Riverside Center for Rehabilitation and Nursing

Based on observation and staff interviews during the standard recertification survey, the facility did not ensure that residents were cared for in a manner that maintains and enhances the residents dignity during dining. Specifically, on 1 of 2 units, 2 residents ( #'s: 12 and 82 ) were not served and fed concurrently with the other residents seated at their dining table and on 2 of 2 units residents were not given a choice regarding clothing protectors. 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

During observation of lunch in the North Unit's dining room on 5/9/11 at 12:10 pm, resident #82 was seated at the table with other resident s who were eating lunch. Resident # 82 waited 15 minutes for her tray to be served to her.

During an interview on 5/9/11 at 1:00 pm, the Registered Nurse / Unit Manager (RN/UM) stated that the residents seated at the same table are usaully served their food at the same time,. but sometimes the food trays for the residents who are seated at the table, are not on the same food cart. The RN/UM also stated that it was not acceptable for the resident to have to wait 15 minutes to receive her food while the other residents seated at her table were eating.

Finding #2

During observation of breakfast in the North Unit's dining room on 5/12/ 11 at 8:30 am, Resident #12 was observed seated at a table with another resident who was eating. Resident #12 was looking at his food but was unable to feed himself. The diet technician brought the resident his own utensils and placed the utensils which were in a paper wrapper next to his plate. The resident continued to look at his food and after some difficulty managed to unwrap his utensils . He was not able to feed himself and had made several unsuccessful attempts to pick up the bacon with his fingers. The resident continued to look at the other resident seated at the table who was eating. At 8:50 am, which was 20 minutes later, the RN/UM attempted to feed the resident but he had a coughing spell and had to be taken out of the dining room.

During an interview on 5/12/11 at 9:30 am, the RN/UM stated that the resident has his own utensils because he was complaining that the adaptive utensils were too heavy and that the utensils are usually on the food tray . She also stated that the resident was not feeling well today. She stated that the Diet Technician co-ordinates the times for the distribution of trays.

During an interview on 5/16/11 at 8:45 am, the Diet Technician stated that the other resident who was seated at resident #12 table receives an early tray because he is independent and is a very slow eater. She also stated that resident # 12 needs to be fed and the nurse or CNA feed him. The diet technician also stated that the nursing staff were all busy at the time. She stated that she was aware of the situation and felt very uneasy because resident # 12 was not being fed.

Finding #3

During observation of the lunch meal on the South unit on 5/9/11, 2 residents were observed having clothing protectors placed on them without being asked if they wanted a clothing protector.

During an interview on 5/9/11 at 12:23 pm, the certified nurse assistant (CNA) stated she does not usually ask the residents if they want a clothing protector and always puts one on them.

During an interview on 5/9/11 at 12:40 pm, the RN/UM stated the staff should be giving the resident a choice of using the clothing protector.

Finnding #4

During observation of the lunch meal on the the South Unit on 5/12/11 at 8:07 am, the CNA placed a clothing protector on the resident without first asking the residents permission. The CNA stated " I'm going to place this on you so you don't make a mess".

During an interview on 5/12/11 at 8:37 am, the CNA stated she just placed the clothing protector on the resident without asking the resident and she should have qasked the resident first.

During observation of the lunch meal on the North Unit on 5/12/11 at 8:20 am clothing protectors were placed on several residents without the residents being asked if they wanted the clothing protector .

During an interview on 5/12/11 at 9:30 am the LPN stated that most of the residents on this unit wear the clothing protectors and the staff knows which residents don't want the clothing protectors.

10 NYCRR 415.5(a)

Based on observation, medical record review and staff interview during the recertification survey, the facility did not ensure each resident's drug regimen must be free from unnecessary drugs for for three (# 's 51, 73, and 83) of ten residents reviewed for unnecessary medication use. Specifically, the facility did not ensure it provided clinically pertinent rationale or adequate indication for use of atypical antipsychotic medications or document how benefit of the use of atypical antipsychotics outweighed the risks for two residents (#73 and 83), did not ensure adequate monitoring of one resident receiving multiple blood pressure medications (#83), and did not ensure a recommended gradual dose reduction of an atypical antipsychotic for one resident (#51). This resulted in no actual harm with the potential for more than minimal harm, that is not immediate jeopardy. This is evidenced by:

Resident #83
The resident was admitted on 2/1/11 with diagnoses of cerebrovascular accident, dementia, and chronic obstructive pulmonary disorder. The Minimum Data Set (MDS) dated 2/8/11 noted that the resident had no signs or symptoms of delirium, was assessed as having moderately impaired cognition, and noted that there was evidence of acute changes in mental status from the resident's baseline. It was documented that behaviorally, delusions were noted, and that the resident had physical behaviors toward others, verbal behaviors toward others and wandering behaviors one to three days in frequency over the prior seven days. It was noted that the resident's behavior did not put him at risk for physical illness or injury, did not interfere with care, or participation in activities or social interaction, and did not put others at significant risk for physical injury or significantly disrupt care or the living environment.

An undated care plan titled "Psychotropic Drug Use" and last updated on 2/17/11 noted that the resident had a need for pharmalogical behavior modification as evidenced by episodes of agitation. The specific medication and dosage ordered was noted on the care plan as Seroquel 25 milligrams twice a day at 1:00 pm and 10:00pm.

Observation was made of the resident during the day and evening shifts on 5/10/11 and 5/11/11. At all times, the resident was observed sitting quietly and calmly in a chair, in the hall, near the nurse's station. He was noted to be smiling and pleasantly interacting with others as they walked by him.

Admission physician orders dated 2/1/11 documented an order for Seroquel 25 milligrams (mg) by mouth at hour of sleep for insomnia. An interim physician order dated 2/9/11 noted the resident had increased agitation and the resident's Seroquel 25 mg was increased from once a day to twice a day (at 1:00 pm and 10:00 pm) for this agitation. It also noted on this order that a psychiatry evaluation was to be obtained .

There was no documented evidence in the physician's notes of an adequate indication for use of the Seroquel with this resident or how benefit of the Seroquel use outweighed the risks .

There was no documented evidence in psychiatry notes dated 2/21/11 and 4/4/11 of an adequate indication for use of the Seroquel with this resident or how benefit of the Seroquel use outweighed the risks .

A pharmacy consultation report dated 2/7/11 identified that the resident was taking an antipsychotic, Seroquel, but did not have an appropriate associated diagnosis in addition to symptoms due to: mania or psychosis; or due to behavioral symptoms that present a danger to the resident or others; or that the symptoms were significant enough causing the resident to be experiencing inconsolable or persistent distress or a significant decline in function and/or substantial difficulty receiving needed care. In response to this pharmacy consultation, the physician responded on 2/11/11 that the resident was on Seroquel before coming to the facility and that according to the family, the Seroquel was started because the resident was not able to sleep. It was here that the physician noted questioning psychosis. No change in the Seroquel was made by the physician in response to the pharmacy consultation recommendation on this report.

During an interviewat 5:20 pm on 5/16/11 with a 3:00 pm to 11:00 pm Certified Nursing Assistant (CNA), he stated that he knew the resident very well and never had a problem with him.

In interview with a 7:00 am to 3:00pm CNA, on 5/12/11 @ 8:58 am, she stated he was always very good in the morning and was very bright and pleasant. At noon time, she stated he got a little confused stating he was waiting for his wife. She stated she had been his primary aid for the day shift since he was admitted. She stated she had never observed any behavior problems with him.

In an interview with a 7:00 am to 3:00 pm LPN, on 5/12/11 at 9:08 am, she stated that when the resident was first admitted he was very agitated and confused. She stated that lately he had been very good, only getting frustrated at times.

During interview the Registered Nurse Unit Manager (RNUM) on 5/12/11 at 12:18 pm, stated she knew that when the resident was admitted he was agitated. She reported that she thought initially the resident came in on the Seroquel for insomnia, however, she stated she had never seen it used for such an indication. She stated she did not know why the Seroquel was increased but noted that the physician's order stated it was for increased agitation and stated that the nurse's notes documented the resident as having general agitation. She stated the resident was admitted on the Seroquel from another nursing home. She stated she had not known the resident to have had harmful behaviors to himself or others.

During interview the attending physician on 5/12/11 at 2:15pm stated that the resident was admitted with vascular dementia with psychosis and was on Seroquel 25 milligrams daily for this. When the physician was informed by the surveyor that the Seroquel was noted in his orders to be prescribed for insomnia on admission, the physician disagreed stating he believed it was documented in his notes that the Seroquel was being administered for acute psychosis. (On later review of the physician notes, there was no documented evidence of such). He stated on admission and shortly after, the resident became psychotic and agitated for which he increased the Seroquel to twice a day until evaluated by psychiatry. The physician was unable to recall the resident's specific presentation of psychotic behaviors. (On later review of the physician notes and orders, there was no documented evidence of what the resident's specific psychotic behaviors were). He then stated two psychiatrists saw the resident and assessed the resident to be doing well on the Seroquel so they recommended continuation. He stated that for newly admitted patients, he usually did not make any changes in resident' medications, and stated that because he was not an expert in the area of psychotropic medication management, he relied on psychiatric recommendations regarding antipsychotic medication administration.

Additionally, the facility did not ensure adequate monitoring of this newly admitted resident on multiple blood pressure medications.

Admission physician orders dated 2/1/11 and routine physician orders dated 3/31/11 and 4/28/11 documented orders for administration of Metoprolol (blood pressure medication) 25 milligrams twice a day and Lisinopril (blood pressure medication) 20 milligrams once a day, with no parameters for administration or frequency for blood pressure monitoring.

