Spring Creek Rehabilitation & Nursing Care Center

Based on observations and staff interviews, the facility did not ensure that staff followed infection control program to prevent the potential spread of infection and cross contamination. This was evidenced by: 1) A phlebotomist observed not practicing hand hygiene prior to drawing the resident's blood. (Resident #213) 2) Storage of a box disposable diapers on the floor. 3) Storage of disposable cutlery under the sink in the medication room. 4) Staff not practicing hand hygiene during a dressing change 5) Resident care items were stored on the floor in the clean supply room. This was evident for 2 of 34 residents reviewed for significant care concerns ( Residents 61 and 213). and on floors 1, 2 and 3.

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

The findings are:

Resident #213 is a female with diagnoses which include Cancer. The resident is alert and oriented to person, place and time.

1) On 9/21/11 at 10:25 AM a phlebotomist entered the resident's room to draw a blood sample from the resident. Upon entering the room the phlebotomist used his bare hands to review a paper lab slip and hold a caddy with his lab supplies, donned gloves and proceeded to draw blood from the resident. The surveyor did not observe the phlebotomist wash his hands prior to donning the gloves and drawing blood from the resident.

The phlebotomist was interviewed on 9/21/11 at 10:35 AM. He stated that he washed his hands prior to entering the room. The phlebotomist also stated the he should have washed his hands prior to donning gloves and drawing the resident's blood.

2) During a wound care dressing change observation for Resident #61 on 9/23/11 at 11:05 AM, the following was observed: The Registered Nurse (RN) washed her hands, applied gloves, and removed the resident's soiled dressing using both hands. The RN removed and replaced the right glove, cleanse the wound with normal saline, and removed and replaced the right glove. The RN applied ointment and covered the wound with gauze. The RN did not the gloves on her left hand during the entire procedure. There was no hand hygiene observed between changing of gloves.
The RN was immediately interviewed and stated that she should have washed or sanitized hands between gloves.

3) During a tour of the facility's laundry room on the first floor 9/23/11 at 10:20 AM a box of disposable diapers was observed on the floor. The laundry aide was immediately interviewed and stated that she when the linen cart are returned, she removes the disposable diapers from the linen cart and stores them in the box on the floor, until she restocks the linen carts for each unit.
The Environmental Services Director was interviewed on 9/23/11 at 10:30 AM and stated that the box should not have been placed on the floor.

4) On 9/23/11 at 11:22 AM. on unit 2 c/d plastic forks and spoons were observed in cardboard boxes stored under the sink. The LPN was interviewed immediately after the observation. She stated that she does not know who put those items under the sink, they should not be under the sink. She stated that disposable cutlery should be stored in the pantry.

5) During a tour of unit 3 c/d on 9/22/11 at 10:48 AM, a bag containing a pair of heel protectors and a bag containing a helmet were observed being stored on the floor in the "clean holding room". The RN who accompanied the surveyor on the tour removed the items off the floor and placed the items on a shelf, the clean bath care supplies.
The RN was immediately interviewed and stated that the items should not have been placed on the floor.

415.19(a)(1-3)

Based on observations and staff interviews, the facility did not ensure that nourishment areas on the units were maintained to prevent food borne illness.
This was evident in the pantries on 3 of 3 units.

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

The findings are:

1) On 9/20/11 at 10:15 AM the second floor C/D unit pantry refrigerator was observed to have several bags of unlabelled, undated foods as follows:

a) A quarter container of left over Chinese noodles in a plastic bag with no label, no name or date.
b) A deli package of Turkey breast in a plastic bag with name and dated 9/16/11 ( over 4 days).
c) A plastic bag with left over steak and vegetable in a Styrofoam container, with name and no date on it.

2) On 9/22/11 at 11AM the 3rd floor c/d units pantry ice machine was observed with brownish, reddish dried substance on the ice dispenser. There was also a black colored substance observed in the drainage area below the dispenser.

3) On 9/22/11 at 11:10 AM the 4th floor c/d units pantry ice machine was also observed with brownish, reddish dried substance around the ice dispenser. There was also stagnant water containing a slimy appearing substance. There was also a black colored substance in the drainage area below the dispenser.
The registered nurse supervisor who witnessed the observation was immediately interviewed and stated that the housekeeping department was responsible for cleaning the pantry equipment on a daily basis.

