Pontiac Nursing Home

Deficiency Details, Certification Survey, February 12, 2013

PFI: 0732
Regional Office: Central New York Regional Office

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

Scope: Pattern

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on observation, record review, and staff interview
conducted during the extended and abbreviated surveys (Complaint # NY00122263, NY00121297, and NY00126387), it was determined for 11 of 13 residents reviewed for falls/fractures and/or injuries of unknown origin (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19), 1 of 1 resident reviewed for elopement (Resident #3), and 1 of 1 resident for unsafe smoking (Resident #23), the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, 19, and 23, the facility:
- failed to assess the effectiveness of the residents' comprehensive care plan (CCP) after each accident;
- failed to determine the root cause of all accidents; and
- failed to notify the Director of Nursing, Acting Administrator, Supervising Administrator of all accidents.
This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, 19, and 22. The facility implemented corrective measures to remove the Immediate Jeopardy prior to survey exit on 2/12/2013.
Findings include:

SMOKING:
1) Resident #23 was admitted to the facility on 2/8/2013 with diagnoses including schizophrenia.

A review of the resident's hospital records included:
- an admission history dated 1/11/2013, documented the resident was a smoker;
- a history and physical note dated 1/13/2013 documented the resident smoked a pack of cigarettes a day for the past 40 years;
- a social work progress note dated 1/15/2013 documented the resident's IQ was below 70; and
- hospital discharge instructions/medication list dated 2/7/2013 documented the resident was on a Nicotrol inhaler while in the hospital.

The resident's admission physician's orders dated 2/8/2013 did not include a Nicotrol inhaler or other medication to aide in smoking cessation.

The Director of Nursing's (DON) progress note the dated 2/8/2013 at 7:05 PM, documented she was called to the resident's unit due to the smell of smoke in the hallway because the resident tried to smoke in her room. The DON documented a certified nurse aide (CNA) noticed the "smoldering trash can," removed the resident from the room, called for assistance, and poured water over the trash can. The resident's room was searched and cigarettes and a lighter were found, and removed. The note recorded nurse practitioner (NP) was called who gave an order for the resident to have a nicotine patch. The facility's Administrator was called and the resident was placed on hourly checks.

The inventory of the resident's personal affects dated 2/8/2013 did not document cigarettes or a lighter were found with the resident's possessions at the time of admission. The sections where the form was to be signed by the CNA and Unit Manager were blank.

The 2/8/2013 Incident Report included:
- a statement from CNA #9 documented she noticed the hallway was "smokey," she observed the resident's "trash can was on fire," she went to the nurse's station to get the charge nurse, she removed the resident from the room, and she "helped contain the fire."
- a statement from CNA #7 documented he observed a "couple of paper towels and plastic on fire in the trash can" and when the trash can did not fit under the faucet, he poured cups of water over the trash can. CNA #7's statement documented the trash can was "smoldering with a little bit of flames."
- a statement from licensed practical nurse (LPN) #3 documented when she went to the room she observed a "small red glow" at the bottom of the trash can, she instructed a staff to pick the trash can up and place it under the faucet, and when the trash can did not fit under the faucet, they doused the "embers" with water.
- an investigation summary and conclusion written by the Director of Nursing (DON) documented the resident was newly admitted to the facility and attempted to smoke in her room. Staff smelled smoke and found the garbage can "smoldering." Staff removed the resident and poured water on the garbage can.
- The report documented the resident's comprehensive care plan (CCP) was updated.
- The investigation was signed as reviewed by the DON and the current Administrator (hired on 2/8/2013).
- There was no documented evidence the resident was interviewed.
- The investigation:
- did not address the resident's smoking status at the time of admission;
- did not determine a reason for not providing the smoking cessation medication the resident received in the hospital;
- did not determine how the resident was able to have smoking materials in her possession; and
- did not address that facility staff did not follow the facility's fire procedure.

On 2/9/2013 at 1:45 PM, the current Administrator stated in an interview, the resident was admitted to the facility on 2/8/2013 around 3 PM. He stated the staff did not thoroughly check her belongings and were not aware she had smoking materials. He said staff smelled smoke and when they went to her room they realized she had thrown a cigarette in the trash can. The staff poured water on the trash can, did not pull the fire alarm, and put the fire out on their own. After the incident, three lighters and cigarettes were found in the resident's room.

The resident's current undated CNA care instructions documented the resident was on 1 hour checks. The instructions did not document the resident's smoking incident, the fire, or the reason for 1 hour checks.

The resident's undated Interim Plan of Care contained no documentation related to smoking or the fire.

The comprehensive care plan (CCP) dated 2/9/2013 documented the "resident requires 1:1" and included activity preferences. The CCP contained no documentation of smoking history, the fire, or the reason for 1:1 supervision.

A 2/9/2013 activities progress note written by the Acting Administrator documented the resident was "observed smoking in her room" and required 1:1 visits.

On 2/11/2013 at 10:10 AM, the Acting Administrator stated in an interview, the facility reviewed hospital records prior to the resident being admitted and knew she used a Nicotine inhaler in the hospital. She stated since the resident did not smoke in the hospital from 1/11/2013 - 2/8/2013, she was a former smoker. She said the facility did not expect the hospital to send a resident to the facility with smoking materials.

On 2/11/2013 at 10:10 AM, the resident stated in an interview, she smoked a pack of cigarettes a day since she was 16 years old. She stated she did not start the fire accidentally from trying to smoke, she lit tissues on fire on purpose, as she did not want to be in this nursing facility.

On 2/11/2013 at 11:20 AM, the DON stated in an interview, she interviewed the resident as part of the investigation and the "resident wanted to smoke." She stated after the resident smoked in her room, she obtained a nicotine patch for her. She said she did not know why this was not done before the smoking/fire incident.

On 2/11/2013 at 11:47 AM and 12:10 PM, the LPN Manager (LPN #2) stated in an interview, when the resident was admitted, she faxed the hospital discharge summary to the physician and the physician called her with the admission orders. She stated the physician may have ordered the Nicotrol inhaler or a nicotine patch at that time and she might not have heard him. She stated she read all orders back to the physician over the phone.

On 2/11/2013 at 2:05 PM, the Acting Administrator stated she wrote the resident's CCP on 2/9/2013 documenting the need for 1 hour checks. She stated she only wrote an "activities care plan" as her background was in activities and she would have expected nursing to write a CCP that addressed the resident's smoking history and the fire. The Acting Administrator stated she remembered the DON telling her right after the fire that the resident set the fire on purpose. She stated she did not know why this was not addressed in the resident's medical record or the facility's investigation.

FALLS:
2) Resident #6 was admitted to the facility on 11/26/2012 with diagnoses including Parkinson's disease and dementia.

The admission Fall Risk Assessment dated 11/26/2012 documented the resident was not at high risk for falls. The assessment documented "unable to verify" in the section for history of falls and the section assessing gait/balance was crossed out.

Nursing progress notes documented:
- on 11/26/2012, the resident was unable to participate in the admission assessment related to him "slapping out," having an inability to answer questions, biting the bed linens, and an "unstable condition;"
- on 11/27/2012, the resident was "very shakey," "throwing himself around the bed." The nurse noted the bed was placed against the wall; and
- on 11/29/2012, the resident was found standing in his room, tipped over the bed side table, and was shaky.

The comprehensive care plan (CCP) dated on 11/30/2012, documented the resident was cognitively impaired due to Alzheimer's dementia and was at risk for falls. Interventions included educating the resident on safety awareness "as able;" reminding him to use the call bell; moving his room closer to the nurse's station "as indicated;" transferring him with a mechanical lift, and providing a semi-low bed against the wall.

The nursing progress note dated 12/1/2012 at 1:45 AM, documented the resident was found on the floor next to his bed and sustained an open scab on the right foot, second toe.

The Fall Risk Assessment, dated 12/1/2012, documented the resident was at high risk for falls.

The CCP dated 12/1/2012, documented a protective alarm system (PAS) was applied.

The physician's orders dated 12/3/2012, documented the resident was to have a PAS alarm at all times in and out of bed.

Nursing progress notes documented:
- on 12/6/2012, the resident attempted to stand on his own and removed the PAS;
- on 12/6/2012, the resident was "non-complaint" had the PAS alarm on and leaned forward in the chair, setting the alarm off;
- on 12/7/2012, the resident was walking in the hall alone and had removed the PAS;
- on 12/7/2012 and 12/9/2012, the resident was leaning forward in the chair; and
- on 12/10/2012, the PAS rang frequently as resident leaned forward in chair.

The CCP dated 12/12/2012, documented staff witnessed the resident slide out of his wheelchair and land on the foot pedals, sustaining an abrasion to the rib area. The resident was sent to the emergency room for evaluation and returned the same day. There was no documentation if the PAS was in place or sounding at that time .

The 12/15/2012 and 12/16/2012 nursing progress notes documented the resident removed the PAS many times.

A physician's note, dated 12/18/2012, documented the resident had a recent fall which was "most likely multifactorial but primarily due to lack of safety awareness." The resident was to continue on fall precaution and he was "advised on fall prevention."

The CCP documented on 12/22/2012, the resident was found kneeling on the floor. There was no documented change to the planned interventions or rationale for continuing the same plan.

Nursing progress notes documented:
- on 1/3/2013, the resident could not use a call bell related to confusion;
- on 1/6/2013, the resident attempted to self-transfer; and
- on 1/7/2013, the resident could not use a call bell, slid to his knees and laid down on the floor.
The nursing notes did not document the use of a PAS on these dates.

The CCP dated 1/7/2013, documented the resident's body was stiff and rigid due to his Parkinson's disease and he was totally dependent on staff for bed mobility. The plan included the use of 1/2 side rails in bed to aide in bed mobility and to use a PAS.

Nursing progress notes documented on 1/8/2013, the resident was found lying on the floor near the bed and the PAS was sounding.

The resident's CCP was updated to include the falls and did not document changes to the planned interventions or a rationale for continuing the same plan.

A physician's progress note, dated 1/8/2013, documented the resident "apparently had two falls since last night." The physician documented the falls were "most likely multifactorial but primarily due to lack of safety awareness." The resident was to continue on fall precautions. The note did not document specific fall precautions for the resident.

The Minimum Data Set (MDS) assessment, dated 1/15/2013, documented the resident was cognitively moderately impaired and required total dependence for most activities of daily living (ADL). The MDS recorded the resident did not have any falls since the admission assessment, and the resident did not use restraints.

Nursing progress notes documented:
- on 1/18/2013, the alarm sounded and the resident was found on floor on his knees, near the bed;
- on 1/19/2013, the resident was observed self-transferring with the alarm sounding;
- on 1/25/2013, the resident was observed walking down hall unassisted and had removed the PAS; and
- on 2/1/2013, the resident fell forward from the wheelchair at 2 AM, there was no documentation if the PAS was in place or sounding .

The RN Supervisor stated in an interview on 2/5/2013 at 10:25 AM, the resident fell frequently.

The resident was observed on 2/6/2013 at 10:14 AM. He was lying in bed with one end of the PAS attached to his shirt and the box of the PAS resting on the bed unsecured. The resident's bed was against the wall and both 1/2 side rails were in the up position.

On 2/6/2013 at 11:15 AM, CNA #4 stated in an interview, the resident used a PAS at all times and 2 side rails when he was in bed. She stated when he was first admitted, he rolled out of bed, and the side rails were started at that time. She stated when she applied a PAS to a resident in bed, she clipped one end to the resident's shirt and clipped the box to the bed sheet.

On 2/6/2013 at 11:25 AM, CNA #3 stated in an interview, when a resident was in bed, she clipped the PAS to their shirt and laid the box on the bed. She stated the resident was to use the PAS and side rails when he was in bed.

Observations of the resident included:
- on 2/6/2013 at 9:50 AM, he was lying in bed, the bed was against the wall, and both half side rails were in the up position;
- on 2/6/2013 at 10:55 AM, the resident was sitting on the side of the bed with his feet on the floor and the PAS was not sounding. As the resident moved around and tried to stand, the PAS sounded, and staff responded.
- on 2/6/2013 at 3 PM, the resident was in bed with both side rails up, the PAS was clipped to the resident's shirt and the box was attached to the pillow case; and
- on 2/6/2013 at 3:20 PM, the resident was standing up trying to put his pants on. The PAS was clipped to his shirt and the box was on the bed, and the PAS was not sounding.

On 2/6/2013 at 5:10 PM, LPN #1 stated in an interview, admission fall risk assessments were done by the RN Supervisor or Director of Nursing (DON). She stated therapy provided all fall prevention interventions at the time of admission. She stated the Supervisor or DON were responsible for completing the initial CCP and implementing fall prevention interventions at the time of admission. She stated after admission, if a resident fell, whoever completed the accident and incident report was responsible for implementing changes to the CCPs as needed.

On 2/7/2013 at 8:50 AM, the physical therapist stated in an interview, he would expect a referral if a resident removed their PAS repeatedly. He stated if that was occurring, staff should also position the PAS in a place where the resident could not access it. He stated when the PAS was used in bed, it was clipped to the resident's shirt and the box was to be secured to a fixed object, such as the head board. He stated he was not aware the PAS alarms were not being applied properly. He stated he recommended the side rails for the resident for fall prevention as they "reduce risk significantly," "protects" residents, and "keeps them in bed." He stated the facility discussed resident falls 3 times a week at morning meeting and this resident should be discussed as he fell frequently. The therapist stated nursing discussed the resident with him when he was on the nursing unit.

On 2/7/2013 at 9:40 AM, LPN #2 stated in an interview, the resident was to wear a PAS at all times. She stated the team met weekly on Tuesdays to discuss falls and interventions.

On 2/7/2013 at 9:40 AM, the DON stated she was responsible for updating CCPs after falls and she was trying to delegate that to the Supervisors as she was having difficulty keeping up with them.

On 2/7/2013 at 1:40 PM, CNA #11 stated in an interview, when a PAS was used, she clipped the PAS to the resident's clothing and secured the box to the bottom sheet or pillows. She stated she was not instructed on how to apply the PAS properly.

On 2/7/2013 at 2:22 PM, the resident was sitting in the wheelchair. The PAS was secured to the back of the wheelchair and it was not clipped to the resident's clothing.

On 2/12/2013 at 12:20 PM, the resident was sitting in the wheelchair. The PAS was secured to the back of the wheelchair and it was not clipped to the resident's clothing.

ELOPEMENT
3) Resident #3 had diagnoses including Alzheimer's dementia and impulse control disorder.

The comprehensive care plan (CCP) dated 9/26/2012 documented the resident had cognitive deficits with an expected continued decline, was visually impaired, able to see large print only, had trouble finding the correct word when speaking, was at high risk for falls, and wore a Wanderguard (a device to detect wandering) bracelet.

The 9/26/2012 Wandering Risk Assessment documented the resident was cognitively impaired with poor decision making skills, ambulated independently without assistance devices, had visual or auditory deficits, and had a history of attempting to leave the facility without informing staff or without supervision.