Facility documentation of blood pressure monitoring was completed every shift for the first four days after admission and noted the resident's blood pressures as: 111/68, 101/56, 143/69, 83/46, 106/63, 110/60, 134/54, 110/56, and 108/62. Facility documentation of blood pressure monitoring was completed monthly thereafter and was noted as: 110/60 on 2/10/11, 90/58 on 3/2/11, 169/91 on 4/5/11, and 132/76 on 5/3/11. Variations in the resident's blood pressure were noted over time with incidents of low blood pressures recorded.

In interview with the attending physician on 5/16/11 at 4:45 PM, he stated that if a resident was on more than one blood pressure medication and if the resident was stable in condition, he would usually look for the resident's blood pressure to be monitored once a week. He stated he didn't always order parameters for blood pressure medications and it would depend on the resident's condition. When asked if he monitored this resident's blood pressure over time since admission, he refrained from answering the question and rather inquired what the most resident's most recent blood pressure was May. When informed that it was 132/80, he then stated he would not be concerned and would say the resident was doing fine.

During interview with the consultant pharmacist on 5/17/11 at 9:40 am, she stated that when a resident was on two or more blood pressure medications, then she would typically recommend weekly blood pressure monitoring. She stated in regards to this resident's variations in blood pressure after admission and monthly thereafter, she would have recommended closer monitoring of the resident's blood pressure because of the noted low blood pressures and possibly to have them taken at different times of the day. She stated that this would give a better picture of how the resident was really doing on the blood pressure medications to the physician. She stated that during her monthly reviews she had not specifically evaluated this resident's blood pressure medications for adequate monitoring.

Resident #73
The facility did not ensure it p rovided a clinically pertinent rationale or adequate indication for the use of Zyprexa (an atypical antipsychotic medication with a black box warning that states use may increase risk of cardiovascular or infection-related death in elderly patents with dementia and that it isn't approved to treat patients with dementia -related psychosis) with the resident and did not document how the benefit of the continued Zyprexa use outweighed the risks of its use.

The resident was admitted on 6/12/09 with anxiety, depression and history of urinary tract infections. The Minimum Data Set (MDS) dated 10/12/10 assessed the resident as having a Brief Interview for Mental Status (BIMS) score of " 3'", indicating severe cognitive impairment. It noted no signs or symptoms of delirium. It also assessed the resident as having no psychosis or behavior problems. It lastly noted that the resident received an antipsychotic, anti anxiety, and antidepressant medication in the prior seven days.

An undated "Psychotropic Drug Use" care plan noted that the resident had a need for pharmacological behavior modification as evidenced by depression and anxiety and was noted as last updated in 3/2011. It was noted the resident started Zyprexa 2.5 milligrams (mg) once a day on 5/19/10 for three days and that it was then increased to 5 mg once a day. It noted that the resident's mood and overall behavior patterns were well controlled with no adverse reactions.

The resident was observed sitting with her son in the hallway on 5/16/11 at 10:00 am. She was noted to be quiet and calm. She became anxious when the son stood up to leave her, but the son verbally reassured her and she calmed.

Routine physician orders dated 1/4/11, 3/2/11 and 5/3/11 documented an order for Zyprexa 5 mg once a day for agitation.

Physician's renewal and progress notes dated 11/1/2010, 12/29/10, 1/4/11, 3/2/11, 3/29/11, 3/30/11 and 5/3/11 did not p rovide clinically pertinent rationale or adequate indication for the continued use of Zyprexa with the resident and did not document how the benefit of the continued Zyprexa use outweighed the risks. These notes addressed the resident having signs and symptoms of depression, sadness, and weepiness.

There was no documented evidence in psychiatry notes dated 12/28/10 and 3/7/11 of an adequate rationale or indication for continued use of the Zyprexa with this resident or how benefit of the continued Zyprexa use outweighed the risks .

During interview with a 7:00 am to 3:00 pm Certified Nursing Assistant (CNA) on 5/16/11 at 10:35 am, he stated the resident wais anxious and cried a lot. He stated he used a calm approach with her and for some reason, he could always easily get her to smile.

During interview with a 7:00 am to 3:00 pm Licensed Practical Nurse (LPN) on 5/16/11 at 10:40 am, she stated the resident could be weepy in the morning, but was usually good during day. She stated that the staff had no real behavior issues with her and stated that the resident was usually content.

During interview with the Registered Nurse Manager (RNUM) 5/16/11 @ 11: 25 AM, she stated the resident was weepy on occasion. She stated she did not believe it was distressing to her at this time. She stated she could not see that any gradual dose reduction of the Zyprexa had been addressed by the physician, pharmacist, or psychiatrist.

During interview with the psychiatrist on 5/16/11 at 1:40 pm, he stated that he had not been the psychiatrist involved in management of this resident's antipsychotic medications up to this point. He stated that he felt the Zyprexa may have been indicated initially based on her described presentation with psychotic symptoms. However, had he been involved, then he stated he would have reviewed the resident six months from when it was started. He stated if the resident was no longer exhibiting psychotic signs or symptoms, then he would have recommended a trial reduction in the medication based on standard gradual dose reduction procedures for atypical antipsychotics. He stated he was new to the facility and that this was something he knew had to be looked at because of the number of residents currently on antipsychotic medications in the facility.

During interview with the consultant pharmacist on 5/16/11 at 2:45 pm, she stated that per her records, the resident had been seen by the psychiatrist in December 2010 and that he was monitoring her for psychotropic medication use. She stated that since the psychiatry consultation listed the Zyprexa at the top of the note, then she considered this to be that the psychiatrist had reviewed the antipsychotic medication for possible dose reduction or continued use. She stated she would not make a recommendation to the attending physician regarding indication for continued use or possible dose reduction of antipsychotic medications if she saw evidence that psychiatry had reviewed them on consultation.

In interview with the attending physician on 5/16/11 at 3:10 pm, he stated had not been using Zyprexa with the resident for psychotic signs or symptoms, but that he had used it an attempt to improve her mood and enhance her Major Depressive Disorder in the face of anxiety. He verbalized his rationale for continued use of the Zyprexa may have not been clearly documented in his notes. He stated the Zyprexa had never been used for behavior or psychosis, but rather as a supplement to improve and enhance her mood.. He stated the resident cried almost every time he talked to her. He stated since he had not documented his rationale for continued use without reduction in his notes, he would be sure to look at this, reevaluate and document it thoroughly at his next visit. He stated he knew weepiness was not an adequate indication for use of Zyprexa but reiterated that his goal for use was enhancement of her mood along with other psychotropic medications.

Resident # 51
The facility did not ensure that the resident received a recommended gradual dose reduction of Haldol (an atypical antipsychotic medication with a black box warning that states elderly patients with dementia-related psychosis are at increased risk for death and that it isn't approved for treatment of dementia-related psychosis).

The resident was admitted to the facility on 12/9/08 with the diagnoses of dementia with delusions, hypertension and depression. The Minimum Data Set (MDS) dated 2/24/11 assessed the resident as rarely/never understands and rarely/never understood and having severly impaired cognitive skills for daily decision-making.

The physician ( MD) order dated 5/12/11 documented an order for Haldol one milligram (mg) three times a day by mouth (po) .

The psychiatrist consultation dated 12/13/10 documented that the resident had a diagnosis of dementia with delusions, had no adverse effects from the Haldol, and to continue the same dose of Haldol. The psychiatrist consultation dated 4/11/11 documented that the resident had a diagnosis of dementia, was due for an attempt at dose reduction, and recommended reduction of the Haldol to two times a day.

The facility's vendor pharmacy consultation report dated 4/11/11 documented that the maximum daily dose threshold for the use of Haldol, in individuals taking this medication to manage behavioral symptoms related to dementing illnesses, was Haldol two mg daily. In addition, this same pharmacy consultation report recommended to re-evaluate the continued use of Haldol at this dose perhaps decreasing it from one mg to to 0.5 mg and to continue the other two doses at one mg for three weeks, then decreasing further. This pharmacist consultation documented that if the Haldol was to continue at the current dose, the prescriber should document an assessment of the risks versus benefits and indicate a valid therapeutic intervention for the resident. The attending MD documented on the consultation report on 4/21/11 that he declined the pharmacist recommendation on the rationale that the family requested no change in medications.

The attending MD Interim Renewal Note note dated 1/31/11 and 5/12/11 documented the resident had Haldol prescribed as a psychotropic drug, did not document if a dosage reduction was attempted in the prior three months and did not document the reason for not reducing the dose.

During an interview on 5/13/11 at 10:30 am, the Registered Nurse / Unit Manager (RNUM) stated that the provision of medications is based on family and Heath Care Proxy (HCP) approval . She stated that when the psychiatrist had recommended to reduce the Haldol dosage , she had spoken to the family regarding the psychiatrist"s recommendation and reviewed the risk and benefits with the resident's family . The RNUM stated that the family did not want to the resident's Haldol dosage reduced and she reported this to the MD. The MD had told the RNUM at that time he was not going to change the Haldol order and would do as the family requested.

During an interview on 5/13/11 at 10:50 am, the MD stated that he did not decrease the resident's Haldol dosage with respect to the family's wishes.

During an interview on 5/13/11 at approximately 1:00 pm, the psychiatrist stated that that the MD's rationale, not to reduce the Haldol because of the family wishes and as documented by the MD on the pharmacist recommendation report was not appropriate.

10 NYCRR 415.12 (l)(1)

Based on observation and staff interviews, during the standard recertification survey, the facility did not ensure that a sanitary environment was provided for residents and staff. Specifically, 2 of 2 refigerators located in the nourishment kitchens on 2 of 2 units were not maintained in a sanitary condition. This resulted in no actual harm with the potential for more than minimal harm which is not immediate jeopardy. This is based on the following:

Finding #1

During observation of the South Unit 's nourishment refrigerator on 5/17/11 at 11:00 am the refrigerator was observed to be in need of cleaning . There were dried food particles in the vegetable bin and spilled fluids inside the refigerator. There was a sytrofoam cup with a straw in it which was not labeled or dated .

