Gold Crest Care Center

Based on observations, record review and staff interviews, the facility did not ensure that residents received services with reasonable accommodations of individual needs. Specifically, a clock was not functionally in a resident's room and a resident was served lunch fifty-five minutes after the other residents. This was evident for 2 out of 26 sampled residents. (Residents #13 and #28)ne

This resulted in no actual harm with potential for more than minimal harm.

The findings are:

1) Resident #13 has diagnoses that include Diabetes Mellitus, Dementia and Osteoporosis. The Minimum Data Set 2.0 dated 12/14/09 documented that the resident has short and long term memory problems and is moderately impaired for cognitive skills for daily decision making.

On 2/1/2010 at 4:15pm, during medication pass observation, it was observed in the resident #13's room that the clock on the wall read 8:40. On 2/2/10 and 2/3/10 at 9:15am, the clock read 8:40.

On 2/3/10 at 9:40am, the registered Nurse (RN) Manager was interviewed and stated that any staff member who sees the clock not working or with the wrong time should bring it to the attention of the Nurse or Maintenance Department. They will check the clock and put new in batteries in the clock.

On 2/3/10 at 2:55pm, the Director of Nursing was interviewed and stated that nursing is responsible for informing maintenance when the clocks are not working.

2) Resident #28 is an 86 year old female with diagnosis which include: Hypertension, Anemia, Anxiety and Rectal Bleeding.

On 02/02/2010, during a lunch meal observation, it was observed that the lunch truck came to the unit at 12:20 pm. The first resident was served immediately. Resident #28 was seated at a table with four residents. At approximately 12:24PM, 4 residents at resident #28 table were served their meal. Resident #28 was not served her meal. Resident #28 asked for her tray and stated several times "I am here, I am not dead." She was also observed looking at the truck and watching the CNAs (Certified Nurse Assistants) distribute the meal trays. The Licensed Practical Nurse (LPN) in charge started looking for the resident's tray on the truck. The CNA then stated the tray is not in the truck. The LPN called several times to the kitchen. The CNA then went down to the kitchen and came back with the resident's tray at 12:45 PM.

During an interview with the LPN immediately after meal she stated the resident was transferred to the unit from the first floor on 2/1/10.

The Food Service Director was interviewed at 1:00PM on 2/2/10 and stated that he made the necessary updates to the lunch ticket.

415.5(e)(1)

Based on observations, record review and staff interviews, the facility did not ensure that there was an ongoing activities program to meet the needs of the residents. This was evident for 1 of 30 sampled residents (Residents #6).

This resulted in no actual harm with potential for more than minimal harm.

The findings are:

1) Resident #6 is a 68 year old female with diagnoses which include Parkinson's, Dementia, Hypertension, Diabetes and Depression.

The MDS 2.0 (Minimal Data Set) dated 10/1/09 documented that the resident's cognition is moderately impaired with long and short term memory problems. This MDS documented that the resident is involved in activities 1/3 - 2/3 of the time and her preferences include music and watching TV. Additionally, this MDS documented that the resident is totally dependent on staff for all activities of daily living.

The CCP (Comprehensive Care Plan) for Therapeutic Recreation dated 10/8/09 documented 3 interventions "establish eye contact, address by name, visit 1:1 (one to one) in room." The CCP evaluation dated 1/7/10 documented "Resident continues to Passively Accepting all 1:1 from staff while Passively Participate in some day room programs such as (sing a long, Music,...) Goal + (and) plan ongoing x (times) 3 months."

On 2/1/10 at 9am, during the tour of the third floor, it was observed that the January, 2010 activities schedule was posted on the wall near the Nursing Station. There was no activity schedule posted for February, 2010.

On 2/1/10 at 1:45pm-2:40pm and 2/2/10 at 11am - 11:40am, resident #6 was observed in the dining room in her wheel chair asleep at a table.

On 2/3/10 at 10am - 11:30am, the resident was observed in the dining room in her wheel chair asleep. The television was on and there was no activity in progress. There was 1 Certified Nursing Assistant (CNA) present between 10am and 10:30am who was observed filling out papers. Another CNA entered the dining room at 10:30am and was observed not interacting with the resident. At 11am, the third CNA entered the dining room, this CNA did not interact with the resident. The television remained on and no activity occurred.

