Rosewood Heights Health Center

Deficiency Details, Certification Survey, March 9, 2010

PFI: 0657
Regional Office: Central New York Regional Office

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

Scope: Pattern

Severity: Actual Harm

Substandard Quality of Care

Corrected Date: May 13, 2010

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

Based on observations, record reviews, and staff interviews conducted during the extended survey, it was determined the facility did not ensure that residents received the necessary care and services to prevent the development of new pressure ulcers and/or promote the healing of existing pressure ulcers for 5 of 10 residents reviewed with pressure ulcers (Residents #2, 3, 9, 23, and 27). Specifically, facility staff did not: assess or monitor resident skin/open areas on a regular and timely basis (Residents #2, 3, 9, 23, and 27), notify the physician of skin changes (Residents #9 and 23), provide treatments and interventions as ordered and in a timely manner (Residents #2, 3, 9, and 23), update care plans and/or care cards as necessary (Residents #9 and 23), and clarify treatments as necessary (Residents #23). This resulted in actual harm that is not immediate jeopardy for Residents #9, 23, and 27; no actual harm with potential for more that minimal harm that is not immediate jeopardy for Residents #2 and 3, and sub-standard quality of care..

THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEYS OF August 20, 2008 AND May 6, 2009, AND FROM THE ABBREVIATED SURVEY of December 7, 2009.

Findings include:

1) Resident #23 had diagnoses including a long standing Stage IV sacral pressure ulcer, cerebral vascular accident (CVA - stroke) with hemiparesis (one sided weakness), dementia, diabetes mellitus and chronic renal disease.

On December 7, 2009, the resident was seen by a wound care consultant for "sacral decubitus", who documented the pressure ulcer was "clean except for the right lateral edge"; that had "some necrotic muscle in it." The consultant debrided the area and specified "we need to be certain (the resident) is being rotated on a regular basis. The consultant's recommended to "change the treatment to Collagenase twice a day; pack with Kerlix roll and use Hypafix" and to follow-up in 2-3 weeks.

The resident's Minimum Data Set (MDS) assessment, dated January 15, 2010, documented the resident's cognitive skills for daily decision making were moderately impaired, his decisions were poor, and he was totally dependent on 2 staff for bed mobility, transfers, and bathing. The MDS documented the resident had two Stage IV pressure ulcers, his skin was desensitized to pain/pressure, he had pressure relief devices for his bed/chair; was on a turn and position program; and had nutrition interventions to manage his skin problems.

On January 19, 2010, nursing notes documented the resident had a temperature of 101 degrees, was lethargic and unable to cooperate with neurological checks. The resident was sent to the hospital.

The transfer information sent to the hospital, dated January 19, 2010, documented the resident had a "very large sacral/buttocks pressure ulcer" that was positive for MRSA (methicillin resistant Staphylococcus Aureus), and was to being sent to rule out sepsis.

The resident was re-admitted from the hospital on January 29, 2010, with discharge diagnoses that included sepsis.

Re-admission orders, dated January 29, 2010, signed by the nurse practitioner ordered the resident to have the Stage IV sacral wound treated with 1/4 strength Dakin's solution (antiseptic solution with sodium and hypochlorite) with Kerlix (type of gauze) packed into the wound, cover with an ABD (type of gauze pad), and change every 12 hours.

On February 4, 2010, the nurse practitioner ordered blood work every week for the resident, with the results placed in the physician's lab (laboratory) book.

On February 8, 2010 at 6:40 AM, nursing notes documented the resident's temperature at 5 AM was 100.7 degrees. The resident was administered Tylenol and when the temperature was rechecked at 6:30 PM, it was 97.6 degrees. The note specified the nursing supervisor was made aware. Nursing notes, dated February 9, 2010 was 100.2 degrees at 11:30 PM and Tylenol was given. The note documented the resident's temperature at 2:30 AM remained 100.2 degrees, and noted that the supervisor was made aware.

An untimed nurse practitioner order, dated February 9, 2010, ordered the resident be sent to the emergency room due to "acutely abnormal labs".

The hospital discharge summary, dated February 19, 2010, documented "the most striking feature of (the resident's) clinical situation is his extensive Stage IV presacral/lumbar ulcer." The discharge diagnoses included "sepsis secondary to presacral ulcer pathogens', extensive Stage IV ulcer contributing to chronic protein malnutrition, The note specified that the hospital's plastic surgeon consultant "estimated that this lesion covered 18% of his total body surface area." The note documented the surgical consultant reported the resident's status was "dire with his leaking extensive amounts of protein onto the wound." He noted the resident "could not be sustained in any other position other than the supine (face up) position." The note documented that a "specialty bed" was used to minimize pressure and specified the surgical consultant "indicated (the resident's) position, plus his state of nutrition looked grim", in view of the extension of his sacral wound and his recurrent episodes of infection.

The resident's re-admission orders dated February 19, 2010 by the nurse practitioner, ordered the resident to be on bedrest, and turned and positioned every 2 hours "around the clock". The resident's treatment orders included the resident's sacral pressure ulcer was to be irrigated every 12 hours with 1/4% strength Dakin solution, pack with Kerlix, and cover with and ABD. The resident's treatment orders for the right and left hip pressure ulcers included Collagenase (a debriding ointment to the wound's eschar (dead tissue) daily and cover with a gauze dressing. There were no orders at that time for the resident to receive outside wound care consultations.

On March 4, 2010 at 2:30 PM, the surveyor observed the resident's pressure ulcer treatment by an LPN (licensed practical nurse). The sacral pressure ulcer was observed to be very large, with a significant amount of yellow drainage which flowed from tunneling area of the wound; there were areas of slough on the sacral ulcer wound bed; and there was a necrotic area above the wound bed. The resident's left hip area was observed with an area of necrosis, and the hip area wound bed had an area of slough. The LPN was observed to irrigate the sacral wound bed with Dakin's solution, and then apply dry Kerlix to the wound bed.

On March 4, 2010 at 3 PM, the LPN who did the resident's treatment at 2:30 PM, stated the physician did not see the resident's wounds during rounds that morning. She stated that the resident went to an outside clinic for wound treatment, but had not been scheduled to go to the clinic since his return from the hospital on February 19, 2010.

The resident's "Re-admission Nursing Assessment", dated February 19, 2010 and completed by the unit registered nurse (RN) manager, specified there was an alternating pressure mattress on the resident's bed, he was dependent for bed mobility, he was on a turning scheduled every 2 hours, and noted the head of his bed should be less than 30 degrees, except for meals. The assessment was not completed regarding the assessment of the resident's sacral area pressure ulcers, as the RN documented the resident's sacral dressing was not removed, "as solution (Dakins' solution and Collagenase) unavailable to do treatment as ordered."

Two different, and undated "Plan of Care" sheets, used by the certified nurse aides (CNAs) for resident care, were provided to the surveyor on March 1, 2010 at 10:45 AM and March 3, 2010 at 8:45 AM, respectively. These 2 plans documented the resident was to have wedges when he was turned and positioned, and specified he used a mechanical lift for transfers. These care guides did not document the preventative skin measures that were specified on the resident's re-admission nursing assessment dated February 19, 2010. For example, care interventions not documented on the CNA care guides included bedrest, turning and positioning the resident every 2 hours, and keeping the head of bed less than 30 degrees, except for meals.

The resident was observed on March 2, 2010 to be positioned on his right side with the head of his bed elevated at 30 to 45 degrees during all the following observations: 8:55 AM, 9:25 AM, 10 AM, 12:30 PM, between 1:10 PM and 1:30 PM, as the LPN fed the resident lunch, and between 2:20 PM and 2:50 PM.

The treatment LPN was interviewed on March 2, 2010 between 1:10 PM and 1:30 PM, and stated the resident did not get out of bed because of his sacral wound, and said that he was supposed to be turned every 2 hours.

On March 2, 2010, the certified nurse aide (CNA) assigned to the resident for the 7 AM to 3 PM shift, was observed coming out of the resident's room at 3:15 PM.

When the CNA left the room, the resident was observed to be positioned on his left side. At 3:15 PM, the CNA was asked about the care she provided to the resident for the day shift. The CNA stated she "just finished doing his care." The CNA said she provided the resident with care that day, after the LPN completed his treatments.

The resident was observed on March 3, 2010 to be positioned on his left side, with the head of the bed raised to 30 - 40 degrees, between 8:10 AM and 8:45 AM, and between 8:50 AM and 9:00 AM. The resident was observed to be positioned on his left side, with the head of the bed elevated to 45 to 60 degrees at 10:30 AM, between 10:40 AM and 10:50 AM, at 11:50 AM; at 12:40 PM; at 12:55 PM; at 1:10 PM; and at 1:30 PM.

On March 4, 2010 at 11:20 AM, the unit LPN was asked how she knew that residents received the care they needed. The LPN said the CNAs had care guides, and showed the surveyor a line for CNAs to sign that indicated they provided the assigned care.

The facility could not provide the surveyor with copies of the "Plan of Care" sheets that documented care was provided to the resident from 7 AM to 11 PM on March 2 and 3, 2010.

When the unit RN manager was interviewed on March 4, 2010 at 9:10 AM, she stated she should have updated the resident's Plan of Care sheet with the bedrest order, the turn and position schedule by documenting "TS" (key notes that TS directs staff to turn the resident every 2 hours).

The resident's medication and treatment LPN was interviewed on March 5, 2010 at 9:45 AM, and said CNAs were responsible for their assigned resident care, as directed on the unit's Resident Plan of Care sheets. She stated that she helped staff with resident care when she could, and helped when she was in the resident room at 8 AM when she administered medications. She said she could not make sure all the assigned resident care was done.

The "Skin Condition Monitor" sheet, dated February 19, 2010 by the RN manager, specified the resident's wounds (from hospital records dated February 12, 2010) included 3 areas of skin breakdown: the sacral wound measured 19.5 centimeters (cm) x 13 cm x 3 cm, with undermining at 8 and 2 o'clock; the wound base was 70% pink and 30% yellow; with eschar at 12 o'clock that measured 4 cm x 7 cm. The RN documented the resident's left hip area was 4 cm x 7.5 cm, 100% eschar, and the surrounding skin had tape irritation; the resident's right hip area had a 2 cm x 4 cm dry, healing pressure ulcer.

The comprehensive care plan (CCP), reviewed by the interdisciplinary team on February 24, 2010, documented the resident had VRE (an antibiotic resistant infection) in his sacral wound, had a Stage III pressure area on his left buttock and a Stage IV pressure area on his sacrum. The CCP did not include Stage II or unstageable pressure areas. The goals were for the areas to show signs of granulation and improvement by taking weekly measurements, and being free of infection with no purulent drainage, odor, or erythema, in 4 to 6 weeks. The interventions were to do the treatments as ordered, evaluate the effectiveness as needed, to observe for evidence of resolution or worsening of condition; to obtain medical/surgical consultation as needed; and to assess for signs and symptoms of infection.

On March 3, 2010, the resident's "Skin Condition Monitor" sheet documented the resident's skin status included:
- left hip area measured 8 cm x 4.5 cm, was unstageable, with 100% eschar;
- the sacral Stage IV pressure ulcer measured 19 cm x 11 cm x 1.5 cm, was 90% pink and 10% spotted black;
- the area directly above the sacrum measured 6.4 cm x 3.6 cm, was unstageable, with 100% eschar;
- the Stage II left lower buttocks measured 3 cm x 5 cm, was red with no drainage.

Review of the resident's medical record from February 2010 to March 3, 2010 revealed no documented assessment of the resident's pressure ulcers between February 19, 2010 and March 3, 2010. When requested, the facility could not provide documentation that the resident's pressure ulcers were assessed when he returned from the hospital on February 19, 2010, until March 3, 2010.

The 24 Hour report, dated February 28, 2010 for the 3 PM to 11 PM shift, noted the resident had wound drainage with a "greenish tint". Review of the resident's record from February 2010 to March 3, 2010 revealed no documentation related to the wound drainage, or that it was reported to the medical staff.

The resident's March 2010 Treatment Administration Record (TAR) noted the resident was scheduled to have his sacral decubitus wound treatment at 10 AM and 10 PM daily and the right and left hip area wound treatment was to be done daily. The TAR was initialed as being done at those times. There was no additional documentation on the TAR related to the sacral wound treatments done at times other than those scheduled. There was no documentation on the TAR related to the appearance of the wounds, or the areas of eschar.

During an interview on March 5, 2010 at 9:45 AM, the resident's medication and treatment LPN was asked when the resident's skin treatment was done. The LPN stated that at 10 AM (when the resident's skin treatment was ordered), she was still in the dining room feeding different residents their breakfast.

The unit RN manager was interviewed on March 4, 2010 at 9:10 AM, and stated she tried to assess the residents on her two units "when she could". She said the residents' pressure areas were supposed to be measured/assessed weekly. At 4:30 PM that afternoon, the unit RN manager stated the physician did not see the resident's sacral ulcer that morning, as the LPN was still doing the medication pass, and the treatment would not have been done in a timely manner (after the physician observed the wound). The RN manager stated she had not seen the resident's sacral ulcer.

During a telephone interview on March 5, 2010 at 10:25 AM, the physician stated she did not know if she had seen the resident's sacral pressure ulcer and his other wounds since his re-admission on February 19, 2010). The physician said she looked at wounds when she was told they looked worse. She said "otherwise they were followed by the skin team." When asked if she would document her wound observations, she stated she would not document it, as it was "usually" documented somewhere else in the resident's record. The physician stated that the resident was followed by an outside wound consultant, but did not know when the resident was scheduled to see the consultant.

Review of the resident's physician and nurse practitioner orders from February 19 2010 to March 3, 2010 revealed no documented orders for the resident to be scheduled to see the outside wound consultant.

The unit LPN was interviewed on March 4, 2010 at 3 PM and asked about the procedure for ordering a wound consult for the resident. The LPN stated it was up to the nurse practitioner to order one.

The nurse practitioner was interviewed on March 5, 2010 at 8:30 AM and asked about ordering a wound consult for the resident's pressure ulcers. The nurse practitioner said no one told her to order a consult. She stated she thought the facility's skin team was following the resident and said she had not observed the resident's multiple wounds since his re-admission on February 19, 2010.

During a telephone interview on March 5, 2010 at 10:50 AM with the wound physician consultant, he stated the resident's pressure ulcer should have been assessed by qualified personnel within 2 to 3 days after his readmission to the facility. The consultant said the wound treatment was not ordered correctly, as it should be to soak the gauze in Dakin's solution," not irrigate the wound with Dakin's. After the surveyor described the sacral ulcer, the physician said facility staff should have notified him that the wound bed had changed, and said the resident should be sent to the hospital for evaluation of his sacral ulcer.

In summary, the resident experienced harm, as the facility:
- did not ensure the resident's sacral pressure ulcer was assessed in a timely manner after his readmission from the hospital;
- did not ensure the resident's sacral pressure ulcer was evaluated on a weekly basis and as needed;
- did not ensure the physician and the wound care consultant physician were not notified when there was a change in the sacral wound appearance and drainage;
- did not ensure the CCP was revised to include revised assessments of the resident's pressure ulcers;
- the resident was positioned with his head at 30 degrees or less, when he was not eating to decrease the force that was applied to his sacral wound, which would promote healing;
- the resident was repositioned every 2 hours as ordered; and
- the resident's ulcer treatments were completed in a timely manner as scheduled.

2) Resident #9 was admitted to the facility with diagnoses of Alzheimer's dementia, insulin dependant diabetes mellitus, fracture of T3 (thoracic vertebra), type III odontoid fracture and a subarachnoid and epidural hemorrhage as a result of a fall on March 20, 2009.

The quarterly Minimum Data Set dated January 5, 2010 documented the resident had short and long term memory loss and his cognitive skills were severely impaired. He was totally dependant for all activities of daily living and incontinent of bowel and bladder. He had functional limitations in range of motion in his neck and lower extremities with partial loss in his upper extremities.

The Skin Condition Monitor sheets, dated November 11, 2009, documented the resident had an intact clear fluid filled blister to the right heel measuring 3.8 cm (centimeters) by 2 cm. The treatment was skin prep to the blister every shift, to wear blue boot/heel floats, no sneakers, may wear cotton sock. On November 16, 2009, the blister was unchanged. On November 24, 2009 the blister was now dried with tan/light brown colored dried calloused area no longer fluid filled blister beginning to slough off at proximal edge of calloused area, measuring 3.6 cm by 1.8 cm. On December 21, 2009 there was an open blister 4 cm by 2 cm. The treatment was changed to cleanse with normal saline, pat dry, apply DuoDerm hydroactive gel, Telfa, and wrap with Kerlix, change every day per formulary and to continue blue booties, white socks and no shoes. On December 22, 2009 the nurse practitioner (NP) assessed the wound and documented exposed pink wound bed with noted partial thickness loss of calloused area that had covered the area from December 1 to December 21, 2009, with small amount of serosanguinous drainage from wound bed. The treatment order was changed to discontinue DuoDerm hydroactive gel and dressing treatment and start Telfa with pad dressing change every 3 days and as necessary, check every shift for increased drainage, no shoes/footwear to right lower extremity, use blue heel float with wheelchair leg rest elevated, no pressure to heels. On January 4, 2010 the area was pink and intact, no drainage or redness noted, healing well and measured 3.5 cm by 3 cm. On January 13, 2010 the wound was nicely pink, no drainage, healing well measuring 3 cm by 3 cm. On January 25, 2010 the area was pink "with dark brown to outer edges, NP to assess, now unstageable." The area was not measured.

A progress note written by the NP dated January 27, 2010 documented "seen for blackened eschar on right heel. Area on posterior heel is blackened, no redness, no mushy skin, no pain on palpation. Will keep heel elevated, use skin prep and skill boots."

The current Comprehensive Care Plan dated February 1, 2010 and the current Resident Plan of Care (used by the certified nurse aides as a guide to specific resident care) dated March 5, 2010 did not include information relative to the resident's pressure ulcers.

