Chestnut Park Rehabilitation and Nursing Center

Based on record review and staff interview during the standard recertification survey, the facility did not maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, the facility did not have a system to thoroughly track infections. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Finding # 1

The facility's did not ensure an appropriate and thorough system for tracking infections and disease for each resident.

During an interview on 12/8/11 at approximately 3:00 pm , the Assistant Director of Nursing (ADON), when questioned as to how the facility tracks infections and diseases, produced some notes documented on several sheets of approximately 5 x 9 notepapers. The ADON then produced a list of current infections which were documented in the computer but some were incomplete as to causative organism, treatment and precautions /isolation and outcome. When questioned as to the tracking for the previous months, the ADON stated they are archived in the computer but she did not know how to obtain them. The ADON stated she realized that since computerization the system for tracking was not as complete.

NYCRR 10 415.19(a)(1-3)

Based on medical record review and staff interview during the recertification survey the facility did not ensure the Pre-Admission Screen Resident Review (PASRR, form DOH-695) was complete for four of 28 (# 87, 92, 96 and 97) residents reviewed during the recertification survey. Specifically, two screens were not completed for a resident prior to admission, one screen had only the demographics for the resident and question # 36 completed and one screen was not completed by a certified screener who had a 10 digit screening identification number. This caused no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident # 87:
There was no PASRR (screen) for the resident completed prior to admission.

The resident was admitted on 7/15/11 with diagnoses of hypertension, Parkinson disease and esophageal reflux. The Minimum Data Set (MDS) dated 7/25/11 assessed the resident as having no cognitive deficits.

The screen was dated 7/15/11 and completed by the Director of Social Work (DSW) at the nursing home after admission.

During an interview on 12/8/11 at 1:15 pm, the DSW stated she would like to say that each screen was reviewed before the resident was admitted, but then stated that this was not always the case. She stated about fifty percent were received and reviewed prior to admission. The DSW further stated that if the resident was not admitted with a completed screen she completed a screen once they were admitted. The DSW was aware the screen was supposed to be used in screening if the admission was the appropriate level of care for the resident.

During an interview on 12/8/11 at 1:45 pm the Administrator stated that sometimes the screen was faxed with the admission paperwork, but that more often than not, the screens were brought with the resident. The Administrator stated he was aware that the regulation required review of the screen prior to admission to ensure the appropriate placement of the resident, but stated that the screens were not always received for review prior to admission.

Resident # 92:
The resident's screen was started by the DSW at the facility after the resident was admitted and was never completed.

The resident was admitted on 9/2/11 with diagnoses of diabetes mellitus, depression and hypertension. The MDS dated 9/12/11 assessed the resident as cognitively intact.

The screen was dated 9/2/11 and only had the demographics (resident name and social security number) and question # 36 completed.

During an interview on 12/8/11 at 1:15 pm, the DSW stated she would like to say that each screen was reviewed before the resident was admitted, but that this was not always. She stated about fifty percent were received and reviewed prior to admission. The DSW further stated that if the resident was not admitted with a completed screen, then she completed a screen once they were admitted. The DSW stated she is aware the screen was supposed to be used in screening if the admission was the appropriate level of care for the resident.

During an interview on 12/8/11 at 1:45 pm the Administrator stated that sometimes the screen was faxed with the admission paperwork, but more often than not, the screens were brought with the resident. The Administrator stated he was aware that the regulation required review of the screen prior to admission to ensure the appropriate placement of the resident, but stated that the screens were not always received for review prior to admission.

Resident # 96:
There is no signature or ten digit ID completed on the screen form.

The resident was admitted on 10/28/11 with diagnoses of diabetes mellitus, depression and diverticulitis. The MDS dated 11/3/11 assessed the resident as being cognitively intact.

During an interview on 12/8/11 at 1:15 pm the DSW, stated she would like to say that each screen was reviewed before the resident was admitted, but that this was not always the case. She stated about fifty percent were received and reviewed prior to admission. The DSW further stated that if the resident was not admitted with a completed screen, she completed a screen once they were admitted. The DSW was aware the screen was supposed to be used in screening if the admission was the appropriate level of care for the resident.

During an interview on 12/8/11 at 1:45 pm, the Administrator stated that sometimes the screen was faxed with the admission paperwork, but more often than not, the screens were brought with the resident. The Administrator stated he was aware that the regulation required review of the screen prior to admission to ensure the appropriate placement of the resident, but stated that the screens were not always received for review prior to admission.