On 2/3/10, the February, 2010 activities schedule documented the following:
9:45am gardening and 11:15am music hour. These activities did not occur in the dining.

The Registered Nurse (RN) was interviewed on 2/3/10 at 9:30am and stated that the CNAs are to observe the residents in the dining room and give them snacks. The RN further stated that activity staff comes to the unit to do activities with the residents.

On 2/3/10 at 11am, the Acting Activities Director was interviewed and stated that she is covering for the Recreation Director who is out on maternity leave. She stated that today was her first day on the job. She explained that the activities schedule was not followed accordingly, there was no gardening and music hour. She further stated that the activities schedule needs to be reviewed and adjusted.

The CNA who was in the dining room at 11:30am was interviewed on 2/3/10 at 11:30am and stated that she is responsible for monitoring the dining room and to make sure the residents are safe, comfortable and their needs are met. The CNA further stated that she does not get involve with recreational activities because this is the activities department responsibility.

415.5(f)(1)

Based on observations, record reviews and staff interviews, the facility did not ensure that physicians' orders were implemented as evidenced by not applying a hand splint, not obtaining laboratory tests, not obtaining blood pressures, not providing a resident chopped foods and not performing fingersticks according to the physician's orders. This was evident for 4 of 30 sampled residents. (Residents #8, #9, #13 and #17)

This resulted in no actual harm with potential for more than minimal harm.

The findings are:

1.) Resident #8 is a 90 year old male with diagnoses which include Hypertension, Dementia and Alzheimer.

The MDS (minimal data set) 2.0 dated 12/21/09 documented that the resident's cognition is severely impaired with long and short term memory problems. The MDS documents that the resident is totally dependent on staff for all ADL's (activities of daily living).

On 2/1/10 at 9:30am and on 2/3/10 at 10:45am to 11:15am, the Resident was observed in his room sitting in a geri-chair in his room and the resident was not wearing a hand splint.

The Physicians orders dated 1/22/10 documented "right hand splint to be worn daytime off for hygiene, meal time and ROM (range of motion). "

The CCP (Comprehensive Care Plan) dated 9/16/09 documented "resident with contractures on: rt (right wrist), R (right) hand splint to be worn at all times except hygiene, ROM (range of motion) & (and) meal time."

On 2/3/10 at 11:15am, the CNA (Certified Nursing Assistant) was interviewed and stated that she reads the accountability book but did not see the right hand splint at the bottom of the page. She further stated that she has just started on this resident's assignment in February and does not recall ever seeing the hand splint.

On 2/5/10 the Rehab Director was interviewed and stated that it is the responsibility of the CNA to apply the splint. She added that the Rehab department conducts quarterly checks to monitor devices but that its not a formal audit. She was not aware that the splint was missing for 2 days.

2.) Resident #9 an 82 year old male admitted to the facility with diagnoses which include Diabetes Mellitus, Hypertension, Right Femoral Bypass and Peripheral Vascular Disease (PVD).

The Minimum Data Set 2.0 (MDS) dated 12/31/09 documented that the resident is independent with decision making, alert, oriented to time, place and person.

The physician's order dated 12/24/09 documented urine analysis (UA), complete blood count (CBC), electrocardiogram (EKG) and Chest X-ray.

There is no documented evidence that the EKG and Chest X-ray were done.

On 1/19/2010, the physician ordered fingerstick blood sugar (FSBS) two time a day (BID) at (@) 6:30 AM and 4:30 PM with Novolog sliding scale as follows:
0-----200---0 unit
201--250---4 units
251--300 -- 7 units
> ( greater )300 -- 10 units and call Medical Doctor (MD) .

The medication administration record (MAR) dated 1/19/2010 to 2/21/2010 documented that the times of the FBSB were transcribed to be done at 6:30 AM, 11:30AM, 4:30PM and at 9:00PM. The MAR documented that the FBSB was to be done four times instead of twice a day as ordered by the medical doctor.

On 1/21/2010, the MAR documented that at 9:00PM the FS result was 207 and the resident received 4 units of the Novolog.

During an interview with the Registered Nurse Unit Manager on 02/02/2010 at 3:00PM she stated that the RN made a mistake of transcribing the order for the resident's fingersticks. The Registered Nurse Unit Manager further stated that there were no results found for an EKG and chest x-ray.

