Auburn Nursing Home

Based on record review and interview conducted during the standard survey, it was determined the facility did not ensure menus planned to serve all 90 residents of the facility met the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council. Specifically, the facility's Disaster Menu was not adequate in protein, did not include portion sizes to be served, and did not include reasonable variety. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

- The facility's Disaster Menu, dated February 5, 2008, did not document portion sizes for the planned food and fluid items. The amount of milk, cottage cheese, macaroni and cheese, beef stew, meat salad and peanut butter were not specified to ensure adequate protein was provided to the residents.

- Day 3 of the 3 day Disaster Menu was inadequate for high biological protein content, as there was no high protein food served at breakfast, and at supper, vegetable soup, a peanut butter and jelly sandwich, and fruit for dessert was planned.

- The Disaster menu did not specify portion sizes for each food and fluid planned to guide staff serving the food to ensure adequate amounts of food and fluids were provided to ensure the basic nutritional needs of the residents were met.

- The lack of specified portion sizes on the Disaster did not provide the necessary information for the registered dietitian (RD) to analyze the menu for nutritional adequacy.

- The Disaster Menu did not provide variety to ensure palatability as there were 2 hot meals planned for 3 days; and peanut butter and jelly sandwiches were planned twice in 3 days.

The RD and diet technician were interviewed on October 28, 2009 at 12:30 PM. The diet technician stated the menu, provided during survey, was the disaster menu to be used if needed and was provided by the Food Service Director. The RD stated the menu was not reviewed by her for adequacy, and was not sure when it was developed.

In summary, the facility did not ensure the disaster menu was nutritionally adequate, and provided reasonable variety and palatability.

10NYCRR 415.14(c)

Based on staff interviews and observations during the standard survey, it was determined the facility did not ensure there was an ice dispenser available on the 2 nursing units to provide ice for residents' beverages, in conformance with state regulations. This resulted in no actual harm with potential for minimum harm that is not immediate jeopardy.
Findings include:

During the initial tour on October 27, 2009 from 9:45 AM to 10:30 AM, a service aide was observed in the Southeast Unit nourishment room getting the morning nourishments prepared for the residents. The service aide stated the ice was brought from the ice machine in the kitchen. The bin ice machine was observed that morning at 10:15 AM to be stored in an alcove outside the main kitchen.

When the Northwest Unit was observed on October 27, 2009 between 9:10 AM and 11 AM, there was no ice dispenser observed in the nourishment room, or elsewhere on the unit. Ice was observed in the nourishment kitchen stored in an ice chest.

During an observation in the Southeast Unit south corridor on October 27, 2009 at 10:25 AM, ice was observed in plastic container on the nourishment cart used to pass fluids to the residents.

During observations of the Southeast Unit on October 27, 2009 between 2:30 PM and 4 PM, and on October 29, 2009 between 9 AM and 10 AM, no ice dispenser was observed in the unit.

In summary, the facility did not have an ice dispenser available in the nursing units to provide ice for residents' beverages.

10NYCRR 713-1.2(c)(9)

Based on observation, record review, and staff and resident interview conducted during the standard survey, it was determined the facility did not make reasonable accommodations to meet individual residents' needs and preferences for 17 of the 28 residents who shared bathrooms with residents of the opposite gender (Residents #4, 7, 23, 25, 34-57). Specifically, these 17 residents (Residents #4, 7, 23, 25, 34-57) were not provided with a physical environment that maintained their dignity and well being as they had to share their toileting facilities with residents of the opposite gender. For 1 resident of the 13 anonymous residents at the resident group meeting, the facility did not accommodate the resident's preference for a tub bath, rather than a shower. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) During the resident group meeting held on October 27, 2009 at 2:30 PM with 13 anonymous residents in attendance, 2 residents stated they did not like sharing a bathroom with residents of the opposite gender who were in the adjoining room. They said the residents from the adjoining room continuously knocked on the bathroom door when they were in there. These 2 residents stated that sometimes the other residents locked the door from the inside and then forget to unlock it, so they could not get in. The residents said sometimes the residents from the adjoining room open the bathroom door while they were in there, not affording them any privacy.

The rooms of Residents #4, 7, 23, 34-54, (24 residents in 12 resident rooms) were observed on October 28, 2009 between 5 PM and 5:15 PM. These rooms shared the bathroom with residents of the opposite gender.

The CNA (certified nurse aide) Daily Care Records, undated and used at the time of survey, were reviewed for Residents # 4, 7, 23, 34-54). Review of these care records revealed these 17 residents used the toilets in their bathrooms that were shared by the opposite gender.

The social workers were interviewed on October 29, 2009 at 2:10 PM and stated they were aware 1 resident was upset about the shared bathroom; and said the resident was on a list for a room change.

In summary, the facility did not accommodate the preferences of the residents as their physical environment did not maintain residents' dignity and well being.

2) During the resident group meeting held on October 27, 2009 at 2:30 PM with 13 anonymous residents, the residents stated there was no tub available for use in the facility, if they preferred a tub bath to a shower.

One anonymous resident at the group meeting stated she was afraid of a shower and received bed baths, as she refused the shower. She stated she was told by a staff member that there was a tub in the facility, however it was not "workable". Review of this resident's Weekly Skin Check Flow Sheet for October 2009 confirmed the resident refused a shower on October 6, 13 and 20, 2009. This flow sheet specified that the resident "wants a bathtub" and was given a bed bath.

During an observation of the facility bathing suites on October 27, 2009 between 3:45 and 4:30 PM, there was 1 bathing suite observed in each of the 4 corridors: south, east, north and west. The bathing suites in the south, east, and west corridors each had a shower and a home style bathing tub, without a mechanical lift. The tubs in the bathing suites were observed not be accessible to residents with physical weakness and impairment.

The bathing tub in the north corridor bathing suite was observed on October 29, 2009 at 10:25 AM in a locked room, accessed via the shower room. The bathing tub in the north corridor bathing suite was a whirlpool tub with a mechanical lift.

When the Maintenance Director was interviewed on October 29, 2009 at 10:25 AM, he stated the whirlpool tub in the north corridor bathing suite had been out of service for over 2 years. He said he was not aware of a plan to repair or replace the tub.

In summary, there was no bathing tub available in the facility accessible and available for resident use.

