Northwoods Rehabilitation & Extended Care Facility at Moravia

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure the necessary treatment and services were provided to prevent the development of pressure ulcers and promote healing for 1 (Resident #3) of 2 sampled residents reviewed with pressure ulcers. Specifically, Resident #3 developed 2 Stage II pressure ulcers after she was assessed at mild risk for skin breakdown. After Resident #3 developed pressure ulcers, the facility did not ensure the treatment provided was ordered by the physician. The facility did not ensure pressure-relieving measures were developed and implemented timely and consistently. The facility did not ensure Resident #3's pressure ulcers were assessed timely; and did not notify the physician and registered dietitian (RD) timely regarding the resident's skin breakdown. There was no documented evidence the interdisciplinary team assessed the reason 2 heel pressure ulcers developed and staff dressed the resident in shoes after heel blisters were present. This resulted in actual harm that is not immediate jeopardy.
Findings include:

The Skin Policy, last revised June 15, 2009, documented:
- new skin issues were to be assessed by the RN within 24 hours of identification;
- the RN was to "initiate preventive measures for pressure relief";
- the skin care coordinating nurse would notify the interdisciplinary team, including the physician, when a skin breakdown occurred, if it deteriorated and when it resolved;
- a physician's order would be "obtained for any treatment of a skin issue."

Resident #3 was admitted to the facility on September 7, 2010 with diagnoses including Alzheimer's, bi-polar disorder, Parkinsonism, and hypertension.

The Braden Scale (for predicting pressure ulcer risk), dated September 8, 2010, documented the resident scored "22" (score greater than "18" = not at risk) and was not at risk for pressure ulcer development at that time.

On September 8, 2010, registered dietitian's (RD) assessment documented the resident's skin was intact.

The Minimum Data Set (MDS) assessment, dated September 21, 2010, documented the resident had severely impaired cognition, did not have a pressure ulcer, had a pressure- relieving device for the bed, and did not have a pressure-relieving device for the chair.

The comprehensive care plan (CCP), initiated September 22, 2010, documented the resident had "potential for skin breakdown", without rationale. The plan included a weekly skin check and reporting skin concerns to nursing.

On September 27, 2010, a telephone physician's order was obtained to send the resident to the emergency room for increased agitation and suicidal ideation. The resident was hospitalized and returned to the facility on October 6, 2010.

The "Admission Nursing Assessment", signed by the licensed practical nurse (LPN) on October 6, 2010. The registered nurse (RN) signed this form as "RN Assessment Review" on October 7, 2010. There was no documented admission weight for the resident.

The Braden Scale, updated October 6, 2010, documented the resident scored "17" ( 15-18 = mild risk) and was at mild risk for pressure ulcer development. The resident's risk level increased from her prior assessment, as her activity level declined from "walks frequently" to "chairfast", with limitations in sensory perception, occasionally moist skin, and limitations in mobility.

On October 19, 2010, the attending physician signed the resident's October 6, 2010 hospital discharge summary, signed the resident's re-admission telephone orders dated October 6,2010, and signed other telephone orders dated October 7, and October 11, 2010. There was no other documented physician's note in the resident's medical record after that date.

The licensed practical nurse's (LPN) progress note, dated November 12, 2010, documented the resident was observed with intact "water blisters" on both heels. Booties were applied to the resident's feet and her feet were elevated on a pillow. There was no physician's treatment order on November 12, 2010 for the resident's heel blisters. There was no documentation in the resident's medical record that the physician was notified on the change in the resident's skin status.

The LPN's November 15, 2010 progress note documented the resident was "crying", had shoes on, and complained of pain. The resident's shoes were removed, and the blister on the right heel was "now broken and red." The LPN documented the area was cleansed, antibiotic ointment was applied, and a dry dressing was applied. The note documented the blister on the left heel was dry, the fluid had dissipated, and border gauze was applied.

There was a telephone physician's order, dated November 15, 2010, for treatment to the resident's heel blisters; (triple antibiotic ointment and a wound dressing to her right heel, and border gauze for the left heel. Both treatments were to be done twice a day.) The order was signed by the Director of Nursing on November 15, 2010 at 3 PM. There was no evidence the physician signed this order and no evidence the physician was made aware of the resident's change in skin status.

The was no documented evidence in the medical record that the resident's shoes (and how they fit) were assessed by the interdisciplinary team, as a possible cause for her heel pressure ulcers.

The first documented assessment by the registered nurse (RN) was noted on the Skin Condition Monitor sheets, signed by the RN on November 15, 2010. The monitor sheets documented the resident was "identified" with 2 bilateral Stage II pressure ulcers on November 12, 2010. The RN assessment specified the resident had:
- a 10 centimeter (cm) x 10 cm intact blister on the right heel;
- a 5.7 cm x 5.7 cm intact blister on the left heel.
There was no documentation on the Skin Condition Monitor sheet or, in the resident's medical record that the RN notified the attending physician and the registered dietitian (RD) regarding the change in the resident's skin status. There was no documented evidence the interdisciplinary team assessed the reason the resident developed pressure ulcers when she was a low risk.

The November 16, 2010 LPN's progress note documented the resident was to wear booties at all times due to pressure areas.

On November 16, 2010, the CCP was updated with the documented change to apply bilateral Spenco (pressure relieving) booties to the resident "at all times due to pressure."

The Nursing Assistant Care Sheet (used by certified nursing aides, CNAs when providing care), updated on November 16, 2010, documented the resident was to wear bilateral Spenco booties at all times. The change in care plan was implemented 4 days after the pressure ulcers were initially identified.

The resident's November 2010 treatment administration record (TAR) documented that beginning on November 16, 2010, the resident was to wear Spenco booties at all times.

A November 17, 2010 nursing progress note documented there was a moderate amount of serous (pale yellow, transparent fluid) drainage from the resident's right heel blister.

The Skin Condition Monitor sheets, dated November 18, 2010, documented the RN assessed the resident's right heel to be "open blister with skin flap over"; the left heel was described to be "intact flattened blister, dry."

On November 22, 2010 at 1:05 PM, the resident was observed sitting in a geri-chair without a pressure-relieving cushion. On November 23, 2010 at 8:46 AM, the surveyor observed the resident being transferred by 2 CNAs using a gait belt. There was no pressure-relieving cushion in her gerichair and her Spenco booties were off. At 9:20 AM, the surveyor observed the resident in a reclined geri-chair, without a pressure-relieving cushion and at 12 PM, the resident was in the dining room, sitting in her reclined gerichair without a pressure-relieving cushion .

On November 23, 2010 at 12 PM, the surveyor interviewed the Director of Therapy, who was a certified occupational therapy assistant (COTA). She stated nursing staff decided on cushions for chairs. She stated cushions were not her "forte", and when nursing asked for her expertise, she deferred to the licensed (rehabilitation) therapists.

On November 23, 2010 at 12:05 PM, a CNA told the surveyor the resident spent the majority of time in the geri-chair, or in her bed.

On November 23, 2010 at 1:35 PM, the surveyor interviewed the RN Manager, who was new to the facility. The RN stated she was unaware the resident did not have a cushion in her geri-chair and said a geri-chair did not provide pressure relief. She stated the resident was assessed to be at mild risk for pressure ulcer development, had 2 blisters, and was to wear Spenco booties at all times. She stated, to her knowledge, the Spenco booties were implemented on November 15, 2010, the day she initially assessed the resident's areas.

On November 23, 2010 at 1:50 PM, the surveyor observed the resident's heels during a dressing change. On the inside portion of the right heel, a closed, red, circular area with 2 very small, dark spots were observed. The LPN completing the dressing change told the surveyor at that time that the area was previously fluid filled and was now flattened. On the bottom of the resident's left heel, the surveyor observed a circular area. The LPN stated the areas were not open and were kept covered. She stated she thought the areas may have been caused by pressure from the shoes the resident used to wear.

On November 23, 2010 at 2:35 PM, the RD was interviewed and said she could not recall Resident #3. She stated due to recent changes in nursing management, she was not notified of nutrition concerns as consistently as she had been in the past.

On November 23, 2010 at 3 PM, the Director of Nursing was interviewed, and stated the current COTA (Director of Rehab) had not taken on the responsibility of issuing pressure relieving devices to residents. She stated the goal was for the new RN Manager to begin coordinating wound rounds and issuing pressure relieving devices. She said the resident should have had a cushion in the geri-chair. There was no rationale why the physician was not notified, and did not sign the treatment order for the resident's skin breakdown, as specified in the facility skin care policy.

In summary, Resident #3 developed 2 Stage II pressure ulcers after the facility assessed her to be at mild risk for skin breakdown:
- The facility did not ensure the treatment provided was ordered by the physician.
- The facility did not ensure pressure-relieving measures were developed and implemented timely and consistently.
- The facility did not ensure Resident #3's pressure ulcers were assessed timely.
- The facility did not notify the physician and registered dietitian (RD) timely regarding the resident's skin breakdown.
- There was no documented evidence the interdisciplinary team assessed the reason 2 heel pressure ulcers developed and staff dressed the resident in shoes after heel blisters were present.

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

Based on observation, record review, and interviews with staff and family members conducted during the standard survey, it was determined the facility did not ensure 1 of 4 residents (Resident #3) reviewed for nutrition concerns, maintained acceptable parameters of nutrition status. Specifically, when Resident #3 experienced a significant weight loss, a change in feeding ability, and developed 2 pressure ulcers, the facility did not ensure the resident was consistently provided with adequate feeding assistance at meals to maintain her nutrition status and promote healing of her skin breakdown; did not ensure the resident's CCP and nursing assistant care sheet were updated when the resident was unable to feed herself; did not ensure the RD was notified timely and her nutritional status were re-assessed, when the resident had a 12.4 pound (8.8%) weight loss in 1 week and then developed skin breakdown. This resulted in actual harm that is not immediate jeopardy.
Findings include:

The facility's Weights policy, dated January 2009, documented residents were weighed on admission, every week for 4 weeks after admission, and then weighed monthly (minimally).

Resident #3 was admitted to the facility on September 7, 2010 with diagnoses including Alzheimer's disease, bi-polar disorder, and hypertension. Admission orders included a no extra salt, regular consistency diet, antihypertensive and psychotropic medications.

The comprehensive resident assessment, dated September 7, 2010, did not document a height or weight for the resident, and specified the resident was independent with eating.

The "Yearly Weight Record" did not document a weight for the resident on the day of admission or on the following day (September 8, 2010.)

The registered dietitian's (RD) assessment, dated September 8, 2010, documented the resident weighed 142 pounds (source of weight not specified) and was 5 foot, 7 inches tall. There was no ideal weight range or desired weight range documented. The resident's calorie and protein needs were assessed to be at baseline. The resident's food intake was documented as "not enough data". The documented nutrition goal was for the resident's "weight stability". The resident was provided a no extra salt diet, with a bedtime snack of ice cream.