The Skin Condition Monitor sheets on February 3, 2010 documented the right heel continued with black area, boggy surrounding tissue, pink over edges, measuring 3.5 cm by 3.0 cm. On February 9, 2010: continued boggy dark area measuring 3.5 cm by 4 cm. On February 17, 2010: dark area improved, scab like to upper heel, pink outer area. The area was not measured. On March 1, 2010 the area measured 4.5 cm by 4.5 cm, open blister-like area, outer edges moist, wound bed red, slight bloody drainage. Surrounding tissue moist and macerated. On March 1, 2010 there were 2 new areas on his inner knees. There was a fluid filled blister on the left inner knee which measured 1.0 cm by 1.0 cm. There was a fluid filled blister on the right inner knee which measured 1.5 cm by 1.0 cm. The treatment was for skin prep to blistered area daily and a pillow between knees.

On March 1, 2010, the registered nurse (RN) Unit Manager wrote a new treatment order on a physician telephone/verbal order sheet which read: "New TX (treatment) to right heel, Skin prep, off-load at all times, no shoes, pillow between legs while bedrest, Skin prep to bilateral blisters inner knees per (Rosewood) protocol." (The facility's "Skin Integrity Prevention and Treatment" policy and procedure, revised February 9, 2010, documented " 'Rosewood Skin Care Protocols' may be used for interim/one-time on sentinel orders for alteration of skin. As soon as possible the physician or nurse practitioner must write/sign the order." The facility's "Skin Care Protocols and Products" guidelines listed numerous prevention techniques and products to be used for varying skin problems presented by the resident.) The RN Unit Manager's verbal order of March 1, 2010 had not been signed by a physician or nurse practitioner as of March 5, 2010.

The Skin Condition Monitor sheets of March 1, 2010 described the resident's blisters on the inner aspect of both knees, and under the heading of "Treatment," listed "Skin Prep to blister area daily" and "pillow between legs."

The resident was observed out of bed in his wheelchair on March 2, 2010 at 9:35 AM and again at 1:30 PM. His lower extremities were elevated and his heels rested directly on the elevated wheelchair footrests. He was wearing white socks and no shoes.

At 3:05 PM on March 2, 2010, the resident was observed in bed with his heels resting directly on the mattress, with no blue booties on his feet and no pillow between his knees. There were two bloody stains on the right side of the bottom sheet where his right heel had rested. At 4:40 PM the resident was observed out of bed in the wheelchair, his lower extremities elevated and his heels resting directly on the elevated wheelchair footrests.

On March 3, 2010 at 8:50 AM, the resident was observed in his room in his wheelchair, his legs elevated and heels resting directly on the wheelchair footrests. There were 2 bloody stains on the right side of the bottom sheet of his bed where his right heel had rested. At 9:20 AM, 11:10 AM, and 1:35 PM, the resident was observed in the dining room in the wheelchair with his heels resting directly on the elevated wheelchair footrests.

The Skin Condition Monitor sheet documented on March 3, 2010 a new area on the resident's right lateral heel with fluid-filled blister measuring 3.5 cm by 2.0 cm. Treatment included blue Skill boots and pillow under legs to off-load heels.

On March 4, 2010 at 8:30 AM, the resident was observed in his room in his wheelchair, his legs elevated and heels resting directly on the wheelchair footrests. There were 2 bloody stains on the right side of the bottom sheet of his bed where his right heel had rested.

On March 4, 2010 at 11:15 AM, an licensed practical nurse (LPN) told the surveyor the resident's family requested the attending physician look at the resident's pressure areas. The attending physician assessed the right heel and both inner areas on the knees. When the wife removed the resident's sock on the right foot, the sock stuck to the open area on the right heel and the resident cried out in pain when the sock was removed. The wife said the area did not look like that on Sunday. She said when she removed his sock on Sunday "a big chunk of skin came off" and it was draining. The attending physician said she was starting the resident on an antibiotic. A copy of the physician's progress note was requested and the surveyor was told by the ward clerk the progress note was dictated and would take a couple of days to get. (On March 9, 2010, a copy of the physician's progress note was again requested and the surveyor was told they could not find the note in the system.)

On March 4, 2010 at 2 PM, the RN Unit Manager measured the wounds on the right heel and both knees. The measurements were:
- right heel measured 4.5 cm x 5 cm;
- right lateral heel measured 6 cm x 5 cm;
- right knee 2.5 cm x 2 cm;
- left knee 3.5 cm x 1.5 cm (open area), 2.5 cm redness surrounding open area.

When interviewed on March 4, 1010 at 2 PM, the RN Unit Manager was asked why there was no dressing on the right heel especially when the heel was draining. The RN said since they no longer had a Wound Care Nurse, she had consulted with the Assistant Director of Nursing (ADON) and they decided the area was wet (draining) so leave it open and do skin prep to surrounding area and try to dry the area up. The Skin Care Protocols dated November 19, 2009 documented for Stage II pressure ulcers to always provide pressure relief. If blister not open, apply dry dressing until it opens. If open and on an extremity, clean with normal saline, skin prep to surrounding skin, DuoDerm hydroactive gel to wound bed, Telfa and Kling every day.

During an interview on March 4, 2010 at 2:15 PM with the LPN treatment nurse, the LPN was asked if she did the treatment on the resident's pressure ulcers. The LPN said she used skin prep on the pressure ulcers on the right heel and both knees. The LPN was asked if the areas were open and she said yes, they were. She was asked if she reported the open areas to the Unit Manager and she said she did report them yesterday (March 3, 2010).

During an interview on March 4, 2010 at 4:30 PM, the ADON was asked about the resident's pressure ulcer treatment. She said she and the RN Unit Manager discussed it. She said the area started to drain several days ago and they wanted to dry it out. They had used DuoDerm in the past but decided to use skin prep and leave the area open.

When interviewed on March 5, 2010 at noon, the certified nurse aide (CNA), who was assigned to the resident during the week and usually works the 7 AM to 3 PM shift, said she was told yesterday to put a pillow between the resident's knees. The resident was wearing the blue booties but she was told on Monday (March 1, 2010) not to put them on by the Unit Manager. When she came in the morning there was a stain on the sheet where his right heel was.

When interviewed on March 5, 2010 at 12:45 PM, the attending physician was asked when she was first notified of the resident's open areas and when would she expect to be notified. The attending physician said the resident had a pressure ulcer on his right heel that they cleared up. The attending physician said she was notified yesterday (March 4, 2010) about the new areas on his knees and right heel. She would expect to be notified when the areas were found and treatment initiated.

On March 5, 2010 at 1:10 PM, the RN Unit Manager said she wrote the order on March 1, 2010 per Rosewood protocol, after consulting with the ADON, who suggested the treatment. (The Skin Integrity Prevention and Treatment policy and procedure, revised February 9, 2010, documented " 'Rosewood Skin Care Protocols' may be used for interim/one-time on sentinel orders for alteration of skin. As soon as possible the physician or nurse practitioner must write/sign the order.")

In summary, the resident experienced harm when his pressure ulcers became larger, as the facility failed to:
- assess/measure the heel pressure ulcer on a weekly basis and as needed;
- notify the attending physician in a timely manner when there was a change in the appearance and drainage of the heel ulcer;
- notify the attending physician when two new open areas were discovered on both knees, and as a result the areas became infected and resident was placed on an antibiotic;
- document the pressure ulcers on the Comprehensive Care Plan and the Resident Plan of Care; and
- ensure the resident's heels were off-loaded when in bed and in the wheelchair with a pillow under his legs and with pressure relieving boots on.

3) Resident #27 had diagnoses including dementia, prostate cancer, and heart disease.

The Admission Nursing Assessment, dated November 18, 2009, documented the resident had the following wounds:
- a Stage I pressure ulcer measuring 2 centimeters (cm) x 2 cm on his left heel;
- an unstageable pressure ulcer measuring 0.2 cm x 0.2 cm on his right heel;
- a deep purple, non-blanchable area measuring 8 cm x 8 cm on the coccyx, with multiple "denuded" areas in the center of the area; and
- a blister on the right gluteal fold.

The admission Minimum Data Set (MDS) assessment, dated November 25, 2009, documented the resident had severe cognitive impairment; had short and long term memory deficits; required extensive assistance of 2 or more persons for bed mobility, transfer, dressing, personal hygiene, and bathing; was non-ambulatory; and had 1 Stage I pressure ulcer. The Resident Assessment Protocol (RAP) summary section of the MDS documented that pressure ulcers were identified and addressed in the resident's care plan.

The most recent Skin Integrity/Pressure Ulcer Risk Assessment form, dated December 2, 2009, documented the resident sat in a chair for extended time and was incontinent of bowel or bladder most of the time (3 points). The total risk score was not documented. The form documented the resident did not have the risk factor of PVD. The form did not document the resident had a previous pressure ulcer; needed assistance to move in bed; and was unable to walk or transfer independently (8 points). The resident's total score, if all risk factors had been considered, would have been 11. The form documented, "If score is over 10, refer to skin care protocols for appropriate actions to take."

The current comprehensive care plan (CCP), last updated December 29, 2009, documented the resident had multiple unstageable pressure ulcers. Interventions included utilization of a pressure-relieving mattress and chair cushion, off-loading the resident's lower extremities, and use of blue booties when in bed. The CCP did not document staff assessed the resident's pressure ulcers for improvement and/or deterioration, and did not document a plan to assess the resident's skin for new areas of skin breakdown.

Physician's orders regarding the resident's pressure ulcers, documented:
- February 9, 2010: left sacrum: DuoDerm Signal (dressing); change Monday, Wednesday, Friday; left heel: Aquacel (treatment) and dry dressings Monday, Wednesday, and Friday: right bunion: skin prep, open to air;
- February 16, 2010: appointment to be made with wound clinic "soon;"
- March 4, 2010: nurse practitioner (NP) telephone order: Stage IV left heel, Aquacel and dressing change 3 times weekly, and DuoDerm dressing to coccyx "per wound clinic."

At 9:35 AM on March 5, 2010, a surveyor observed the resident's skin and wound treatments, which were done by the licensed practical nurse (LPN) treatment nurse. Also present were the Assistant Director of Nursing (ADON), and the NP. Seven new areas which were not previously identified or subsequently assessed, were observed by the surveyor. At the surveyor's request, they were measured and assessed by the ADON:
- right hallux (large joint of the great toe): 1.1 cm x 1 cm; unstageable (hard, darkened material covering it);
- right great toe: 0.4 cm x 0.5 cm; unstageable (hard, black material);
- right heel: 4.5 cm x 3 cm; unstageable (purple area);
- right ankle: 0.5 cm x 1 cm; unstageable (purple area);
- side of right foot, near fifth toe: 2.5 cm x 1 cm; unstageable (dark, fluid-filled blister);
- front of lower right leg: 1.4 cm x 0.5 cm; unstageable (hard, dark material); and
- front of lower left leg: 1 cm x 2 cm; unstageable (hard, dark material).
Also observed at that time were:
- left heel: 4.8 cm x 3.5 cm x 0.7 cm (depth); Stage IV; and
- coccyx: a DuoDerm dressing was adhered directly to the open wound, leaving some of the wound uncovered. The LPN stated the dressing, which was dated March 5, 2010, was applied by the night nurse. The NP assessed the wound as 8.5 cm x 6 cm in size, Stage II, with a small, unstageable area within it.

When interviewed at 10:40 AM on March 5, 2010, the NP stated the DuoDerm dressing should not have been applied directly to the open wound on the resident's coccyx. She then gave the LPN a verbal order for a larger dressing (Tegasorb) to cover the entire wound.

The resident's Skin Condition Monitor Sheets did not document identification or assessment of the 7 new wounds listed above. Between the dates of November 18, 2009 and February 9, 2010, the Skin Condition Monitor sheets documented the following assessments of wounds on the resident's right and left heels and coccyx:
- an unstageable pressure ulcer measuring 0.2 cm x 0.2 cm was identified on the resident's right heel on November 18, 2009, and was healed on January 4, 2010;
- a Stage I pressure ulcer measuring 2 cm x 2 cm was identified on the resident's left heel on November 19, 2009, and was healed on January 4, 2010;
- an unstageable pressure ulcer measuring 2 cm x 2.5 cm was was identified on the back of the resident's left heel on January 14, 2010. The area was described as a callus that pulled away from the surrounding tissue, leaving an open margin measuring 0.2 cm. The next assessment of the area, dated January 20, 2010, described the area as a red, dry scab, measuring 1.7 cm x 1 cm. The last assessment, dated January 29, 2010, documented the measurements (1.7 cm x 1 cm) and no wound description; and
- an unstageable pressure ulcer measuring 8 cm x 8 cm x 0.2 cm was identified on the resident's coccyx on November 18, 2009, and the area healed on November 30, 2009. A Stage II pressure ulcer measuring 3.5 cm x 4.5 cm was identified on January 18, 2010. The area was reassessed on January 29, 2010 and February 3, 2010. On the last assessment documented (February 9, 2010), the area measured 2.6 cm x 1 cm, and was described as Stage II with a red wound base.

During an interview with the RN unit manager at 10:35 AM on March 5, 2010, she stated the resident's wounds were not assessed since February 9, 2009.

The facility skin policy, original issue date of October 1997, instructs the RN to document weekly all skin integrity alterations, such as pressure ulcers, on the Skin Condition Monitor Sheet, and to obtain a treatment order from the physician.

In summary, the resident experienced harm when the facility failed to consistently assess the resident's pressure ulcers, and did not identify, assess, and treat 7 new pressure ulcers, and
- a left heel pressure ulcer, which progressed from Stage II to Stage IV, was not assessed by the facility for 1 month;
- a pressure ulcer on the resident's coccyx, which was not assessed for 1 month, progressed in size, and had a dressing improperly applied to the open wound; and
- the physician was not notified of the progression of the resident's coccyx pressure ulcer and the 7 new pressure ulcers observed during survey.

10 NYCRR 415.12 (c)

F248 483.15(f)(1): ACTIVITY PROGRAM MEETS INDIVIDUAL NEEDS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.

Citation date: March 9, 2010

Based on record reviews, observations, and interviews with staff, families, and residents conducted during the standard survey, it was determined the facility did not provide for an ongoing program of activities designed to meet the interests and the well-being of 4 of 27 sampled residents (Residents #1, 2, 23, and 24). Specifically, Resident #1 was not assessed for her activity interests; facility staff were not aware of the resident's preferences; and the resident was not provided with a minimum number of activities as planned. Resident #2's preferences for independent recreation activity were not assessed and were not communicated to direct care staff. Resident #23 was not provided meaningful and stimulating daily activities while on bedrest; recreational staff did not determine and communicate the resident's preferences for independent recreational activities, including music and television viewing to direct care staff. Resident #24 was not provided with daily meaningful, stimulating activities, and was not provided with equipment needed for music, television, and reading materials. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #24 had diagnoses including congestive heart failure, arthritis, and depression.

The resident's Therapeutic Recreation Initial Assessment, dated February 16, 2009, documented she enjoyed reading "mysteries", watching television, and listening to music.

The resident's Minimum Data Set assessment, dated January 27, 2010, documented the resident's daily decisions were made consistent, reasonable; the resident had reduced social interaction; and had a hearing impairment. The MDS documented the resident did not ambulate, and required extensive assistance of 2 staff for bed to chair transfers and for bed mobility. The MDS specified the resident was awake all/most of the morning and afternoon, and was involved in activities one third to two thirds of the time while awake and not receiving personal care.

Review of the resident's Therapeutic Recreation Monthly Activity Attendance record revealed the resident attended 13 group programs in November 2009, no group programs in December 2009, and 1 group activity in January 2010. The resident had 0 documented individual interventions/activities in November 2009, had 12 in December 2009, and 10 activities in January 2010.

The resident's Therapeutic Recreation Progress Note, dated January 22, 2010, documented the resident preferred activities in her room or in the unit day room. The note documented the resident was pleasant, alert, enjoyed spending time in her room, and therapy recreation staff provided materials so the resident could self recreate in her room. The progress note documented the resident watched television and read books and magazines, when she was not in a structured recreation program.

The comprehensive care plan (CCP), dated January 27, 2010, documented therapy recreation staff would provide materials for the resident's independent recreation; specified the resident was hard of hearing, and that she needed to be seated near the group leader during activities.

The Interdisciplinary Care Plan Conference documentation, dated January 28, 2010, noted the resident preferred to stay in her room, enjoyed books, magazines, television, and music. The conference note documented recreation staff did 1:1 visits.

Review of the resident's Therapeutic Recreation Monthly Activity Attendance records revealed the resident did not attend a group program in February 2010, and had 12 social contacts in February 2010. The last documented social contact was February 25, 2010.

The resident's current Resident Plan of Care did not document the resident's preferences for activities, including television and types of reading material. This Resident Plan of Care was used by certified nurse aides (CNAs) to provide care, and was given to the surveyor on March 1, 2010 at 10:45 AM.

On March 2, 2010 between 11:00 AM and 12:30 PM, the resident was observed in bed in her semi-private room, with her roommate's television turned onto a children's cartoon channel. (The resident did not have a television.)

The resident was observed multiple times on March 2, 2010 (at 9:25 AM, 11:45 AM, 12:30 PM, 1 PM, 2:20 PM, and 5 PM) to be in bed, wearing bedclothes. The resident was not reading and there was no television or music turned on. There was 1 book observed on the resident's overbed table; there was no musical equipment observed to provide music for the resident.

When the surveyor spoke with the resident on March 3, 2010 at 8:10 AM, the resident stated she had "no plans" for the day.

On March 3, 2010 at 8:50 AM, at 9:25 AM, and at 10:30 AM, the resident was observed in bed with bedclothes on, with no television, no music, and was not reading. At 9:25 AM, the resident stated to the surveyor that she had nothing to do, and she wished she could go to work.

On March 3, 2010, the resident was observed in bed, with bedclothes on, watching television on her roommate's side of the room at 10:50 AM, 11:10 AM, 11:50 AM, 12:40 PM, 12:55 PM, 1:10 PM, 2:30 PM, and 5:55 PM.

During an interview on March 3, 2010 at 4:50 PM, the resident was asked what she had done all day. The resident pointed to her roommate's television and said she watched "TV." The resident stated she had not gotten out of bed all day, and said she did not have a remote for her roommate's television.

On March 4, 2010 at 8:30 AM, when asked what the resident planned to do that day, she pointed to her roommate's television (which was turned off), and said she was going to watch television. When asked, the resident stated she did not have a remote control to the television.

