Ramapo Manor Center for Rehabilitation & Nursing

Based on record review and interviews, the facility did not ensure that a Comprehensive Care Plan was developed for each resident who was admitted to the facility based on his/her assessments. Specifically, two residents did not have urinary incontinence care plans and two residents did not have discharge planning care plans, (Residents #206 and 252, and 24 and 211, respectively.) This was evident for 4 of 46 sampled residents.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY

Findings are:

1.a. Resident # 206 is 83 years old and was admitted to the facility on 7/28/11 with diagnoses including Diabetes Mellitus, Lymphadema, Chronic Renal Failure, Chronia Obstructive Pulmonary Disease and Dementia. The resident is incontinent of feces and urine. She has a care plan for fecal incontinency but a review of her Care Plan revealed that there was no care plan for urinary incontinence.

Review of the October, 2011 quarterly Minimum Data Set (MDS - an assessment tool) revealed that the resident was incontinent at all times.

On 12/ 29/11 at 2:30PM, in an interview with a Certified Nursing Assistant (CNA) who cared for Resident #206, she stated that the resident is incontinent of urine at all times. She needs to have her diapers change upon awakening, after breakfast, before lunch, after lunch and again before dinner.

In an interview with the Unit Manager Registered Nurse on this same day , 12/29/11 at 2:45PM, she reviewed the Care Plan and stated that the resident was recently transferred from another unit and she (the RN) did not realize there was no care plan for urinary incontinence and that there should be.

1.b. Resident #252 is a 93 year old female who was admitted to the facility on 5/17/2011 and after hospitalization on 7/27/11, was readmitted on 8/1/11. The resident has diagnoses including Hypertension, Arthritis, Dementia and Depression.

According to a readmission Minimum Data Set Assessment (MDS), an assessment tool, dated 8/8/2011 and a quarterly assessment dated 8/11/11, the resident's cognitive status was assessed as BIMS = 7, requiring extensive assistance of 1 person for toileting and was continent of bowel and bladder.

According to a quarterly MDS dated 11/4/11, the resident's cognitive status was assessed as 2 on the BIMS scale, requiring limited assistance of 1 person for toileting and was always incontinent of bowel and bladder.

The Certified Nurse Aide was interviewed on 12/30/11 at 12:30PM and at that time she stated that the resident is toileted every 2 hours and whenever necessary. She further stated that sometimes the resident will request to be toileted and is occasionally continent, but is frequently incontinent of bowel and bladder.

A review of the Interdisciplinary Team Care Plan revealed no care plan to address the incontinence of the resident.

The Registered Nurse/Charge Nurse (RN) was interviewed on 12/30/11 at 1:00PM. The RN stated that since the resident's return from the hospital her level of cognition had declined and sometimes she did not recognize some members of her family. When asked if there was a care plan to address the incontinence of the resident, the RN stated that she thought that there was a care plan. The RN was unable to locate the document and stated that she would complete one.

2.a. Resident #211 was admitted to the facility on 10/27/11 to receive Restorative Physical Therapy for a Compression fracture .

A review of the resident's Social Service Notes dated 10/27/11 indicated that the resident plans to return home to her apartment.

A review of Interdisciplinary Team Progress Notes was unable to locate a writtten care plan for the resident's discharge home.

In an interview with the Case Manager on 12/29/11 at 2:10PM, she stated that facility does not have a written discharge care plan with measurable goals and objectives. She further stated that she addresses the resident's discharge planning in her Social Service Notes.

2.b. Resident # 24 was admitted to the facility on 10/21/11 for wound care following amputation of her left 5th toe. Other diagnoses include, Diabetes Mellitus and Peripheral Vascular Disease with recurrent ulcers.

Review of the MDS 3.0 dated 10/24/11 Admission Assessment revealed that the resident has a discharge plan in place.

Review of the Social Services Assessment (undated) revealed a heading - Discharge Plan : "To return home when medically feasible."

Review of the History and Physical dated 10/22/11 revealed "Discharge Plan: when able."

Review of the medical record revealed that the resident has non healing diabetic foot ulcers and was admitted to the facility after having her left 5th toe amputated. She requires skilled nursing care at this time.

Review of the Comprehensive Care Plan revealed no evidence of a discharge care plan with measurable goals and objectives related to the resident's potential for discharge.

In an interview with the Case Manager who does the discharge planning on 12/29/11 she stated that there is no discharge plan in the chart. She further stated that she documents all her conversations with residents and families as well as any other information regarding discharge in a binder that she keeps in her office. There is nothing in the resident's medical record that contains this information..

In an interview with the Social Worker on 12/29/11 at 3:00PM she stated that she usually writes a discharge plan in her notes and there is usually a discharge plan documented by the rehabilitation department in their notes. However, she further stated, there is no coordinated discharge plan for the resident.

