Hudson Pointe at Riverdale Center for Nursing & Rehabilitation

Deficiency Details, Certification Survey, March 7, 2011

PFI: 1232
Regional Office: MARO--New York City Area

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F246 483.15(e)(1): ACCOMMODATION OF NEEDS AND PREFERENCES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 29, 2011

A resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

Citation date: March 7, 2011

Based on observation, record review and staff interviews, the facility did not ensure that a resident without clothing received clothing. This was evident for 1 of 42 sampled residents. (Resident #189)

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

The finding is:

Resident #189 is a 90 year male with diagnoses which include Coronary Artery Disease, Hypertension, Cerebrovascular Accident, Dementia, Hemiplegia and Seizure Disorder.

On 3/1/11 and 3/2/11 both at noon, the resident was observed wearing a hospital gown while in his room sitting in his recliner. The observation of the resident's closet revealed one pair of shorts.

The MDS ( Minimum data Set) 3.0 dated 12/8/10 (Annual) documented that the resident is not interviewable, with severely impaired cognition. He needs total assistance with activities of daily living (ADL).

The admission "Social Service Assessment" dated 4/18/10 documents that the resident has no known family.

The "Residents Personal Possessions" and "Resident Clothing Inventory Sheet" form has no documented personal items.

The Care Plan dated 2/17/11 for "cognitive status" secondary to Vascular Dementia documents that all ADL's are anticipated by staff. The Care Plans dated 12/8/10, 2/10/11, 2/17/11 for "ADL" documents that the resident needs total assistance with bathing, hygiene, dressing and toileting.

On 3/2/11 at 11:45am the CNA (Certified Nursing Assistant) stated that the resident has no clothing and therefore she did not dress him.

On 3/2/11 at 1:30pm the Director of Social Work was interviewed and stated that the resident was admitted on 3/25/10 without any clothing.

On 3/2/11 at 1:40pm the Unit Social Worker was interviewed and stated that
she does not assess the resident for clothing. When a resident is admitted to the facility with no clothing, they are provided donated clothing. When asked about the process for tracking and providing clothing, she stated that the CNA's are responsible for completing the resident "Personal Possessions List" and are responsible for notifying the Social Worker when a resident needs clothing.

On 3/2/11 at 3pm The Director of Social Work stated that the resident did not receive funds until December 2010 and currently has a balance of $150 as of March 2011. She added that there was no donated clothing that would have fit him properly because most of the clothing is for small sized ladies.

On 3/3/11 at 9 am the Unit Social Worker added that she had seen the resident on the initial admission and there after for assessments. She stated that she did not know if he had clothing, that if he needed something then nursing would tell her.

415.5(e)(1)

F248 483.15(f)(1): ACTIVITY PROGRAM MEETS INDIVIDUAL NEEDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 4, 2011

The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.

Citation date: March 7, 2011

Based on observation, record review and resident and staff interviews, the facility did not provide activities to meet the interests of a resident.
This was evident for 1 of 3 residents reviewed for activities in a sample of 42 residents reviewed for significant care concerns (Resident #194).

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

The finding is:

Resident #194 was admitted to the facility on 5/21/10 with diagnoses including Coronary Artery Disease, Hypertension and Senile Dementia.

The resident's initial "therapeutic activities assessment" dated 5/26/10 documented that his interests included watching TV (television), sports, dance and conversation.

The MDS (minimum data set) 3.0 assessment dated 1/28/11 documented that the resident's cognition was moderately impaired.

The resident was interviewed on 3/1/11 at 8:25 AM and stated that among the activities offered by the facility, music was the only thing that met his interests. He further stated that he did not know of any activity that was offered in the evenings.

The resident was observed ambulating back and forth on the unit on 3/1/11 between 9AM and 12:30 PM. There was no redirection or encouragement provided by the staff to involve the resident in any activities. The resident was not observed watching TV in the day room and there was no TV in his room. On 3/4/11, the resident was observed sitting in the day room from 11AM to 11:30 AM. There was music playing in the background.