During an interview on 5/17/11 at 3:00 pm, the Registered Nurse / Unit Manager ( RN/UM) observed the refrigerator and stated that it needed to be cleaned and the styrofoam cup with a straw in the cup should not have been in the refrigerator.

Finding #2

During observation of the North Unit's nourishment refrigerator on 5/17/11 at 2:00 pm , the refrigerator was observed to be in need of cleaning. There were visisble spots of spilled food and liquids .

During an interview on 5/17/11 at 2:30 pm, the RN/UM stated that the refrigerator needed to be cleaned because of the spillage .

10 NYCRR 415.29

Based on observation, interview and document review the facility did not ensure that resident care equipment was maintained in safe operating condition for three residents (#12, # 62, # 69) of three residents observed for accident hazards. Specifically: the bed canes/rails on three beds were not properly affixed to the beds per manufactures specifications. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident # 62

During an interview with the resident on 5/16/11 at 4:36 pm the residents bed was observed to have a gap approximately 4" between the bed cane/ rail and mattress.

Resident # 69

On 5/11/11 at 8:00am the resident was observed in bed, bed at lowest position with a mat on the floor. There was a gap between the mattress and bed cane/side rail of 3-4 inches, larger at the head of bed that toward the foot of the bed.

On 5/13/11 at 8:44 am the resident's bed was observed with approximately a 4" gap between the bed cane/rail and mattress. The resident was not in the bed.

Resident # 12

On 5/12/11 at 9:45 am the bed in the residents room was observed to have a gap between the bed cane/rail and mattress of approximately 4 ".

On 5/13/11 at 8:50 am the residents bed was observed to have an approximate 4" gap between the bed cane/rail and the mattress.

During an interview with the Director of Maintenance on 5/13/11 at 7:40 am he said that the side rails/bed canes do not come on the beds. He provided information on the bed canes/rails from the manufacturer which documented that the bed cane/rail device should be affixed to the bed so that the device butts against the edge of the mattress for both single and double devices.

During an interview with the Director of Maintenance on 5/15/11 at 815 am he stated the bed canes/rails were here when he got here a little over a year ago. He stated that they don't do any maintenance on them other than if they slip or move. He stated his maintenance worker puts them on the beds and did not know if the maintenance worker knew how to affix them to the bed according to the manufactures specifications. He stated he did not know the bed canes/rails needed to be butted against the mattress. He further stated they don't have a a system in place to check on them to make sure they fit properly and are working properly.

10 NYCRR 415.5(e)(1)(2)

Based on observation, medical record review and staff interview the facility did not 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 on the recertification survey. Specifically, the facility did not maintain personal protective equipment for 1 of 1 resident observed on isolation, 2 of 3 glucometers observed were not disinfected between resident use and 1 of 2 units did not maintain clothing protectors in a manor to prevent the spread of infection. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Finding #1:
The facility did not maintain personal protective equipment for a observation of a resident on isolation precautions.

During an observation on 5/9/11 at 12:21 pm a Certified Nurses Aide (CNA) was observed assisting a resident with their lunch meal. The resident was on contact precautions. After assisting the resident, the CNA removed the residents clothing protector and her gloves and placed them on the residents meal tray. The CNA then proceeded to leave the resident room without washing her hands and went into the main dining room on the unit and discarded the gloves and clothing protector in the garbage in the dining room, and washed her hands in the dining room.

During an interview on 5/9/11 at 12:38 pm the CNA was asked what type of isolation the resident was on and the CNA stated she would have to check with the nurse. She thought contact but was unsure. She stated she was not aware she should be disposing the gloves in the resident room.

During an interview on 5/9/11 at 1:35 pm the Licensed Practical Nurse (LPN) stated the resident is on contact isolation due to colonized ESBL urine (a bacterial organism), she stated the linen should be discarded in the room and staff should be washing hands before leaving the room. She would discuss this with a CNA if she observed an issue otherwise the Registered Nurse Manager (RNM) reviewed isolation techniques with the staff.

During an interview on 5/16/11 at 11:30 am the RNM who stated that the proper technique would have been the gloves be disposed of in the resident room and hands washed in the resident room. She said that she worked part time on infection control and did not complete audits on staff to ensure they were following proper technique.

Finding #2:
Glucometers were not disinfected in between resident use.

During an observation of blood glucose fingerstick on 5/11/11 at 4:35 pm, the LPN on the South unit used the facility's glucose meter to test the blood glucose levels on 2 residents. The LPN cleansed the glucose meter with an alcohol swab, but did not disinfect the glucose meter with the facility's disinfectant wipe which contains bleach. The LPN then used the same glucose meter on the second resident.

During an observation of blood glucose fingerstick on 5/16/11 at 8:00 am, the LPN on the North unit used the glucose meter and placed the meter in the medication cart without disinfecting the glucometer.

During an interview on 5/11/11 at 4:50 pm, the LPN stated that the glucose meter was to be cleaned with an alcohol swab between each resident's use. When questioned what the facility's policy or procedure for disinfecting the glucose meter, the LPN stated she would have to check the facility's policy.

During an interview on 5/11/11 at 5:00 pm the RNM, who is also the facility's Infection Control Nurse, stated that the glucose meter is cleansed with alcohol. She also stated that the procedure had changed and at one time nurses had been disinfecting the glucose meter with bleach wipes but she thought it had been changed and now the nurses were wiping the glucose meter with alcohol swab. The RNM /Infection Control nurse could not provide any policy or procedure which addressed the disinfection of the glucose meter.

The facility's policy and procedure titled Glucometer Checks , revised 11/09 documented to clean the glucometer by wiping the outer casing with an alcohol swabs as needed to clean debris from casing.

The RNM could not produce an Infection Control Policy for disinfecting the glucose meter.

During an interview 5/16/11 at 8:20 am , the LPN, who placed the glucometer back in the medication cart stated she should have wiped the outside of the glucose meter with an alcohol swab or hand sanitizer wipe (which does not contain bleach).

Finding #3:
During an observation on 5/9/10 at 12:10 pm, in the North dining room a resident was folding a stack of clothing protectors. The resident was observed touching her nose with her hand as she was folding the clothing protectors. The resident then carried the folded clothing protectors holding them against her clothes and also placing some clothing protectors in the basket of her walker before placing them on the shelf for storage to enable residents use.

During an interview on 5/9/11 at approximately 1:00 pm the RNM stated that the resident was a former employee and she has been folding the clothing protectors as a diversional activity to keep her occupied . The RNM stated she now realizes it was an infection control concern.

10NYCRR 415.19 (a)(1-3)

Based on observation, record review and interview the facility did not maintain an environment free of accident hazards for three (#'s- 12, 62, 69) of three residents of 7 residents reviewed for a potential for accident hazards during the recertification survey. Specifically: the facility improperly affixed bed canes/ rails to three residents beds. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident # 62
The residents initial Minimum Data Set dated 2/22/11 assessed that the resident was cognitively intact.

A nurses note of 2/25/11 at 2:00pm documented that the nurse was called to the residents room to observe the resident with her right arm bent and in the bed cane and her right buttock and legs on the floor. The resident had an 8 cm skin tear on the right inner arm by her elbow. She complained of right groin and right ankle pain. A call was made to 911 and the resident was sent to the hospital. At 10:30pm the resident returned from the hospital with a Tegaderm in place to the right elbow skin tear.

During an interview with the resident on 5/16/11 at 4:36 pm the residents bed was observed to have a gap approximately 4 " between the bed cane/ rail and mattress. The resident was sitting in her wheelchair and was asked about the time she injured herself in the the bed cane. The resident said she was in bed and she was reaching for her call bell which had fallen on the floor. She stated she put her hand through the slot between the mattress and rail. She got the bell but tried to twist her hand and it got caught. She said she got a scrape near her elbow from the rail. She said she did not need stitches or a bandage at the time.

During an interview at 5:20 pm on 5/16/11 the Registered Nurse Manager (RNM) stated that on 2/15/11 she saw the resident's arm in the bed cane, her elbow was between the the rail and the mattress. She noted the skin tear when they got the resident up. She did not have a skin tear before that. The RNM stated she lowered the bed and put a mat on the floor as interventions, but did not do anything about the bed cane. The RNM stated the resident uses the bed canes for mobility still. Bed canes are what the facility has to use. She stated the bed canes have been on the resident's bed since she was admitted. The RNM stated she did not look to see if the bed canes fit properly.

During an interview with the Director of Maintenance on 5/13/11 at 7:40 am he said that the side rails/bed canes do not come on the beds. He provided information on the bed canes from the manufacturer which documented that the bed cane/rail device should be affixed to the bed so that the device butts against the edge of the mattress for both single and double devices. The Director of Maintenance stated he was not aware of this. He stated that the facility was not checking to ensure that the devices were being affixed to the beds correctly.

Resident # 69
The annual MDS of 4/5/11 documented that the resident was cognitively intact.

On 5/11/11 at 8:00am the resident was observed in bed, bed at lowest position with a mat on the floor. There was a gap between the mattress and bed cane/side rail of 3-4 inches, larger at the head of bed that toward the foot of the bed. At this time the residents roommate said that the resident does try to get out of bet at night, she said that if the resident drops her remote she will try to get it.

A Comprehensive Care Plan dated 4/7/11 for at risk for falls, documented to use bilateral bed canes as an enabler.

During an interview on 5/12/11 at 12:38 pm with the residents regular Certified Nurse Aide (CNA) he was asked if the resident could get out of bed. He said yes, one time she got out of bed and tried to move her dresser. He said if she dropped her TV remote she would lean over to try to pick it up if she was in bed.

On 5/13/11 at 8:44 am the resident's bed was observed with approximately a 4" gap between the bed cane/rail and mattress. The resident was not in the bed.