415.11(c)(1)

Based on observation and staff interview, the facility did not provide residents with a dignified dining experience. Specifically, Residents were observed sitting in the hallway of Unit 03, in a row, during the lunch meal with hospital style overbed tables in front of them. This was evident for 4 residents reviewed during dining room meal observations (Residents #44, 212, 295, 298) for 1 of 7 units (Unit 03).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

On 12/29/11 at 12:30PM, four residents # 44, 212, 295, and 298 were observed sitting in the hallway of Unit 03, in a row with hospital style overbed tables in front of them during the lunch meal. On 12/30/11 at 12:35PM, three residents # 44, 295, and 298 were observed again sitting in the hallway, in a row with hospital style overbed tables in front of them during the lunch meal.

In an interview with the Licensed Practical Nurse(LPN), Unit Manager on 12/30/11 at 2:00PM, she indicated that there is not space at the table on the unit for all the residents.

415.5(a)

Based on interview and record review, the facility did not ensure that a resident was free from unnecessary drugs. Specifically a resident who was receiving Lasix therapy (a diuretic) did not have the required laboratory tests for adequate monitoring of the medication. This was evident for one of 10 residents reviewed for unnecessary medications(#27).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident # 27 was admitted to the facility on 2/17/11 with diagnoses including Dementia, Hypertension and Gout. Review of the Physician's Order dated 12/27/11 revealed that the resident was receiving Lasix (a diuretic) for the treatment of Hypertension (high blood pressure).

Review of drug information from drugs.com revealed that suggested monitoring for Lasix therapy included periodic monitoring of serum electrolytes (sodium, potassium, calcium and chloride).

Review of the Physician's Orders dated 12/27/11 revealed "Lab Orders: Electrolytes every six months."

The most recent laboratory results were dated 5/10/11, more than 7 months ago.

In an interview with the RN unit manager on 12/30/11 at 11:30AM regarding the lack of the required laboratory testing, she stated that the night staff is responsible for picking up those orders but there is no documented evidence that it was done.
In an interview with the MD on 12/30/11 at 12:45PM, he stated that he was unaware that the laboratory tests had not been done.

415.12(l)(1)

Based on observation and interviews, the facility did not ensure that the residents environment was as free from accident hazards as possible. Specifically, on Unit 4/5, the Emergency Door was observed held open with a linen sheet as well as, keys in the lock to override the alarm system. This was evident on 1 of 7 facility nursing units (Unit 4/5).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

Observation of the Emergency Door on Unit 4/5 on 12/29/11 at 10:45AM, revealed this door held open with a linen sheet. Further observation at that time, revealed keys in the lock. This door was easily opened by surveyor.

In an interview with the Registered Nurse Unit Manager (RNUM) at that time, she stated that the Emergency Door should never be held open and the alarm disabled, and that she never saw this before. When asked by surveyor who could have done this, the RNUM stated that "perhaps it was the housekeeper...it looks like him out by the garbage bins".

In an interview with the Maintainance Director at 10:55AM, he stated that the "Emergency Door should never be held open and the alarm disabled."The policy is for" housekeeping to bring the garbage bin down stairs and out around the building to the garbage bins."

In an interview with the housekeeper at 10:59AM, after observing him come into Unit 4/5, through the Emergency Door with an empty bin, he stated that "I always prop open the door and put my keys into lock to take off alarm, it is easier to bring garbage out."

In an interview with facility Administrator at 11:05AM, he revealed the area near the Emergency Door was under surveillance with a camera. The Administrator also added that leaving the Emergency Door held open and with the alarm disabled is not to occur.

Review of the video tape from 10:35AM, with the Administrator and Maintainance Director at 11:15AM , revealed this housekeeper coming out of the dirty utility room with a large bin of garbage and going out the Emergency Door.

Both the Administrator and Maintainance Director stated at that time, that this practice is not to occur and they will take immediate action.

415.12(h)(1)

Based on observation and staff interview, the facility did not ensure that the dining room program had sufficient space to accomodate the dining needs of all the residents. Specifically, residents were observed sitting in the hallway of Unit 03, in a row, during the lunch meal with hospital style overbed tables in front of them. This was evident for 4 residents reviewed during dining room meal observations (Residents #44, 212, 295, 298) for 1 of 7 units (Unit 03).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

On 12/29/11 at 12:30PM, four residents # 44, 212, 295, and 298 were observed sitting in the hallway of Unit 03, in a row with hospital style overbed tables in front of them during the lunch meal. On 12/30/11 at 12:35PM, three residents # 44, 295, and 298 were observed again sitting in the hallway, in a row with hospital style overbed tables in front of them during the lunch meal.