The 9/26/2012 social services progress note documented the resident was very confused, had advanced dementia, and rarely articulated a sentence or responded appropriately.

The 10/7/2012 Director of Nursing (DON) progress note documented at 8:50 AM, the resident went out the patio door and was seen opening the gate. A staff member noticed the resident through the window and the resident was easily re-directed back into the facility.

The 10/7/2012 Accident/Incident Report documented the resident went out to patio, attempted to get through the gate and certified nurse aide (CNA) #2 saw the resident from the window of a another resident's room. The corrective action was listed as "maintenance to check gate to make sure it is latched daily." Attached to the form was an unsigned staff statement documenting the staff person was in another resident's room picking up a meal tray and saw the resident out the window walking "under the ramp." The report was signed by the Supervising Administrator, the Director of Nursing (DON), the licensed practical nurse (LPN) Manager (LPN #1), the Medical Director, and the physical therapist.

The CCP dated 12/18/2012 documented the resident continued with a Wanderguard bracelet.

During an interview with LPN #1 on 2/5/2013 at 10:00 AM, she stated the resident wore a Wanderguard and had an incident where he went out the patio door unsupervised. She stated the gate off the patio was left open, the resident exited the gate, walked under the ramp outside, and was seen walking outside by a staff member who was in another resident's room providing care. She stated she did not know how long the resident was outside.

During an interview with LPN #1 on 2/6/2013 at 11 AM, she stated since the resident eloped in October of 2012, maintenance checked the patio gate to ensure it was latched.

During an interview with a maintenance staff person on 2/6/2013 at 11:10 AM, he stated the gate off the patio had a lock and they were not allowed to lock it. He stated he was not told to check that the gate was latched, he did not keep a log that the gate was latched, and he did not routinely check the gate.

During an interview with the DON on 2/6/2013 at 12:50 PM, she stated she was aware there was not a Wanderguard mechanism on the patio doors and residents with Wanderguards should not go out to the patio by themselves. She stated all residents were checked every 2 hours. She stated the resident's CCP was not changed to prevent reoccurrence because the resident currently relied more on a wheelchair for mobility.

During an interview with the Acting Administrator and Supervising Administrator on 2/6/2013 at 1:40 PM, the Acting Administrator stated she was not aware of the resident's elopement until today. The Supervising Administrator stated he signed the accident/incident report and did not remember the incident. They stated residents with Wanderguard bracelets were allowed to go outside to the patio alone as it was a "resident common area." They stated the patio doors did not have Wanderguard alarms on them and there was no policy addressing the use of the patio by residents. The Acting Administrator stated if LPN #1 wrote on the accident and incident report that maintenance was going to check that the gate was latched every day, then LPN #1 should have followed-up with maintenance to ensure this was implemented.

The DON stated in an interview on 2/7/2013 at 9:35 AM, she was responsible for updating residents' CCPs following any type of incident. She said she was trying to delegate some of that to the Supervisors.

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The Immediate Jeopardy situation was removed prior to survey exit on 2/12/2013 based on the following corrective actions taken by the facility:
- revised the Falls policy and Post Falls policy to include evaluating CCPs for effectiveness and revising interventions as needed and trained staff regarding the new policies.
- revised the Smoking and Fire Prevention policies to include educating newly admitted residents with a history of smoking of the smoke free status of the facility and with their permission inspect their personal belongings to ensure there are no smoking materials and trained staff regarding the revised policies.
- revised and updated Resident #23's CCP to include a history of smoking, and the fire incident, and trained staff regarding these changes.
- revised the Elopement policy to include resident's with Wanderguards not being allowed to exit the building to the patio unsupervised and trained staff on the revised policy.
- all staff will be trained before returning to duty.

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

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

Scope: Pattern

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: April 12, 2013

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

Based on observation, record review, and staff interview conducted during the extended and abbreviated surveys (Complaint #NY00121297 and NY00122263), it was determined for 11 of 13 residents (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19) reviewed for falls/fractures and/or injuries of unknown origin, and for 1 of 1 resident (Resident #3) reviewed for elopement, the facility failed to thoroughly investigate and report incidents when required to the New York State Department of Health (NYSDOH). For 4 of 5 newly hired employees (Employees #1, 2, 3, and 5), the facility did not complete required pre-employment screening. Specifically, for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19, the facility:
- failed to consistently conduct investigations of falls, injuries of unknown origin, and elopements to rule out abuse, neglect, or mistreatment; and
- failed to notify the Director of Nursing (DON), the Supervising Administrator, and the Acting Administrator of every incident.
For Residents #1, 3, 4, and 8, the facility failed to report incidents to the NYSDOH when required. For Employees #1, 2, and 3 the facility did not verify the employee's licenses or check references prior to hire; and for Employee #5, the facility did not verify the employee with the certified nurse aide (CNA) registry prior to hire. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19, and regarding lack of employee screening no actual harm with potential for more than minimal harm that is not immediate jeopardy to residents. The facility implemented corrective measures to remove the Immediate Jeopardy prior to the survey exit on February 12, 2013.
Findings include:

FALLS
1) Resident #1 had diagnoses including dementia.

The comprehensive care plan (CCP) dated 9/12/2012 documented the resident was at risk for falls and required extensive assistance of 2 persons for transfers. The CCP recorded the resident had a history of anxiety, was impatient, and could be demanding, crass or rude when speaking.

The Minimum Data Set (MDS) assessment dated 10/02/2012, documented the resident's cognition was moderately impaired.

The Accident/Incident Report dated 10/1/2012, documented the resident was found on the floor at 10 PM and sustained an "aprox" one inch skin tear" above his right ear. The report included:
- 10/3/2012, certified nurse aide (CNA) #8 documented the resident was on the floor and wanted to get up. The resident's head was bleeding and "we" got the resident up for further assessment. The resident was placed in the wheelchair and his head was bandaged.
- 10/1/2012, licensed practical nurse (LPN) #3 documented the resident's left temple was bleeding. The resident did not complain of pain; range of motion was done; he was assisted to a wheel chair; brought to the nurse's station for monitoring; and oxygen was given. The resident stated he hit his head "hard", neurological checks (an assessment of neurological functioning) were started and the physician was notified. The resident was sent to the emergency room due to a "deep cut on his left temple."
- 10/1/2012, LPN #4 documented the resident denied he was hurt and stated he wanted to get up. A cut was observed on the left side of the resident's head, a pressure dressing was applied and the resident was assisted to the wheelchair. Neurological checks were started and were within normal limits.
- The physician was notified at 10:30 PM and the resident was sent to the hospital at 10:45 PM for evaluation and treatment of the head wound.
- The "Designee Administrator" signed the Accident/Incident report as complete on 10/03/2012. The director of Nursing (DON) signed the report without a date.
- The "Conclusion" section of the Accident/Incident Report was not completed (was blank) including, whether the accident/incident was avoidable or unavoidable and whether the investigation revealed there was cause to believe abuse, mistreatment or neglect occurred.

The facility's investigation dated 10/1/2012 included no documented evidence it was beyond the LPN's scope of practice to:
- assess the resident after he was found on the floor; and
- move the resident off the floor into a wheelchair, before he was assessed by a qualified person (physician, registered nurse).
The resident's medical record included no documented evidence the resident was assessed by a qualified person, following a head injury, and in addition the incident was not reported to the NYSDOH.

In an interview with the Assistant Administrator on 11/28/2012 12:50 PM she stated LPN #3 was the nursing supervisor when the resident was found on the floor on 10/2/2012.

LPN #3 was interviewed on 11/28/2012 at 1:28 PM and 2:26 PM and stated she was the nursing supervisor when the resident was found on the floor. She said she assessed the resident and determined there was no change in his cognition or range of motion. LPN #3 stated she determined the resident was able to be assisted up from the floor.

During an interview with LPN #3 on 12/05/2012 at 7:15 AM, she stated at her direction two staff members lifted the resident off the floor, using a gait belt, as she pushed the wheelchair under the resident. LPN #3 stated she did not call the physician until after the resident was lifted off the floor placed in a wheelchair and brought out to the nursing station. She said she called the physician because she thought the resident needed stitches to the head wound. She said she did not notify the Director of Nursing as she saw "a little blood" and thought the resident needed "stitches." LPN #3 stated she did not check the resident's vital signs until he was in the wheelchair at the nurses station.

The DON was interviewed on 12/05/2012 at 8:12 AM, and stated she did not know whether it was beyond an LPN's scope of practice to assess residents. She said the facility's investigation was incomplete as there was no determination if the incident was unavoidable. She stated she obtained, reviewed, and signed investigations. The DON said an LPN could move a resident after doing an assessment if there was no injury. She stated an RN would assess the resident when one was available.

During an interview with the Acting and Supervising Administrators on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Supervising Administrator stated he signed all Accident/Incident Reports and when he signed them they did not always include staff statements or additional investigation.

The DON stated in an interview on 2/7/2013 at 9:35 AM, she was newly hired, was aware the facility was not completing thorough investigations of incidents, and had not gotten around to making any changes.

On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed. They stated the facility's incident reporting process had changed and they did not know where investigations of incidents were documented. They stated there used to be investigations attached to Accident/Incident Reports and there no longer were. The Acting Administrator stated it was the responsibility of "whoever signs off" an Accident/Incident report to ensure it was a complete investigation.

INJURIES OF UNKNOWN ORIGIN
2) Resident #4 had diagnoses including dementia, impulse control disorder and osteoporosis.

A nursing progress note dated 8/12/2012 documented the resident had edema (swelling) to the right ankle, pain, "grimacing" with standing and an x-ray was ordered.

The 8/12/2012 x-ray report documented the resident had a non-displaced fracture of the right ankle.

A nursing progress note dated 8/12/2012 documented the resident was to be transferred with a mechanical lift as he had pain and swelling of the right ankle.

The licensed practical nurse (LPN) #2's progress note dated 8/13/2012 documented she phoned the resident's family member to tell her about the fracture and the family member asked how it happened. LPN #2 documented she responded "I'm unsure d/t (due to) his condition and movement it could be a possibility of anything."

The 8/21/2012 physician's progress note documented the resident's fractured ankle was to be "investigated as per facility policy."

The facility was unable to provide an investigation upon request by the surveyors.

The 12/13/2012 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, he was dependent on staff for activities of daily living (ADL), and he had falls without injury.

The resident was observed on 2/5/2013 at 12:25 PM sitting, in the hallway, in a reclined geri-chair.

The physician stated in an interview on 2/7/2013 at 11:45 AM, he was aware of the resident's fractured ankle and was involved with the care. He stated the facility should have completed an investigation to determine how the fracture occurred.

During an interview with the Director of Nursing (DON) on 2/7/2013 at 10 AM, she stated she could not find an investigation for the resident's fractured ankle.

During an interview with the Acting and Supervising Administrators on 2/7/2013 at 12:05 PM, the Supervising Administrator stated he did not remember the resident's fracture and was not employed by the facility at that time. The Acting Administrator stated she remembered the resident having edema and thought he did not have a fractured ankle. The Acting Administrator stated the fracture should have been investigated and reported to the New York State Department of Health (NYSDOH) and was not. The Acting Administrator stated the facility did not have a mechanism in place to ensure incident reports or investigations were completed for each incident, including injuries of unknown origin.

ELOPEMENT
3) Resident #3 had diagnoses including Alzheimer's dementia and impulse control disorder.

The comprehensive care plan (CCP) dated 9/26/2012 documented the resident had moderate cognitive deficits, was visually impaired, was able to see only large print, had trouble finding the correct word when speaking, was at high risk for falls, and wore a Wanderguard (a device to detect wandering) bracelet.

The 9/26/2012 Wandering Risk Assessment documented the resident was cognitively impaired with poor decision making skills, ambulated independently without assistance devices, had visual or auditory deficits, and a history of attempting to leave the facility without supervision or informing staff.

The 10/7/2012 Director of Nursing (DON) progress note documented at 8:50 AM, the resident went out the patio door and was seen opening the patio gate. The staff noticed the resident through the window and the resident was easily re-directed back into the facility.

The 10/7/2012 Accident/Incident Report documented the resident went out to patio, attempted to get through the gate and staff (certified nurse aide, CNA, #2) saw him from the window of another resident's room. The corrective action was "maintenance to check gate to make sure it is latched daily." The report included an unsigned staff statement documenting the staff person went to another resident's room to pick up a meal tray, looked out the window, and saw the resident walking "under the ramp outside." The report was signed as reviewed by the Administrator, the DON, the licensed practical nurse (LPN) Manager #1, the Medical Director, and the physical therapist. The report documented the incident was "unavoidable" and was not reported to the NYSDOH.

During an interview with LPN #1 on 2/5/2013 at 10 AM, she stated the resident wore a Wanderguard bracelet and had an incident in October 2012, where he went out the patio door, that had no Wanderguard alarm. She stated the patio gate was left open by the lawn crew, the resident exited the gate, and was walking under the ramp when he was seen by a staff member from another resident's room. She stated she did not know how long the resident was outside, or outside of the patio.

During an interview with the DON on 2/6/2013 at 12:50 PM, she stated she did not consider the resident's incident an elopement as staff "caught him," he came back inside easily, and he did not leave the facility grounds. She stated he was in an area that he should not have been as she would not allow residents with Wanderguards to go to the patio without supervision. She stated his care plan was not changed to prevent reoccurrence as over time he relied on a wheelchair more for mobility. She stated the Acting and Supervising Administrators made the determination of which incidents should be reported to the NYSDOH and she did not have a copy of the NYSDOH incident reporting manual.

During an interview with the Acting and Supervising Administrator on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Acting Administrator stated she was not aware of the resident's elopement until today as she did not sign off on accident/incident reports. The Supervising Administrator stated he signed the report and did not remember the incident. The Supervising Administrator stated the incident should have been reported to the NYSDOH. He stated he signed all incident reports and when he signed them they did not always include staff statements or investigation to determine if abuse or neglect occurred.

On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed. They stated the facility's incident reporting process changed and they were not sure where they could find thorough investigations of incidents. The Acting Administrator stated "whoever signs off" on the accident and incident reports should be ensuring they were complete.
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The Immediate Jeopardy situation was removed prior to the survey exit on 2/12/2013 based on the following corrective actions taken by the facility:
- revised the Accident and Incident Report form to include a thorough investigation of all allegations of abuse, neglect, and mistreatment;
- trained the majority of staff members on abuse prevention and completing thorough investigations, and the remaining staff would be inserviced before returning to duty;
- revised policies and procedures to address post-fall practices; and
- revised the LPN job description to ensure assessments were conducted by qualified professionals.

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EMPLOYEE SCREENING:
4) Per an undated list of new employees (Probationary Employee Listing):
- Employee #1 was a registered nurse (RN) hired 11/30/2012;
- Employee #2 was a licensed practical nurse hired 12/21/2012;
- Employee #3 was an RN hired 11/15/2012; and
- Employee #5 was a certified nurse aide (CNA) hired 1/21/2013.

The facility could provide no documented evidence the license status of Employees #1, 2, and 3 was checked with the state education department.

