Rosewood Heights Health Center

Deficiency Details, Certification Survey, December 7, 2012

PFI: 0657
Regional Office: Central New York Regional Office

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

Scope: Pattern

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: February 14, 2013

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

Citation date: December 14, 2012

Based on observation, record review, and interview with staff and residents conducted during the extended survey, it was determined for 8 of 16 residents (Residents #15, 31, 32, 33, 34, 37, 39, and 47), reviewed for swallowing concerns, 2 of 9 residents (Residents #16 and 43), reviewed for falls and 1 of 30 sampled residents (Resident #44), the facility did not ensure adequate supervision and assistance devices to prevent accidents. Specifically:
- for Residents #15, 31, 32, 33, 34, 37, 39, and 47 the facility failed to have a system in place to ensure an effective care plan was developed, communicated with direct care staff, and implemented to assist residents who were at risk for aspiration (taking foreign matter, such as food, into the lungs);
- for Residents #31, 32, 33, 34, and 39, the facility failed to implement supervision as planned for those residents, at risk for aspiration, who ate in their rooms;
- for Residents #15, 34, 37, and 39, the facility failed to ensure residents were positioned properly while being fed; and
- for Residents #34, 39, and 47, the facility failed to develop and implement a system to educate and monitor family and visitors who fed residents who were at risk for aspiration;
- for Resident #47, the facility failed to reassess the resident following a choking incident.
This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Residents #15, 31, 32, 33, 34, 37, 39, and 47.
- For Resident #16 the facility did not reassess the plan of care when a low bed was not available;
- for Resident #43 the facility did not ensure the chair alarm was implemented and planned; and
- for Resident #44 the facility did not ensure the room was free from accident hazards.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #16, 43, and 44.

The facility implemented measures to remove the Immediate Jeopardy on December 13, 2012.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS OF June 18, 2012, October 14, 2011, and January 1, 2011.

Findings include:

The facility procedure titled "Meal Captain" dated December 2012 documented the designated meal captain responsibilities include: ensuring residents receive correct food/fluid consistencies; ensuring room trays are correct, all items are on the tray, and food/fluid consistencies are correct; assigning a staff member to supervise resident's eating in their rooms, ensuring residents receive adaptive equipment as on the meal ticket; ensuring resident are positioned correctly for meals, assigning staff to resident rooms who require assistance and who are on aspiration precautions. The Nurse Manager ensures residents being fed by family are fed in a safe manner, family must be trained by speech therapy, and demonstrate correct techniques and knowledge before feeding the resident.

The facility procedure titled "Thickened Liquids/Aspiration precautions dated November 2012, documented pre-thickened fluids are used, thickened liquids are supplied to the nursing units from dietary, except for pudding thick liquids and soup. Once a new liquid consistency order is written the staff will fax the order to the pharmacy and dietary. "The Speech Language Pathologist is responsible for the training of staff on thickening of items."

The facility policy titled "Dining Experience" dated November 28, 2011 documented for resident's with feeding strategies staff will refer to the Resident Plan of Care sheets for the specific requirement. Residents who require supervision for meals, regardless of time of day, or day of week, will not be allowed to eat meals unsupervised in their rooms. All of these residents will be required to eat their meals in the dining room. Interventions to use when a resident is at risk for aspiration include: feed the resident slowly; position in an upright position during meals and for 15 - 30 minutes after meals and ensure food and fluid consistency is correct.

CONCERNS WITH FEEDING
1) Resident #39 had diagnoses including dementia, a cerebrovascular accident (CVA, stroke) and moderate to severe dysphagia (difficulty swallowing).

The September 12, 2012 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, fed herself after meal set-up, did not have signs/symptoms of a possible swallowing disorder, and received a mechanically altered diet.

The November 15, 2012 speech language pathologist (SLP's) evaluation documented the resident was coughing when eating. The recommendations included a ground consistency diet, with nectar thick liquids and no bread. The evaluation documented the resident was able to have thin liquids via a Provale cup (specialized cup that delivered a specific amount of fluid for each swallow).

The modified barium swallow evaluation report dated November 21, 2012 documented the resident had aspiration after swallow with thin liquids and silent aspiration with nectar consistency liquids. The evaluation recorded the resident was able to tolerate nectar thick liquids given 1/2 teaspoon at a time, and thin liquids in a 5 cubic centimeters (cc) Provale cup.

The SLP note dated November 26, 2012 documented the resident was trialed on Honey consistency via a cup. She documented she would check with the modified barium swallow therapist to ensure it was safe for the resident to have honey consistency liquids in a cup.

The November 27, 2012 physician's order documented the resident's diet was ground consistency with honey thick liquids, no bread products and thin liquids via a 5 cc Provale cup.

The SLP progress note dated November 28, 2012 documented the resident was tolerating honey consistency liquid well.

The comprehensive care plan (CCP) dated December 1, 2012 documented the resident's diet order was ground consistency with honey thick liquids.

The Resident Plan of Care (RPOC, used to direct care) dated December 4, 2012 documented the resident's diet order was soft consistency with nectar thick liquids and no bread products. The RPOC did not document the resident's current diet order of ground and liquid consistency of honey.

On December 5, 2012 at 6:05 PM, the resident was observed in bed being fed supper by a friend. The resident's meal included 2 ground chicken patties served on buns. The resident's menu slip documented the resident was not to receive bread.

In an interview on December 5, 2012 at 6:05 PM the resident's friend stated she fed the resident once a week, in the evening. The friend stated the resident did not eat usually eat bread as she had no front teeth and bread "sticks to her teeth." She said she was going to feed the resident the ground chicken without the bun. She stated the only time she fed the resident bread was when sloppy joes were served, as the meat made the bread soggy, and the resident could then eat it.

On December 6, 2012 at 5:45 PM, the resident was observed sitting in her bed, being fed by a family member, and the head of the bed was not elevated to 90 degrees. The resident had 3 juices that were nectar thick consistency and ice cream on her supper tray. The resident's meal ticket documented she was on honey thick consistency, and did not include ice cream.

In an interview with the resident's family member on December 6, 2012 at 5:45 PM, she stated she fed the resident supper twice a week. She said she knew the head of the resident's bed should be elevated higher, but the resident did not like to sit upright, when she ate. The family member stated the resident could not eat bread as she "chokes on it." She stated on occasion, the resident was given bread, such as a hot dog roll, depending on the dietary server. She said on occasion, she requested a tuna or peanut butter sandwich from dietary and noticed when she cut the crust off, the resident was able to eat them. She stated the resident liked to have ice cream for dessert.

On December 6, 2012 at 5:50 PM, the registered dietitian (RD) stated in an interview, the resident was not served bread because she had a swallowing issue. She stated the resident should not have been given ice cream as that was not honey thick consistency. She said the resident's drinks should have been honey thick consistency.

On December 6, 2012 at 6 PM, licensed practical nurse (LPN) #8 Supervisor, stated in an interview, she was told by dietary staff that the resident's daughter may have put the juices on the resident's tray and that was why she received the incorrect consistency fluids. She stated she did not know if the non-staff members who fed the resident received training.

On December 7, 2012 at 10 AM, the SLP stated in an interview, the resident's meal ticket documented no bread as the resident could not properly chew it. She stated the resident should not receive any bread or bread products. The SLP stated ice cream was not safe for residents on honey thick consistency diets. The SLP said residents should be positioned upright at 90 degrees when eating and minimally at 70 degrees.

On December 10, 2012 at 1:25 PM, certified nurse aide (CNA) #6 stated in an interview, the resident's visitors bought in food for her and stored it in a cabinet in her room. She stated she thought the resident had fruit cups and soup in her room at present.

On December 10, 2012 at 1:35 PM, CNA #7 stated in an interview, she was aware visitors fed the resident in the evening and at times brought in food for her. She stated one family member brought in milkshakes and they were safe for the resident if she drank them right away.

On December 10, 2012 at 1:45 PM, CNA #8 stated in an interview the resident ate supper in her room every evening and was fed by visitors.

On December 10, 2012 at 2:10 PM, the RN Manager stated in an interview, she was not aware the resident was fed supper by visitors most evenings. The RN said she was not aware the resident had food visitors brought in stored in her room.

Observations made on December 10, 2012 at 2:20 PM showed fruit cups, pudding, and Jello cups were in a cabinet in the resident's room.

On December 7, 2012 at 10 AM during the interview with the SLP, she stated the facility recently implemented new standards for altered consistency diets.

The facility's undated Thickened Liquid Consistency Guide documented Jello was a thin liquid.

In summary, for Resident #39, the facility:
- failed to provide the resident with the consistency food and fluid as ordered by the physician;
- failed to ensure the resident was properly positioned when being fed;
- failed to ensure non-staff members who fed the resident were trained and supervised; and
- failed to ensure the food brought in by non-staff members was monitored for the appropriate consistency.

UNTIMELY FOLLOW-UP AFTER A CHOKING INCIDENT
2) Resident # 47 had diagnoses including oral pharyngeal dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD), Parkinson's disease, dementia and anxiety.

The Minimum Data Set (MDS) assessment dated August 1, 2012 documented the resident was severely impaired cognitively. The resident required limited assistance of one person for eating and was on a mechanically altered diet.

The comprehensive care plan (CCP) dated August 15, 2012 documented the resident was to be fed and did not specify if the resident could be fed by a family member.

The physician orders dated August 25, 2012 documented the resident was to receive a ground diet with pureed fruit and vegetables, and nectar thick liquids.

The Nutrition Care Plan Review Evaluation dated September 5, 2012 documented the resident was fed by staff. The evaluation documented the resident had swallowing problems per the speech language pathologist's (SLP) evaluation of May 5, 2012.

Nursing progress notes dated September 7, 2012 documented the resident "had sandwich and tater tots" for supper. The resident tried to cough up large amounts of food particles and when she was unable to do so, the resident was suctioned.

An Event Report dated September 7, 2012 documented at 6:30 PM, after eating supper, the resident began to cough. She brought up small pieces of food, continued to cough and was unable to clear her airway. The resident's oxygen saturation was 87 percent, and she was suctioned for a moderate amount of food particles. The report documented the resident's cough was less frequent but wheezing developed in the lungs. The resident was given a nebulizer breathing treatment and her oxygen saturation level was 99 percent afterwards. The report did not document if the resident received the correct consistency food.

The nursing progress notes dated September 7, 2012 documented the resident was suctioned deeper, a second time, for a couple pieces of food. The physician was notified and ordered a chest x-ray, nothing by mouth except clear liquids "tonight", a nebulizer treatment every 4 hours until morning and an antibiotic.

On September 8, 2012 the physician documented the resident had an "episode of aspiration" the previous day. The resident was eating her meal "being fed by her husband" and the episode of aspiration was reported to include food "such as tater tots."

The physician's orders dated September 8, 2012 changed the resident's diet to pureed with honey thick liquids, with aspiration precautions, and a swallowing evaluation.

The CCP dated September 18, 2012 documented the resident was to receive pureed food with honey thick liquids and was on aspiration precautions. The CCP did not document specific strategies to be implemented when feeding the resident.

On September 18, 2012, the dietitian documented the resident's swallowing evaluation was pending.

The SLP Swallowing Evaluation, dated September 20, 2012, documented the resident was seen for overt signs and symptoms of aspiration due to oropharyngeal dysphagia. The SLP recommendations included:
- changing the resident's fluid consistency to pudding thick;
- alternating bites and sips;
- siting upright at 90 degrees during meals and for 30 minutes after meals;
- supervision at meals; and
- oral care after meals.
The SLP documented "aspiration precautions."

The CCP did not document the feeding interventions as per the SLP's recommendations until an entry on December 10, 2012.

The MDS assessment dated October 17, 2012 documented the resident was on a mechanically altered diet and required extensive assistance with eating.

On December 13, 2012 between 9:40 - 10 AM, the corporate registered dietitian (RD) and the supervising RD were interviewed. They said the SLP provided services on an as needed basis and that may have effected the timeliness of the resident's swallow evaluation. They said the resident's tater tots should have been pureed as per the physician's order.

The Director of Rehabilitation Therapy was interviewed on December 13, 2012 at 9:55 AM and stated if she had been notified of the resident's physician order for a swallowing evaluation, it would have been completed more timely. She said she had no documentation she was notified.

The SLP was interviewed at 10 AM on December 13, 2012 and stated she performed the resident's swallowing evaluation as soon as she was aware of the order. She recommended pudding thick liquids and started the resident on speech therapy. The SLP stated she did not know the resident was being fed by her husband. She said she did not educate or train him to safely feed the resident.

In summary, for Resident #47:
- the facility failed to ensure the resident was evaluated by the SLP, as ordered by the physician, in a timely manner.
- the facility failed to ensure an effective care plan was developed, communicated with direct care staff, and implemented to assist the resident who was at risk for aspiration; and
- the facility failed to develop and implement a system to educate and monitor family and visitors who fed residents at risk for aspiration.

UNSAFE POSITIONING DURING MEALS
3) Resident #37 had diagnoses including aphasia, depression, and spastic quadriplegia (paralysis of the arms and legs with muscle stiffness).

The speech language pathologist's (SLP) evaluation dated March 31, 2011 documented the resident was at risk for choking and aspiration when not seated upright at meals. The SLP documented the resident did not like to be seated upright at meals. The recommendations included positioning the resident upright at meals with support, and leaving the resident upright for a half an hour after eating for safe swallowing completion.

The Minimum Data Set (MDS) assessment dated June 28, 2012 documented the resident's cognitive skills for daily decision making were moderately impaired and the resident did not reject care. The resident required total assistance with eating and had impairments in range of motion (ROM) of his arms and legs.

A physician's progress note dated September 24, 2012 documented the resident "does require extensive amount of nursing support in terms of his activities of daily living (ADL) in light of his spastic quadriplegia."

A nursing quarterly assessment dated October 4, 2012 documented the resident did not have swallowing difficulty.

The resident's comprehensive care plan (CCP) dated October 4, 2012 documented; "feeding strategies per SLP recommendations." (The CCP did not list the specific strategies to be used when feeding the resident.)

The physician's orders dated November 19, 2012 documented the resident was to receive a regular, unmodified consistency, diet.

A nursing progress note dated November 27, 2012 documented, "Spoke to resident about current plan of care. Resident is in agreement."

The resident's plan of care (RPOC, used to direct care), dated December 4, 2012, documented the resident was "noncompliant with out of bed" and "Torso/w/for meal only." There was no explanation of what "torso/w/for meal only" meant. The RPOC did not document the resident was on aspiration precautions when not seated upright for meals.

Observations on December 5, 2012 showed:
- At 12:55 PM, the resident was lying flat in the bed, the head of the bed was not elevated. He was being fed beef stroganoff and noodles by certified nurse aide (CNA) #9.
- At 1:20 PM, the head of the resident's bed was elevated to less than 30 degrees. CNA #9 was feeding the resident, and stated to the surveyor the resident liked to lay flat in bed when he ate and the head of the bed was elevated as much as he allowed.

On December 5, 2012, between 5:55 - 6:20 PM, the resident was observed lying in bed, with the head of bed elevated 30 degrees. The resident was being fed supper by CNA #10 and was chewing his food for an long time before swallowing.

On December 6, 2012 at 8:45 AM, the resident stated in an interview, he did not mind sitting upright for meals and that some staff did sit him upright.

On December 6, 2012 at 9:20 AM, the resident was observed lying in bed with CNA #6 feeding him. The head of bed was slightly elevated.

On December 6, 2012 at 1:20 PM, the registered nurse (RN) Manager stated in an interview, she did not know how the resident was positioned at meals as she never observed him eating.

On December 7, 2012 at 10 AM, the Director of Rehabilitation and the SLP stated neither were familiar with the resident. The SLP stated, in general, residents should be upright for meals and if 90 degrees was not possible, she would recommend 70 degrees.

On December 7, 2012 at 11:30 AM, the registered dietitian (RD) stated in an interview, she was not familiar with how the resident was positioned when he ate as she never saw him eating.

On December 10, 2012 at 9:36 AM, the RD stated in an interview, there was no list of residents on aspiration precautions. She stated the RPOC should document all residents who were on aspiration precautions.

Review of the resident's RPOC, dated December 4, 2012, did not document he was on aspiration precautions when not seated upright at meals.