In an interview with the Licensed Practical Nurse(LPN), Unit Manager on 12/30/11 at 2:00PM, she indicated that there was not space at the table on the unit for all the residents.

415.29(e)(1-4)

Based on interview and record review, the facility did not ensure that the pharmacy review identified the lack of adequate monitoring for medication. Specifically a resident who was receiving Lasix therapy (a diuretic) did not have the required laboratory tests for the monitoring of that medication. This was evident for one of 10 residents reviewed for unnecessary medications(#27).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident # 27 was admitted to the facility on 2/17/11 with diagnoses including Dementia, Hypertension and Gout. Review of the Physician's Order dated 12/27/11 revealed that the resident was receiving Lasix (a diuretic) for the treatment of Hypertension (high blood pressure).

Review of drug information from drugs.com revealed that suggested monitoring for Lasix therapy included periodic monitoring of serum electrolytes (sodium, potassium, calcium and chloride).

Review of the Physician's Orders dated 12/27/11 revealed "Lab Orders: Electrolytes every six months."

The most recent laboratory results were dated 5/10/11, more than 7 months ago.

Review of the the monthly pharmacy review for the months of November and December 2011 revealed no evidence that the lack of monitoring was identified by the Pharmacy Consultant.

In an interview with the Pharmacy Consultant on 12/30/11 at 12:15PM he stated that they usually give 30 days for the facility to get the labs done, however he could not explain why the December review did not indicate that the labs had not been done.

415.18(c)(2)

Based on interview and record review, the facility did not ensure that the use of an indwelling Foley catheter was medically justified. This was evident for one of two residents reviewed for catheterization(#380).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident # 380 was admitted to the facility on 12/21/11 with diagnoses including Left Lower Lobe Pneumonia, Sepsis, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease and a history of Myocardial Infarction (heart attack).

Review of the admission information for the resident revealed that she was admitted to the facility from the hospital on 12/21/11 for "short term stay." Her diagnoses after admission were "Cardiac Cath 12/19/11 - Foley."

Review of the Comprehensive Care Plan (not dated) for Foley Catheter revealed that the resident was admitted with the Foley catheter.

In an Interview with the Registered Nurse unit manager on 12/29/11 at 12:30PM regarding the reason for the Foley catheter she stated that there really isn't a diagnosis that would indicate the need for the Foley catheter. She further stated that she thought the catheter was still in place because the resident's primary physician is on vacation and the covering physician hasn't written the order to have the catheter removed. She stated that they usually try to remove the catheter as soon as the resident is admitted.

In an interview with the covering physician at 12:35PM on 12/29/11 he stated that there is no reason for the Foley catheter to remain, and it will be removed at midnight tonight so her urine output can be monitored during the night once the catheter is removed.

Following surveyor intervention an order was written for the removal of the catheter.

415.12(d)(2)

Based on observation and interview, it was determined that corridor doors to resident rooms were not maintained in a manner necessary to ensure their ability to resist the passage of smoke and fire in that they were impeded from closing in case of emergency. This was evidenced by:
1) the positioning of resident bathroom doors on 3 of 7 units or 'teams' (1,2,3), which when fully opened, blocked the resident corridor doors on 1 of 2 floors (upper floor) from closing; and
2) doors on 2 of 7 teams (2, 6) on 2 of 2 floors were being held open with unapproved hold-open devices.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are (not all inclusive):

On 12/29/11, while conducting life safety rounds between 8:00 AM and 2:30 PM, impediments to closing corridor doors to resident rooms were observed. These impediments could prevent the doors from resisting the passage of smoke and fire in an emergency. The following was noted:

1. When fully opened (approximately 80% or more), resident bathroom doors were noted to impede the corridor door from closing. This was noted in rooms on resident 'teams' 1, 2, and 3. Examples include but are not limited to:

Team 1: Rooms # 2, 7, 9, 12, 14
Team 2: Rooms # 40, 43, 47, 50, 53
Team 3: Rooms # 21, 28, 32, 36

In an interview at 8:30 AM the same day, the Maintenance Director stated that he would discuss options with the Administrator for correcting the observations noted.

2. Unapproved hold open devices, i.e. wood or plastic chocks, were noted to be proping corridor doors to non-hazardous areas open. Examples include:
Team 2: Resident rooms # 16, 47
Team 6: Shower room door

In an interview at approximately 9:30 AM the same day, the Maintenance Director stated that he would replace the hold open devices with approved devices.