The facility could provide no documented evidence reference checks were done, as part of the hiring process, for Employees #1, 2, and 3.

Per the Candidate Search Details (CNA registry check) dated 2/5/2013, the CNA registry check for Employee #5's status as a CNA was done on 2/5/2013.

The Acting Administrator was interviewed on 2/6/2013 at 3 PM. She stated individual departments were responsible for screening their employees.

The Director of Nursing (DON) was interviewed on 2/6/2013 at 3:05 PM. She stated she had not been involved in the recent hiring of nurses. She was not sure if the nursing department was responsible for screening new nursing employees. She stated the part time receptionist usually checked two references for new employees. She stated she was aware the license status of licensed employees could be checked online; she did not check the license status of each newly hired licensed nurses.

The part-time receptionist was interviewed on 2/6/2013 at 3:30 PM. She stated she checked the CNA registry for new employees, and did not check the online license status of licensed employees.

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

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

Scope: Pattern

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on record review and staff interview conducted during the extended and abbreviated surveys (Complaint #NY00121297 and NY00122263), it was determined for 11 of 13 residents reviewed for falls/fractures and/or injuries of unknown origin (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19) and 1 of 1 resident reviewed for elopement (Resident #3), it was determined the facility failed to operationalize policies and procedures that prohibit mistreatment, neglect, and abuse of residents. For 4 of 5 newly hired employees (Employees #1, 2, 3, and 5), the facility did not operationalize policies to ensure pre-employment screening was completed. Specifically, for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19, the facility:
- failed to consistently conduct investigations of falls, injuries of unknown origin, and elopements to determine if abuse, neglect, or mistreatment occurred; and
For Residents # 1, 3, 4, and 8, the facility failed to report injuries and incidents to the New York State Department of Health (NYSDOH). Regarding Employees #1, 2, 3, and 5, the facility did not complete all required pre-employment screening. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Residents # 1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19, and no actual harm with potential for more than minimal harm that is not immediate jeopardy regarding the lack of employee screening. The facility implemented corrective measures to remove the Immediate Jeopardy prior to the survey exit on February 12, 2013.

The facility's undated "Job Description and Performance Standards for LPN (licensed practical nurse) Clinical Coordinator/Charge Nurse" documented the LPN was to "supervise and assess resident care and take appropriate action" and to "perform comprehensive assessment/observation of residents as assigned."

The facility's current Abuse Prevention and Reporting policy dated 8/25/09 documented all alleged or suspected incidents of abuse or neglect would be thoroughly investigated and the findings documented in a report format. If abuse or neglect were identified or if a conclusion could not be drawn the incident would be reported to the NYSDOH.

Findings include:

FALLS
1) Resident #1 had diagnoses including dementia.

The Accident/Incident Report dated 10/1/2012, at 10 AM, documented the resident was found on the floor with an "aprox" one inch skin tear above his right ear on the side of his head. The report included:
- 10/1/2012, licensed practical nurse (LPN) #3 documented the resident's left temple was bleeding. The resident did not complain of pain, range of motion was done, and he was placed in a wheel chair and oxygen was applied. The resident was brought to the nurse's station desk for monitoring. The resident stated he hit his head "hard", neurological checks (an assessment of neurological functioning) were started and the physician was notified. The resident was sent to the emergency room "d/t (due to) a deep cut on his left temple."
-The "Conclusion" section of the report was not completed (was blank) including whether the accident/incident was unavoidable or avoidable and whether the investigation revealed there was cause, or no cause, to believe abuse, mistreatment or neglect occurred.
-The "Designee Administrator" signed the Accident/Incident report as complete on 10/03/2012. The Director of Nursing (DON) signed and did not date the report.

There was no documented evidence the facility identified it was beyond the scope of practice for the LPN to assess and move the resident off the floor before an assessment by a qualified professional (physician, registered nurse). There was no documented evidence the facility reported to the NYSDOH the LPN assessed the resident.

The Acting Administrator was interviewed on 1/3/2013 at 12:45 PM, and stated the Supervising Administrator was responsible for operationalizing the facility's policies and procedures.

The Supervising Administrator was interviewed on 1/23/2013 at 9:10 AM, and stated he was ultimately responsible for operationalizing the facility's policies and procedures.

During an interview with the Acting and Supervising Administrators on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Supervising Administrator stated he signed off all Accident/Incident Reports and when he signed them they did not always have staff statements or an investigation.

In an interview on 2/7/2012 at 9:30 AM the DON stated in an she was newly hired by the facility, she was aware the facility was not completing thorough investigations of resident incidents, and had not gotten around to making any changes.

On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed and they both stated the facility's incident reporting process changed and they were not sure where they could find thorough investigations of incidents. They stated investigations used to be attached to Accident/Incident Reports and no longer were. The Acting Administrator stated "whoever signs off" on the accident and incident reports should be ensuring they were complete. The Acting Administrator said the facility did not have a mechanism in place to ensure incident reports or investigations were completed for each incident.

INJURIES OF UNKNOWN ORIGIN
2) Resident #4 had diagnoses including dementia, impulse control disorder, and osteoporosis.

An 8/12/2012 nursing progress note documented the resident had edema to the right ankle, pain, "grimacing" with standing, and an x-ray was ordered.

The 8/12/2013 x-ray report documented the resident had a non-displaced fracture of the lateral malleolus (ankle bone) and mild degenerative changes in the ankle.

At on 2/5/2013, the facility's investigation of the resident's fractured ankle was requested. The facility was not able to provide an Accident/Incident Report or an investigation.

During an interview with the Acting and Supervising Administrators on 2/7/2013 at 12:05 PM, the Acting Administrator stated when the resident was found with a fracture of unknown origin, it should have been investigated and reported to the NYSDOH and was not.

ELOPEMENT
3) Resident #3 had diagnoses including Alzheimer's dementia and impulse control disorder.

The 10/7/2012 Accident/Incident Report documented the resident went out to patio, attempted to get through gate and staff (certified nurse aide, CNA, #2) saw the resident from the window of a another resident's room. The corrective action was listed as "maintenance to check gate to make sure it is latched daily." Attached to the form was an unsigned staff statement documenting the staff person went to another resident's room to pick up a meal tray, looked out the window, and saw the resident walking "under the ramp outside." The report was signed as reviewed by the Administrator, the Director of Nursing (DON), the licensed practical nurse (LPN) Manager (LPN #1), the Medical Director, and the physical therapist. The report documented the incident was "unavoidable" and was not reported to the NYSDOH.

During an interview with the Acting and Supervising Administrators on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Acting Administrator stated she was not aware of the resident's elopement until today as she did not sign accident and incident reports. The Supervising Administrator stated he signed the report and did not remember the incident. The Supervising Administrator stated the incident should have been reported to the NYSDOH. He stated he signed off on all incident reports and when he signed them they did not always include staff statements or investigations.

On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed. They stated the facility's incident reporting process changed and they were not sure where they could find thorough investigations of resident incidents. The Acting Administrator stated "whoever signs off" on an accident/incident report should ensure the investigation was completed.

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The Immediate Jeopardy situation was removed prior to survey exit on 2/12/2013 based on the following corrective actions taken by the facility:
- revised the Accident and Incident Report form to include a thorough investigation of all allegations of abuse, neglect, and mistreatment;
- trained the majority of staff members on abuse prevention and completing thorough investigations, the remaining staff would be trained before returning to duty;
- revised policies and procedures to address post-fall practices;
- revised the LPN job description to ensure assessments were conducted by qualified professionals.

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EMPLOYEE SCREENING:
4) Per an undated list of new employees (Probationary Employee Listing):
- Employee #1 was a registered nurse (RN) hired 11/30/2012;
- Employee #2 was a licensed practical nurse hired 12/21/2012;
- Employee #3 was an RN hired 11/15/2012; and
- Employee #5 was a certified nurse aide (CNA) hired 1/21/2013.

There was no documented evidence the license status of Employees #1, 2, and 3 was checked with the state education department.

There was no documented evidence reference checks were done, as part of the hiring process, for Employees #1, 2, and 3.

Per the Candidate Search Details (CNA registry check) dated 2/5/2013, the CNA registry check for Employee #5's status as a CNA was done on 2/5/2013.

The Acting Administrator was interviewed on 1//6/2013 at 3 PM. She stated individual departments were responsible for screening their employees.

The Director of Nursing (DON) was interviewed on 1/6/2013 at 3:05 PM. She stated she had not been involved in the recent hiring of nurses. She said she was not sure if the nursing department was responsible for screening new nursing employees.

10NYCRR 415.4(b)

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

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on record review and staff interview conducted during the extended and abbreviated surveys (Complaint #NY00121297, NY00122263, and NY00126387), it was determined for 11 of 13 residents (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19), reviewed for falls/fractures and/or injuries of unknown origin, for 1 of 1 resident (Resident #3), reviewed for elopement and for 1 of 1 resident (Resident #23), reviewed for unsafe smoking the facility failed to ensure Administrative staff administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the Administrator failed to ensure thorough investigations were completed for accidents and incidents; failed to ensure care plans were reviewed for effectiveness after each incident; failed to ensure the root cause of incidents was determined, and failed to report incidents when required to the New York State Department of Health (NYSDOH). Refer to F225, F226, and F323. This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, 19, and 23.
Findings include:

During an interview with the Acting and Supervising Administrators on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Supervising Administrator stated he signed off on all Accident/Incident Reports and when he signed them they did not always have staff statements or investigations attached. The Acting Administrator stated she did not review or sign off on all Accident/Incident Reports and was notified of resident incidents from 24 hour report or in the team meeting which was held three times a week.

During an interview with the Director of Nursing (DON) on 2/7/2012 at 9:35 AM she stated she was newly hired at the facility, she was aware the facility was not completing thorough investigations of resident incidents, and had not gotten around to making any changes.

On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed a second time. They both stated the facility's incident reporting process changed and they were not sure where they could find thorough investigations of resident incidents. They stated investigations used to be attached to Accident/Incident Reports and no longer were. The Acting Administrator stated "whoever signs off" on the accident/incident reports should be ensuring they were completed. The Acting Administrator stated the facility did not have a mechanism in place to ensure incident reports or investigations were completed for each resident incident, including injuries of unknown origin.

On 2/9/2013 at 1:45 PM, the current Administrator stated in an interview, Resident #23 was admitted to the facility on 2/8/2013 around 3 PM. He stated the staff did not thoroughly check her belongings and were not aware she had smoking materials. He said staff smelled smoke and when they went to her room they realized she had thrown a cigarette in the trash can. The staff poured water on the trash can, did not pull the fire alarm, and put the fire out on their own. After the incident, three lighters and cigarettes were found in the resident's room.

On 2/11/2013 at 2:05 PM, the Acting Administrator stated she wrote Resident #23's comprehensive care plan (CCP) on 2/9/2013 documenting the need for 1 hour checks. She stated she only wrote an "activities care plan" as her background was in activities and she expected nursing to write a CCP that addressed the resident's smoking history and the fire. The Acting Administrator stated she remembered the DON telling her right after the fire that the resident set the fire on purpose. She stated she did not know why this was not addressed in the resident's medical record or the facility's investigation.

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The Immediate Jeopardy situation was removed prior to survey exit on 2/12/2013 based on the following corrective actions taken by the facility:
- revised the Accident and Incident Report form to include a thorough investigation of all allegations of abuse, neglect, and mistreatment, and of accidents;
- trained the majority of staff members on abuse prevention and how to complete thorough investigations, remaining staff will be trained before returning to duty;
- revised policies and procedures to address post-fall practices;
- revised the LPN job description to ensure that assessments were completed by qualified professionals.

10NYCRR 415.26

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

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on record review and staff interview conducted during the extended and abbreviated surveys (Complaint #NY00121297, NY00122263, and NY00126387), it was determined for 11 of 13 residents (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19), reviewed for falls/fractures and/or injuries of unknown origin, for 1 of 1 resident (Resident #3), reviewed for elopement and 1 of 1 resident (Resident #23), reviewed for unsafe smoking the facility's quality assurance (QA) committee failed to identify significant concerns with accident and abuse investigations. Specifically, the facility's QA committee failed to identify concerns with the investigation process as thorough investigations were not completed; failed to identify concerns with the effectiveness of residents' care plans in preventing incidents/accidents, and failed to identify which incidents, accidents, or injuries of unknown origin were required to be reported to the New York State Department of Health (NYSDOH). Refer to F225, F226, and F323. This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, 19, and 23.
Findings include:

During the entrance interview on 2/5/2013 at 9:50 AM, the Acting Administrator stated herself and the Director of Nursing (DON) were the Quality Assurance (QA) coordinators.

During an interview with the DON on 2/7/2013 at 9:40 AM, she stated the Acting Administrator was in charge of QA. The DON stated she missed the last QA meeting. The DON said she did not know if the facility was auditing or reviewing resident falls or injuries of unknown origin. The DON stated she was aware the facility was not completing thorough investigations of resident incidents and since she was newly hired, she was not yet able to implement changes.

During an interview with the Acting Administrator on 2/7/2013 at 12:05 PM, she stated the facility did not have a mechanism in place to ensure incident reports or investigations were completed. She stated this could only be caught if the facility conducted chart audits and compared the chart audits to the accident/incident reports, and she stated they did not do that.

The Acting Administrator was interviewed on 2/8/2013 at 9:30 AM and stated audits conducted in regards to accident and incident reports included whether or not the accident and incident reports were signed by the Supervising Administrator and physician and- whether there was a change in physician's orders as a result of an incident. She stated the facility did not audit or review whether thorough investigations were completed following incidents.

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The Immediate Jeopardy situation was removed prior to survey exit on 2/12/2013 based on the following corrective actions taken by the facility:
- revised the Accident and Incident Report form to include a thorough investigation of all allegations of abuse, neglect, and mistreatment;
- trained majority of staff members on abuse prevention and how to complete thorough investigations, remaining staff will be trained before returning to duty;
- revised policies and procedures to address post-fall practices; and
- revised the LPN job description to ensure assessments were completed by qualified professionals.

10NYCRR 415.27(a-c)

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

Scope: Isolated

Severity: Actual Harm

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on record review, observation, and interview with staff and residents conducted during the standard survey, it was determined for 4 of 4 residents (Residents #8, 10, 11, and 13), reviewed for pressure ulcers, the facility did not ensure a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically, for Resident #8 the facility
- did not monitor and assess pressure ulcers regularly;
- did not observe the resident's skin integrity regularly to ensure pressure ulcers were identified timely; and
- did not ensure the resident's 3 Stage II pressure ulcers received appropriate treatment;
For Resident #13, the facility:
- did not monitor and assess pressure ulcers regularly;
- did not observe the resident's skin integrity regularly to ensure pressure ulcers were identified timely, and
- did not ensure the plan of care was revised when needed to prevent the progression of pressure ulcers.
For Residents #10 and 11, the facility
- did not ensure a comprehensive plan of care was developed and implemented for pressure ulcer prevention and
- did not ensure the resident's skin was monitored regularly to identify pressure ulcers timely.
This resulted in actual harm, multiple Stage II pressure ulcers, for Residents #8 and 13 and no actual harm with the potential for more than minimal harm that is not immediate jeopardy for Residents #10 and 11.
Findings include:

1) Resident #8 had diagnoses including generalized weakness, coronary artery disease, and hypertension.