3) Resident #17 is a 50-year-old whose diagnoses include Metastatic Breast Cancer (with mets to the lung, liver, and brain) and Chronic Obstructive Pulmonary Disease.

The Minimum Data Set 2.0 Assessment (MDS) dated 10/22/09 documented that resident has moderately impaired cognition.

The monthly physician's orders dated 1/4/10 documented "weekly blood pressure on Tuesday on 3-11 shift."

The interim physician's orders dated 1/14/10 documented a laboratory order for a Depakote level.

The Medication Administration Record (MAR), dated 1/4/10 to 2/3/10 documented that the resident 's blood pressure was not taken on 1/12/10, 1/19/10, 1/26/10, and 2/2/10.

The facility laboratory book documented that on 1/18/10, a laboratory technician wrote an "E" next to the resident's Depakote level request. According to the key at the bottom of the lab book sheet, "E" means "tech (technician) unable to draw."

There was no documented evidence in the resident's medical record that the Depakote level was done.

The Registered Nurse Manager (RNM) was interviewed on 2/4/10 at 11:35am and stated that the blood pressures were not done. The RNM explained that the first nurse that reviews the physician's monthly orders creates the MAR for the month. The areas for the blood pressure are usually blocked out for the month at that time. The MAR was only blocked for one blood pressure to be taken in the past month.

The Registered Nurse (RN) that created the MAR was interviewed on 2/4/10 at 12:46pm and stated that when reviewing the physician's orders, he created the MAR. The RN explained that he usually blocks off the dates that blood pressures are to be taken. The RN further stated that failure to block off the dates was an oversight.

The lab technician was interviewed on 2/4/10 at 3:20pm. The lab technician stated that he did attempt to draw the resident's blood on 1/18/10 but was unable to do so. The lab technician explained that he is supposed to tell the nurse on the unit if he cannot draw. The lab technician stated that he could not remember which nurse he spoke to that day.

The RNM was interviewed on 2/4/10 at 12:32pm and 3:30pm about the Depakote level. The RNM stated that she was working the day that the lab technician attempted to draw blood for the Depakote level, and she was not informed by the lab technician that there were any problems. The RNM stated that she is supposed to review the lab book daily every morning. She admitted that she did not review the book on 1/18/09 and therefore did not know the lab was unable to be drawn. If a lab is unable to be done for any reason, the nurse is supposed to inform the physician.

4) Resident #13 is an 87 year old male admitted to the facility on 6/23/2000 with diagnoses which include Diabetes Mellitus, Osteoporosis, Psychosis Dementia and Cardiovascular disease.

The Minimum Data Set 2.0 Assessment dated 12/14/09 documented that the resident has short and long-term memory impairments and moderately impaired decision making.

The Physician's order dated 1/28/10 documented "... No Concentrated Sweets, Chopped Diet."

The Resident's Diet Slip dated 2/2/10 documented lunch NCS (No Concentrated Sweets) Chopped.

On 2/3/10 at 12:30pm, the resident was served chopped hamburger on a bun and whole baby carrots. The resident did not eat the carrots.

On 2/3/10 at 3pm, the Clinical Dietician was interviewed and stated that vegetables are not cut. The Clinical Dietician further stated that it might be a little hard for him to chew.

On 2/3/10 at 3:15pm, the Director of Nursing was interviewed and stated whatever diet the physician orders, food will be given as ordered. The Director of Nurses further stated that if the diet is chopped, all the foods on the resident's tray should be chopped.

415.11(c)(3)(ii)

Section 7.2.1.5.4 states that a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches (86 cm) and not more than 48 inches (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the egress door from the beauty parlor, on the 2nd floor, is equipped with a latching/locking device which could be released with only one releasing operation from the egress side and that the door locking devices to the soiled utility rooms are provided with the familiar type of door releasing devices.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On February 1, 2010 and February 2, 2010, at 9:30 AM to 2:30 PM, the following was observed.
(1) The corridor door to the beauty parlor on the 2nd floor, is equipped with locking/latching device, which in addition to the door knob type latch releasing device has a thumb twist type lock releasing device located in the center of the door knob. This door fastening device, when engaged, would require more than one operation to open the door from the egress side (the twisting of the thumb twist lock releasing device and operating the door knob to release the regular door latching device). Also, the thumb twist type of lock releasing device will be difficult to operate during darkness.