A quarterly "activities department progress note" dated 1/28/11 documented the resident's activity preferences as "exercise, music/dance, entertainment, handgrooming and conversational visits". The progress note also documented a plan to greet the resident daily and invite him to music and conversational activities.

The CCP (comprehensive care plan) for Therapeutic Activities dated 1/28/11 documented that the resident was alert and oriented, enjoyed conversations and music and had a short attention span. The CCP also documented a plan for 1:1 (one to one) visits 3 to 4 times per week.

A CCP for wandering dated 2/2/11 documented an intervention for involving the resident in activities and diversional tasks such as recreational activities.

The Activity Calendar for March, 2011 was reviewed. This activity calendar documented that on 13 of 31 evenings Bingo was scheduled at 6:15 pm. On 3/8/11, a Mardi Gras was scheduled. There was no other scheduled activity after 2:30 PM on the other 18 days of the month.

An interview was conducted with the Activities Director on 3/3/11 at 3:10 PM. She stated she did not have sufficient staff in the evenings other than for Bingo 3 days per week and that art and craft supplies were given to the residents who were interested to use in their rooms in the evenings. She also stated that residents were taken to the 5th floor on big sports games days to watch the TV there. She further stated that resident #194 did not like to leave the floor and did not show an interest in these activities.

An interview was conducted with the Recreation Therapy Aide on 3/3/11 at 3:25 PM. She stated that the resident did not remain in activities for very long due to a short attention span. She further stated that he did not like to leave the unit so activities should have been provided for him to do on the unit.

415.5(f)(1)

F514 483.75(l)(1): CLINICAL RECORDS MEET PROFESSIONAL STANDARDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 2, 2011

The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Citation date: March 7, 2011

Based on record review and staff interviews, the facility did not ensure that the resident's medical record accurately reflects administration of a supplement. This was evident for 1 out of 42 residents sampled for review of significant care concerns. (Resident #27)

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

The finding is:

Resident #27 is a an 85 year old female with diagnoses which include Dementia Alzheimer's Type, History of Breast Cancer with Mastectomy, and Artero- sclerotic Heart Disease (ASHD).

On 2/28/2011, during the dining observation at 12 noon, the resident was observed seated in the day room with the CNA (Certified Nurse Assistant) attempting to feed her. In front of the resident among the items on the tray, it was observed a can of Glucerna next to the plastic cup, half filled with a thick, cream colored liquid.

On 2/28/2011 at 2PM the resident #27 was observed seated in the day room and in front of her were observed 2 cups - one with juice and and one with a thick, cream colored liquid. The resident was refusing to drink the liquids.

On 2/28/2011 at 3:45 observed the resident seated in the dining room and in front of the resident there was 2 cups, one with juice and a cup with thick, cream colored liquid. The resident was not drinking the liquids, in spite of encouragement.

The monthly physician's order form dated 1/31/2011 document Glucerna Shake
8 oz PO (orally) TID (three times daily) + (and) with meals.

The medication administration record (MAR) dated 2/1/2011 to 2/28/2011 documented administration of Glucerna shake 8 oz PO TID and with meals at 7am, 10am, 12noon, 5pm, and 7 pm, daily from 2/1/2011 until 2/27/2011.
The MAR documents administration of Glucerna shake 5 times daily, instead of 6 times daily as per the physician's orders.

The calorie count dated 2/16/2010 and 2/17/2010 documented that the resident was given Glucerna shake 8oz at 3 PM and consumed 50%.

The dayshift Licensed Practical Nurse was interviewed on 2/28/2011 at 3;10 PM, and while looking at the MAR for February stated that the administration of Glucerna shake was documented five times instead of six times. She stated that "The night shift nurse transcribes the MD (physician's) orders to the MAR, the physician and three nurses sign the orders... There should have been 3 PM administration documented here. I don't know why its not here."