During an interview on 5/12/11 at 3:50 pm the RNM was shown the resident's bed with the gap between the bed canes and the mattress. She was asked if this could be a hazard for this resident and she said yes.

Resident # 12
The MDS of 3/15/11 documented that the resident had moderately impaired cognition.

On 5/12/11 at 9:45 am the bed in the residents room was observed to have agap between the bed cane/rail and mattress of approximately 4 ". The resident stated at that time that he was not sleeping well. He stated he thought he was a restless sleeper. He stated he uses the rails to get up and turn around. He said he has not hit himself on the rails and hasn't gotten caught in space between rail and mattress yet, but he could not say it won't happen.

On 5/13/11 at 8:50 am the residents bed was observed to have an approximate 4" gap between the bed cane/rail and the mattress. The resident was not in the room. At this time the resident's roommate said that this resident is a restless sleeper at night and has awakened him at night because of that.

The Restraint Screen dated 3/11/11 noted other device as bed against wall and bed canes. The Physical Restraint Decision Tree noted bed against wall and bed canes. A 3/14/11 note documented bed against wall for room rearrangement and bilateral bed canes used as an enabler.

There was no CCP for the bed canes/rails.

During an interview on 5/12/11 at 3:10 pm the resident's CNA was asked about the resident using the bed canes/rails. She stated the resident can use them to turn side to side, but did not think the resident could use them independently. She stated the resident gets in bed about 8:30 pm then watches TV. The CN A stated she has not seen the resident sleeping, she is not here then. The CNA said he is reliable when he tells you something.

During an interview on 5/12/11at 3:16 pm with the residents regular Licensed Practical Nurse she was shown the bed canes/rails on the residents bed and asked about the gap. She said the rail is to big, it should be closer to the mattress. That gap is not appropriate, it could be or hazard for someone who wiggled in bed. She thought the resident moved minimally in bed.

During an interview on 5/12/11 at 3: 30 pm the RNM stated the resident uses the bed canes/rails as an enabler. She stated he doesn't try to get up himself, he requires assist with bed mobility. She did not think the bed canes/rails were a hazard for for this resident. They could be a hazard for someone else.

10 NYCRR 415.12(h)(1)

Based on observation, interview and review of facility documents the facility did not identify and correct a Quality of Care deficient practice for three (#'s-12, 62, 69) of three residents observed for accident hazards. Specifically: bed canes/rails were improperly affixed to beds which did cause a skin tear to one resident. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident # 62

During an interview with the resident on 5/16/11 at 4:36 pm the residents bed was observed to have a gap approximately 4 " between the bed cane/ rail and mattress. The resident was sitting in her wheelchair and was asked about the time she injured herself in the the bed cane. The resident said she was in bed and she was reaching for her call bell which had fallen on the floor. She stated she put her hand through the slot between the mattress and rail. She got the bell but tried to twist her hand and it got caught. She said she got a scrape near her elbow from the rail. She said she did not need stitches or a bandage at the time.

Resident # 69
On 5/11/11 at 8:00 am the resident was observed in bed. The bed was in the lowest position with a mat on the floor. There was a gap between the mattress and bed cane/side rail of 3-4 inches, larger at the head of bed than at the foot of the bed.

On 5/13/11 at 8:44 am the resident's bed was observed with approximately a 4" gap between the bed cane/rail and mattress. The resident was not in the bed.

Resident # 12
On 5/12/11 at 9:45 am the bed in the residents room was observed to have a gap between the bed cane/rail and mattress of approximately 4 ".

On 5/13/11 at 8:50 am the residents bed was observed to have an approximate 4" gap between the bed cane/rail and the mattress.

During an interview with the Director of Maintenance on 5/13/11 at 7:40 am he said that the side rails/bed canes do not come on the beds. He provided information on the bed canes/rails from the manufacturer which documented that the bed cane/rail device should be affixed to the bed so that the device butts against the edge of the mattress for both single and double devices.

During an interview with the Director of Maintenance on 5/15/11 at 8:15 am he stated the bed canes/rails were here when he got here a little over a year ago. He stated that they don't do any maintenance on them other than if they slip or move. He stated his maintenance worker puts them on the beds. He stated he did not know if the maintenance worker knew how to affix them to the bed according to the manufactures specifications. He stated he did not know the bed canes/rails needed to be butted against the mattress. He further stated they don't have a system in place to check on them to make sure they fit properly and are working properly.

During an interview on 5/17/11 at approximately 3:00 pm with the Director of Nursing (DON) she was asked how the facility identifies issues for the Quality Assurance Committee(QAC) to address. She stated she tracks quality indicators reports, audits, morning reports and other areas. Then they develop action and audit areas of a specific concern. The DON was asked if the facility did environmental rounds. She said yes, they go into resident rooms, look at equipment, beds, bed canes/rails. She stated they did not identify the problem of the bed canes improperly affixed to the beds.

10 NYCRR 451.27(a-c)

Based on observation and staff interviews during the standard recertification survey, the facility did not provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment. Specifically on 2 of 2 units the residents personal toiletry items such as tooth brushes and hair brushes were not properly stored and labeled and on 1 of 2 units the tub and shower stretcher was not maintained in a clean condition. 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

Observation of the residents bathrooms on the South Unit on 5/17/11 at 10:30 am identified the following:

Room S 104 - comb on top shelf in shared bathroom not labeded and bed pan in bathroom was not labeled.
Room S 110 resident's comb , toothbrush , sarna lotion, toothpaste, and mouth wash were not labeled.

During an interview on 5/17/11 at 10 :45 am, the certified nurse assisitant (CNA) stated that usually the resident in the bed by the door uses the top shelf but there really is no way of being certain which toiletry items belong to which resident if the items are not labeled.

Finding #2

Observation of the residents rooms on the North Unit on 5/17/11 at 1:45 pm identified the following :

Room 116 there was an unlabeled hair brush and comb on the top shelf and an unlabeled comb and deodorant on the lower shelf .

During an interview on 5/17/11 at 1:50 pm , the CNA stated the the resident's combs, deodorant and hair brush should be labeled with the resident's name.

Finding #3

Observation of the tub room on the South Unit on 5/17/11 at approximately 11:00 am identified the following:
The tub had soap scumb , small brown particles and brown stains on the inside and crusted tannish matter on the outside.
The shower stretcher was observed to have some tan matter and brown particles on the mesh under the blue shower strecther mat.

During an interview on 5/17/11 at 11:15 am , the CNA stated that the tub is used for several of the residents.

During an interview on 5/17/11 at 3:00 pm the Registered Nurse / Unit Manager (RN/UM) stated that the tub and shower stretcher needed to be cleaned and should be cleaned after each resident's use.

10NYCRR 415.5(h)(2)

Based on observation and staff interview the facilty did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable during the recertification survey. Specifically, on 2 of 2 units for 2 of 4 medication carts, and one of two refrigerators the facility did not ensure stock medication that had expired was removed from the medication carts and refrigerators. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Findings #1:
During an observation on 5/11/11 at 2:45 pm of one of the North unit medication carts a stock bottle of Zinc was observed to have an expiration date of 8/2010, Calcium 600 with Vitamin D 400 was observed to have an expiration date of 4/201, Vitamin C expiration date of 2/2011.

During an interview on 5/11/11 at 3:00 pm the Licensed Practical Nurse (LPN) stated the medication carts are checked weekly and the pharmacist also checks the medication carts. She was not sure what the pharmacist checks for but the carts were checked recently and there should be no issues.

During an interview on 5/11/11 at 3:40 pm the Registered Nurse Manager (RNM) stated there should be no medications that are expired on the medication carts. She stated the nurses should be checking the cart and checking the stock medications before administration of the medications. She had the nurse remove the medications from the cart that had expired.

Findings #2:
During an observation on 5/11/11 at 2:15 pm of one of the South medication carts a stock bottle of mint antacid was observed to have an expiration date of 2/2011, a bottle of Bisacodyl which was opened 7/8/10 had an expiration date of 5/2011.

During an interview on 5/11/11 at 2:55 pm the LPN stated she checks the medications weekly, she disposes of the medications when she finds them. The LPN was shown the expired medications and she promptly removed the medications from the cart. She further stated she was not aware of any expired medications in the medication cart or the medication room refrigerator.

During an interview on 5/11/11 at 3:20 pm the RNM stated that the LPN's check the medication carts and medication room refrigerators, she does not maintain them nor does she carry keys to access these rooms.

Finding #3:
During an observation on 5/11/11 at approximately 2:35 pm the South Unit medication room refrigerator was observed to have a bottle of influenza that had expired 3/31/2011.

During an interview on 5/11/11 at 2:55 pm the LPN stated she checks the medications weekly, she disposes of the medications when she finds them. The LPN was shown the expired medications and she promptly removed the medications. She further stated she was not aware of any expired medications in the medication cart or the medication room refrigerator.

During an interview on 5/11/11 at 3:20 pm the RNM stated that the LPN's check the medication carts and medication room refrigerators, she does not maintain them nor does she carry keys to access these rooms.

10 NYCRR 415.18 (d)

Based on observation and interview the facility did not store, prepare, distribute and serve food under sanitary conditions in the main kitchen and in one of two dining rooms observed during the recertification survey. Specifically: there was lack of appropriate hand washing and handling of eating equipment in the North dining room; in the main kitchen there was lack of appropriate hand washing, food was not held at the proper temperatures, there was lack of appropriate cleaning/storage of eating equipment and equipment was not maintained in sanitary condition. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

During observation of lunch on 5/9/11 at 12:00 pm in the North Unit 's dining room the following was identified :

Finding #1

At 12:05 pm the Registered Nurse / Unit Mananger (RN/UM) held the inside and the rim of a resident's sippy cup and straw with ungloved hands / fingers while feeding a resident.