10NYCRR 415.11(e)

Based on observation and interview the facility did not ensure that food was stored, prepared, distributed and served under sanitary conditions in one of one kitchens and one of three dining rooms during the recertification survey. Specifically: food in the dining room was not served under sanitary conditions, food in the kitchen was not prepared under sanitary conditions, dishes/cookware were not sanitized adequately, and glassware was not stored under sanitary conditions. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Finding 1
During observation of the noon meal on 12/5/11 at 12:05 pm a food service worker (FSW) wiped sauce off a bowl with her finger, then wiped her finger on a damp cloth. She then picked up a biscuit and put it on a plate. She did this several more times. After she finished serving the food the FSW was asked about wiping the bowels with her finger, wiping her finger on the damp cloth then handling biscuits. She said she probably should not have done that. She stated she was not aware she did it.

During an interview on 12/9/11 at approximately 11:00am the Food Service Manager (FSM) stated the FSW should not have wiped hand on cloth then handled biscuits.

Finding 2
On 12/7/11 at 7:45 AM the cook was observed to open a garbage can with bare hands then put gloves on without washing his hands. He then started cutting tomatoes for a salad. The cook was asked if he washed his hands before he put his gloves on. He said no. At this time the FSM was asked what should have happened. He stated that after handling something like a garbage can the cook should have washed his hands before putting on the gloves.

Finding 3
On 12/7/11 at 7:50 am the sanitizer in the three compartment sink was tested with the test strip. It showed the concentration was 100 ppm. The FSM said the manufacturers recommendation for the concentration was 200-400 ppm. He was asked if someone routinely checked the concentration. He said it was done, but not daily and they do not record the concentrations.

On 12/7/11 at 1:45 pm the dishware was observed being run through the dish machine. The FSW was observed to stack glasses in each other wet and put them in a bin to use again. This occurred several times. She was asked if she always did it that way. She and the other FSW nearby said yes. They said they were not trained otherwise.

During an interview on 12/7/11 at 2:00pm the FSM was asked if it was appropriate to put glasses away wet, he stated no.

10 NYCRR 415.14(h)

Based on medical record review and staff interview during the standard recertification survey the facility did not ensure that 1 (#24) of 9 residents entire drug regimen was monitored to promote and maintain the resident's highest practical mental , physical and psychological well being. Specifically, the facility did not ensure that the resident's dilantin levels, a blood test utilized to monitor the amount of dilantin in the resident's blood, was monitored. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident #24
The resident was admitted to the facility on 1/10/03 with the diagnoses of diabetes, seizure disorder, and hypertension. The Minimum Data Set (MDS) dated 10/27/11 assesed the resident as having short and long term memory problems and severely impaired cognitive skills for daily decision making.

Review of the resident's lab results and physician's orders revealed that the resident has not had a Phenytoin (Dilantin) level (, a blood test used to monitor the resident's Dilantin level and to monitor toxicity) since 2009. The resident's dilantin level in 2009 was 15.5 which was within the normal range of 10-20)

The Physician's orders dated 12/9/11 documented Dilantin Infatabs 50mg 3 tablets (150mg) by mouth (po) every am and Dilantin Infatab 50 mg 4 tablets (200mg) po every evening.

The Palliative Care Plan documented that the resident was not to have any laboratory tests.

During an interview on 12/7/11 at 1:30 pm, the resident's attending physician stated that he was not aware that the resident had not had a Dilantin level drawn since 2009. In addition, the physician stated that even though the resident was on Palliative care , the resident should have have had a Dilantin Level drawn every year to monitor for toxicity.

10NYCRR 415.12(1)(1)

Nurses Notes

12/5 /11 Seizure like episode at 18:15 lasting approx 60 sec

Based on record review and interview the facility did not immediately inform the resident's physician when there was a significant change in the residents physical, mental, or psychosocial status for one ( # 45) of three residents reviewed for nutrition during the recertification survey. Specifically: the resident experienced an 8 pound weight gain in one week and the physician was not informed timely. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Resident # 45
The resident was admitted to the facility on 7/21/11 with diagnoses of congestive heart failure, atrial fibrillation and pneumonia. The Minimum Data Set of 7/31/11 assessed that the resident was cognitively intact, understands and was understood. It further documented the residents weight as 141 lbs and that there was no weight loss.

The weight records documented: Admission wt. 7/21/11= 132.5 lbs, 7/24/11=133 lbs, 7/31/11=141 lbs. (an 8 lb increase in one week), 8/7/11=142.2 lbs, 8/17/11=143 lbs, 8/21/11=142 lbs.