On December 10, 2012 at 12:41 PM, the resident was observed lying in bed with the head of bed elevated to approximately 30 degrees. The resident was being fed a grilled cheese sandwich by a CNA.

On December 10, 2012 at 1:45 PM, CNA #8 stated in an interview, the resident did not like to be upright when he ate. She said she did not know what "torso w/ meal only" meant on the RPOC. The CNA stated the resident was non-complaint with therapy recommendations.

On December 10, 2012 at 3:15 PM, the Administrator stated in an interview, if a resident ate meals in their room daily it should be documented on the CCP. The Administrator stated she was not aware of the resident's preference to eat in a reclined position.

On December 11, 2012 at 12:40 PM, the resident was observed lying flat in bed being fed lunch by a CNA.

In summary the facility:
- failed to ensure the resident was positioned safely while eating; and
- failed to have a system in place to ensure an effective care plan was developed, communicated to direct care staff, and implemented to assist the resident to eat safely.

UNSUPERVISED DINING
4) Resident #31 had a diagnosis including chronic obstructive pulmonary disease, aortic stenosis, and obstructive sleep apnea.

The resident's Minimum Data Set (MDS) assessment dated October 19, 2012 documented the resident had moderate cognitive impairment. The resident was independent with eating, required assistance with setup and was on a mechanically altered diet.

The physician order dated November 6, 2012 documented the resident was to have a swallowing evaluation to determine the most appropriate diet.

The swallowing evaluation dated November 7, 2012 documented the resident had mild oral dysphagia (difficulty swallowing) marked by no teeth or dentures and increased chewing time with some meats.

The speech language pathologist (SLP) progress note dated November 7, 2012 recommended all meat and large pieces of food should be cut up and the resident was to alternate bites and sips.

The physician order dated November 8, 2012 documented the resident was to receive a regular consistency diet and thin liquids. The physician ordered all meat and large pieces of food were to be cut up by staff.

The resident plan of care (RPOC, used to direct care) dated December 7, 2012 documented the resident was on aspiration precautions and his meat and large pieces of food were to be cut up by staff.

The comprehensive care plan (CCP) dated December 10, 2012 documented the resident had a swallowing problem and interventions included staff cutting meat into small pieces and the use of verbal cues to remind the resident to alternate solids and liquids.

On December 10, 2012 from 1:30 - 1:49 PM, the surveyor observed the resident sitting on the side of his bed eating lunch. The resident's lunch included two hot dogs which were not cut up. The meal ticket documented meat and large pieces of food were to be cut up by staff. No staff entered the resident's room during the observation.

When interviewed on December 10, 2012 at 1:45 PM, CNA #4 stated there was no one assigned to supervise residents who ate in their rooms. She said the CNAs walk by and make sure the residents are okay. She stated she was not aware of any resident on aspiration precautions. CNA #4 said aspiration precautions meant the resident could choke easily.

Observations on December 10, 2012 at 1:50 PM, showed CNA #5 brought Resident # 31's meal tray out of his room. There was one hot dog on the tray.

When interviewed on December 10, 2012 at 1:50 PM, CNA #5 stated she did not know who supervised residents who ate in their rooms. She stated when residents were on aspiration precautions it was documented on the RPOC and meant a resident could choke easily.

In summary, for Resident #31, the facility:
- failed to have a system in place to ensure an effective care plan was developed, communicated with direct care staff, and implemented to assist residents who were at risk for aspiration; and
- failed to implement supervision, as planned, when the resident ate in his room.

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The facility implemented measures to remove the Immediate Jeopardy situation on December 13, 2012, including:
- developed an accurate list of residents on aspirations precautions;
- developed a plan to supervise those residents, who were at risk for aspiration, who wished to dine in their rooms;
- developed new policies and procedures to address families feeding residents; and
- developed a plan to train family members on safely feeding residents.

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ENVIRONMENTAL HAZARDS:
4) Resident #44 had diagnoses including non-Alzheimer's dementia, traumatic brain injury, and chronic obstructive pulmonary disease (COPD).

The Minimum Data Set (MDS) assessment dated June 20, 2012 documented the resident's cognitive skills for daily decision making were severely impaired, and he was totally dependent on staff for most activities of daily living.

A physician's order dated December 3, 2012 documented the resident was to receive 1 Duoneb nebulizer (breathing treatment) 3 times a day for one week and every 4 hours as needed, if short of breath or wheezing. These orders were discontinued on December 10, 2012.

The resident's room was observed on December 10, 2012 at 12:17 PM, December 11, 2012 at 10:05 AM, and December 13, 2012 between 1:25 - 1:45 PM. During each observation, the piped in wall oxygen was running and there was no oxygen tubing or nebulizer attached to the oxygen.

During an interview with the registered nurse (RN) Manager on December 13, 2012 between 1:25 - 1:45 PM, she stated she was not aware the oxygen was running in the resident's room, the resident was not currently using oxygen.

On December 13, 2012 at 1:45 PM a maintenance staff checked the resident's wall oxygen and stated to the surveyor, it "sometimes does that" it just needs a plug.

On December 13, 2012 between 1:45 - 2:36 PM, the Director of Maintenance stated he was aware maintenance staff checked the resident's wall oxygen unit that day. He said he did not have a record of being notified previously that there was a concern with the resident's wall oxygen unit running when it was not in use.

In summary, the facility did not ensure the resident's environment was free of accident hazards as the resident's wall oxygen unit was continuously running when not in use.

FALLS:
5) Resident #43 had diagnoses including a cerebrovascular accident (CVA, stroke), anoxic (decreased oxygen) brain injury, and seizure disorder.

The November 16, 2012 nursing assessment documented the resident was not at risk for falls, had no "specific safety concerns" and did not require "special safety equipment."

The November 23, 2012 Minimum Data Set (MDS) assessment documented the resident was severely impaired cognitively, required limited assistance of one person for transferring and walking, and extensive assistance for toileting/personal hygiene/dressing/bathing. The MDS recorded the resident had fallen, since the last assessment, and had no injury.

The November 23, 2012 nursing progress note documented the resident tried to stand up on his own and sat on the foot rests of the wheelchair.

The November 23, 2012 Resident/Visitor Event Report documented the resident was counseled on ensuring his wheelchair breaks were locked when transferring himself.

The comprehensive care plan (CCP) dated November 28, 2012 documented the resident had impaired judgment and balance and fell within the past 30 days. The CCP documented the resident had bed and chair alarms and did not specify the date the alarms were implemented.

The November 29, 2012 nursing progress note documented the resident transferred, toileted and ambulated himself.

The November 30, 2012 nursing progress note documented the resident was found on the floor between the bed and chair. The resident was educated on safety awareness with "little understanding." The Resident/Visitor Event Report of the same date documented a bed and chair alarm were implemented.

A December 2, 2012 nursing progress note documented the resident was found on the floor after trying to transfer himself. The Resident/Visitor Event Report, of the same date, did not document whether the resident's bed or chair alarm were in use or functioning at the time of the fall.

The Resident Plan of Care (RPOC, used to direct care) dated December 4, 2012 documented the resident at risk for falls and transferred with moderate assistance of 1 person. The RPOC did not document the resident used a bed or chair alarm.

On December 5, 2012 between 11:10 - 11:40 AM, the registered nurse (RN) Manager stated in an interview, the resident had been falling frequently.

The resident was observed on December 6, 2012 at 5:50 PM. He was outside the dining room, sitting in the wheelchair. He stood up on his own, no alarm sounded. The resident was unsteady, his wheelchair was not locked and began to roll backwards. The surveyor alerted a staff member.

On December 13, 2012 at 9:30 AM, the RN Manager stated in an interview, the resident was care planned to have a bed/chair alarm on at all times. She stated he was accepting of the alarms.

The staff member who assisted the resident back to his room on December 6, 2012 at 5:50 PM was not available for interview.

In summary, Resident #43 was not consistently provided with bed/chair alarms as planned.

10NYCRR 415.12 h(1) (2)

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

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: February 14, 2013

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: December 14, 2012

Based on record review and staff interview conducted during the extended survey, it was determined the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents for 77 residents on aspiration (taking foreign matter into lungs) precautions, including Residents #11, 15, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 47, who were reviewed for swallowing concerns. Specifically, the QA committee failed to identify concerns with providing adequate supervision during meals, failed to identify concerns with non-staff members feeding residents; failed to provide training and oversight to non-staff members who fed residents; failed to identify concerns with residents receiving inappropriate food/liquid consistency, failed to identify concerns with improper or inadequate use of adaptive feeding equipment, and failed to implement corrective measures. Refer to F323 and F365. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of Residents #11, 15, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 47.

The Immediate Jeopardy situation was removed on December 13, 2012, prior to the survey exit.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS OF June 18, 2012 and October 14, 2011.

Findings include:

The Administrator was interviewed on December 10, 2012 at 3:15 PM and stated she was not sure if audits were being conducted to monitor residents on aspiration precautions or the positioning of residents when eating. She stated prior to survey, she was not aware there were concerns with the manner in which residents were positioned when they were eating.

The Director of Nursing (DON) stated in an interview on December 10, 2012 at 6:00 PM, nursing audited 10 residents per week on each unit during meals. She stated the audits did not identify concerns with residents' positioning at meals; did not identify concerns with residents receiving the incorrect consistency of food and fluid, and did not identify concerns with adaptive feeding equipment that would affect swallowing.

In summary, the facility failed to ensure the QA committee identified concerns and implemented corrective measures for residents on aspiration precautions, providing supervision at meals, and providing the proper food/fluid consistency and adaptive feeding equipment.

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The Immediate Jeopardy situation was removed on December 13, 2012 based on the following corrective actions taken by the facility:
- developing an accurate list of residents on aspirations precautions;
- developing new policies and procedures to address families feeding residents;
- developing a plan to train family members on safely feeding residents;
- developing a plan to supervise those high risk residents who wished to dine in their rooms;
- training staff on providing residents with their ordered food and fluid consistency and assistive devices; and
- developing a plan to oversee meal service on the nursing units to ensure the proper food consistency was served and residents had their ordered assistive devices.

10NYCRR 415.27(a-c)

F365 483.35(d)(3): FOOD IS PREPARED TO MEET INDIVIDUAL NEEDS

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: February 14, 2013

Each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Citation date: December 14, 2012

Based on observation, record review, and staff and family interviews conducted during the extended survey, it was determined for 7 of 16 residents reviewed for swallowing concerns (Residents #11, 31, 32, 35, 36, 38, and 39), the facility did not provide food prepared in a form to meet individual needs. Specifically, the facility failed to provide Residents #11, 31, 32, 35, 36, 38, and 39 with their accurate food/fluid consistency or with assistive devices as planned and ordered by the physician. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety for Residents #11, 31, 32, 35, 36, 38, and 39.

The facility implemented measures to remove the Immediate Jeopardy on December 13, 2012 prior to exit.

Findings include:

The facility procedure titled "Meal Captain" dated December 2012 documented the designated meal captain responsibilities include: ensuring residents receive correct food/fluid consistencies; ensuring room trays are correct, all items are on the tray, and food/fluid consistencies are correct; assigning a staff member to supervise resident's eating in their rooms, ensuring residents receive adaptive equipment as on the meal ticket; ensuring resident are positioned correctly for meals, assigning staff to resident rooms who require assistance and who are on aspiration precautions. The Nurse Manager ensures residents being fed by family are fed in a safe manner, family must be trained by speech therapy, and demonstrate correct techniques and knowledge before feeding the resident.

The facility procedure titled "Thickened Liquids/Aspiration precautions dated November 2012, documented pre-thickened fluids are used, thickened liquids are supplied to the nursing units from dietary, except for pudding thick liquids and soup. Once a new liquid consistency order is written the staff will fax the order to the pharmacy and dietary . "The Speech Language Pathologist is responsible for the training of staff on thickening of items."

The facility policy titled "Dining Experience" dated November 28, 2011 documented for resident's with feeding strategies staff will refer to the Resident Plan of Care sheets for the specific requirement. Residents who require supervision for meals, regardless of time of day, or day of week, will not be allowed to eat meals unsupervised in their rooms. All of these residents will be required to eat their meals in the dining room. Interventions to use when a resident is at risk for aspiration include: feed the resident slowly; position in an upright position during meals and for 15 - 30 minutes after meals and ensure food and fluid consistency is correct.

1) Resident #39 had diagnoses including dementia, a cerebrovascular accident (CVA, stroke) and moderate to severe dysphagia (difficulty swallowing).

The September 12, 2012 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, fed herself after meal set-up, did not have signs/symptoms of a possible swallowing disorder, and received a mechanically altered diet.

The November 15, 2012 physician's orders documented the resident was to have a speech language pathologist's (SLP) evaluation and a modified barium swallow (a swallow study).

The November 15, 2012 SLP's evaluation documented the resident was coughing when eating. The recommendations included a ground consistency diet, with nectar thick liquids and no bread. The evaluation documented the resident was able to have thin liquids via a Provale cup (specialized cup that delivered a specific amount of fluid for each swallow).

The modified barium swallow evaluation report dated November 21, 2012 documented the resident had aspiration after swallow with thin liquids and silent aspiration with nectar consistency liquids. The evaluation recorded the resident was able to tolerate nectar thick liquids given 1/2 teaspoon at a time, and thin liquids in a 5 cubic centimeters (cc) Provale cup.

The SLP note dated November 26, 2012 documented the resident was trialed on Honey consistency via a cup. She documented she would check with the modified barium swallow therapist to ensure it was safe for the resident to have honey consistency liquids in a cup.

The November 27, 2012 physician's order documented the resident's diet was ground consistency with honey thick liquids, no bread products and thin liquids via a 5 cc Provale cup.

The SLP progress note dated November 28, 2012 documented the resident was tolerating honey consistency liquid well.

The comprehensive care plan (CCP) dated December 1, 2012 documented the resident's diet was ground consistency, no bread, honey thick liquids and thin liquids via a 5 cc Provale cup with direct staff supervision.

The Resident Plan of Care (RPOC, used to direct care), dated December 4, 2012 documented the resident's diet order was soft consistency with nectar thick liquids and no bread products. The RPOC did not document the current order for ground consistency, honey thick liquids, and thin liquids via a 5 cc Provale cup with supervision.

On December 5, 2012 at 6:05 PM, the resident was observed sitting in her bed being fed supper by a friend. The resident's menu slip documented she was not to receive bread. The resident's supper included 2 ground chicken patties, served on buns. The resident's friend stated, in an interview at that time, she fed the resident supper once a week. She said the resident did not usually eat bread and the only time she fed her bread was when sloppy joes were on the menu. She stated the sloppy joes made the bread very soggy and the resident was then able to eat the bread.

On December 6, 2012 at 5:45 PM, the resident was observed sitting in her bed being fed by her family member. The resident's supper was served and she received 3 nectar thick juices and ice cream. The resident's meal ticket documented she was on honey thick liquids, ice cream was not on the meal ticket. The resident's family member stated, in an interview at that time, she fed the resident supper 2 nights a week and the resident could not eat bread because she "chokes on it." She stated on occasion, the resident received bread with her meals, such as a ground hot dog on a roll, and that depended on which dietary server was working. She stated on occasion, she requested a tuna or peanut butter sandwich from dietary and noticed if she cut the crust off, the resident could eat the sandwiches. She stated the resident liked ice cream for dessert.

On December 6, 2012 at 5:50 PM, the registered dietitian (RD) stated in an interview, the resident did not receive bread due to a swallowing issue. She stated the resident should not have been given ice cream because that was not a honey thick consistency item. She said the resident's drinks should have been honey thick consistency.

On December 6, 2012 at 6 PM, licensed practical nurse (LPN) #8 Supervisor, stated in an interview, she was told by dietary staff that the resident's daughter may have gathered her beverages that evening and that was why she received the incorrect fluid consistency.

On December 7, 2012 at 10 AM, the SLP stated in an interview, the resident had poor chewing skills and could not properly chew bread. She stated she should not receive any bread or bread products. The SLP stated ice cream was not safe for resident's on honey thick consistency liquids.

On December 10, 2012 at 1:35 PM, certified nurse aide (CNA) #7 stated in an interview, she was aware visitors fed the resident in the evening and at times brought in food for her. She stated one family member brought in milkshakes and to her knowledge, they were safe as long as the resident drank them right away.