The nursing note dated 12/24/12 documented the resident had an open area on the coccyx and Allevyn (a type of dressing was applied)

The Minimum Data Set (MDS) assessment dated 12/24/2012 documented the resident had severely impaired cognition, required extensive assistance with bed mobility, total dependence with toileting, personal hygiene, and bathing, was frequently incontinent of bladder and bowel, and had unhealed pressure ulcers.

The Pressure Ulcer Risk Assessment Tool dated 12/25/2012 documented the resident was at high risk for developing pressure ulcers.

The Pressure Ulcer Record (Weekly Pressure Ulcer Assessment) dated 12/25/2012 documented the resident had a Stage II pressure ulcer on the right buttock/sacrum area which measured 2 centimeter (cm) x 3 cm, and an unstageable pressure ulcer on the left buttock which measured 7 cm x 8 cm.

A nurse practitioner (NP) order dated 12/25/2012 documented to cleanse both pressure ulcers with wound cleanser, pat dry, apply Allevyn border (a dressing), and change every 3 days and prn (as needed) when soiled.

On 1/2/2013 the resident's Pressure Ulcer Record documented there was improvement to the pressure ulcers, and the treatment was changed to periguard ointment (a skin protectant).

The Nurse Practitioner (NP) orders dated 1/2/13 documented the resident was to have periguard ointment applied to the buttocks and inner groin area every shift for 14 days.

The MDS dated 1/5/13 documented the resident was at risk for developing pressure ulcers, had 2 Stage I pressure ulcers and 3 Stage II pressure ulcers. The MDS recorded the resident had pressure relieving devices for the chair and bed.

The Comprehensive Care Plan (CCP) dated 1/9/2013 documented the resident had pressure ulcers on the buttocks and sacrum. Interventions included to provide treatment as ordered, monitor status on weekly skin rounds and prn, and notify the physician/NP of progress and the need to change treatment as needed. The CCP documented the resident was frequently incontinent of bowel and bladder, required extensive assistance with mobility, transfer, locomotion, dressing, personal hygiene, toileting, and bathing. The CCP did not document the use of pressure relieving devices for the resident's bed or chair.

The Pressure Ulcer Record dated 1/16/2013 documented two pressure ulcers on the resident's left buttock, one measured 1 cm x 1 cm, and the second measured 2 cm x 1 cm. The pressure ulcer on the resident's right buttock/sacrum area was resolved.

There was no documented evidence, in the resident's medical record, the pressure ulcers on the resident's left buttock were assessed after 1/16/2013.

The 1/2013 treatment administration record (TAR) documented periguard ointment was applied, as ordered, to the resident's buttocks from 1/5/2013 - 1/31/2013.

The certified nurse aide (CNA) accountability record dated 2/2013 did not document the use of pressure relieving devices for the resident's bed or chair.

On 2/5/2013 at 10:20 AM, the resident stated to the surveyor he had "two big sores" on his hips and "no one does anything for them." He stated staff applied cream "once in a while."

On 2/5/2013 at 10:25 AM, licensed practical nurse (LPN) #2 stated the resident had an allergic reaction to the disposable briefs. She said periguard was used on the residents buttocks. LPN #2 stated there were no resident's with pressure ulcers residing on the unit.

On 2/7/2013 at 9:40 AM, the resident stated to the surveyor he had pain in his buttocks. Upon observation, (at that time) the resident had two open areas on his left buttock, both measured approximately 1 cm x 0.5 cm, and one open area on his right buttock, which measured approximately 2 cm x 1 cm. The wound beds were pink with no drainage or odor.

On 2/8/2013 at 10:40 AM, the surveyor observed the Director of Nursing (DON) and NP assess and provide wound care treatment to the resident's open areas. The DON stated both open areas on the left buttock were Stage II pressure ulcers measuring 1 cm x 0.3 cm. The DON said the resident had a Stage II pressure ulcer on the right buttock measuring 2 cm x 1.5 cm.

When interviewed on 2/8/2013 at 10:43 AM, the DON stated pressure ulcer assessments were performed weekly by herself or the registered nurse (RN) Supervisor. She stated she had not yet developed a schedule to determine who was responsible for skin/wound rounds.

When interviewed on 2/8/2013 at 10:45 AM, the LPN #2 stated she did not see any pressures ulcers on this resident two days ago when she applied periguard ointment to his buttocks.

An NP order dated 2/8/2013 documented the resident was to receive a compound of Balmex/Nystatin/Hydrocortisone Butyrate (topical ointment to promote healing) to the buttocks and coccyx each shift.

When interviewed on 2/11/2013 at 11:15 AM, the DON stated any open areas or issues with resident skin would be reported initially to an LPN. The LPN would then contact the RN Supervisor or DON, and the physician or NP for a treatment order.

When interviewed on 2/11/2013 at 1:30 PM, Certified Nurse Assistant (CNA) #7 stated he was aware this resident had pressure ulcers, was not sure if the resident's pressure ulcers developed in the facility or not, and did not know how they developed.

When interviewed on 2/11/2013 at 1:40 PM, CNA #6 stated she was aware the resident had pressure ulcers. She said he came to the facility, from the hospital with pressure ulcers because of his refusal of care. She stated the resident would not stay off his back even though he was encouraged to.

When interviewed on 2/11/2013 at 2:20 PM, LPN #6 stated the resident was originally on the first floor unit and when he was transferred to the current unit, he had the pressure ulcers. She stated the pressures ulcers may have developed from shearing, he tends to stay in bed and at times he slides across the incontinence pad and his pants get twisted.

When interviewed on 2/11/2013 at 3:35 PM, LPN #2 stated any problems related to residents' skin were reported to her. She and a CNA examined 8 residents' skin every Monday through Friday and if any issue was found, it was reported to the RN Supervisor or DON who would assess the area. She stated she did not keep documentation of these skin checks. She stated she would contact the NP or physician for treatment orders. Skin/wound rounds were performed on Tuesdays by the physician and wounds/pressure ulcers were tracked on a wound tracking sheet kept in the residents' chart. She stated she told the physician which residents to assess and did this by giving him the pressure ulcer record from each medical record.

When interviewed on 2/12/2013 at 10:30 AM, the Acting Administrator, who was the quality assurance (QA) coordinator, stated to her knowledge, skin checks were done weekly on bath days by RNs or by the NP with the LPN Nurse Managers. She did not know if this was documented. She stated QA audits included positioning, preventative devices, and whether residents with skin breakdown had interventions or orders.

The 2/2013 TAR documented periguard ointment was applied to the resident's buttocks from 2/1/2013 - 2/11/2013. Balmex/Nystatin/Hydrocortisone Butyrate was applied to the resident's buttocks/coccyx from 2/8/2013 - 2/10/2013.

2) Resident #13 had a diagnosis including dementia and diabetes.

The Resident Status Sheet (care instructions) dated 10/28/2012 documented the resident was to be turned and repositioned every 2 hours.

The Minimum Data Set (MDS) assessment dated 12/6/2012 documented the resident had severely impaired cognition, required total dependence with bed mobility, toileting, personal hygiene and bathing, and was always incontinent of bladder and bowel. The resident had pressure reducing devices for the bed and chair and was on a turning and repositioning program.

The comprehensive care plan (CCP) dated 12/19/2012 documented the resident had fragile skin with potential for skin breakdown, and was incontinent of bowel and bladder. Interventions included inspect the skin with morning care, evening care and bathing, provide incontinence care every 2 - 4 hours and prn (as needed), and provide preventative skin care after each incontinent episode. The CCP did not document the use of pressure relieving devices.

The Pressure Ulcer Risk Assessment Tool dated 12/19/2012 documented the resident was at moderate risk for pressure ulcer development.

The treatment administration record (TAR) documented the resident received Calmoseptine ointment (skin barrier) to his buttocks every shift from the 12/23/2012 day shift through the 1/6/2013 day shift.

The Pressure Ulcer Record (Weekly Pressure Ulcer Assessment) dated 12/31/2012 documented a Stage II abrasion to the resident's sacrum/buttocks area which measured 0.5 centimeters (cm) x 0.5 cm, and to monitor response to hydrocolloid (a type of dressing) treatment.

The nursing note dated 12/31/2012 documented the resident developed a small open area on the sacrum/coccyx.

The CCP updated 12/31/2012 documented the resident had a Stage II pressure ulcer. The location of the pressure ulcer was not identified. An intervention was to apply hydrocolloid dressing as ordered, change every three days and prn.

There was no documented physician or nurse practitioner (NP) order to treat the resident's pressure ulcer with a hydrocolloid dressing (as in the care plan) until 1/3/2013.

An NP order and progress note dated 1/3/2013 documented the resident was to receive Allevyn (a type of dressing) to the coccyx (sacrum/buttocks area) and to change the dressing every 72 hours and prn. The open area was documented as a Stage III pressure ulcer which measured 1.0 cm x 1.5 cm. No other documentation in the resident's medical record described this open area as a Stage III.

The resident's Pressure Ulcer Record dated
- 1/6/2013 documented "open abrasions noted to sacrum and buttocks";
- 1/13/2013, the record documented "treatment continues with Allevyn to small open abrasions"; and
- 1/20/2013, documented "continues with current treatment to abrasions, Allevyn dressings."
The resident's Pressure Ulcer Record dated 1/6/2013, 1/13/2013, and 1/20/2013 did not document the stage or size of the pressure ulcer on the resident's sacrum/buttocks.

The Pressure Ulcer Record and a registered nurse progress note dated 1/25/2013 documented:
- three Stage II open areas to the posterior left thigh which were caused by scratching;
- a Stage II open area to the right buttock which measured 1.0 cm x 0.5 cm x 0.3 cm; and
- a Stage II open area to the coccyx which measured 0.5 cm x 0.5 cm x 0.3 cm.
The RN did not stage the pressure ulcers, with depth, as Stage III. There was no further documentation on the Pressure Ulcer Record regarding these ulcers. There was no documented evidence the CCP was updated.

An NP progress note dated 1/25/2013 documented the resident had three Stage II open areas on his posterior left thigh area, one Stage II open area on his right buttock, and one Stage II open area on his coccyx.

An NP order dated 1/25/2013 documented the resident was to receive wound gel (medicated gel to treat wounds) to all open areas on buttocks, A&D ointment to the surrounding tissue and cover with a Telfa (non-stick) dressing, change daily and prn.

The resident's Treatment Administration Record (TAR) documented an Allevyn dressing was applied to the resident's coccyx every 72 hours from 1/4/2013 - 1/25/2013; and wound gel was applied to the open areas on the resident's buttocks, A&D to the surrounding tissue, and covered with a Telfa dressing daily from 1/26/2013 - 2/10/13.

A nursing progress note dated 2/6/2013 documented an open area on the resident's right outer heel which measured 1.2 cm x 1 cm. After the development of the open areas, there was no documented evidence the CCP was updated, a cause was determined, or a plan implemented to prevent worsening.

On 2/7/2013 between 5:45 PM - 6:40 PM the resident was observed in his geri-chair being fed supper and sitting in his room.

When interviewed on 2/8/2013 at 9:30 AM, the registered nurse (RN) Supervisor stated all pressure ulcer assessments were completed by herself or the Director of Nursing (DON). She stated they had not developed a system to determine who specifically performed the assessments.

When interviewed on 2/8/2013 at 10:43 AM, the Director of Nursing (DON) stated pressure wound assessments were performed weekly by either herself or the RN Supervisor. She stated she had not yet developed a schedule to determine who was responsible for skin rounds.

On 2/11/2013 at 10 AM, the surveyor observed the resident's incontinence care provided by two certified nurse assistants (CNA) #6 and #14. The resident's brief was wet and he had been incontinent of stool. After the resident was cleansed there were no open areas or skin breakdown visible, specifically on the coccyx or sacrum. There was a dressing observed on the resident's right buttock and a dressing on the right heel.

On 2/11/2013 at 10:45 AM, the surveyor observed the DON and NP provide wound treatment to the right buttock and right heel.
-The right buttock had a pressure ulcer which was rectangular in shape, approximately 4 cm x 3 cm, 100% red, moist with no drainage, and no odor.
- The right heel had a pressure ulcer which was round in shape, approximately 2 cm x 2 cm, and 100% slough (soft, moist, dead tissue).
The NP stated, to the surveyor, the heel pressure ulcer was a Stage II, and there was maceration (softening of skin) around the ulcer.

The Pressure Ulcer Record dated 2/11/2013 documented the coccyx/sacrum (surveyor observed as right buttock) pressure ulcer was Stage II, 4 cm x 3.2 cm, 100% red, and "resident has old areas of previous healed ulcers on buttocks and sacrum, fragile skin." There was no further progress note or assessment of the pressure ulcer from 1/25/2013 - 2/11/2013. (On 1/25/2013, this pressure ulcer measured 1.0 cm x 0.5 cm x 0.3 cm).

When interviewed on 2/11/2013 at 11:15 AM, the DON stated any open areas or issues with resident skin would be reported initially to the Licensed Practical Nurse (LPN). The LPN would then contact the RN Supervisor or DON. The LPN would also contact the physician or NP.

When interviewed on 2/11/2013 at 1:30 PM, CNA #7 stated he was aware this resident had pressure ulcers, was incontinent and could not move on his own, and staff had difficulty repositioning him in his recliner chair.

When interviewed on 2/11/2013 at 1:40 PM, CNA #6 stated she was aware this resident had pressure ulcers and that he developed them in the facility. She was not sure if they were healing or not.

When interviewed on 2/11/2013 at 2:20 PM, the LPN #6 stated the resident did not have the pressure ulcers very long. She didn't think the resident's nutrition was as good as it used to be and that it was difficult to turn and reposition him when he was in his recliner chair.

3) Resident #11 was admitted to the facility with diagnoses of vascular dementia, coronary artery disease, and hypertension.

The Pressure Ulcer Risk Assessment Tool dated 12/10/2012 documented the resident was at risk for developing pressure ulcers.

The comprehensive care plan dated 12/18/12 documented the resident had peripheral vascular disease with potential for pain and skin breakdown.

The Minimum Data Set (MDS) assessment dated 12/31/2012 documented the resident's cognition was severely impaired, he was dependent on staff for most activities of daily living (ADLs), was at risk for pressure ulcers, did not have a current pressure ulcer, and used a pressure relieving device in the bed and chair.

The CCP dated 1/2/13, documented the resident developed an ulcer on the left heel, which was documented as healed on 1/10/13. There was no documentation, in the CCP of preventative interventions for the resident's heels.

On 2/5/2013 at 10 AM, licensed practical nurse (LPN) Manager #1 stated in an interview, the resident did not have a pressure ulcer.

The Resident Status Sheet (CNA care instructions) dated 2/7/13 documented the resident was to wear heel protectors at night.