The occupation therapy (OT) assessment, dated September 8, 2010, documented the resident fed herself, after meal set-up.

The September 21, 2010 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required supervision/1 person physical assistance for eating, weighed 142 pounds, was on a therapeutic diet, received a dietary supplement between meals, and did not have a pressure ulcer.

The comprehensive care plan (CCP), initiated on September 22, 2010, documented the resident required assistance to meet self care needs, and a goal for weight maintenance. The CCP did not document the resident's feeding ability.

On September 27, 2010, a telephone physician's order was obtained to send the resident to the emergency room for increased agitation and suicidal ideation. The resident was hospitalized and returned to the facility on October 6, 2010.

The hospital discharge summary, dated October 6, 2010 documented the resident was seen by psychiatry who documented "recent changes in her medication dosage may have led to increased agitation"; and seen by a neurology consult with recommendations to use "atypical neuroleptics" ( also known as antipsychotics, and used to treat symptoms of bipolar disorder).

The "Admission Nursing Assessment" was signed by the licensed practical nurse (LPN) on October 6, 2010. The registered nurse (RN) signed this form as "RN Assessment Review" on October 7, 2010. There was no documented admission weight for the resident and her skin integrity was not addressed.

The October 7, 2010 OT assessment documented the resident required maximum assistance for feeding. This was a change from the September 8, 2010 OT assessment that documented the resident was able to feed herself.

A verbal physician's order, dated October 7, 2010, was obtained for the resident to receive Restorative OT five times a week, to focus on activities of daily living (ADLs).

The most current nursing assistant care sheet (used by certified nursing aides \ for care instructions), was dated October 7, 2010. It documented the resident required supervision for eating and specified "self" for eating. The findings from the October 7, 2010 OT assessment that specified the resident required maximum assistance for feeding was not documented on the CNA care sheet or the CCP.

On October 12, 2010, the registered dietitian (RD) note documented the resident's average meal intake was 70%. The plan was to continue to monitor.
The yearly weight record documented the first weight obtained in the facility since the resident's re-admission was on October 13, 2010. The resident's weight was 141 pounds.

Review of "Nursing Rehab Notes" dated October 16, 2010 through October 25, 2010 revealed the resident had periods of increased agitation, weepiness, variable intake and ability to feed self, with no edema present. For example:
- on October 16, 2010 during the 3 PM - 11 PM shift, the resident had no documented complaints, was weepy at times, and had fair intake of food and fluids.
- On October 18, 2010 during the 3 PM - 11 PM shift, the resident was documented to have a "good" appetite and fed herself supper.

On October 23, 2010, Restorative OT was discontinued, with the physician signing the order on November 2, 2010.

On October 25, 2010 during the 7 AM to 3 PM shift, "Nursing Rehab Notes" documented the resident had "increased agitation and screaming; refused lunch"; received an order for intramuscular Haldol (anti-psychotic medication); friend visited and fed the resident her lunch. On the 3 PM to 11 PM shift that date, nursing documented the resident was "crying in the dining room; ate 1/2 her supper and drank 120 cc's."

Review of the resident's weight record revealed the resident weighed:
- 140 pounds on November 2, 2010
- 127.6 pounds on November 9, 2010 (12.4 pound weight loss in 1 week)
- 128 pounds on November 12, 2010
- 128 pounds on November 13, 2010
- 127 pounds on November 14, 2010
- 125 pounds on November 16, 2010.
There were no documented weights after November 16, 2010 for this resident.

There was no documented evidence the RD re-assessed the resident after her 8.8 % weight loss in 1 week (November 2 to November 9, 2010); and lost an additional 2.6 pounds in the following week (10.7% weight loss in 2 weeks). There was no documented evidence changes were made to the resident's CCP.

There were no documented physician notes that addressed the resident's weight loss.

The Skin Condition Monitor sheet, dated November 12, 2010, documented the resident was found with a 10 cm (centimeter) x 10 cm Stage II pressure ulcer on the right heel; and a 5.7 cm x 5.7 cm Stage II pressure ulcer on the left heel.

There was no documentation in the resident's medical record the RD was notified of this skin breakdown, or that the RD re-assessed the resident's plan, when the pressure ulcers developed.

On November 16, 2010, the CCP was updated and documented the resident was to wear bilateral Spenco booties "at all times, due to pressure." There were no changes regarding the resident's feeding ability or weight loss.

On November 22, 2011, the CCP documented a care plan meeting was held that date. The only documented change was that the resident was "no longer a risk for elopement." The resident's feeding ability, weight loss, and varied intake was no addressed.

On November 22, 2010 at 12:30 PM, the surveyor observed the resident seated in the dining room with the noon meal set-up on the table in front of her. The resident received ham, potatoes, spinach, bread, cake, milk, and coffee. The resident was eating the orange slice that was the garnish for the meal. At 12:43 PM, the resident was bent over at the table, with her nose almost touching the table. The resident ate the orange slice and did not attempt to eat or drink other items. At that time, a staff member sat with the resident and fed her. At 12:56 PM, the staff member left the table; the resident was observed to have eaten "bites" of the cake, ham and potatoes, and drank 1/2 the coffee.

On November 23, 2010 at 8:29 AM, the surveyor observed the resident sitting at a table in the dining room, bent forward, with her nose approximately 1 inch from the food that was set-up in front of her. No staff sat with the resident, and she did not attempt to feed herself. At 8:46 AM, the surveyor returned to the dining room, as the resident was being taken from the room. The resident's food was observed; she had eaten bites (less than 25%) of the egg and cold cereal. The resident's coffee cup was empty and she drank some of her juice.

The resident's long term companion and power of attorney was interviewed on November 23, 2010 at 1:20 PM. She told the surveyor the resident had a drastic change in her condition. She stated, in addition to losing her ability to ambulate, the resident used to feed herself. She said "now when she visited" she had to feed her.

On November 23, 2010 at 12:40 PM, the surveyor interviewed the Director of Therapy, (a certified occupational therapy assistant, COTA), who stated when the resident was admitted, she was ambulatory and walked laps around the unit daily. The Director stated the resident was no longer ambulatory and could not stand on her own or transfer herself.

On November 23, 2010 at 2:25 PM, the surveyor interviewed the registered nurse (RN) Manager and a licensed practical nurse (LPN) and asked them for any other available weights for the resident after November 16, 2010. No additional weights were provided.

On November 23, 2010 at 2:35 PM, the RD was interviewed via the telephone and was not able to recall Resident in question. She stated she reviewed the weight book and identified weight concerns. The RD said she was at the facility weekly and was not notified of nutrition concerns such as weight or skin issues by nursing, as there had been changes in nursing management. She stated she was responsible for identifying nutrition concerns when she was at the facility and addressing those concerns. She said she would address a weight loss if a resident lost 5% in 1 month or 10% in 6 months.

In summary, Resident #3 experienced harm (a significant weight loss and the development of pressure ulcers) as the facility:
- did not ensure the resident was consistently provided with adequate feeding assistance at meals to maintain her nutrition status and promote healing of her skin breakdown;
- did not ensure the resident's CCP and nursing assistant care sheet were updated when the resident was unable to feed herself;
- did not ensure the RD was notified timely and her nutritional status were re-assessed, when the resident lost 12.4 pounds (8.8% loss) in 1 week; and lost an additional 2.6 pounds the following week (overall 10.7% loss in 2 weeks); and developed pressure ulcers.

10 NYCRR 415.12 (i)(1)

Based upon observations, resident record reviews, activity calendar review, and staff interviews conducted during the standard survey, it was determined the facility did not provide an ongoing program of activities designed in accordance with the comprehensive assessment to meet the interests and needs of 6 ( Residents #2, 3, 4, 5, 6, and 8) of 9 sampled residents reviewed for activity concerns. Specifically, the facility did not ensure Residents #2, 3, 4, 5, 6, and 8 were provided with sufficient, meaningful, consistently scheduled, activities designed to meet their needs and preferences. For Resident #6, the comprehensive care plan (CCP) did not address her activities needs. For Resident #5, the CCP did not include interventions for diversional activities. For Residents #3 and 4, there were no current activity assessments; their CCPs did not address activities; and were not individualized.
Findings include:

RESIDENT REVIEWS:
1) Resident #2 had diagnoses including dementia, Down's syndrome, and mental retardation.

The resident's annual Minimum Data Set (MDS) assessment, dated December 22, 2009, documented the resident had moderately impaired cognition; was awake most of the shift; preferred all activities, except talking and helping others.

The Minimum Data Set (MDS) assessment, dated August 24, 2010, documented the resident had moderately impaired cognition, was dependent upon staff for transferring out of bed and mobility on the unit. The resident was assessed as awake most of the time and he was involved in activities 1/3 to 2/3 of the time.

The activities's progress note, dated September 2, 2010, documented when the resident "was up", he liked music programs.

The resident's current comprehensive care plan (CCP), dated November 21, 2010, documented the resident may be socially isolated, because of his Down's syndrome diagnosis, his communication difficulty, his hearing impairment, and his inability to express himself verbally. The CCP documented the resident enjoyed sensory programs, carrying stuffed animals, and looking at magazines. The plan for the resident was to take him to activities that matched his preferences, and to provide magazines for him to look at.

The resident's "Activities Attendance Sheets", dated November 1 through 22, 2010, documented the resident attended activity programs including hydration pass, television or radio programing. These programs were not appropriate for, and were not individualized to meet this hearing impaired resident. There were no documented attendance sheets provided (when requested) for November 6, 7, 13, 14, 15, and 21, 2010. (These dates were the weekend dates that the Director of Activities did not work.)

The surveyor observed the resident on November 22, 2010 at 3:00 PM, as he laid in bed with his eyes closed. When the resident was observed on November 23, 2010 at 8:25 AM in the dining room, his eyes were closed; at 9:05 AM that same day, the resident sat in the hall, next to his room, with his eyes closed.

The Director of Activities was interviewed on November 23, 2010, between 2:55 PM and 3:25 PM. She stated she considered the activity plan for the resident to be "anything musical, carrying his stuffed animals, a back rub, offering a drink, and talking to him."

2) Resident #6 had diagnoses including mild mental retardation, mood disorder, Parkinson's dementia and seizure disorder.

The Initial Activity Assessment, dated January 25, 2010, documented the resident previously lived at a group home and, when asked what she liked to do, the resident smiled and said she liked whatever was asked. The Assessment Audit Tool documented the resident's interests included: game shows on television, watching bingo, card playing (with help), music, talking, and coloring books.

The social history, completed by the social worker on January 29, 2010, documented the resident stayed busy with hobbies, reading, or a fixed daily routine.