On December 10, 2012 at 2:10 PM, the RN Manager stated in an interview, she was not aware the resident received the incorrect food consistency at 2 supper meals.

In summary, for Resident #39, the facility failed to provide the resident with the food and fluid consistency as ordered by the physician.

2) Resident #11 had diagnoses including senile dementia, dysphagia (difficulty swallowing), failure to thrive, and malnutrition.

The August 29, 2012 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required set-up and supervision with meals.

A nursing progress note dated September 20, 2012, documented a swallowing evaluation was needed as the resident refused to drink thickened liquids.

The October 18, 2012 modified barium swallow (a swallow study), documented the resident presented with decreased ability/ to chew and decreased tongue base retraction which led to the resident's dysphagia. The speech language pathologist's (SLP) final assessment recommended the resident receive a ground diet and either nectar thick liquids or thin liquids via a 10 cubic centimeters (cc) Provale cup (a specialized cup that delivered 10 cc per swallow).

The resident plan of care (RPOC, used to direct care), dated December 5, 2012, documented the resident required a regular ground diet with thin liquids via a Provale cup, and did not include nectat thick liquids.

Observations on December 5, 2012 at 5:50 PM, showed:
- a certified nurse aide (CNA) encouraged the resident to come to the table and told him she would get his coffee and meal;
- the CNA gave the resident coffee in a regular mug;
- after a few minutes, the RN Manager took the mug of coffee away from the resident, and said to the surveyor "we're getting his cups that he uses now;"
- the resident was given nectar thick apple juice, tasted it and said he did not want it;
- at 6:15 PM, the RN Manager said to the surveyor she was calling the kitchen again for the resident's Provale cup;
- at 6:21 PM, the Provale cup was delivered to the unit; and
- the resident was no longer in the dining room.

Observations on December 6, 2012 showed:
- at 8:40 AM, a CNA gave the resident thin consistency orange juice, milk, and coffee in regular glasses;
- the resident drank the coffee;
- 12:40 PM, a CNA gave the resident thin water in a regular glass and coffee in a Provale cup; and
- the resident drank the water and the coffee.

On December 7, 2012 at 8:40 AM a CNA was observed giving the resident thin consistency water in a regular glass. At 9:20 AM the resident was observed in the dining room, with thin coffee in a regular mug. CNA #11, who was assisting the resident, was interviewed at that time and stated the resident had a barium swallow evaluation "about a month ago" and "passed" and could now have thin liquids with supervision.

The RPOC dated December 10, 2012, documented the resident was to receive a ground diet with thin liquids via a Provale cup. The RPOC recorded the resident required supervision and was on aspiration precautions. The RPOC did not specify what the aspiration precautions were.

Observations on December 10, 2012 at 12:30 PM showed:
- a CNA gave the resident thin consistency water, coffee, and chocolate milk in regular glasses;
- the resident drank the coffee; and
- a CNA brought the resident a second cup of coffee in a Provale cup, and left the chocolate milk and water in regular cups.

Observations on December 11, 2012 at 8:40 AM, showed CNA #11 gave the resident thin consistency chocolate milk in a regular glass and coffee in a Provale cup. The resident drank the chocolate milk.

During an interview on December 11, 2012 at 2:30 PM, the RN Manager stated Provale cups were sent from dietary with the resident's meal. She said the resident had been getting one Provale cup and she was not sure what beverages were being served in the Provale cup. The RN said she thought it depended on the resident's preference.

In summary, the facility failed to provide the resident with the fluid consistency and assistive devices as planned and ordered by the physician.

3) Resident #31 had a diagnosis including chronic obstructive pulmonary disease (COPD), aortic stenosis, and obstructive sleep apnea.

The resident's Minimum Data Set (MDS) assessment dated October 19, 2012 documented the resident had moderate cognitive impairment. The resident was independent with eating, required assistance with setup and was on a mechanically altered diet.

A nursing progress note dated November 1, 2012 documented the resident choked on pineapple bits while in the dining room.

A nutrition progress note dated November 6, 2012 documented the resident had a coughing episode on November 1, 2012. The note documented the resident stated "it hurts to swallow." The resident's diet was downgraded to ground consistency for safety precautions.

The physician order dated November 6, 2012 documented the resident was to have a swallow evaluation for the most appropriate diet consistency.

The swallow evaluation dated November 7, 2012 documented the resident had mild oral dysphagia (difficulty swallowing) marked by no teeth or dentures, increased chewing time and difficulty with some meats.

The speech language pathologist (SLP) note dated November 7, 2012 documented the recommendation to cut up the resident's meat and large pieces of food, and to alternate bites and sips.

The physician order dated November 8, 2012 documented the resident was on a regular consistency diet and thin liquids. The physician ordered meat and large pieces of food were to be cut up by staff.

The comprehensive care plan (CCP) dated November 8, 2012 documented the resident was at nutritional risk related to aspiration precautions. The CCP recorded meat and large pieces of food were to be cut up by staff.

The resident plan of care (RPOC), used to provide care, dated November 30, 2012 documented meat and large pieces of food should be cut up by staff, and verbal cues given to the resident to alternate solids and liquids.

The CCP dated December 10, 2012 documented the resident had a swallowing problem. Interventions were for staff to cut meat into small pieces and use verbal cues to alternate solids and liquids.

On December 10, 2012 from 1:30 - 1:49 PM, the surveyor observed the resident sitting on the side of his bed eating lunch. The resident's lunch included two hot dogs which were not cut up. The meal ticket documented meat and large pieces of food should be cut up by staff. No staff entered the resident's room during this observation.

When interviewed on December 10, 2012 at 1:45 PM, CNA #4 stated no one was assigned to supervise residents who ate in their rooms. She said the CNAs walked by and made sure the residents were OK. She stated she was not aware of any resident on aspiration precautions and was not aware of any resident who had recently choked.

On December 10, 2012 at 1:50 PM, CNA #5 was observed removing the resident's lunch tray. There was one hot dog on the tray.

When interviewed on December 10, 2012 at 1:50 PM, CNA #5 stated she did not know who supervised residents who ate in their rooms. She stated residents on aspiration precautions were listed on the RPOC sheets. She stated she was not aware of any resident who had recently choked.

When interviewed on December 13, 2012 at 9:50 AM, the dietician stated she learned of the resident's November 1, 2012 choking episode by going through the progress notes on November 6, 2012. She stated she spoke to the SLP about getting a swallowing evaluation, which was done the next day.

In summary, the facility failed to provide the the resident with food consistency as ordered by the physician.

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The facility implemented measures to remove the Immediate Jeopardy on December 13, 2012, including:
- trained staff on providing residents with food/fluid consistency and assistive devices as ordered by the physician; and
- developed a plan to oversee meal service on the nursing units to ensure food/fluid consistency and assistive devices were provided as ordered by the physician.

10 NYCRR 415.14(d)(3)

F517 483.75(m)(1): PLANS TO MEET EMERGENCIES/DISASTERS

Scope: Widespread

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.

Citation date: December 14, 2012

Based on record review, staff interview, and observation conducted during the standard survey, it was determined the facility did not ensure the disaster plan included detailed plans to address all potential emergencies and disasters, specifically loss of water and loss of the telephone system. The plans for loss of water and loss of power were neither complete nor current. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Loss of Water
The facility disaster plan addressing loss of water was not dated. There was no documentation in the Loss of Water plan indicating the storage location of the facility's emergency water supply (a surveyor observed the emergency water supply stored in the facility on December 7, 2012 between 11 AM and 12 PM.) The disaster plan did not address an emergency involving a boil water notice (water available but not fit for consumption). The disaster plan did not address resident bathing, housekeeping, and use of the dishmachine in the kitchen.

The phone number for an emergency contact in the plan erroneously included the phone number for the suburban water service provider, rather than the city water department that is responsible for the municipal water system within the city limits (the facility is located within city limits.) Phone contact information for the city water department was not included in the plan.

2) Loss of Telephone System
The facility disaster plan addressing loss of the phone system was not dated. The plan for loss of the phone system did not address use of cellular phones (other than the administrator's cellular phone), and did not address how nursing staff would contact emergency services and medical staff to ensure resident's medical needs would be met.

There was no documented evidence the disaster plan was revised/updated in the last 5 years.

On December 7, 2012, the Plant Operations Director was interviewed regarding the disaster plan at 9:30 AM. He stated the facility was scheduled to begin reviewing and updating the disaster plan today, and it was postponed due to the survey.

The Administrator was interviewed on December 7, 2012 at 4:25 PM. She stated she was aware the disaster plan needed to be updated, and the facility management team planned to revise the disaster plan. She did not know when the disaster plan was last updated.

In summary, the facility did not ensure the disaster plan thoroughly addressed all potential disasters.

10NYCRR 415.26(f)(1)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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: December 14, 2012


Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 3 of 10 sampled residents, (Residents #34, 40, and 41), reviewed for activities of daily living (ADLs), and for 5 residents outside of the sample (Residents #50, 51, 56, 57, and 64) who required ADL assistance, the facility did not provide the necessary services to maintain good nutrition, hydration, grooming, and personal hygiene.
Specifically, for Residents #34, 50, 51, and 64 were not assisted with proper positioning when out of bed, Resident #34 did not have a towel placed behind the neck when fatigued, as planned, and Residents #50, #51, and #64 did not have their feet supported when seated in gerichairs. For Residents #40 and #41, staff did not ensure the residents planned feeding strategies were implemented. Residents #5 6 and #57 did not receive hair cuts in a timely manner, and Resident #56 did not receive timely assistance with changing soiled clothing. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings Include:

POSITIONING
3) Resident #34 had diagnoses including dementia, osteoporosis, and anxiety disorder.

The resident's Minimum Data Set (MDS) assessment dated August 2, 2012 documented the resident's cognition was severely impaired, and the resident required extensive assistance of one person for activities of daily living (ADL), including eating.

A physical therapy discharge summary dated October 24, 2012 documented the resident was "unable to maintain neck in upright position when fatigued." The summary recorded caregivers were educated on application and use of a towel roll for support of the posterior neck when the resident was reclined.

A physical therapy recommendation dated October 24, 2012 documented to "place towel roll behind neck when resident is fatigued and reclined in wheel chair."

The resident's plan of care (RPOC), used by certified nurse's aides to provide care, dated December 10, 2012 documented the resident was to have a "rolled towel behind neck when fatigued."

The resident's comprehensive care plan (CCP) dated December 10, 2012 did not address the resident's ability to hold her head up without a supportive device, or what to do should the resident become fatigued.

The resident was observed on December 5, 2012 at 10:21 AM sitting in her wheelchair. The resident's head was tipped back and the resident was observed shifting herself in the chair.

The resident was observed on December 10, 2012 between 12:15 - 12:34 PM. The resident was sitting in the wheelchair, her head was tipped back and she was not able to keep her head straight. At 12:34 PM, the resident's husband wheeled her into the dining room and fed her lunch. Her head remained tipped back throughout lunch, there was no assistive device behind her neck.

On December 11, 2012 at 12:03 PM the resident was observed in her room seated in her wheelchair. The resident's head was tilted to the right and back there was no towel in place for support. At 12:45 PM the resident was in the dining room with her husband who tilted the residents head forward with his hands. At 2:40 PM the resident was in the dining room seated in her wheelchair with her head tilted back, her neck bent and there was no towel in place for support.

During an interview with the registered nurse (RN) Manager on December 13, 2012 at 1:30 PM she stated resident had chair and bed alarms, fall mats, and a low bed. She said she knew that physical therapy had talked to the spouse regarding a cushion behind the residents back, and he did not want it.

In summary, the facility, did not ensure, for a resident that is unable to carry out their own activities of daily living, the resident received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

GROOMING
4) Resident #56 was admitted to the facility on November 28, 2012 with diagnoses including dementia.

The comprehensive care plan (CCP) dated November 29, 2012 described the resident as having impaired cognition, with a decline in physical status. The goal was for the resident to have his needs met, including to be dressed and groomed appropriately. The CCP documented the resident required limited assistance with activities of daily living.

On December 5, 2012 between 1:15 PM and 1:30 PM, the resident was observed in the unit dining room. The resident's hair was unkempt and was long in the back and around his ears. The resident's hair remained in the same condition when observed on December 10, 2012 at 12:15 PM, and December 11, 2012 at 12:40 PM.

On December 11, 2012, the resident was observed in the unit dining room, at the table, at 1 PM. The resident attempted to drink his cup of water and spilled it onto the table and his clothing. Nursing staff, including the registered nurse (RN) Manager, cleaned up the table and the floor. At 1:29 PM, the resident was observed standing up at the table and the licensed practical nurse (LPN) Meal Captain approached the resident and upon seeing his pants were wet, asked him if he spilled something. As the LPN escorted the resident out of the dining room she was overheard stating to another staff member, she had to take the resident from the dining room because he needed his clothing changed and he was becoming combative.

On December 11, 2012 at 1:30 PM, the RN Manager was interviewed and stated she was not aware the resident's pants were wet when she cleaned the spill from the table.

On December 13, 2012, the resident was observed at 12:40 PM with his hair long and unkempt. A certified nurse aid (CNA), from the resident's unit was interviewed at the time of the observation, and stated the resident was new and they usually waited until they thought there was money was in the resident's account before calling for a hair appointment. She stated if a resident did not have money they would inform the activity leader or the social worker.

In summary, the facility did not provide the necessary services to maintain good grooming and did not assist the resident, in a timely manner, with changing his wet clothing.

NUTRITION
2) Resident #41 had diagnoses including dementia, dehydration, and depression.

The resident's Minimum Data Set (MDS) assessment dated September 12, 2012 documented the resident's cognition was severely impaired. The MDS recorded the resident required assistance of one person for activities of daily living (ADL), and required set up and supervision with eating.

The resident's plan of care (RPOC, used to direct care), dated December 5, 2012 documented the resident was to have meals set up, was to alternate solids with liquids when eating, and was to stay out of bed for 30 minutes after meals.

The resident was observed on December 6, 2012, in the dining room during breakfast at 8:45 AM and lunch 12:15 PM, feeding himself, without being encouraged by staff to alternate solids and liquids.

The resident's comprehensive care plan (CCP) dated December 10, 2012 documented the resident was at risk for aspiration and weight loss. Interventions included:
- eat only with supervision;
- small bites and sips;
- check mouth after meal for pocketed food and debris;
- sippy cup for liquids; and
- alternate liquids with solids.

The resident was observed in the dining room on December 10, 2012, and December 11, 2012 feeding himself breakfast. The resident was not encouraged to alternate solids and liquids, or to take small bites and sips, a sippy cup was not provided, and staff did not check his mouth after the meal.

During an interview on December 10, 2012 the LPN said the resident was on aspiration precautions. She stated the resident got verbally aggressive when staff sat with him during meals, "so to preserve his dignity we allow him to be independent as possible."

In summary, the facility did not ensure the resident's nutritional needs were being met safely when they did implement the feeding strategies as planned.

10 NYCRR 415.12(a)(3)

F241 483.15(a): DIGNITY

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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.

Citation date: December 14, 2012

Based on observation, record review, and staff and resident interview conducted during the standard survey, it was determined the facility did not ensure care and services maintained or enhanced the dignity, respect and self esteem for 1 of 30 sampled residents (Resident #41), 3 residents outside the sample (Residents #51, 53, and 61), 12 anonymous residents at the group meeting, and unidentified residents on Unit 3. Specifically,
- for Resident #51, the facility did not keep the resident sufficiently covered when out of his room.
- For Resident #53, two licensed staff members entered the resident's room and did not sufficiently cover the resident in a timely manner.
- For Resident #61, staff administered nasal spray in view of another resident.
- For 12 anonymous residents at the group meeting, Resident #41, and unidentified residents on Unit 3, the facility did not provide a dignified dining experience.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF JUNE 18, 2012.

1) Resident #53 had diagnoses including dementia and depression.

The Minimum Data Set (MDS) assessment dated October 17, 2012 documented the resident had moderate cognitive impairment and was independent with mobility, utilizing a wheelchair, required supervision with dressing, and limited assistance with personal hygiene.

The Resident Plan of Care (RPOC, used to direct care), dated December 10, 2012, documented the resident propelled himself in a wheelchair and liked to go back and forth to his room.