The unit therapeutic recreation staff was interviewed on March 4, 2010 at 2:20 PM, and stated the resident liked to read, and recently refused offers of books and magazines. When asked what other activities she did with the resident, the activity staff member stated she visited with the resident and her roommate. She said she had visited with the resident that week (first week of March 2010). The staff person stated the resident liked to watch television, and had no explanation when the surveyor stated the resident did not have her own television. The activity staff person said that the resident liked music, and had no comment when she told that the resident had no equipment in her room that provided music. When the surveyor described the resident (to the recreation staff) as being in bed with no music, no access to television, and not reading, the recreation staff person stated she observed the resident that way as well.

In summary, the facility:
- did not ensure the resident was provided with equipment and reading materials that enabled her to independently participate in her preferred activities.
- did not ensure the resident's activity preferences were communicated to direct care staff.

2) Resident #2 had diagnoses including dementia, cerebral vascular accident (CVA, stroke) with hemiparesis (weakness on one side), and depression.

The resident's Minimum Data Set (MDS) assessment, dated February 5, 2010, documented the resident's cognitive skills for daily decision making were poor, and cues/supervision were required. The MDS assessment documented the resident did not ambulate; and was awake all/most of the morning and afternoon, and was involved in activities one third to two thirds of the time that he was awake and not receiving personal care. The MDS assessment documented the resident required total assistance from two staff for bed to chair transfers, and from one staff person for movement around the unit.

A review of the Interdisciplinary Care Plan Conference, dated February 12, 2010, revealed the therapeutic recreation staff noted the resident accepted 1:1 visits, and refused other interventions.

The comprehensive care plan, reviewed February 12, 2010, did not document specific activities that the resident enjoyed, including types of television viewing.

The resident's activities note, dated January 29, 2010, documented the resident had no physical, cognitive, or communication changes in the last quarter. The note specified the resident preferred to stay in his room watching television; staff provided 1:1 visits; he was encouraged to come out of his room for activities; and he received daily visits from his wife. The note specified the resident attended 29 group programs in October 2009; 13 programs in November 2009; and no group activity programs in December 2009, January 2010, or February 2010. The note documented the resident received 13 individual interventions, including pet visits and 1:1 visits, in both October 2009 and November 2009; 12 activities in December 2009; and 10 individual activities in both January and February 2010.

The resident's most recent social visit was documented to be on February 25, 2010. The note did not address the resident's decrease in both the number of group programs the resident attended or the number of individual interventions he received.

The resident's current Resident Plan of Care, used by certified nurse aides (CNAs) to provide care, was provided to the surveyor on March 1, 2010 at 10:45 AM. This plan did not document the resident's preferences for activities, including television viewing.

The resident was observed on March 2, 2010 at 8:55 AM, 9:25 AM, 11 AM, 11:45 AM, 12:30 PM, 12:55 PM, 2:20 PM, 2:55 PM, and 5 PM. He was in bed, awake, with his television turned onto detective show reruns throughout the day.

The resident was interviewed on March 3, 2010 at 8:50 AM and asked what he liked to watch on television. The resident said that he liked to watch westerns and game shows.

A CNA, assigned to the resident's care on the 3 PM to 11 PM shift, was interviewed on March 3, 2010 at 6:20 PM. When asked what the resident liked to watch on television, the CNA stated the resident liked to watch the science fiction and black entertainment channels.

On March 4, 2010 at 2:20 PM, the unit therapeutic recreation staff member was interviewed and stated she worked part time. She said she did not know the resident's preferences for television viewing, and had not done 1:1 visits during the first week of March 2010.

The resident's wife was interviewed over the telephone on March 3, 2010 at 1:15 PM. She stated she visited the resident 3 times per week (Mondays, Wednesdays, and Fridays) due to her own illness. The wife's visiting schedule conflicted with activity staff documentation dated January 29, 2010 that specified the resident's wife visited daily.

In summary, the facility:
- did not ensure the interdisciplinary team addressed the resident's decreased attendance at group programming;
- did not ensure the therapeutic recreation staff maintained, or increased the resident's individual interventions, when the resident's attendance in group programming decreased, and when his wife's visits decreased;
- did not ensure activity staff were aware of the resident's preferences for activities, including television viewing;
- did not ensure the resident's preferences for individual and group activities were communicated to the direct care staff.

3) Resident #1, admitted on October 21, 2009, had diagnoses including dementia and a history of a stroke, with expressive aphasia (impaired ability to express oneself).

The resident's undated Therapeutic Recreation Initial Assessment, documented the resident was admitted on October 21, 2009, and noted her mini mental status examination scored "0", on a 30 point scale, with no additional documentation related to her cognitive status. There were multiple areas on the assessment form left "blank":
- Communication, which included vision, hearing, mode of communication, and speech;
- Physical, which included the resident's ambulation abilities, and her ability to self propel in a wheelchair;
- Leisure History and Interest, which included the resident's interests and hobbies, her attitude towards involvement in activities, any potential problems that may interfere with recreation; and a documented initial treatment plan. There was no staff signatures on this assessment form.

The resident's Minimum Data Set (MDS) assessment, dated November 4, 2009, documented the resident's skills for daily decision making were severely impaired, she never/rarely made decisions, and there was no documentation on the customary routines section, that the resident used to spend most of her time alone or watching television.

The Care Conference Notes, dated January 28, 2010, documented activity staff did 1:1 visits and brought the resident to programs in her wheelchair.

The comprehensive care plan (CCP), reviewed by the interdisciplinary team, dated January 28, 2010, documented the resident's family was very involved in her care and visited regularly. A goal on the CCP was that the resident would accept a minimum of three 1:1 weekly visits, and/or attend a minimum of 3 programs a week for social, cognitive, and sensory stimulation over the next 90 days. The CCP interventions included: 1:1 visits and encourage the resident to attend activities outside of her room. There were no documented preferences regarding television viewing.

Review of the resident's February 2010 Therapeutic Recreation Monthly Activity Attendance records, between February 20 and February 28, 2010, revealed the resident received 1 individual visit and attended 1 group activity (bingo).

The unit's Resident Plan of Care, used by certified nurse aides (CNAs) to provide care, was provided by the facility on March 1, 2010 at 10:45 AM. This plan had no documentation of the resident's customary/routine preferences for activities, including television viewing.

On March 2, 2010 between 11:00 AM and 12:30 PM, the resident was observed to be in bed, with the television turned onto a children's cartoon channel.

The resident's family member was interviewed on March 2, 2010 at 12:30 PM, and stated the resident liked to watch game shows, and old shows like Mayberry RFD and Lawrence Welk.

The unit's activity staff person was interviewed on March 4, 2010, and stated she was a part time employee, started work at the facility in November 2009, and was not aware that the resident's admission assessment was incomplete. The staff member was unable to tell the surveyor what the resident's preferences were for television viewing. When asked about her interaction with the resident, the activity staff stated she stopped into the resident's room to visit with her and her roommate. She said she had not done room visits during the current week (first week of March 2010).

In summary:
- the facility did not complete a resident assessment to identify the resident's interests and activities, to enhance her level of mental and psychosocial well-being;
- the facility did not ensure the staff were aware of the resident's preferences for activities, including television viewing;
- the facility did not ensure the resident received the needed staff assistance to watch her preferred television shows ;
- the facility did not ensure the resident was involved in the minimum amount of activities as planned.

10 NYCRR 415.5 (f)(1)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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.

Based on observations, resident and staff interviews, and record reviews during the standard survey, it was determined the facility did not provide the necessary care and services to 8 of 12 residents (Residents #1, 2, 4, 7, 8, 9, 19, and 24) reviewed for activities of daily living (ADLs) and 1 resident (Resident #31) outside the sample, who required extensive assistance with toileting, incontinence care, turning and repositioning, and/or assistance at mealtime. Specifically, Residents #1, 2, 7, 8, 9, 19, 24, and 31 were not provided with timely assistance to meet their personal hygiene needs. For Resident #4, who was observed to be improperly positioned in bed during meals, there were no feeding instructions for staff to use to assist the resident to maximize her food and fluid intake. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #1 had diagnoses including dementia and cerebral vascular accident (CVA, stroke) with hemiparesis (weakness on one side).

The resident's Quarterly Nursing Summary Note, dated January 30, 2010 to February 5, 2010, documented the resident preferred to get out of bed before 10:30 AM.

The resident's Minimum Data Set (MDS) assessment, dated February 5, 2010, documented the resident's daily decision making skills were poor, and required cues and supervision. The MDS assessment documented the resident did not ambulate; required extensive assist of one staff for dressing; extensive assist of two staff for bed mobility; and total assistance of 2 staff for transfers, personal hygiene, and bathing. The MDS assessment documented the resident was incontinent of bowel and bladder.

The comprehensive care plan (CCP), dated February 10, 2010, documented the resident was to be transferred with a mechanical lift, was to go back to bed after lunch, and was to be turned and repositioned every 2 hours and as needed. The CCP documented the resident was on aspiration precautions and staff were to follow the speech language pathologist's (SLP's) recommendations for feeding the resident. The CCP documented the resident fed himself after the meal was set up, and required constant assistance to finish his meal.

The resident's current Resident Plan of Care form, provided to the surveyor on March 1, 2010 at 8:45 AM, documented the resident was supposed to be transferred out of bed using a mechanical lift; was a total assist for bathing, dressing, grooming, and hygiene; and was on aspiration precautions. The form documented incontinent residents should receive incontinence care per the facility policy.

The resident was observed lying on his back in bed with his bedclothes on, and the head of his bed elevated at a 45 to 60 degree angle, on March 2, 2010 between 8:55 AM and 1 PM (at 8:55 AM, 9:25 AM, 9:40 AM, 11 AM, 11:45 AM, 12:30 PM, 12:55 PM, and 1 PM).

On March 2, 2010 at 9:40 AM, the resident was observed drinking juice from his breakfast tray. There were 2 spoonfuls of pureed food on his bedclothes, and pureed eggs and toast directly on his tray, with no staff observed in his room.

At 1 PM on March 2, 2010, the resident was observed attempting to eat chocolate ice cream from a disposable container. He made five attempts to get ice cream onto his spoon with no success. During this observation, a unit CNA looked in on the resident and stated she wanted to know why he was not in his chair. In addition to the two spoonfuls of pureed food on his bedclothes (as observed at 9:40 AM), there was a spoonful of pureed vegetables on his left hand, and there were no staff in his room.

At 2:20 PM on March 2, 2010, the resident was observed in bed on his back, wearing a shirt, with the head of his bed elevated at a 30 degree angle.

When the resident was observed at 5 PM on March 2, 2010, the resident was wearing bedclothes while in bed on his back.

Review of the resident's medical record revealed no documented reason why the resident was not out of bed and transferred to his chair on March 2, 2010.

During an interview on March 4, 2010 at 1:45 PM, the 7 AM - 3 PM certified nurse aide (CNA) was asked to describe the care she provided to the resident. The CNA stated she washed the resident, including personal hygiene care, and fed him. When asked what time the CNA washed the resident and provided him personal hygiene care, she stated it was after lunch. The CNA stated she knew it was after lunch because she asked him about all the food on his bedclothes.

The 3 PM to 11 PM CNA who provided care on March 2, 2010 for the 3 PM to 11 PM shift, was interviewed on March 3, 2010 at 6:20 PM. When the CNA was asked to describe the care she provided to the resident, she stated she bathed him, shaved him, and repositioned him before dinner, and repositioned him again after dinner.

A licensed practical nurse (LPN) was interviewed on March 4, 2010 at 11:20 AM, and asked how she knew care was provided to the unit's residents. The LPN reviewed a Resident Plan of Care form and showed where the CNA and the LPN were supposed to sign their copy at the end of their assigned shift, thus verifying resident care was done.

When requested, the facility could not provide signed copies of the resident's March 2, 2010 Resident Plan of Care forms for the 7 AM to 3 PM and 3 PM to 11 PM shifts that specified care was provided as planned.

In summary, the facility did not ensure the resident:
- received personal hygiene care as needed;
- was turned and positioned every 2 to 5 hours and as needed;
- had aspiration precautions followed during meals with constant monitoring
- received hygiene care after meals;
- was assisted out of bed to his chair consistently by 10:30 AM.

2) Resident #19 was admitted to the facility with diagnoses of multiple sclerosis, rheumatid arthritis, and hypothyroidism.

The admission Minimum Data Set (MDS) assessment, dated December 14, 2009, documented the resident had no short or long term memory problems and had some difficulty in making decisions in new situations. The resident was totally dependent in dressing, bathing, and personal hygiene but was independent with eating after being set up.

The comprehensive care plan (CCP), dated December 22, 2009, and the current Resident Plan of Care, dated March 5, 2010, did not document that the resident was to be washed and dressed on the 11 PM-7 AM shift; and did not specify that the resident wanted to eat breakfast in the dining room and attend exercise group.

Nursing notes, dated February 21, 2010 by the 11 PM to 7 AM licensed practical nurse (LPN), documented the resident was up in the wheelchair all night. The note specified that the LPN and the certified nurse aide (CNA) asked the resident several times to go to bed, but the resident refused.

Nursing notes, dated February 21, 2010 at 1:45 PM by the registered nurse (RN), documented the resident was up all night in the wheelchair. The note specified the resident refused morning care, and refused to relieve pressure by going back to bed. The RN documented she spoke to the resident about skin integrity and relieving pressure on her bottom. The resident said she would go to bed after bingo.

During an interview with Resident #19 on March 4, 2010 at 9:10 AM, the resident said she liked to get up and eat breakfast in the dining room and did not like to eat in bed. She said she also liked to get up to go to exercise group in the morning. There were several days when she did not get up until after 11 AM, so she refused to go to bed one night, because she was afraid she would miss the exercise group again.

An interview was conducted on March 5, 2010 at 9:05 AM with the LPN team leader, who was asked about Resident #19's routine. The LPN said the resident wanted to be up for bingo and for exercise group. The LPN said staff did not get her up the previous day, so the resident stayed up all night in her wheelchair so she would not miss her activities. The LPN said the resident needed the Hoyer lift and 2 staff members to transfer the resident.

During an interview on March 5, 2010 at noon with a CNA assigned to Resident #19, the CNA was asked about the resident's morning routine. The CNA said the resident liked to be up for breakfast and go to activities, especially the morning exercise group. She said usually the 11 PM -7 AM shift got the resident washed and dressed, and then the 7 AM-3 PM shift would get her up. If there was only 1 CNA on 11 PM-7 AM, then the resident does not get washed and dressed. The CNA said she had to prioritize: if the resident was washed and dressed, she could get her up; otherwise, she needed to get residents up who were on aspiration precautions, or needed to be fed. She stated she would then "do the resident" after breakfast.

In summary, the facility did not ensure the resident received activities of daily living (ADL) care, in a timely manner.

3) Resident #7 had diagnoses of degenerative arthritis, spinal stenosis, osteoarthritis, and hypertension.

The annual Minimum Data Set (MDS) assessment dated January 12, 2010 documented the resident had no memory problems and had some difficulty in making decisions in new situations. The MDS specified the resident required extensive assistance in dressing and personal hygiene, was totally dependent for bathing, and was independent with eating, after being set up.

The comprehensive care plan (CCP) dated January 22, 2010 documented the resident was at risk for altered skin integrity related to immobility and incontinence. Since the resident did not get out of bed she needed to be changed routinely. The resident was to be turned and positioned at least every 2 hours when in bed. The CCP specified the resident was to be toileted at least every 2-4 hours per request, or provided with the bedpan while in bed, per request. Her buttocks and peri-care were to be cleaned with soap and water after each episode of incontinence. The CCP documented the resident required maximum nursing assistance with bed mobility, transfers, locomotion, dressing, grooming and toileting.

During an interview on March 4, 2010 at 9:30 AM with the alert and oriented resident, she stated no staff member had been in to care for her, since 9 PM the previous evening. She said she had not been washed, changed, or turned and repositioned. Her roommate, Resident #31, agreed with the resident and said she also had not received care that night. Resident #7 said she would like to get out of bed; however there was not enough staff to get her up and get her back to bed at a reasonable time. She said she was sometimes left up for more than 3 hours, because there was not enough staff to put her back to bed. The resident said this caused her pain to sit that long. She said she chose to eat cold cereal for breakfast, because all the hot foods were cold by the time she received them. The resident said she disliked going to the dining room for meals, because the staff did not allow enough time for other residents to swallow their food. "They just shovel the food into their mouths."

At 10:15 AM on March 4, 2010, Residents #7 and 31 were observed not to receive care for the day. Resident #7 was observed to receive morning care at 10:45 AM.

An interview was done with the CNA who worked the 11 PM -7 AM shift on March 4, 2010. She stated the other CNA took care of the residents on the side of the unit where Resident #7 resided. She said that other CNA left the unit at 5 AM.

In summary, the facility did not ensure the resident received:
- timely incontinence care;
- turning and positioning every 2 to 3 hours, and as needed.

10 NYCRR 415.12 (a)(3)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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

Citation date: March 9, 2010

Based upon observations, record reviews, staff interviews, and resident interviews conducted during the standard survey, it was determined for 1 of 1 residents reviewed for elopement (Resident #14), for 1 of 12 residents reviewed for falls (Resident #29), for 4 of 7 sampled residents (Residents #2, 8, 27, 28) and 2 out of sample residents (Residents #32 and 34) each reviewed swallowing and eating concerns, and for 1 of 6 soiled utility rooms (Unit #6), the facility did not ensure each resident received adequate supervision and assistive devices to prevent accidents and did not ensure the environment remained free of accident hazards. Specifically:
- regarding elopement risk, there was no documented assessment to evaluate Resident #14 and no plan of care developed and implemented to ensure the resident could safely be out of the facility on his own; there were no revisions to the resident's plan of care and staff were not educated to prevent recurrent elopement; there was no physician's order for the resident to go out on pass; there were no attempts to locate the resident in a timely manner when he did not return to the facility at the appropriate time.
- regarding lack of supervision and safe environment for residents with swallowing problems and risk for choking, Residents #32 and 34 were not properly positioned for meals; Resident #28 did not have an effective care plan in place to prevent this non-compliant resident from consuming foods and thin liquids from other residents' trays and from the unit pantry; Resident #2 was observed on several occasions to eat unassisted and improperly positioned in his room, contrary to the plan of care; Resident #27 was not evaluated by a speech language pathologist to determine feeding techniques to minimize the risk for choking and aspiration.
- regarding fall risks, the facility did not ensure there was an effective care plan developed when Resident #29 was non-compliant in safe transfers.
- regarding accident hazards, the facility stored hazardous chemicals stored in the Unit #6 soiled utility room.
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 SURVEYS OF AUGUST 20, 2008 AND MAY 6, 2009.