At 12:30 pm the RN/UM was feeding a resident and had to leave the dining room to answer the phone. The RN/UM returned to the dining room and went to another resident's table to inform the resident that someone had called and then proceeded feeding the same resident without washing her hands or using the hand sanitizer.

During an interview at approximately 1:00 pm , the RN/UM stated she did not realize that her ungloved hand /fingers had touched the inside of the resident's cup and straw and she had not used the hand sanitizer after talking on the phone and prior to entering the dining room

Finding #2

At 12 :25 pm an LPN held the inside and rim of resident's sippy cup and straw with ungloved hands./ fingers while feeding a resident.

During an interview at approximately 1:30 pm the LPN stated that she did not realize that she had touched the inside of the residents sippy cup and the straw with her ungloved hand .

Finding #3

At 12 :35 pm a Certified Nursing Assistant (CNA) interrupted feeding a resident to adjust the resident's recliner and did not wash his hands or use the hand sanitizer before continuing to feed the resident.

During an interview on 5/9/11 at 1:05 pm the CNA stated he should have washed his hands after adjusting the resident recliner.

Kitchen Observations

Finding #1

On 5/9/11 at 8:30 am the sinks at the doorway entrance of the kitchen and the other sink located at the other side of the kitchen did not have any soap. There weren't any bottles of soap in the soap dispenser units.

During an interview on 5/9/11 at 8:45 am, the Food Service Director (FSD)stated that the staff usually use the sink in the bathroom which was located across the hall from kitchen doorway entrance. He also stated he did not know why the soap dispensers at the 2 sinks in the kitchen did not have any soap containers.

Finding 2

On 5/16/11 at 8:14 am during the tray line a Food Service Worker (FSW) was observed at his station. He had gloves on and was touching a tray, inside the lids for the entree items on the steam table but did not change his gloves. During an interview with this FSW at 8:30 he stated he did not wash his hands before putting the gloves on before trayline. He stated he usually uses the restroom across the hall to wash his hands.

Also during this tray line service the cook was observed handling the entree food items with a hole in his right glove. He used a towel to bring over a tray of pancakes but did not change his gloves. When the Cook did change his gloves he did not wash his hands first. During interview with the Cook at this time he stated he should have washed his hands.

Finding 3

On 5/16/11 At 8:15 am a box of unpasturized eggs were observed sitting on the floor in the kitchen near the trayline. During an interview with the FSD on 5/17/11 at 11:10 am he stated the eggs were delivered at 7:45 am on 5/16/11. He stated he tries to put the food delivery away as quickly as possible. He puts the produce away first, then frozen foods and then refrigerated items and works his way through. He stated deliveries used to come at 10:00 am and there was more help to put things away. He did not know why the deliveries have been coming earlier for the past month.

On 5/16/11 at 1:21 pm the temperatures in the 2 reachin coolers were 52 & 56 degrees respectively. The thermometers inside the coolers were 45 and 42 degrees respectively. At this time the night Cook stated the outside thermometers must not be working, she did not know how long.

Finding 4

The walk in refrigerator/cooler had a broken gasket near the handle, the refrigerator handle was dirty and the edge of the refrigerator was dirty with what looked like mold on 5/16/11 at 8:50 am. The handle of this cooler was also dirty with built up grime. The handles of the cooks cooler near the prep area also were dirty with grime. The Day Cook stated at that time that he cleans as he goes. The cooks clean their side and FSWs clean their side.

During an interview with the FSD on 5/17/11 at 11:10 am he stated he did not know how long the gasket has been broken. He said the black stuff on edge of door (mold) is from condensation. If it is cleaned daily, there should not be black buildup.

Finding 5

During an observation in the dish room at 9:38 am on 5/10/11 a FSW was stacking lids, trays and dishes on each other while they were wet. At 10:00 AM the FSW said she normally dry dishes with a cloth but none were available today, that is why she is stacking them wet. Then she went and got a towel and dried trays, lids and dishes. She said she was trained to dry dishes with a towel.

During an interview the FSD on 5/17/11 at 9:57 am he stated-Staff are supposed to let things air dry before putting them away

10NYCRR415.14(h)

Based on observation, medical record review and staff interview the facility did not ensure the assessment accurately reflected the resident status. Specifically, for 1 ( Resident #12) of three residents reviewed the facility did not ensure the residents' pressure ulcer was accurately assessed on the Minimum Data Set (MDS). This caused no actual harm but has the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident # 12:

The resident was admitted on 10/27/10 the MDS dated 4/7/11 section M assessed the resident was at risk for the development of pressure ulcers and documented the resident does not have any unhealed pressure ulcers.

The resident was observed being transferred to the bathroom on 5/13/11 at 1:00 pm by a Certified Nurses Aide who was carrying the residents wound vacuum ( used to treat pressure sores).

The physicians' interim renewal note dated 3/10/11 and 5/5/11 documented that the resident has a buttock pressure ulcer.

The physicians' order dated 5/8/11 documented a wound vacuum (vac) to a stage 3 area on the left buttocks.

The physician order dated 3/17/11 documented off loading at all times for the area and the wound vac treatment continued.

The wound care center progress note dated 2/8/11 documented the patient was being seen for an ulcer on the coccyx. The note further documented that the resident had a stage 3 decubitus ulcer on the coccyx area.

The wound care center progress note dated 4/21/11 documented the resident was being treated at the wound care center for a coccygeal/sacral pressure ulcer that the resident has had since 12/2010.

During an interview on 5/10/11 at 9:55 am the Licensed Practical Nurse (LPN) on the South Unit stated this resident has a pressure ulcer that originated as what looked like a boil but is now open.

During an interview on 5/17/11 at 10:10 am the attending physician stated the resident started with an abscess on her buttock but it is currently a pressure ulcer and the resident is being treated at the wound care center for the pressure ulcer.

During an interview on 5/18/11 at 8:50 am the MDS Coordinator stated that she did not document a pressure area on the MDS as the resident does not have a pressure area. She said that the area was an abscess. When further questioned with the documentation provided by the wound care center which documented the resident has a pressure area and the documentation by the physician, which also documented the resident had a pressure ulcer the MDS coordinator said she would challenge that documentation.

10NYCRR 415.11 (b)

Based on observation, medical record review and staff interview the facility did not ensure that a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity was completed. Specifically, for one ( Resident # 12) of three residents reviewed for pressure ulcers the facility did not ensure a resident with a pressure ulcer was accurately assessed on the comprehensive Minimum Data Set (MDS). This is evidenced by the following:

Resident # 12:
The resident was admitted on 10/27/10. The significant change MDS dated 1/6/11 section M assessed the resident was at risk for the development of pressure ulcers and documented the resident does not have any unhealed pressure ulcers.

The resident was observation on 5/13/11 at 1:00 pm being transferred the resident was transferred to the bathroom as the Certified Nurses Aide carried the residents wound vacuum (used as a treatment for pressure sores).

The wound tracking sheets dated 1/3/10 documented the size as 2.6 x 2.8 x 1.8 centimeters
stage 3. (This has a line through it indicating an error was made). Also documented was a moderate amount of drainage, odor and wound bed has 50% granulation and 50 % slough there is undermining also documented. It is also documented the resident is being referred to the wound care center on 1/19/11, the wound is being irrigated with normal saline, pack lightly with Aquacel rope and dry dressing every day.

The physician order dated 12/9/10 documented pressure mapping to buttocks and coccyx.

The physician order dated 1/11/11 documented left buttock with a stage 3 wound and Bactrim DS was ordered twice a day for 10 days.

The physician order dated 2/23/11 documented a wound vacuum treatment to a stage 3 on the buttocks.

Interview on 5/10/11 at 9:55 am with the Licensed Practical Nurse on the South Unit who stated when asked if any residents currently have any pressure sores the LPN stated this resident has one that originated as what looked like a boil but is now open.

Interview on 5/17/11 at 10:10 am with the attending physician who stated the resident started with an abscess on her buttock but it is currently a pressure ulcer and the resident is being treated at the wound care center for the pressure ulcer.

Interview on 5/18/11 at 8:50 am the MDS Coordinator stated that she did not document a pressure area on the MDS as the resident does not have a pressure area. She said that the area is an abscess. When further questioned with the documentation provided by the wound care center which documented the resident has a pressure area and the documentation by the physician, the MDS coordinator said she would challenge that documentation. She reiterated the resident has an abscess.

10NYCRR 415.11(a) (3) (i)

Based on record review and interview the facility did not develop a comprehensive care plan that included measurable objectives and timetables to meet the residents medical, nursing and psychosocial needs for 1 (#12) of 4 residents reviewed of 30 residents identified through Minimum Data Set and chart review during the recertification survey. Specifically: problems of risk for dehydration and abnormal labs were identified but specific measurable interventions and timetables were not specified. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident #12
The resident was admitted to the facility on 3/8/11 of patellar and T-9 fractures, Gastroesophageal Reflux Disease, hydronephrosis. The Minimum Data Set of 3/15/11 documented a weight of 142 lbs for the resident.

The Comprehensive Care Plan dated 3/15/11 documented the resident was at risk for dehydration and abnormal lab data of Albumin of 3.0 (normal is 3.4-5) and BUN of 50 normal is 7-23). There were no goals listed for these problems. The interventions for the problem of at risk for dehydration were to monitor for signs/symptoms of dehydration, but did not indicate what the signs/symptoms of dehydration were. The intervention to offer adequate fluids of 1931 cc per day, did not specify how to do this such as how much fluid to put on the residents trays and what to give between meals. The intervention for the problem of abnormal labs was to monitor lab data, there were no specific interventions addressing what interventions would bring the abnormal lab data ( low albumin ) back to normal.

