did not realize the west wall of the general storage room was not intact.

In summary, the facility did not ensure the walls of the general storage room had a one hour fire rating.

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

K25 NFPA 101: SMOKE PARTITION CONSTRUCTION

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

Citation date: June 18, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure the smoke barrier was maintained on one of 7 floors observed with smoke barriers, the Service Level. Specifically, the Service Level smoke barrier included 2 unprotected door openings, a door opening in to the Social Service offices and a door in the large meeting room (incorrectly labeled "occupational therapy" on the floor plan). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The Service Level was observed on June 15, 2012 between 10:40 AM and 11:30 AM. A set of cross corridor doors (smoke barrier doors/"fire doors") was present between the Social Services offices and the large storage room across the corridor.

The Maintenance Director was interviewed on June 15, 2012 between 10:40 AM and 11:30 AM. He stated did not know the route of the smoke barrier from the smoke barrier doors to the outside walls, and was not aware there was a problem with the smoke barrier.

The surveyor determined that any possible route for the smoke barrier to get to the outside walls on the north and south sides of the building involved doors either without self-closing devices, or doors that were held open with unapproved hold open devices. The corridor doors to the 2 social worker offices, and the single door between the 2 social worker offices, all lacked self-closing devices. The double corridor doors at the east end of the large meeting room both had self-closing devices and were held open with unapproved hold open devices (kickstops). The single corridor door at the west end of the large meeting room lacked a self-closing device.

During a second observation of the Service Level on June 15, 2012 at 3:30 PM, the double corridor doors at the east end of the large meeting room remained held open with unapproved hold open devices (kickstops).

In summary, the facility did not ensure the smoke barrier was maintained in one of 7 floors.

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