The Registered Nurse Manager was interviewed on 2/28/2011 at 3:30 PM and stated that the resident received her Glucerna shake every afternoon at 3 PM and this should have been documented.

The evening shift Licensed Practical Nurse was interviewed on 3/7/2011 at 11 AM and stated that she regularly gives to the resident supplement on evenings and she was giving her Glucerna at 3 PM, 5 PM, and 7 PM. She stated that the resident was getting the supplement on the same schedule (6 times per day) for several months prior to February and could not explain why 3PM administration was not documented on the MAR. "It was overlooked."

415.22 a (1-4)

F241 483.15(a): DIGNITY

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 7, 2011

The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Citation date: March 7, 2011

Based on observation, record review and staff interview, the facility did not ensure that a resident's dining experience was dignified. Specifically, the resident was restricted from eating in the common dining area and was set up in the hallway outside her room with meals served on an overbed table. This was evident in 1 of 4 resident dining rooms (2nd floor) and for 1 of 42 residents reviewed for significant care concerns (# 51).

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

The finding is:

Resident #51 is a 71 year old who was admitted to the facility on 6/18/2010 with diagnoses including Hypertension, Diabetes and Chronic Obstructive Pulmonary Disease (COPD).

A MDS (minimum data set) 3.0 assessment dated 1/25/11 documented that the resident was oriented to time and had a BIMS (brief interview for mental status) score of 12 out of 15. The MDS also documented the resident had no alterations in mood or behavior.

The resident's record documented that she was transferred to the second floor on 8/27/10.

A CCP (comprehensive care plan) for activities of daily living dated 12/26/10 documented "resident eats on the hallway during meals due to behavior".

The resident was observed during lunch on 2/28/11 at 12:20 PM eating in the hallway on an overbed table. She consumed a canned supplement and left the meal untouched. The resident was observed on 3/3/11 at 12:10 PM and on 3/4/11 at 12:30 PM eating in the hallway outside her room with the meal served on an overbed table. The resident consumed none of the meal except for a canned supplement and a container of milk on both days.

During an interview that was conducted with the resident on 3/2/11 at 9:33 AM, she stated that since transferring from the first to the second floor, 6 months ago, she had not been allowed in the dining room, but had been placed in the hallway to eat. During the interview, the resident was observed frequently clearing her throat and wiping the phlegm with a towel that she kept folded in her lap.

The second floor seating chart for dining did not include an assigned seat for resident # 51.

The Dietician was interviewed on 3/3/11 at 12:15 PM and stated that seating charts are designed by Dietary and Nursing. She also stated that the resident had the habit of clearing her throat when she was on the first floor but they had assigned her a table location that was suitable to everyone as there was more dining space on that floor.

The RN (registered nurse) unit manager was interviewed on 3/3/11 at 12:20 PM and stated that the resident was placed in the hallway to eat due to her constantly bringing up phlegm. She also stated that the resident is always wiping her mouth which she believed was offensive to other residents. The RN manager further stated that there was no documentation that other residents complained of being offended by resident # 51.

An interview was conducted with the assigned CNA (certified nursing assistant) on 3/4/11 at 12:40 PM who stated that the resident eats outside in the hallway because of spitting.

415.5(a)

F250 483.15(g)(1): MEDICALLY RELATED SOCIAL SERVICES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 29, 2011

The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Citation date: March 7, 2011

Based on observation, record review and staff interviews, the facility did not ensure that social services was provided for a resident without clothing. This was evident for 1 of 42 sampled residents. (Resident #189)

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

The finding is:

Resident #189 is a 90 year male with diagnoses which include Coronary Artery Disease, Hypertension, Cerebrovascular Accident, Dementia, Hemiplegia and Seizure Disorder.

On 3/1/11 at noon and 3/2/11 at noon, the resident was observed wearing a hospital gown while in his room sitting in his recliner. The resident's closet contained one pair of shorts.