The physician orders documented that: on 7/21/11 the physician ordered Lasix (a diuretic used to remove fluid)20mg every day, on 8/23/11 the physician ordered Lasix 40mg every day, and on 8/29/11 the physician ordered to apply TED stockings on both lower legs every am and to take them off every evening and to give Lasix 40mg two times a day.

The nurses notes documented:
On 8/3/11 that oxygen was used on and off throughout the shift and some wheezing was noted early in the shift but resolved with rest period. There was no coughing.
On 8/5/11 that there was some increased shortness of breath with exertion which resolved with rest.
On 8/10/11 the pulse oxygen was 88% ( normal 90-100%) after ambulating 100 feet without oxygen. The resident was wheezing and slightly short of breath. This resolved with rest.
On 8/12/11 the resident was noted to have increased shortness of breath with exertion which resolved with rest.
On 8/15/11 and 8/16/11 the resident had increased shortness of breath noted with exertion which resolved with rest and supplemental oxygen.
On 8/17/11 the resident had increased shortness of breath with exertion and that the resident used portable oxygen when ambulation with good effect.
On 8/19/11 that increased shortness of breath continued with exertion.
On 8/22/11 that the resident was complaining of difficulty breathing this am and that the resident was seen by the Physician Assistant today and laboratory work was ordered.

During an interview on 12/7/11 at 11:30 am the Registered Nurse Manager was asked if she remembered the residents 8 lb weight loss in July and if the physician was notified. She looked at nurses notes and said there was nothing documented there. She thought she must have discussed it but could not remember. She said she normally documented if she talks to the doctor. She asked the Licensed Practical Nurse, who knew the resident, if she remembered, she said she did not remember.

During interview with the Registered Dietitian on 12/7/11 at 12:58pm she said she did not notify anyone of the residents 8 lb weight gain. She stated she knew the resident from a previous admission. With his history an 8 lb weight gain should have been addressed and the physician should have been notified.

During an interview on 12/7/11 at l:03 pm the residents physician said he would expect to be notified of an 8 lb weight gain in one week, especially someone with this residents history.

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

Based on record review and interview the facility did not provide services by qualified persons in accordance with each residents written plan of care for one ( # 47) of one resident reviewed for skin conditions during the recertification survey. Specifically: booties were not applied as care planned for this resident. This resulted in no actual harm with a potential for more than minimal harm that was not immediate jeopardy. This is evidenced by:

Resident # 47
The resident was admitted on 9/8/08 with diagnoses of dementia, depression and osteoarthritis. The Minimum Data Set (MDS) of 8/13/11 and 11/9/11 assessed that the resident had severe cognitive impairment, needed total assist of one staff for bed mobility and did not walk. These MDS's also documented the resident was at risk for developing pressure ulcers.

The Comprehensive Care Plan (CCP) dated 8/26/11 documented a goal that the resident will have no skin breakdown for the next 90 days. The approaches included a pressure reducing mattress, pressure reducing device for the chair, Lotus gel cushion on the bed for pressure relief. The CCP dated 11/21/11 had a goal that the resident will have no further skin breakdown with an approach that the resident will wear bilateral prafo boots (blue foam booties) while in bed.

The Physical Therapy Quarterly Screen dated 11/15/11 documented under the treatment plan that the resident received prafos for skin protection.

The care card in the unit folder was undated. It had an intervention dated 9/3/11 to encourage the use of prafos when in bed. This information was also in the computer kiosk (actually used by staff to provide care to the resident).

During interview on 12/7/11 at 5:15pm an evening Certified Nurse Aide (CNA) stated the resident sleeps on her back and that for the last week or so she has been putting air boots on the resident at night. She said she has worked with the resident for about 6 weeks. Prior to the resident developing the sores on her ankles she did not remember the resident using booties. She was asked if she had put boots on the resident (prior to the ankle sores) when she cared for her and she said no.

During interview on 12/8/11 at 6:30am the night LPN stated he put ace wraps on the resident every morning before she got out of bed and before care. He said he never saw boots until about a week ago. He stated he has taken care of the resident since June. He said he had heard last night that the resident was supposed to have worn the prafo boots at night since August 2010.

During interview on 12/8/11 at 11:45 am the residents usual day CNA stated the resident is supposed to have booties on in bed, but this is recent. She stated the resident used to have prafo booties booties a long time ago, more than 6 months but then they stopped.