The quarterly interdisciplinary review of the CCP, dated October 26, 2010, documented the resident continued with demanding behaviors, and changes were made to her medications. The CCP note specified the resident often requested to go back to bed and participated in activities "with prompting". The CCP did not address an individualized activity plan for the resident.

An activity note dated November 10, 2010, documented the resident attended music programs, received 1:1 visits, and often requested to return to her room to lay down. On that date, the resident was actively brought into the conversation throughout the program. The note specified the resident remained at the activity while the other residents worked on centerpieces; the resident did not request to go back to bed.

On November 22, 2010, from 10:00 AM to 10:30 AM, and from 1:30 to 2:00 PM, the surveyor observed the resident sitting in her room; from 2:00 PM to 4:50 PM, the resident was observed to be resting/sleeping in bed. On November 23, 2010 at 9:15 AM, the resident was observed seated outside her room; at 1:10 PM that date, the surveyor observed the resident sitting in her wheelchair in her room.

A certified nurse aide (CNA) (familiar with Resident #6) was interviewed on November 23, 2010 at 1:10 PM. She stated the resident's normal routine was to be in the dining room for meals, with a morning nap for an hour or an hour and a half. After lunch, the resident was either taken back to her room, or she remained out by the desk. The CNA said the resident attended some activities; it depended on the program. The programs the resident attended included music programs and "tapes".

Review of the resident's activity attendance record for November 1 through November 22, 2010 revealed the resident attended group programs on 8 of the 22 days. On 14 days during that time, there was no documented evidence the resident participated in activities.

3) Resident #5 had diagnoses including Alzheimer's type dementia, mood disorder, depression and hypersexual behavior.

The Initial Activity Assessment, unsigned and undated, documented the resident's previous occupation was working in a bakery. The resident's routine was: up early in the morning; liked sitting and watching people in the afternoon; and watched television in the evening. The resident did not identify any specific hobbies of interest, and specified he "likes to do things but nothing on a regular basis".

An Assessment Audit Tool, dated June 18, 2010 and completed by the Activity Director, identified the resident's hobbies to include: gardening, pets, bird watching, fishing, cooking (sometimes), reading, and traveling. The resident liked sports including baseball, football, NASCAR, basketball and the Olympics. The assessment tool documented interests in dancing, movies, fixing things, talk radio, all types of music, being outside, swimming, and going to restaurants.

The current comprehensive care plan (CCP), established on June 3, 2010 and updated on September 10, 2010, had no documented interventions by the activity department. The resident exhibited inappropriate touching and made sexually inappropriate comments. The CCP specified to "see attached behavior management plan". The resident's Behavioral Management Plan specified the resident's inappropriate behaviors, and included providing diversional activities. There were no individualized interventions related to diversional activity programming; the plan did not address the resident's previously documented interests to ensure his psychosocial well-being was enhanced . The CCP did not address the resident's individualized interests and needs and did not identify a program designed to meet these needs.

The interdisciplinary progress notes, dated October 13, 2010 through the time of survey (November 23, 2010), documented the resident spent time in his room, in the dining room for meals, and in the lounge/dining room watching television.

The surveyor observed the resident on November 22, 2010 seated in his room at 10:05 AM. The resident's television was turned on, and was placed high on the wall and angled away from the resident's seat. The resident was observed to remain in his room until the noon meal, when he was observed seated alone in the dining room at 12:50 PM. At 1:20 PM, the surveyor observed the resident to be escorted back to his room by the certified nurse aide (CNA). The resident was observed in his room through 3:00 PM that afternoon. The surveyor's meeting with the resident group was held between 3:00 and 4:00 PM that afternoon and the resident did not attend. He was observed in his room following the group meeting, (from 4:40 PM through 5:15 PM) when escorted to the dining room. The resident remained in his room throughout the day, other than for meals.

Review of the November 2010 attendance record for November 1 through November 22, 2010, revealed the resident attended group programming 6 of those 22 days.

RESIDENT GROUP INTERVIEW:
During the resident group meeting held on November 22, 2010 at 3:00 PM with 6 anonymous residents in attendance, the residents told the surveyor there was not enough variety in the programs offered at the facility. For example, the residents all said that on "some days, the only activities were television shows.

ACTIVITY CALENDAR:
The November 2010 activity calendar documented that on November 22, 2010, the Director of Activities was on vacation and the planned activities were: 10 AM music, 11 AM "Price Is Right", and 2 PM Bingo. The first 2 activities on the calendar were television based programs; the Bingo activity was to be conducted by a staff member from another department.

The November 2010 activity calendar documented on November 23, 2010, the Director of Activities was on vacation and the planned activities were: 10 AM music, 11 AM "Price Is Right", 2 PM television "in rooms", and 4 PM games shows. All planned activities were television based programming.

GENERAL OBSERVATIONS:
The activity calender for November 22, 2010, documented music was scheduled for 10 AM. At 10:35 AM on November 22, 2010, one (unidentified) resident was observed in the activity/lounge. The television was playing a country music station, with the volume turned down low; and only able to be heard if seated directly in front of the television. As the surveyor entered the room, the licensed practical nurse (LPN) came in and transported the resident in her wheelchair back to the unit. At 10:55 AM no residents were observed in the dining room/lounge at this planned activity program, and the country music station continued to play on the television at a low volume.

On November 23, 2010 at 11:45 AM and 12 PM, the surveyor observed the dining room. The "Price Is Right" game show was playing on the television, with Resident #15 and 5 unidentified residents were seated in the dining room. The Director of Activities interacted with Resident #15 while he watched the game show, and the other 5 unidentified residents sat in a disinterested manner, with their eyes closed, or playing with their shoes or socks.

STAFF INTERVIEWS:
The Director of Activities was overheard on November 22, 2010 at 3:50 PM telling unidentified residents in the dining room that Bingo was not on the calendar until "last week", because she was on vacation.

During an interview with the Director of Activities on November 23, 2010, between 2:55 PM and 3:25 PM, she told the surveyor the activity calendar for November 2010 was "very unusual", because she was on vacation, and there was no other activity staff that worked in the activities department. When asked about the activity programming, the Director stated:
- the music program consisted of music on the stereo, or channel 37 or 69 on television.
- the "Price Is Right" was a game show on television; the televisions in residents' rooms and in the dining room should be set to channel 67.
- she passed drinks to make sure the residents had hydration and made sure their needs were meet. Passing drinks was counted as a "coffee hour", and the time spent with each individual varied between "at least a couple of minutes to 10 minutes".
- she was the only individual who worked in the activities department, and she worked 6 hours per day, 5 days a week.
- when she was not in the facility, she could "not guarantee anything was done except music" for an activity;
- if she was not in the facility, the certified nurse aides (CNAs) would do the hydration pass, and put on music or television.
- when she did not work, there was no documentation of residents' activity participation.
- the residents were not getting enough activities to prevent them from becoming bored.

The Director of Nursing (DON) was interviewed on November 23, 2010 at 3:40 PM, and stated the Director of Activities was responsible for activities in the facility. The DON stated there was a morning and afternoon hydration pass done by the Director of Activities and should not be counted as an activity for the residents. She was unaware that "music" on the calendar meant it was the radio playing.

During a second interview with the Director of Activities on November 23, 2010 at 4:20
PM, she stated she reviewed the activity calendar and activity records. She said when she was not at work, (including weekends and vacation), she could not guarantee activities occurred as she was the only employee in the activities department. The Director of Activities stated when she was not at the facility, she tried to have staff ensure the televisions were turned on, and plan television programming.

In summary, the facility:
- did not ensure Residents #2, 3, 4, 5, 6, and 8 were provided with sufficient, meaningful, consistently scheduled activities.
- the comprehensive care plan (CCP) did not address Resident #6's activities needs.
- the CCP did not include interventions for Resident #5's diversional activities.
- For Residents #3 and 4, there were no current activity assessments; and no individualized CCPs developed to address their activities needs.

10 NYCRR 415.5 (f)(1)

Based upon observations and staff interviews conducted during the standard survey, it was determined the facility did not provide effective housekeeping and maintenance services to maintain a sanitary and orderly environment and eliminate persistent odors on 1 of 2 dining areas (main dining room), in both bathing areas (small and large shower rooms), in the public restroom, in the nourishment pantry, and in 1 of 8 sampled resident rooms (resident room #9). Specifically, the facility did not maintain floors and furniture in the main dining room; did not maintain the floors and walls in bathing areas and public restrooms; did not store sterile water supplies in a safe manner; and did not keep the facility free from persistent odors. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the building inspection conducted on December 3, 2010 between 1:15 AM - 3:15 PM, the following observations were made:
- cracks and stains were present on the dining room floor;
- stains were present on the public bathroom floor;
- cracked ceramic tiles were present on the large shower room floor;
- the bathroom floor in resident room #9 had stains and a persistent urine odor was noted in the room and in the corridor;
- ceramic wall tiles in the small shower room were caved in;
- bottles of sterile water were stored in a box beneath unprotected drain pipes from the nourishment pantry sink;
- a small table in the dining room had a chipped table top edge and lacked a tablecloth.

The Director of Housekeeping was interviewed on December 3, 2010 at 1:40 PM. She stated she had not been able to get the stains out of the dining room floor or the public bathroom floor; said she was down 1 housekeeper; and stated she had been working on a floor care schedule.

During the interview with the Director of Housekeeping at 1:50 PM on December 3, 2010, she stated she thought the nurse aides were responsible for storage of water bottles under the nourishment sink. She said she did not realize it was a housekeeping duty. At 2:25 PM, the Director of Housekeeping told the surveyor she was aware of the persistent odor in room #9. She stated they cleaned it frequently, but could not eliminate the odor.

The surveyor interviewed the Director of Maintenance on December 3, 2010 at 2:50 PM. He stated he was aware of the problems in the bathrooms, and felt they would have to get someone to fix the wall in the small shower room. At 3:00 PM, he told the surveyor he was unaware of the chipped edge to the small dining room table. When the surveyor spoke with the Director of Housekeeping also at 3:00 PM, she stated the other 6 tables had tablecloths. She said the small table did not have one, because they were out of them.

In summary, the facility did not provide effective housekeeping and maintenance services to maintain a sanitary and orderly environment as evidenced by the observed findings in regard to the upkeep of dining and bathing areas; the improper storage of resident care supplies; and the existence of persistent odors.

10 NYCRR 415.5(h)(2)

Based on observations and staff interviews conducted during the standard survey, it was determined the facility did not ensure an accounting of controlled drugs, including narcotics, was maintained on the facility's 1 nursing unit an accounting, as required. Specifically, the keys to the medication room and narcotic lock box were passed from 1 licensed nurse to another licensed nurse, without documented evidence a reconciliation of the controlled drugs was done. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

On November 22, 2010 at 3:15 PM, the surveyor observed the following:
- licensed practical nurse (LPN) #4 asked LPN #5 for the "keys".
- LPN #5 gave LPN #4 a set of keys.
- LPN #4 entered, then left, the medication room; and returned the set of keys to LPN #5.