On December 11, 2012 at 8:15 PM, Resident #53 was observed in the hallway near the nurses' station seated in his wheelchair. The resident was wearing a hospital gown that was open in the back, and exposed his back from shoulders to waist. The licensed practical nurse (LPN), who was in the hallway speaking with the resident, made no attempt to cover the resident. Other residents were present in the hallway at that time.

At 8:45 PM, on December 11, 2012 the resident was observed in the hallway near the nurses station. He spoke to a staff member at the desk and was observed wheeling his chair down the hallway toward his room. The resident's hospital gown was open in the back and exposed his back from shoulder to waist. The evening RN supervisor was standing at the elevators facing the resident. She stated to the surveyor the staff "just put him" in his hospital gown and he had already been in bed. She said he was often anxious about his medications and as a result, came out to the nurses for reassurance. The RN did not attempt to cover the resident.

In summary, the facility did not maintain the resident's privacy of body when he was sufficiently covered when out of his room.

2) Resident #51 had diagnoses including arthritis, coronary artery disease (CAD) and depression.

The Minimum Data Set (MDS) assessment dated August 22, 2012 documented the resident was cognitively intact, required total assistance with dressing and was always incontinent of bowel and bladder.

The comprehensive care plan (CCP) dated December 3, 2012 documented the resident required assistance with dressing both the upper and lower half of her body, and wore briefs that were changed every 2 to 3 hours.

On December 6, 2012 at 9:05 AM, the resident was observed sitting up in bed. Her hospital gown was in front of her, off her shoulders, and her back and her incontinent briefs were exposed. The resident was visible from the doorway and from her roommates side of the room. At 9:10 AM the registered nurse (RN) Manager entered the room to answer her roommate's call bell, she spoke to the roommate and left the room. The licensed practical nurse (LPN) entered a minute later, spoke to the resident's roommate and left the room. At 9:15 AM two certified nurse aides (CNAs) returned to the room to provide the resident with her breakfast tray. At that time, the CNA covered the resident.

In summary, the facility did not maintain the resident's privacy of body when two licensed staff members entered the resident's room and did not sufficiently cover the resident in a timely manner.

3) On December 5, 2012 between 1:05 and 1:12 PM, a certified nurse aide (CNA) was observed setting up lunch trays in the Unit 3 dining room. The CNA was observed to abruptly place items on trays in front of unidentified residents. Small amounts of liquids were observed spilling during this process and the staff member was did not clean up the spills.

During the resident group meeting, held with 12 anonymous residents, on December 6, 2012 at 10:45 AM, the residents stated staff (CNAs) ignored residents and did not treat them in a dignified manner. They stated, for example, when preparing their trays at meal time, if the staff member spilled a drink onto food items, they left it and did not replace the items or clean up the spill.

Review of the resident council minutes revealed this concern was discussed at the September 19, 2012 meeting.

On December 5, 2012 at 5:50 PM, a CNA was observed pouring Resident #40's drink into a glass, when it squirted from the container into the resident's coffee. The CNA walked away and made no attempt to replace the resident's coffee.

On December 11, 2012 between 12:25 PM and 12:45 PM a CNA was observed bringing a cup of ginger ale to an anonymous female resident. The liquid was spilling over the sides of the cup as the CNA walked to her. The CNA placed the cup on the resident's place setting, did not dry or clean it, and walked away wiping her own hands on her scrub top.

In summary, the facility did not provide a dignified dining experience for the residents.

10 NYCRR 415.5 (a)

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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: December 14, 2012

Based on observation, staff interview and record review conducted during the standard survey, it was determined for 5 of 13 residents (Residents #1, 6, 9, 16, and 37), reviewed for infection control and 5 residents outside of the sample (Residents #50, 52, 63, 69, and 70), the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection. Specifically:
- for Residents #6, 50, and #52, droplet precautions were not appropriately implemented;
- infection control techniques were not maintained during Resident #16's tracheostomy (trach) stoma (a direct airway through the trachea allowing a person to breathe without using the nose or mouth) care;
- Residents #1, 37, and 70 were not provided with food/beverages according to proper infection control procedures;
- there were breaches in hand hygiene technique during medication administration to Residents #9 and 69; and
- the glucometer used on Resident #63 was not properly disinfected.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS OF June 18, 2012, October 14, 2011, and January 14, 2011.

Findings include:

TRACHEAL STOMA CARE:
Resident #16 had diagnoses of laryngeal carcinoma (cancer of the voice box), status post laryngectomy (removal of the voice box and separation of the airway from the mouth and noise), and tracheostomy.

The Minimum Data Set (MDS) assessment dated August 22, 2012 documented the resident was cognitively impaired.

The physician's orders dated December 4, 2012 documented the resident was to receive suctioning as needed orally and nasopharyngeal and routine trach care every shift.

On December 6, 2012 at 10 AM, licensed practical nurse (LPN) #1 was observed doing the resident's stoma care. LPN #1 set up her supplies and washed her hands. When washing her hands, LPN #1 did not use friction with washing or rinsing. After cleansing the resident's stoma, LPN #1 obtained an uncovered suction catheter that was hanging over the resident's wall oxygen set-up, wiped it with an alcohol pad, and used the catheter to suction around the resident's stoma.

On December 6, 2012 at 3:30 PM, LPN #2 was observed doing the resident's stoma care. LPN #2 washed her hands, then she picked up the resident's bed control and the fall mattress from the floor. LPN #2 without engaging in hand hygiene, donned gloves and administered stoma care. After cleaning the resident's stoma, LPN #2 took an uncovered suction catheter, that was hanging over the resident's wall oxygen set-up, and suctioned around the resident's stoma. LPN #2 did not clean the catheter before she used it. When she finished the resident's stoma care, LPN #2 washed her hands, for less than 10 seconds, without using friction.

The Infection Control registered nurse (RN) stated in an interview on December 6, 2012 at 4:05 PM she reviewed proper handwashing techniques with new employees at the time of hire.

During an interview on December 13, 2012 at 10:20 AM with LPN #1, she stated she cleaned the resident's suction catheter with an alcohol pad prior to using it and that was her usual process.

LPN #2 was unavailable for interview on December 13, 2012.

In summary, for Resident #16, the facility did not ensure proper infection control techniques were utilized during resident care in regards to handwashing and suctioning.

PRECAUTIONS:
2) Resident #6 had diagnoses including quadriplegia, cerebral palsy, and coronary artery disease.

The comprehensive care plan (CCP), updated on October 22, 2012, documented the resident was able to make herself understood, understood others, and required total assistance with activities of daily living (ADL).

A physician's progress note dated November 26, 2012 documented the resident was seen for a "complaint of viral-like syndrome for the last day or so with a non productive cough."

A physician's order dated November 27, 2012 documented the resident was to receive Tamiflu (used to treat flu) 75 milligrams (mg) every day for 14 days.

A physician's order dated November 29, 2012 documented the resident was to be on droplet precautions for 7 days.

There was no documented evidence the resident's CCP was updated to include droplet precautions.

The nursing progress notes documented on November 29, 2012, the resident appeared to be acutely ill, with a cough, and was to be on droplet precautions for 7 days.

The registered nurse (RN) Manager stated in an interview on December 5, 2012 at 10:30 AM, the resident was on droplet precautions.

The Resident Plan of Care (RPOC) dated December 5, 2012 did not document the resident was on droplet precautions.

On December 6, 2012, a nursing Infection Control progress note documented the resident had a productive cough with green-colored sputum. The resident was to continue on droplet precautions.

A nurse practitioner progress note dated December 6, 2012 documented the resident had a cough with a productive sputum of greenish color and remained on droplet precautions.

During an observation on December 6, 2012 at 9:40 AM, the certified nurse aide (CNA) entered the resident's room without wearing a mask, gown or gloves. The CNA set-up the meal tray and left the room. At 9:50 AM the CNA entered the resident's room and removed the meal tray without wearing a mask, gown, or gloves.

On December 6, 2012 at 4:30 PM, the Infection Control RN stated in an interview if a resident was on droplet precautions, staff were to wear a gown, gloves, and a mask when going into the room.

In summary, the facility did not follow infection control precautions for a resident on drop precautions when they went in to her room with out donning gown, gloves, or mask.

FOOD AND BEVERAGE HANDLING:
3) Resident #37 had diagnoses including aphasia, and spastic quadriplegia.

The Minimum Data Set (MDS) assessment dated June 28, 2012 documented the the resident was dependent on staff for eating.

The Infection Control registered nurse (RN) stated in an interview on December 6, 2012 at 4:05 PM that the facility had "so much flu" and she reviewed handwashing with new staff at the time of hire.

During an interview with the Director of Nursing (DON) on December 7, 2012 at 9 AM, she stated that the facility started the "whole house on Tamiflu" and staff were monitored for illness and sent home if they were ill.

On December 10, 2012 between 12:41 PM and 12:50 PM, a certified nurse aide (CNA) #1 was observed feeding the resident a grilled cheese sandwich with her bare hands. During the meal, CNA #1 was coughing into a napkin and did not engage in hand hygiene and continued to feed the resident.

On December 10, 2012 at 1:50 PM, CNA #1 stated in an interview, she did not wear gloves when she fed the resident a sandwich that day and she did not state a reason. She stated she was not sick, she had "allergies" and that was why she was coughing when she fed the resident.

In summary, the facility did not ensure staff utilized proper infection control techniques when feeding residents.

GLUCOMETER CLEANING
4) The facility policy, Blood Glucose Monitoring, revised August 2012, documented that following each finger stick glucose testing, staff are to disinfect the exterior surfaces of the glucometer with Clorox wipes in a concentration of 1:10. The wipes are stored locked in the medication cart.

At 8:18 AM on December 6, 2012, a surveyor observed Resident #63's glucose fingerstick testing, performed by a licensed practical nurse (LPN) medication nurse. Upon completion of the test, the LPN wiped the top of the glucometer with alcohol hand sanitizer.

During an interview with the LPN at 8:22 AM on December 6, 2012, she stated she used alcohol to clean the glucometer after use. She stated she did not know how other nurses cleaned glucometers, as she was an agency nurse.

In summary, the facility did not ensure staff properly disinfected a glucometer after use.

10NYCRR 415.19

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: February 14, 2013

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.

Based on observation, record review, and staff interview conducted during the standard and abbreviated surveys (complaint #NY00123975), it was determined the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated and reported to the New York State Department of Health (NYSDOH) when necessary for 1 of 18 residents (Resident #15), reviewed for accidents, 2 of 18 residents (Residents #45 and 46), reviewed for abuse/neglect, 1 of 13 residents (Resident #47), reviewed for swallowing concerns, and 2 residents outside of the sample (Resident #54 and 55). Specifically:
- For Resident #47, the facility did not thoroughly investigate and report a choking incident to the NYSDOH.
- For Resident #46 the facility did not thoroughly investigate allegations of abuse and did not ensure the resident was protected from the accused while the investigation was pending.
- For Residents #45, 54, and 55, the facility did not investigate or report to the NYSDOH incidents of resident to resident sexual aggression and did not develop a plan to prevent further potential abuse.
- For Resident #15, the facility did not thoroughly investigate 2 incidents of falls.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #47 had diagnoses including dementia, Parkinson's disease and dysphagia.

The Minimum Data Set (MDS) assessment dated August 1, 2012 documented the resident had severe cognitive impairment, required limited assistance with eating, and was on a mechanically altered diet.

The physician's orders dated August 25, 2012 documented the resident was to receive a ground diet with pureed fruits and vegetables, and nectar thick liquids.

On September 7, 2012, the Supervisor shift report documented the resident was coughing and choking at supper and was suctioned.

An incident report dated September 7, 2012 documented the resident began to cough, brought up small pieces of food, continued to cough, and was "unable to clear" (the airway). The resident was suctioned for a moderate amount of food particles. The report documented staff were educated to supervise the resident's eating. The report was completed by the licensed practical nurse (LPN) on September 7, 2012; signed by the registered nurse (RN) Manager on September 14, 2012; signed by the Director of Nursing (DON) on September 17, 2012; signed by the Administrator on September 20, 2012, and signed by the Medical Director on September 27, 2012. There were no staff or witness statements attached to the report, the investigation did not document who fed the resident, whether the resident was properly fed, or whether the resident received the food and fluid consistency as ordered.

On September 8, 2012 the physician documented the resident had an "episode of aspiration" (taking foreign matter into the lungs, such as food) the previous day. The resident was eating her meal "being fed by her husband" and the episode of aspiration was reported to include food "such as tater tots."

The DON was interviewed on December 13, 2012 between 10 AM and 10:15 AM and stated when an investigation was done, staff involved or working that shift were to be interviewed and witness statements were to be completed. She stated choking was a negative outcome and was reportable to the NYSDOH. The DON stated she did not complete the incident report when the resident choked as someone else was responsible for investigations at that time. She stated the report was not complete, it should include witness statements, and should have been reported to the NYSDOH.

In summary, for Resident #47, the facility:
- did not ensure a choking incident was thoroughly investigated as the investigation did not determine whether the resident received the proper food/liquid consistency, who fed the resident, or whether proper feeding techniques were utilized; and
- did not ensure the choking incident was reported to the NYSDOH as required.

2) Resident #46 had diagnoses including dementia, anxiety and depression.
i
The 24 hour report dated October 4, 2012 documented the resident reported being raped by a certified nurse aide (CNA). The resident's family called the police, the Nurse Manager was aware, and an investigation was initiated.
i
The physician's progress note dated October 4, 2012, documented the resident stated an employee raped her and "unfortunately" as a result of her dementia, it was difficult to determine if that was an accurate statement. The note documented social services and nursing would be involved and if the resident's account appeared legitimate the nurse practitioner (NP) would examine the resident and determine if any type of penetrating injury had occurred. The physician's progress note documented the resident's "statement will be investigated in its entirety."

The registered nurse's (RN) progress note dated October 4, 2012, documented:
- she was notified by the physician the resident "accused" a CNA of rape;
- the resident stated she screamed during the "entire incident";
- the resident did not initially state she was raped;
- her account of the incident was inconsistent;
- when the NP examined the resident the resident stated she was raped "back here" pointing to her buttocks;
- the RN asked the licensed practical nurse's (LPN) who worked the evening on October 3, 2012 if she heard screaming and the nurse stated she heard staff "yell" for her and she went to "the room" during care.

The LPN's progress note dated October 4, 2012, as a late entry for October 3, 2012, documented she heard staff yell from the resident's room, she went to the room and found the resident in the bathroom being washed up by the CNA. The LPN documented the resident stated "we were awful people" and would be sorry in the morning.

The Minimum Data Set (MDS) assessment dated October 9, 2012, documented the resident had severely impaired cognition, required extensive assistance for hygiene care and toileting, was usually understood and understood others, did not have behavioral symptoms, and did not reject care.

An undated "Investigation and Conclusion" and "Investigation Summary" documented:
- on October 4, 2012, the resident told her family member a staff member "raped her the day before;"
\i - there was no evidence of physical abuse, neglect or harm;
- the "Impression" was the resident had advanced dementia and a history of behaviors. The resident was in a facility that was not familiar to her and she was angry at her family for placement in the facility;
- the resident was unable to determine if a staff member, or a resident, committed a crime against her; and
- there was no evidence of sexual assault or abuse found.

There was no documented evidence witness statements were obtained from staff who worked the evening of October 3, 2012 when the alleged incident occurred with the exception of the LPN progress note. There was no documented evidence in the investigation or the resident's medical record the resident was protected from the accused CNA while the investigation was pending.

The RN Manager stated during an interview on December 12, 2012 at 12:30 PM, she determined the alleged abuse did not occur as there were inconsistencies in the resident's "story." She stated the accused CNA was not removed from resident care during the investigation as "by the time" she had talked to the CNA it was a "dead issue." She stated the accused CNA denied the accusations, he "did not look suspicious," and she could tell if someone was suspicious. The RN stated she did not report the incident to the NYSDOH as that was not her responsibility.

The Director of Nursing (DON) was interviewed on December 12, 2012 at 2:30 PM, and stated she believed a thorough investigation was completed. She stated an investigation was started immediately and there was no evidence to support the incident had occurred.

In summary, the facility did not ensure a thorough investigation, of alleged sexual abuse, was completed to determine if abuse occurred, as they:
- did not conduct thorough interviews with all staff involved with caring for the resident at the time of the incident; and
- did not protect the resident from further abuse, while the investigation was pending, as the accused CNA continued to provide care to the resident.