During interview on 12/9/11 at 10:45 am the Registered Nurse Manager said said she wanted staff to try to put prafo boots on the resident. She said the resident did not like the prafos and had refused them but she had still wanted staff to try. She stated staff do not sign for the boots so there would be no record if they tried. She stated refusals would be in nurses notes.

Nurses notes were reviewed for several months and no refusals were documented.

10 NYCRR 415.11(c)(3)(ii)

Based on observation and staff interview during the standard recertification survey, it was determined that the facility did not comply with construction standards of Title 10 of the New York State Code of Rules and Regulations. 10 NYCRR section 711.15 (m) (2) requires that facilities constructed prior to 02/01/1966 shall have night lighting in patient rooms. 10 NYCRR section 713-1.19(d) (2) requires that facilities constructed between 02/01/1966 and 07/01/1990 shall have at least one light fixture for night lighting switched at the entrance to each patient room. Specifically, night-lights are not provided in the resident rooms on 2 of 2 nursing units. This resulted in the potential for minimal harm. This is evidenced as follows.

Observation on 12/06/2011 at 10:20 am revealed that night-lights were not provided in the north wing and south wing resident rooms.

The maintenance supervisor stated in an interview conducted on 12/06/2011 at 9:20 am that it could not be accounted for as to why night lights were not installed in resident rooms.

10 NYCRR 711.15 (m) (2), 713-1.19(d) (2)

Based on observation and staff interview during the recertification survey, the facility did not ensure that the required nursing staffing information was posted in a prominent place that was readily accessible to residents and visitors. Specifically, the daily nursing staffing information was not posted in an area that was readily accessible to the resident's and visitors for two of two units. This resulted in no actual harm with the potential for minimal harm that is not immediate jeopardy. This was evidenced by the following:

During an observation on 12/5/11 at 9:45 am, the daily nursing staffing was noted by a surveyor to be posted in one area on the South Unit, on a bulletin board, which was not easily accessible for residents and visitors . This bulletin board was located in the hallway on the South Unit leading to the Director of Nurse's office, and was observed as not visible to the residents and visitors on the other two halls of the South Unit or to the three halls on the North Unit.

During an interview on 12/5/11 at 1:15 pm , the administrator was agreeable that the daily nursing staffing was not posted in a readily accessible area and stated that the daily nursing staffing was in fact posted only on the South Unit. He stated he would have this daily nursing staffing information moved to the main entrance to the facility so that it was posted in a more prominent place that was readily accessible to the residents and visitors.

10 NYCRR 415.13

dowctrlrmshadectd ain Based on observation and staff interview during the standard recertification survey it was determined that the facility did not maintain the integrity of 4 of 4 smoke barriers observed. NFPA 101 ain Life Safety Codeain 2000 edition section 8.3.2 requires that smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling. Specifically, the Chestnut Hall, Maplewood, Pine Tree, and South End Zone 3 smoke barriers were not continuous through all concealed spaces. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The Chestnut Hall, Maplewood, Pine Tree, and South End Zone 3 smoke barriers were inspected on 12/06/2011 at 2:30 pm. The Pine Tree smoke barrier had an 8-inch by 12-inch hole in room 218, a 4-inch square section of unprotected metal in room 216, 2 unsealed penetrations in the corridor, and one unfilled penetration in the cable room. The Chestnut Hall smoke barrier had a 3-inch hole and 2 unsealed penetrations in the corridor. The South End Zone 3 smoke barrier 4-inches of loose fill in one hole and 2 unsealed penetrations. The Maplewood smoke barrier had one unsealed penetration.

The maintenance supervisor stated in an interview conducted on 12/06/2011 at 3:45 pm, during survey observations, that the holes and penetrations noted above were present.

2000 NFPA 101 19.3.7.3, 8.3; 1997 NFPA 101 13-3.7.3, 6-3; 10 NYCRR 415.29, 711.2(a) (1)
ain
ain The following requirements of the Life Safety code have been previously waived. The results of the current survey and review of the facility's previously submitted justifications reaffirm that adequate safeguards remain in place to protect residents, visitors and staff, and that correction would pose an undue hardship. The continued waiver of the following items is recommended. Please indicate your request for renewal or submit a plan of correction in the space provided on this form.

Smoke dampers shall be installed at or adjacent to the point where ducts pass through required smoke barriers, but in no case shall the smoke damper be installed more than two (2) feet from the barriers, or after the first duct inlet or outlet.