The MDS (Minimum Data Set) 3.0 dated 12/8/10 (Annual) documented that the resident is not interviewable and with severe impaired cognition. He needs total assistance with activities of daily living (ADL).

The admission "Social Service Assessment" dated 4/18/10 documents that the resident has no known family.

The "Residents Personal Possessions" and "Resident Clothing Inventory Sheet" form has no documented personal items.

The Care Plan dated 2/17/11 for "cognitive status" secondary to Vascular Dementia documents that all ADL's are anticipated by staff.

The Care Plans dated 12/8/10, 2/10/11, and 2/17/11 for "ADL" documented that the resident needs total assistance with bathing, hygiene, dressing and toileting.

On 3/2/11 at 11:45am, the CNA (Certified Nursing Assistant) stated that the resident has no clothing and therefore she did not dress him.

On 3/2/11 at 1:30pm, the Director of Social Work was interviewed and stated that the resident was admitted on 3/25/10 without any clothing.

On 3/2/11 at 1:40pm, the Unit Social Worker was interviewed and stated that
she does not assess the resident for clothing. When a resident is admitted to the facility with no clothing, they are provided donated clothing. When asked about the process for tracking and providing clothing, she stated that the CNA's are responsible for completing the resident "Personal Possessions List" and are responsible for notifying the Social Worker when a resident needs clothing.

On 3/2/11 at 3pm The Director of Social Work stated that the resident did not receive funds until December 2010 and currently has a balance of $150 as of March 2011. She added that there was no donated clothing that would have fit him properly because most of the clothing is for small sized ladies.

On 3/3/11 at 9 am the Unit Social Worker added that she had seen the resident on the initial admission and there after for assessments. She stated that she did not know if he had clothing, that if he needed something then nursing would tell her.

The Policy and Procedure for "Resident Clothing" documents that all residents will be dressed in clothing, which provides comfort and dignity. ..... In those instances when there is insufficient resources available to the resident, the facility will attempt to provide the resident with clothing.... The Social Worker is responsible to "Verify the need for clothing and Investigates the resources available (if any) in residents personal account with the Bookkeeping Office.

415.5(g)(1) (i-xv)

F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4): NOT EMPLOY PERSONS GUILTY OF ABUSE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 15, 2011

The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Citation date: March 7, 2011

Based on staff interviews and record review, the facility did not investigate a resident's allegation that her money was stolen by staff members. This was evident for 1 out of 3 residents reviewed for abuse out of a sample of 42 residents reviewed for significant care concerns.
(Resident #205)

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

The finding is:

Resident #205 is a 61 year old female with diagnoses which include. Cerebral Vascular Accident (CVA) with left hemiparesis, and Vascular Dementia.

The most recent Minimum Data Set (MDS 3.0) dated 2/2/2011 documents that the resident was disoriented to time and had a BIMS (Brief Interview for Mental Status) score of 10 out of 15. This MDS also documents that the resident has no signs and symptoms of Delirium.

On 3/1/11 at 10:06 AM, the Resident was interviewed. The Resident stated that when she was in room 117 which is located on the first floor, one hundred dollars was stolen from her by a Certified Nurse's Assistant (CNA) . She was unable to recall the date of the incident. She stated that she had $1800 in cash and was counting it while in bed. At this time, two CNAs entered her room to provide care. She stated that she told them not to turn her because she had cash in the bed. She was turned anyway and one hundred dollars fell to the floor. She stated that she saw the CNA pick up the money and place it in her pocket in view of the other CNA. She stated that she reported it to the Director of Nursing (DON) on the same day. She stated that her money was never returned, and the DON has not spoken to her about the money since she reported the incident.

On 3/3/11 at 2:45 PM, the Certified Nurse's Assistant (CNA) identified by the resident was interviewed. She stated that she could not recall the specific date of the incident, but it was prior to the resident being transferred from the rehabilitation unit on the 1st floor. The CNA stated that the unit's nursing supervisor informed her that the resident accused her and the other CNA of stealing her money.