3) Resident #45 had diagnoses including dementia.

The resident comprehensive care plan (CCP) dated September 26, 2012 had no documentation regarding concerns with behavior.

The Minimum Data Set (MDS) assessment dated October 1, 2012 documented the resident's cognition was moderately impaired. The resident did not exhibited behavioral symptoms, did not reject care, did not wander, and was independent with mobility.

A nursing progress note dated October 11, 2012 documented, the "resident participated in inappropriate sexual behaviors this shift" and the residents were separated.

A resident Event Report completed by a registered nurse (RN) on October 11, 2012 was completed for Resident #54 documenting a sexual incident between Residents #54 and #45. There was not an Event Report completed for Resident #45.

There was no documented evidence Resident #45's CCP was updated following the sexual incident with Resident #54 to prevent further incidents.

A nursing progress note dated November 10, 2012 documented, the "resident was involved with inappropriate sexual behaviors" with another resident (Resident #55).

There was no documented evidence an Event Report was completed following the November 10, 2012 incident and no documented evidence Resident #45's CCP was updated to prevent further sexual incidents.

A nursing progress note dated December 6, 2012 documented, "another resident was laying" on the resident's bed and he was standing next to the bed. The other resident (Resident #55) was redirected out of the room "without incident. There had been no physical contact." There was no documented evidence how staff determined there had been no physical contact between the residents as an investigation was not documented.

A nursing progress note dated December 11, 2012 at 3:30 PM, documented a CNA was heard yelling loudly down the hall asking staff if they had seen Resident #45. The CNA opened the door to the resident's dimly lit room accompanied by the RN Manager and a surveyor. One of the staff members was heard stating "you can't be in there together" and Resident #55 was escorted by staff out of the room. Resident #45 exited the room independently and began swearing at the staff and stated they had no right to remove her from his room.

The RN Manager's progress note dated December 11, 2012 documented at "approximately" 3:30 PM that day, a female resident was lying on the resident's bed. The female was redirected to leave the room and the resident became loud, angry and used profanity.

During an interview with the RN Manager on December 11, 2012 at 5:56 PM, she stated other female residents could be at risk as a result of the resident's behaviors and she should have changed the CCP to implement a plan to protect residents from sexual incidents.

The CNA who was looking for the resident at 3:30 PM on December 11, 2012, was interviewed at 6:45 PM on December 11, 2012. She stated staff were told to try to keep those 2 (Residents #45 and #55), away from each other. She said it was difficult to watch the resident all the time and said "I think they have a thing for each other." She said they had been found together on more than one occasion during the past week and she was told by staff, Resident #45 was found "sometimes" with "his pants down." She said the unit licensed practical nurse (LPN) was aware of the incidents between the two residents.

There was no documented evidence the facility investigated the alleged incident where the resident was found with Resident #55 with his "pants down."

The Director of Nursing (DON) was interviewed on December 11, 2012 at 7:40 PM and said there were no other investigations initiated or completed related to resident to resident sexual behavior. She said, on the dementia unit, the residents wandered and Resident #55 was known for wandering in and out of other resident rooms. The DON said from the information she had, there was no evidence the residents "were doing anything." She said she reviewed the incident from December 6, 2012 and did not see a need to conduct and investigation. She was not aware of any incidents from December 6 - 11, 2012.

On December 11, 2012 at 8:20 PM an LPN familiar with the residents was interviewed and stated she was told last "Thursday or Friday" by the RN Manager to tell the CNAs to keep the residents apart. She stated she believed it was "on Friday" when an incident occurred and Resident #55 was found in Resident #45's room. She observed Resident #55 not "fully dressed" when she was removed from Resident #45's room. The LPN stated the RN Manager was notified when it happened.

There was no documented evidence the facility investigated the incident when Resident #55 was found partially clothed in the resident's room.

During an interview with the DON on December 12, 2012 at 11:43 AM, she stated she had not heard anything regarding recent incidents with Resident #45. She stated she spoke to the RN Manager and CNAs on that unit and it was determined there was no evidence of sexual contact between the residents.

The DON was interviewed on December 13, 2012 at 10 AM and stated incident reports were usually initiated by the RN Managers and should include statements from staff involved/working on the date of the incident. She stated any incident with a negative outcome was reportable to the NYSDOH. She said included resident to resident abuse was an example of a reportable event.

In summary, the facility:
- did not conduct a through investigation of incidents of resident to resident sexual aggression to determine if abuse occurred;
- did not develop a plan to prevent further sexual aggression; and
- did not report resident to resident sexual aggression to the NYSDOH.

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

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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: December 14, 2012

Based on record review and staff interview, conducted during the standard survey, it was determined for 4 of 18 residents (Residents #15, 45, 46 and 47), reviewed for abuse and neglect, and for 2 residents outside of the sample (Residents #54 and 55), the facility did not implement written policies and procedures that prohibited mistreatment, neglect and abuse of residents. Specifically, for Resident #15's falls, Residents #45, 54 and 55's resident to resident sexually aggressive behavior, and Resident #46's alleged abuse from a staff member, staff did not operationalize the facility's written policies and procedures for resident abuse/neglect reporting and investigation. 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 June 18, 2012

Findings include:

1) Resident #47 who had diagnoses including dementia and dysphagia, had a choking incident on September 7, 2012 and the investigation was not thorough or complete. The incident was not called into the New York State Department of Health in accordance with State law.

2) Resident #45 who had diagnoses including dementia, had 4 documented resident to resident incidents that involved either Resident #54 or #55 and the incidents were not thoroughly investigated.

3) Resident #15 had diagnoses including early dementia, depression, and osteomyelitis, and had 2 falls in October 2012. There were no investigations completed regarding these falls.

4) Resident #46 who had diagnoses including dementia and depression reported alleged abuse from a staff member. The investigation into the allegation was not thorough and there was no documented evidence the facility protected the resident from the accused while the investigation was pending.

The facility Abuse Policy revised by the Director of Nursing (DON) in August 2012, documented the facility:
- will adhere to laws on reporting of and response to alleged and substantiated incidents of resident abuse, neglect and mistreatment;
- all reports of mistreatment, neglect or abuse of residents will be thoroughly investigated; and,
- residents involved in allegations of abuse will be protected from harm during investigations of reported abuse.

The Director of Nursing (DON) was interviewed on December 13, 2012 between 10:00 AM and 10:15 AM. She stated she recently took over the responsibility of reviewing all incidents/investigations related to abuse, neglect or mistreatment. She was aware there was a problem with the previous person who reviewed the reports, and stated she was not aware of the problem "to this level".

In summary, the facility did not operationalize the facility's written policies and procedures for resident abuse/neglect reporting and investigations.

10NYCRR 415.4(b)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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

Based on record review, observations, and resident and staff interviews conducted during the standard survey, it was determined the facility did not ensure acceptable parameters of nutritional status were maintained for 5 of 11 sampled residents (Residents #10, 14, 15, 16, and 31) reviewed for weight and nutrition concerns. Specifically, the facility did not complete Resident #10's reassessments timely, did not update the plan of care, did not implement strategies to address nutritional status, and did not ensure the resident's supplements were received. For Resident #14, the facility did not ensure a weight change was evaluated timely and did not reassess the plan of care. For Resident #15, dietary did not reassess the resident timely after the development of a deep tissue injury. For Resident #16, the facility did not complete a timely re-weight. For Resident #31, there was no documented evidence that weekly weights, twice a week weights and reweights were done per physician's orders and plan of care. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings Include:

1) Resident #14 was admitted in June 2012 with diagnoses including Alzheimer's disease, depression, diverticulosis and gastroesophageal reflux disease (GERD).

On September 5, 2012, the Nutrition Care Plan Review Evaluation documented the resident's weight was within the goal weight of 150 to 160 pounds and was 155.1 pounds at that time.

The Minimum Data Set (MDS) assessment dated September 5, 2012 identified the resident with severe cognitive impairment; required set up and supervision with eating; and weighed 155 pounds.

On September 5, 2012, the resident's comprehensive care plan (CCP) documented the resident's weight was overall stable. The goal was met and ongoing.

The unit weight book documented the resident's weight on October 1, 2012 was 157.7 pounds; on November 1, 2012, the resident's weight was 151.8 pounds in this weight book. There was no documented evidence the resident was re-weighed following the loss of greater than 5 pounds from October 2012 to November 2012.

On November 15, 2012, the physician progress note documented the resident's weight was 157.7 pounds "which is up about 2 pounds". There was no documented evidence the physician was aware of the documented weight of 151.8 pounds on November 1, 2012.

On December 1, 2012, the resident's weight was recorded in the weight book as 141.4 pounds.

A dietary progress note, completed by the dietitian, dated December 5, 2012, documented she was aware "via wt (weight) book review", the resident had a 10.7 pound weight loss in one month. The dietitian described the resident's intake as "remains fair" and specified she would reassess the resident's nutrition plan of care when a reweight became available.

The resident was observed on December 5, 2012 from 12:30 PM to 1:30 PM. The resident was served his meal at 1:15 PM; ate approximately 2 bites of the meal; got up from the table at 1:18 PM and walked out of the dining room.

The evening meal was observed being served at approximately 5:30 PM. The resident was observed leaving the table at 5:35 PM. Staff redirected the resident back to the table several times; at 6:37 PM, the resident had left the table and had eaten half a roll and drank a glass of juice and milk.

Review of the resident's Meal Monitoring Record for December 3, 2012 through December 9, 2012 revealed the resident ate 50% or less of solids for 19 out of the 21 meals. Nine of these 19 meals were documented as refused (R) or 0% intake.

Review of the resident's Snack Summary for December 3, 2012 through 12, 2012 revealed no documented evidence the resident consumed his bedtime (HS) snack during this time.

On December 11, 2012, the registered nurse (RN) Manager was interviewed between 2:45 PM and 3:15 PM regarding weights. She stated the policy specified the "day aides'" were to weigh the resident's and enter these weights into the weight book. She stated the dietitian reviewed the information and notified the RN Manager if a resident had a weight loss. The RN explained that the dietitian then made up a sheet of residents who required re-weights and nursing would follow through based on dietary's recommendations.

On December 12, 2012, the interdisciplinary team documented a care plan conference was held for this resident. Notes from the conference documented the resident's weight was stable and there was no documented evidence that changes were made to the resident's CCP related to his nutritional needs.

The unit re-weight record for December 2012 was reviewed on December 13, 2012. As of that date, there was no documented evidence the facility obtained a reweight for the resident.

The dietitian responsible for the resident's plan of care was interviewed on December 13, 2012 at 12:10 PM. She stated the certified nurse aides (CNAs) had 7 days from the first of the month to do the monthly weights. The dietitian reviewed the weights once they were recorded for the month, and then calculated the percentage of change. If there was a significant change of 5% in one month, the dietitian requested a reweight and the CNAs had 5 days to obtain the residents' reweights. The dietitian checked daily for these reweights. If the reweight verified the initial weight, the resident's plan of care would be reassessed, and a progress note was written. The dietitian reviewed the weight book and calculated Resident #14's weight to reflect a 10.7% weight loss in one month. Upon noticing a reweight had not been completed, the dietitian stated she would give staff a "gentle reminder". If the reweight showed the resident had this significant weight loss, she would "just update the profile and let staff know".

In summary, for this resident who had a documented significant weight loss in one month and whose intake was fair to poor, the facility:
- did not verify the resident's weight change in a timely manner; and
- did not reassess the resident's plan of care based on the weight loss and decreased intake.

2) Resident #10 had diagnoses including dementia, depression, and epilepsy.

The Minimum Data Set (MDS) assessment, dated August 29, 2012, documented the resident's cognitive status was severely impaired, she was able to understand others and make herself understood some times, and required assistance from staff for all activities of daily living (ADLs). The MDS recorded the resident had a poor appetite almost every day and weighed 90 pounds.

Review of the resident's records revealed the resident weighed 90 pounds August 28, 2012; weighed 82 pounds on October 26, 2012. Review of the resident's comprehensive care plan (CCP) revealed the resident's nutritional status was not re-assessed in October 2012 when the resident lost 8 pounds (8% loss) 1 month.

The dietitian's progress notes dated November 1, 2012 documented the resident had a significant weight loss of 14.2 % over the past month. The dietitian stated staff recommended chocolate milkshakes and a donut be added throughout the day. On November 14, 2012 the dietitian documented she was notified of the resident's poor food intake and documented she would add a peanut butter and jelly sandwich with meals.

Review of the resident's meal monitoring record and snack summary documented for the week of:
- November 5, 2012, the resident refused 10 of 19 meals and 5 of the 11 snacks offered.
- November 12, 2012, the resident refused 10 of 21 meals and 14 of 26 snacks offered.
- November 19, 2012, the resident refused 10 of 19 meals and 5 of 11 snacks offered.
- November 26, 2012, the resident refused 12 of 21 meals and 18 of 22 snacks offered.

The resident's weight record documented the resident weighed 78 pounds on November 26, 2012, reflecting an additional 4 pound loss from October 2012.

The resident's plans of care (RPOC) dated December 5, 2012 and December 11, 2012 did not have interventions documented that would assist or encourage the resident to increase her meal and fluid intake.

When interviewed on December 13, 2012 at 9:20 AM, the registered nurse (RN) Manager stated she thought it was "around November 6", 2012 when she was notified of the resident's weight loss. The RN Manager stated that the weight loss "was an ongoing thing". She stated she told her staff the resident had lost weight; they were to encourage her to come to the dining room for meals and give her what she wanted to eat. She stated she felt the situation was a dietary issue. The RN Manager said weight loss had not been discussed with the interdisciplinary team because the resident was not due for a team meeting until December 19, 2012. When asked, she was not sure if the resident consumed her nourishment snacks as planned.

The dietitian was interviewed on December 13, 2012 at 12:10 PM and stated she was not aware the resident had refused all nourishments that week.

In summary, the facility did not:
- make timely reassessments of the resident's nutritional status;
- did not evaluate and revise the resident's plan of care as needed to ensure its effectiveness; and
- did not ensure the resident was provided supplements as planned.

3) Resident #31 had a diagnosis including chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and obesity and was admitted on October 5, 2012.

The admission nutrition screen, dated October 5, 2012, documented the resident's weight was 250 pounds, reflecting a 20 to 25 pound loss from January 2012.

The comprehensive care plan (CCP), dated October 11, 2012, documented the resident was to be weighed weekly for 4 weeks, then monthly, and then as needed.

The resident's nutritional evaluation dated October 11, 2012 documented the resident's weight was pending.

The resident's Minimum Data Set (MDS) assessment dated October 19, 2012 documented the resident had moderate cognitive impairment. The resident's weight was documented to be 250 pounds.

Review of the weight worksheet for October 2012 revealed no documented weekly weights for the resident.

The November 2012 weight worksheet documented the resident weighed 272.6 pounds (no specific date given).

The physician's order, dated November 3, 2012, documented the resident's weight was to be checked every Monday and Thursday.

Physician's progress notes, dated November 6, 2012, documented the resident had a weight increase of 22.6 pounds. The documented plan was to check weights every Monday and Thursday.

The November 2012 weight worksheet documented the resident's reweight was 253 pounds (no specific date given).

On November 13, 2012, the physician's progress note documented the resident was refusing to be weighed.

Nutrition progress notes, dated November 20, 2012, documented the resident was "continuing to experience a poor appetite" and the need to increase the resident's intake. The resident's weight status was not addressed at that time

The December 2012 weight worksheet documented the resident weighed 236.8 pounds (no specific date given.)

The dietitian, was interviewed on December 13, 2012 at 9:50 AM, to discuss the resident's fluctuating weight status and poor intake. The resident's weight in October 2012 was 250 pounds; in November 2012 was 272.6 pounds with a reweight of 253 pounds; and December 2012 weight of 236.8 pounds. The dietitian stated the resident's appetite was poor. She stated she updated the resident's preferences and was offering those foods. She stated she ordered a re-weight for December 2012 but was not given the result.

There was no documentation in the resident's medical record or plan of care that the resident had a pending re-weight or of the "Monday and Thursday" weights as ordered.

The registered nurse (RN) Manager, when interviewed on December 13, 2012 at 12:40 PM, stated she was not aware of any reweights being scheduled for December. She stated the weight folder did not have any reweights listed for December.