2000 NFPA 101 19.3.7.3, 8.3, 19.5.2.1, 9.2, 9.2.1; 1999 NFPA 90A 3-3.5.1; 1997 NFPA 101 13-3.7.3, 6-2, 13-5.2.1, 7-2, 7-2.1; NFPA 90A (1996) 3-3.5.1; 42 CFR 483.70 (a)

ain\i The smoke dampers in the smoke barrier walls in the A and B residential units are located three (3) feet from the smoke barrier wall.

The ducts are strapped to the ceiling to prevent a collapse during a fire. It is not physically possible to relocate the smoke dampers.ain

dowctrlrmshadectd ain Based on staff interview and review of inspection records during the standard recertification survey, it was determined that the automatic sprinkler system was not tested in accordance with adopted regulations. NFPA 25 ain Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systemsain 1998 edition section 2-3.3 requires that alarming devices servicing sprinkler systems shall be tested quarterly, and section 2-4.1.4 requires that a minimum of two spare sprinklers of each type and temperature rating installed shall be provided. Specifically, 1 of the past 4 required sprinkler system flow alarm device tests was not conducted, and spares of each type and temperature rating were not provided. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The sprinkler system inspection records were reviewed on 12/05/2011. The records showed that the flow alarm devices were not tested during the second quarter of 2011.

The maintenance supervisor stated in an interview conducted on 12/05/2011 at 2:45 pm that the required second quarter of 2011 testing was missed by a few days.

Documentation provided by the facility administrator on 12/06/2011 revealed that the sprinkler system testing company did not conduct the required second quarter of 2011 test due to scheduling difficulties.

The supply of spare sprinkler heads was inspected on 12/05/2011 at 3:05 pm. Spares of pendent sprinkler heads and blue-colored upright sprinkler heads were not provided.

2000 NFPA 101 19.7.6, 4.6.12, 9.7.5; 1998 NFPA 25 2-3.3, 2-4.1.4; 1997 NFPA 101 7-7.6; 1995 NFPA 25 2-3.3, 2-4.1.4; 10 NYCRR 415.29, 711.2(a)(1)ain

dowctrlrmshadectd ain Based on record review and staff interview during the standard recertification survey, it was determined that the facility did not test and maintain the fire alarm system in accordance with adopted regulations. NFPA 72 ain National Fire Alarm Codeain 1999 edition section 7-1.1.2 requires that defects and malfunctions shall be corrected, and sections 7-2.2 and 7-3.2 require that heat detectors require annual heat tests and/or function tests. Specifically, the fire alarm system batteries were not replaced as required, and 17 of 17 heat detectors were visually inspected only and not heat tested and/or function tested. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

Record review of the fire alarm system testing records for years 2011 and 2010 on 12/05/2011 revealed that the heat detector initiating devices, 17 total devices, were accorded a visual inspection only within the past 12 months. These records do not document that the fire alarm system batteries have been tested.

The maintenance supervisor stated in an interview conducted on 12/06/2011 at 1:00 pm that the " silver dome " heat detectors were not tested by the contracted fire alarm system testing company.

2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-1.1.2, 7-2.2, 7-3.2; 1997 NFPA 101: 7-6.1.4; 1996 NFPA 72: 7-1.1.2, 7-2.2, 7-3.2; 10 NYCRR 415.29, 711.2(a)(1)ain

Based on interview and record review during the standard recertification survey, it was determined that the facility did not maintain emergency generator testing records (testing records) according to adopted regulations. NFPA 99 Standard for Health Care Facilitiesnone 1999 edition section 3-4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systemsnone 1999 edition section 6-3.4 requires that the facility maintain operational testing records that include the date, exercising period, performance, identification of the servicing personnel, and identification of any unsatisfactory condition with the appropriate corrective action and re-testing. Specifically, 12 of the last 12 months of testing records do not show the exercising period. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The facility testing records for the period of 12/2010 through 11/2011 were reviewed on 12/05/2011. The testing records did not show the exercising period.

The maintenance supervisor stated in an interview conducted on 12/05/2011 at 2:45 pm that the testing records for 11/2010, 12/2010, and 06/2011 are not available.

1999 NFPA 99 3.4.4.1, 1999 NFPA 110 6-3.4, 6-4.2; 1996 NFPA 99 3.4.4.1; 1996 NFPA 110 6-3.4, 6-4.2; 10 NYCRR 415.29(a)(2), 711.2, 713-1.19(h)