Findings include:

ELOPEMENT RISK:
1) Resident #14 had diagnoses that included a malignant neoplasm of the temporal lobe (brain tumor), seizures, and a personality disorder related to the increased size of the tumor.

The resident's Minimum Data Set (MDS) assessment, completed January 11, 2010, documented the resident had modified decision making skills in familiar situations, exhibited some difficulty in new situations, and required extensive assistance with his activities of daily living (ADLs).

The resident's comprehensive care plan (CCP), last reviewed January 12, 2010, documented the resident was non-compliant with his plan of care, was in denial of his illness, and was at risk for falling due to weakness and his disease process. There was no documented evidence of an assessment to evaluate the resident to determine if he could be out of the facility safely on his own, or a plan of care to ensure the resident's safely when he was out on pass.

A registered nurse (RN) progress note, dated February 3, 2010 at 9:15 AM, documented the resident had left the facility on February 2, 2010 at 11:30 AM and had not returned. There was no documented evidence of the resident going out on pass on February 2, 2010 in the medical record, or on the Resident Sign In / Sign Out Sheet which was kept on the unit. There was no documented evidence of a current physician's order for the resident to go out on pass for either the day or overnight. The progress note documented the RN placed a telephone call to the resident's brother asking about the resident's whereabouts. The brother contacted the resident, and then telephoned the facility stating the resident was on his way back. The brother stated the resident had not known he could not stay out overnight.

An RN progress note, dated February 3, 2010 at 9:30 AM, documented the resident returned to the facility at 9:30 AM, 22 hours after leaving the facility. There was no documented evidence of an attempt to locate the resident before 9:15 AM on February 3, 2010. There was no documented investigation completed to determine whether neglect occurred. There was no documented evidence care plan revisions and staff were educated to prevent recurrence of the resident leaving without a physician's order.

During an interview with the Director of Nursing (DON and the Assistant Director of Nursing (ADON)on March 4, 2010 at 9 AM, the DON stated a resident who left the facility on a day pass would be expected to return to the facility before midnight on the day of the pass. She stated the facility did not feel an incident report or investigation was needed, as the resident was not an elopement risk and was able to make his own decisions. She stated the facility did not educate the resident on what a day pass meant. When the resident returned to the facility he had been educated, and there had not been a problem since.

During the interview with the ADON on March 4, 2010 at 9 AM, she stated a physician's order was written on September 18, 2009 for the resident to go out on day pass. She said the order did not get faxed to the pharmacy, and was left off the monthly renewal orders.

The physician was interviewed on March 4, 2010 at 10:50 AM, and stated he was not sure what was done to determine if the resident was appropriate to go out on pass. He stated he was not the resident's physician at the time the order was written in September of 2009. He said the intent of a day pass order would be for the resident to go out and return, following facility rules. He said he was not notified that the resident was out of the facility for 22 hours, and his expectation would be that the facility would notify him of this.

The licensed practical nurse (LPN #1) who worked the 7 AM to 9 PM on February 2, 2010, was interviewed on March 4, 2010 at 11:55 AM, and stated she was not sure what time the resident went out on pass. She stated the resident was not back when she left the facility at 9 PM.

During a telephone interview on March 4, 2010 at 12:05 PM, LPN #2, who cared for the resident on the 3 PM to 11 PM shift on February 2, 2010, stated the resident had already left the facility when she came in at 3 PM. She said she notified the RN Supervisor when the resident did not return at 9 PM, and the Supervisor told her to try to locate the resident by contacting any numbers listed in his medical record. She said she called the resident's cell phone and left a message asking the resident to call the facility. LPN #2 stated the resident called her back at the end of the shift and stated he was on his way back. She said she notified the Supervisor and the oncoming shift of this, although she could not remember if she documented it. There was no documented evidence of the phone call or attempts to locate the resident.

During a telephone interview on March 4, 2010 at 12:40 PM, LPN #3, (who worked the resident's unit from 11 PM on February 2 through 7 AM on February 3, 2010), stated the resident did not return to the unit during her shift, and she did not make any attempts to locate him. She stated she did not know if the 11 to 7 shift Supervisor tried to locate the resident. She said when she went off duty at 7 AM, the resident had not returned.

When LPN #4 (cared for the resident from 7 AM to 3 PM on February 2, 2010) was interviewed on March 4, 2010 at 1:40 PM, she stated she remembered the resident had a family member visit him that day, although she did not remember if the resident went out on pass.

The RN Unit Manager was interviewed on March 4, 2010 at 3:10 PM and said she worked on February 2, 2010 although she was not aware the resident went out on pass. She was unaware the resident did not return at the appropriate time, until the following day when she came into work. She stated she was not aware of any attempts to locate the resident or contact his family until 9:15 AM on February 3, 2010, and said there should have been attempts to locate him before that time. The Unit Manager stated she had not revised the resident's care plan and did not educate the staff to prevent a recurrence.

During an interview on March 4, 2010 at 4:30 PM with the 3 PM to 11 PM RN Supervisor who worked on February 2, 2010, she stated she thought nursing staff tried to contact the resident's brother when he did not return. She said she reported the resident had not returned from pass to the 11 PM to 7 AM Supervisor and did not report it to the DON or Administration. She stated she would have notified them, if she thought the resident was in any danger.

During an interview on March 5, 2010 at 9:45 AM, the certified nurse aide (CNA), who cared for the resident on 7 AM to 3 PM on February 2, 2010, stated she did not know what time the resident left to go out on pass. She said she thought the nurses were aware he left.

The 11 PM to 7 AM shift RN Supervisor was not available for interview.

In summary, the facility:
- did not ensure there was an assessment to evaluate the resident or a plan of care to ensure the resident could safely be out of the facility on his own.
- did not ensure there was revisions to the plan of care and staff education to prevent a recurrence of the incident.
- did not ensure there was a current physician's order for the resident to go out on pass.
- did not ensure the resident or a responsible party signed the resident out before he left the facility.
- did not ensure attempts were made, in a timely manner, to locate the resident when he did not return to the facility at the appropriate time.
- did not ensure the physician and facility administration were notified of the incident.
- did not enure an investigation completed to rule out neglect, to also determine if the NYSDOH (New York State Department of Health) should be notified.

LACK OF SUPERVISION OF RESIDENTS AND LACK OF SAFE ENVIRONMENT FOR RESIDENTS AT RISK FOR CHOKING/ASPIRATION:
2) Resident #8 was admitted to the facility with diagnoses of chronic alcoholism, dysphagia (swallowing difficulty), and prostatic hypertrophy (enlarged prostate).

The resident was discharged to the nursing home on January 21, 2010 from the hospital. The hospital discharge summary, dated January 21, 2010, documented dysphagia was diagnosed through a modified barium swallow test. Speech therapy recommended a pureed diet, honey-thick liquids via cup, medications given whole, in pureed food. Aspirations precautions were to be observed.

The Minimum Data Set (MDS) dated January 30, 2010 documented the resident had short term memory loss and cognitively moderately impaired. The resident needed extensive assistance with activities of daily living including bathing, dressing, toileting, and ambulation; needed supervision to eat after set up.

The comprehensive care plan (CCP) dated February 10, 2010 documented the resident was on a pureed diet with honey-thickened liquids. The CCP did not document the resident was on aspiration (inadvertent inhalation of foreign substance into the lungs) precautions.

A review of the undated Resident Plan of Care, (verified by the registered nurse (RN) manager on March 5, 2010 at 10:40 AM as currently in use), documented the resident is on aspiration precautions.

During the survey from March 1, 2010 to March 5, 2010, the resident was observed eating his meals in his room, with no supervision present.

During an interview on March 5, 2010 at noon with the certified nurse aide (CNA) caring for the resident, the CNA was asked if the resident was on aspiration precautions. The CNA stated "no," then looked at the Resident Plan of Care and said he was on aspiration precautions. She said she did not know that information until she just looked at that Resident Plan of Care. The CNA said the resident refused to come to the dining room and did not let her do too much for him.

In summary, the facility did not consistently implement supervision during meals for this resident with swallowing difficulties.

3) Resident #34 had diagnoses including dementia, agitation, and dysphagia (difficulty swallowing).

The Minimum Data Set (MDS) assessment dated December 24, 2009 documented the resident had severe cognitive impairment; had periods of restlessness and lethargy; had chewing/swallowing problems and required total assistance with eating.

The physician's orders dated February 18, 2010 documented the resident was to receive a regular, pureed diet.

The comprehensive care plan (CCP) dated December 24, 2009 documented the resident received altered consistency diet due to his dysphagia and chewing issues. The goal identified was for the resident would tolerate his puree diet without evidence of problems. The plan included feeding the resident.

On March 2, 2010 from 1 PM to 1:20 PM, the resident was observed sitting in his wheel chair in the dining room, being fed lunch by the certified nursing aide (CNA). The resident's his head was tilted back unsupported, and his chin was positioned upward. The resident was fed large spoons of puree food and given thin liquids from a cup, while positioned in this manner.

On March 3, 2010 from 9:50 AM to 10 AM, the resident was observed in the dining room, sitting in his wheelchair, being fed breakfast by the licensed practical nurse (LPN). The resident's head was tilted back unsupported, with his chin upward, as he was fed his puree food. During lunch that day, the resident was observed being fed in the same manner as described at breakfast

The LPN was interviewed on March 5, 2010 at 10:30 AM and stated the resident slouched in his chair and should be more upright when being fed, with his head facing forward. He stated if he noted a problem while feeding the resident, he would have stopped and repositioned the resident.

In summary, the facility did not ensure the resident was properly positioned when fed by staff.

FALL RISK:
4) Resident #29 was admitted to the facility on December 27, 1996 with pertinent diagnoses including epilepsy, schizophrenia, mental retardation, anxiety, diabetes, obesity, and retinopathy.

The comprehensive care plan (CCP) dated December 8, 2009 documented the resident had a history of falls and was non-compliant with transfers and ambulation; needed to be encouraged to wait for assistance for transfers; was not compliant with care. The CCP specified the resident was on psycho-active medications; transferred with standby assistance; and required a blue mat chair alarm when placed in a wheel chair. A call bell was to be in reach at all times.

The current, undated Resident Plan of Care documented the resident required maximum assistance for bathing, dressing, grooming, and hygiene care; required standby assistance for transfers with verbal cueing; was on seizure precautions; and a Dycem (non-skid mat) must be placed beneath her wheel chair cushion to prevent sliding; and she used a bed and chair alarm.

The Unit #4 charge nurse, a licensed practical nurse (LPN), was interviewed on March 5, 2010 at 9:20 AM regarding the undated Resident Plan of Care. The LPN stated this was the current one in use for the resident. She stated the facility changed their system about one month before.

The Minimum Data Set (MDS) assessment, dated December 9, 2009, documented the resident was moderately impaired with decision making; required extensive assistance of one person with transfers, dressing, and personal hygiene; and displayed behaviors that were not easily altered that included resisting care 4-6 days per week.

A nursing progress note dated February 26, 2010 at 4:30 PM documented the resident was found on the floor between her bed and the wheel chair on February 26, 2010 at 11:00 AM. The resident was not clear how the fall occurred, and stated her right forearm was sore; no bruising was apparent.

The incident report dated February 26, 2010 documented the resident initially stated her right forearm was sore, but later stated her left leg was sore.

The care plan was updated on February 26, 2010 to include the use of a Dycem beneath her wheel chair cushion, and the use of a bed alarm. The Post Fall Evaluation form dated February 26, 2010, documented the resident was non-compliant with therapy's recommendations for standby assistance for transfers, and a call bell was to be kept in reach.

The physical therapist was interviewed on March 3, 2010 at 11:00 AM. She stated the resident was last seen in physical therapy on June 11, 2009 because she had been in the hospital for 5 days. The resident was not ambulatory at that time. The resident currently required one person assist to transfer into/out of bed, or on/off the toilet. She stated the resident could barely stand on her own as she was incredibly weak.

The resident was observed and interviewed in her room on March 3, 2010 at 11:11 AM by both the surveyor and the physical therapist. The resident was seated in her wheel chair, and she stated she could not use the bathroom as her wheel chair did not fit through the door. She also stated her back and neck hurt her because she had fallen on the floor "yesterday".

The resident's assigned CNA was interviewed on March 3, 2010 at 11:25 AM. He stated the resident's wheel chair did fit through the bathroom door, and demonstrated it with the resident at that time. He said the resident would sometimes try to stand by herself or transfer herself to the toilet when left alone in the bathroom to brush her teeth, even though she knew she was not supposed to do so.

The physical therapist was interviewed on March 4, 2010 at 2:30 PM. She stated she reassessed the resident on March 3, 2010, and she recommended the resident should be reminded not to transfer independently, should be provided standby assistance and set up for grooming as previously ordered, and should remain seated during grooming with no standing.

On March 5, 2010 at 9:25 AM, the resident was observed wheeling herself into the bathroom by herself, and she did not have the chair alarm attached to the wheel chair. The alarm device was observed on the resident's dresser.

The resident's assigned CNA, a male, was interviewed on March 5, 2010 at 9:30 AM. He stated he was aware that the resident was supposed to use a bed and chair alarm. He stated he had put the chair alarm on the resident at approximately 8:00 AM, and he was aware the resident had removed it, because he had seen the resident in the dining room between 8:30 AM - 8:45 AM without the chair alarm. He stated the resident often removed the chair alarm, and would refuse to use it.

On March 5, 2010 at 9:32 AM, the Unit #4 charge nurse LPN, stated the resident often refused to use the chair alarm, was especially reluctant to use it when her sister visited. When asked what they did when the resident refused to wear the chair alarm, she replied there was not much you could do when the resident wanted to have her own way.

In summary, for a resident with a history of multiple falls, the facility did not ensure there was an effective care plan developed and/or implemented for periods when the resident was non-compliant with the use of her bed and chair alarms, and/or transfers from her wheel chair without staff assistance as the resident was observed alone in her room and bathroom during the survey without her chair alarm; and per staff interviews, staff were aware the resident had removed the device, and did not have an alternative plan to provide an equivalent degree of safety to prevent the resident from falling.

ACCESS TO HAZARDOUS CHEMICALS:
5) The upper safety latch to the door of the soiled utility room on Unit #6, a designated dementia unit, was observed left unlatched on multiple occasions (February 28, 2010 at 5 PM, March 2, 2010 at 1:45 PM, and March 3, 2010 at 9:05 AM). At these same times, the cabinet door to the lockable blood spill cabinet that contained hazardous chemicals including disinfectants and cleaners was simultaneously left unlocked, thereby permitting unauthorized access to these hazardous products by confused residents.

One licensed practical nurse (LPN) standing at the medication cart on Unit #6 was interviewed on March 4, 2010 at 4:27 PM. She stated the soiled utility door was often left unlatched by staff, and she did not believe the blood spill kit door was ever kept locked, and she did not know if there was a key to the lock or where it was kept, if there was one. A second LPN, who overheard the other LPN, stated the blood spill kit was used a few days ago by nursing or housekeeping staff, the blood spill cabinet door was supposed to be locked, and she produced the key, which was kept behind the nursing station.

In summary, the facility did not ensure residents could not gain unauthorized access to hazardous chemicals stored in the Unit #6 soiled utility room.

10 NYCRR 415.12 (h)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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

Citation date: March 9, 2010

Based on observations, and staff interviews conducted during the standard survey, it was determined for 2 of 3 test trays sampled, (on Units #5 and 6) the facility did not ensure food was palatable and served at the proper temperature. Specifically, hot foods and cold beverages were not served at palatable temperatures for test trays taken on February 28, 2010 (Unit #6), and on March 2, 2010 (Unit #5). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

A test tray was sampled on Unit #6 for the supper meal on February 28, 2010 at 6:40 PM, at the time of the last resident served. The following unpalatable food and drink temperatures were tasted and recorded:
- Chicken Parmesan on a bun - 100 degrees F. not hot tasting;
- Stewed vegetables - 110 degrees F. - tasted lukewarm;
- Barley soup - 97 degrees F. - not hot tasting;
- Milk - 67 degrees F. - tasted warm;
- Coffee - 101 degrees F. - not hot tasting.

A test tray was sampled on Unit #5 for the lunch meal on March 2, 2010 at 1:15 PM, at the time of the last resident served. The following unpalatable drink temperature was tasted and recorded:
- chocolate shake - 55 degrees F. - tasted warm.

The food service manager, interviewed on March 3, 2010 at 6:15 PM, stated dietary performed test trays twice weekly, and they had not been finding any problems. He said he believed the problem for the warm shake for the lunch meal on March 2, 2010 was due to the refrigerator being used, so he changed the refrigerator being used for the shake, and got better temperatures today. He believed the poor temperatures for the test tray taken on February 28, 2010 was beyond his control, as staff took too long to pass the trays.

In summary, the facility did not ensure that hot and cold food and drink was served to residents at palatable temperatures.

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

F353 483.30(a): SUFFICIENT NURSING STAFF ON A 24-HOUR BASIS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: Except when waived under paragraph (c) of this section, licensed nurses and other nursing personnel. Except when waived under paragraph (c) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Based on observations, record reviews, and interviews with staff and residents conducted during the standard survey, it was determined, for 7 of 30 sampled residents (Residents # 1, 2, 7, 8, 9, 19, and 24) and for 1 resident outside of the survey sample (Resident #31), the facility did not ensure there were sufficient nursing staffing levels to maintain the highest practicable level of well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the lack of sufficient staff on duty affected multiple areas of resident care and resident quality of life, and adversely affected the staff's ability to provide care in a timely manner, including: not providing timely assistance with personal hygiene, toileting, and bathing (Resident #1, 2, 7, 8, 9, 19, 24, and 31); not providing timely pressure relieving interventions (Residents #1, 2, 7, and 9); not providing consistent care routines (Resident #1, 2, 7, 19, and 24); not providing required assistance during meals (Resident #1 and 2); and not attending to the specific needs of residents (15 of anonymous 16 residents in attendance at the group meeting). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

RESIDENT GROUP INTERVIEW:
During the Resident Group Interview held on March 2, 2010 at 2 PM, 15 out of 16 anonymous residents who were in attendance, complained about the lack of staff in the facility and as a result of insufficient staffing, their care needs were not being met. The following complaints were made by residents during the group interview:
- call bells not being answered timely or not being answered at all; staff walking past residents' rooms and ignoring their call bells; one resident who needed assistance with toileting and whose call bell went answered, was forced to urinate in her undergarments;
- showers not being given to residents according to their shower schedule; some residents had not received a shower in several weeks, and were being given bed baths instead;
- a resident requested a glass of water in the middle of the night, and there was no aide available to assist him;
-a resident regularly made up his own bed, as there was no staff available to complete this task;
-a resident was administered an antibiotic 5 days after laboratory tests confirmed he had an infection;
- a resident was told to "go away" by staff when he was not able to locate anyone on his unit, and knocked on the staff break room door for assistance;
- residents not receiving their morning care in time to attend activities;
- residents waiting a long time for their meals to be served in the dining room and;
-certified nurse aides (CNAs) working double, and sometimes triple, shifts.