10NYCRR 415.5 (e)(1)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure sinks used by nursing and dietary staff were equipped with non-hand controls for 4 of 9 handwashing sinks observed. Specifically, handwashing sinks, without non-hand controls, were observed in the kitchen, the Northwest Unit nourishment room, the Southeast Unit nursing office, and the Southeast Unit's 2 shower rooms. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

On October 27, 2009 between 9:30 AM and 11 AM, the handwashing sinks in the kitchen and in the Northwest Unit nourishment room were observed to have hand controls.

On October 27, 2009 between 3:30 PM and 4:30 PM in the Southeast Unit, hand controls on handwashing sinks were observed in the east shower room, the south shower room, and the nursing office.

When the Maintenance Director was interviewed on October 27, 2009 at 3:45 PM, he stated he was unaware the controls on some of the handwashing sinks, used by nursing and dietary staff, did not comply with state requirements.

In summary, all the controls on handwashing sinks used by nursing and dietary staff did not comply with requirements for non-hand type controls.

10NYCRR 711.5(l)(9)

Based on observations, record reviews, and resident and staff interviews conducted during the standard survey, it was determined the facility did not ensure 3 of 19 sampled residents (Residents #1, 4, and 13) received the necessary care and services to attain or maintain their highest practicable well-being, in accordance with their assessment and care plan. Specifically, R esident #13's complaints of a sore bottom was not addressed in a timely manner, resulting in expressed discomfort each day of survey, and requiring a change in her normal daily routine. For Resident #1, podiatry recommendations were not implemented; Resident #4, was not re-positioned as planned and the resident's right hand was not assessed for tightness and cleanliness. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #13 was admitted to the facility with diagnoses of rheumatoid arthritis and Parkinson's disease.

The Minimum Data Set (MDS), dated October 12, 2009, documented the resident had no memory deficits had modified independence with some difficulty in decision-making abilities in new situations. The MDS did not identify any pain symptoms for the resident and no skin ulcers were specified. The MDS documented she had pressure relieving devices for the chair and the bed, and was on a turning and positioning program.

The comprehensive care plan (CCP), dated July 29, 2009, documented the resident was at high risk for pressure ulcers, was resistive to lying down during the day, and "sits up in the wheelchair for extended periods". Staff were to encourage the resident to take naps after lunch. The CCP specified the resident had a cushion in the wheelchair and a "Stage 3/4 mattress".

On October 19, 2009, a note by the occupational therapist documented the resident required total assistance for bed mobility, and extensive assistance for bathing, dressing, toileting and grooming.

During the tour on October 27, 2009 between 9:15 AM and 10:15 AM, Resident #13 said "I'm sore", to the surveyor and licensed practical nurse(LPN) charge nurse when they entered her room. The resident said she had a "sore bottom", and wanted to lie down. The LPN told the resident she would have staff come back to assist her.

From 2 PM to 2:30 PM, and from 4:10 PM to 5:40 PM on October 27, 2009, whenever the surveyor looked into the resident's room, the resident was observed to be lying in bed.

At 10:35 AM on October 28, 2009, the resident was heard calling for help. A certified nurse aide (CNA) was heard telling the resident to give her "a minute", and said she would be right back, as she walked past the resident's room. The resident was observed in her room sitting in her wheelchair, with the mechanical lift pad under her. The resident was observed with tears in her eyes. She told the surveyor she had a "sore bottom" and wanted to go to bed. From 10:35 AM to 10:55 AM that morning, the resident was heard calling "nurse, nurse". At 10:55 AM, a nursing student went into the resident's room with a mechanical lift, and put the resident to bed.

At 5:00 PM on October 28, 2009, the resident was observed up in her wheelchair in her room. At 5:45 PM on the same date, the resident was observed eating her supper in bed. The resident told the surveyor she did not want to eat in bed, and said she "usually ate in the chair". She stated her "bottom hurts" and she wanted to lie down "before".

At 7:30 PM on October 28, 2009, the resident's CNA told the surveyor that the resident was in bed, because before dinner, she was "complaining of her bottom hurting". She said the resident usually was up, and said this was a new "complaint" from the resident.

A nursing note, dated October 29, 2009, documented the resident complained of "soreness" to her buttock when she was up in the chair. The note specified the resident was given Tylenol 650 mg at 5:30 PM, and put to bed, at her request.

The resident's skin was observed on October 29, 2009 at 10:30 AM with the registered nurse (RN) Clinical Coordinator. The resident's buttocks were red, and a small, open area was observed on her right inner gluteal fold, that measured 0.1 cm x 0.1 cm, and less than 0.1 cm deep. The Clinical Coordinator said the resident "is not receptive to going back to bed and sits up in the wheelchair", with a mechanical lift pad under her. When the Clinical Coordinator was asked if the Hoyer pad defeated the purpose of a pressure relieving pad, she said the facility did have removable lift pads. She stated therapy determined who received the removable pad. The Clinical Coordinator stated until that morning, she did not know that the resident had been complaining of a sore bottom.

Review of the Weekly Pressure Ulcer/Skin Monitoring Record dated October 29, 2009, revealed on that date, the resident developed an unstaged area, with the measurements as above, on her right inner gluteal fold. The documented "probable cause" was "brief elastic". gel cushion was noted as the chair cushion. The form specified a treatment of "Dermamed" was initiated on that date.

During an interview with the physical therapist (PT) and occupational therapist (OT) on October 29, 2009 at 10:40 AM, the therapists were asked who decided what kind of lift pad a resident received. The PT stated therapy developed the care plan and decided what kind of pad a resident would sit on. The PT stated nursing decided if the lift pad stayed under the resident, or was removed. The therapists were asked if lift pad was not removed, would the purpose of a pressure relieving pad be defeated. The therapists said yes it would, "but as we said", nursing determined if a left pad was removed or not.

In summary, the resident exhibited discomfort each day during survey, had to change her daily routine, and had to be put to bed earlier and more often than usual, as the facility did not conduct a timely assessment of her sore "bottom" and provide timely treatment and monitoring.

2) Resident #1 had diagnoses of dementia, diabetes and was legally blind.

The August 24, 2009 Minimum Data Set (MDS) assessment documented the resident's cognitive status was moderately impaired, and he required assistance from staff for all activities of daily living (ADL).

The July 9, 2009 nursing note documented the resident had several scabbed areas on his bilateral toes, and had a scab on the right shin area. The note specified the resident continued to remove his socks and shoes, using his feet to propel himself around in the scoot chair.