In summary, there was no documented evidence that weekly weights, twice a week weights and reweights were obtained for the resident per physician's orders and plan of care.

10 NYCRR 415.12(i)(1)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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: December 14, 2012

Based on observation, review of resident council minutes, and interview with staff and residents during the standard survey, it was determined the facility did not ensure 216 residents (who have oral intake) on 5 of 5 skilled nursing units the had the right to make choices about aspects of their life that were significant to them (including 10 anonymous residents at the resident group meeting and Resident #59). Specifically, the remodeling of the dining areas on each of the 5 units led to the elimination of the residents' ability to independently access snacks, as desired. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) During the resident group meeting held on December 6, 2012 at 10:45 AM, 11 anonymous residents told the surveyor they no longer could get snacks independently. They stated the facility had remodeled all the food service areas and this interrupted their access to snacks. The residents stated refrigerators were accessible, but they could no longer independently help themselves to crackers, cookies, and other "dry goods" for between meal snacks.

On December 7, 2012 at 11:30 AM, Resident #59 stated she was upset she was unable to get crackers independently as she had in the past. She escorted the surveyor into the unit dining room to show the current set up, which restricted residents from access to the nourishment kitchen. In the cupboards in the nourishment kitchen were: diet cookies, graham crackers, saltine crackers, and bread. A refrigerator was available, to the residents, in the dining room. Resident #59 stated "if you want something to eat, you can't get it".

On December 7, 2012 at 2:20 PM, the Food Service Manager was interviewed. He stated the residents had access to ice cream and he was not aware of any current system to allow residents access to snacks such as cookies and crackers. He stated residents were not allowed in the pantry (nourishment kitchen), behind the steam table.

In summary, the facility did not allow residents the right to obtain snacks of their choosing, when independent access to these items was significant to the residents.

10 NYCRR 414.5 (b)(1-3)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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: December 14, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure appropriate treatment and services were provided to 1 of 9 residents (Resident #32) reviewed for psychotropic medications. Specifically, for Resident #32, the facility did not reassess and implement an individualized plan to address the resident's mental and psychosocial adjustment difficulty when he consistently refused care and meals. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF JUNE 18, 2012.

Resident #32 had a diagnosis of depression, and status/post motor vehicle accident with brain injury.

The admission history and physical dated June 18, 2012 documented the resident was being treated for depression with Celexa (an antidepressant) 20 milligrams (mg) daily.

The physician note dated August 7, 2012 documented the resident was counseled regarding his hygiene. "He has been very resistant to taking a bath or shower" and gets very combative with the staff. "I am trying an Ativan (antianxiety) 0.5 milligrams (mg) 30 minutes before his shower to see if we can calm his agitation and will monitor his response to treatment."

The Minimum Data Set (MDS) assessment dated September 12, 2012 documented the resident had severe cognitive impairment, moderate depression and rejected care.

A nursing progress note dated September 14, 2012 documented the resident's body odor was very strong and he refused to bathe. The staff documented several attempts were made to encourage the resident to bathe. The nurse practitioner (NP), registered nurse (RN) Manager, and Director of Nursing (DON) were notified.

The comprehensive care plan (CCP) dated September 28, 2012 documented the resident received Celexa (an antidepressant) for depression. The CCP documented, many years ago the resident was diagnosed with bipolar disorder, and was never treated as he spent much of his life homeless. The CCP did not address the resident's former lifestyle, his past diagnosis of bipolar disorder, or interventions to address his psychosocial well-being.

The recreation progress note dated September 28, 2012 documented the resident refused all group program invitations. The plan included on going one to one visits, and keeping the resident informed of scheduled events.

The nutrition progress note dated October 18, 2012 documented the resident refused medications, showers, meals, fluids, and weights. The note documented he stayed in bed until supper, which was the only meal he ate.

The physician's progress note dated November 14, 2012 documented the resident was noncompliant with his medications and his daily hygiene.

The physician's order dated November 14, 2012 documented the resident continued to receive Celexa 20 mg daily and Ativan 0.5 mg, twice a week, 30 minutes before his shower.

The resident's meal monitoring record dated November 26 - December 12, 2012 documented he refused to eat 28 of 48 meals provided.

During an observation between 8:55 - 10:20 AM on December 6, 2012, the resident was in bed awake. He stated to the surveyor he did not eat breakfast and was not offered a breakfast tray that morning.

During an interview with CNA #4 on December 6, 2012 at 12:05 PM, she stated she did not give the resident breakfast because he normally refused it.

The resident plan of care (RPOC, used to direct care) dated December 7, 2012 documented the resident needed consistent verbal prompting to shower. There was no further documentation regarding resident refusals of care or interventions in place to address refusals.

The registered dietitian (RD) documented on December 11, 2012 the resident refused refused to speak to her or the speech language pathologist (SLP), and refused meals, even after being reapproached. The RD documented the plan was to monitor and reapproach as needed.

During an interview with the registered nurse (RN) Manager at 4:20 PM on December 11, 2012, she stated the resident refused weights, showers, activities of daily living (ADLs), and meals much of the time. She stated there was nothing specific in the CCP addressing his refusals.

During an interview with CNA #2 at 4:25 PM on December 11, 2012, he stated he was not able to get the resident to shower. He stated he told his charge nurse when the resident refused. He stated the resident often told him to get out of his room.

During an observation at 8:45 AM on December 12, 2012, the resident was awake and in bed. He refused to talk to the surveyor. The resident's room had strong urine and body odor.

During an interview with CNA #3 at 8:50 AM on December 12, 2012, he stated he was not successful in getting the resident to shower or complete his ADLs. He stated he told his charge nurse of the refusal.

During an interview with the master of social work (MSW) consultant on December 12, 2012 at 3:20 PM she stated she would expect the social workers to notify her regarding resident behavior, such as refusal of care. She said there was a mechanism in place for the social workers to contact her when needed.

In an interview on December 12, 2012 at 6:50 PM the MSW stated if a resident refused care, she would expect the staff to find out the reason why they were refusing.

During an interview with the registered dietitian (RD) at 9:50 AM on December 13, 2012, she stated she tried to talk to the resident about his poor intake at meals and his preferences but he refused to allow her in his room. She stated she observed him occasionally eating in the dining room. The RD said the resident refused to be weighed since July 2012. The nursing staff weighed residents when they received a shower but he refused showers.

In summary, the facility did not ensure treatment and services for mental psychosocial difficulties were provided when the resident consistently refused care and meals.

10 NYCRR 415.12(F)(1)

F492 483.75(b): COMPLIANCE WITH FEDERAL/STATE/LOCAL LAWS/PROFESSIONAL STANDARDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

Citation date: December 14, 2012

Arial Baltic; Based on record review and staff interview conducted during the standard survey, it was determined the facility did not comply with its provider agreement in regard to billing for 1 of 2 residents (Resident #49) who appealed the facility's decision to end Medicare coverage (requested a Medicare Demand Bill). The facility billed the resident and accepted payment of the private pay per diem rate prior to the appeal being resolved by the Medicare Intermediary. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Per a Medicare Cut A Letter dated September 10, 2012, Resident #49 was admitted to the facility August 15, 2012. The facility determined the resident's stay would not no longer be covered by Medicare September 12, 2012. The resident's representative signed the notice September 12, 2012 and checked that she wanted an appeal (wanted the Medicare Intermediary to review the facility's decision to end Medicare coverage).

Per an interview with health information management (medical records) staff on December 6, 2012 at 8:50 AM, Resident #49's payor source was private.

Per business office staff interviewed December 7, 2012 at 12:15 PM:
- another facility took over the business office function for this facility at the end of September 2012;
- the facility had not received a response from the Medicare Intermediary regarding Resident #49's appeal, as the demand bill had just been sent;
- Resident #49's private per diem charges for September 2012 had been paid;
- the business office was going to apply the September 2012 payment to another billing period; and
- current business office staff understood regulatory expectations regarding not billing and accepting payment while an appeal was undergoing review by the Medicare Intermediary.

Per an undated ledger for Resident #49, Resident #49's payor source was private, and the private per diem charge for September 2012 (after the resident's Medicare coverage ended) was $6270 for room and board from September 12 through 30, 2012.
The private payment of $6270 for September 2012 was credited on October 12, 2012.

In summary, the facility billed and accepted payment for private per diem charges prior to the appeal being resolved by the Medicare Intermediary.

10NYCRR 415.1(b)(4)

F250 483.15(g)(1): MEDICALLY RELATED SOCIAL SERVICES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Citation date: December 14, 2012

Based on record review and staff interview conducted during the standard survey, it was determined for 1 of 11 sampled residents (Resident #45), reviewed for provision of medically related social services, the facility did not ensure medically related social services to attain or maintain the highest practical physical, mental, and psychosocial well being were provided. Specifically, for Resident #45, social services did not assess the resident or develop and implement a safe plan of care to address the resident's behaviors following incidents with female residents. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings Include:

Resident #45 had diagnoses including dementia.

A transfer communication form dated September 12, 2012 documented the resident was wandering in to other resident rooms and was transferred from unit 2 to unit 6.

A nursing progress note dated September 12, 2012 documented the resident was wandering in and out of many rooms, pushed a certified nurse aide (CNA), and had "inappropriate talk." There was no explanation of what the "inappropriate talk" was.

The comprehensive care plan (CCP) dated September 26, 2012 had no documentation regarding any concerns with the resident's behavior.

The resident's Minimum Data Set (MDS) assessment dated October 1, 2012 documented the resident's cognition was moderately impaired, the resident did not have any behavioral symptoms, did not reject care, and did not wander. The resident was independent with mobility, and required limited assistance with personal hygiene.

Medicare skilled nursing observation charting notes dated October 1 - 5, 2012 documented the resident wandered the halls oblivious to safety, and on 3 occasions was resistive to care.

A social work annual note dated October 10, 2012 documented, "Inappropriate sexual behavior per LPN (licensed practical nurse)". There was no further documentation by the social worker related to the resident's behavior.

The social worker who documented the above incident was unavailable for an interview.

A Medicare skilled nursing observation charting note dated October 11, 2012 documented, "socially inappropriate behavior observed."

A nursing progress note dated October 11, 2012 documented, the "resident participated in inappropriate sexual behaviors this shift." Resident #54 was separated from Resident #45 and the supervisor was notified.

A resident event report dated October 11, 2012 documented the supervisor was called to the unit regarding "an inappropriate encounter between 2 residents" (Resident #54 and 45). The report documented Resident #54 approached Resident #45 "and lifted up her shirt and inserted her breast in to the resident's open mouth." The residents were redirected by staff and moved to different areas of the unit. The report documented the care plan was updated and family and social services were notified. The report recorded there was "no evidence of abuse or neglect noted." Both residents were "alert to self only" and "unable to recall incident." The Director of Nursing (DON) signed the report on October 12, 2012, the Medical Director signed the report on November 1, 2012, and the Administrator signed the report without dating it. There was no documented evidence on the report of social service involvement.

Both nursing and social work progress notes dated October 26, 2012 documented the resident was found arguing with another resident.

A nursing progress note dated November 10, 2012 documented, the "resident was involved with inappropriate sexual behaviors" with another resident (Resident #54). Staff escorted Resident #54 out of Resident #45's room.

There was no social work documentation related to the incident in the resident's medical record.

There was no documented investigation for the November 10, 2012 incident of inappropriate sexual behavior.

There was no documentation on the CCP regarding the resident's inappropriate sexual behavior.

A nursing progress note dated December 6, 2012 documented, "another resident was laying" on Resident #45's bed and he was standing next to the bed. The other resident (Resident #55) was directed out of the room" without incident. The note recorded there had been no physical contact between the residents.

There was no documented evidence, in the resident's medical record, that the resident's CCP was updated to reflect interventions and approaches to implement to prevent further incidents, and to protect the safety of the residents.

On December 11, 2012 at 3:30 PM, a CNA was heard yelling down the hallway, with panic in her voice, asking staff if they had seen Resident #45. The CNA then opened the door to the resident's darkly lit room accompanied by the RN Manager. One of the staff members was heard stating "you can't be in there together" and Resident #55 was escorted by staff out of the room. Resident #45 exited the room independently and began swearing at the staff and stated they had no right to remove Resident #55 from his room.

The RN Manager was interviewed on December 11, 2012 at 3:35 PM after Residents #45 and #55 were separated and she stated this "has happened before between these two." The RN said neither of the residents was competent to make the decision to be in a consenting sexual relationship.

During an interview with the registered nurse (RN) Manager on December 11, 2012 at 5:56 PM she stated:
- the social workers assigned to the unit for the past couple of months were new;
- she became aware of the incident when she walked by the resident's room, the resident was standing next to his bed, and there was a woman lying in the bed;
- the same thing happened with this female resident "last week" and it was documented in a progress note;
- an incident occurred on November 10, 2012 with another resident; and
- the most current social service note for this resident was dated October 10, 2012.

There was no documented evidence in the resident's medical record social services addressed the resident's sexually inappropriate behavior.

On December 11, 2012 at 6:45 PM, the CNA who found the residents together on December 11, 2012, was interviewed. The CNA stated staff were told to try to keep Residents #45 and 54 away from each other. She said they had been found together on more than one occasion during the past week and she was told Resident #45 "sometimes would have his pants down."

During an interview with the social worker on December 12, 2012 at 10:30 AM s he stated:
- this was not her primary unit, but she was covering today;
- she expected unit staff to make social services aware of resident incidents;
- she was not notified of the incident that occurred last night and she was not familiar with the residents involved;
- she did not assess the resident;
- she did not discuss the incident with the facility's Master of Social Work (MSW) consultant; and
- the only time she would be involved regarding these incidents was if the psychologist made recommendations.

The MSW consultant stated in an interview on December 12, 2012 between 3:20 - 3:45 PM, she was not informed of the incidents with Resident's #45 and 54. She said the social workers should have notified her of any resident to resident inappropriate behavior. The MSW stated these behaviors should have been addressed by social services, and there was a mechanism in place for her to be contacted whenever they needed her assistance.

In summary, the facility did not ensure social services assessed the resident or developed and implemented a safe plan of care addressing the resident's behaviors following incidents of inappropriate behavior.

10NYCRR 415.5(g)(1)(i-xv)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

Based on the comprehensive assessment of a resident, the facility must ensure that -- (1) A resident who has been able to eat enough alone or with assistance is not fed by naso gastric tube unless the resident ' s clinical condition demonstrates that use of a naso gastric tube was unavoidable; and (2) 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.

Citation date: December 14, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure 1 of 2 sampled residents reviewed for tube feeding (Resident #7) received the appropriate treatment and services to maintain health. Specifically, the facility did not ensure Resident #7's feeding tube placement was verified and feeding residuals were assessed, prior to administering a water flush. 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 June 18, 2012.

Findings include:

Resident #7 had diagnoses including quadriplegia due to anoxic (absence of oxygen) brain damage, gastrostomy (stomach feeding tube), and dysphagia (swallowing difficulty).

The comprehensive care plan (CCP), dated September 28, 2012, documented the resident required a PEG (percutaneous endoscopic gastrostomy) feeding tube related to the resident's multiple diagnoses. CCP interventions included staff were to check for tube placement, aspirate and measure residual contents prior to feedings, and flush before and after all feedings.

Observation of the resident on December 6, 2012 at 3:35 PM, found the resident's tube feeding alarm ringing. At 3:50 PM, the surveyor observe an licensed practical nurse (LPN) enter the resident's room. The LPN told the surveyor she was going to turn the resident's tube feeding off and flush the tube, prior to the certified nurse aides (CNA) rounds. The LPN then flushed the resident's PEG tube with 30 cubic centimeters (cc) of water. The LPN did not check for tube placement or any residual contents in the resident's stomach, before flushing the feeding tube with water. When interviewed, following the procedure, the LPN stated she should have checked placement prior to giving the resident water through her PEG tube.

The registered nurse (RN) manager was interviewed on December 6, 2012 at 4:00 PM. The RN manager stated the resident's tube should have been aspirated and checked for placement before administering the water flush.

In summary, the facility did not ensure the resident's tube placement was verified and residual amounts were checked prior to a water flush.