During an interview on 5/13/11 at 12:30 pm the Diet Technician (DT) stated the Registered Dietitian (RD) does the Care Plan for Nutrition and writes in the interventions for the problems identified. She did not know why the RD did not address interventions for the low albumin. The DT stated that when she was made aware on 5/4/11 of the lower albumin level of 2.8 she recommended the intervention of giving the resident the protein supplement of Prostat 101. The physician ordered it and it was placed on the care plan.

10 NYCRR 415.11(c)(1)

Based on interview and record review the facility did not review and revise the resident's plan of care for one (# 62) of three residents observed of 7 residents reviewed for accident hazards during the recertification survey. Specifically: bed cane/rails were not documented on the residents comprehensive care plan as an assistive device. Additionally, after the resident received a skin tear from a bed cane/rail there was no revision of the comprehensive care plan to prevent repeat injury from the bed cane/rail. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident #62
The residents initial Minimum Data Set dated 2/22/11 assessed the resident was cognitively intact.

A nurses note of 2/25/11 at 2:00pm documented that the nurse was called to the residents room to observe the resident with her right arm bent and in the bed cane and her right buttock and legs on the floor. The resident had an 8 cm skin tear on the right inner arm by her elbow. A call was made to 911 and the resident was sent to the hospital. At 10:30 pm the resident returned from the hospital with a Tegaderm in place to the right elbow skin tear.

During an interview with the resident on 5/16/11 at 4:36 pm the residents bed was observed to have a gap approximately 4" between the bed cane/ rail and mattress. The resident was sitting in her wheelchair and was asked about the time she injured herself in the the bed cane. The resident said she was in bed and she was reaching for her call bell which had fallen on the floor. She stated she put her hand through the slot between the mattress and rail. She got the bell but tried to twist her hand and it got caught. She said she got a scrape near her elbow from the rail. She said she did not need stitches or a bandage at the time.

During an interview on 5/16/11at 5:20 pm the Registered Nurse Manager (RNM) stated that on 2/15/11 she saw the residents arm was in the bed cane, her elbow was between the rail and the mattress. She noted the skin tear when they got the resident up. The RNM stated she lowered the bed and put a mat on the floor as interventions, but did not do anything about the bed cane. The RNM stated the resident uses the bed canes for mobility still. Bed canes are what the facility has to use. She stated the bed canes have been on the resident's bed since she was admitted. The RNM stated she did not look to see if the bed canes fit properly.

Review of the resident's comprehensive care plan on 5/16/11 found no documentation of the resident using bedcanes/rails.

During the interview at 5:20 pm on 5/16/11 the RNM stated that she lowered the bed and put a mat on the floor as interventions (on the care plan). She stated she did not do any interventions to prevent injury from the bed cane. She stated the resident uses the bed canes for mobility still. She stated the bed canes should have been on the resident's care plan but could not find them on it. The bed canes were found documented on the CNA Care Plan sheet found in the residents room (this sheet was updated 3/1/11). The RNM did confirm that the bed canes were on the resident's bed since her admission.

During an interview on 5/17/11 at 10:30 am the resident's physician stated he could not remember the incident. He was asked what he would have done if he had known the bed canes caused the injury. He stated he would have talked with the resident because she is cognitively intact. He would have discussed with her, if she used the bed cane/rail and also look at the call bell and come up with some back up system if she dropped it.

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

Based on resident and staff interview the facility did not ensure the resident received prompt efforts by the facility to resolve grievances that the resident may have during the recertification survey. Specifically, for one resident (# 75) of four residents out of a total of 18 residents interviewed about personal property the resident reported a missing necklace and staff did not follow up to ensure all efforts to locate the missing item were implemented. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

The Minimum Data Set of 4/12/11 under the section the Brief Interview for Mental Status assessed that the resident had no cognitive impairment.

During an interview on 5/11/11 at 1:39 pm the resident stated that the facility never got back to her after she complained of a necklace being missing this past Christmas. The missing necklace was reported to the evening supervisor. The resident stated that the supervisor and and my daughter came into my room to look for it, but didn't find it. The resident stated no one ever came back to let me know results of their investigation.

During an interview on 5/15/11 at approximately 4:00pm the Evening Supervisor stated that the resident told him that she had a wrapped present under her Christmas tree and it was missing. He stated that he and the daughter searched the room extensively but couldn't find it. He stated he did not report it to anyone else or fill out a tracking form. He said normally he would have filled out a tracking form.

During and Interview on 5/11/11 at 2:35 pm the Director of Social Services stated the missing necklace was not reported to her, and she did not have a form in her file for reporting the missing necklace. She stated a tracking form should be initiated for any missing items, they are available at the nursing station. She was asked what more she would have done if she had received the missing item tracking form. She said we would search the room and let each department know so they could look in their area. I would have done more investigation. I would have followed up with her and her family if I had known.

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

Based on medical record review and staff interview during the recertification survey, the facility did not ensure review of the resident's total program of care, including medications and treatments, at each visit for one (#73) of ten residents reviewed for unnecessary medications. Specifically, the physician did not ensure documented evidence for review of Zyprexa (an atypical antipsychotic medication with a black box warning that states use may increase risk of cardiovascular or infection-related death in elderly patients with dementia and that it isn't approved to treat patients with dementia -related psychosis) use with the resident at each visit for clinically pertinent rationale and adequate indication for continued use. This resulted in no actual harm with the potential for more than minimal harm, that is not immediate jeopardy. This is evidenced by:

Resident #73
The resident was admitted on 6/12/09 with anxiety, depression and history of urinary tract infections. The Minimum Data Set (MDS) dated 10/12/10 assessed the resident had severe cognitive impairment. It noted no signs or symptoms of delirium. It also assessed the resident as having no psychosis or behavior problems. It lastly noted that the resident received an antipsychotic, anti anxiety, and antidepressant medication in the prior seven days.

Routine physician orders dated 1/4/11, 3/2/11 and 5/3/11 documented an order for Zyprexa 5 mg once a day for agitation.

Physician's renewal and progress notes dated 11/1/2010, 12/29/10, 1/4/11, 3/2/11, 3/29/11, 3/30/11 and 5/3/11 did not p rovide documented evidence of clinically pertinent rationale or adequate indication for the continued use of Zyprexa with the resident and did not document how the benefit of the continued Zyprexa use outweighed the risks. These notes addressed the resident having signs and symptoms of depression, sadness, and weepiness.

During an interview on 5/16/11 at 3:10 pm the attending physician, stated he had not been using Zyprexa with the resident for psychotic signs or symptoms, but that he had used it an attempt to improve her mood and enhance her Major Depressive Disorder in the face of anxiety. He verbalized his rationale for continued use of the Zyprexa may have not been clearly documented in his notes. He stated the Zyprexa had never been used for behavior or psychosis. He stated the resident cried almost every time he talked to her. He stated he knew weepiness was not an adequate indication for use of Zyprexa but reiterated that his goal for use was enhancement of her mood along with other psychotropic medications. He stated since he had not documented his rationale for continued indication and use without reduction of the Zyprexa in his notes in the resident's medical record, he would be sure to look at this, reevaluate and document it thoroughly at his next visit.

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

Based on observation, medical record review and staff interview during the recertification survey, the facility did not develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for one (#88) of three residents reviewed for abuse, out of eighteen residents interviewed. Specifically the facility did not ensure staff/consultant employees operationalized the facility's written policy and procedure for resident abuse reporting and investigation for one resident's report of abuse. Additionally, the facility did not ensure consultant employees received education and training on the facility's abuse reporting and investigation protocol. This resulted in not actual harm with the potential for more than minimal harm. This is evidenced by:

Resident #88
The resident was admitted on 1/28/11 with diagnoses of Type II Diabetes, macular degeneration, and depression and anxiety. The Minimum Data Set (MDS) dated 2/4/11 documented that the resident had intact cognition. It also noted the resident as having good recall. It documented that the resident was independent in bed mobility and transferred with setup help only. Her vision was noted as severely impaired on this MDS.

During initial interview with the resident on 5/9/11 at 2:19 pm, she was questioned in regards to rough treatment by staff. She stated one morning she was in bed, a Certified Nursing Assistant (CNA) abruptly pulled the sheets right off her bed. She stated the CNA roughly got her out of bed by pulling on her arm and had done this so quickly that the resident almost fell. She stated the CNA hurt her arm and was rushing with her to get her out of bed. She stated that this happened about two months ago. She stated that she did not report this incident to anyone at first, but then the next morning, the CNA did the same thing to her again. She stated that this was when she went to the head nurse to report the incident. She stated that while she was reporting it to the nurse, the CNA overheard her and admitted to having done this. She stated that both incidents occurred a little bit after 7:30am, but that she couldn't't recall the specific dates. She could not recall the CNA's name, and stated she had never seen her before. She stated she didn't't know what happened after she reported it, but stated that it hadn't happened again. The resident stated the CNA probably thought she was being funny and that the staff at the facility probably came to the conclusion that the CNA didn't mean anything by it. She stated she also talked to the psychologist about the incidents and the psychologist also told her that the CNA probably didn't mean anything by it. Since that time, the resident stated she hadn't heard anything more about it.

A " Cognitive Loss/Dementia " care plan dated 2/4/11 documented that the resident had no long term memory impairment with mild short term memory loss and the resident was independent in decision making. An update in this care plan on 4/2/11 noted that the resident had no changes in her cognitive status.

An " ADL Function/Rehab Potential " care plan dated 2/7/11 noted the resident as being independent with setup for bed mobility and transfers, and as being independent in walking with a wheeled walker.

A care plan for " Visual Function " dated 2/4/11 noted that the resident was legally blind and that staff were to announce themselves when entering the room.

There was no documented evidence in the Nurse's Note that the resident had verbalized concerns with rough handling by staff with care.