In summary, the residents did not believe their needs were met in a timely manner by nursing staff.

OBSERVATIONS:
During a tour of Unit 5 on March 1, 2010 at 10:30 AM, the census for that day was 44 residents with a capacity of 46. There were 3 certified nurse aides working with 2 licensed practical nurses and 1 registered nurse unit manager, who covered 2 units. There were 11 residents requiring a mechanical lift to get out of bed, 26 residents requiring set up for meals, 6 residents needing to be fed, 2 residents requiring assistance with feeding and 1 resident needing verbal cueing. There were 12 residents still in bed with hospital gowns on. The Resident Plan of Care scheduled 2 showers a week for each resident, with 7 showers scheduled for Monday morning. When the CNAs were asked about their assignments, 2 CNAs said they were responsible for 15 residents and the 3rd CNA said she was assigned a wing (15-16 residents).

A CNA on Unit 6 was observed on March 1, 2010 at 7 PM to be standing up while feeding 2 residents at the same time (Residents #6 and 33). The CNA alternated putting spoonfuls of food into the residents' mouths. The surveyor asked the CNA about the manner she used while feeding. and the reason for the 70 minute wait Residents #6 and 33 experienced before being fed. The CNA said, "I can't sit down. We never have enough help. We got too many (residents). We have to check them all. I am telling it like it is." The CNA stated, "they don't give us enough help. They take (staff) from us."

STAFF INTERVIEWS:
During an interview on March 2, 2010 at 9:45 AM, a CNA on Unit 5 was asked about her assignment, as there were 3 CNAs working that day on the 7 AM to 3 PM shift. The CNA said they do the best they can, sometimes they can give showers; they try but showers are not always done.

When interviewed on March 3, 2010 at 12:15 PM, a CNA from the sixth floor stated that since they were short 1 CNA that day, (3 CNAs instead of 4), she was given extra residents to provide care to. The CNA said supplies that were normally kept in Resident #4's room were not there. She said she had to get the supplies from the linen cart so she could finish. When asked by the surveyor why Resident #4's morning care was being provided at 12 PM, the CNA said it was because they had 3 CNAs instead of 4 on the floor, and it was taking her longer to provide care to the residents she was assigned to. The CNA stated, "I am working a double (shift) today."

During an interview on March 4, 2010 at 5:20 PM with a CNA who worked 11 PM to 7 AM, the CNA said she did what she could when she was by herself. She stated she answered call bells and did rounds. When she was by herself, she said she could not get the residents up early when they wanted to be, so the day shift had to "do" them.

A unit RN manager was interviewed on March 4, 2010 at 9:10 AM, and stated she replaced the interim RN manager "a few weeks ago." She said she also remained responsible for a second nursing unit, and relied on the interim unit RN manager as the backup RN for the resident's unit. The RN manager stated she tried to get residents' skin assessments done when she could, but was frustrated that she could not get all the work done. She said all residents' pressure areas were supposed to be measured/assessed weekly.

During an interview on March 5, 2010 at noon with a CNA on Unit 5, the CNA said there was a resident who stayed up all night in her wheelchair because she did not want to miss the morning exercise group. When there was one CNA on 11 PM to 7 AM, the CNA said this resident was not washed or dressed before breakfast. The CNA stated the CNA on the day shift did not have time to get her up. She said the day shift CNA had many other residents who needed to get up, such as residents on aspiration precautions and any resident who needed to be fed, as they had to be up for breakfast.

LPN #2 was interviewed on March 5, 2010 at 9:45 AM, and asked how she knew that resident care was done. LPN #2 stated CNAs were responsible for their resident care assignments; and that the CNAs had their resident care guides, and that she helped when she could. LPN #2 stated she administered medications and helped residents with their meals in the dining room, and could not be sure that all resident care was completed.

In summary, staffing shortages adversely affected the staff's ability to provide care in a timely manner.

INDIVIDUAL RESIDENTS:
1) Resident #7 was admitted to the facility with diagnoses of degenerative arthritis, spinal stenosis, osteoarthritis, and hypertension.

The comprehensive care plan (CCP) dated January 22, 2010 documented the resident was at risk for altered skin integrity related to immobility and incontinence. Since the resident does not get out of bed she needs to be changed routinely. Her buttocks and peri-care were to be cleaned with soap and water after each episode of incontinence. The resident required maximum nursing assistance with bed mobility, transfers, locomotion, dressing, grooming, and toileting.

During an interview on March 4, 2010 at 9:30 AM, the resident, who is alert and oriented, said no staff member had been into her room to care for her since 9 PM the night before. She said she was not washed, changed, or turned and repositioned. Resident #7 said she would like to get out of bed; however there is not enough staff to get her up and get her back to bed at a reasonable time. She said she is sometimes left up for more than 3 hours because there is not enough staff to put her back to bed. The resident said this causes her pain to sit that long.
The resident was observed being given morning care at 10:45 AM.

Resident #31, the roommate of Resident #7 spoke to the surveyor on March 4, 2010 at 9:30 AM and said the information given by Resident #7 was true and said she also was not given care the evening of March 3 through the morning of March 4, 2010.

Resident #7's skin was observed on March 4, 2010 at 5 PM with the registered nurse (RN) Unit Manager. The resident's buttocks were observed to be red. The surveyor told the RN nurse manager that Residents #7 and 31 did not receive care for more than 13 hours, from 9 PM on March 3, 2010 (according to both residents) until 10:45 AM that day.

An interview was done with the CNA who worked the 11 PM - 7 AM shift on March 4, 2010. From 5 AM until 7 AM she was the only CNA on the unit. She said the other CNA did the side that Resident #7 was on and she was supposed to care for her. She said that CNA left at 5 AM. The CNA said she does the best she can when she is alone; she makes rounds and answers call bells.

In summary, the facility did not ensure the resident received the care she was assessed as requiring, including:
- being changed routinely;
- personal hygiene care as needed for an incontinent resident; and
- turning and positioning every two to three hours and as needed.

2) Resident #2 had diagnoses including dementia and cerebral vascular accident (CVA, stroke) with hemiparesis (weakness on one side).

The resident's Quarterly Nursing Summary Note, dated January 30, 2010 to February 5, 2010, documented the resident preferred to get out of bed before 10:30 AM.

The resident's Minimum Data Set (MDS) assessment, dated February 5, 2010, documented the resident's daily decision making skills were poor, and required cues and supervision. The MDS assessment documented the resident did not ambulate; required extensive assist of one staff for dressing; extensive assist of two staff for bed mobility; and total assistance of 2 staff for transfers, personal hygiene, and bathing. The MDS assessment documented the resident was incontinent of bowel and bladder.

The comprehensive care plan (CCP), dated February 10, 2010, documented the resident was to be transferred with a mechanical lift, was to go back to bed after lunch, and was to be turned and repositioned every two hours and as needed. The CCP documented the staff were to follow the speech language pathologist's recommendations for feeding the resident, and the resident was on aspiration precautions. The CCP documented the resident fed himself after set up, and required constant assistance to finish his meal.

During the initial tour of the fourth floor nursing unit on March 1, 2010, the unit secretary stated there were 45 residents on the unit.

The resident's current Resident Plan of Care form, provided March 1, 2010 at 8:45 AM, documented the resident was supposed to be transferred out of bed using a mechanical lift; was a total assist for bathing, dressing, grooming, and hygiene; and was on aspiration precautions. The form documented incontinent residents should receive incontinence care per the facility policy.

The resident was observed in his bed, on his back, with the head of his bed at a 45 to 60 degree angle, and with his bedclothes on March 2, 2010 at 8:55 AM, 9:25 AM, 9:40 AM, 11 AM, 11:45 AM, 12:30 PM, 12:55 PM, and at 1 PM.

During the observation on March 2, 2010 at 9:40 AM, the resident was observed drinking juice from his breakfast tray. There were two spoonfuls of pureed food on his bedclothes, there were pureed eggs and toast on his tray, and there were no staff in his room.

During the observation on March 2, 2010 at 1 PM, the resident was observed attempting to eat chocolate ice cream from a disposable container. He made five attempts to get ice cream onto his spoon with no success. In addition to the two spoonfuls of pureed food on his bedclothes (as observed at 9:40 AM), there was a spoonful of pureed vegetables on his left hand, and there were no staff in his room. During this observation, a unit CNA (not assigned to provided the resident care) looked in on the resident and stated she wanted to know why he was not in his chair.

During an observation on March 2, 2010 at 2:20 PM, the resident was observed in bed on his back, with the head of his bed at a 30 degree angle, and with a shirt on.

There was no documentation in the resident's record that noted a reason the resident was not out of bed to his chair on March 2, 2010.

Review of the fourth floor nursing unit's assignment sheet, dated March 2, 2010 for the 7 AM to 3 PM shift, revealed the certified nurse aide (CNA) assigned to provide the resident his care on March 2, 2010 during the 7 AM to 3 PM shift, was responsible to provide care to the resident and 12 other residents. The CNA was one of 3 CNAs assigned to this nursing unit for the 7 AM to 3 PM shift.

During an interview on March 2, 2010 at 12:30 PM, the CNA assigned to the resident stated she did not work on the unit, and had been floated to the unit that day.

During an interview on March 4, 2010 at 1:45 PM, when asked to describe the care she provided the resident, the certified nurse aide (CNA) assigned to provide the resident care on March 2, 2010 during the 7 AM to 3 PM shift stated she washed the resident, including personal hygiene care, and fed him. When asked what time the CNA washed the resident and provided him personal hygiene care, she stated it was after lunch. The CNA stated she knew it was after lunch because she asked him about all the food on his bedclothes.

During an interview on March 5, 2010 at 9:45 AM, when asked how she knew that resident care was done, a licensed practical nurse (LPN) stated the CNAs were responsible for their resident care assignments, the CNAs had their resident care guides, and she helped when she could. The LPN stated she administered medications and helped residents with their meals in the dining room, and could not be sure that all resident care was being completed.

In summary, the facility did not ensure adequate staffing was provided for the resident to receive the care he was assessed as requiring and according to his preferences, including:
- personal hygiene care as needed for an incontinent resident;
- turning and positioning every two to three hours and as needed;
- constant assistance with meals, including aspiration precautions, and hygiene care after his meals;
- out of bed to his chair by 10:30 AM.

3) Resident #19 was admitted to the facility with diagnoses of multiple sclerosis, rheumatid arthritis, and hypothyroidism.

The admission Minimum Data Set assessment dated December 14, 2009 documented the resident had no memory problems; was totally dependent in dressing, bathing, and personal hygiene; and was independent with eating after being set up.

The Comprehensive Care Plan dated December 22, 2009 and the current Resident Plan of Care dated March 5, 2010 did not document that Resident #19 was to be washed and dressed on the 11 PM-7 AM shift and her wanting to eat breakfast in the dining room and attend exercise group.

Nursing notes dated February 21, 2010 at 1:45 PM by the registered nurse (RN) documented the resident had been up all night in the wheelchair, refused morning care, and refused to relieve pressure by going back to bed. The RN spoke to the resident about skin integrity and relieving pressure on her bottom. The resident said she would go to bed after bingo.

During an interview with Resident #19 on March 4, 2010 at 9:10 AM, the resident said she likes to get up and eat breakfast in the dining room and she does not like to eat in bed. She also likes to get up to go to exercise group in the morning. There were several days when she did not get up until after 11 AM so she refused to go to bed one night because she was afraid she would miss the exercise group again.

An interview was done on March 5, 2010 at 9:05 AM with the LPN team leader, who was asked about Resident #19's routine. The LPN said the resident wanted to be up for bingo and for exercise group. The day before, the staff did not get her up, so she stayed up all night in her wheelchair so she would not miss her activities. The LPN said the resident needs the Hoyer lift and 2 staff members to transfer the resident.

During an interview on March 5, 2010 at noon with a CNA, who has been assigned to Resident #19, the CNA was asked about Resident #19's morning routine. The CNA said the resident liked to be up for breakfast and go to activities, especially the morning exercise group. The CNA stated if there was only one CNA on 11 PM - 7 AM, then the resident did not get washed and dressed. The CNA said she had to prioritize: if the resident was washed and dressed, she could then get her up; otherwise, the CNA said she needed to get residents up who were on aspiration precautions or needed to be fed.

In summary, the facility did not ensure a resident, who required total assistance with activities of daily living, received care in a timely manner.

10 NYCRR 415.13 (a)(1)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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: March 9, 2010

Based on record review and staff interviews conducted during the standard survey, it was determined the facility did not ensure appropriate treatment and services were provided to 1 of 19 residents reviewed with depression or behavioral problems (Resident #14) to maintain their highest level of psychosocial and mental functioning. Specifically, the facility did not ensure Resident #14 was referred for a psychological consultation in a timely manner. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #14 had diagnoses that included a malignant neoplasm of the temporal lobe (brain tumor), with mood and personality disorders related to the increased size of the tumor.

The resident's Minimum Data Set (MDS) assessment, completed January 11, 2010, documented the resident had modified decision making skills in familiar situations, exhibited some difficulty in new situations, and had persistent anger with himself or others.

The resident's comprehensive care plan (CCP), last reviewed by the facility's interdisciplinary team on January 12, 2010, documented the resident was non-compliant with his plan of care, had anger over his disease process related to a loss of control, and was in denial of his illness.

A physician's progress note, dated January 14, 2010, documented the resident "appears mildly depressed, and becomes agitated when referring to physical therapy or talking about his left sided paralysis"; and specified the resident had "psychosis, personality changes, most likely related to his tumor." The note documented the resident would be started on Zoloft (an antidepressant), and a psychological consultation would be ordered.

A physician's order was written on January 14, 2010 for a psychological consultation. There was no documented evidence that a referral was made for a psychological consultation, and no documentation that a consultation was completed, until it was brought to the registered nurse (RN) Unit Manager's attention at the time of survey.

During an interview on March 4, 2010 at 9:15 AM with the RN Unit Manager, she stated she did not see a consultation from the psychologist in the resident's medical record. She stated when an order was written for a psychology consultation, the social worker completed a referral form which was given to the psychologist, who did his own scheduling.

The unit Social Worker was interviewed on March 4, 2010 at 9:30 AM and stated she did not remember writing a referral for a psychological consultation for the resident, and would check with the Social Services Director to see if she made one out. She stated that typically the Unit Manager or the Social Worker made out a referral and gave it to the psychologist.

At 10:30 AM on March 4, 2010, the Director of Social Services told the surveyor that a referral had not been made out and should have been.

In summary, for this resident with depression and psychosocial difficulties coping with his disease process, the the facility did not ensure the resident received a timely referral for a psychological consultation, as ordered by the physician.

10 NYCRR 415.12 (f)(1)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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

Citation date: March 9, 2010

Based on observations, record reviews, and interviews with staff and residents during the standard survey, it was determined the facility did not develop, review, and revise the comprehensive care plan (CCP) for 2 of 30 residents reviewed for care planning (Residents #16 and 29) to ensure they met each resident's medical, nursing, and mental psychosocial needs identified in their comprehensive assessments. Specifically, the facility did not ensure Resident #29's CCP was accurate and complete regarding the amount of assistance the resident required for activities of daily living (ADLs); did not ensure the CCP addressed the resident's gender preference for care givers; did not develop an alternate plan when the resident self-transferred and was non-compliant with the use of a chair alarm. For Resident #16, the facility did not ensure the CCP was accurate and complete regarding the resident's vision impairment, psychoactive medications, incontinence, and fall risk; and current, accurate care instructions were not documented for direct care staff. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #29 had diagnoses including epilepsy, schizophrenia, mental retardation, depression, anxiety, osteoporosis, diabetes, and retinopathy (vision deficit).

The CCP, dated December 8, 2009, documented the resident was on psychoactive and anti-seizure medications; had a history of falls; was non-compliant with transfers, ambulation, care, and diet recommendations; and needed to be encouraged to wait for assistance for transfers. The CCP documented the following instructions/interventions:
- the resident was to be educated regarding the risks/consequences of not following the recommended diet, care, and fluid restrictions;
- staff were not to argue with the resident, and were to document the resident's refusals;
- the resident was to be provided consistent care givers;
- the resident was to be transferred with standby assistance;
- the resident was to have a blue mat chair alarm when she sat in a wheel chair. After a fall, an update to the CCP was made on February 26, 2010 to utilize a bed alarm in addition to the chair alarm.

The undated Resident Plan of Care, used by certified nurse aides (CNAs) to provide care, documented:
- the resident required standby assistance for transfers, with verbal cueing;
- the resident was to have a bed and chair alarm;
- the resident was to have no male CNAs providing personal care.

The licensed practical nurse (LPN) charge nurse was interviewed on March 5, 2010 at 9:20 AM regarding the undated Resident Plan of Care. The LPN stated this was the current one in use for the resident, and it did not match the interventions in the CCP.

When the LPN charge nurse, was re-interviewed on March 5, 2010 at 10:15 AM about the resident's care plan interventions, the LPN charge nurse stated the resident no longer requested that no male CNAs provide care, as specified on the current Resident Plan of Care. When asked when this change occurred, the LPN stated it occurred "last Fall", when the resident and her family said they would allow a male CNA to care for her.

When the resident was interviewed on March 5, 2010 at 10:00 AM, she stated the male aide washed her hair that morning, and she liked him.