10 NYCRR 415.12(g)(2)

F431 483.60(b), (d), (e): PROPER LABELING OF DRUGS AND BIOLOGICALS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Citation date: December 14, 2012

Based upon observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not provide for safe and secure storage of controlled drugs and biologicals for 2 of 5 nursing units (Units 2 and 3). Additionally, a controlled drug for Resident #69 (outside the sample) was not disposed of in accordance with State law. Specifically, medication carts containing controlled drugs were not locked in accordance with State and Federal laws on Units 2 and 3. For Resident #69, a controlled drug was disposed without a witness to the disposal. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facility Narcotics Storage policy, dated October 21, 2009, documented only controlled substances that were necessary for the medication pass may be stored in medication carts. At the end of the medication pass, all controlled substances would be returned to the controlled drug cabinet in the medication room.

1) At 10:30 AM on December 6, 2012, a surveyor observed 2 medication carts in an unlocked closet on Unit 2, in the presence of 2 medication nurses. Neither cart was secured to prevent removal of the carts from the closet. A float LPN #3 (licensed practical nurse) was observed to unlock the medication cart and its controlled drug locked box. The controlled drug locked box contained multiple doses of the following narcotic pain relieving medications: OxyContin, Lortab, Norco, Percocet and the tranquilizer Librium. LPN #4 (agency nurse) opened the second medication cart and controlled drug locked box. The controlled drug locked box contained multiple doses of the following narcotic pain medications: morphine, hydrocodone, Lyrica, OxyContin, Lortab, percocet, and the anti-anxiety medication Xanax. LPN #4 stated it was not her practice to lock the medication cart to the wall.

During an interview at 11:06 AM on December 6, 2012, the registered nurse (RN) Unit Manager stated the medication cart should have been stored in a closet. She then moved the cart to a closet, and locked it to a cable attached to the wall.

2) On December 5, 2012 at 11:40 AM, on Unit 3, the surveyor observed 2 medication carts in a closet with the closet doors partially opened. Licensed practical nurse (LPN) #6 was interviewed at that time and stated her medication cart did not have narcotics in it at that time. She verified this and opened the cart. She stated the carts were stored in the unlocked closed and when she left the unit she would tether her cart to the wall. The second medication nurse, LPN #7, unlocked his medication cart. This second cart contained multiple doses of the following controlled drugs: clonazepam (type of sedative), lorazepam (anti-anxiety), morphine, and alprazolam (anti-anxiety) . LPN #7 stated he did not lock his medication cart to the wall and did not know how to do that.

In summary, the facility did not ensure controlled drugs were stored in accordance with State and Federal laws.

3) At 3:50 PM on December 6, 2012, a surveyor observed the medication pass performed by an agency licensed practical nurse (LPN #5) on Unit 4. LPN #5 administered Librium (tranquilizer) 10 mg to the resident, and stated she had removed an extra capsule of Librium from the medication blister pack in error. She then disposed of the Librium in the sharps container attached to the medication cart.

During an interview with LPN #5 at 4:45 PM on December 6, 2012, she stated that she should have disposed of the Librium in the presence of a second nurse.

In summary, the facility did not ensure that a controlled drug was disposed of by one nurse with a second nurse to witness the disposal.

10 NYCRR 415.18(d)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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

Citation date: December 14, 2012

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 1 resident (Resident #16) reviewed with a tracheostomy (trach)stoma (a direct airway through the trachea allowing a person to breathe without using the nose or mouth) the facility did not provide proper respiratory care and treatment. Specifically, the resident's physician's orders were not followed in regards to oxygen delivery and suctioning. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #16 was admitted to the facility with diagnoses of laryngeal carcinoma (cancer of the voice box), status post laryngectomy (removal of the voice box and separation of the airway from the mouth and noise), and tracheostomy.

The Minimum Data Set (MDS) assessment, dated August 22, 2012, documented the resident had moderate cognitive impairment and was dependant for all activities of daily living.

The physician's orders, dated December 4, 2012, documented the resident was to receive oxygen continuously at 5-6 liters (L) per minute at 28 percent, humidified, via a trach collar. The resident was to be suctioned as needed through the mouth and nose and receive trach care every shift.

The resident was observed on December 6, 2012 at 8:45 AM, his oxygen was set at 7 L, with the percentage between 0 and 28.

Observations on December 6, 2012 showed:
- At 9:25 AM, the resident's trach collar was not directly over the stoma as it was turned and off to the side;
- LPN #1 did not adjust the resident's trach collar as she provided care to the resident from 9:25 - 9:45 AM;
- At 9:45 AM, LPN #1 dipped a gauze pad into normal saline, squeezed the pad, and used it to wipe around the stoma; and
- LPN #1 repeated the process with a second gauze pad, the resident started coughing, and normal saline was observed running down the resident's chest.
The resident coughed up cream colored sputum through the stoma, and LPN #1, using a suction catheter, suctioned around the resident's stoma.

In an interview on December 6, 2012 at 9:55 AM, LPN #1 stated she used "saturated" 4 x 4 pads when she cleaned the resident's stoma. She said the resident had "so much congestion" it was difficult too clean his stoma.

On December 6, 2012 at 10:10 AM, the resident was observed with his oxygen set at 7 L and the percentage halfway between 0 and 28.

The treatment administration record (TAR), dated December 1-6, 2012, documented the resident was to have oxygen at 5 - 6 L and 28 percent, via a humidified trach collar, continuously.

During an interview on December 6, 2012 at 10:10 AM, LPN #1 stated she checked the resident's oxygen percentage every shift and it should be set at 28 percent. She said she did not check the oxygen liter flow as that was set by the registered nurse (RN) when the resident returned from the hospital. LPN #1 said she signed the resident's TAR. She stated she thought it was acceptable to suction around the stoma when doing trach care.

On December 6, 2012 at 3:30 PM, LPN #2 was observed doing trach stoma care for the resident. The resident's oxygen was set at 6 L and 28 percent . LPN #2 poured normal saline onto gauze pads, squeezed the pads and used them to wipe around the stoma, she used a dry gauze pad to dried around the stoma. LPN #2, using a suction catheter, suctioned around the resident's stoma.

The RN Manager stated in an interview on December 13, 2012 at 9:30 AM, she did not know if the nurses should be suctioning around the resident's stoma and she would have to clarify the order.

During an interview, on December 13, 2012 at 10:20 AM, LPN #1 stated she was unaware there was not a physician's order to suction around the resident's stoma as she had always done it. She stated she was concerned about the normal saline running into the resident's stoma, and she tried to squeeze most of the saline out of the gauze pads before she used them.

LPN #2 was unavailable for interview on December 13, 2012.

In summary, for Resident #16, the facility:
- did not ensure the resident's oxygen liter flow and percentage were set according to the physician's order;
- did not ensure the nurses followed proper treatment standards when caring for the stoma site.

10NYCRR415.12(k)(5)(4)

F309 483.25: PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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.

Based upon record review, observations, and staff and resident interviews conducted during the standard survey, it was determined the facility did not ensure 2 of 4 residents (Resident #5 and #10) reviewed for prevention of skin breakdown, received the necessary treatment and services to maintain the highest practicable physical well being. Specifically, for Residents #5 and 10, pressure relief interventions were not planned, were not consistently implemented and were not reassessed in a timely manner to prevent further skin breakdown. 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 June 18, 2012 and October 14, 2011

Findings Include:

1) Resident #10 had diagnoses including dementia, degenerative joint disease, and osteoporosis.

The comprehensive care plan (CCP) dated August 14, 2012, documented:
- pressure relieving/reducing devices in bed and chair as indicated; and
- physical and occupational therapies to evaluate as needed for positioning equipment.

The Minimum Data Set (MDS) assessment dated August 29, 2012, documented the resident's cognitive status was severely impaired, she was able to understand others and some times made herself understood, she was unable to ambulate and required assistance from staff for all activities of daily living. The MDS recorded the resident's skin was intact, she was at risk for developing pressure ulcers, and used a pressure reducing device for the chair.

Nursing progress notes dated November 24, 2012, documented the resident had a "Stage I" on her right shoulder. The note recorded staff were educated to position the resident off of her right shoulder and apply skin prep (a topical application that toughens skin) to the area.

Physician's orders dated November 25, 2012 documented to apply skin prep to the resident's right shoulder twice daily until the "Stage I pressure wound" was healed.

The resident plan of care (RPOC, used to direct care) dated December 10, 2012 documented the resident used a contour cushion in her wheelchair for positioning.

Observations made on December 11, 2012 at 2:15 PM, showed t he resident sitting in her wheelchair on a contour cushion. There were 2 areas of redness on the resident's spine. The RN Manager stated to the surveyor she was not aware of the reddened areas and they appeared to be from pressure against the back of the wheelchair. She said she would notify the nurse practitioner (NP)immediately to assess the areas.

When interviewed December 12, 2012 at 8:50 AM, the RN Manager stated the NP assessed the resident's back and there were no reddened areas.

On December 13, 2012 at 9:30 AM the RN Nurse Manager and the surveyor observed the resident's back. There was a large reddened area on the resident's spine. The RN Nurse Manager stated this area was not present earlier and it must have been caused by pressure from the back of the wheelchair.

Observations made on December 13, 2012 at 10:20 AM showed the skin care team assessing the resident's back. The NP stated at that time the resident had a Stage I pressure ulcer on her back. The physical therapist stated he would look into a different wheelchair with a backing that would reduce the pressure on the resident's back.

When interviewed on December 13, 2012 at 10:15 AM the RN Manager stated she was aware of the Stage I pressure ulcer on the resident's right shoulder and when she assessed it a few days later, the area was healed. The RN Manager stated the resident was at risk for skin breakdown because she was "bony." She said the resident had a Gaymar (pressure reducing) cushion in her wheelchair. The RN Manager stated she became sidetracked and forgot to order a Gaymar overlay for the resident's bed when the Stage 1 pressure ulcer was found on the right shoulder. The RN Nurse Manager stated "I did not think of getting physical therapy involved."

In summary, the facility did not plan, implement or re-assess effective pressure relieving interventions in a timely manner for the resident.

2) Resident #5 had diagnoses including dementia, anxiety, and diabetes mellitus.

The admission nursing assessment, dated November 29, 2012, documented the resident had blanchable redness in the middle of her back, and was at risk for developing pressure ulcers. The preventive measures included pillows under arms and elbows, a bed wedge, blue booties, an alternating pressure mattress (APM), and off loading heels while in bed.

The physician's admission history and physical examination, dated November 29, 2012, documented the resident had profound dementia.

The physical therapy evaluation, dated November 29, 2012, documented the resident had an extremely kyphotic thoracic curve (rounding of the back) and decreased sitting balance .

The physical therapy/occupational therapy recommendations dated November 2012, included changing the resident's position every 2 hours while in bed, and transfer the resident out of bed, to a gerichair, via a mechanical lift.

The comprehensive care plan (CCP), dated November 29, 2012, documented the resident had potential for impaired skin integrity related to limited mobility. The plan included using a pressure relieving/reducing device in the chair "as indicated."

Nursing progress notes, dated November 30, 2012 and December 1 - 2, 2012, documented the resident was out of bed in a gerichair.

A physician's order, dated December 2, 2012, documented to apply skin prep (a topical application that toughens skin) to the resident's midback bony prominence twice daily.

The Resident Plan of Care (RPOC, used to direct care), dated December 4, 2012, documented the resident was to be turned and positioned every 2 hours. The RPOC did not specify the resident was to have a pressure relieving chair cushion.

Occupational therapy progress notes, dated December 5, 2012, documented the resident was repositioned in her chair with pillows behind her head, and under her elbows and heels.

During an observation on December 5, 2012 at 5:05 PM, the resident was sitting in a gerichair without a pressure relieving cushion.

The Minimum Data Set (MDS) assessment, dated December 6, 2012, documented the resident was non-ambulatory; required extensive assistance with bed mobility, transfer, personal hygiene, toileting, and bathing; was on a turning and repositioning program; was at risk for developing pressure ulcers; and had a pressure reducing device for the chair.

During observations on December 6, 2012 at 8:10 AM and 12:45 PM, the resident was sitting in a gerichair without a pressure relieving cushion.

At 1:15 PM on December 6, 2012, the resident was observed in the dining room, sitting in a gerichair, feeding herself lunch, moaning. At 1:16 PM, the registered nurse (RN) Supervisor spoke to the resident, and the resident said she had pain in her back.

Observations on December 6, 2012 at 1:25 PM, showed the resident complained of pain as she was transferred to her bed by staff. The skin over the bony prominence of the resident's back was reddened.

During an interview with the resident's assigned CNA, on December 6, 2012 at 1:30 PM, she stated they were told the resident did not need a pressure relieving cushion in her gerichair, as she was repositioned, in the gerichair, when it was reclined.

During an interview with the RN Unit Manager on December 6, 2012 at 1:30 PM, she stated the resident had been seen by physical therapy (PT).

The physical therapy assistant (PTA) Director of Rehabilitation was interviewed at 9 AM on December 12, 2012, and stated the physical therapist, who did the resident's initial chair assessment, was no longer employed by the facility. She stated therapy staff were aware of the redness over the resident's spine, and provided the gerichair because the family wanted her to be "comfortable." She stated the gerichair had a "built in cushion." She said she had no documentation that the "built in cushion" provided pressure reduction.

In summary, for a resident at risk for skin breakdown, the facility did not plan, implement, and reassess the resident for effective pressure relieving interventions in a timely manner.

10 NYCRR 415.12

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 resident outside of the sample (Resident #58), reviewed for medication administration, and 1 of 11 residents (Resident #33) reviewed for infection control, the facility did not ensure services provided met professional standards of quality. Specifically, Resident #58's nebulizer treatment (a breathing treatment) was not administered according to professional standards of quality. For Resident #33, the facility did not ensure the resident's test results for TB screening were determined. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #58 had diagnoses including advanced dementia and chronic obstructive pulmonary disease (COPD).

The Minimum Data Set (MDS) dated August 29, 2012 documented the resident's cognition was severely impaired and the resident was dependent on staff for most activities of daily living.

The physician's orders dated November 15, 2012 documented the resident had an order for 1 vial of albuterol sulfate, 2.5 milligrams (mg)/3 milliliters (ml) vial-nebulizer every 6 hours and as needed.

A physician's progress note dated November 15, 2012 documented the resident had chronic contractures of her upper and lower extremities.

The resident's comprehensive care plan updated (CCP) December 6, 2012 had no documentation regarding the resident's independent use of the nebulizer.

The resident was observed on December 5, 2012 at 1:05 PM. She had a nebulizer mask on, the nebulizer was running, and no staff members were in the room. The resident's head was down and the nebulizer mask was not completely covering the resident's mouth and nose. The mask was positioned off to the side of the mouth and nose. The licensed practical nurse (LPN) entered the room during the observation and stated the resident was a "very contracted woman" so when she administered the nebulizer she stayed near her room in adjacent rooms. She stated she did not stay in the room with the resident the entire 10 minutes the nebulizer was running.

On December 10, 2012 between 12:50 PM and 1 PM, the resident was in her room with a nebulizer treatment running. The mask was not directly over the resident's mouth. The LPN entered the room during the observation and took the mask off the resident. The nebulizer treatment was observed and was not fully completed. The LPN held the mask in front of the resident's face (not touching the face) and did not secure the mask to the resident. The LPN stated she had to hold the mask in front of the resident as the resident sometimes took the mask off.

In summary, the facility did not administer the resident's nebulizer treatment according to professional standards of quality.

2) Resident #33 had diagnoses including history of aspiration pneumonia, dementia, and heart disease.

The facility policy, Resident Immunization and Tuberculosis Testing, reviewed March 2010, documented that residents were tested for TB infection upon admission. If the first test was negative, a second test was done 7 days later.

The Admission Assessment, dated December 7, 2012, documented the resident did not have history of a positive PPD (purified protein derivative, a skin test used to determine the presence of TB infection).

The resident's physician's orders, dated December 7, 2012, included an order for administration of PPD tests on December 8 and 15, 2012.

A nursing progress note, dated December 8, 2012 (no time specified), documented a PPD was administered to the resident's left forearm.

The resident's December 2012 medication administration record (MAR) documented a PPD was administered on December 8, 2012, and the result was not determined.

The Therapeutic Recreation Initial Assessment, dated December 10, 2012, documented the resident was alert, oriented, and pleasant.

The resident's Tuberculosis Testing form, reviewed by the surveyor on December 11, 2012, was blank.