The July 23, 2009 nursing note documented the scabs remained on the resident's toes on both feet. The note specified the resident's left foot had 2 new areas on his toes.

The July 29, 2009 podiatry note documented there were ulcerations on the resident's right second and third toes. The note documented diabetic shoes would be the best for this resident, if he remained ambulatory, due to the extra depth toe box and multi-density shoe inserts.

The July 30, 2009 nursing note documented the resident's right foot toes (first, fourth, and fifth) had intact scabs, and scabs on the resident's left foot toes (fourth and fifth). The note documented the resident continued to self-propel in the wheelchair and drag his feet along the floor.

The August 6, 2009 nursing note documented the areas on the resident's toes were all scabbed. The note documented gauze was placed between the resident's and measures were taken to prevent the resident from removing his shoes. The nursing note documented the resident was at risk for increased problems with his feet due to his diabetes.

Review of the nursing notes from July 30, 2009 through October 28, 2009, and the comprehensive care plan (CCP), dated October 28, 2009, revealed no documentation that the diabetic shoes recommended by the podiatrist were addressed and/or obtained for the resident.

The October 13, 2009 physician's orders did not address diabetic shoes for the resident.

The registered nurse (RN) manager was interviewed on October 29, 2009 at 1:30 PM. She stated she did not realize the podiatrist had written a note regarding the resident needed diabetic shoes.

The Director of Social Services was interviewed on October 29, 2009 between 2:10 PM and 3:00 PM. She stated it was unclear if the podiatrist was going to order the diabetic shoes, or if the facility was to order them for the resident. It was learned it was the role of social services department to obtain clothing for residents when needed. The Director was not aware these shoes were to be obtained, as the physician did not order them.

In summary, the facility did not ensure the interdisciplinary team addressed the recommendation by the podiatrist in a timely manner, for the resident to have diabetic shoes to aid in the healing of his toes.

3) Resident #4 was admitted to the facility with diagnoses including Alzheimer's disease, depression, diabetes, bradycardia (heart disease), and glaucoma.

The Minimum Data Set (MDS) assessment dated October 12, 2009 identified the resident as non-ambulatory and dependent in activities of daily living (ADLs), with the need for a mechanical lift for transfers.

The comprehensive care plan (CCP), dated October 16, 2009, identified the resident with an open area on the left buttock. The CCP and the undated certified nursing aide (CNA) Daily Care Record interventions, included repositioning the resident every 2 hours, and as needed.

The resident was observed in bed on his back, on October 27, 2009 between 9:15 AM and 10:30 AM, and on October 28, 2009 at 10:40 AM.

The resident's family member was interviewed on October 28, 2009 at 1:00 PM and stated she was told by the staff they get him out of bed early. The family member did not know why the resident remained in bed after 10:30 AM on both October 27 and 28, 2009.

A certified nurse aide (CNA) was interviewed on October 28, 2009 at 7:30 PM. She stated she was told the resident was up early before breakfast that morning, so she assisted him to bed before supper, as a result.

The resident was observed on October 29, 2009 from 8:00 AM to 10:30 AM to be lying on his back in bed.

In summary, the facility did not ensure the resident received the re-positioning assistance as planned and was not assisted out of bed in the morning, in a timely manner.

Resident #4 was also observed on October 28, 2009 at 12:15 PM in a recliner in his room with his right hand in a clenched position. At 12:50 PM , the resident was observed in the dining room and the resident's family member was feeding the resident. His right hand remained in the clenched position.

At 1:00 PM on October 28, 2009, the resident's family member was interviewed. At the request of the surveyor, the family member attempted to open the resident's right fist and straighten the resident's fingers; the resident pulled his hand back and hollered "Ow".

On October 29, 2009, the physical therapist (PT) was interviewed from 11:30 AM to noon. The PT stated residents are screened for range of motion on admission, quarterly, annually, and upon referral from nursing. At the request of the surveyor, the PT assessed the resident's ROM in both hands. When the PT attempted to open the resident's right hand, the resident screamed. The PT stated he did not know what caused the resident's pain in his hand, and stated the resident "might have an area of irritation". The PT described the resident's right hand as having "some contraction". The PT said the comprehensive care plan (CCP) should address what care staff provided to maintain the resident's range of motion. Upon review of the resident's current CCP dated October 2009 , there was no evidence range of motion was addressed.

The certified nurse aide (CNA) caring for the resident was interviewed by both the surveyor and PT at 11:45 AM on October 29, 2009. The CNA stated the resident always "yells" when the aide opened the resident's right hand. The CNA said the resident's right hand "has been like that since he came" to the facility. She stated she opened the resident's hand to clean it "regularly" and said the nurses were aware of the resident's discomfort.

On October 29, 2009 between 11:30 AM and noon, the PT was interviewed. The PT was asked, based on his above assessment, what did he expect should occur for this resident. The PT initially stated if it ( the resident's right hand) were to get "worse", nursing should notify the rehabilitation department. Based on PT's observation of the resident at that time, the PT stated he would try to get the resident to tolerate a "hand protector". The therapist stated the PT who assessed the resident for the October 12, 2009 MDS was on vacation.

An interview was held with the LPN charge nurse for the day shift on October 29, 2009 at 1:25 PM. She said she was unaware Resident #4 had any pain in his hands.

On October 29, 2009 at 6:10 PM, Resident #4's right hand was observed to have a hand splint in place. A registered nurse (RN), with a surveyor present, assessed the resident's right hand at that time. There was dirt and dried skin observed in the creases of the hand and between the fingers. After the hand was cleaned by the RN, a small open area was observed by the fifth digit, with dirt and dried skin in one of the hand's creases.

In summary, the facility did not provide an adequate assessment and care for this resident with limited range of motion as the resident's right hand was painful to open and when opened was observed with dirt and dried debris.

10 NYCRR 415.12

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the nurse call system operated properly in 11 of 14 resident rooms (rooms #15, 18, 19, 22, 24, 25, 26, 27, 31, 32, and 33) tested in the Northwest unit; and did not ensure there was a nurse call system in 2 of 4 visitor toilet rooms. Specifically, the tone (sound) in the nurse call system did not operate unless the nurse call system button was continuously depressed (when pressure on the button was released the tone/sound stopped) in 11 resident rooms. The men's and women's toilet rooms near the lobby (accessible to residents) did not have a nurse call system. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) On October 27, 2009 between 3:30 PM and 5:30 PM, a surveyor heard call bells at the Northwest nursing station ring, and then go off. When a certified nursing aide (CNA) was interviewed at 5:15 PM, she stated the residents turned the call bells off.