The Housekeeping Director was interviewed on 9/23/11 at 9:55 AM and stated that there is a housekeeper assigned to each unit who is responsible for cleaning the ice machines and the pantry equipment. He further stated that he was aware that the plastic parts of the ice dispenser were difficult to keep clear and that the drains were not flowing well.

415.14(h)

Based on observations, interviews and record reviews the facility did not provide a resident with needed grooming.
This was evident for 1 of 34 residents reviewed for significant care concerns (# 113) who was observed with untrimmed and dirty nails during the entire survey.

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

The finding is:

Resident #113 was admitted to the facility on 6/16/09 with diagnoses of Hypertension,Cerebrovascular Accident with Hemiplegia,and Dementia.

The MDS (Minimum Data Set) 3.0 annual assessment dated 5/23/11 documented that the resident requires extensive assistance of 1 person for ADL (activities of daily living) and grooming.

On 9/21/11 at 12: 15 PM the resident was observed in the dining room with dirty untrimmed nails. The resident was again observed with untrimmed dirty nails on 9/22/11 at 11 AM and on 9/23/11 at 10:05 AM .

The assigned CNA (certified nursing assistant) was interviewed on 9/23/11 at 11:35 AM and stated that she washed the resident in bed that morning, but, did not clean under the resident's nails. She stated that she washed the resident's hands quickly to take him to the dining room for breakfast. She further stated that the CNAs are responsible for trimming resident's nails. She also stated that the resident usually cooperates with care and does not fight.

The registered nurse supervisor (RNS) was interviewed on 9/23/11 at 11:45 AM and stated the CNA trims nails except for Diabetics or residents on anticoagulants who get their nails trimmed by the licensed nurse. The RNS also stated that she "spot checks" the residents especially the ones assigned to the float CNA. She further stated that the resident had been assigned to a float CNA for the entire survey due to his regular CNA having a family emergency and not working since 9/21/11. She stated she does not recall checking on resident #113. She stated she was not aware of the condition of his nails until brought to her attention by the surveyor.
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415.12(a)(3)

Based on observations, staff interview and record reviews the facility did not ensure that a resident's dental status was accurately reflected on the comprehensive assessment. This was evident for 1 of 34 residents reviewed for significant care concerns (#113).

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

The finding is:

Resident #113 was admitted to the facility on 6/16/09 with diagnoses of Hypertension,Cerebrovascular Accident with Hemiplegia,and Dementia.

The MDS (Minimum Data Set) 3.0 annual assessment dated 5/23/11 documented that the resident requires extensive assistance of 1 person for Activity of Daily Living and grooming. The oral/dental status assessment documented "none of the above" as the response for any teeth or mouth disorder.
The assessment of whether the resident had "obvious or likely cavity or broken natural teeth" was left blank.

A Comprehensive Care Plan (CCP) for oral health dated 5/24/11 documented "oral health at risk due to broken, loose or carious teeth".

An updated CCP dated 8/17/11 documented "no s/s (signs/symptoms) dental problem past 3 months".

The resident was observed on 9/21/11 at 12:18 PM, in the dining room, the resident has decayed and missing teeth.

The registered nurse supervisor (RNS) was interviewed on 9/23/11 at 11:45 AM and stated that she initiated the care plan because she was aware that the resident "had bad teeth". She further stated that the resident was receiving a special mouthwash from the dentist for caries because he had refused extraction of the bad teeth. She also stated that the MDS should have been completed correctly to reflect the resident's status.

415.11(a)(2)

Based on observations, resident and staff interviews, the facility did not ensure that the phlebotomist provided the resident privacy during care. Specifically; the phlebotomist did not close the privacy curtain prior to drawing the resident's blood. This was evident for 1 out of 40 residents in the Census pool observed for care concerns during Stage one. (Resident #213).

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

The finding is:

Resident # 213 is a female who is alert and oriented to person, place and time.