During an interview with LPN #5 on November 22, 2010 at 3:20 PM, she told the surveyor that she had responsibility for the keys to the medication room and narcotic lock box. She said she gave these keys to LPN #4, without a reconciliation of the narcotics, because "I trust her" and that this "was always done."

On November 23, 2010 at 1:22 PM, the surveyor observed the following:
- LPN #3 gave the keys to the medication room and narcotic lock box to LPN #2, without a reconciliation of the narcotics.
- LPN #2 entered and exited the medication room, and stated "I got the narcotics I need".
- LPN #2 returned the keys to the medication room and narcotic lock box to LPN #3, without a reconciliation of the narcotics.

LPN #2 was interviewed on November 23, 2010 at 1:22 PM. She said when the surveyor observed her in the medication room, she took Ambien (medication for sleep), Vicodin (narcotic pain medication), and Klonopin (psycho-active medication for seizures or panic attacks) from the narcotic lock box. She stated there were narcotics for "probably" 15 residents remaining in the narcotic lock box.

In an interview with LPN #3 on November 23, 2010 at 1:25 PM, she stated she was the nurse responsible for the keys to the medication room and narcotic lock box, and that she gave the keys to LPN #2 without a reconciliation of the narcotics. She said that was her normal practice.

LPN #2 was re-interviewed on November 23, 2010 at 2:00 PM. She stated the narcotics should be counted at the beginning and end of the shift. She stated each nurse use to have a set of the keys, but now the nurses "worked off one set".

An inventory of the controlled substance storage unit was done by LPNs #2, #3 and a surveyor on November 23. 2010, between 1:40 PM and 2:00 PM 2010. The inventory included:
- 56 tablets of Ambien, 5 milligrams (mg);
- 105.5 tablets of Ativan (medication for anxiety), 0.5 mg;
- 19 tablets of Restoril (medication for sleep), 30 mg;
- 99 tablets of Klonopin, 0.125 mg
- 105 tablets of Darvocet N-100 (medication for pain);
- 210 tablets of Lyrica (used to treat nerve pain and fibromyalgia ), 150 mg;
- 211 tablets of hydrocodone/acetaminophen (narcotic pain relief, Lortab, Vicodin)
- 3 tablets of Vimpat (medication for seizures), 150 mg;
- 51 cubic centimeters (cc) Roxanol (narcotic pain relief), 20 mg per cc.

During an interview with LPN #3 on November 23, 2010 at 3:00 PM, she stated whoever had medication cart #2, also had the keys to the medication room and narcotic lock box. She stated she knew the narcotic count was correct, because each medication nurse only counted and took the narcotics for their assigned residents.

The Director of Nursing was interviewed on November 23, 2010 at 3:25 PM, and stated the medication nurse that worked on the second medication cart was responsible for the keys to the medication room and narcotic lock box. The DON said there should be a reconciliation of the narcotics before the keys were given to another nurse. The DON stated she was not aware the keys were passed from nurse to nurse, without reconciliation of the narcotics.

In summary, the facility:
- did not ensure medication nurses implemented safe and appropriate procedures for maintaining security of medications.
- did not ensure an accurate reconciliation and accounting of controlled drugs was conducted when keys to the medication cart and narcotic lock box were passed from nurse to nurse.

10 NYCRR 415.18(e)

Based on observation, record review and staff interview conducted during the standard survey, it was determined the facility did not ensure 4 of 9 residents observed during the medication administration (Residents #11, 12, 13, and 14) were free from significant medication errors. Specifically, medications were observed to be administered to Residents #11, 12, 13, and 14 after their scheduled time. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #12 had multiple diagnoses including breast cancer.

The physician's progress note, dated September 28, 2010, documented the resident had breast cancer and was on chemotherapy. The resident's nausea and vomiting was "ok" with the medication Reglan (to aid nausea).

The resident's November 2010 medication administration records (MAR) documented the resident was scheduled to receive 5 milligram (mg) Reglan, 1 hour before meals, at 7:30 AM, 11:30 AM, and 4:30 PM.

On November 22, 2010 at 12:30 PM, the surveyor observed lunch in the dining room.

The surveyor reviewed the resident's MAR during the medication pass on November 22, 2010 at 1:55 PM. The 11:30 AM dose of Reglan was not signed as administered.

The licensed practical nurse (LPN) medication nurse was interviewed on November 22, 2010 at 1:55 PM and told the surveyor that she forgot to sign the MAR earlier, but did administer the Reglan. The surveyor observed the LPN as she reconciled the Reglan dispensing package. The Reglan count revealed the dose of medication was not given. At 1:58 PM, the LPN told the surveyor that she did not give the resident the 11:30 AM Reglan, as she "must have forgotten".

In summary, the facility did not ensure that Resident #12 was free from significant medication errors when the resident did not receive the 11:30 AM dose of Reglan 1 hour before lunch.

2) Resident #11 had diagnoses including a cerebrovascular accident (CVA, stroke).

The physician's orders dated November 2, 2010, documented the resident was to receive Creon-24 CPEP (pancreatic enzyme) at 8:00 AM, 12:00 PM, and 6:00 PM..

At 2:15 PM on November 22, 2010, the surveyor observed the licensed practical nurse (LPN) administer the resident the 12:00 PM dose of Creon-24 CPEP.

During an interview with the LPN on November 22, 2010 at 2:30 PM, she stated the resident did not receive the 12:00 PM dose of Creon-24 CPEP until 2:15 PM, because she was "a little bit behind". She stated this was a new shift for her, and she was not used to it.

In summary, the facility did not ensure Resident #11 was free from significant medication errors, when the resident received his 12:00 PM dose of Creon-24 CPEP, 2 hours and 15 minutes after the scheduled administration time.

3) Resident #13 had diagnoses including Alzheimer's disease and glaucoma.

The physician's order dated October 5, 2010 documented the resident was to receive Cosopt (eye drops to treat glaucoma) twice a day.

The resident's November 2010 medication administration record (MAR) documented the Cospot was to be administered at 9 AM and 1 PM.

On November 22, 2010 at 2:15 PM, the surveyor observed the licensed practical nurse (LPN) administer the resident's 1:00 PM dose of Cosopt at that time.

During an interview with the medication LPN on November 22, 2010 at 2:30 PM, she told the surveyor the resident's 1:00 PM dose of Cosopt eye drops were administered late, because she "was behind."

At 3:25 PM on November 22, 2010, the medication LPN told the surveyor that she did not let anyone to know she was running behind.

The Director of Nursing (DON) was interviewed on November 23, 2010 at 3:30 PM and stated she was not aware the medications were administered late November 22, 2010. The DON said she went to the unit twice on November 22, 2010, and the medication LPN stated she was "okay."

In summary, the facility did not ensure that Resident #13 was free from significant medication errors when the resident received the 1 PM dose of Cosopt 1 hour and 15 minutes after the scheduled administration time.

10 NYCRR 415.12(m)(2)

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the facility did not ensure 2 (Residents #3 and 9) of 3 sampled residents, reviewed for restraints, were free from their use, unless medically necessary. Specifically, for Residents #3 and 9, there were no specific medical symptoms that warranted the use of restraints; there were no individualized parameters for the use of their restraints; there was no documented evidence the restraints were assessed as the least restrictive device and used for the least amount of time as necessary; and there was no documented evidence the facility developed and implemented a plan to reduce or eliminate their restraints. There also was no reassessment of Resident #3's care plan, after she was injured by the use of a restraint. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY of December 10, 2009.

Findings include:

1) Resident #9 had a pertinent diagnosis of severe dementia.

The resident's current Nursing Assistant Care Sheet, dated July 15, 2010 (and used by the aides to provide care). The form noted the resident's use of a self-release seat belt when seated in the wheelchair or recliner. There was no further directives for the use of the belt.

Nursing notes documented:
- on September 8, 2010, the resident was observed with a light pink rash around the umbilical area.
- on September 11, 2010, the red area on the abdomen appeared to be skin "shear" described as "probably" from leaning over the seatbelt and rubbing her abdominal area.
- on September 13, 2010, the resident had a small red area on her abdomen, not open, and looked "to be from bending over and the belt rubbing on that area".
- on September 14, 2010, the red area "where seat belt lays" was fading.
- on September 21, 2010, the area was observed during skin check and continued to be red and improving.

There was no documented evidence the use of the seatbelt was re-assessed in relation to the risk of injury caused by the restraint.

The Minimum Data Set (MDS) assessment, dated September 28, 2010, identified the resident with poor short term memory, and moderate impairment in daily decision making ability. The resident had periods of restlessness and daily exhibited socially inappropriate behavior. She was non-ambulatory, required extensive to total assistance with all activities of daily living (ADLs), and was not identified as using a restraint.

The comprehensive care plan (CCP), last revised on October 7, 2010, documented the resident was at risk for falls due to dementia, tremors, and an unsteady gait. The resident had a history of sliding out of chairs and attempting unsafe transfers. Due to this history, the plan included the use of a "self-release seatbelt". There was no other documentation on the CCP of the resident's seatbelt use.

The physician orders, dated November 2, 2010, included the resident's self-releasing alarmed seat belt to be used in the wheelchair or recliner. The physician's order did not include a medical reason for the use of the belt.

Multiple restraint assessments on a single form, initiated November 11, 2009 and updated January 27, 2010, April 12, 2010, July 5, 2010 and October 7, 2010, documented the resident used a wheelchair with a seatbelt and anti-thrust cushion, to keep safe from falls. The multiple restraint assessments were reviewed and signed by registered nurses (RNs), who noted the seatbelt was planned as a restraint; no changes were made on the restraint updates.

On November 22, 2010 the surveyor observed the resident during the initial tour from 9:45 AM through 10:30 AM on November 22, 2010. The resident sat across from the nursing station in a wheelchair, with a seatbelt applied, leaning forward and removing her socks. When the surveyor attempted to speak to the resident, the resident's response was incoherent. The resident did not respond when the surveyor asked about the seatbelt.

At 1:00 PM on November 22, 2010, the surveyor observed the resident with the seatbelt in place, as she sat in the dining room, being fed by a family member. When the surveyor asked the family member when the seat belt was released, she stated "sometimes" she released it.

On November 22, 2010 at 5:40 PM, when the surveyor observed the resident, her seatbelt was in place as she sat at the dining room table.

On November 23, 2010 at 9:20 AM, the resident was observed with her seatbelt in place, as she sat across from the nursing station.