On October 28, 2009 between 7:30 and 7:40 PM, a CNA and registered nurse (RN) Supervisor were asked about the nurse call system on the Northwest unit. The call lights were observed to remain lit, with the sound turning on and off frequently. The CNA stated the call bells only worked on Northwest unit while the residents were "holding it down". The RN stated that was not the way the call bells worked on the Southeast unit and was unaware the callbells worked differently on the Northwest unit.

Observations of nurse call system on October 29, 2009 between 10 AM and 12:30 PM revealed the call system did not function consistently on the Southeast and the Northwest units. In 11 rooms in the Northwest Unit (Rooms #15, 18, 19, 22, 24, 25, 26, 27, 31, 32, and 33), the nurse call system sound/tone sounded only when they the call button was continuously depressed (when pressure released the tone/sound stopped).

When the nurse call system in the Southeast unit was checked in 8 resident rooms on October 29, 2009 between 11 AM and 12:30 PM, the tone in the nurse call system continued to operate after pressure on the call button was released.

When the Maintenance Director was interviewed on October 29, 2009 between 10 and 11 AM, he stated the nurse call system was the original nurse call system, and he believed the nurse call system was operating within its design parameters. He stated some of the components in the nurse call system, for example some of the nurse call cords, had been replaced, and some components were original. He stated for the original nurse call system, the tone (sound) did not sound continuously unless the resident maintained pressure on the button that turned on the signal in the nurse call system. He stated there were no outstanding (uncompleted) work orders to repair the nurse call system.

In summary, the operation of the nurse call system in the building was not consistent, due to the tone not operating in 11 of 14 resident rooms in the Northwest Unit when the call button was not continuously depressed.

2) There were 2 toilet rooms for visitor and/or staff use near the main lobby, directly across the corridor from the Southeast unit nursing station. When the men's and women's toilet rooms were observed on October 28, 2009 10:40 AM, both were unlocked. Neither the men's or women's toilet room was equipped with a call bell.

When the Maintenance Director was interviewed on October 29, 2009 at 12:10 PM, he stated he believed the 2 toilet rooms near the front lobby were not intended for resident use and were kept locked.

When the 2 toilet rooms near the front lobby were checked on October 29, 2009 at 12:10 PM, the men's toilet room was unlocked.

In summary, the facility did not provided a nurse call system to the 2 toilet rooms in the front lobby that were accessible at times to residents.

10NYCRR 415.29(b)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure 6 of 7 residents reviewed for restraint concerns (Residents #1, 4, 8, 9, 14, and 15), and for 1 resident outside the sample observed with a restraint (Resident #32) had the right to be free from physical restraints not required to treat their medical symptoms. Specifically, the facility:
- did not ensure full siderail restraints were ordered by a physician to treat Resident #9's medical symptoms; and did not ensure safety concerns related to her seizure disorder were addressed.
- did not ensure siderail restraints were used to treat medical symptoms for Residents #4, 8 and 14.
- did not ensure the least restrictive alternatives were attempted for Residents #4, 8 and 14, before the use of full siderails.
- did not assess Resident #1's shoes as a restraint, when duct tape was used to prevent the resident from removing his shoes and normal access to his body.
- did not ensure Resident #1's lap buddy and scoot chair, ordered by the physician, specified when the the lap buddy and scoot chair were to be used, to ensure it was the least restrictive device, and used for the least amount of time.
- did not ensure Residents #15 and 32's lap buddy restraints were released at mealtimes, when 1:1 supervision was provided.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #1 had diagnoses of dementia, legal blindness, and diabetes.

The quarterly Minimum Data Set (MDS) reviews, dated June 10, 2009 and August 24, 2009, documented the resident's cognitive status was moderately impaired and the resident required supervision. The resident needed assistance from staff for all of his activities of daily living (ADLs).

A nursing note, dated July 9, 2009, at 8:13 AM, documented the resident "continues to remove shoes/socks and used his feet to propel self around in scoot chair"; and specified "areas on bilateral toes remain scabbed".

A July 30, 2009 nursing note documented the resident continued to have scabs on the first, fourth, and fifth toes on the right foot, and scabs on the fourth and fifth toes on the left foot. The note documented the resident continued to self-propel in the wheelchair and dragged his feet along the floor. The note specified sneakers would be put on when they arrived, to help protect the resident's feet, and the shoes would be secured with duct tape.

A nursing note, dated August 6, 2009 at 10:44 AM, documented all areas on the resident's toes were bilaterally scabbed. The note specified will continue to place 2 x 2 gauze between toes for protection, and duct taping laces to discourage the resident from removing (his) shoes."

The comprehensive care plan (CCP), currently in use and dated October 28, 2009 did not address the use of duct tape as a restraint to prevent the resident from removing his sneakers

On September 9, 2009, rehabilitation therapy documented a progress note specifying the resident was issued a new reclining wheelchair to help prevent falls; and was given a lap buddy "to discourage from self standing."

The October 13, 2009 physician orders continued the orders for a scoot chair and a reclining wheelchair with a lap buddy. The orders did not document care instructions when the scoot chair, or the reclining wheelchair with lap buddy, were to be used.

The CCP, updated on October 28, 2009, did not provide care guidelines for staff regarding when to use the scoot chair or reclining wheel chair and lap buddy.

The Director of Social Services/unit social worker was interviewed on October 29, 2009 between 2:10 PM and 3:00 PM. She stated the resident had a scoot chair and "wore it out", and was currently using a "borrowed" scoot chair, as well as the lap buddy. When asked how staff knew when to use the "restraints", the social worker stated the resident's CCP "should say" when to use the scoot chair, when to use the lap buddy, and when the restraints should be released. When questioned about the resident's shoes with duct tape over the Velcro , the social worker stated she had not considered them as a restraint.

In summary, the facility:
- did not ensure there were physician orders with care guidelines for the staff when to use the scoot chair, or the lap buddy on the reclining wheelchair for the resident;
- did not ensure the use of the least restrictive restraining devices were used first;
- did not ensure there were individualized plans to release these restraints;
- did not ensure the use of duct tape over the resident's "laces" was addressed as a restraint, as the tape was used to prevent the resident from removing his shoes.