10NYCRR 711.2(a)(1)
2000 NFPA 101: 19.3.6.3

1998 NFPA 25, Chapter 2-2.1 Sprinklers, Section 2-2.1.1 states: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
1999 NFPA 13 Chapter 5-5.6 Clearance to Storage.
The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

This Requirement is not met as evidenced by:

Based on observation and interview, the facility did not ensure that the sprinkler system is continuously maintained in reliable operating condition as evidenced by:

1. all components of sprinkler heads and piping were not maintained free of foreign materials, i.e. paint and spray on fire retardant; and
2. at least 18 inches of clearance was not maintained between the top of storage and sprinkler head deflectors.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During life safety rounds conducted between 8:30 AM and 2:30 PM on 12/29/11, it was observed that sprinkler heads and piping were not maintained free of foreign materials, and at least 18 inches of clearance was not maintained between the top of storage and sprinkler heads. Examples include but are not limited to:

Team 2:
Utility room storage area - paint noted on one deflector, and cardboard boxes stored within 6 inches of sprinkler head.
Staff/visitor toilet - paint on one deflector
Medical Records office - binders stored within 6 to 8 inches of sprinkler head
Dry food storage room within stairwell to basement - paint on 2/3 sprinkler heads

Team 3:
Nurse Station - stuffed animals stored on top of cabinets were within 6 to 8 inches of the sprinkler head.
Linen closet - bags containing blankets were stored on the top shelf within 6 inches of the sprinker head.

Team 6:
Rose Room dining room pantry - paint on sprinkler head
Basement:
Maintenance Shop - one sprinkler pipe noted to be coated with sray-on fire retardant
Medical Supplies room - several cardboard boxes stored on top shelf within 6-8 inches of sprinkler head.
In an interview the same day at approximately 12:15 PM, the Maintenance Director stated that he would have the paint and spray on retardant removed from affected sprinkler heads and piping, and that he would ensure that proper clearance is maintained below sprinkler heads.

10NYCRR 711.2(a)
2000 NFPA 101 : 19.3.5, 9.7.1
1999 NFPA 13 : 5-5.6
1998 NFPA 25: 2-2.1

Life Safety Code section 19.3.2.6 requires that cooking facilities be protected in accordance with 9.2.3. Section 9.2.3 requires that commercial cooking equipment be in accordance with the requirements of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.
NFPA 96 requires that wet chemical extinguishing systems be maintained, inspected, and tested in accordance NFPA 17A, Standard for Wet Chemical Extinguishing Systems. NFPA 17A requires the monthly visual inspection of the extinguishing system.ne
This Requirement is not met as evidenced by:
ne Based on observation and staff interviews, the facility did not ensure the fire suppression system in the food preparation area of the main kitchen was properly maintained in accordance with applicable NFPA standards.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.ne
The findings are:

On 12/29/11 at approximately 9:00 AM, two (2) of two (2) of the fire suppression system discharge nozzles of the fire suppression system in the kitchen were found to be grease laden. Examination of the inspection tag for the Ansul system revealed that it was last inspected on 10/11 and that visual inspections were being conducted monthly. However, a sticker for the last inspection and cleaning of the hood duct system was lacking.

In an interview at the time, the Food Services Director stated that the company that services the hood duct system is due back at the facility soon. In a separate interview at that time, the Maintenance Director stated that the discharge nozzles of the fire suppression system would be cleaned as soon as possible.
10NYCRR 711.2(a)
2000 NFPA 101: 19.3.2.6, 9.2.3
1998 NFPA 96: 8-2
1998 NFPA 17A-1998: 5-2
10NYCRR 415.29(a)(1)(2)

The following Life Safety Code waiver ( s ) are on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waivers to be continued.

K017, S/S=B

1) Both the sitting area in team 3 and the personal care area, which were located in wing 0103, were not separated from the corridors. Separation by construction having at least a one hour fire resistance rating is required.
2) The corridor walls do not extend above the drop ceiling. Corridor walls must extend through concealed spaces to the floor or roof slab above.

10 NYCRR 711.2(a )
2000 NFPA 101- 19 .3.6.1, 19.3.6.2.1

The following Life Safety Code waiver ( s ) are on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waivers have been granted have not changed. The facility wishes the waivers to be continued.

K040, S/S=B

1) The exit door at the end of the basement in wing 0103 is an over head (garage-type) door. Exit doors are required to be of a swinging type.
2) The door to the gift shop in wing 0303 is a sliding-type door. A self-closing, positive latching door is required.

10 NYCRR 711.2(a )
2000 NFPA 101 - 7 .2.1

The following Life Safety Code waiver ( s ) are on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waiver was granted. Please indicate if the facility wishes the waiver to be continued.

K029, S/S=B

The following hazardous areas located in the basement below wing 0103 are considered to be hazardous: the storage room (between the men's locker room and the repair shop), the soiled linen room and the activities storeroom. All of those areas are fully sprinklered, but not completely separated by construction having at least a one hour fire resistance rating with a 3/4 hour fire rated door.

NYCRR 711.2(a )
2000 NFPA 101 - 19.3.2.1