The Director of Rehabilitation Therapy was interviewed on November 23, 2010. She told the surveyor she "typically" was not involved in restraint assessments "at this time". She stated she generally attended part of the interdisciplinary team meeting, but was not usually present for the entire meeting.

In summary, for Resident #9, the facility:
- did not correctly identify the use of the seat belt as a restraint in the MDS or on the CCP, when the resident was unable to release it on command, and was unable to describe the reason for its use.
- did not have a physician's order that documented the restraint was necessary to treat a medical symptom.
- did not provide clear guidelines for staff, individualizing the use of the restraint for the least amount of time necessary.
- did not re-assess the application of the restraint, when there was documented evidence the restraint caused a reddened area on the resident's abdomen.

2) Resident #3's diagnoses included Alzheimer's disease.

The September 21, 2010 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and did not utilize a restraint.

The comprehensive care plan (CCP), initiated September 21, 2010, documented the resident required a restrictive device related to dementia and a history of rolling out of bed. The plan was to provide safe seating in a geri-chair with a tray table. The device was to be used as needed for agitation, combativeness, and unsafe behaviors.

Review of the September 2010 physician's orders and treatment administration record (TAR) revealed no documented evidence a geri-chair with tray table restraint was ordered or used.

On October 6, 2010, a device/restraint assessment signed by the Director of Nursing (DON) documented the resident was to use a geri-chair with a tray as needed, due to increased confusion, agitation, and inability to be redirected. The portion of the assessment for the interdisciplinary team to sign was not completed. Review of the medical record revealed no documented evidence of a physician's order for the lap tray restraint.

A nursing note, dated October 7, 2010, documented nursing discussed the resident with the Director of Therapy; the plan was to trial a lap buddy as needed in the wheelchair. A verbal physician's order was written on that date for a lap buddy "as needed" for safety; to be released every 2 hours. There was no documented evidence the geri-chair with lap tray was ordered.

The occupational therapy (OT) assessment, dated October 7, 2010, documented the resident flexed forward when sitting, and used a lap buddy to "increase safety."

The Nursing Assistant Care Sheet (used to provide care), dated October 7, 2010, documented the resident had a geri-chair with a lap tray to be used "as needed" and released every 2 hours and at meals. The care sheet did not document the use of the lap buddy.

Review of the October 2010 nursing progress notes documented both restraints (lap buddy and geri-chair with lap tray) were used on October 9, 18, 20, and 21, and 23, 2010. On October 8, 10, 11, and 12, 2010, nursing progress notes documented the lap buddy was used and the resident leaned forward in the wheelchair.

A nursing progress note dated October 12, 2010, documented the resident was observed with bruises on the abdominal area "possibly from geri chair tray table," and a large, soft mass was felt on the abdomen's right side; the registered nurse (RN) was notified. There was no documented evidence the resident's plan of care was re-assessed following these injuries.

A nursing note written on October 19, 2010, documented the lap tray was used.

On October 22, 2010, a nursing note documented a restraint was not needed and a geri-chair with an over bed table was used.

On October 25, 2010, a verbal physician's order was written to discontinue the wheelchair with the lap buddy.

The resident's October 2010 treatment administration record (TAR) documented the resident had 2 restraints, a lap buddy and lap tray, both to be used as needed.

The resident's monthly physician orders dated October 29, 2010, documented the resident had an order for the geri-chair with lap tray as needed, to be released every 2 hours and at meal time. The order was renewed on November 2, 2010.

Nursing progress notes dated November 15 and 16, 2010, documented a restraint was not needed those days.

The resident's November 2010 TAR documented the geri-chair with lap tray was initialed for by nursing daily during the month.

On November 22, 2010 at 1:05 PM and November 23, 2010 at 8:46 AM, the surveyor observed the resident to be seated without the lap tray in a reclined geri-chair.

On November 23, 2010 at 12:05 PM, the surveyor interviewed a certified nurse aide (CNA) who stated the resident had a lap tray and a lap buddy; the CNA said the resident did not use those anymore. She stated the current plan was for the resident to be seated in a geri-chair with her legs elevated. She thought the resident stopped using the lap buddy and lap tray "about a month ago."

On November 23, 2010 at 1:35 PM, the RN Manager was interviewed and said the resident had an order for a geri-chair with lap tray as needed. She stated she was newly hired by the facility and had not seen the resident use the restraint. She said the order did not specify when the lap tray was to be used; and she had not seen the resident try to get out of the chair. The RN Manager stated she was unaware whether the geri-chair in the reclined position had been assessed as a restraint, as she was not certain of the resident's ambulation and transfer abilities.

On November 23, 2010 at 2:55 PM, 2 licensed practical nurses (LPNs) showed the surveyor the resident's TAR with the restraint documented and signed for. The LPNs stated the resident had not used the restraint "lately. even though it was initialed in the TAR." They said they "went down the TAR and initialed it, even when it was not used." The LPNs stated the restraint was used when the resident was agitated or tried to get out of the chair. One of the LPNs stated there were restraint release logs, but she unable to locate the resident's log.

In summary, for Resident #3, the facility:
- did not ensure restraints were ordered to treat specific medical conditions.
- did not ensure there were specific parameters for the use of "as needed" restraints and an individualized plan for the restraints was developed.
- did not ensure the care plan was reassessed, when the resident was injured by the restraint.

10 NYCRR 415.4(a)(2-7)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure services provided met professional standards of quality for 1 (Resident #4) of 4 sampled residents reviewed for weight/nutrition, and for 2 (Residents #6 and 11) of 9 residents observed during medication administration. Specifically, when Resident #4 was readmitted from the hospital with a 27 pound weight gain, a reweight was not obtained to verify its accuracy; and Residents #6 and 11 were administered non-crushable medications in "crushed" form. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #4 had diagnoses including congestive heart failure (CHF) and hypertension.

The facility's Weight policy, dated January 2009, documented residents, who experienced a weight change of 3 or more pounds, would be weighed again for 3 consecutive days.

The August 31, 2010 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, did not have edema, weighed 120 pounds, and her weight was stable.

The quarterly nutrition assessment, dated August 31, 2010, documented the resident's diet order was no extra salt (NES); and specified her weight was stable for the past 6 months.

The yearly weight record documented the resident weighed 117 pounds on September 21, 2010; and weighed between 123-125 pounds on October 22-24, 2010.

The resident was hospitalized from October 31 to November 18, 2010 with a gastrointestinal bleed.

On November 18, 2010, the readmission nursing assessment and yearly weight record documented the resident weighed 150 pounds (a 27-pound increase from October 23, 2010).

The November 18, 2010 nursing note documented the resident was readmitted with pitting edema of her legs/feet; and noted the resident was "puffy all over" her hands and abdomen.

The resident's November 18, 2010 readmission physician orders documented the resident's diet order was NES and was ordered to receive Lasix (diuretic) daily.

Nursing notes, dated November 19, 20, 21, and November 22, 2010, documented the resident had edema to the extremities, face, and abdomen.

The comprehensive care plan (CCP), updated November 22, 2010, documented the resident was at risk for fluid deficit related to diuretic use. Interventions included monitoring weights, monitoring labs, and providing a NES diet.

Review of the medical record revealed no documented evidence the resident was weighed after November 18, 2010.

On November 23, 2010 at 2:25 PM, the licensed practical nurse (LPN) was interviewed and stated when the resident was readmitted, she was filled with fluid; staff were concerned; and they "couldn't wait to get her on a scale." She stated the resident was not reweighed.

On November 23, 2010 at 2:30 PM, the registered nurse (RN) Manager stated in an interview, that she discussed the resident's weight gain with the physician and did not document the conversation in the medical record. The RN stated the resident was reweighed after November 18, 2010.

On November 23, 2010 at 2:34 PM, the surveyor interviewed the attending physician who stated he was notified of the resident's weight gain and said fluid had been an issue for her. He stated the resident had a new diagnosis of CHF.

On November 23, 2010 at 2:35 PM, the registered dietitian (RD) stated in an interview, that she was not notified of the resident's weight gain, and if she was aware, she would have addressed a significant weight change.

In summary, the facility did not ensure the resident was reweighed to verify the accuracy of her 27 pound weight gain to ensure close monitoring of the resident's status.

2) Resident #6 had diagnoses including dementia and seizures.

The resident's Minimum Data Set (MDS) assessment dated October 12, 2010, documented the resident had severely impaired cognition and did not have a swallowing problem.

The physician's orders dated November 2, 2010, documented the resident was on a regular diet.

The resident's November 2010 MAR (medication administration record) documented the resident was to receive 500 mg (milligrams) Depakote DR (delayed release, medication for seizures); this medication was to be swallowed whole and not crushed. The November 2010 MARs documented the resident was on a regular diet.

During an observation of the medication administration on November 22, 2010 at 2:00 PM, the medication licensed practical nurse (LPN) #1 prepared, crushed, and administered medications to Resident #6, including 500 mg of Depakote DR.

During an interview with the medication LPN #1 on November 22, 1010 at 2:25 PM, she stated she crushed the Depakote DR, because the resident could not take her medications whole and she assumed the medication could be crushed.

The surveyor interviewed the pharmacist on November 23, 2010 at 2:30 PM. The pharmacist stated if the resident could not swallow her medication, the pharmacy should have been called to see if another form of the medication was available. He added that Depakote DR "was available as a liquid."

In summary, the facility did not ensure professional standards of quality were met when the resident was administered "crushed" 500 mg Depakote DR.

3) Resident #11 had diagnoses including a cerebrovascular accident (CVA. stroke).

The resident's Minimum Data Set (MDS) assessment dated September 13, 2010, documented the resident had moderately impaired cognition and a chewing and swallowing problem.

The physician's orders dated November 2, 2010, documented the resident was to receive 200 milligrams (mg) of Topiramate (seizure medication) 3 times a day. The resident was on a pureed diet.

The resident's November 2010 MAR (medication administration record) documented the resident was on a pureed diet; and was to be administered 200 mg Topiramate, "swallowed whole".

During the medication administration observation on November 23, 2010 at 8:55 AM, medication licensed practical nurse (LPN) #2 prepared Resident #11's medications, including crushing 200 mg Topiramate and administered it to the resident.

LPN #2 was interviewed at 9:00 AM on November 23, 2010. She stated she crushed the 200 mg Topiramate, because the resident was on a pureed diet, and his pills were crushed.

At 2:30 PM on November 23, 2010, the pharmacist stated during an interview that when a resident's MARs documented a medication that was to be administered "whole", she expected it not to be crushed. The pharmacist said if the resident could not swallow medication, the pharmacy should be called to see if another form was available.

In summary, the facility did not ensure professional standards of quality were met when Resident #11 received crushed 200 mg of Topiramate, which was to be given "whole."