(2) The corridor doors to the soiled utility rooms, on the 2-4 floors, are equipped with door locking/latching devices which are released by the thumb twist type latch/lock releasing device from the egress side. This type of latching releasing device is not easily operable and would not be readily operated during darkness. Only knobs, levers, and panic bars are the acceptable type of latch releasing devices, as per Annex A of NFPA101.

On February 2, 2010, at approximately 2:30 PM, the facility director of maintenance stated that familiar type of latch releasing device which are operable by single operation will be installed on all egress doors.

II. Section 7.1.10.1, states that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the exit discharge area, adjacent to the laundry area, in the basement, is maintained free of standing water.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On February 1, 2010, at 9:30 AM to 2:30 PM, it was observed that the exit discharge area, immediately outside of the exit door, adjacent to laundry area, in the basement, had a large puddle of water. The standing water at the exit discharge would impede the safe exit for the occupants in case of fire or other emergency. On February 2, 2010, at approximately 2:30 PM, the facility director of maintenance stated that drain at the exit discharge location is being cleaned to remove the standing water.

III. Section 7.2.1.5.1, states that doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Lock, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the doors to the walk-in refrigerator and the walk-in freezer are free of any locking devices which cannot be operated from the egress side. (inside)

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

The findings include:
On February 1, 2010, at 9:30 AM to 2:30 PM, it was observed that doors to the walk-in refrigerator and the walk-in freezer are equipped with padlocks. These locks, if engaged,could not be opened from the egress side (from inside the walkin refrigerator and freezer). The egress doors cannot be equipped with any door locking devices which could not be operated from the egress side. On February 2, 2010, at approximately 2:30 PM, the facility director of maintenance stated during the exit conference, that the padlocks have been removed from the refrigerator and freezer doors. The director further stated that locking devices which could be operated from the egress side have been ordered from the refrigeration company.

711.2 (a)(1)

Physical Plant Violation - State Only

713-1 Standards of Construction for Nursing Home
NYCRR 713-1.18 (d)(2)(iii):

The ventilation systems shall be designed and balanced to provide the pressure relationship as shown in Table 8.

This requirement is not met as evidenced by:

Based on observation, it was determined that the facility did not ensur e tha t the laundry area, in the basement, is ventilated to provide the equal pressure relationship to the adjacent corridors/rooms, with a minimus of 2 changes of outdoor air per hour supplied to the room and the total of 10 air changes per hour supplied to the room with all air exhausted directly to outdoors.

The findings include:
On February 1, 2010 and February 2, 2010, at 9:30 AM to 2:30 PM, it was observed that although the laundry area is equipped with duct work and through the wall fan units for air supply and exhaust ventilation system, the ducted air supply system and the through the wall fan units were shut down. Only the exhaust fan unit was operating at the time of the environmental tour of the laundry facility. Upon interview, the facility director of maintenance stated that the wall fan units is shut down by the staff because of the supply of outside cold air. The director further stated that the ducted air supply system is has not been functional for sometime. The facility must install and maintain a functional air supply and exhaust ventilation system in the laundry area and balance the ventilation system to comply with the pressure relationship per table 8 of the NYCRR 713-1.18. On February 2,2010, at approximately 2:30 PM, the director of maintenance stated that the HVAC company will be contacted to provide the required ventilation sytem for the laundry area.

NYCRR 713-1.18( e )(2)(iii)
Backflow preventers (vacuum breakers) shall be installed on hose bibbs, janitor's sinks, bed pan flushing attachments and on all other fixtures to which hoses or tubings can be attached.

This requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the water fixtures for the hair-wash sink contained within the beauty parlor on the 2nd floor to which a h ose is attached , is equipped with the backflow preventer ( vacuum breaker ).

The findings include:
On February 2, 2010, at 9:30 AM to 2:30 PM, it was observed that the hair-wash sink contained within the beauty parlor, on the 2nd floor, has a hose attached to the water line. The hose attachment lacks a backflow preventer (vacuum breaker). On February 2, 2010, at approximately 2:30 PM, during the exit conference, the facility director of maintenance stated that the vacuum breaker is being installed at the hose attachment for the hairwash sink in the beauty parlor.