The 2/2013 Nursing Assistant Clinical Accountability Record used by the certified nurses aides (CNA), had no documentation of interventions used for pressure ulcer prevention.

The resident was observed on 2/8/13 at 9:55 AM sitting in a wheelchair near the nurses station wearing his shoes and socks. At 11:05 AM the surveyor saw a gauze dressing on the resident's left lower leg. The registered nurse (RN) Supervisor stated she did not know the reason for gauze dressing.

On 2/8/13 at 12:10 PM, a surveyor and the RN Supervisor observed the resident's skin:
- left heel unstageable pressure ulcer measuring 2 cm x 2 cm with "gray spongy" eschar (dead tissue) measuring 1 cm x 0.7 cm in the center; and
- right foot Stage I measuring 3 cm x 3 cm with the center brown measuring 0.6 cm x 0.2 cm;
- the gauze wrap and dressing were removed from the left lower leg, there was green drainage noted halfway up the left leg. The RN Supervisor stated the dressing must have been over the resident's left heel ulcer and had fallen off. She stated the resident's plan included heel protectors and he should be wearing them.

On 2/8/2013, the nurse practitioner (NP) ordered skin prep to the resident's left heel every shift for an unstageable pressure ulcer.

On 2/11/2013 at 8:55 AM CNA #12 stated in an interview, if she saw an issue with a resident's skin she would go to the charge nurse. She stated to her knowledge, routine skin checks were not done on all residents.

On 2/11/2013 at 9 AM, CNA #7 stated in an interview, he looked at residents' skin every 2 hours when he provided care and let the nurse know if there was a concern.

On 2/11/2013 at 9:05 AM, LPN #5 stated in an interview the charge nurse checked 8 residents' skin each day Monday through Friday. She stated none of these skin checks were documented.

10NYCRR 415.12(c)(1)(2)

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

Scope: Widespread

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure the Director of Nursing (DON) functioned as the DON on a full-time basis. Specifically, at the time of the survey, the DON had responsibilities including completing accident/incident reports and investigations, developing/updating residents' comprehensive care plans (CCP), completing admission assessments, assessing wounds, completing risk assessments, completing Minimum Data Set (MDS) assessments, assessing residents after falls or incidents, overseeing infection control, administering treatments, and administering medications. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The review of the facility's FSR (Facility Survey Report), signed on 2/5/2013 by the Supervising Administrator documented the DON had no other responsibilities in the facility in addition to the role of DON.

During an interview with the DON on 2/7/2013 at 9:40 AM, she stated she was responsible for updating residents' comprehensive care plans (CCP) following incidents/accidents, ensuring interventions were carried out, reviewing all accident and incident reports, and conducting investigations into incidents. She stated she was trying to delegate the updating of resident's CCPs to the Supervisors and at the time there was 1 registered nurse (RN) Supervisor.

During an interview with the DON on 2/12/2013 at 9:55 AM, she stated she was responsible for coordinating nursing staffing. She stated she resided in the facility for 5 days straight, then went out of town for 2 days. She stated when she was in town, she received calls on the evening and night shifts and responded to the resident units to address issues or assess residents following falls or incidents. She stated her responsibilities included updating resident CCPs, assessing wounds, supervising nurses, checking physician's orders, completing and overseeing the Minimum Data Set (MDS) assessments, investigate incidents and accidents, providing inservices to staff, and feeding residents. She stated occasionally she would also administer medications and treatments. She stated other responsibilities included overseeing infection control, completing admission assessments, and completing all risk assessments (elopement, skin, pain, abuse, pressure, urinary/bowel, fall, and restraints).

10NYCRR 415.13(b)(1)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

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

Based on observation, record review, and staff interview conducted during the standard and abbreviated survey (NY00122263), it was determined for 11 of 16 residents (Residents #6, 7, 8, 9, 10, 13, 14, 17, 18, 19, and 20) reviewed for activities of daily living (ADLs) and 12 residents outside of the sample (Residents #22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, and 35), the facility did not ensure residents who required assistance with ADLs received the necessary assistance. Specifically, Resident #14 had a significant, unplanned weight loss and was not provided with adequate ADL assistance to maintain good nutrition; Resident #10 was not provided with assistance with foot care, and Residents #6, 7, 8, 9, 13, 17, 28, 19, 20, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, and 35 were not provided assistance to maintain good grooming and personal hygiene including assistance with shaving, changing soiled clothing, washing/brushing their hair, cleaning soiled shoes, and/or cleaning soiled glasses. 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 including dementia and glaucoma.

The Nutrition Weight Record documented the resident's weight was stable between 130 and 133 pounds from January to June of 2012. The resident weighed 125 pounds in July of 2012, and 116.4 pounds in August 2012.

The 8/31/2012 registered dietitian's (RD) assessment documented the resident had a significant, unplanned weight loss and ongoing weight loss was "not indicated." The resident ate 21% at meals, had regular complaints of hunger, fed herself after set-up "with increased encouragement and cueing," ate in the dining room, and received high calorie foods/fluids at and between meals. The RD documented she discussed with direct care and nursing staff the need to encourage the resident to consume the supportive nutrition provided.

Nursing progress notes documented on 9/1/2012, 9/2/2012, 9/3/2012, and 9/15/2012, the resident's appetite was poor.

The Nutrition Weight Record documented the resident was weighed weekly in September 2012 and weights included: 115.4 pounds, 113. 8 pounds, 112.7 pounds, and 111.7 pounds.

The 9/26/2012 RD's assessment documented the resident continued with poor intake, weight loss, and consumed 16% at meals. The resident continued with high calorie foods/fluids between meals, including a new order for Ensure (a supplement) with medication passes. Direct care staff were aware of the importance of providing and encouraging nutrition interventions.

The 10/25/2012 RD's assessment documented changes were made to the resident's meal plan and "success with interventions is dependent upon acceptance/consumption."

The 11/8/2012 Minimum Data Set (MDS) assessment documented the resident usually understood others, was usually understood, had highly impaired vision, had severely impaired cognition, had a poor appetite almost daily, resisted care, needed extensive assistance for eating, and had a significant, unplanned weight loss.

The 11/8/2012 and 11/9/2012 MDS nurse's progress notes documented the resident had a significant change related to a decline in activities of daily living (ADL) and now preferred to stay in bed all the time. The nurse attempted to complete MDS interviews with the resident and the MDS nurse documented the resident was not able to remember information discussed 5 minutes prior.

The comprehensive care plan (CCP) dated 11/14/2012 documented the resident needed "limited assistance" with eating, refused meals at times, scored a "0" on the Brief Interview for Mental Status (BIMS), and had anorexia of aging/unintended weight loss. The resident was to be re-approached "as needed" when she refused meals, was to be provided with planned supplements, and her family was encouraged to bring in her preferred foods.

The 11/19/2012 nurse practitioner's (NP) progress note documented the resident had a decline in nutritional status which was a natural outcome of dementia. The NP documented she would be provided with supportive care and her care plan would be adjusted accordingly.

The 11/21/2012 RD's assessment documented the resident weighed 106 pounds, ate minimal solids, and received calories in excess of her needs via the meal plan.

The 11/29/2012 NP's progress note documented the resident had failure to thrive and anorexia and the plan included encouraging intake.

The 12/7/2012 RD's assessment documented the resident weighed 105.2 pounds, was "refusing most meals," and the resident's family member provided updated food preferences.

The 12/8/2012 nursing progress note documented the resident refused foods.

The Nutrition Weight Record documented the resident weighed 102.8 pounds in January 2013.

Nursing progress notes documented on 1/6/2013, 1/21/2013, 1/23/2013, and 2/5/2013, the resident had a poor appetite and refused meals.

The current certified nurse aide (CNA) care instructions was dated as last revised on 11/14/11, did not include information addressing the resident's feeding ability or where she ate her meals.

The February 2013 CNA Accountability Record and Assignment documented the resident needed both "intermittent assist" and "continued supervision/assist" at meals.

On 2/5/2013 at 1:05 PM, a cart of lunch trays, including the resident's, was delivered to the unit. At 1:20 PM, CNA#3 delivered the lunch tray to the resident's room, placed it on the overbed table, poured a milkshake into a glass, and immediately left the room. The resident remained lying in bed, covered up and appeared to be sleeping. At 1:35 PM, the CNAs were observed picking up other residents' lunch trays placing them on the meal cart. The resident's tray remained on the overbed table and no staff entered the room since the tray was delivered. When the surveyor left the unit at 1:48 PM, the resident's tray remained on the overbed table and no staff had entered the room since the tray was delivered at 1:20 PM.

On 2/5/2013 at 2:45 PM and 3:10 PM, the resident was observed lying in bed, covered up.

On 2/6/2013 at 9:50 AM, the resident was observed lying in bed, covered up. When the surveyor entered the room the resident asked for a drink. The surveyor asked CNA #3 who gave the resident a vanilla milkshake. The resident drank the whole thing and asked the surveyor how she could get more. The resident's call bell was on an upholstered chair next to her bed and was not within her reach. The surveyor asked the resident if she wanted her call bell so she could ask staff for more and the resident said no, one was enough.

On 2/6/2013 at 6:10 PM, the resident was observed lying in bed, covered up, the room was dark, and the resident's supper tray was on the tray table. The tray table was positioned over the resident who was lying down in bed. The resident woke up when the surveyor knocked on the door. The surveyor asked the resident if she was going to eat and the resident was not aware the tray tale was positioned across her body with her supper on it.

On 2/6/2013 at 6:10 PM, CNA #10 stated she delivered the resident's supper tray. She stated the resident was "legally blind, could see a little, and was very confused." She stated the resident could feed herself so staff "bounce in and out and encourage her." CNA #10 sat down with the resident until 6:12 PM, when she left the room to assist another resident. At 6:20 PM, no staff had entered the resident's room, the resident drank her glass of milk, laid down in the bed and covered herself up. No food was eaten at that time.

On 2/7/2013 at 6:11 PM, a CNA (unidentified) was observed sitting in the resident's room, telling her what was on her supper tray. The resident's room was dark, the lights were not on. At 6:14 PM, the CNA left the room and as she as leaving, she turned the light on. Between 6:14 PM and 6:25 PM, no staff had entered the resident's room. At 6:25 PM, the surveyor entered the room and asked the resident if she received enough food. The resident stated she did not receive a meal yet. The resident's meal was on the table in front of her. The surveyor asked the resident if she was going to eat and the resident stated "have I got anything?" On the resident's table was her supper tray, untouched. The resident's call bell was not within reach. At that time, the CNA entered the room and asked the resident if she was going to eat. The resident stated "how can I eat nothing?" The CNA told her she had a supper tray and the resident asked "I do." The CNA sat on the edge of the bed and began telling the resident what was on the tray.

On 2/11/2013 at 3:30 PM, the LPN Manager (LPN #2) stated in an interview, the resident used to work the night shift and woke up at 4:30 or 5 PM. She stated the resident continued to do this, walked the halls at that time and ate. She stated the resident refused breakfast and lunch daily as a result and ate supper. She sometimes ate in the dining room and that "depends on her mood." She stated she fed herself and if she was oriented to the food at the beginning of the meal she could remember it for the entire meal.

On 2/11/2013 at 4:15 PM, the RD stated in an interview, the resident spent a lot of time in her room and ate meals in her room. She stated she made many changes to the resident's meal plan over the past several months. The RD said to her knowledge, the staff made attempts to feed the resident and the resident refused many meals.

2) Resident #10 was admitted to the facility with diagnoses including chronic kidney disease, coronary artery disease and hypertension.

The resident's Minimum Data Set (MDS) assessment, dated 1/10/2013 documented the resident was severely cognitively impaired, required extensive assistance of 1 or 2 staff for most activities of daily living, and did not resist care.

The comprehensive care plan (CCP) dated 1/23/2013, documented the resident needed extensive assist with bathing and personal hygiene. The resident had a potential for skin breakdown and staff was to inspect skin with morning and evening care and when bathing. The staff was to keep the resident's skin clean and dry.

The Nursing Assistant Clinical Accountability Record and Assignment dated 2/2013 documented the resident received a shower on the 3-11 shift on 2/1/2013 and 2/5/2013.

On 2/8/2013 at 10:30 AM, observation of the resident's feet were done with the registered nurse (RN) Supervisor. After the RN removed the resident's left sock, dirt was observed between the resident's second and fourth toes, and dirt was observed between all toes on the right foot. The RN and CNA (who was present) stated the staff should be cleaning between the resident's toes when he was washed or bathed. The resident was observed by the surveyor to have long nails on both feet. The resident stated at that time he would allow the staff to cut his nails if they offered.

3) Resident #17 had a diagnosis of multiple sclerosis and muscular dystrophy.

The resident's Minimum Data Set (MDS) assessment, dated 1/3/2013, documented the resident's cognition was intact, she rejected care 1 to 3 days, and required extensive assistance with personal hygiene.

The comprehensive care plan (CCP) dated 1/16/2013 documented the resident had a self care deficit with bathing, hygiene, dressing, and grooming, would bathe twice per week, dress appropriately, be well groomed and comfortable with proper hygiene maintained. The resident required extensive assistance with personal hygiene and bathing.

Observations on 2/5/2013 at 12:45PM at 3:10 PM, showed the resident's hair that was unkempt and not clean looking.

On 2/6/2013 at 9:05 AM during the resident group meeting, the resident stated there was not enough staff to assist her with showers.

On 2/7/2013 at 5 PM, certified nurse aide (CNA) #13 stated in an interview this resident was supposed to take a shower every day, which alternated between the day and evening shift. She stated some days "we can't get to her because of staffing." She stated residents were showered according to a schedule kept in front of the nursing assistant accountability book. She stated most residents were showered on the day and evening shift and if they were not scheduled for a shower on a particular day, they were given a total bed bath in the morning and again in the evening. The total bed bath included a wash of the face, hands, top half of body, perineal area, and back. She stated if a resident refused a shower, they were re-approached later and offered the shower again. If they continued to refuse, the charge nurse would be notified and the refusal was documented in the accountability book. Residents' hair was maintained by a hairdresser if the resident had money or a shampoo was given on shower day. Shaving was provided daily in the morning, sometimes on the evening shift, on shower day or any other time they would need it. Dirty clothes were put in the soiled utility room.

On 2/8/2013 at 11:15 AM, CNA #7 stated in an interview this resident was showered on the night shift and he had never assisted her with a shower. He stated residents were scheduled a shower twice a week, divided between the day and evening shift. He stated he was not able to give two showers per week per resident and at times wasn't able to complete showers once a week due to resident refusals or combativeness. For residents not scheduled for a shower, they were washed during morning and evening care which included a wash of the face, chest, underarms, and perineal area. When a resident refused care, he would try to get a female CNA to assist the resident and if the resident still refused, he would let the charge nurse know. Residents' hair were brushed during morning care and shaving was provided as needed and at least once per week. Dirty clothes were sent to the laundry.

On 2/8/2013 at 11:25 AM, the resident was observed sitting in the hallway by the nurse's station. Her hair was unkempt.