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

Based on observation, record review, and interview with staff and residents conducted during the standard survey, it was determined the facility did not ensure the ability to perform activities of daily living (ADL), including eating, did not diminish unless unavoidable for 1 (Resident #4) of 2 sampled residents reviewed for ADL decline/concerns. Specifically, staff did not provide Resident #4 with utensils to feed herself in a timely manner; and did not offer to reheat Resident #4's food, when utensils were later provided. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #4 had diagnoses including congestive heart failure and hypertension.

The August 31, 2010 Minimum Data Set (MDS) assessment documented the resident had modified independence with decision making, no memory impairment, and fed herself independently.

The comprehensive care plan (CCP), updated November 22, 2010, documented the resident was to be encouraged to complete meals and consume fluids. The CCP did not document the resident's eating ability.

On November 23, 2010 from 8:25 to 8:45 AM, the surveyor observed the resident sitting in the wheelchair in her room, with the breakfast tray in front of her, on an overbed table. The resident received eggs, toast, cream of wheat, coffee, white milk, and chocolate milk. The resident did not receive utensils. At 8:36 AM, the surveyor observed the resident trying to pick up the eggs with her hands and eat them. The surveyor entered the room at that time. The resident told the surveyor that staff set-up her meals, and then left her alone in her room. The resident stated "sometimes, someone checked" on her during the meal; and "sometimes" staff did not return to her room, after delivering her meal tray. When the surveyor asked the resident if she rang her call bell, the resident stated she "did not want to bother" the staff. At 8:45 AM, staff had not yet returned to the resident's room.

At 8:45 AM on November 23, 2010, the surveyor interviewed the certified nurse aide (CNA), who said she was responsible for residents who ate in their rooms. The CNA initially told the surveyor that she set-up all residents' meal trays when they ate in their room. The CNA then stated she did not set-up Resident #4's breakfast meal. She stated she was supposed to monitor the residents in their rooms; and was not aware Resident #4 did not have eating utensils. The CNA said the resident did not receive utensils, because "she normally ate in the dining room" and utensils were provided at the tables in the dining room. She stated only residents who normally ate in their rooms received utensils on their meal trays. Following the interview, the CNA provided silverware to the resident. The CNA did not offer to reheat the resident's meal, that sat in her room for 20 minutes, before the CNA provided eating utensils.

Review of the consumption record for November 23, 2010, revealed the resident ate "bites" of the breakfast meal that day; and drank 80 cc (cubic centimeters) of the drinks.

In summary, the facility:
- did not ensure staff provided feeding utensils to allow the resident to feed herself in a timely manner.
- did not ensure staff offered to reheat the resident's meal after it sat uncovered for 20 minutes without eating utensils present.
- did not provide the resident with timely oversight when she dined in her room, to ensure her ability to feed herself independently did not diminish.

10 NYCRR 415.12(a)(1)(i-v)

Based on observation, record review, and interviews with staff and family members conducted during the standard survey, it was determined the facility did not conduct a comprehensive assessment within 14 days after a significant change occurred for the 1 (Resident #3) sampled resident that had a significant change in physical status. Specifically, for Resident #3 who experienced a decline in activities of daily living (ADL), developed 2 pressure ulcers, and had a significant weight loss, a significant change assessment was not completed. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #3 was admitted to the facility on September 7, 2010 with a diagnosis of Alzheimer's disease.

The admission Minimum Data Set (MDS) assessment, dated September 21, 2010, documented the resident:
- had severely impaired cognition with memory impairments;
- was independent with bed mobility;
- required supervision with transferring, walking, dressing, and eating;
- required limited assistance for toileting, personal hygiene, and bathing;
- did not use any transfer aides such as bed rails, mechanical lift, or slide board;
- was not primarily wheeled in a wheelchair for locomotion;
- weighed 142 pounds;
- did not have a pressure ulcer.

The October 6, 2010 physical therapy (PT) assessment and the October 7, 2010 occupational therapy (OT) assessment documented the resident required moderate assistance for transferring, was no longer ambulatory, and required maximum assistance for activities of daily living (ADL), including eating, dressing, hygiene, and bathing. When the resident's status documented in the PT and OT assessments was compared with the September 1010 MDS assessment, the resident's ability to perform multiple ADLs declined.

The yearly weight record documented the resident weighed between 125 and 128 pounds on November 9 through 15, 2010. This was a 9.9-11.9% weight loss since the initial MDS assessment completed on September 21, 2010.

The Skin Condition Monitor documented the resident was found with a Stage II pressure ulcer on both heels on November 12, 2010.

On November 23, 2010 between 8:29 and 8:46 AM, the surveyor observed the resident at the breakfast meal. The resident did not attempt to feed herself and was fed by staff. At 8:46 AM, the resident was transferred by 2 certified nurse aides (CNA) from a dining room chair to a geri-chair.

On November 23, 2010 at 8:56 AM, the Director of Nursing (DON), who coordinated the facility's MDS assessments, provided the surveyor with a list that documented the most recent MDS completed for the resident was dated September 21, 2010.

On November 23, 2010 at 12:05 PM, a CNA was interviewed and stated the resident "used to be" ambulatory, but now was no longer able to walk independently.

On November 23, 2010 at 12:40 PM, the surveyor interviewed the Director of Therapy, (a certified occupational therapy assistant, COTA), who stated that when the resident was admitted, she was ambulatory and walked laps around the unit daily. The Director stated "functionally", the resident had a "significant change", as she was no longer ambulatory and could not stand on her own or transfer herself. The Director said she completed the therapy portions of the MDS assessment based on the assessments done by the licensed therapists. She stated she did not know how a resident would trigger for a significant change assessment, and did not know the criteria for that type of assessment.

On November 23, 2010 at 1:20 PM, the resident's family member told the surveyor the resident had a drastic change in her condition. She stated in addition to losing her ability to ambulate, the resident used to feed herself. She stated when she visited the resident the week before, she had to feed her.

On November 23, 2010 at 2:35 PM, the registered dietitian (RD) was interviewed via the telephone and was not able to recall Resident #4 or, whether that resident had weight loss.

The DON was interviewed on November 23, 2010 at 3 PM, and stated the resident had a decline in condition that was likely due to the progression of the Alzheimer's disease. She stated a significant change assessment was not completed as the resident's ambulation was the only change she had. She stated she had not thought about the resident's transfer ability, and was unaware the resident had a significant weight loss.

In summary, the facility did not ensure a significant change assessment was completed for Resident #3 when she had a decline in her ability to perform ADLs, had a significant weight loss, and developed 2 Stage II pressure ulcers.

10 NYCRR 415.11(a)(3)(ii)

Based upon record review and staff interviews conducted during the standard survey, it was determined for 1 (Resident #5) of 10 sampled resident records reviewed, the facility did not maintain their clinical records in accordance with accepted professional standards and practices that were complete, accurate, and readily accessible. Specifically, for Resident #5 with inappropriate behaviors, the facility did not include the resident's behavior plan in his medical record as specified in the CCP to ensure it was readily accessible at all times to all members of the interdisciplinary team; did not ensure the resident's 2 behavior plans (with the same date) contained the same planned interventions; did not ensure revisions made to the resident's medical record were signed and dated. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #5 had diagnoses including dementia, mood disorder, and depression.

The comprehensive care plan (CCP) "established" June 3, 2010, documented the resident had a history of inappropriate behaviors. The plan specified "see attached behavior management plan". The behavior plan was not located when the surveyor reviewed the resident's medical record on November 22, 2010.

The surveyor interviewed the Director of Social Services on November 23, 2010 at 2:45 PM. The social worker she stated the resident's behavior plan was in the resident record. She reviewed the resident's medical record at that time and was unable to locate the plan.

Two behavior management plans, each dated June 3, 2010, were provided to the surveyor on November 23, 2010 at 3:00 PM. These 2 plans contained differing information regarding interventions to use for the resident's behavior. One plan documented the resident was on 15 minute checks; was encouraged to be at arm's length from non-ambulatory residents; was to have a room that was not close to female residents; and was allowed to direct his own activities and "cares", by being offered choices. The other behavior plan also dated June 3, 2010, did not include the intervention for 15 minute checks; and did not specify that the resident was to direct his own activities and care, by being offered choices. This second plan documented the resident was "to maintain" arm's length (other plan specified to encourage resident to be at arm's length) from non-ambulatory residents.

The resident's CCP included forms identified as "Care Plan Update and Meeting Summary". One of the forms documented 15 minute checks were discontinued on September 10, 2010. Other Care Plan Update and Meeting Summary forms documented the following:
- An undated form, signed by the dietitian, addressed discontinuing specific food items at bed time and adding other snack items.
- An undated form, signed by the social worker, addressed changes in the resident's fluids provided at meals.

In summary, the facility:
- did not include the resident's behavior plan in his medical record as specified in the CCP to ensure it was readily accessible at all times to all members of the interdisciplinary team;
- did not ensure the resident's 2 behavior plans (with the same date) contained the same planned interventions;
- did not ensure that when revisions were made to the resident's medical record, they were signed and dated.

10 NYCRR 415.22 (a) (1-4)

Based on observation, interview, and record review conducted during the standard survey, it was determined the facility did not maintain an infection control program designed to prevent the transmission of infection for 1 (Resident #1) of 2 sampled residents reviewed for infection control concerns. Specifically, the facility did not ensure staff used proper infection control techniques when Resident #1 was placed on infection control precautions for methicillin resistant Staphylococcus aureus (MRSA, a drug resistant bacteria) in the sputum; and staff did not utilize personal protective equipment when entering Resident #1's room. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #1 had diagnoses including chronic obstructive lung disease (COPD, lung disease).

The resident's Minimum Data Set (MDS) assessment, dated August 24, 2010, documented the resident did not have cognitive impairment. The resident was awake most of the time, moved independently throughout the facility, and preferred most activities within the facility.

The resident's hospital discharge paperwork, dated November 11, 2010, documented the resident's discharge diagnoses were tracheal bronchitis, and MRSA positive sputum, which was a "fairly resistant organism".

The resident's comprehensive care plan (CCP), updated on November 12, 2010, documented the resident was readmitted from the hospital, and was to wear a mask when he was out of his room.

Physician's progress notes, dated November 16, 2010, documented the resident had a productive cough, was to continue antibiotics, and have a follow-up sputum culture.

Nursing notes, dated November 12, 2010, documented the resident returned from the hospital with MRSA positive sputum. The note documented the resident "may" wear a mask when in the hallways.

Nursing notes, dated November 15, and 19, 2010, documented the resident was out of his room with a mask on.

During the initial unit tour on November 22, 2010 at 10:15 AM, the surveyor asked the charge licensed practical nurse (LPN) if any residents were on infection control precautions for any infections, including MRSA. The LPN told the surveyor that the resident was on precautions for MRSA in his sputum.