The Social Worker's note dated 2/18/11 document that the resident was transferred to the 2nd floor on 2/17/11.

On 3/3/11 at 3:15 PM the DON was interviewed. He stated that the resident reported to him that she was missing money. He could not recall the specific date she reported this to him. He stated that the resident first stated that she lost money. She later accused the two CNAs of stealing the money, but gave conflicting statements as to who she thought may have taken the money. The DON stated that he asked the resident if she wanted to file a formal grievance and she stated no. The DON stated that the resident later informed him that she found her money and wanted to withdraw her complaint. He stated that the allegation was not documented as a complaint, because the resident stated that she did not want to file a complaint. The DON did not provide documented evidence that the resident's allegations were investigated. DON stated that the resident provided conflicting statements and he could not substantiate her allegations against the staff. The DON did not provide documented evidence that he investigated the resident's allegations.

The facility's policy and procedures on abuse dated 9/01 and revised on 4/09 includes the misappropriation of resident's funds in it's definition of abuse. It defines "Misappropriation of resident property" as ....'meaning the temporary or permanent use of a resident's....money without the resident's consent. The procedure for abuse investigation is to investigate any complaint of resident abuse.

The resident's medical record was reviewed. There was no documented evidence of the resident's allegation in the nurse's or social worker's notes. The grievance records from 1/2010- 3/7/2010 were reviewed, there was no documented evidence that the resident's allegation that staff misappropriated her funds were documented and investigated.

415.4(b)(1)(ii)

F226 483.13(c): POLICIES, PROCEDURES PROHIBIT ABUSE, NEGLECT

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 15, 2011

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Citation date: March 7, 2011

Based on resident and staff interviews and record review, the facility did not implement its policy for abuse, neglect and mistreatment when it did not investigate a resident's allegation that her money was stolen by staff members. This was evident for 1 out of 3 residents reviewed for abuse out of a sample of 42 residents reviewed for significant care concerns.
(Resident # 205)

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

The findings include:

Resident # 205 is a 61 year old female with diagnoses which include. Cerebral Vascular Accident (CVA) with left hemiparesis, and Vascular Dementia.

The most recent Minimum Data Set (MDS 3.0) dated 2/2/2011 documents that the resident was disoriented to time and had a BIMS (Brief Interview for Mental Status) score of 10 out of 15. The MDS also documents that the resident has no signs and symptoms of Delirium.

On 3/1/11 at 10:06 AM, the Resident was interviewed. The Resident stated that when she was in room 117 which is located on the first floor, one hundred dollars was stolen from her by a Certified Nurse's Assistant (CNA) . She was unable to recall the date or of the the incident. She stated that she had $1800 in cash and was counting it while in bed. At this time two CNAs entered her room to provide care. She stated that she told them not to turn her because she had cash in the bed. She was turned anyway and one hundred dollars fell to the floor. She stated that she saw the CNA pick up the money and place it in her pocket in view of the other CNA. She stated that she reported it to the Director of Nursing (DON) on the same day. She stated that her money was never returned, and the DON has not spoken to her about the money since she reported the incident.

There was no documented evidence of the resident's allegation in the nurse's or social worker's notes.

The grievance records from 1/2010 to 3/7/2010 did not documented any evidence that the resident's allegation that staff misappropriated her funds were investigated.

On 3/3/11 at 3:15 PM the DON was interviewed. He stated that the resident reported to him that she was missing money. He could not recall the specific date she reported this to him. He stated that the resident first stated that she lost money. She later accused the two CNAs of stealing the money, but gave conflicting statements as to who she thought may have taken the money. The DON stated that he asked the resident if she wanted to file a formal grievance and she stated no. The DON stated that the resident later informed him that she found her money and wanted to withdraw her complaint. He stated that the allegation was not documented as a complaint, because the resident stated that she did not want to file a complaint. The DON did not provide documented evidence that the resident's allegations were investigated. DON stated that the resident provided conflicting statements and he could not substantiate her allegations against the staff. The DON did not provide documented evidence that he investigated the resident's allegations.