The Minimum Data Set (MDS) assessment, dated December 9, 2009, documented the resident had moderate cognitive impairment; required extensive assistance of 1 person for transfers, dressing, and personal hygiene; had limited range of motion and partial loss of voluntary movement of her legs and feet; and displayed behaviors not easily altered, including resistance to care 4-6 days a week.

The physical therapist was interviewed on March 3, 2010 at 11:00 AM. She stated when the resident was last seen in physical therapy on June 11, 2009, she was non-ambulatory and required the assistance of 1 person for transfer into/out of bed and on/off the toilet. The therapist stated the resident could barely stand on her own, as she was "incredibly weak."

The resident was observed and interviewed in her room on March 3, 2010 at 11:11 AM by both the surveyor and the physical therapist. The resident was seated in her wheel chair, and said she could not use the bathroom, as her wheel chair did not fit through the door. The resident stated staff were supposed to help her, had left her clothes on the dresser, and said staff would not hang them up in the bathroom for her. She stated her back and neck hurt, as she had fallen on the floor the day before.

The resident's assigned male CNA was interviewed on March 3, 2010 at 11:25 AM. He stated the resident's wheel chair did fit through the bathroom door, and he then wheeled the resident into the bathroom. He said the resident would sometimes try to stand by herself or transfer herself to the toilet, when left alone in the bathroom to brush her teeth.

The physical therapist was re-interviewed on March 4, 2010 at 2:30 PM. She stated she re-assessed the resident on March 3, 2010, and recommended the resident be encouraged to remain seated during grooming, with standby assistance, and set-up as previously recommended.

On March 5, 2010 at 9:25 AM, when the resident was observed wheeling herself into the bathroom, the chair alarm was not attached to the wheel chair. The chair alarm device was observed on the resident's dresser at that time.

The resident's assigned male CNA was re-interviewed on March 5, 2010 at 9:30 AM and asked about the resident's alarms. He stated he was aware the resident was supposed to have bed and chair alarms. He said he attached the chair alarm to the resident at approximately 8:00 AM that morning. He said he was aware the resident removed it, because he saw the resident without the chair alarm in the dining room that morning between 8:30 AM - 8:45 AM. He stated the resident often removed the chair alarm, and would refuse to use it.

The LPN charge nurse, interviewed on March 5, 2010 at 9:32 AM, stated the resident often refused to use the chair alarm, especially when family visited. When asked what was done when the resident refused to wear the chair alarm, the LPN replied not much could be done when the resident "wanted to have her own way."

In summary, the facility did not ensure the resident's care plan interventions were complete and accurate as:
- the CCP and Resident Plan of Care documented conflicting information regarding the amount of assistance required for toileting, hygiene, dressing, and transfer;
- the resident's gender preference for CNAs was no longer accurate;
- there was no plan of care developed to ensure the resident's safety when she self-transferred and was non-compliant with the use of a chair alarm.

2) Resident #16 had diagnoses including stroke with left hemiparesis (weakness), glaucoma and retinopathy (vision deficit), left above knee amputation, and dementia with behavioral disturbance.

The Re-admission Nursing Assessment, dated November 12, 2009, documented the resident was always incontinent of bowel and bladder, was non-ambulatory, required extensive assistance for transfer, and had a fall risk score of 12, with a score of 10 or more signifying a risk for falls. The assessment documented the resident's fall risk was related to independence and incontinence, vision impairment, weakness/paralysis, gait difficulty, dizziness/loss of balance, the use of 2 or more medications, and a change in medication in the past 5 days.

Physician's orders, dated January 21, 2010, documented the resident received medications including Norvasc (antihypertensive), Risperidone (antipsychotic), and 2 topical medications for glaucoma (Timolol and Travatan).

The quarterly Minimum Data Set (MDS) assessment, dated January 22, 2010, documented the resident had mild cognitive impairment, received antipsychotic and antidepressant medications everyday, was non-ambulatory, and was continent of bowel and bladder.

During an interview with the RN MDS coordinator at 11:30 AM on March 3, 2010, she stated the MDS of January 22, 2010 incorrectly identified the resident as continent of bowel and bladder. She stated the resident was frequently incontinent of bowel and bladder.

The unsigned Quarterly Nursing Summary Note, dated January 23, 2010 - January 29, 2010, documented the resident was continent of bowel and bladder, and received Cymbalta (antidepressant) and Risperidone for dementia with agitation. The Fall Assessment documented the resident's risk score was 9, related to independence and continence, gait difficulties, intermittent confusion, and 2 or more medications. The January Fall Assessment did not identify the resident's vision impairment (1 point); and the weakness/paralysis (1 point).

The comprehensive care plan (CCP), last reviewed and updated by the interdisciplinary team on February 5, 2010, documented the resident had poor eyesight; was unable to self-transfer; and was incontinent of bowel and bladder. The CCP documented the resident's Wanderguard (electronic monitoring device) was trialed for removal on April 16, 2009. The CCP's most recent intervention for incontinence, dated July 10, 2008, documented the resident refused a toileting schedule. The CCP did not include current planning/interventions for:
- impaired vision;
- incontinence/toileting;
- psychotropic and antidepressant medications;
- fall risk.

The current, undated Resident Plan of Care, used by certified nurse aides (CNAs) to provide care, documented the resident wore incontinence briefs; was at risk to fall; and was an elopement risk and had a Wanderguard. The Resident Plan of Care did not include the frequency for toileting/ change of incontinence briefs.

When the resident observed sitting in the dining room at 6:10 PM on March 1, 2010, he was not wearing a Wanderguard.

The registered nurse (RN) supervisor was interviewed regarding the resident's care plan at 11:25 AM on March 3, 2010. She stated the resident's Wanderguard was not replaced after the trial for removal in April 2009, because the resident was no longer at risk for elopement. After reviewing the CCP, the RN supervisor stated the resident should have a care plan related to falls and incontinence.

In summary, the facility did not ensure the resident's care plan interventions related to vision impairment, psychoactive medications, incontinence, and fall risk; and direct care staff were current, accurate and complete.

10 NYCRR 415.11 (c)(1)

F241 483.15(a): DIGNITY

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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: March 9, 2010

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the facility did not promote care in a manner that maintained or enhanced the dignity and respect for 2 of 30 sampled residents (Residents #4 and 6), and for 3 residents outside the sample (Residents #33, 35, and 36). Specifically, Residents #4 was left fully exposed in bed and in view of others while being provided care; Residents #6 and 33 waited 70 minutes to be fed, and were fed by a staff member who stood over the residents; Resident #35 was administered an insulin injection; Resident #36 had a blood glucose finger stick test done in view of others; and Resident #35 was wheeled backwards in her wheelchair, through the corridor and into the dining room, without explanation from staff. 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 AUGUST 15, 2007, AUGUST 20, 2008, AND MAY 6, 2009 SURVEYS.

Findings include:

1) Resident #4 had diagnoses including dementia, atrial fibrillation, weakness, chest pain, and a history of falls.

The comprehensive care plan (CCP) dated February 22, 2010 documented the resident had limitations in terms of her range of motion, ability to perform ADLs (activities of daily living), and ability to transfer and ambulate.

The Minimum Data Set (MDS) assessment, dated February 25, 2010 documented the resident had memory deficits, and was cognitively impaired to a moderate degree. The MDS assessment documented the resident was able to make herself understood and had difficulty understanding others. The resident was dependent on staff for her ADLs including bathing, and dressing.

On March 3, 2010 at 12 PM, the resident was observed from the corridor, to be lying in bed face up and fully exposed. The certified nurse aide (CNA) providing morning care, was observed to come out of the resident's room, leave the door open and proceed down the corridor, to obtain wash cloths from the linen cart. The resident was observed to be left lying in bed, uncovered. The privacy curtain had not been pulled around the resident's bed. When the CNA saw the surveyor standing outside the resident's room, she ran back to the resident's room after she obtained the wash cloths. As the CNA re-entered the resident's room, she said, "I'm sorry" to the surveyor, and closed the resident's door behind her.

When interviewed on March 3, 2010 at 12:15 PM, the CNA stated that supplies normally kept in the resident's room were not there, and she needed to leave the resident (while still giving care) to get the supplies from the linen cart. The CNA said, "I should have covered her (the resident) up, and should have pulled the privacy curtain."

In summary, the facility did not ensure the resident was cared for in a manner and in an environment that maintained or enhanced her dignity and respect, as she was left fully exposed and in view of others during care.

2) Resident #6 had diagnoses including Alzheimer's disease, severe dementia with psychosis, and depression.

The Minimum Data Set (MDS) assessment, dated December 14, 2009, documented the resident was cognitively impaired to a moderate degree and was totally dependent upon staff for all ADLs (activities of daily living), including eating. The MDS documented the resident sometimes understood others and sometimes could make himself understood.

The undated Resident Plan of Care, used by the certified nurse aides (CNAs) to provide care, documented the resident received a no concentrated sweets diet with a ground consistency, and received total assistance from staff during meals.

Resident #33 had diagnoses including mental retardation, severe dementia, and depression.

The Minimum Data Set (MDS) assessment dated January 13, 2010 documented the resident was cognitively impaired to a severe degree and was totally dependent upon staff for all ADL's (activities of daily living), including eating. The MDS documented the resident sometimes understood others and sometimes could make herself understood.

The comprehensive care plan (CCP), last reviewed by the interdisciplinary team on January 26, 2010, documented the resident received a no concentrated sweets (NCS) diet with a pureed consistency and thin liquids; and was fed by staff at meals.

On March 1, 2010 at 5:35 PM, the food cart was observed to be delivered to the unit dining room. At 6:45 PM, Residents #6 and 33 were observed seated next to each other in the unit dining room, as they waited to be fed their supper meals. Resident #6 was seated in his wheelchair, off to one side of the dining room with an overbed tray table positioned in front of him. Resident #33 was seated in her Broda chair (chair that prevents rising) with an overbed tray table positioned next to her. At 6:50 PM, a CNA started to feed both Residents #6 and 33 at the same time, while standing between them. The CNA alternated putting spoonfuls of food into their mouths. There was little or, no social interaction from the CNA when feeding the residents. At 7:10 PM, the CNA continued feeding the 2 residents in the same above manner.

The CNA, feeding Residents #6 and 33, was interviewed on March 1, 2010 at 7 PM. The surveyor asked the CNA about standing to feed residents and about Residents #6 and 33 being fed 70 minutes after the tray cart arrived. The CNA stated, "I can't sit down," and then said "we have to check them all.

In summary, the facility did not ensure both residents were cared for in a manner and in an environment that maintained or enhanced their dignity and respect, as:
- Residents #6 and 33 waited 70 minutes to be fed their supper meal.
- Staff stood above and between the 2 residents, while alternately feeding them, with little or no social interaction with the residents.

3) During observation of the medication pass on the fifth floor at 5:15 PM on March 2, 2010, the licensed practical nurse (LPN) medication nurse was observed to inject insulin into the abdomen of Resident #35, as the resident's roommate watched. After the injection, the LPN was observed to wheel the resident backwards in her wheelchair through the corridor and into the dining room.

The LPN was interviewed at 5:30 PM on March 2, 2010. When asked if she usually gave injections in view of others, the LPN stated she was not paying attention and could have drawn the curtain to provide privacy to the resident during care. When the LPN was asked if she usually wheeled residents backward in their wheelchairs, the LPN stated she wheeled the resident backward because the wheels on the wheelchair did not turn easily.

In summary, staff provided care to the resident in view of others, and staff wheeled the resident backward through the corridor.

10 NYCRR 415.5 (a)

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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.

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the facility did not maintain an infection control program designed to prevent or minimize the development and transmission of disease and infection for 1 of 27 current residents in the survey sample (Resident #26) for 2 residents outside of the survey sample (Residents #38 and 39), and for the approximately 46 residents on 1 of 6 nursing units (Unit 5). Specifically, food served to Residents #26, 38, and 39 were handled by staff with their bare hands; and clean resident supplies were not stored in a sanitary manner on Unit 5. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #26 has diagnoses including dementia, diabetes, and depression.

The Minimum Data Set assessment dated January 27, 2010 documented the resident had short and long term memory impairment with severe cognitive impairment. This assessment recorded the resident needed total assistance with eating.

The Physician's orders dated March 1, 2010 documented the resident was to receive a ground diet with nectar thick liquids.

The comprehensive care plan dated March 3, 2010 documented the resident was to be fed by staff as needed.

Observations made on March 3, 2010, at 9:53 AM, showed the certified nurse aide (CNA) feeding the resident in the dining room. The CNA tore 2 slices of toast into small pieces and fed them one at a time to the resident using her bare hands. The CNA then broke off pieces of a banana and fed them to the resident using her bare hands. There was no type of barrier between the CNAs hands and the resident's toast/banana as she fed her.

In a telephone interview with the CNA on March 5, 2010 at 11:50 AM, she stated she was told not to wear gloves when feeding residents. She said she always washes her hands after serving and before feeding residents.

In summary, the facility did not ensure a sanitary environment when staff fed the resident by touching food items with their bare hands.

2) Resident #38 had diagnoses including dementia.

During supper on February 28, 2010 at 6 PM, a certified nurse aide (CNA) was observed in the Unit 6 dining room standing at the steam table, as she waited for a tray to be prepared. The CNA was observed to cough into her ungloved hands. The CNA did not wash her hands or use a hand sanitizer after she coughed. The CNA was then observed to pick up a prepared tray from the steam table with her ungloved hands, add beverages to the tray, deliver the tray to a resident, and set-up the meal for the resident. The CNA continued delivering trays and setting-up meals for other residents in the Unit 6 dining room. A few minutes later at 6:10 PM, the same CNA was overheard by the surveyor saying, "I think I cut my finger. It really hurts." Later that same day at 6:50 PM, the same CNA was observed to cut Resident #38's chicken Parmesan sandwich in half, and hand it to him with her ungloved hands.

When interviewed on March 4, 2010 at 4:55 PM, the Director of Nursing (DON) stated this was not an acceptable practice and the CNA should have been wearing gloves when handling food. The DON said after the CNA coughed into her hands, she should have washed her hands. The DON said the facility currently did not employ an infection control registered nurse (RN), and it was her responsibility to ensure the problem was corrected.

When interviewed on March 4, 2010 at 5:15 PM, the CNA who was assisting with meals in the Unit 6 dining room during supper on February 28, 2010, stated she was not aware of the facility's policy about wearing gloves when handling food. She said that in some facilities you are supposed to wear gloves and in others you do not have to. The CNA said she had no place to put gloves when she would need to take them off to assist residents with other tasks. The CNA said there were no glove stations (glove dispensers) in the Unit 6 dining room. When the CNA was asked by the surveyor about coughing into her hands, she said she coughed into her sleeve.

In summary, the facility did not ensure good infection control practices were followed to prevent the spread of infection within the facility, as staff were not maintaining proper hand hygiene.

3) During the building inspection of Unit #5 on March 1, 2010 between 3:07 PM - 4:08 PM, 4 cardboard boxes containing catheter irrigation sets were observed stored on the floor of the clean utility room.

In summary, the facility did not ensure resident care supplies were properly stored as resident care supplies (catheter irrigation sets) were stored in cardboard boxes placed directly on the floor of the Unit #5 clean utility room. The supplies were not protected from contamination; the floor was not easily cleanable; and the water absorbant containers were susceptible to the growth of mildew.

10 NYCRR 415.19 (a)(1-3)

F334 483.25(n): INFLUENZA AND PNEUMOCOCCAL IMMUNIZATION

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

The facility must develop policies and procedures that ensure that -- (i) Before offering the influenza immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. The facility must develop policies and procedures that ensure that -- (i) Before offering the pneumococcal immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicated, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. (v) As an alternative, based on an assessment and practitioner recommendation, a second pneumococcal immunization may be given after 5 years following the first pneumococcal immunization, unless medically contraindicated or the resident or the resident's legal representative refuses the second immunization.

Citation date: March 9, 2010

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure 1 of 18 residents reviewed for immunizations (Resident #16) was offered influenza immunization, unless the immunization was medically contraindicated or the resident had already been immunized; and did not ensure the resident's medical record included documentation that the resident either received the influenza immunization, or did not receive the immunization due to medical contraindication or refusal. Specifically, the facility did not ensure Resident #16's medical record included documented evidence the resident or his legal representative received education regarding the benefits and potential side effects of influenza vaccine at the time the vaccine was refused; and there was no documented evidence the vaccine was offered at a later date. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #16 had diagnoses including dementia, stroke, and peripheral vascular disease.

The re-admission Nursing Assessment, dated November 12, 2009, documented the resident had not received influenza vaccine.

The quarterly Minimum Data Set (MDS) assessment, dated January 22, 2010, documented the resident had mild cognitive impairment and did not receive the influenza vaccine, as the facility was unable to obtain the vaccine.

The resident's immunization record documented the resident refused influenza immunization in 2005, 2006, 2007, and 2008. The resident's medical record did not contain documentation that the resident was offered influenza immunization after 2008, and did not document the resident was educated regarding the benefits and potential side effects of influenza vaccine.

When interviewed at 11:30 AM on March 3, 2010, the registered nurse (RN) supervisor stated she could find no documentation that the resident was offered influenza immunization during the 2009-2010 influenza season, and there was no documented evidence the resident was educated regarding the benefits and potential side effects of influenza vaccine

In summary,
- there was no documented evidence the resident or legal representative received education regarding the benefits and potential side effects of influenza vaccine at the time the vaccine was refused;
- there was no documented evidence the vaccine was offered at a later date.

10 NYCRR 415.19 (a)

F156 483.10(b)(5) - (10), 483.10(b)(1): INFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC.

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under 1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing. The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and inform each resident when changes are made to the items and services specified in paragraphs (5)(i)(A) and (B) of this section. The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate. The facility must furnish a written description of legal rights which includes: A description of the manner of protecting personal funds, under paragraph (c) of this section; A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels. A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care. The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

Citation date: March 9, 2010

Based on record reviews and staff interviews conducted during the standard survey, it was determined the facility did not ensure advance directives were formulated in accordance with residents' wishes and State law for 1 of 30 sampled residents (Resident #4) reviewed for advance directives. Specifically, the advanced directives of the resident were not determined in a timely manner, and the resident's medical record contained contradictory information regarding the resident's resuscitation status, cardio-pulmonary resuscitation (CPR) versus (vs.) do not resuscitate (DNR). 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 SURVEY OF MAY 6, 2009.