On November 22, 2010 between 10:35 AM and 4:00 PM, the surveyor observed an isolation cart (containing personal protective equipment, including face masks) outside the resident's room.

At 12:50 PM on November 22, 2010, the surveyor observed the resident out of his room wearing a face mask (covering his mouth). At that time, the resident told the surveyor he was in the hospital for bronchitis, and the face mask was for the protection of himself and others.

On November 22, 2010 at 1:48 PM, the resident was observed in his room. The surveyor observed the medication LPN enter the resident's room twice, without wearing personal protective equipment. At that time, the LPN told the surveyor that the resident had MRSA in his sputum, and she assumed she should have worn a gown, but she did not feel like it. She stated "sometimes", she would put a mask on, and "sometimes", the resident would help the nurses by putting a mask over his mouth.

During an interview with the resident's physician on November 23, 2010 at 2:34 PM, he stated the resident had MRSA in his sputum. He stated if nursing staff had direct contact with the resident's sputum, he would expect a mask, gown, and gloves to be worn.

The Director of Nursing (DON) was interviewed on November 23, 2010 at 3:30 PM. She stated the resident had MRSA in his sputum, and her expectations were for the nursing staff to wear a mask when they entered the resident's room

In summary, the facility did not ensure proper infection control techniques were followed for Resident #2, who had MRSA positive sputum, as the nurse did not wear a mask when she entered the resident's room.

10 NYCRR 415.19 (a), (b)(1)

Based on observations, staff interviews, and record reviews conducted during the standard survey, it was determined the facility did not provide adequate supervision and assistance to prevent accidents for 2 of 10 sampled residents (Residents #5 and 6). Specifically, Resident #5, who exhibited inappropriate sexual behaviors toward other residents, the facility did not evaluate the effectiveness of planned interventions to prevent the behavior and did not thoroughly investigate 2 incidents when the planned interventions were not followed. Resident #6 was on seizure precautions and the facility did not provide the planned supervision to maintain the resident's safety. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #5 had diagnoses including Alzheimer's disease, mood disorder, and hypersexual behavior.

The Nursing Assistant Care Sheet (used when providing care), dated May 28, 2010 and identified by unit staff as the current plan followed by the certified nurse aides (CNA), documented the resident required 2 staff members for all care; and specified the resident's move to a private room to ensure privacy and "alone time". The resident had been placed on 15 minute checks and these were discontinued. There were no dates documented on this care guide when these 15 minute checks were initiated or discontinued. The care guide documented an alarm was to be turned on when the resident was in his room.

The Minimum Data Set (MDS) assessment, dated August 10, 2010, identified the resident with poor short and long term memory, and moderately impaired daily decision making ability. The resident's mental function was documented as varying over the course of the day. The resident was described to need supervision with all activities of daily living (ADLs).

The comprehensive care plan (CCP), reviewed on September 27, 2010, identified the resident's history of inappropriate behaviors, including inappropriate touching and making sexually inappropriate comments. The CCP documented the resident had a history of deactivating alarms (to alert staff to his whereabouts). Planned interventions included: a private room; escorting the resident to the dining room and leaving him there, only when staff were present; laser alarms activated at night outside the resident's room to remind the resident to request assistance; and monitoring the resident's mood/behavior. The CCP documented the resident was previously on 15 minute checks that were discontinued on September 10, 2010. The CCP specified "see attached behavior management plan". When the surveyor reviewed the resident's medical record on November 22, 2010, there was no documented evidence of a behavior plan.

Nursing progress notes, dated October 6, October 8, and October 13, 2010, each documented the resident was sexually inappropriate toward nursing staff.

On October 15, 2010, a nursing progress note documented the resident shut both alarms off when they sounded. The note documented a staff member was in the next room and heard the alarms. The note specified the resident "did it again" that afternoon, and was "1/4 the way down the hall before he was seen by staff". A second nursing note dated October 15, 2010 documented the Director of Nursing (DON) was aware the alarms were shut off and 1:1 was to be started for the resident.

When the surveyor reviewed the facility's Incident/Accident reports on November 22, 2010, there was no documentation that a report was completed for the October 15, 2010 incident.

The DON was interviewed, with the Director of Social Services on November 23, 2010 at 3:00 PM. When the surveyor asked about the resident turning off the alarms, the DON stated after his October 15, 2010 incident, maintenance readjusted the position of the alarms so the resident would not be able to turn one of them off, without the other alarm sounding. She stated staff were responsible for maintaining the alarms in the correct positions. The DON was interviewed, with the Director of Social Services on November 23, 2010 at 3:00 PM. The DON stated she did not recall the resident being placed on 1:1, as there was not enough staff to do so on Friday October 15, 2010. The licensed practical nurse (LPN) who wrote the October 15, 2010 nursing note regarding the 1:1, entered the conversation and stated the resident was on 1:1 "over that weekend", immediately following the incident. The DON stated an incident report was done and, after looking for the report, was unable to locate it.

Nursing notes, dated October 16, 2010, documented the resident was on 1:1 until 11 AM, and staff were with the resident in the dining room, until after lunch. Following lunch, the note specified the resident remained in the dining room watching television. The nursing note documented no other residents were around, and staff were nearby at the desk.

On October 17, 2010, nursing notes documented the resident continued to be on 1:1 and no inappropriate behaviors were reported. There was no further documentation of the resident being monitored on 1:1.

On October 19, 2010, a nursing note documented the resident came out of the bathroom in the dining room, passed a female resident, and placed his head on her shoulder. The resident was immediately redirected and was instructed by the nurse that behavior was not allowed. The note documented staff believed the resident was trying to move the resident forward, so he could get by her.

When the facility's Incident/Accident reports were reviewed on November 22, 2010, there was no documented evidence a report was completed for the incident on October 19, 2010.

A social work quarterly summary, dated November 8, 2010, noted the resident remained on medications for mood disorder, depression, and hypersexual behavior, with fair effect. Multiple care plan interventions were noted to be in place to address the resident's inappropriate sexual behavior. There was no documentation pertaining to the resident's behavior of turning off his alarms on October 15, 2010; no documentation pertaining to the incident of October 19, 2010; and no documentation when the resident was placed on 1:1. There was no documented evidence the resident's care plan was re-assessed and/or revised following his October 15, 2010 and October 19, 2010 incidents.

The surveyor observed the resident on November 22, 2010 at 10:10 AM, as he sat in his room. An alarm sounded as the surveyor walked from the hallway toward the resident's room. The alarm was reset by the housekeeper who was in the hallway at the time. A second alarm was observed across the hall and did not sound.

On November 22, 2010, the resident was observed leaving his room at 5:15 PM and the alarms sounded when he entered the hallway. The resident looked at the surveyor and stated "they're both ringing real good". A CNA was observed running down the hallway, and turned off the alarms. The CNA walked with the resident toward the dining room and the resident reached over to the aide; and was observed to hug and kiss her.

On November 23, 2010 at 1:10 PM, the surveyor interviewed a CNA who stated she worked at the facility for several months, and was aware of Resident #5's behaviors and plan of care. The CNA stated the sheets with the CNA care information were located in the resident's closet and in the CNA book. If any changes were made to a resident's care, it was noted on a clipboard at the nursing station. She stated Resident #5 had the motion detector alarms in the hallway and when they were installed, the 15 minute checks were discontinued. If the alarms sounded, all facility staff knew to respond. The CNA said she never saw the resident turn the alarms off, "although" she heard that he had. She stated she did not believe changes were made to the plan of care and was not aware of the plan for 1:1. She said the resident was able to attend activity programs, as long as he was an arm's length away from female residents.

At 1:45 PM on November 23, 2010, the surveyor observed the resident in his room. One of the hall alarms was turned on and the other hall alarm was observed to be turned off.

The Director of Social Services was interviewed on November 23, 2010 at 2:45 PM. The social worker stated the resident had a behavior plan. When she reviewed the resident's medical record, she did not locate the plan in the record. (The plan was later provided to the surveyor). She stated the plan identified the resident's need to be with a staff member when in the general public, and the resident needed to be at arm's length away from other residents.

Two behavior management plans, identified as being the resident's current behavior plan by the DON, (both dated June 3, 2010), were provided to the surveyor at 3:00 PM on November 23, 2010, after the surveyor and the Director of Social Services were both unable to locate it in the resident's medical record. One of the plans noted the resident was on 15 minute checks and the other behavior plan did not. Preventative measures included: a private room; provide diversional activity; have 2 staff members during his care; maintain an arm's length distance from non-ambulatory residents. If inappropriate behavior occurred, the resident was to be redirected and firmly told that his behavior was not acceptable; and the interaction was to be discontinued and reapproached later to complete care. If a behavior episode occurred, the plan specified it was to be reported to the team for review of the plan.

In summary, for Resident #5 with a history of inappropriate sexual behavior toward staff and female residents, the facility:
- did not monitor the effectiveness of the planned interventions for preventing behaviors;
- did not thoroughly evaluate 2 incidents when the planned interventions were not followed;
- did not ensure the planned intervention of providing 1:1 was assessed prior to being discontinued.

2) Resident #6 had diagnoses including mild mental retardation (MR), Parkinson's syndrome, dementia and seizure disorder.

The Minimum Data Set (MDS) assessment, dated July 20, 2010, documented the resident's poor recent and remote memory; she had severe limitation in daily decision making; was non-ambulatory; and required extensive to total assistance with activities of daily living (ADLs).

A nursing note, dated August 31, 2010, documented the resident had a seizure that lasted from 5:40 PM to 5:50 PM. A second nursing note at 6:45 PM documented the resident had a second seizure; the physician was contacted; and the resident was to be monitored.

On September 1, 2010, a nursing note specified the resident had a seizure that lasted 4 minutes. A second nursing note that date documented the certified nurse aide (CNA) observed "another seizure". The resident was transferred to the hospital due to the increased seizure activity. The nursing note revealed the resident returned from the emergency room on the same date.

On September 2, 2010, a nursing note for the 7 AM to 3 PM documented continued periods of twitching with blank effect and questioned continued small frequent seizure activity.

On September 2, 2010, the evening shift and the night shift nursing notes documented the resident continued to have small seizures.

On September 3, 2010, a nursing note documented the resident had another seizure. Following discussion with the physician, the resident was sent to a different hospital for further evaluation.

On September 7, 2010, nursing noted the resident returned from the hospital with changes in her medication orders; no further seizure activity was noted at the time.

The comprehensive care plan (CCP), updated by the interdisciplinary team on October 26, 2010, documented the resident's seizure disorder. The plan specified the resident was not to be left unattended in her room, and was to be seated in the hallway near the nursing station.

The Nursing Assistant Care Sheet, dated November 10, 2010, used by the certified nurse aide (CNA) for care instructions, identified the resident's need for seizure precautions. The care sheet specified "do not leave unattended in room"; and sit the resident near the nursing station.