The facility's policy and procedures on abuse dated 9/01 and revised on 4/09 includes the misappropriation of resident's funds in it's definition of abuse. It defines "Misappropriation of resident property" as ....'meaning the temporary or permanent use of a resident's....money without the resident's consent. The procedure for abuse investigation is to investigate any complaint of resident abuse.


415.4.(b)

F247 483.15(e)(2): RESIDENT RECEIVES NOTICE BEFORE ROOM/ROOMMATE CHANGE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 1, 2011

A resident has the right to receive notice before the resident's room or roommate in the facility is changed.

Citation date: March 7, 2011

Based on record review and resident and staff interviews, the facility did not ensure that a resident was notified of a new roommate prior to a new roommates arrival. This was evident for 1 of 4 residents reviewed for admission/transfer and discharge care concern. Resident #142.

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

The finding is:

Resident #142 is an 81 year old male with diagnoses which include right knee Osteoarthritis, Osteomyelitis, and Cataracts.

The Annual MDS 2.0 dated 4/28/10 documents that the residents cognition is intact, with no memory deficits.

On 3/1/11 at 11:30am, during a resident interview, the resident presented as alert and oriented to time, place and person. The Resident stated that he had a roommate change within the last 9 months of residing in the facility. He stated that approximately 1 month ago his roommate passed away, and that a new roommate was placed in his room. He stated that he was not informed that he was getting a new roommate.

On 3/7/11 at 11:30am the Director of Social Work was interviewed and stated that the resident's previous roommate had expired in the hospital on 1/17/11 and that a new resident was placed in that room on 1/20/11. She stated that there is no documentation regarding the resident being informed of a new roommate arrival.

On 3/7/11 at 11:45 am the Unit Social Worker was interviewed and stated that she did not discuss the arrival of a new roommate with the resident.

415.5(e)(2)

F371 483.35(i): STORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 5, 2011

The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Citation date: March 7, 2011

Based on observation and staff interviews, the facility did not ensure that the foods were not stored in the 2nd floor pantry under sanitary conditions and the kitchen floor was not clean.

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

The finding are:

1) On 2/28/11 at 9 am during the initial tour of the kitchen and on 2/28/11 at 11:30am the following was observed:

The kitchen floor was dirty with food particles between the tiles. Especially, by the prep table and cook area.

On 2/28/11 at 11:30am the FSD (Food Service Director) was interviewed and stated that he was aware of the problem. He added that he put in a request to the Maintenance Department to have the floor grouted.

On 2/28/11 at 12:33pm the Director of Maintenance was interviewed and stated that he was aware of the problem in the kitchen, that the floors need re-grouting for approximately 6 months.

2) On 3/3/11 at 10:20am on the 2nd floor, the pantry refrigerator was observed with a plate of food which contained chicken, beef and potato. There was no label or date observed on the food.

On 3/3/11 at 11:30am the FSD was interviewed and stated that he is responsible to check the pantry refrigerator daily on all units to ensure that everything is dated and labeled. He stated that he had checked the 2nd floor refrigerator this morning but he did not see a plate of food.

On 3/3/11 at 11:35am the RN (Registered Nurse) Manager was interviewed. She stated that yesterday a family came in and brought in a plate of food for a resident. She further stated that the staff is supposed to label and date the food when it is put into the residents' pantry refrigerator.

415.14(h)

K15 NFPA 101: INTERIOR FINISH - ROOMS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: May 2, 2011

Interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings, has a flame spread rating of Class A or Class B. (In fully sprinklered buildings, flame spread rating of Class A, Class B, or Class C may be continued in use within rooms separated in accordance with 19.3.6 from the access corridors.) 19.3.3.1, 19.3.3.2

Citation date: March 7, 2011

Based on observation, it was determined that the facility did not ensure that wall coverings (panels of decorative cork boards/papers) installed in the dining rooms on resident floors have a flame spread rating of class "A" , class "B" or class "C".