2) Resident #9 was admitted to the facility with pertinent diagnoses of multiple sclerosis and a seizure disorder.

The Informed Consent for Physical Restraints was signed by a family member on May 29, 2008, which gave consent for 2 full side rails for the resident. There was no documentation the resident was involved in the decision-making process when the consent was signed.

The Minimum Data Set (MDS) dated May 12, 2009 documented the resident was independent in decision making, had no short or long term memory deficits, had 2 full siderails; and was totally dependent on 2 people for bed mobility.

The Side Rail Assessment Tools, dated August 4, 2009 and October 27, 2009, both documented the resident did not have a medical symptom for the use of a siderail; and specified that there was no risk if the resident used siderails.

The comprehensive care plan (CCP), dated August 7, 2009, documented the resident had 2 siderails, to assist with positioning. The current CCP, dated October 21, 2009, documented the resident had the potential for injury, secondary to seizure disorder. There was no documented evidence the resident had any seizure activity since November 17, 2008.

The undated CNA (certified nursing aide) Daily Care Record documented the resident required a mechanical lift with assistance from 2 people for transferring, required total assistance for bath/hygiene. for "positioning in bed" the CNA Daily Care Record documented staff were to "reposition slowly"; the section for "turns self" was left blank. Regarding siderails, "2 siderails for positioning" was checked for the resident on this record.

Review of the most current physician orders, dated October 23, 2009, revealed the use of 2 full siderails restraints were not ordered/addressed.

On October 28, 2009 at 5 PM, the resident was observed in bed with 2 full siderails in the raised position. When the resident was interviewed that evening at 7:30 PM, she remained in bed with the raised siderails. The resident was asked why she had the siderails in place. She stated she did not know why she had them. She said she had "a grand mal seizure years ago, but they "were now controlled" and that she "hasn't had anymore". The resident said she was on medication and the medication levels were monitored. When the resident was asked about the siderails being padded, she said she would not want them padded, as she felt they would make her feel "too closed in".

The social worker was interviewed on October 29, 2009 between 2 PM and 2:30 PM and asked about padded siderails for this resident with a seizure disorder. The social worker stated no one on the interdisciplinary team thought about the risks of open side rails for someone with seizure precautions.

In summary, the facility:
- did not address the risks/benefits of open siderails for this resident with a history of seizures;
- did not ensure there was a current physician order for the resident's siderail restraints;
- did not ensure the resident was involved in the decision-making process and gave consent for using 2 full siderails.

3) Resident #15 was admitted to the facility with diagnosis of Alzheimer's dementia.

The Minimum Data Set (MDA), dated September 21, 2009, documented the resident's cognitive status was severely impaired, had devices and restraints that included side rails that were not "full", and used a chair that prevented rising.

A Restraint Assessment Record, dated September 23, 2009, documented an interdisciplinary team decision to place a lap buddy on the resident, when she was out of bed in a reclining wheelchair. The medical diagnosis for the use of the restraint was the resident's advanced dementia.

The comprehensive care plan (CCP), updated September 23, 2009, identified the resident's use of the lap buddy related to impaired safety awareness and sliding in wheelchair. The plan included releasing the restraint "per policy especially when 1:1".

On October 29, 2009 between 8:10 AM and 8:35 AM, Resident #15 was observed with her lap buddy in place, while being fed by a certified nurses aide (CNA). At 8:40 AM, the CNA was observed wheeling the resident out of the dining room without the resident's lap buddy in place. The CNA was interviewed at that time and asked why the lap buddy was off the resident at that time and not removed during the meal. The CNA said she forgot to remove it at breakfast, and decided to remove it as she was taking residents out of the dining room. The CNA said the resident's lap buddy was to be removed at meals and every 2 hours.

In summary, the facility did not ensure a resident was free from physical restraints during a time she was receiving 1:1 care from a staff member.

10 NYCRR 415.4(a)

Based on observation, resident and staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure 5 residents of the 13 anonymous residents at the resident group meeting, were able to choose their personal schedules for getting up and going to bed; and did not ensure 2 anonymous residents at the resident group meeting were able to receive small portions of food. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Five residents of the anonymous 13 residents at the resident group meeting, on October 28, 2009 between 2:30 PM and 3:30 PM, said they did not have the choice of the time they got up for the day. Residents stated had to wait until staff were available to assist them out of bed, and to assist them to bed at the end of the day. The residents stated that when residents asked staff at the nursing station for help, residents were sometimes told there were only 2 staff on duty to take care of all the residents on the unit.

- During observations on the Northwest Unit on October 27, 2009 between 9:15 AM and 10:15 AM, at least 6 residents remained in bed, as follows:
- Resident #58 was in bed between 9:15 and 10:15 AM;
- Resident #59 was in bed between 9:30 and 10 AM;
- Resident #4 was in bed at 10 AM;
- Resident #60 was in bed receiving care at 10:15 AM;
- Resident #61 was in bed receiving care at 10 AM; and
- Resident #5 was in bed at 10 AM.

- On October 27, 2009, 8 residents (Residents # 2, 4, 6, 16, 20, 21, 24, 25) were observed to be undressed for the night, waiting for their supper meal by 5:40 PM. Review of each of their comprehensive care plans (CCPs) and their certified nurse's aide (CNA) care cards revealed there was no specified notations that these residents were bedfast.

- Resident #4 was observed to be undressed and still in bed waiting to get up on October 27, 2009 between 09:20 AM to 10:30 AM, during the initial tour. The resident was observed to be undressed for the night, and waiting for the supper meal that same day at 5:40 PM. Review if the resident's CCP and CNA care card revealed no specifications that the resident was bedfast. On October 28, 2009, the resident was observed being fed supper in bed. During an interview with the CNA at 7:30 PM that evening, she stated the resident was put to bed early, because he got up early. This conflicted with the observations made the morning of October 27, 2009.

- A CNA on the Northwest Unit, interviewed on October 28, 2009 between 7:30 and 7:40 PM, stated residents who need a mechanical lift to be transferred were assisted back to be right after supper. Three other CNAs interviewed on October 28, 2009 between 7:30 PM and 7:40 PM on the Northwest Unit stated they were not sure why so many residents were in bed before supper.

- During an interview on October 29, 2009 at 10:30 AM, a CNA was asked how CNAs knew which residents they were to get up and what time they were to do this. The CNA said they went by the assignment book. The CNA said "You look to see who has appointments, who has outside appointments and residents in physical therapy always go first." The CNA stated there was no set time, "but all residents should be up by 11 AM". The CNA said "the CNAs figure it out on their own; we decide who gets up first and who gets up last."