A psychotherapy progress note dated 4/18/11, written by the facility's consultant psychologist, documented that the resident verbalized some anxiety regarding activity of daily living (ADL) issues. This notation was vague and provided no specific information into what the resident had verbalized. It was then noted that the psychologist looked with the resident at the possibility of the resident's anxiety in terms of her interpretation. It was noted that the more the psychologist addressed this with her, the less anxious the resident became. It was noted that in general there were some issues with trust and that she was frightened by a visual occurrence (seeing small children whom she knew were not there). It lastly documented that the psychologist spoke with the Registered Nurse Unit Manager (RNUM) about the resident having transient visual hallucinations and about ADL care issues.

During a second interview with the resident on 5/13/11 at 9:08 am, she again stated that the incident of rough treatment by the CNA occurred two months ago. She repeated the incident exactly as she had described it in the initial interview, with no variation. She again could not recall the name of the CNA, but stated she knew the CNA was small in frame and stature.

The facility's policy for resident abuse reporting and investigation last revised on 1/27/09 documented that it was the responsibility of all facility employees, consultants, and physicians to immediately report any incident or suspected incidents of resident abuse, mistreatment, neglect, theft, misappropriation of property or any resident injuries of unknown source. It also documented that all reports of resident abuse neglect, mistreatment, theft, misappropriation of property and any injuries of unknown source should be promptly and thoroughly investigated by facility management.

During an interview with the Registered Nurse Unit Manager (RNUM) on 5/13/11 at 9:15 am, she was unaware that the resident had any issues of staff treatment. She stated that the psychologist only came in the evening and that maybe she had reported the information from her 4/18/11 progress to the evening RN supervisor. She stated if it did occur then it should be documented in the Nursing Notes and there should be an investigation into it. She stated if there was an investigation into it, then the facility Social Worker (SW) would have the investigation.

During an interview with the facility SW on 5/13/11 at 9:24 am, she stated she was unaware of any rough treatment by staff having occurred with this resident. She stated that she had no investigation into abuse for this resident.

During interview with the consultant psychologist on 5/13/11 at 11:32 am, she stated she reported the resident having verbalized being yanked out bed by staff to the evening RN supervisor after her 4/18/11 visit with the resident. She stated, however, that she had reported this to the evening supervisor in the context of the resident having visual hallucinations of Lilliputians (i.e. hallucinations about little people).

During an interview with the evening Registered (RN) supervisor on 5/13/11 at 3:42 pm, who had been working on the night of 4/18/11, she stated she recalled the psychologist giving her information about the resident having hallucinations of little people, but stated she did not recall anything about the resident having concerns related to caregivers, activities of daily living, or having been yanked out of bed or roughly treated by staff. She stated that if she had been informed of such, then she would have immediately informed the Director of Nursing Services about it. She stated she would have immediately begun an investigation into possible abuse having occurred, and would have sent the caregiver in question home until the investigation was completed.

During an interview on 5/16/11at 9: l 0 am with the SW, she stated that she trained staff on abuse and/or neglect on orientation and annually. She stated that she did not provide training to any staff other than facility staff and stated that she believed the Employee Health Nurse would have been responsible for education of consultants.

During interview with the Employee Health Nurse on 5/16/11 at 9:20 am, she stated that she and the social worker shared the responsibility of educating staff on abuse and neglect in orientation and yearly. She stated that she did not generally do training on the facility abuse prohibition program with consultants because they are licensed staff. She stated she thought she didn't have to do this training with consultants since they would have had to go through the New York State mandated abuse training for their licensure.

During a final interview with the facility social worker on 5/16/11 at 9:35 am, she stated that if a resident had verbalized any concerns with rough care, even if it had been in the context of hallucinations, then she would have expected the psychologist to report it to the nursing supervisor so the staff person in question could be removed from care for protection of the residents and so that investigation into the incident could have been completed to determine whether or not possible abuse had occurred.

10 NYCRR 415.4 (b)

Based on medical record review and staff interview during the recertification survey, the facility did not ensure that the drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist for two (#53 and 83) of ten residents reviewed for unnecessary medications. Specifically, the facility did not ensure that blood pressure medication regime was reviewed at least once a month by a pharmacist in regards to adequate monitoring for one resident and did not ensure that an atypical antipsychotic administered to one resident was reviewed at least once a month for adequate indication and continued rationale for use without gradual dose reduction for one resident . This resulted in no actual harm but had the potential for more than minimal harm that is not immediate jeopardy:

Resident #83
The facility did not ensure that the resident's blood pressure medication regime was reviewed at least once a month by a pharmacist in regards to adequate monitoring.

The resident was admitted on 2/1/11 with diagnoses of cerebrovascular accident, dementia, and chronic obstructive pulmonary disorder. The Minimum Data Set (MDS) dated 2/8/11 noted that the resident had no signs or symptoms of delirium, that the residents had moderately impaired cognition.

Admission physician orders dated 2/1/11 and routine physician orders dated 3/31/11 and 4/28/11 documented orders for administration of Metoprolol (blood pressure medication) 25 milligrams twice a day and Lisinopril (blood pressure medication) 20 milligrams once a day, with no parameters for administration or frequency for blood pressure monitoring.

Facility documentation of blood pressure monitoring was completed every shift for the first four days after admission and noted the resident's blood pressures as: 111/68, 101/56, 143/69, 83/46, 106/63, 110/60, 134/54, 110/56, and 108/62. Facility documentation of blood pressure monitoring was completed monthly thereafter and was noted as: 110/60 on 2/10/11, 90/58 on 3/2/11, 169/91 on 4/5/11, and 132/76 on 5/3/11. Variations in the resident's blood pressure were noted over time with incidents of low blood pressures recorded.

There was no documented evidence of consultant pharmacist reports reviewing the facility's monitoring of this resident on multiple blood pressure medications.

During interview with the consultant pharmacist on 5/17/11 at 9:40 am, she stated that when a resident was on two or more blood pressure medications, she would typically recommend weekly blood pressure monitoring. She stated in regards to this resident's variations in blood pressure after admission and monthly thereafter, she would have recommended closer monitoring of the resident's blood pressure because of the noted low blood pressures and possibly to have them taken at different times of the day. She stated that during her monthly reviews she had not specifically evaluated this resident's blood pressure medications for adequate monitoring.

Resident #73
The facility did not ensure that Zyprexa (an atypical antipsychotic medication with a black box warning that states use may increase risk of cardiovascular or infection-related death in elderly patients with dementia and that it isn't approved to treat patients with dementia -related psychosis) administration was reviewed at least once a month for adequate indication and continued rationale for use without gradual dose reduction for one resident.

The resident was admitted on 6/12/09 with anxiety, depression and history of urinary tract infections. The MDS dated 10/12/10 assessed the resident had severe cognitive impairment. It noted no signs or symptoms of delirium. It also assessed the resident as having no psychosis or behavior problems. It lastly noted that the resident received an antipsychotic, anti anxiety, and antidepressant medication in the prior seven days.

Routine physician orders dated 1/4/11, 3/2/11 and 5/3/11 documented an order for Zyprexa 5 milligrams (mg) once a day for agitation.

There was no documented evidence of consultant pharmacist reports reviewing the indication and continued rationale for use of Zyprexa over time with the resident and without gradual dose reduction.

During interview with the consultant pharmacist on 5/16/11 at 2:45pm, she stated that per her records, the resident had been seen by the psychiatrist in December 2010 and that he was monitoring her for psychotropic medication use. She stated that since the psychiatry consultation listed the Zyprexa at the top of the note, she believed that the psychiatrist had reviewed the antipsychotic medication for possible dose reduction or continued use. She stated she would not make a recommendation to the attending physician regarding indication for continued use or possible dose reduction of antipsychotic medications if she saw evidence that psychiatry had reviewed them on consultation.

10 NYCRR 415.18 (c) (1)

Based on interview and record review the facility did not ensure the resident maintained acceptable parameters of nutrition for one ( #12) of 4 residents reviewed for nutrition. Specifically: reweighs were not being done and weight loss was not addressed timely, the resident's low albumin was not addressed timely, fluid intake was not being monitored over time in a resident with periodic episodes of diarrhea. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident #12
The resident was admitted to the facility on 3/8/11 with diagnoses of patellar and T-9 fractures, Gastroesophageal Reflux Disease, hydronephrosis. The Minimum Data Set of 3/15/11 documented a weight of 142 lbs for the resident.

The Comprehensive Care Plan for Nutrition dated 3/15/11 documented to monitor weights and problems of potential for dehydration and abnormal labs of Albumin and BUN.

Record review of weekly weights documented: 3/14/11 wt was 142 lbs; 3/21/11 wt was 139 lbs; 3/28/11 wt was 143.7 (no reweigh was done); 4/4/11 wt was 149 lbs (no reweigh was done); 4/11/11 wt was 143.3 ( no reweigh was done); 4/18/11 wt was 143.3; 4/24/11 wt was 139.3 ( no reweigh was done); 5/5/11 wt was 134.3 (no reweigh was done until 5/10/11. That weight was 132.8 lbs.

The facility policy revised on 7/22/04 for Weight Monitoring documented that it is the facility policy to monitor resident's weights from the time of admission and to provide interdisciplinary support and or intervention to avert adverse trends. The policy further documented that any fluctuation of three lbs or more must be reported to the nurse manager and will require a reweigh by a licensed nurse. A three pound fluctuation in a resident's weight will be referred to the Nutrition Alert Committee.

During an interview the Registered Nurse Manager (RNM) on 5/13/11 at 11:30am stated that they do reweighs when there is a 5 lb fluctuation from the previous week The reweigh should be done the next day or in a couple of days. She stated the Diet Technician comes to the unit and takes the weights and lets the Dietitian (RD) know who needs to be reviewed for weight loss.