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 28, 2011, at 10:00 AM to 2:30 PM, it was observed that the facility is protected with automatic extinguishing system (sprinkler system). The wall surfaces in the resistant dining rooms on the nursing units are covered with two panels of corkboard/paper construction (measuring approximately 25 ft by 3 ft, each). Facility has no documentation to show that the wall coverings (corkbord panels) have a flame spread rating of class "A", class "B", or class "C", in accordance with 19.3.6. On February 28, 2010, at approximately 1:00 PM, the facility's director of maintenance stated that the wall coverings (panels) in the resident dining rooms will be either treated with class A finish material or will be removed.

711.2 (a)(1)

K29 NFPA 101: HAZARDOUS AREAS - SEPARATION

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: April 28, 2011

One hour fire rated construction (with hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Citation date: March 7, 2011

Based on observation, it was determined that the facility did not ensure that the boiler room is separated from the garbage area with at least a smoke resistive partition.

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 28, 2011 , at 10:00 AM to 2:30 PM, it was observed that the facility boiler is provided with an automatic extinguishing system (sprinkler system). The boiler room enclosure wall toward the garbage area is penetrated by a ventilation fan opening. The sprinklered hazardous areas are to be separated from other areas by at least smoke resistive partitions. On February 28, 2011 at approximately 11:00 AM, the facility's director of maintenance stated that ventilation opening from the boiler room to the garbage area will be protected by a smoke activated damper.

711.2 (a)(1)

Z570 713-2: STANDARDS OF CONSTRUCTION FOR NEW NURSING HOME

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 2, 2011

Citation date: March 7, 2011

Physical Plant Violation - State Only

NYCRR 713-2.21 (d)(2)(ii)

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 and staff interview ,it was determined that the facility did not ensure that the kitchen areas are ventilated to provide the minimum of 2 air changes of outdoor air per hour supplied to the area with the total of 10 air changes per hour supplied to the area.

The findings include:
On February 28, 20, at 10:00 AM to 2:30 PM, it was observed that although, the facility installed an air supply ventilation equipment for the kitchen, the equipment (air handler) was shut down at the time of the survey. The facility's director of maintenance stated that because of the heated air supply via the air supply equipment the kitchen areas become very hot and the equipment has to be turned off. With the air supply turned off, the kitchen hood exhaust system and the other exhaust ventilation in the kitchen would pull air from the adjacent corridors. The kitchen air supply and exhaust system must be operated to maintain an equal pressure in relationship to the adjacent areas (corridors) of the building. On February 28, 2011, at approximately 12:00 PM, the director of maintenance stated that the kitchen air supply equipment has been restored and was running at that time.

NYCRR 713-2.21(d)(2)(v):

(v) All central ventilation or air conditioning systems shall be equipped with filters having efficiencies no less than those specified in Table 9. The filter bed shall be located upstream of the air conditioning equipment, unless a prefilter is employed. In this case, the prefilter shall be upstream of the equipment and the main filter may be located further downstream.

This requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the air supply equipment ( air handler) for the kitchen area is equipped with a filter bed located upstream of the air supply equipment.

The findings include:
On February 28, 2011, at 10:00 AM to 2:30 PM, it was observed that the facility installed a central air handling equipment for the kitchen area,in the basement. During the inspection, it was noted that the air handler is equipped with one filter bed (threw-in type filter) located downstream to the equipment (the motor fan unit). The central air handling equipment with only one filter bed must have its filter bed located upstream of the air equipment (motor fan unit). The throw-in type filter was also not properly dimensioned and gasketed to provide seal against air leak. There was an approximately 6 inch gap between the filter frame and the outside ductwork of the equipment . On February 28, 2011, at approximately 2:00 PM, the facility's director of maintenance stated that the HVAC company will be contacted to evaluate the proper placement of the filter bed in the air handling equipment and make correction as per 713-2.21.