In summary, all residents were not allowed to choose their personal schedules, pertaining to when they got up for the day and when they went to bed.

2) Two anonymous residents at the resident group meeting on October 28, 2009 between 2:30 and 3:30 PM stated they wanted small portions at meals and they did not receive them.

When the trayline service was observed in the kitchen on October 27, 2009 between 12:15 PM and 12:30 PM, and on October 29, 2009 between 12:20 PM and 12:30 PM, there were no utensils in the trayline to serve small portions to residents.

Small portions were not served when the evening meals was observed in the Northwest Unit dining room on October 27, 2009 at 5:40 PM.

The undated facility menu extensions, printed October 27, 2009, did not include an extension for small portions.

In summary, the facility did not provide small portions for those residents who requested them.

10NYCRR 415.5(b)

Based on staff interview and record review conducted during the standard survey, it was determined the facility did not ensure services met professional standards of quality for 2 of 5 residents reviewed for incidents/accidents (Residents #1 and 17). Specifically, the facility did not ensure that Residents #1 and #17 were assessed by a registered nurse (RN) after falls during the night shift (11:00 PM to 7:00 AM). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #1 had diagnoses of dementia, legal blindness, and diabetes.

The August 24, 2009 Minimum Data Set (MDS) documented the resident's cognitive status was moderately impaired and supervision was required. The resident needed assistance from the staff for all of the activities of daily living (ADLs).

A July 18, 2009 nursing note documented the resident was found on the floor mat next to the bed, with no apparent injuries. The licensed practical nurse (LPN) documented the resident was assisted to his feet with 2 staff members.

A July 31, 2009 LPN nursing note documented the resident was found beside his bed with his knees on the mattress on the floor. The LPN documented a head to toe assessment was completed and no injury was found.

An August 4, 2009 LPN nursing note documented the resident was found on his knees next to the mattress on the floor. Both of the resident's knees were specified to be reddened.

A September 24, 2009 LPN nursing note documented the resident was discovered on his knees on the mat beside the bed. The resident was found to be having seizure-like activity. The LPN documented a head to toe assessment was completed. The seizure activity lasted about 5 minutes. The resident responded to verbal stimuli.

An October 3, 2009 LPN nursing note documented the resident was kneeling on the mattress on the floor next to the bed. The LPN specified the resident's extremities were within normal parameters with no complaints of pain.

There was no documented evidence a RN (registered nurse) assessed the resident after the falls on July 18, July 31, August 4, September 24 and October 3, 2009.

The Administrator was interviewed on October 29, 2009 at 2:30 PM. She stated the facility did not staff an RN on the night shift, and there was a shortage of RNs to fill positions.

In summary, the facility did not ensure that Resident #1 was assessed by an RN in a timely manner after each of the resident's multiple falls.

2) Resident #17 had diagnoses of congestive heart failure, chronic renal failure, and chronic obstructive pulmonary disease.

The October 2, 2009 Minimum Data Set (MDS) documented the resident had modified independence in decision-making abilities, and had difficulty in new situations. The resident required assistance from staff for activities of daily living (ADL).

An August 3, 2009 LPN nursing note documented the resident was found sitting on the floor leaning against the bed. The resident stated he had started to slip and had nothing to grab onto, so he lowered himself to the floor using the over the bed table. The LPN specified the resident's range of motion was within normal limits and the resident moved all extremities with ease. There was no documented evidence the resident was assessed by a registered nurse (RN) after the fall.

An October 24, 2009 LPN nursing note documented the resident was found on the floor at the resident's bedside at 10:00 PM. The LPN specified no injuries were observed from the fall. There was no documented evidence the resident was assessed by an RN.

The Administrator was interviewed on October 29, 2009 at 2:30 PM. She stated that the facility does not staff a RN on the night shift, and there was a shortage of RNs to fill those positions.

In summary, the facility did not ensure that Resident #17 was assessed by a registered nurse in a timely manner, after 2 falls.

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

Based on record review, and staff and resident interview conducted during the standard survey, it was determined the facility did not ensure 1 of 9 residents reviewed for behavior concerns, (Resident #8), received appropriate treatment and services to correct assessed problems related to mental of psychosocial adjustment difficulty. Specifically, the facility did not address Resident #8's ongoing behavior and did not develop a care plan to address the behavior and need for psychological intervention. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #8 was admitted to the facility with diagnoses of cerebral vascular accident with left hemiplegia (stroke with left sided weakness) and depression.

The facility's "Assessment of Psychopharmacologic Medication Use" dated June 16, 2009, documented the resident was on Zoloft (an antidepressant) 100 mg every day for depression. The form specified some interventions were 1:1 visits, encouraging out of room activities, providing opportunities to express concerns and validate them, and continuing the current dose of (antidepressant) medication.

The resident's current comprehensive care plan (CCP) dated July 29, 2009 documented the resident had depression and occasional emotional distress. One documented intervention was to refer the resident for psychological evaluation and/or follow-up, as necessary. Another problem identified on the CCP was that the resident had stress incontinence and a history of episodes of diarrhea. One of the interventions included staff was to "support resident's feelings concerning incontinence."

The Minimum Data Set (MDS) dated July 30, 2009 documented the resident was independent in decision making, with some difficulty making decisions in new situations. The MDS specified the resident had unrealistic fears, had sad, pained expressions, was usually continent of bowel, and was occasionally incontinent of bladder.

A nursing note dated September 3, 2009 at 2:49 PM documented the resident was alert and oriented and able to make her needs known. The note specified the resident refused ambulation daily and only got up days that her hair care would be done. The resident was continent of bowel, and incontinent of bladder.

A nursing note dated September 30, 2009 at 11:34 PM documented resident did not get out of bed on the 3 PM to 11 PM shift. The note specified the resident was incontinent of bowel and bladder, was given the bedpan as needed, and noted the resident rang fairly frequently for the bedpan.

A nursing note dated October 15, 2009 at 12:29 AM documented the resident did require Imodium (a medication to treat diarrhea) occasionally for chronic loose stools.

During an interview with the resident on October 27, 2009 between 3:30 PM and 4:10 PM, the resident told a surveyor that "activities" did not interest her, as she had bowel problems, and was afraid to go out. The resident said she was afraid to get out of bed, because she could not control her bowels. She stated she would love to get up and out of bed, as it was sad being in bed all the time. The resident said she "missed the sunshine" on her face.