Findings include:

Resident #4 was admitted to the facility on February 18, 2010, with diagnoses of dementia, atrial fibrillation, weakness, chest pain, and a history of falls.

The Admission Nursing Assessment dated February 18, 2010 documented the resident's advance directives was full code (CPR) (cardiopulmonary resuscitation).

The Admission History and Physical dated February 21, 2010 documented the resident's advance directives status was DNR.

The resident's undated face sheet documented the resident's advance directives status included DNR (do not resuscitate).

There was no documentation on the Social Work Social History form dated February 22, 2010 regarding the resident's advance directives status.

The Minimum Data Set (MDS) admission assessment, dated February 25, 2010, documented the resident had memory deficits, and was cognitively impaired to a moderate degree. The MDS documented the resident was able to make herself understood and had difficulty understanding others.

The resident's medical record was reviewed by the surveyor on March 2, 2010. There was no documented evidence the MOLST (Medical Orders for Life Sustaining Treatment) form was completed to determine and specify her advance directives.

When interviewed on March 2, 2010 at 11:10 AM, the unit social worker stated the resident's MOLST form was on her desk to be reviewed. She said the resident transferred from the second floor to the sixth floor on February 22, 2010. She stated the social worker on the second floor had a conversation with the resident's family member who requested more time before making a decision about the resident's advance directives. The social worker reviewed the resident's medical record and found no documented evidence a conversation had taken place with the resident's family member, regarding the resident's advance directives. When asked by the surveyor what the facility policy was regarding when the MOLST form should be completed, the social worker said she did not know the policy.

When the surveyor reviewed the interdisciplinary progress notes, there was no documented evidence from February 18, 2010 through March 3, 2010, that a conversation occurred with the resident's family member regarding advance directives.

The CPR/DNR/DNI (Do Not Intubate) - MOLST Forms Policy (last reviewed/revised by the facility in October 2008) documented "a copy of the MOLST form should be made immediately and maintained in the chart at all times."

When interviewed on March 4, 2010 at 2:45 PM, the Director of Social Work stated it was her understanding the MOLST form should be completed within 48 hours after the resident was admitted to the facility.

When re-interviewed on March 5, 2010 at 11 AM, the Director of Social Work stated it was the unit social worker's responsibility to complete the resident's MOLST form. The Director said there should have been documentation in the resident's medical record regarding the conversation about advance directives that took place with the resident's family member.

In summary,
- the advanced directives of the resident were not determined in a timely manner. - the resident's medical record contained contradictory information regarding the resident's resuscitation status (CPR vs. DNR).

10 NYCRR 415.3 (e)(2)(iii)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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

Citation date: March 9, 2010

Based on record reviews and staff interviews during the standard survey, it was determined the facility did not ensure accidents/incidents were thoroughly investigated for 2 of 30 sampled residents (Residents #1 and 14). Specifically, when Resident #14 was absent from the facility for 22 hours, did not ensure a thorough investigation was conducted to determine if abuse, neglect, or mistreatment occurred and report the incident to the New York State Department of Health (NYSDOH); and did not obtain a physician's order to ensure the resident was able to safely go out on pass. For Resident #1, the facility did not ensure thorough investigations were completed regarding her bruises, and did not document a thorough evaluation of the care giver's possible role in the resident's bruising. 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 AUGUST 20, 2008 AND MAY 6, 2009 SURVEYS.

Findings include:

1) Resident #14 had diagnoses that included malignant neoplasm of the temporal lobe (malignant brain tumor) with left hemiparesis (left sided paralysis), seizures, and mood and personality disorders, related to the increased size of the tumor.

The resident's Minimum Data Set (MDS) assessment, completed January 11, 2010, documented the resident had modified decision making skills in familiar situations and exhibited some difficulty in new situations only.

The resident's comprehensive care plan (CCP), last reviewed by the interdisciplinary team January 12, 2010, documented the resident was non-compliant with the safety regime in place for him, and was in denial of his illness. The CCP documented the resident required assistance with his personal hygiene, was at risk for falls, and was on psychoactive medication, due to his disease progression.

A physician's progress note, dated January 14, 2010, documented the resident was showing signs of depression and would be started on Zoloft (an antidepressant). The note documented the resident had a history of seizures, was showing signs of depression, had "psychosis, personality changes", and would be "monitored closely." There was no documented evidence the physician as assessed the resident, regarding his ability to safely leave the facility on pass.

On February 2, 2010, the facility's 24-hour Report documented the resident went "OOP" (out on pass) on the 3 PM to 11 PM shift. There was no documented current physician's order for the resident to go out on pass, no documentation on the "Sign Out/Sign In Sheet".

During an interview on March 4, 2010 at 11:55 AM, a licensed practical nurse (LPN #1), who worked 7 AM to 9 PM on February 2, 2010, stated she was not sure what time the resident left the unit. She stated she thought it was on the 3 PM to 11 PM (3-11) shift.

During a telephone interview on March 4, 2010 at 12:05 PM, LPN #2, who worked the 3 PM to 11 PM shift on the resident's unit, stated the resident was already out on pass when she arrived at work at 3 PM. She said that at 9 PM, the resident was not back in the facility, so she notified the evening registered nurse (RN) supervisor. The RN Supervisor told her to telephone the resident's contacts in his medical record and try to locate him. The LPN said she found the resident's cell phone number, called him, and left him a message, asking him to call the facility. She stated the resident called back at 11 PM, as she was leaving work and said he was on his way back. She said she notified the Supervisor and the oncoming shift of this.

During a telephone interview on March 4, 2010 at 12:40 PM, LPN #3, who worked the 11 PM to 7 AM (11 to 7) shift on February 2 into February 3, 2010, stated the resident did not come back on her shift. She stated the 11 to 7 shift Supervisor was aware the resident had not returned. She stated she did not try to contact the resident, and did not know if the Supervisor did or not.

During a telephone interview on March 4, 2010 at 1:40 PM, LPN # 4, who worked the 7 AM to 3 PM (7 to 3) shift on February 2, 2010, stated she remembered the resident had a family member visit him that day, although she did not remember if the resident went out on pass.

On February 3, 2010 at 9:15 AM, a nursing note documented the resident went out on pass at 11:30 AM on February 2, 2010 and had not returned. The note specified that a telephone call was placed to the resident's brother asking about the resident's whereabouts. The brother stated he would contact the resident and have him call the facility. At 9:20 AM on February 3, 2010, a nursing note documented the resident called back and stated he was on his way back to the facility. At 9:30 AM, another nursing note specified that the resident had returned. There was no documented evidence the physician was notified of the resident's absence from the facility for 22 hours, and no documentation that the resident was assessed by qualified professional staff when he returned.

During an interview on March 4, 2010 at 3:10 PM, the RN Unit Manager stated she worked on February 2, 2010, although she was unaware the resident went out on pass. She said she did not know the resident had not returned on time, until she came to work at 8 AM on February 3, 2010. She stated she did not think there was an attempt to locate the resident before the morning of February 3, 2010, when the unit RN called the resident 's brother. She said she thought the unit RN assessed the resident when he returned. The RN Unit Manager stated no investigation was completed into the incident. She said she had not done any staff education to prevent a reoccurrence.

During an interview on March 4, 2010 at 9 AM, the Director of Nursing (DON) stated an incident report was not completed and an investigation had been conducted. The DON stated the resident was able to make his own decisions, and was not an elopement risk. She stated the facility did not educate the resident on the meaning of a day pass, and said he did not know that he could not stay out overnight. When the resident returned to the facility, the DON said he was educated, and there had been no problem since that time.

During an interview on March 4, 2010 at 10:50 AM with the physician, he stated he was unaware the resident was out of the facility on pass for 22 hours ion February 2, 2010. He said he would have expected the facility to notify him. When asked about the criteria for writing orders for residents to go out on pass, the physician stated that if a resident was stable, he would determine they were safe to have a pass. He said that he had not written an order for this resident to leave the facility on pass.

The 11 PM to 7 AM shift Supervisor was no longer employed at the facility and not available for interview.

In summary, when the resident left the facility and did not return for 22 hours, the facility:
- did not ensure a thorough investigation was conducted to determine if abuse, neglect, or mistreatment occurred and report the incident to the New York State Department of Health (NYSDOH).
- did not obtain a physician's order to ensure the resident was safely able to go out on pass.

2) Resident #1, admitted on October 21, 2009, had diagnoses including dementia and history of a stroke with expressive aphasia (impaired ability to express oneself).

The resident's admission Minimum Data Set (MDS) assessment, dated November 4, 2009, documented the resident's skills for daily decision making were severely impaired; the resident was totally dependent on 2 staff for transfers; and the resident required extensive assistance of 1 person for bed mobility.

On November 6, 2009 at 11:45 PM, a registered nurse (RN)'s notes documented the resident was found with bruises on her right and left shins, had fragile "paper thin" skin, and specified the resident bruised easily. The RN documented she was told by facility staff that the resident's family member transferred and toileted the resident. The RN documented a message was left for the unit manager to follow up with the family.

On November 16, 2009 at 2:15 AM, nursing notes documented the resident was found with a bruise on her right hip; the nursing supervisor was notified.

On November 17, 2009 at 2:30 AM, the RN supervisor notes documented the resident was found with a right hip bruise, (3.5 centimeters (cm) x 4 cm), that was dark purple; the cause was unknown. The RN documented the resident attended a day program at another facility, and the family had been observed transferring the resident without staff assistance. The note specified the family member did not use a mechanical lift as designated in the care plan. The RN supervisor documented that follow-up/education on proper transfer technique should be done with the family.

The RN who documented the resident's bruise on November 6, 2009, and the RN supervisor who documented on the resident's November 16, 2009 bruise, no longer worked at the facility, and could not be interviewed.

On January 5, 2010, the nursing notes documented the resident was found with a right inner thigh bruise.

During an interview on March 5, 2010 at 10:05 AM, the registered (RN) manager during the time the resident's bruises were identified, stated she was familiar with the resident and her family. She said she was not aware that the family was evaluated by the facility at any time since the resident's admission, to determine if they were safely able to provide personal care to the resident, including transfers, toileting, and hygiene. The RN stated the investigations for the resident's bruises on November 6, 2009, November 16, 2009, and January 5, 2010 could not be located.

The resident's MDS assessment, dated January 28, 2010, documented a change from the November 4, 2009 MDS assessment, as the resident required extensive assistance of 2 staff for bed mobility.

The comprehensive care plan (CCP), dated January 28, 2010, documented the resident required total assistance with most aspects of her care, related to her dementia and impaired mobility. The CCP documented the resident required transfer assistance from 2 staff, and required total assistance with bathing, dressing, grooming, and hygiene. The CCP noted the family was very involved with her care and visited almost every day.

On January 31, 2010 at 5 PM, the RN supervisor documented the staff notified her at 8 AM that the resident had a bruise with swelling. The RN documented the round, swollen, bruised area on the resident's forehead measured "approximately" 2.5 cm. The RN documented staff did not know what happened, and had not seen the bruise/swelling the previous day. The RN documented the family, who provided the resident with her evening care the night before, did not know what happened to the resident. The RN note specified the January 30, 2010 evening nurse stated she gave the resident an inhalation treatment at 10 PM, after the family had left, and did not notice any bruising/swelling at that time.

On January 31, 2010, the facility Resident/Visitor Event Report documented a certified nurse aide (CNA) reported the resident had a bruised and swollen area above her right eye. The RN supervisor documented she obtained witness statements, requested witness statements be obtained from the night CNAs, and was not sure if this incident was resident abuse.

LPN #2's statement for the Resident/Visitor Event Report documented that at 7:15 PM on January 30, 2010, she observed the resident in bed, with her family was in the room. LPN #2 did not notice a bump or bruise on the resident's forehead at that time. LPN #2 specified she administered a medication to the resident at 9:30 PM, and did not notice a bruise or swelling. Statements were attached to the facility's January 31, 2010 incident report were from the 7 AM to 3 PM CNA who reported the resident's bruise, and from the 3 PM to 11 PM licensed practical nurse (LPN #1), who reported the bruise to the supervisor.

There were no statements provided from the night CNAs, as requested/ documented by the RN supervisor on the January 31, 2010 facility Resident/Visitor Event Report.

On the January 31, 2010 Resident Abuse Investigation Report, the RN supervisor documented staff's "theory" was that the resident's bruises were caused by the family when they toileted the resident. The RN documented the family member stated nothing happened when the family was there, and said they would have reported it, if something had happened. The RN documented she was unable to determine what caused the resident's bruising; specified the resident may need a physical therapy evaluation, and documented the family may have to be asked not to toilet the resident.

On January 31, 2010, the Director of Nursing (DON) documented on the Resident Abuse Investigation Report that the resident's bruise was caused by the "primary caregiver" not holding the resident up in the bathroom; and the resident struck her forehead on the rail of the toilet.

The Resident Abuse Investigation Report, signed by the RN supervisor on January 31, 2010, and was signed by the DON on February 10, 2010, 10 days after the resident's bruising was reported.

On March 2, 2010 at 12:30 PM the resident's family member was interviewed and stated the resident's bruise was not caused when family transferred/toileted the resident. The family member said he told the facility that information.

The physical therapist and physical therapy aide were interviewed on March 5, 2010 at 9:55 AM, and stated they did not know the resident's family was involved in the resident's care. They stated they did not evaluate the resident's family regarding their ability to safely transfer and toilet the resident. The physical therapist stated they would have worked with the family if they had known they were involved with her care. When asked whether occupational therapy (OT)evaluated the resident and her family, the physical therapist reviewed the resident's medical record and stated OT had not worked with the resident when she was admitted, and did not work with the resident's family.

The Director of Nursing (DON) and the RN on the unit at the time of the resident's injuries of unknown origin, were interviewed on March 5, 2010 at 10:05 AM. They stated the cause of the resident's bruises was from a family member's transfer technique. The DON stated she documented, "primary caregiver" as the cause on the facility's Resident/Visitor Event Report, dated January 31, 2010, in reference to the family member who provided care to the resident. The DON said the family member had not been evaluated or retrained since that time. The DON could not provide documented investigations into the resident's November 6, 2009, November 16, 2009, and January 5, 2010 bruises, and did not know what was done related to the resident's injuries of unknown origin.

In summary, the facility:
- did not ensure thorough investigations were completed for the resident's bruises from an unknown origin;
- did not ensure an evaluation of the care giver, who was identified as the probable cause of the resident's bruises, was completed and documented by qualified staff.

10 NYCRR 415.4 (b)(1)(ii)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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.

Based on observations, record reviews, and interviews with staff conducted during the standard survey, it was determined the facility did not provide necessary podiatry care for 2 of 30 sampled residents (Residents #4 and 8). Specifically, Residents #4 and 8 were in need of podiatry services and did not receive those services in a timely manner. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #4 had diagnoses including dementia, atrial fibrillation (irregular heartbeat), coronary artery disease and a history of falls. She was admitted to the facility on February 18, 2010.

The Admission Nursing Assessment dated February 18, 2010 documented the resident had "extremely long, curled toenails and reddened feet." Both (bilateral) lower legs and feet were dry with hard, brown skin.

The Admission History and Physical dated February 21, 2010 documented the resident had "significant stasis dermatitis and brawny (thickening) skin stasis changes on her lower extremities." There was no documentation regarding the condition of the resident's feet or toenails.

The comprehensive care plan (CCP) dated February 22, 2010 documented the resident had limitations in terms of her range of motion, ability to perform ADLs (activities of daily living), and ability to transfer and ambulate. There was no documentation regarding the condition of the resident's feet and toenails or approaches/interventions listed on the CCP.

The Minimum Data Set (MDS) assessment dated February 25, 2010 documented the resident had memory deficits, and was cognitively impaired to a moderate degree. The MDS assessment documented the resident was able to make herself understood and had difficulty understanding others. The resident was dependent on staff for her ADLs including bathing, and dressing. The MDS assessment documented the resident had no foot problems.

When interviewed on March 4, 2010 at 8:55 AM, the unit ward clerk was asked about a podiatry schedule for residents. She stated she kept an "unofficial list." A physician's order was needed before a resident could be seen. The ward clerk said if the physician did not order a podiatry consult within 6 months, she would tell the nurse manager, who would then write the request in the nurse practitioner's (NP) book. She said the podiatrist came to the facility every 2 weeks and saw 15 residents at each visit. The ward clerk said there was no podiatry schedule for March 2010 at that time.

On March 4, 2010 at 9:30 AM, a surveyor reviewed the podiatry schedule from the date of the resident's admission (February 18, 2010) through March 8, 2010. There was no documented evidence the resident had been seen by the podiatrist. There was no documentation that the resident was scheduled for an upcoming podiatry appointment.

On March 4, 2010 at 10:45 AM, 2 surveyors observed the resident in her room, lying in bed. An observation of the resident's feet was completed by the surveyors, the Unit Manger, and a licensed practical nurse (LPN). The resident's toenails on both feet were observed to be very elongated and curled. There was blood observed at the nail bed of the left great toenail. The resident's left great toenail was measured by staff to be 5 centimeters (cm) in length.

When interviewed about the condition of the resident's toenails on March 4, 2010 at 10:50 AM, the Unit Manager said, "obviously she (the resident) needs podiatry." The Unit Manager said the physician and NP should have assessed her and "definitely she (the resident) should go out to podiatry."

When interviewed by telephone on March 5, 2010 at 12 PM, the primary physician said he was not able to recall the resident and could not answer the surveyor's questions. The physician said he did not recall the condition of the resident's toenails. When the surveyor described the resident's toenails to the physician after having observed them, the physician stated the resident should be seen by podiatry as soon as possible.

When interviewed by telephone on March 5, 2010 at 1:20 PM, the podiatrist said he was not familiar with the resident. When asked by the surveyor if he received a referral for the resident, the podiatrist said, "I doubt it." The podiatrist said the facility had the list, and if the resident's name was not on the list, then he would not have the referral. The podiatrist said he would need a physician's order before he saw a resident, and was available to provide emergency care to residents if notified by the facility.

In summary, the facility did not ensure the resident received the necessary care and treatment by the podiatrist since her admission.