The 2/2013 Nursing Assistant Clinical Accountability Record and Assignment for hygiene care completed did not have documentation 2/7/2013 - 2/10/2013 on the day shift, and 2/5/2013 - 2/10/2013 on the night shift.

10NYCRR 415.12(a)(3)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on observation, staff interview and record review conducted during the standard survey, it was determined for 4 of 4 residents (Resident #6, 11, 16, and 18), reviewed for side rail use, the facility did not ensure residents had the right to be free from physical restraints imposed for purposes other than to treat medical conditions. Specifically, Resident #6 had side rails without an order, without a medical need, and without documented evidence the resident could use side rails for positioning. Resident #11 had side rails that were not included in the plan of care, and the use of side rails was not reassessed following a fall when the resident's arm was stuck in the side rail. For Resident #16, the facility did not accurately implement the physician's order for side rails and the side rails were not documented in the plan of care. Resident #18 had a side rail that was not included in the plan of care and there was no physician's order for the use of the side rail. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #11 had diagnoses including impulse control disorder, anxiety, and dementia.

Nursing progress notes between 8/21/2012 and 10/31/2012 documented the resident wandered, went in to other residents' rooms, yelled, grabbed at staff and other residents, and had repetitive statements and questions. There was no documentation regarding the use of side rails.

Nursing progress notes between 11/1/2012 and 11/25/2012 documented, the resident attempted to self transfer, alarmed his protective alarm system (PAS) multiple times, yelled/grabbed others, and had increased anxiety. There was no documentation regarding the use of side rails.

A nurse practitioner's progress note (NP) dated 12/13/12, documented the resident was extremely restless, had anxiety, aggression, depression, delusions, dementia and an impulse control disorder.

A nursing note dated 12/18/2012, documented the resident returned from a hospital after a surgical intervention to his hip following a fall.

A physical therapy note (PT) progress dated 12/19/2012 had no documentation regarding the use of side rails.

The Minimum Data Set (MDS) assessment dated 12/31/2012, documented the resident did not have a restraint, had severely impaired cognition, exhibited inattention, disorganized thinking, and altered level of consciousness during the assessment period. The resident was dependent staff for most activities of daily living (ADL).

Nursing progress notes between 1/3/2013 and 1/15/2013, documented the resident was found lying on the floor and was unable to use the call bell related to confusion.

The comprehensive care plan (CCP) dated 1/16/2013, documented the resident had a history of repetitive behaviors, including taking things apart, unmaking the bed, and a history of being non-complaint with safety measures. The CCP documented on 1/14/12 the resident was found on floor lying on their side with slight redness scrape to the right elbow. On 1/19/2013 the CCP documented the resident was found sitting on floor and a floor mat was to be placed next to bed.

The Accident/Incident report dated 1/14/2013 documented the resident fell, had a side rail in place at the time of the fall, and was "non complaint with safety measures."

A nursing note dated 1/19/2013 documented the resident was found sitting on floor in the room next to bed with the PAS attached. The resident slid out of bed and his arm was caught in the side rail. He sustained right upper arm redness.

A NP's progress note dated 1/21/2013 documented the resident had a small abrasion on the back and upper right arm from a fall. Recommendations included to "continue him on fall precautions. We cannot discuss fall prevention with him secondary to his dementia and his inability to understand. We will continue monitoring."

The February 2013 certified nurse's aide (CNA) assignment record had no documentation the resident had a side rail in place.

The physician's orders dated 2/4/2013, documented the resident had a PAS and a semi low bed against the wall. There was no documentation regarding the use of side rails on the physician orders.

The resident Status Sheet, used by the CNAs to direct care, dated 2/7/2013, documented "Half siderails", without specification of one or two 1/2 side rails.

The resident was observed on 2/12/2013 at 9:50 AM and 10:42 AM lying in bed with a 1/2 side rail in the up position.

During an interview with CNA #1 on 2/12/2013 at 12:36 PM she stated the resident had confusion, required help with all of his ADLs, was at risk for falls, and used the side rail to pull himself if needed.

During an interview with the licensed practical nurse (LPN) Manager, LPN #1, on 2/12/2013 at 1:30 PM she stated the resident was very confused and severely demented. She said the resident had a 1/2 side rail up on his bed that was used for bed mobility and the resident was able to understand verbal cues to assist with positioning. She stated there should be an order for the 1/2 side rail and there was not. LPN #1 stated side rails could be applied to a resident at any time by nursing after they obtained a physician's order. The use of a side rail was then documented on the CCP and in the nursing notes, and the team would review side rail use quarterly. After reviewing the record, LPN #1 stated the resident was found on the floor on 1/19/13, she did not recall the event, and the the residents arm was "wedged in the side rail" per the note. LPN #1 stated without checking the incident report she did not know what was done following the incident. She stated she did not see an order for changes to be made to the plan of care.

The Director of Nursing (DON) provided the 1/19/2013 incident report on 2/12/2013 at 3:15 PM. The report contained no documentation the resident's side rails were reviewed and reassessed for appropriateness following the incident.

2) Resident #6 had diagnoses including dementia, Parkinson's disease, and hypertension.

A nursing progress note dated 11/26/2012, documented any "physical or verbal stimulation sends him into involuntary motion", and to monitor him for safety. There was no documentation regarding the use of side rails.

Nursing progress notes documented:
- on 11/27/2012, documented the resident was "very shakey and throwing himself around the bed against the wall" and he was swinging arms at staff during care;
- on 11/29/2012, the resident tipped over a tray table, threw bedding, and was shaky;
- on 11/30/2012, the resident was agitated; and
- on 12/1/2012, a protective alarm system (PAS) was applied for safety.

An accident/incident reported dated 12/1/2012 documented the resident was found next to his bed, it documented "N/A" in regards to the use of side rails.

Nursing progress notes documented:
-on 12/5/2012, the resident required total assist for all activities of daily living (ADLs);
- on 12/6/2012, the resident was found sitting up in bed, set off his alarm, leaned forward, and was non-compliant; and
- on 12/9/2012, the resident attempted to stand.

An accident/incident report for a fall dated 12/12/2012 documented the resident did not have side rails.

The resident's comprehensive care plan (CCP) updated 12/12/2012, documented the resident had cognitive impairment, could be combative with care, had impaired safety awareness, was unable to comprehend use of a call bell, and to assure adaptive devices are used as indicated, and had bi-lateral half side rails in bed to aide with bed mobility.

The Interim Plan of Care (undated) attached to the comprehensive care plan, had no documentation regarding the use of side rails.

A nurse practitioner note dated 12/20/2012, documented the resident had a history of confusion, and dementia with numerous falls.

An accident/incident report dated 12/22/2012 documented the resident was found in his room on the floor and documented side rails as "N/A"

Nursing progress notes documented:
- on 12/23/2012, the resident was attempting to climb out of bed, and was combative;
- on 1/3/2013, the resident did not use a call bell due to confusion and had been exiting his bed late evening shift;
- on 1/6/2013, the resident attempted to transfer self; and
- on 1/8/2013, the resident was found on the floor next to his bed.

A physician's progress note dated 1/8/2013, documented the resident was on fall precautions, had 2 falls "last night" and was expected to have "further decline in cognitive and functional status as consistent with the natural course of his dementing illness." He would be closely monitored and his care and treatment plans would be updated.

An accident incident report for a fall dated 1/8/2013 documented the resident had a half side rail up.

The Minimum Data Set (MDS) assessment dated 1/15/2013, documented the resident's cognitive skills were moderately impaired, the resident had physical and other behavioral symptoms 1 to 3 days during the assessment period, and required total dependence with one to two persons physical assist for most activities of daily living (ADL). The resident did not have a bed rail.

A nursing note dated 1/18/2013, documented the resident was found on the floor in his room on his knees.

The 2/2013 certified nurse aide (CNA) accountability record had no documentation regarding the use of side rails.

The current physician's orders dated 2/1/2013, had no documentation the resident was to have side rails.

The resident's current resident status sheet (undated), posted in the resident's room to direct care givers, had no documentation regarding the use of side rails.

Observations of the resident during survey included:
- on 2/6/2013 at 9:50 AM, the resident was lying in bed on his left side. The resident's bed was against the wall and there were 2 half side rails raised on the bed;
- on 2/6/2013 at 10:14 AM, the resident was lying in bed with 2 half side rails up. The resident was seen again between 10:14 and 11:05 am, in bed with a half side rail up on the left and right side of the bed; and
- 2/6/2013 at 10:55 AM, the resident was observed to sit himself up in bed. Two side rails were raised on the bed, the resident stood himself up, his alarm sounded and staff responded.

During an interview with CNA #4 on 2/6/2013 at 11:15 AM, she stated the resident had side rails, and they were to be up whenever he was in bed. She stated they were in place as resident was rolling when he was first admitted.

During an interview with CNA #3 on 2/6/2013 at 11:25 AM she stated the resident had "side rails", that the resident's cognition fluctuates, and that he attempts to get up on his own.

The resident was observed on 2/6/2013 at 3 PM in bed with a half side rail up on the left and right side of the bed.

During an interview with the physical therapist on 2/7/2013 at 8:50 AM, he stated therapy was involved with the initiation of side rails, they offer suggestions for when to use them, and notified maintained to install them. He stated side rails may be placed if the resident had a fall as side rails "reduces risk significantly, protects them, and keeps them in bed." He was not sure if the facility used side rails if a bed was against the wall, or if a resident had a low bed, as it could be a risk of injury during transfer. He stated side rails were "not necessarily" labeled a restraint and he did not feel they were a concern for entrapment. He stated all side rails should be documented on the CCP and interventions, including side rails, would be discussed at the facilities morning meetings. He said if the resident had a bed against the wall, the resident should only have 1 side rail up, not two, and he was not aware the resident had 2 1/2 side rails up. He said the resident was not alert and was not aware of why the side rails were in place. He stated the resident had side rails to prevent falls.

During an interview with the licensed practical nurse (LPN) Manager, LPN #2, on 2/7/2013 at 9:40 AM, she stated that the resident had hallucinations on admission, that he was a "night" person. She stated the resident had side rails to help with safety awareness and to hold the "urinal." She stated that a registered nurse (RN) would do an assessment for restraints, and that the resident had one half side rail on the bed at this time.

During an interview with the Director of Social Work on 2/8/2013 at 11:45 AM she stated side rails were reviewed and sometimes used for enabling and mobility. She stated that it was nursing and therapy that initiated the side rails, but that it was the interdisciplinary team that reviewed their use.

During an interview LPN #2 on 2/11/2013 at 3:30 PM, she stated side rails were discussed in morning meetings and were used for mobility and for hanging "urinals." She stated nursing was able to obtain telephone orders for side rails and they were reassessed. She stated residents were asked "does this help you?" when side rails were reassessed. She stated this was done quarterly and written in the nursing progress notes.

During an interview with LPN #1 on 2/1/2013 at 1:30 PM, she stated residents with side rails should have an order for them, side rails should be documented on the CCP and in the nurses notes. The use of side rails should be discussed at morning meeting, and when the CCP was reviewed quarterly.

3) Resident #18 had diagnoses including recurrent falls, anxiety, psychosis, and dementia.

The nursing progress notes dated 11/05/2012 to 11/23/2012, documented the resident was alert with confusion, made attempts to transfer self, and detached his personal alarm system frequently. The nursing note did not document the use of side rails.

The most current occupational therapy note in the resident's medical record dated 11/23/2012 had no documentation regarding the use of side rails.

Nursing notes dated 11/23/2012 to 12/12/2012, documented the resident was alert with confusion, continued to make attempts to transfer self, and detached his personal alarm system frequently. The nursing note did not document the use of side rails.

The Minimum Data Set (MDS) assessment dated 12/13/2012, documented the resident was severely cognitively impaired, required limited to extensive assistance for most activities of daily living (ADL), had a fall during the assessment period, and did not have a bed rail.

Nursing progress notes dated 12/13/2012 to 12/20/2012 had no documentation regarding the use of side rails.

A nurse practitioner's (NP) progress note dated 12/20/2012 documented the resident had a history of falls, was on fall precautions and "because of his poor memory and his dementia, he does not remember our instructions." The plan was to continue him on safety equipment and monitor. The NP note did not document the use of side rails.

The nursing notes dated 12/21/2012 to 1/3/2013 documented the resident was alert with confusion, made attempts to self transfer and did not document the use of side rails.

An NP's note dated 1/3/2013 documented the resident was attempting to transfer himself from the bed to the chair and tripped and fell. The NP did not document the use of side rails.

Nursing notes dated 1/3/2013 to 1/10/2013 documented the resident was alert with confusion and made attempts to self transfer. There was no documentation regarding the use of side rails.

The current physician orders dated 1/10/2013 had no documentation regarding the use of side rails.

The NP's note dated 1/10/2013 documented the resident had recurrent falls, and abrasions secondary to his unawareness of safety. That he attempts to get out of his bed without assistance, and that he did not have physical restraints. There was no documentation regarding the use of side rails.

The comprehensive care plan (CCP) updated 1/12/2013, documented the resident continued to make poor choices, was non compliant with safety measures, and had no documentation regarding the use of side rails. The Interim Plan of Care (undated) attached to the CCP had no documentation regarding the use of side rails and document for physical restraint "N/A"

Nursing notes dated 1/12/2013 to 1/28/2013 documented the resident was alert with confusion and made attempts to self transfer. There was no documentation regarding the use of side rails. There were no nursing notes after 1/28/2013.

During an interview with the physical therapist on 2/7/2013 at 8:50 AM, he stated therapy was involved with the initiation of side rails, offered suggestions for their use and notified maintenance to install. He stated side rails may be placed if the resident had a fall. He was not sure if the facility used side rails if a bed was against the wall, or if a resident had a low bed, as it could be a risk of injury during transfer. He stated side rails are "not necessarily" labeled a restraint, that he did not feel they were a concern for entrapment. He stated all side rails should be documented on the CCP, but that interventions, including side rails, would be discussed at the facilities morning meetings. He said if the resident had a bed against the wall, the resident should only have 1 1/2 side rail, not too, and he was not ware the resident had 2 1/2 side rails up. He said the resident was not alert and was not aware of why the side rails are in place. He stated the resident has side rails to prevent falls currently.

The resident was observed in his room, in bed, on 2/8/2013 at 9:36 AM, with a half side rail up.

During an interview with the Director of Social Work on 2/8/2013 at 11:45 AM she stated that she was involved with restraints and side rails. she said they were reviewed, and are sometimes used to enable and mobility. She stated that it was nursing and therapy that initiated the side rails, and the interdisciplinary team reviewed their use.

During an interview with CNA #5 on 2/8/2013 at 11:35 AM she stated the resident had 1 half siderail and his bed against the wall. his side rail was used for "movement."

The resident was observed on 2/11/2013 at 9:28 AM and 11:20 AM in bed, with a half side rail up.

During an interview with licensed practical nurse (LPN) #2 on 2/12/2013 at 2:45 PM she stated the resident was alert with "interim confusion" and that he had a half rail at night to hold his "urinal."