During an interview with the certified nurse aide (CNA) on October 28, 2009 at 11:35 AM, the CNA was asked if the resident was on a toiling program. The CNA said it was "hard enough to get the resident out of bed for her hairdresser", as the resident "needed a mechanical lift" for transfer. The CNA said the resident was continent of bowel and rang to use the bedpan.

The nurse practitioner (NP) was interviewed on October 28, 2009 at 1 PM and was asked if she was aware the resident would not get out of bed because she was afraid she would be incontinent of bowel. The NP said she had "no idea, but would look into it". At 3 PM that day, the NP told the surveyor she looked into it, and would work with the resident. The NP stated she had no idea the resident was fearful of getting out of bed because of bowel incontinence. She said she told the resident she would try to get her bowels under control. The NP stated the resident agreed to try, but did not know if she could.

The Director of Social Services was interviewed on October 29, 2009 at 2 PM, and stated the interdisciplinary team had not considered a psychological consult for the resident.

In summary, the facility did not ensure the interdisciplinary team developed and implemented a plan of care that addressed the resident's concerns and behaviors regarding staying in bed in her room most of the time.

10NYCRR 415.12(f)(1)

Based on record review, resident and staff interview, and observations conducted during the standard survey, it was determined the facility did not ensure the infection control program was designed to provide a sanitary environment and prevent the transmission of disease and infection for 1 resident (Resident #33) observed during a medication pass observation. Specifically, appropriate handwashing was not done by the licensed practical nurse (LPN) prior to administering mediation to Resident #33. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Finding include:

1) During the medication pass on October 28, 2009 at 9:20 AM, the medication licensed practical nurse (LPN) was observed to pull out the blister packs containing the Resident #33's medications from the medication cart . When the LPN pulled the blister packs out, the divider separating the blister packs fell on the floor. The LPN picked the divider off the floor, and put the divider into the waste receptacle on the medication cart. The LPN then was observed to continue to prepare the medication for Resident #33, without washing her hands.

The LPN was interviewed on October 28, 2009 at 9:40 AM. She stated she was very nervous and forgot to wash her hands after she picked the divider off the floor.

In summary, the LPN did not wash her hands after her hands became soiled during the medication pass.

10NYCRR 415.19(a)(1-3)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure services were provided to maintain a sanitary and orderly interior, specifically related to the condition of 5 wheelchairs and 2 lap buddies in disrepair during the survey. Wheelchairs for Residents #27, 28, 29, 30 and 31 and lap buddies for Residents #1 and 26 were observed in disrepair. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

WHEELCHAIRS
1) Resident #31's wheel chair was observed on October 27, 2009 at 10:25 AM, to be in poor condition. The left arm vinyl was cracked; the right arm vinyl covering was observed to have a few tears; the right leg rest pad had ripped corners with foam exposed. When the resident was observed in the unit dining room on October 29, 2009 at 12:10 PM, the wheelchair was observed in the same condition.

2) Residents #28, 29, and 30 were observed sitting in unit dining room on October 27, 2009 at 4:55 PM, with their wheel chair arm rests in poor condition. Resident #28's left arm rest was observed to be cracked and worn. Resident #29's right and left arm rests were cracked with small tears. Resident #30's vinyl covered left arm rest was cracked and worn.

3) Resident #27 was in the unit dining room on October 29, 2009 at 11:50 AM in a wheelchair. Positioned against the back of the wheelchair, behind the resident's back, was a large piece of uncovered foam, with the resident name written on the top of it in black marker.

LAP BUDDIES
4) Resident #1's lap buddy was observed with rips; observed on October 27, 2009 at 10:00 AM when the resident sat in unit hallway, and at 6:10 PM, as resident was in unit dining room.

5) Resident #26's gray lap buddy was observed to have a ripped corner, with foam exposed, on October 29, 2009 at 11:50 AM, as the resident sat in unit hallway.

The Environmental Services Director was interviewed on October 29, 2009 between 11:50 AM and 12:45 PM. He stated wheelchairs and other chairs were cleaned by environmental services staff, once per week in the evening. Environmental service staff began completing a log to document wheelchair cleaning approximately 3 weeks ago. Staff was expected to observed wheelchairs in need of repair during the cleaning process and report the chairs needed repair.

The weekly wheelchair cleaning logs for the weeks of September 30, October 7, and October 14, and October 21, 2009 documented the date wheelchairs were cleaned and identified wheelchairs with an identified number, rather than by the resident's name.

When the Maintenance Director was interviewed on October 29, 2009 between 12:30 PM and 12:45 PM, he stated there were no uncompleted work orders for wheelchair repairs.

In summary, the facility did not maintain all resident wheelchairs and lap buddies in good condition.

10NYCRR 415.5(h)(2)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not provide proper respiratory care for 1 of 5 residents (Resident #12) reviewed with oxygen. Specifically, Resident #12 did not receive continuous oxygen at 3 liters per minute on a consistent basis, as ordered by the physician. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #12 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and hypertension.

The Minimum Data Set (MDS) assessment dated October 12, 2009 identified the resident with short term memory impairment and moderately impaired cognition. The MDS noted the resident was on oxygen and required assistance of 1 with activities of daily living (ADLs).

The physician orders, dated October 23, 2009, identified the resident to be on 3 liters of oxygen via nasal canula, with no further specifications.

On October 27, 2009 at 6:40 PM, the resident was observed sitting in her wheelchair in front of the building with a visitor beside her. An oxygen tank was in place attached to the back of the resident's wheelchair and the resident was smoking a cigarette.

On October 28, 2009 at 11:00 AM, the licensed practical nurse (LPN) on the unit stated the resident goes "out front to smoke with friends".

At 7:30 PM on October 28, 2009, 2 CNAs on the resident's unit were interviewed. They stated the resident "goes out and smokes" with her visitors and they "think" she has her oxygen off when she is outside.

The nurse practitioner was interviewed on October 29, 2009 at 6:30 PM. When the surveyor showed her the physician's order, she stated, when the oxygen order was written with no parameters, it was for continuous oxygen. She stated she recently learned the resident was smoking and the order needed to be clarified for the oxygen to be off when the resident was outside.

In summary, the facility did not ensure physician orders for the resident's use of oxygen were clarified to meet her needs.