2) Resident #8 was admitted to the facility with diagnoses of chronic alcoholism, dysphagia, and prostatic hypertrophy (enlarged prostate gland).

The Minimum Data Set (MDS) assessment dated January 30, 2010 documented the resident had short term memory loss and was cognitively moderately impaired. The resident needed extensive assistance with activities of daily living including bathing, dressing, toileting, and ambulation. He was able to eat with supervision from staff after being set up.

Physician's orders dated January 27, 2010 contained an order for a podiatry consultation for the resident's elongated, mycotic (fungal infection) toenails.

On March 1, 2010 at 11:20 AM, the resident was observed in the shower room receiving a shower. His toenails were observed to be very long and curled.

During an interview with the ward clerk on March 2, 2010 at 1:45 PM, she was asked how podiatry appointments were scheduled. The ward clerk said a consultation form was filled out on the unit and sent downstairs to the switchboard operator, who then scheduled the podiatrist.

On March 2, 2010 at 2 PM, an interview was conducted with the switchboard operator in regard to the podiatrist. When asked how she scheduled podiatry appointments, the switchboard operator said she had just taken over the scheduling. She stated there was no system in place, but she was now documenting the date when the request for the podiatry consultation was sent to her. The switchboard operator said the podiatrist told her to cut down on the referral list as there were too many residents scheduled. She said the podiatrist came to the facility twice a month and there were already 15 residents scheduled for March 8, 2009 (the next time the podiatrist was scheduled to visit). She said she was working on a way to prioritize the appointments. The switchboard operator produced a list of residents waiting to be seen by the podiatrist. The list contained the names of 56 residents, which included the 15 residents who were already scheduled to see the podiatrist on March 8, 2010. Resident #8 was 1 of 41 residents not yet scheduled to be seen by the podiatrist.

The podiatrist was interviewed by telephone on March 5, 2010 at 1:20 PM. When asked by the surveyor if he had received a referral for the resident, the podiatrist said, "I doubt it." The surveyor told the podiatrist a physician's order was written for a podiatry consultation due to the resident's long, mycotic toenails on January 27, 2010. The podiatrist said, "I haven't gotten that name."
.
In summary, the facility did not ensure the resident received podiatry services, as ordered by the physician, in a timely manner.

10 NYCRR 415.12 (k)(7)

F309 483.25: PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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

Citation date: March 9, 2010

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure care and services were provided to 1 of 10 residents reviewed for skin issues (Resident #21) to attain or maintain highest physical well being. Specifically, Resident #21, was assessed to be at high risk for skin breakdown. The facility did not ensure staff assessed Resident #21's skin breakdown and did not monitor the area for further skin breakdown, until the surveyor brought it to staff's attention. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #21 was admitted to the faiclity on December 29, 2009 with mutliple diagnoses including obesity, thoracic spinal cord stenosis (narrowing of the spinal cord) with surgical decompression, and neurogenic bladder, with a Foley catheter.

The resident's Minimum Data Set (MDS) assessment, dated January 11, 2010, documented the resident had no recall problems, modified independence in decision making with difficulty in new situations only, and required extensive assistance with personal hygiene. The MDS documented the resident had an indwelling Foley catheter, was frequently incontinent of bowel, was desensitized to pain or pressure, and had surgical wounds.

The resident's comprehensive care plan (CCP), dated January 12, 2010, documented the resident was at high risk for pressure-related skin breakdown secondary to obesity, decline in physical functioning, bowel incontinence, and loss of sensation in the lower extremities. An undated, handwritten entry documented the resident's genitals had an injury. Interventions included pressure reducing devices, treatment as ordered, and "observe area for evidence of resolution or worsening of condition on Skin Monitor Sheet weekly."

A registered nurse (RN) progress note, dated January 25, 2010, documented the resident had 2 open areas on his genitals, one that measured 0.4 centimeters (cm), and the other that measured 0.5 cm. The note specified the areas were believed to be from the catheter coming in contact with the skin. The resident was sent to the emergency room (ER) for evaluation and returned to the facility the same evening, with recommendations for a follow-up with a urology appontment in 1 week.

A physician's order, dated February 3, 2010, documented the catheter tubing was to be taped to the resident's upper thigh "away from the wound" and then taped to the resident's abdomen "to relieve pressure on opening." The physician ordered to "cleanse (the) open area" with "normal saline followed by Triple Antibiotic Ointment (TAO) every shift." Placement of the catheter was to be checked every shift. The physician ordered

The Resident Plan of Care sheet, used by the certified nurse aides (CNAs) as a care guide, for February and March of 2010, documented Sensicare #3 (a protective skin cream) was to be applied to the resident's buttocks twice a day. The Plan of Care sheet did not specify the resident used a Foley catheter.

A licensed practical nurse (LPN) progress note, dated February 4, 2010, documented the open area on the bottom side of the resident's genitals was "red without drainage", and the meatus of his genitals was split, and had no drainage.

A 3 PM - 11 PM nursing note, dated February 5, 2010, documented there was a "scant amount" of blood noted during the treatment to the resident's genitals. "Will monitor."

The next nursing note, dated February 17, 2010 at 11:30 PM, documented the resident's skin breakdown on the resident's genital areas were noted "to be larger, tape holding catheter not holding it in place. Retaped every hour this shift; will forward to next" shift.

The next nursing note was dated March 3, 2010 at 4:15 PM.

Review of the resident's medical record from January 25, 2010 through March 4, 2010, revealed there were no documented nursing progress notes that specified the resident's skin breakdown was monitored by a qualified professional, in a timely manner.

The resident's skin was observed by the surveyor on March 4, 2010 at 2:15 PM with the RN Unit Manager. The resident was observed to have an open area on the left side of his scrotum, measuring 1.0 cm x 0.6 cm, and an open area on the right side of his scrotum, measuring 1.0 cm x 0.7 cm.

During an interview on March 4, 2010 at 2:50 PM, the certified nurse aide (CNA), who cared for the resident that day, stated the resident had "2 little red spots" on either side of his genitals. She stated she applied cream to the areas after she cleaned the resident, and said she reported the areas to the resident's nurse.

During an interview on March 4, 2010 at 3 PM, the licensed practical nurse (LPN) who cared for the resident that day, stated she did not remember anything being reported to her about the resident's skin, and said she was unaware of his open areas.

The Unit Manager was interviewed on March 4, 2010 at 3:20 PM and stated she was aware of the open area on the right side of the resident's scrotum, and thought it was being tracked by the unit RN. She stated she was not aware of new area of skin breakdown on the left side of the resident's scrotum.

On March 5, 2010 at 9 AM, the unit RN was interviewed. She stated she looked at the resident's scrotal area on March 1, 2010, and forgot to write a note. She said the area on the right side of the resident's scrotum was pink, had no drainage, and was "probably a Stage II". She said she was not sure the area was from pressure and she said she was not tracking or measuring it. She stated she was not aware of the new area of skin breakdown on the left side of the resident's scrotum.

In summary, the facility did not ensure the resident's skin breakdown on his genitals were consistently monitored as planned between February 6 through February 16, 2010 and from February 18 to March 4, 2010. New area of skin breakdown were not assessed by the facility until brought to their attention during survey.

10 NYCRR 415.12

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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

Citation date: March 9, 2010

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the facility did not ensure 1 of 30 sampled residents (Residents #14) and 1 resident outside of the survey sample (Resident #37) remained free of significant medication errors. Specifically, Resident #14 missed doses of 3 significant medications when he was out of the facility for an unplanned absence. There was no evidence the resident was assessed and monitored for possible ill effects from the missed medication, the physician was notified of the medication error, or an investigation was completed to identify the error, and ensure the necessary follow-up was completed. For Resident #37, the medication nurse was about to administer the resident an incorrect dose of a medication (Depakene) before being stopped by a surveyor. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #14 had diagnoses that included malignant neoplasm of the temporal lobe (brain tumor) with left hemiparesis, seizures, mood and personality disorders related to the increased size of the tumor.

The resident's Minimum Data Set (MDS) assessment, completed January 11, 2010, documented the resident had modified decision making skills in familiar situations and received antipsychotic medication

The resident's comprehensive care plan (CCP), last reviewed January 12, 2010, documented the resident received anti-psychotropic medication due to his disease progression and mood swings. Interventions included administering the medications as ordered and assessing the resident for effects.

A physician's progress note, dated January 14, 2010, documented the resident was receiving Seroquel (an antipsychotic medication) for his psychosis and personality changes, Depakote (an anti convulsive medication) for his seizure disorder, and Warfarin to prevent deep vein thrombosis (a blood clot in a vein).

A Physician's Order Form, dated January 14, 2010, documented the resident was to receive:
- Seroquel 75 milligrams (mg) orally at bedtime every day.
- Depakote 750 mg orally 2 times a day.
- Warfarin 2 mg orally at bedtime every day.

Review of the Medication Administration Record (MAR) for February 2, 2010 revealed the resident did not receive his scheduled dose of Depakote at 4 PM or his scheduled doses of Seroquel and Warfarin at bedtime. The back of the MAR documented the resident was OOP (out on pass) for all of his medications on the 3 PM to 11 PM shift. There was no documented evidence of the physician being notified of the missed doses of medication.

A registered nurse (RN) progress note, dated February 3, 2010 at 9;15 AM, documented the resident had gone out on pass on February 2, 2010 at 11:30 AM and had not returned. Another RN progress note, dated February 3, 2010 at 9:30 AM, documented the resident had returned to the facility and was questioned about possible alcohol abuse while out. There was no documented evidence the resident was assessed or monitored after he returned to the facility.

During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on March 4, 2010 at 9 AM, the Director of Nursing stated an investigation had not been completed.

During an interview on March 4, 2010 at 10:50 AM, the physician stated he was not notified the resident was out of the facility for 22 hours, and his expectation would be that the facility would notify him of this.

During an interview on March 5, 2010 at 9 AM, the unit RN stated she had talked with the resident, and assessed him, when he returned to the facility at 9:30 AM on February 3, 2010.

During an interview on March 5, 2010 at 10:10 AM, the RN Unit Manager stated the resident was not given his medication on the evening of February 2, 2010 as he did not return to the facility. She stated the physician was not notified as she felt this was a one time occurrence. The resident had been out on pass before, and was given his medication when he returned at the appropriate time. She stated she thought the unit RN had assessed him when he returned and there were no ill effects.

In summary, the facility did not ensure:
- the resident was assessed and monitored for possible ill effects from the missed medications;
- the physician was notified of the missed medications;
- a significant medication error was identified;
- a thorough investigation of the medication error was completed to identify the cause of the error and ensure the necessary follow up was completed.

2) Resident #37 was admitted to the facility with diagnoses of Alzheimer's dementia with behavior disturbances, and seizure disorder.

Physician's order dated February 18, 2010 documented the resident was to received Valproic acid/Depakene (anti-seizure) 250 mg/5 cc syrup, 15 cc by mouth twice daily.

The February 2010 Medication Administration Record documented the Valproic acid 250 mg/5 cc, 15 cc by mouth twice a day was given at 9 AM and 5 PM.

During an observation of a medication pass on February 29, 2010 at 6:10 PM, the licensed practical nurse (LPN) poured 20 cc of Valproic acid/Depakene and started to bring it to the resident. The surveyor stopped the LPN when entering the room and asked him to recheck the cc amount in the medication cup. When the LPN poured the medication into another medication cup, it measured just under 20 cc. When asked what the amount was in the medication cup the LPN said 15 cc and said some medication sticks to the sides of the cup. The surveyor showed the LPN the measurement was at 20 cc and the order was for 15 cc. The LPN discarded the medication and repoured the Depakene. The LPN never checked the blister pack or the bottle of medication three times with the medication administration record prior to administering the medication.

In summary, the facility did not ensure medications were administered according to standards of quality, as:
- the LPN did not check the bottle of medication (Depakene) three times with the medication administration record prior to administering the medication;
- the LPN poured an incorrect dose of the medication and would have administered the medication to the resident if not stopped by the surveyor.

10 NYCRR 415.12 (m)(2)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

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

Citation date: March 9, 2010

Based on observations, staff interviews, and record reviews conducted during the standard survey, it was determined the facility did not provide care or services that met professional standards of quality for 1 of 30 sampled residents (Resident #4). Specifically, upon Resident #4's admission, the facility did not obtain an accurate height and weight to ensure an appropriate nutritional assessment. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
Findings include:

Resident #4 was admitted to the facility on February 18, 2010 with diagnoses that included dementia, atrial fibrillation (irregular heartbeat), coronary artery disease, and a history of falls.

The "Admission Nursing Assessment" dated February 18, 2010 documented the resident was 62 inches tall and weighed 132.7 pounds upon admission. There was no documented evidence regarding what method was used to determine the resident's weight.

There was no documented height and weight for the resident on the hospital discharge summary dated February 18, 2010.

The comprehensive care plan (CCP), dated February 22, 2010, documented the resident had limitations in terms of her range of motion, ability to perform ADLs (activities of daily living), and ability to transfer and ambulate.

The Minimum Data Set (MDS) assessment, dated February 25, 2010, documented the resident had memory deficits, was cognitively impaired to a moderate degree, was able to make herself understood and had difficulty understanding others. The resident was dependent on staff for her ADLs. The MDS assessment documented the resident was 62 inches tall, with no weight documented.

When interviewed on March 4, 2010 at 10 AM, the registered dietitian (RD) was asked by the surveyor how she determined if the resident's height was accurate. The RD stated she would go by the nurses' records.

At 11:10 AM on March 4, 2010, the registered nurse (RN) Clinical Supervisor, who completed the resident's Admission Nursing Assessment on February 18, 2010, was asked how she determined the resident's height. The RN stated that she asked the resident's family. She said, "I trust families." The RN Clinical Supervisor said she should have measured the resident. When she reviewed the resident's Admission Nursing Assessment with 2 surveyors, the RN supervisor said the resident was weighed in her wheelchair.

The registered nurse (RN) Unit Manager was interviewed on March 4, 2010 at 11:15 AM, and said the resident's height was usually determined by the hospital records, or by asking the resident's family when they were admitted to the facility. She stated there was no policy about this. The RN Unit Manager told the surveyors the resident could be measured at that time.

Review of the facility's Weight and Height Policy, dated September 5, 2006, revealed all residents were to be weighed and measured upon admission. The documented purpose was to "insure that the resident maintains body weight and height, unless the resident's clinical condition demonstrates that this is impossible. The day shift staff will do weights. However, admission weights will be done on the shift the resident comes in on."

On March 4, 2010 at 11:20 AM, the surveyors asked the RN Clinical Supervisor to measure the resident who was lying in bed at that time. The RN supervisor measured the resident's height using a tape measure; the resident was 52 inches tall. The RN supervisor could not offer a rationale for the 10 inch discrepancy in the resident's height from the MDS assessment and Admission Nursing Assessment. The RN Clinical Supervisor then reviewed the resident's Admission Nursing Assessment with the surveyors. The RN said the resident was weighed in her wheelchair. The surveyors asked the RN Clinical Supervisor if the resident could be weighed at that time. The resident was weighed in a shower chair at 11:35 AM (on March 4, 2010) by the RN supervisor and the primary certified nurse aide (CNA). The resident's weight was 113.1 pounds, (after subtracting the shower chair's weight). The resident's weight revealed a 19.6 pound discrepancy from the weight recorded on the Admission Nursing Assessment.

The Director of Nursing (DON) was asked about the discrepancy in the resident's height and weight during an interview on March 5, 2010 at 12:40 PM. The DON said the resident should have been accurately weighed and measured by staff upon admission.

In summary, the facility did not ensure professional standards of quality were met, as the resident was not weighed and measured by nursing staff upon her admission to the facility.

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

K62 NFPA 101: SPRINKLER SYSTEM MAINTENANCE

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Citation date: March 9, 2010

Based on review of the Facility Survey Report and the sprinkler system inspection reports, as well as staff interviews conducted during the standard survey, it was determined the facility did not assure required components of the sprinkler system were inspected and tested at the frequencies specified by NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Specifically, 2 of the 4 required quarterly sprinkler inspections for the past 12 months (November 2009 and February 2010) were not completed within the required time frames. The quarterly inspection due for November 2009 was omitted, and the quarterly inspection due for February 2010 inspection was late. There was 7 months between the facility's last 2 quarterly inspections. This resulted in no actual harm with potential for more than minimal harm.
Findings include:

The Facility Survey Report, submitted and signed by the administrator during the survey on March 1, 2010, documented the last sprinkler inspection was performed January 8, 2010.

According to the previous sprinkler system inspection reports reviewed, quarterly sprinkler system inspections were performed on Mar 5, 2010, August 27, 2009, May 15, 2009, and February 23, 2009. Based on the available reports, the November 2009 inspection was omitted, and the February 2010 inspection was late.

The Director of Maintenance interviewed on March 5, 2010 at 11:30 AM, stated the sprinkler inspection company had a contract with the facility to do the quarterly inspections, and they were notified they were late, and the company told him they were short staffed and were having problems keeping on schedule. No inspection was performed on January 8, 2010.

In summary, the facility did not ensure that sprinkler inspections were conducted as required, (on a quarterly basis).

10 NYCRR 415.29(a)(1&2)
2000 LSC 19.7.6
2000 LSC 4.6.12
1999 NFPA 13 Standard for the Installation of Sprinkler Systems 12-1
1998 NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems - Table 5.1

K70 NFPA 101: SPACE HEATERS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 13, 2010

Portable space heating devices are prohibited in all health care occupancies, except in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F. (100 degrees C) 19.7.8

Citation date: March 9, 2010

Based upon observations and staff interviews conducted during the standard survey, it was determined the facility did not ensure portable space heaters were not used in 1 of 8 (M-level) residential floors. Specifically, a portable electric resistance space heater was observed in the physical therapy room located on the main floor level. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
Findings include:

During the building inspection of the first floor (M-level) on March 2, 2010 between 12:40 PM - 2:00 PM, a portable electric resistance space heater was observed in the physical therapy room, plugged into an electrical outlet along the west wall, near the parallel bars.

The Director of Maintenance, interviewed on March 2, 2010 at 12:45 PM, stated he had to use the portable space heater "about 2 weeks ago" during a cold spell, because residents were complaining they were cold.

In summary, the facility did not ensure that portable space heaters were not used in residential areas.

2000 LSC 19.7.8