During an interview the Diet Technician (DT) on 5/13/11 at 12:30pm stated that a reweigh should be done that day or the next day. She stated the resident had a progressive weight loss. She stated that no one did a reassessment of the residents weight loss since there was no assessment form in the resident's medical record. At this time the Social Worker entered the conversation and stated that this resident was noted in morning report however there was no nutrition alert for him. The DT stated she felt the resident needed supplementation sooner, however he refused.

There was no documentation of the weight loss being addressed until 5/10/11 when the physician wrote an order for the RD to review the weight loss. The p hysician also wrote an order on 5/10/11 for 2 cal HN, 120 cc by mouth 3 x day secondary to the residents weight loss.

Laboratory results on 3/10/11 documented an Albumin, which is a measure of protein status, of 3.0 (normal is 3.4-5.0) and a BUN, which is a measure of kidney function, of 50 (normal is 7-23). Laboratory results of 3/17/11 documented Albumin of 2.8 and BUN of 32.

The test results from 3/10/11 were noted on the dietary assessment of 3/15/11. Also documented was that the resident was at high nutritional risk. There was no documentation on this assessment or the Comprehensive Care Plan that addressed what interventions would be done to improve the low Albumin value.

During an interview on 5/13/11 at 12:30 pm the Diet Technician (DT) stated the Registered Dietitian (RD) does the Care Plan for Nutrition and writes in the interventions for the problems identified. She did not know why the RD did not address interventions for the low albumin. The DT stated that when she was made aware on 5/4/11 of the lower albumin level of 2.8 she recommended the intervention of giving the resident the protein supplement of Prostat 101 because something needed to be done.

On 5/4/11 the physician wrote an order for Prostat 101( protein supplementation), one oz. by mouth 2x day due to low albumin level.

The Comprehensive Care Plan for Dehydration/Fluid Maintenance dated 3/17/11 documented to record food and fluid consumption on meal monitoring sheet.

Review of the meal monitoring sheets showed that of the 41 days from 4/1/11 to 5/11/11 the resident did not meet his fluid need of 1931 cc or the sheets were not totaled. Not all of these sheets were yellowed out.

Nurses notes of 4/13/11, 4/17/11, 4/19/11, 4/22/11, 4/30/11 documented that the resident had loose stools.

A physician progress note of 5/4/11 documented the resident had castrointestinal issues with chronic constipation complicated by episodes of diarrhea. The resident had an ileus that resolved. The residents intake is diminished and he has lost weight and has a low Albumin at 2.8. The plan was to hold all laxatives pending results of C Difficile test.

During an interview a Licensed Practical Nurse on 5/13/11 at 10:am stated that the night nurse totals fluid intake on that days monitor sheets, then highlights the next days sheets for the residents who did not meet their fluid needs. that is how we know to encourage more fluid for that resident. She stated the sheets are filed away. She said that the CNAs would not be able to tell if a resident had several days of not meeting their fluid needs.

During an interview on 5/13/11 at 11:50 am the RNM stated that the CNAs and nurses know to increase fluid when the name on the monitor sheet is yellowed out. She stated she did not know how they would determine who is not consistently meeting their fluid needs over a period of time like a week or a month.

10NYCRR415.12(i)(1)

Based on observation, medical record review and staff interview the facility did not ensure that care was provided in accordance with the resident's written plan of care for 1 ( # 51) of 4 residents reviewed of 9 residents screened for psychotropic medications during the standard recertification survey. Specifically, the facility did not monitor the resident's behavior and did not monitor the psychotropic medication regime for effectiveness, side effects and lowest effective dose. This resulted in no actual harm with the potential for more than minimal harm that is not immedicate jeopardy. This was evidenced by the following:

The resident was admitted to the facility on 12/9/08 with the diagnoses of dementia with delusions, hypertension and depression. The Minimum Data Set (MDS) dated 2/24/11 assessed the resident as rarely / never understands and rarely /never is understood and has severly impaired cognitve skills for daily decision making.

Observation of the resident on 5/10/11 at approximately 10:30 and on 5/16/11 at approximately 1 :15 pm revealed the resident to be resting quietly and calmly in the recliner in her room.

The resident's Comprehensive Care Plan (CCP) for Psychotropic Drug Use documented on 1/24/10 that the resident takes Haldol related to dementia and delusions and an interrvention was to assess and evaluate for effectiveness and or adverse effects monthly and prn. There was no documentation of the monthly assessment and effectiveness of Haldol.

There was no documentation of the effectiveness of the Haldol noted in the nurses notes.

During an interview on 5/15/11at 2:15 pm, the CNA stated that if resident is crying or calling out, she notifies the nurse and turns on the TV for the music channel. There was no daily behavior tracking sheet for documentation of the resident's behavior.

During an interview on 5/15/11, the LPN stated that the resident does not have a daily or monthly behavior tracking sheet. She stated that the resident's behavior would be documented in the nurses notes.

During an interview on 5/15/11 at 3:30 pm , the Director Of Social Services stated that the resident's behavior was being monitored only every 4 months for the quarterly MDS.

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

Based on observation, medical record review and staff interview the facility did not ensure that the facility met the professional standards of quality for one (#12) of one residents reviewed with a wound vacuum of three residents reviewed for pressure ulcers during the recertification survey. Specifically, the facility did not ensure a wound vacuum(vac) was monitored according to physician orders. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Resident #12:

The resident was admitted on 10/27/10 with diagnoses of a stage 3 pressure ulcer of the buttocks. The Minimum Data Set dated 4/7/11 aesssed the resident as having intact cognition.

Review of the physician orders dated 5/8/11 documented the resident had a wound vacuum (vac) treatment to the stage 3 on her left buttocks which was to be changed three times weekly, the canister was to be changed every 5 days and the wound vac was to be monitored every 2 hours.

Review of the residents Comprehensive Care Plan for risk for impaired skin integrity has an approach dated 2/18/11 to check the wound vac and drainage canister left upper buttock area every shift until healed.

During an interview on 5/16/11 at 9:15 am the certified nurses aide (CNA) caring for the resident and familiar with the resident, stated she was not aware of any special attention they had to give the wound vac only they had to tell the nurse if it appeared to have stopped working.

During an interview on 5/16/11 at 10:00 am the Licensed Practical Nurse (LPN) stated they document each shift that the residents wound vac is patent. She was not aware they had to monitor the device any more frequently. She said they document the patency of the device in the nurses notes.

During an interview on 5/16/11 at approximately 11:00 am the Registered Nurse Manger (RNM) stated she was not aware of an order to monitor the wound vac every 2 hours. When the RNM was shown the order she stated the monitoring should have been done.

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

Based on record review and interview the facility did not ensure that policies and procedures were designed to implement and reflect the requirements of all components of Criminal History Record Check (CHRC). Specifically, the current policy does not address storage of the CHRC records. This resulted in no actual harm with potential for minimum harm. This is evidenced by the following:

During review of the facilities policy for CHRC on 5/11/11 at 3:00pm the policy documented that the documents pertaining to CHRC submissions and results are strictly confidential and will be kept for six years.

This policy did not address who would have access to the CHRC documents and how they would be kept confidential. There was no policy that stated that any records of conviction that were sent to the facility would be kept secured/ double locked or who would have access to this information.

During an interview the Human Resources Director on 5/12/11 at 8:07 am stated that the policy came from their other facility and agreed this information was not in the policy

10 NYCRR Section 402.7 (d), 402.9 (d), 402.9(b)(2)]

Based on observation and interview the facility did not maintain Criminal History Record Check (CHRC) information on employees strictly confidential. Specifically, CHRC documentation was kept in an unlocked file in an unlocked room. This resulted in no actual harm with a potential for minimum harm. This is evidenced by the following:

During an observation on 5/11/11 at 3:00pm the CHRC files were observed in a file cabinet in a small dining room on the first floor. One employees record of conviction was in this unsecured file along with other CHRC documentation.

During an interview the Human Resources Director on 5/12/11 at 8:07 am stated the CHRC files are stored in the dining room. She stated that when saw the files yesterday they were unlocked and in a room that many people have access to.

402.7(d)(2)

Based on review of inspection records and staff interview it was determined that the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systemsnone 1998 edition Section 2-4.1.4 requires that the owner promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Section 2-3.3 requires that alarming devices servicing sprinkler systems shall be tested quarterly. Specifically, 3 of the last 4 required quarterly sprinkler system test reports stated that 2 sprinkler heads by the first floor elevator machine room are central recalled heads, and 1 of the last 4 required sprinkler system flow alarm tests was not conducted. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The sprinkler system inspection reports for the past four quarters were reviewed on 05/16/2011. The reports dated 04/29/2011, 11/24/2011 & 12/20/2011, and 08/25/2010 showed that 2 sprinkler heads by the first floor elevator machine room are central recalled heads. No report was found for the first quarter of 2011.

The Director of Plant Operations stated in an interview conducted on 05/16/2011 at 11:50 am that having been absent due to medical leave, the sprinkler system was not tested during the first quarter of 2011. The Director of Plant Operations could not account as to why the recalled sprinkler heads were not replaced.

2000 NFPA 101 19.7.5; 1998 NFPA 25 2-4.1.4, 2-3.3; 1997 NFPA 101 7-7.5; 1995 NFPA 25 2-4.1.4, 2-3.3; 10 NYCRR 415.29, 711.2(a)(1)

Based on record review and interview it was determined that the facility did not test the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm Codenone 1999 edition sections 7-2.2 and 7-2.3 require that heat detectors require annual heat tests and/or function tests. 11 of 11 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.

A record review of the facility's fire alarm testing records on 05/16/2011 revealed that facility heat detector initiating devices were accorded a visual test only within the past 12 months.

The Director of Plant Operations stated in an interview conducted on 05/16/2011 at 1:40 pm that after consulting with the contracted fire alarm testing company, the heat detectors were visually inspected only within the past 12 months.

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