During an interview with a licensed practical nurse (LPN) at 3:05 PM on December 11, 2012, she stated the resident's PPD was administered on December 8, 2012, and the result was not determined. The LPN stated the PPD result should have been read on December 10, 2012.

During an interview with the registered nurse (RN) Unit Manager at 2:15 PM on December 12, 2012, she stated the PPD that was placed on December 8, 2012 and the result was not determined.

In summary, the facility did not ensure the resident was screened for TB infection according to accepted professional standards.

10NYCRR415.11(c)(3)(i)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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: December 14, 2012

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure food was prepared under sanitary conditions. Specific concerns included soiled and/or not easily cleanable surfaces in the kitchen (dishroom floor, garbage disposal control box, and greasetrap), a soiled knife left in a food preparation area, the sanitizer solution in the 3 compartment sink was not tested on 1 day, and a pail with cleaning solution was stored on the floor. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) A surveyor observed a soiled knife on a ledge above a food preparation area on December 5, 2012 between 9:45 - 10:45 AM. The ledge was not a holding area for soiled utensils.

2) A surveyor observed the kitchen on December 5, 2012 between 9:30 - 10:45 AM. The garbage disposal control box was soiled with dried on material; the painted surface on the greasetrap was worn and no longer easily cleanable; and the dishroom floor was soiled at the edges with broken china, a knife, and other debris.

A surveyor observed the kitchen again on December 6, 2012 at 4 PM; the garbage disposal control box and dishroom floor remained soiled, and the grease trap surface remained not easily cleanable.

3) During the initial kitchen observation on December 5, 2012 between 10 - 10:45 AM, a dietary staff person was setting up the 3 compartment sink and washing pots.

Interviews during the kitchen observation:
- The potwash person stated she did not test the sanitizer concentration in the 3 compartment sink ,and did not know the location of the test strips to test the sanitizer concentration.

- The Food Service Director was asked if there were test strips to test the sanitizer concentration and where they were located. He was initially unable to find the test strips. He stated a supervisor routinely tested the sanitizer concentration in the 3 compartment sink.

- The Food Service Director was interviewed regarding the December 2012 sanitizer concentration log; he stated he believed the log was not accurately completed on December 5, that it had been completed without the solution being tested.

The December 2012 kitchen log documented the sanitizer concentration in the 3 compartment sink had been tested daily in December 2012, including December 5.

4) A surveyor observed a pail of sanitizer solution stored on the floor of the cold food preparation area between 10:15 -10:30 AM.ne
A second surveyor interviewed the dietary staff person in the cold preparation area on December 5, 2012 between 10:15 - 10:30 AM; she stated she did not realize the pail of sanitizer should not have been stored on the floor.

In summary, the facility did not ensure sanitary conditions were maintained in the kitchen.

10NYCRR 415.14(h), 14.1.110, 14-1.112

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

Scope: Widespread

Severity: Potential for no more than Minimal Harm

Corrected Date: February 14, 2013

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

Citation date: December 14, 2012

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the resident environment was maintained in a sanitary and orderly manner in 5 of 5 resident units (Units 2, 3, 4, 5, and 6). Specific concerns included closet doors not operating properly, furniture and environmental surfaces in poor condition, windows, curtains, and nurse calls system components not maintained in good condition. 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 JUNE 18, 2012 SURVEY.

Findings include:

Surveyors observed environmental issues on resident units:

Unit 6
On December 5, 2012 at 1 PM, the windows in the dining room were cloudy, including the sliding glass door to the small patio/deck. The heating units under the windows in the dining room were scraped, with chipped paint.

On December 5, 2012 between 3 - 4:15 PM:
- one dresser drawer was out of the track in room 603;
- one closet door was not operating properly and the filter was falling out of the heating unit in room 607; and
- the nightstand drawer was out of the track in room 629.

On December 5, 2012 between 5:25 - 6:30 PM:
- Rooms 618, and 627 there was torn veneer on the corridor door near the doorknob;
- part of the switch plate on wall on the right side of the dining room was missing and had jagged edges;
- there were soap stains on the wall under the soap dispenser in the dining room; and
- two overbed tables in the dining room were in poor condition; one was rusty and the other was soiled with caked on food; the tables were observed in the same condition at 1 PM on December 6, 2012 and one was used by Resident #60, and remained in the same condition on December 10, 2012 between 12:30 - 1 PM.

On December 6, 2012 at 8:45 AM the Room 630 corridor door had torn veneer on the doorframe and both corridor and toilet room doors were scraped/scuffed.

On December 10, 2012 between 12:30 - 1 PM:
- Room 605 had torn veneer on the corridor door near the doorknob; and
- Resident #40's wheelchair had a cracked armrest.

Unit 5
On December 5, 2012 between 5:25 - 6:30 PM the veneer on the door and doorframe for room 528 was observed in poor condition.

On December 6, 2012 between 9:30 - 11 AM:
- the door leaf was warped at the bottom and a pin was missing from the closet door in 530;
- a strip of the dresser veneer was peeled off in room 526B; and
- at least 4 hooks were disconnected on the window curtains in room 527.

Unit 4
On December 5, 2012 between 10:30 - 11 AM:
- the nightstand door in room 428 door side was not operating properly/would not stay closed;
- room 412, both closet doors were not operating properly; and
- the door side of room 406, the nightstand drawer was out of the track and the bedside nurse call cord had a sharp metal projection in the area of the missing button.

On December 6, 2012 between 11 AM - 12 PM:
- room 426, the top edge of the nightstand veneer was missing;
- room 421, and 423, there was unsightly dead ivy adhered to the two windows; and
- a package of disposable briefs was stored on the floor of the bathing suite closet.

Unit 3
On December 6, 2012 between 2:45 - 3:45 PM:
- room 321, one of the two windows had dead ivy adhered to it;
- room 318 there were 2 packages of briefs stored on the floor of the toilet room;
- the veneer on the corridor door to room 308 was in poor condition; and
- the device (window restrictor) to limit the window opening in room 318 was missing.

Unit 2
On December 7, 2012 between 9:50 - 11 AM:
- the cover plate was missing from a light switch in room 224;
- the toilet room nurse call pull cord was missing in room 205;
- room 223, there was dead ivy adhered to one of the two windows; and
- in room 227, there was a discolored area of the floor adjacent to the door.

The Plant Operations Director was interviewed on December 7, 2012 at 3:40 PM. He stated the facility did environmental rounds on the resident units. Maintenance checked some resident units daily, there was an audit form, and it "a work in progress."

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

10NYCRR 415.5(h)(2)

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

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: February 14, 2013

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

Citation date: December 14, 2012

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure food was palatable and served at the proper temperature on 2 of 5 nursing units (Units 4, and 5). Specifically, hot food on the steamtables on Units 4 and 5 was not hot enough when tested. This resulted in no actual harm with potential for minimum harm.
Findings include:

1) Two surveyors observed the lunch meal on Unit 4 on December 5, 2012 between 12:30 and 1:15 PM. The puree beef Stroganoff was tasted at 1 PM and it tasted warm/did not taste hot. A surveyor determined the temperature of the puree beef stroganoff to be 126 degrees F. The mixed vegetables were tasted as well, did not taste hot, and the temperature was determined to be 114 degrees F.

The hot holding system did not maintain hot food at or above 140 degrees F, as required.

2) During the resident group meeting held on December 6, 2012 at 10:45 AM, 4 of 12 anonymous residents stated the food was not always served at the appropriate temperature, specifically stating hot foods were not served hot.

A surveyor observed the Unit 5 steamtable was turned off on December 6, 2012 at 12 PM. The dietary aide was interviewed at 12:50 PM and stated he just turned off the steamtable. He said the steamtable was turned on 30 to 40 minutes before food was served.

Two surveyors observed lunch on Unit 5 on December 6, 2012 between 12:45 and 1:10 PM.

Four food items on the steam table were double panned (the pan containing the food was not directly over the well in the steamtable, it was set in another pan over the well):
- mashed potatoes;
- puree steak;
- puree peppers and onions;
- gravy.

A surveyor tasted the ground peppers and onions, and the puree steak; neither was hot.

The surveyor determined temperatures of food items on the steam table, as follows in degrees F:ne - puree steak was 120 degrees;
- ground steak was 135 degrees;
- puree peppers and onions was 126 degrees;
- ground peppers and onions was 116 degrees;
- hamburgers were 126/127 degrees.

The hot holding system did not maintain hot food at or above 140 degrees F as required.

A Food Service Supervisor was interviewed on December 6, 2012 at 1:10 PM. He stated he checked the hot food temperatures for the Unit 5 lunch food today in the kitchen.

The steamtable temperature logs dated November 30, 2012 through December 6, 2012 documented the temperature of the hot food on each unit at lunch was checked and hot (over 140 degrees F) prior to service

The Food Service Director was interviewed on December 7, 2012 at 9:30 AM, he stated he was not aware there were temperature problems with the hot food. He stated the steamtables would be turned on earlier in order to maintain the food at a higher temperature.

In summary, the facility did not ensure food was palatable and served at the proper temperature on 2 of 2 units tested.

10NYCRR 415.14(d)(2)

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

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: February 14, 2013

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: December 14, 2012

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure the environment was maintained in clean condition in 5 of 5 resident units (Units 2, 3, 4, 5, and 6), the main level, and the service level. Specific concerns included lack of consistent, regular floor cleaning in multiple areas of the facility. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM JUNE 18, 2012 AND OCTOBER 14, 2011 SURVEYS.

Findings include:

1) Two surveyors observed the service level clean linen holding room on December 7, 2012 at 11:40 AM; this room's function was exclusively for storage of clean linen, and the room was extremely full of linen on shelves and carts. The floor of the room was very heavily soiled with paper debris, trash, dust, plastic bands used to bind packages of linen, and a hospital gown. There was a small desk in the room; adjacent to the desk was a trash can overflowing with disposable food containers and utensils.

The Environmental Services Director was interviewed on December 7, 2012 at 12:10 PM. He stated a contract company provided linen for the facility. He stated there was an environmental services staff person responsible for cleaning on the service level, and cleaning of the clean linen room was the responsibility of the contract linen company. He stated it was challenging to clean the floor of this room, as it was filled up with carts.

A printed copy of an e-mail message from the contract linen company dated December 7, 2012 documented the contract company was not responsible for floor cleaning in the facility's clean linen room.

2) The floors of activity storage closets on the resident Units were soiled when observed, as follows:
- Unit 4 on December 5, 2012 between 10:30 - 11 AM, and on December 6, 2012 between 11:30 AM - 12 PM, the floor was very heavily soiled with debris and unidentified dried on spilled liquid.
- Unit 1 on December 5, 2012 between 4:25 - 4:35 PM, the floor was soiled with debris and unidentified dried on spilled liquid.
- Unit 5 on December 6, 2012 between 9:30 - 11 AM.
- Unit 3 on December 6, 2012 at 3:20 PM, the floor was soiled along the edges, including multiple mouse droppings.

3) The following resident rooms were observed with soiled floors during environmental rounds, as follows:
- on December 6, 2012 between 9:30 - 11 AM, the floor in room 513 was soiled and dusty under the nightstand, and the top surface of the nightstand in room 527 was dusty;
- on December 6, 2012 between 11 AM - 12 PM, the floor in room 403 was dusty under the dresser, and the toilet room nurse call cord in room 426 was soiled with foreign matter; the cubicle curtain in room 426 was soiled with brown spots;
- on December 7, 2012 between 9:50 - 11 AM, room 212 had a dried on spill in front of the toilet room, and room 277 had a discolored area in front of the corridor door, and spots and dried on spills in front of the dresser.

4) A surveyor observed the floor of the Unit 6 brief storage room was soiled with debris on December 5, 2012 between 3:30 - 4:20 PM.

A surveyor observed the floor of the Unit 5 clean utility room on December 6, 2012 between 9:30 - 10:30 AM; the floor was soiled with debris.

A surveyor observed a box of gloves on the floor of the Unit 4 clean utility room on December 5, 2012 between 10:30 - 11 AM, and December 6, 2012 between 11 - 11:30 AM. A loose brief or package of briefs was on the floor of the Unit 4 bathing suite brief storage closet on December 5, 2012 between 10:30 - 11 AM, and on December 6, 2012 between 11 AM - 12 PM.

The Plant Operations Director was interviewed on December 7, 2012 at 3:40 PM. He stated housekeeping staff did environmental rounds to check housekeeping on the nursing units daily.

In summary, the facility did not ensure the environment was maintained in clean condition.

10NYCRR 415.5(h)(1)

K18 NFPA 101: CORRIDOR DOORS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

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.

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not protect corridor openings with properly latching doors on 4 of 59 sampled resident room doors (rooms 308, 309, 513, and 517) to prevent the passage of smoke and other products of combustion in an emergency. 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 JUNE 18, 2012 SURVEY.

Findings Include:

On December 6, 2012 between 9:45 AM to 3:45 PM, rooms 308, 309, 513, and 517 were observed to have improperly functioning hardware to keep the door closed. The corridor doors to resident rooms 309, 513, and 517 did not latch when tested multiple times; the side leaf for room 308 did not latch into the door frame when tested multiple times. The door latch for room 517 was observed not to line up with the strike plate in the door frame.

During an interview with the Plant Operations Director at 10:10 AM on December 6, 2012, he stated he was aware latching was required for corridor doors. He stated there was not a routine preventative maintenance schedule in place to check door latching.

10NYCRR 711.2(a)(1) and 415.29(a)(1)

K21 NFPA 101: DOORS IN FIRE AND SMOKE PARTITIONS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure is held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of: a) the required manual fire alarm system; b) local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and c) the automatic sprinkler system, if installed. 19.2.2.2.6, 7.2.1.8.2

Based on observation and staff interview conducted during the standard survey, it was determined the facility utilized unapproved hold open devices on 1 set of double doors to the kitchen, on all 5 dining room double doors, on the therapy treatment room double doors, and on the service level housekeeping storage/locker room door. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings Include:

On December 5, 2012 at 9:20 AM and 10:20 AM, the set of double doors leading into the kitchen (main kitchen entrance) was observed to have both doors held open with kick stops (unapproved hold open devices).

A surveyor observed both unit dining room doors (double doors at each dining room main entrance) propped open with kick stops, as follows:
- Unit 1 on December 5, 2012 at 4:35 PM;
- Unit 3 on December 5, 2012 at 12:30 PM, and December 6, 2012 between 2:45 PM and 3:15 PM;
- Unit 4 on December 5, 2012 at 11:35 AM and 1:10 PM, and December 6, 2012 at 11:55 AM;
- Unit 5 on December 6, 2012 at 10:45 AM;
- Unit 6 on December 6, 2012 between 3 PM and 4:15 PM.

The double doors to the first floor therapy treatment room were observed to be propped open with kick stops on December 5, 2012 at 4:25 PM.

When interviewed on December 6, 2012 at 3:40 PM, the Plant Operations Director stated, he was aware that kick stop devices were not allowed.

A housekeeping storage/locker room door was observed to be held open with a chair on December 6, 2012 at 8:30 AM at 11:15 AM. There was a sign on the door indicating it was to remain closed and locked at all times.

When interviewed on December 6, 2012 at 11:15 AM, the Plant Operations Director stated the door should not have been propped the door open.

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: February 14, 2013

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

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure one required exit access corridor (the service level corridor), was separated from use areas with walls with at least 1/2 hour fire rating. Specifically, the service level corridor's width was reduced by the storage of clean linen carts, with this area containing a large quantity of flammable material. 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 JUNE 18, 2012 SURVEY.

Findings include:

Observations of the service corridor, near the clean linen storage room, included:
- on December 6, 2012 at 8:30 AM and at 11:45 AM, the service corridor contained 8 carts full of clean linen. Each cart was approximately 36 inches wide by 60 inches long by 72 inches high.
- the service corridor was approximately 6 feet wide; the effective width of the corridor was reduced to less than 3 feet, due to storage of the clean linen carts in the corridor during these observations.

The Plant Operations Director was interviewed on December 6, 2012 at 11:50 AM; he stated the facility contracted with a company for clean linen and the Environmental Services Director was responsible for the clean linen.

When the Environmental Services Director was interviewed on December 6, 2012 at 12:10 PM, he stated he was unaware that corridors could not be used to store clean linen carts.

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