10NYCRR 415.4(a)(2-7)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure food was prepared under sanitary conditions on 1 of 3 days of kitchen observations, February 6, 2013. Specifically, two turkey roasts were not cooled by an approved method (cooling was not done by a method to allow timely cooling). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

A surveyor observed 2 boneless turkey roasts, approximately 10 pounds each, cooling in the walk in refrigerator on February 6, 2013 at 3:42 PM. The 2 roasts were in a full pan with the cooking liquid, uncut, and loosely covered with aluminum foil. The temperature of one roast was 167 degrees F, and the other roast was 157 degrees F.

The surveyor observed the 2 boneless turkey roasts again on February 6 at 4:30 PM. There was no change in the cooling process. The temperature of one roast was 175 degrees F, and the other roast was 164 degrees F.

The Food Service Director/Cook was interviewed on February 6, 2013 at 4:30 PM. She observed the cooling turkey roasts, and stated the cooling process observed for the 2 turkey roasts was the normal cooling process, and the turkey would be cooled, then sliced the following morning.

A facility invoice from a food vendor dated February 6, 2013 documented the 2 turkey roasts were 11 pounds each (raw weight).

10NYCRR 415.14(h), 14-1.40(b)

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

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

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.

Citation date: February 12, 2013

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for residents on 2 of 2 nursing units, including Residents #6, 7, 8, 9, 10, 13, 14, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, and 12 anonymous residents at the group meeting, the facility did not have sufficient staff to provide nursing related services to attain or maintain the highest practicable physical well-being of each resident. Specifically, deficiencies were identified in the area of activities of daily living (ADL, F312) affecting Residents #6, 7, 8, 9, 10, 13, 14, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, and 12 anonymous residents which resulted from insufficient nursing staffing This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During interviews with the licensed practical nurse (LPN) Manager of Unit 2 (LPN #1) and the registered nurse (RN) Supervisor on 2/5/2013 between 10 AM and 10:30 AM, the following was reported:
- There were currently 38 residents residing on Unit 2 and 37 residents residing on Unit 1.
- The LPN Manager (LPN #2) for Unit 2 was assigned to administer medications and treatments on Unit 2 that day. There was not a second LPN scheduled.
- There were 3 certified nurse aides (CNAs) assigned to each unit that day.

The Resident Census and Conditions of Residents (CMS-672) signed by the Director of Nursing (DON) on 2/6/2013 documented:
- the facility's census was 75 residents;
- there was 1 resident with a pressure ulcer;
- there were 4 residents who were independent with ambulation;
- there were between 52 and 68 residents who needed help from 1 or 2 staff with bathing, dressing, transferring, toilet use, and/or eating.

ACTIVITIES OF DAILY LIVING:
Residents #6, 7, 8, 9, 10, 13, 14, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, and 35, were observed throughout survey and were not provided with necessary ADL assistance. Resident #14 experienced a significant, unplanned weight loss and was not provided with the needed assistance to maintain good nutrition. Resident #10 was not provided assistance with foot/nail care, and Residents #6, 7, 8, 9, 13, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, and 35 were not provided with assistance maintaining good grooming and personal hygiene including assistance with shaving, changing soiled clothing, washing/brushing their hair, cleaning dirty shoes, and/or cleaning dirty glasses. Refer to F312.

At the resident group meeting on 2/6/2013 at 9 AM with 12 anonymous residents in attendance, multiple residents stated there were not enough direct care staff to meet their care needs timely. One resident stated she often was not provided with a shower as planned as a result of low staffing levels.

INTERVIEWS:
- on 2/7/2013 at 5:00 PM, CNA #13 stated in an interview, some residents did not receive showers as planned as a result of "staffing."
- on 2/8/2013 at 11:15 AM, CNA #7 stated in an interview, residents were scheduled to have showers twice a week and this did not always occur related to staffing levels or resident refusals.
- on 2/12/2013 at 12:20 PM, CNA #14 stated in an interview, 3 CNAs were usually scheduled for the day shift. CNA #14 stated yesterday there were 2 CNAs scheduled and 1 was sent out of the facility, for a few hours, to an appointment with a resident. She stated there were 4 CNAs scheduled today so each CNA had around 10 residents to provide care to. She stated when there were 2 or 3 CNAs working it was very difficult to provide all needed care to the residents. She stated showering and grooming were the first things that did not get done when there was not enough staff.
- On 2/12/2013 at 12:30 PM, CNA #12 stated in interview, it was difficult to do a good job and provide all needed resident care when there were not enough CNAs scheduled. She stated there usually 3 CNAs working and that was not enough as each CNA would be responsible for around 12 residents.

On 2/12/2013 at 12:40 PM, LPN #2 stated in an interview the goal was for there to be 3 to 4 CNAs on Unit 2 on the day shift. She stated she scheduled residents' appointment and kept track of them in an appointment book. She stated when she scheduled appointments she tried to have an activities staff, who was a CNA, or an extra CNA go to the appointment with the resident to maintain staffing levels.
Refer to F312.

10NYCRR 415.13(a)(1)(i-iii)

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 20 sampled residents (Resident #20), the facility did not establish and maintain an Infection Control program designed to provide a safe and sanitary environment to help prevent the transmission of disease and infection. Specifically, Resident #20's room was observed with blood spills on the floor, the facility did not clean the blood according to proper infection control techniques, and the facility did not have a policy and procedure directing staff on the proper manner to clean blood spills. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #20 had diagnoses including bladder cancer.

The comprehensive care plan (CCP) dated 4/22/2012 documented the resident refused further treatment for bladder cancer, at times refused to perform activities of daily living (ADL), had an incident where he slipped in spilled urine that was on the floor, and had chronic hematuria (blood in the urine). The resident was to be assisted with toileting as needed, urine spills were to be cleaned up "immediately," the resident was to be monitored for hematuria, the resident was to be provided with urinals in red (isolation) bins and the red bags which were to be changed as needed.

The 12/20/2012 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and needed minimal assistance with toileting.

The 1/24/2013 and 2/3/2013 nursing progress notes documented the resident continued with hematuria.

On 2/5/2013 at 12:20 PM, the resident's room was observed. There was a red isolation garbage can in the room and red stains on the floor.

On 2/8/2013 at 10:30 AM, the resident's room was observed and there were red spills on the floor. The housekeeper was interviewed at that time and stated the red spills were blood, the resident bled on the floor daily as he did not make it to the bathroom on time. She stated when she cleaned the room, she mopped the roommate's side of the room first, then the resident's side of the room. She stated after she was done mopping, she had to change her mop head and water before going to another resident's room. The housekeeper was observed to mop the resident's room and move to the next room when she was done. The housekeeper was observed to clean the next resident's room and mop the floor with the same mop and mop head used in Resident #20's room.

The resident's room was observed on 2/11/2013 at 1:02 PM and there was dark red urine in the urinal that was in the room.

The licensed practical nurse (LPN) Manager (LPN #2) stated in an interview on 2/11/2013 at 3:45 PM, the resident had red isolation bags and a bin in his room and he was to keep his urinal in the red bin and bags as there was blood in his urine. She stated if there were red spots on the floor, nursing or housekeeping would clean them up using a spill kit.

On 2/12/2013 at 10 AM the resident's room was observed with wet, red spills on the floor.

On 2/12/2013 at 10:10 AM, the Director of Housekeeping was interviewed. She stated conflicting information regarding the process for cleaning blood spills. Initially she stated, nursing should clean blood spills using a spill kit and housekeeping should then disinfect the floor with a mop. Later in the interview she stated housekeeping could also use spills kits and clean up blood or could ask nursing to do it for them. She stated the housekeepers should treat the resident's room as an "isolation" room, meaning they should change their mop heads and water before going into another resident's room. The Director of Housekeeping went to the resident's room with the surveyor and observed the spills on the floor. She stated those spills should be cleaned by nursing with a spill kit prior to housekeeping going into the room.

The undated "Daily Cleaning Schedule for Resident Rooms". The cleaning schedule contained no documented instructions for cleaning blood spills in resident rooms and contained no information regarding cleaning "isolation" rooms.

On 2/12/2013 at 10:30 AM, the Acting Administrator stated the facility followed CDC guidelines for cleaning blood spills and did not have a written policy or procedure.

10NYCRR 415.19

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on observation, record review and staff interviews conducted during the standard survey it was determined for 1 of 7 residents (Residents #7), reviewed for swallowing concerns, the facility did not provide food prepared in a form designed to meet individual needs. Specifically, for Resident #7, the facility provided the resident with a mechanical soft diet consistency without an order following a speech evaluation, and did not follow up in regards to the resident's diet consistency following staff concerns. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #7 had diagnoses including bipolar disorder, impulse control disorder, and dysphagia.

Physician's orders, dated 12/31/2012, documented the resident was on puree consistency with nectar thick liquids.

Nursing progress notes documented on 12/31/2012, the resident was on a puree diet with nectar thick liquids.

The initial nutritional assessment, dated 1/4/2013, documented the resident was on pureed with nectar thick liquids per the hospital transfer record. It was recommended a swallowing evaluation be completed to assess the resident's chewing and swallowing ability to assist with assessing appropriate solid consistency and fluid viscosity.

The resident's Minimum Data Set (MDS) assessment, dated 1/7/2013, documented the resident was severely cognitively impaired, the resident required supervision and setup help with her meals and was on a mechanically altered diet.

A physician's telephone order, dated 1/10/2013, documented the resident was to have a swallow evaluation.

A swallowing evaluation, dated 1/10/2013, documented the resident was admitted with the recommendation for puree consistency diet and nectar thick liquids. The speech language pathologist (SLP) recommended, "soft mechanical food consistency" with nectar thick liquids, supervision while dining, and to have several additional sessions to ensure soft is appropriate.

A nutrition note documented by the registered dietitian on 1/10/2013, a swallowing evaluation was completed with the recommendation to upgrade consistency to mechanical soft, continue nectar thickened liquids, and the meal plan was adjusted.

Nursing progress notes, dated 1/10/2013 - 1/15/2013, had no documentation regarding a speech evaluation or the resident's food consistency.

A nurse practitioner (NP) note, dated 1/15/2013, documented "it has been reported to me by the nursing staff that the resident has been having increased coughing during meals. Current diet is nectar thickened fluids, pureed diet."

The resident's comprehensive care plan (CCP), updated 1/16/2013, documented the resident required supervision with eating, was previously on a pureed consistency diet with nectar thickened liquids, and was changed to a mechanical soft diet on 1/10/2013.

The Interim Plan of Care (undated) attached to the CCP, documented the resident was on puree diet with nectar thick liquids.

A social work note dated 1/16/2013 documented the resident's "diet consistency is now mechanical soft."

Nursing notes, dated 1/16/2013 - 2/1/2013, had no documentation regarding a speech evaluation or the resident's food consistency.

The most current physician orders, dated 2/1/2013, documented the resident's diet was pureed.

A NP note, dated 2/1/2013, documented "we did obtain a swallowing evaluation secondary to her dysphagia and she was started on pureed diet with nectar thickened liquids."

The nourishment sheet, used by staff on the unit to clarify residents food and fluid consistencies, dated 2/5/2013 documented the resident was on mechanical soft with nectar thickened liquids.

The resident was observed on 2/5/2013 at 12:37 PM she was sitting in the dining room and had a meal ticket documenting nectar liquids with mechanical soft consistency food. She had mechanical soft chicken on her plate at that time. The resident was observed again at 1 PM and had eaten her entire meal.

On 2/7/2013 at 12:50 PM the resident was observed in the dining room, her meal ticket documented "ground turkey", the resident's plate was almost empty with small pieces of ground turkey on the plate that she was about to consume. At 6:10 PM the residents meal plate was empty and the resident was eating regular consistency lettuce.

During an interview with the licensed practical nurse (LPN) Manager on 2/11/2013 at 11:47 AM and 12 PM, she stated the process to complete orders included:
- nursing calls the physician or NP to obtain resident orders;
- she will fax the physician and/or NP the discharge summary received from the hospital;
- she would read back the orders to the physician or NP;
- she would sign the bottom of the orders; and
- then write a nurses note that the pharmacy was updated.

On 2/11/2013 at 1:02 PM the resident was eating in the dining room, pieces of chicken were left on her plate, the meal ticket read "ground chicken and biscuits" with nectar thick liquids.

During an interview with certified nurse aide (CNA) #6 on 2/11/2013 at 2:25 PM, he stated the resident was on ground mechanical soft diet, sometimes needed cuing at meals, and ate in the dining room.

During an interview with the LPN Manager on 2/11/2013 at 3:30 PM she stated that the resident's current orders documented the resident was on pureed consistency food with nectar thick liquids. There was a swallow evaluation completed on 1/10/2013, and it was recommended to change the resident's diet to soft mechanical food with nectar thickened liquids which was her current diet plan. She stated when a swallow evaluation was completed the SLP copied the evaluation and gave a copy to nursing, the doctor, the NP, and the dietitian. The LPN stated she could not find a physician's order for a mechanical soft diet, but there would have to be an order for a diet change. She stated that a diet consistency change could not be in place until there was a physician's order. She stated the most current diet would be placed on a list located in then nourishment room.

During an interview with the registered dietitian (RD) on 2/11/2013 at 4 PM, she stated the most accurate documentation of a resident's consistency would be the physician's orders. She stated staff on the unit would know the current diet, by viewing a sheet in the nourishment room that lists all resident diets on the floor, and this was updated weekly. She stated that it was possible the pharmacy did not transcribe the order for mechanical soft diet, but that someone should have picked up on that.

During a follow up interview with the RD on 2/11/2013 at 5:20 PM, she stated the resident's order was missed and the NP was taking care of it.

During an telephone interview with the nurse practitioner on 2/12/2013 at 2:22 PM, she stated she did not remember what was written, but that the resident's consistency was changed based on a swallow evaluation. She stated the process to obtain a change would be to talk to the nurse Manager, order a swallow evaluation, the SLP would come in and do the evaluation, and that she goes by the SLP recommendations as "they are the experts."

10NYCRR 415.14(d)(3)

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

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 2 of 3 residents (Residents #8 and 13), reviewed for weight/nutrition concerns, the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, For Resident #8 nutritional recommendations were not implemented and the resident's weight loss was not reassessed timely. For Resident #13, clinical nutrition staff were not notified timely of the resident's pressure ulcers and a nutritional reassessment was not completed timely. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #13 had a diagnosis including hypertension, diabetes, and dementia.

The comprehensive care plan (CCP) dated 10/24/2012 documented the resident had good skin integrity.

A nutrition progress note written by the registered dietitian (RD) dated 10/24/2012 documented the resident's skin was intact and to continue with the current nutritional plan of care which included fortified foods and supplements.

The Minimum Data Set (MDS) assessment dated 12/6/2012 documented the resident's cognitive status was severely impaired and he had no current unhealed pressure ulcers.