10 NYCRR 415.12 (k)(6)

Based on observation, staff interview, and resident and visitor complaints, the facility did not ensure the resident environment was comfortable and homelike due to offensive odors. Offensive odors were noted in the west corridor of the Northwest Unit, the south shower room and in the front lobby area. This resulted in no actual harm with potential for minimum harm.
Findings include:

During the survey, persistent offensive odors were found at various times and locations. For example:

-On October 27, 2009 at 9:15 AM, a strong, stale urine odor was present in the front lobby of the facility.

- There was a strong fecal odor in the west corridor on October 27, 2009 between 9:30 and 10:30 AM, on October 28, 2009 at 4:20 PM, and at 9:00 AM on October 29, 2009.

- An anonymous visitor complained to a surveyor about odor problems in the west corridor on October 28, 2009 between 2 and 4 PM.

- The Southeast Unit south shower room was observed to have a soiled linen hamper in the room and had an unpleasant odor on October 29, 2009 at 9:12 AM; the exhaust fan was off during the observation.

- An unidentified resident was heard complaining about odor problems in the west corridor on October 29, 2009 at 9:30 AM.

- Two surveyors observed a strong fecal odor in west corridor October 29, 2009 at 10 AM.

When the Environmental Services Director was interviewed on October 29, 2009 between 12:45 PM and 1:30 PM, and asked about fragrant odors mixed with other odors in various locations in the facility. He stated he believed the facility's cleaning chemical had minimal fragrance/odor and the odor dissipated quickly. He said housekeeping and nursing staff worked together to minimize the odor issues when there was a particular concern with a resident room. The Director said there was a cleaning schedule for the nursing units, including a schedule to clean resident rooms and shower rooms.

The nursing units were observed on October 27, 2009 between 9:30 AM and 11 AM, and between 2:30 PM and 4:30 PM; and observed on October 29 between 10 AM and 12:30 PM. Minimal ventilation in the facility was found during these observations. Resident toilet rooms had windows with no exhaust ventilation, with one exception. There was little, if any supply ventilation (fresh air) supplied to corridors and resident rooms when these units were observed during the above times.

In summary, the facility did not maintain the resident environment in comfortable and homelike manner due to persistent unpleasant odors.

10NYCRR 415.5(h)(1)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure large, mobile trash containers were stored only in protected areas of the building, as one 48 gallon mobile trash cart was stored in each of the 4 facility corridors. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facility had 2 nursing units, the Southeast (south and east halls) Unit and the Northwest (north and west halls) Unit.

Large, mobile trash trash carts were observed in the facility corridors as follows:
- south corridor on October 27, 2009 at 4:30 PM; on October 28, 2009 at 10:47 AM and 10:53 AM; on October 29, 2009 at 8:35 AM, 9:05 AM, 9:55 AM.
- east corridor on October 27, 2009 at 2:40 PM, 4:30 PM; on October 28, 2009 at 10:47 AM and 10:53 AM; and on October 29, 2009 at 8:35 AM, 9:05 AM, 9:55 AM.
- north corridor on October 27, 2009 9:40 AM, 10:20 AM, 3:17 PM, 3:35 PM; on October 28, 2009 at 10:47 AM and 10:53 AM; and on October 29, 2009 at 8:35 AM, 9:05 AM, 9:55 AM.
- west corridor on October 27, 2009 at 9:35 AM and 10:20 AM; on October 28, 2009 at 10:47 AM and 10:53 AM; and October 29, 2009 at 8:35 AM, 9:05 AM, 9:55 AM.

On October 29, 2009 at 8:30 AM, the large, mobile trash containers were observed labeled with a size of 48 gallons

On October 29, 2009 at 1:15 PM, the 4 mobile trash carts were observed stored in the soiled utility room in the Northwest Unit. The trash carts were labeled "soiled briefs" and an observation revealed one of the trash contained flammable trash, including items other than disposable briefs.

When the Director of Environmental Services was interviewed on October 29, 2009 at 1:20 PM, he stated he had worked in this facility only a few months, and the 48 gallon mobile trash containers were in use in the facility when he began to work there. He was not aware regulations require the large, mobile trash carts to be stored in a protected location (a room with fire rated separation from other areas of the building).

In summary, the 4 large, mobile trash carts were not always stored in a protected location.

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

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure corridors were separated from "use" areas of the building in both of the facility's 2 nursing units, the Southeast Unit and the Northwest Unit. Two partially full clean linen transport carts were stored in a corridor alcove of Southeast Unit; double doors to the laundry room were not smoke-tight; and the Northwest Unit nourishment kitchen had an open transfer grille (an opening through the wall for ventilation) to the corridor. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) When the laundry room was observed on October 27, 2009 at 10:25 AM, the laundry room had double doors to the south corridor. There was a gap between the double doors of less than 1/2 inch.

The laundry room doors were observed on October 29, 2009 at 10:30 AM, and the gap remained between the laundry room doors. On the corridor side of the laundry room doors there were holes in one of the doors remaining from hardware that was no longer attached to the door.

When the Director of Maintenance was interviewed about the gap between the laundry room doors on October 29, 2009 at 10:30 AM, he stated he understood why a smoke-tight separation was required.

In summary, due to the gap between the laundry room doors, the doors did not provide a smoketight separation between the laundry room and the corridor.

2) Two large clean linen carts were observed in an alcove in the south corridor on October 29, 2009 at 9:15 AM, 10:00 AM, 10:30 AM, 11 AM, 12:15 PM, and 12:50 PM. At 12:15 PM, one of the clean linen carts was half full with uncovered linen; the other cart was 3/4 full.

When the Environmental Services Director was interviewed on October 29, 2009 at 11:50 AM, he stated today (October 29) was the day the clean linen was delivered to the facility, and the clean linen would normally be transferred to the smaller clean linen carts at 2 PM.

In summary, there was no fire separation between the corridor and the alcove used as a storage area for clean linen.

3) When the Northwest Unit nourishment kitchen was observed on October 29, 2009 at 11:15 AM, an open transfer grille was observed connecting the nourishment kitchen to the corridor.

When the Maintenance Director was interviewed on October 29, 2009 at 11:15 AM, he stated he had questioned the transfer grille in the past, and he had been advised the transfer grille was allowed.

In summary, the Northwest Unit nourishment kitchen did not have at least a 30 minute fire separation from the corridor due to the open transfer grille.

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