On November 18, 2010, a nursing progress note documented the resident "had shaking" of her right arm. There was no further documentation of this right arm shaking, when the surveyor reviewed the resident's medical record on November 22, 2010.

On November 22, 2010, the surveyor observed the resident between 10:00 AM and 10:30 AM, to be seated in her wheelchair, alone in her room. The resident was looking up at the television in her room. The surveyor observed the resident's right hand to be clenched and shaking.

On November 22, 2010, the resident was observed sleeping in her wheelchair in her room from 1:30 PM to 1:50 PM. At 2:00 PM, a CNA entered her room to transfer the resident to bed for a nap. The resident remained in bed until 4:50 PM, when a CNA entered her room, assisted her out of bed (with the mechanical lift) and transported her to the dining room.

On November 23, 2010, the resident was observed seated in her wheelchair in the hallway outside her room at 9:15 AM. The resident's room was at the end of the hallway, away from the nursing station.

At 1:10 PM on November 23, 2010, the resident was observed sitting in her wheelchair, alone in her room. At that time, a CNA (familiar with the resident's care) described the resident's routine to the surveyor. The CNA stated the resident was up for breakfast in the dining room and then returned to her room for a nap of an hour, or an hour and a half. After the lunch meal, the resident was taken back to her room, or "sometimes" remained by the desk. The CNA said the resident generally was not left in her room. The CNA stated she was aware the resident had seizures in August or September 2010, but did not think it was written on the plan of care, that she needed to remain by the nursing station.

In summary, the facility did not consistently follow the resident's plan of care to provide supervision to maintain the resident's safety, as the resident was observed for extended periods of time alone in her room, sitting in her chair, and outside of her room, away from the nursing station.

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

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure advanced directives were completed in accordance with state law for 2 (Residents #6 and 9) of 10 residents reviewed for advanced directives. Specifically, Resident #6's advance directive for DNR (Do Not Resuscitate) was changed, without input from the attending physician and the appropriate concurring physician, and without a physician's order. Resident #9's advance directive for DNR was changed without input from the attending physician, and the CNAs (certified nurse aides) information conflicted with the physician's order. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY OF December 10, 2009.

Findings include:

1) Resident #6 had diagnoses including mild mental retardation (MR), dementia, and seizure disorder.

The Advanced Directive Policy Review form dated January 21, 2010, following the resident's admission, documented the resident was a full code ( request for cardio-pulmonary resuscitation) per the MR Service Coordinator.

The social history signed and dated by the social worker on January 29, 2010, and signed and dated by the supervising social worker on March 19, 2010, noted the resident did not have any close family contacts, but enjoyed writing letters to her uncle.

According to the Minimum Data Set(MDS) dated February 2, 2010, the resident's residential history prior to placement was a facility for mental retardation or developmental disabilities. The MDS identified the resident with severe cognitive impairment and poor recent and remote memory.

The Advanced Directive Policy Review form documented the resident continued to be a full code as of May 5, 2010.

On September 3, 2010, the form was updated, and documented the resident's sibling verbally consented to a Do Not Resuscitate (DNR) order. It was noted on the form, the resident's sibling was to complete the "form" and return it to the facility. The social worker noted a DNR order was requested from nursing.

A Surrogate Consent To The Issuance Of A Do Not Resuscitate Order dated September 3, 2010 was signed by the resident's sibling requesting the DNR. The decision was noted to be in the resident's best interest as the resident's wishes were not known and could not be ascertained.

The changes in code status from a full code to a DNR were not addressed in the physician progress notes dated September 28, 2010 and October 5, 2010. The October 5, 2010 progress note was the last physician's note in the resident record when reviewed by the surveyor on November 22, 2010.

Social work noted on October 6, 2010 in an interdisciplinary progress note, the resident was a DNR.

A nursing note dated October 15, 2010, documented the physician was contacted regarding the DNR order, and noted the resident's power of attorney (POA) signed a consent for a DNR.

Review of the physician orders dated August 31, 2010 through the most current orders signed on November 2, 2010, revealed no written evidence of a DNR order.

A social work progress note dated November 1, 2010 documented the resident was a DNR.

A red dot was observed on the door of the resident's room on November 22, 2010 at 1:30 PM and a red dot was noted on the binder of her medical record when reviewed on November 22, 2010.

The current Nursing Assistant Care Sheet, identified as the care instructions used by the certified nurse aides(CNA's), was reviewed on November 23, 2010. The form identified the resident's code status as DNR.

At 2:20 PM on November 23, 2010, the director of nursing (DON) was interviewed by the surveyor. She stated the red dot on the doors of the resident rooms and on the binder of the medical records denoted the resident's DNR status. She stated the resident's sister was contacted when the resident was hospitalized for seizure activity on September 3, 2010 and the sister requested the DNR order. She stated when a surrogate requested a DNR, the form was reviewed by the attending physician and an order was written. The DON then reviewed the chart for the physician's order and when she did not find the order, or physician documentation pertaining to the order, she stated, "We dropped the ball". When the surveyor asked for documentation determining the resident lacked capacity, the DON stated the information would have come from "OMRDD" (Office of Mental Retardation and Developmental Disability).

The social worker was interviewed by the surveyor on November 23, 2010 at 2:45 PM. She stated the resident was admitted with mental retardation and the facility used the resident's diagnosis to determine capacity for the DNR. When the DNR was requested, the social worker verbally requested the DNR order from nursing. The social worker 's responsibility included placing the red dot for DNR code status on the door frame and on the resident's record.

In summary, the facility did not implement advanced directives in accordance with New York State law as the resident was designated as having a DNR in place when:
- there was no written evidence the attending physician and a concurring physician from OMRDD determined the resident lacked capacity to formulate a DNR; and
- there was no physician's order for a DNR.

2) Resident #9 had a diagnosis of dementia.

The Minimum Data Set (MDS) assessment dated September 28, 2010 identified the resident with moderate cognitive impairment for daily decision making, and with poor short term memory.

On November 10, 2010, a Surrogate's Consent To The Issuance Of A Do Not Resuscitate Order was signed by the resident's surrogate requesting a DNR.

A physician's order for a DNR was signed and dated November 16, 2010.

The social worker was interviewed by the surveyor on November 23, 2010, and asked about the procedure for advance directive determination. She stated after she received the information from the resident or surrogate, she passed the information to nursing to complete the process. If the resident was a DNR, she placed the red sticker (for DNR notification) on the resident's medical record and on the door frame of the resident's room.

Review of the resident's medical record on November 23, 2010 revealed there was no written evidence the attending physician and a concurring physician had determined the resident lacked capacity.

The current Nursing Assistant Care Sheet, directions for care used by the certified nurse aides (CNAs), identified the resident's Code Status as a full code (request for cardio-pulmonary resuscitation).

In summary, the facility did not implement the resident's advanced directives in accordance with New York State law as the resident was designated as having a DNR in place when:
- there was no written evidence the attending physician and a concurring physician determined the resident lacked capacity; and
- the CNA information for code status conflicted with the physician's order.

10 NYCRR 415.3 (e)(2)(iii)

Based on observations and staff interviews conducted during the standard survey, it was determined for 1 of 2 public toilet rooms (physical therapy), the facility did not ensure the nurse call system was installed and/or fully functional. Specifically, there was no call system installed for the bathroom located in the physical therapy room, which was accessible to facility residents. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the building inspection conducted on December 3, 2010 between 1:15 AM - 3:15 PM, no call system was observed in the public toilet room, located in the physical therapy room, and accessible to residents.

The surveyor interviewed the Director of Maintenance on December 3, 2010 at 1:15 PM. He stated the restroom in the physical therapy room never had a call system installed.

In summary, there was no call system installed for physical therapy's toilet room that was accessible to residents.

10 NYCRR 415.29 (b)
10 NYCRR 713-2.23 (g)

Based on observation and staff interview conducted during the standard survey, it was determined food was not stored under sanitary conditions in the facility's nourishment pantry. Specifically, unlabeled and undated potentially hazardous foods were stored in the nourishment pantry refrigerator. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the initial tour of the nursing unit on November 22, 2010 between 10:05 AM and 10:30 AM, the surveyor observed 8 containers (one-half cup each) of unlabeled, undated food in the nourishment pantry's refrigerator. The unlabeled food in 6 of the containers looked like cottage cheese; the food in 2 of the unlabeled containers looked like egg salad.

On November 22, 2010 at 2:30 PM, the surveyor observed the kitchen aide stocking the unit pantry refrigerator. The unlabeled, undated containers of food remained in the refrigerator. At that time, the kitchen aide told the surveyor that he did "not know anything about those containers." He stated he thought they were all cottage cheese prepared by the cook and used for nourishments. He said he stocked the refrigerator and checked to make sure the large containers of juice were dated if they were opened. He stated he did not look at the nourishments, as those were the cook's responsibility.

On November 23, 2010 at 8:30 AM, the surveyor observed the unit's nourishment refrigerator; the refrigerator contained several small containers of unlabeled, undated food.

On November 23, 2010 at 9 AM, the Food Service Manager was interviewed stated and stated it was the facility's policy to date all opened food items inside the refrigerator. She stated all of the 1/2 cup containers sent from the kitchen should be thrown away. She said the kitchen aide was supposed to check the refrigerator and ensure all opened food was labeled and dated.

In summary, the facility did not ensure potentially hazardous food was properly labeled and dated when stored in the unit pantry nourishment refrigerator.

10 NYCRR415.14(h)

Based upon observation and staff interview conducted during the standard survey, it was determined the facility did not ensure soiled linen/trash receptacles (with capacities exceeding 32 gallons within a 64 square feet area) were stored in a properly designed hazardous area on the 1 facility nursing unit. Specifically, multiple containers of soiled linen and trash exceeding 32 gallons within a 64 square foot area were stored when not in use in the small shower room and in the corridor. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the building inspection, conducted on December 3, 2010 between 1:15 AM - 3:15 PM, the following observations and interviews were made:
- 4 bins of trash/soiled linens were stored adjacent to each other in the corridor. On December 3, 2010 at 2:20 PM, the Director of Housekeeping told the surveyor each bin held between 26 - 30 gallons.
- a triple bin container of trash/soiled linens was observed stored in the small shower room. The room was not designed for hazardous storage, as it was not sprinkled, the door was not rated, and the door lacked a self-closing device. According to the Director of Maintenance interviewed on December 3, 2010 at 2:50 PM, the triple bin was stored in this bathroom after usage.

In summary, multiple containers of soiled linen and trash exceeding 32 gallons within a 64 square foot area were stored when not in use in the small shower room and in the general corridor.

2000 LSC 19.3.2.1 and 19.7.5.5