The Pressure Ulcer Record (Weekly Pressure Ulcer Assessment) and a nursing progress note dated 1/25/2013 documented 5 pressure ulcers which included:
- 3 Stage II (partial thickness loss of skin layers) pressure ulcers on the left hip neat the buttock;
- 1 Stage II pressure ulcer on the right buttock; and
- 1 Stage II pressure ulcer on the coccyx.
The note documented the treatment was deferred to the physician, Unit Manager, and wound team, and placed on 24 hour report.

There was no documented evidence the resident's CCP was updated to include the development of pressure ulcers.

There was no documented evidence the RD reassessed the resident's nutritional plan of care following the development of the pressure ulcers.

The resident was observed on 2/7/2013 at 5:45 PM in the dining room. He was fed by an unidentified licensed practical nurse (LPN) and had consumed most of his food and drinks.

Licensed practical nurse (LPN) #6 was interviewed on 2/11/2013 at 2:20 PM and stated she was aware the resident had pressure ulcers and a possible cause was the resident's nutrition was not as good as it used to be.

The registered dietitian (RD) was interviewed on 2/11/2013 at 4:00 PM and stated she was not aware the resident had pressure ulcers until "today." She stated she would become aware of pressure ulcers after the Nurse Managers left her a note and the resident should be reassessed if he had pressure ulcers.

2) Resident #8 had diagnoses including generalized weakness and a past hip fracture and surgical repair.

The 12/25/2012 Pressure Ulcer Record documented the resident a Stage II pressure ulcer on the sacrum and an unstageable pressure ulcer described as "blackened/brown peeling skin" on the left buttock.

The 12/28/2012 registered dietitian's (RD) assessment documented the resident was readmitted to the facility on 12/24/2012 following a surgical repair of a hip fracture. The resident's weight was 121 pounds, at the low end of his goal weight, and was stable for the past 9 weeks. The resident had skin issues including a left surgical wound and bilateral denuded areas on the buttocks. The RD assessed the resident's calorie and protein needs to be increased related to the fracture and skin issues. The resident received fortified foods with meals and the RD recommended 60 cubic centimeters (cc) of Ensure (a supplement) 4 times a day with medication passes.

The comprehensive care plan (CCP) updated on 12/28/2012 documented the resident's nutrition problems included skin issues. The interventions included Ensure, 60 cc, 4 times a day with medication passes.

The 12/31/2012 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, fed himself after set-up, and had Stage I and Stage II pressure ulcers.

Review of the medical record contained no documented evidence the Ensure was ordered as recommended by the RD and no documented rationale for not initiating the supplement.

The 1/2013 Nutrition Weight Record documented the resident weighed 120 pounds in the first week of January 2013 and 116 pounds in the second week of January 2013 (5 pound/4% in 1 month). A 2/2013 weight was not recorded on 2/5/2013.

There was no documentation of follow up by the RD after the 12/28/2012 progress note to ensure recommendations were implemented and to address the resident's weight loss.

The resident was observed on 2/5/2013 at 12:40 PM. He received a hot entree of chicken, potato, and corn, a sandwich, and a brownie. The resident stated "I don't like it" when asked about the entree. He ate the sandwich and brownie.

On 2/11/2013 at 4:15 PM, the RD stated in an interview, when she recommended a supplement for a resident she sent a communication form to medical staff and they responded. She stated she made changes to the resident's meal plan to promote increased intake as he had skin issues. In regards to the resident, she was not aware that the Ensure was not ordered for him per her recommendations.

10NYCRR 415.12(i)(1)

Resident #13 had a diagnosis including hypertension, diabetes, and dementia.

The comprehensive care plan (CCP) dated 10/24/2012 documented the resident had good skin integrity. There was no update to the care plan which documented the development of pressure ulcers.

A nutrition progress note dated 10/24/2012 documented the resident's skin was intact and to continue with the current nutrional plan of care which included fortified foods and supplements. There was no update to the nutritional progress notes which documented the development of pressure ulcers.

The Minimum Data Set (MDS) assessment dated 12/6/2012 documented the resident's cognitive status was severely impaired and had no unhealed pressure ulcers.

The Pressure Ulcer Record (Weekly Pressure Ulcer Assessment) and a nursing progress note dated 1/25/2013 documented 5 pressure ulcers which included:
- pressure ulcer #1 (proximal left hip, near buttock) - Stage II, 1.0 cm x 1.0 cm x 0.3 cm, 100 % pink tissue appearance, moist pink wound appearance, white moist periwound appearance, no exudate, and positive for pain;
- pressure ulcer #2 ("just distal" to proximal left hip, near buttock) - Stage II, 1.0 cm x 1.2 cm x 0.4 cm, 100 % pink tissue appearance, moist pink wound appearance, white moist periwound appearance, no exudate, and positive for pain;
- pressure ulcer #3 ("even more distal" to proximal left hip, near buttock) - Stage II, 3.0 cm x 1.0 cm x 0.4 cm, 100 % pink tissue appearance, moist pink wound appearance, white moist periwound appearance, no exudate, and positive for pain;
- right buttock - Stage II, 1.0 cm x 0.5 cm x 0.3 cm, 100 % pink tissue appearance, moist pink wound appearance, white moist periwound appearance, no exudate, and positive for pain;
- coccyx - Stage II, 0.5 cm x 0.5 cm x 0.3 cm, 100 % pink tissue appearance, moist pink wound appearance, white moist periwound appearance, no exudate, and positive for pain.
The progress note documented the treatment was deferred to the physician, Unit Manager, and wound team, and placed on report.

The resident was observed on 2/7/2013 at 5:45 PM in the dining room. He was fed by an unidentified licensed practical nurse (LPN) and had consumed most of his food and drinks.

LPN #6 was interviewed on 2/11/2013 at 2:20 PM and stated she was aware the resident had pressure ulcers and a possible cause was the resident's nutrition was not as good as it used to be.

The registered dietitian (RD) was interviewed on 2/11/2013 at 4:00 PM and stated she was not aware the resident had pressure ulcers until "today." She stated she would become aware of pressure ulcers after nurses left her a note.

F467 483.70(h)(2): FACILITY HAS ADEQUATE OUTSIDE VENTILATION

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: April 12, 2013

The facility must have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two.

Citation date: February 12, 2013

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure mechanical exhaust ventilation was operating throughout the building. Specifically, exhaust ventilation was not operating in part of the center area of Units 1 and 2 when tested. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF 12/15/11.

Findings include:

During environmental rounds on Unit 2 on 2/5/2013 between 1:30 and 3 PM, there was no detectable exhaust ventilation in the soiled utility room, the toilet room and tub room in the bathing suite. Both areas are in the center of the unit. There was a strong unpleasant odor in the soiled utility room.

During environmental rounds on Unit 1 on 2/6/2013 between 11 AM and 12:15 PM, there was no detectable exhaust ventilation in the toilet room, the two shower enclosures in the bathing suite, and in resident room 121. The bathing suite is the center of the unit.

The Exhaust Fan Checklist for January and February 2013 documented the exhaust fans were checked nearly daily in 2013.

Maintenance staff stated to the surveyor on 2/7/2013 at 3:44 PM that a belt on one of the exhaust fans was not working properly and needed to be replaced.

10NYCRR 415.29(h)(1&2)

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

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the resident environment was maintained in a sanitary and orderly manner in 2 of 2 resident units, Units 1 and 2. Specific concerns included soiled nurse call cords, soiled floor surfaces, furniture and wheelchairs in poor condition. This resulted in no actual harm with potential for minimal harm.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF 12/15/2011.

Findings include:

1) Resident #21 had diagnoses including depression and peripheral vascular disease (PVD).

The resident's Minimum Data Set (MDS) assessment, dated 12/13/2012, documented the resident's cognition was intact, that the resident required limited assistance with locomotion on the unit, had impairment with one side of her lower extremity, and used a walker and a wheelchair.

The resident's comprehensive care plan (CCP), updated 12/26/2012, documented the resident was a fall risk and to assure adaptive devices are used as indicated

The resident's current status sheet (used by certified nurse aides to provide care), undated, documented the resident used a wheel chair with leg rests

Resident #21 stated during the resident group meeting on 2/6/2013 at 9:05 AM that her wheelchair brakes were not working properly.

The resident was seated in her wheelchair on 2/7/2013 at 4:10 PM; she stated one of the brakes would release when she stood up from sitting in her wheelchair. She stated she notified maintenance staff the wheelchair brakes were not working properly. The resident was observed to stand from a sitting position in her wheelchair, and the right brake released. The surveyor tested the right brake on the resident's wheelchair three times, and observed the right brake would release when the wheelchair brakes were engaged when the wheelchair was moved or if touched lightly.

Maintenance staff was interviewed on 2/7/2013 at 4:40 PM. He stated the work order book for Unit 1 had been missing for a few days. He stated the resident notified him about the problem with the wheelchair brakes, and he forgot about repairing the wheelchair. He stated maintenance staff would normally repair the wheelchair in the facility.

Unit 1
2) A surveyor observed Unit 1 on 2/6/2013 between 11 AM and 12:15 PM, concerns included:
- The plywood covered dresser near the outside wall and the counter around the sink were patched with yellow patching material. Maintenance staff interviewed during the observation stated it had been patched over 12 months ago and the plan was to resurface the counter in the summer;
- the closet door in room 108 was out of the track;
- a drawer pull was missing from the middle drawer of the freestanding dresser in room 101, and the middle drawer was difficult to open;
- In room 113, a long steel radiator cover (over 10 feet long) was disconnected from the radiator, and part of it was on the floor;
- In room 115, the floor was stained/soiled with brown streaks on the window side and the toilet nurse call cord was stained;
- In room 119, the middle drawer of the dresser was difficult to open; per an interview with maintenance staff during the observation, maintenance was not informed of the problem;
- in room 121, the toilet room nurse call station cover was not fastened to the wall on the bottom, and the radiator cover was not attached at the east end, resulting in a metal projection sticking out from the radiator; and
- In room 120, the finish/veneer of the 2 closet doors were in poor condition at the top, and it was difficult to open the middle drawer of the dresser.

Unit 2
3) A surveyor observed Unit 2 on 2/5/2013 between 10:10 and 10:35 AM; environmental concerns included:
- in the day room on the unit was a large upholstered chair. The upholstery was dirty along the seat of the chair and down the side;
- the sliding door to the bathing suite was scraped; and
- the doorway to the soiled utility room was dented and scraped.

A surveyor observed Unit 2 on 2/5/2013 between 1:30 and 2:30 PM; environmental concerns included:
- resident room 211 had 6 floor tiles on the window side of the room with a dark buildup on the tiles. The surveyor was able to remove the discoloration easily with alcohol. The floor remained soiled during a second observation at 4:30 PM.
- in room 208, the top drawer of the dresser on the window side was difficult to open;
- in room 201, the corridor door did not latched when closed without force; maintenance staff interviewed during the observation stated the facility did not check operation of corridor doors;
- in room 215, one drawer pull was missing from the middle drawer of the dresser and one of Resident #22's wheelchair arm covers was torn; and
- in room 220, the nurse call cord in the toilet room was stained.

The Laundry/Housekeeping Supervisor and Maintenance staff were interviewed on 2/6/2013 between 12 and 12:15 PM. They stated management staff did environmental rounds on the resident units monthly which sometimes generated work requests for them.

10NYCRR 415.5(h)(2)

K76 NFPA 101: MEDICAL GAS SYSTEM

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99 4.3.1.1.2, 19.3.2.4

Citation date: February 12, 2013

Based on observation and staff interview conducted during the standard survey it was determined the facility did not ensure 2 of 3 oxygen storage areas were ventilated, the oxygen storage closets on Unit 1 and Unit 2. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Unit 1
1) A surveyor observed the Unit 1 oxygen storage closet on 2/5/2013 at 10:25 AM. There were 9 full (or partially full) E tanks (small tanks) of oxygen in the closet. There was no ventilation in the closet.
Subsequent observations:
- 9 full (or partially full) E tanks on 2/6/2013 at 12:55 PM
- 10 full (or partially full) E tanks on 2/7/2013 at 10:02 AM and 4:30 PM.

Unit 2
2) A surveyor observed the Unit 2 oxygen storage closet on 2/5/2013 at 2:25 PM. There were 7 full (or partially full) E tanks (small tanks) of oxygen in the closet. There was no ventilation in the closet.
Subsequent observations:
- 7 full (or partially full) E tanks on 2/6/2013 at 12:30 PM.

Maintenance staff confirmed via interview on 2/6/2013 at 12:55 PM that there was no ventilation in the Unit 1 oxygen storage closet.

The surveyor interviewed Maintenance staff on 2/7/2013 at 4:40 PM. He stated the facility stored more oxygen tanks in the resident unit oxygen storage closets than it had stored in the past. He said he did not realize ventilation was required for the oxygen storage closets.

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

K17 NFPA 101: CORRIDOR WALLS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 12, 2013

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

Citation date: February 12, 2013

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure corridors were separated from use areas with partitions in one of 3 floors in the building, the basement. Specifically, the basement corridor was utilized as a storage area for trash and clean linen. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Linen Storage in Corridor
1) A surveyor observed unattended clean linen carts stored in the center area of the basement corridor, as follows:
- three full mobile clean linen carts on 2/5/2013 at 3:45 PM; two carts remained at 4:30 PM;
- two full mobile clean linen carts on 2/6/2013 at 10:50 AM;
- 3 full mobile clean linen carts on 2/6/2013 at 3 PM; one full mobile clean linen cart remained at 3:35 PM; and
- one full cart on 2/7/2013 at 4:30 to 4:45 PM.

A large blue mobile cart full of clean linen was also stored in the west end of the basement corridor on 2/6/2012 at 10:50 AM and 12:48 PM.

The Housekeeping/Laundry Supervisor was interviewed on 2/7/2013 at 4:30 PM. She stated laundry staff placed clean linen carts in the basement corridor around 2:45 PM, near the end of their shift. The linen carts contained the linen supply for the 3-11 nursing shift. Normally, the 3-11 shift nursing staff picked up the clean linen carts shortly after the beginning of their shift. She was not sure why there was still a clean linen cart in the basement corridor that had not yet been picked up.

Trash Storage in Corridor
2) A surveyor observed unattended trash stored in the the basement corridor, as follows:
- one partially full mobile trash cart in the west end of the corridor on 2/5/2013 at 3:45 PM;
- one full mobile trash cart in the side corridor on 2/6/2012 at 10 AM;
- one mobile trash cart in the west end end corridor at 3 PM; a nursing staff person was dumping bagged paper trash into the cart during the observation;
- one part full mobile trash cart in the west end of the corridor on 2/6/2013 at 3:35 PM and 4:19 PM; and
- one full mobile trash cart in west end of the corridor on 2/7/2013 at 4:30 to 4:45 PM, full of cardboard.

Maintenance staff was interviewed on 2/7/2013 at 4:40 PM. He stated he was not aware regulations did not allow trash storage in the corridor. He stated the 3 PM - 11 PM shift nursing staff did not take trash outside, they discarded trash into the cart in the basement corridor.

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