On 9/21/11 at 10:25AM the phlebotomist was observed entering the resident's room. The resident shares the room with another resident who was present with the surveyor in the room at this time.
The phlebotomist proceeded to inform the resident that he was there to draw blood for a test. He did not draw the privacy curtain prior to drawing the resident's blood. He drew the blood, thanked the resident and left the room.

The phlebotomist was interviewed immediately after leaving the room at approximately 10:35 AM. He stated that he was not an employee of the facility. He is employed by a laboratory services corporation contracted by the facility. He stated that he was aware of the resident's right to bodily privacy while receiving care, and that he normally draws the privacy curtain prior to providing care to a resident. However, he was rushing to make rounds and forgot to draw the curtain.

The Resident was interviewed on 9/21/11 at approximately 2:45 PM. The resident stated that she had not really noticed if the phlebotomist drew the privacy curtain. and that she was not bothered by him not drawing the curtain.

415.3(d)(1)

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Based on observations and staff interviews the facility did not ensure that required nurse staffing information and resident census information were posted.
This was evident for the entire facility

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

The finding is:

During random observations conducted throughout the survey from 9/20/11 to 9/23/11 there were no posting of the required staffing data observed. There was a sign in the rear of the lobby which read "to review staffing information, see front desk".
The information at the front desk was reviewed on 9/23/11 at 4:27pm and documented the daily schedule for each floor with the names of the licensed staff. No census information was identified on the schedule. There was also an alphabetical census listing of "total number of occupied beds" on a separate clipboard.

On 9/23/11 at 3:30PM the r eceptionist was interviewed and stated that she was provided with new lists every morning.

415.12(a)(l)(i-iii)

Based on record reviews and staff interview the facility did not ensure that they purchased of a surety bond to protect the total amount of resident's funds on deposit in the facility. This was evident for the entire facility.

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

On 9/23/11 at approximately 2:10 PM the facility's Controller was interviewed and provided documentation that the current Surety bond in effect since 11/1/09 was in the amount of $100,000. The total amount in the resident's funds account dated 9/23/11 was $108,418.92. The Controller stated that he does not routinely check the funds balance and Surety bond amount as the total in the resident funds was usually between $70-80,000.

415.26(h)(5(v)

Based on observations and interviews the facility did not ensure that survey results were accessible without residents or visitors having to request them from facility staff. This was evident for the entire facility.

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

The finding is:

On 9/20/11 at approximately 3:30 PM , the President of the resident council was interviewed and that there is no sign posted directing residents where to find the survey results.

During random observations from 9/20/11 to 9/23/11 one sign was observed on a wall in the back lounge area of the lobby. This sign informed residents and the public that survey results were at the front desk. The folder was not visible.

On 9/23/11 at 3:30 PM the receptionist was asked for the survey results. She stated that the survey results are kept in a folder behind her desk and is provided to anyone who asks.

415.3(1)(c)(v)

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 non-hazardous use areas which are equipped with self-closing devices are only held open with devices which will release when the door is pushed or pulled as per 19.3.6.3.3. Reference is made to the held open doors to the female locker room with the help of a chair and the door to the housekeeping office which was held open by means of a metal wedge.

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

The findings include:
On September 20, 2011, at 10:00 AM to 2:00 PM, it was observed that the doors to the use areas are held open by means of furniture or metal wedges wedged under the doors, examples are : the door to the female locker room which was held open by means of a chair, and the door to the housekeeping office which was held open by a metal wedge. These door hold open devices would not allow the doors to close when pushed or pulled in the direction of door swing. Only friction catches or magnetic catches type of hold open devices are recommended under the life safety code. On September 21, 2011, at approximately 11:30 AM, the facility director of maintenance stated that all metal wedges /cocks and other make shift door hold open devices were being removed from the doors to the use areas.

711.2 (a)(1)

Based on observation, it was determined that the facility did not en sure that the doors to hazardous areas are only held open with the approved automatic release devices activated via the fire alarm systems as per 7.2.1.8.2. Reference is made to the doors to food storage room, off the kitchen area the door to the medical supplies storage room; the door to the housekeeping supplies storage room and the door to soiled linen room/central laundry room area on the first floor which were held open with chocks or metal wedges.

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

The findings include:
On September 20, 2011, at 10:00 AM to 2:00 PM, it was observed that the door to hazardous areas, on the first floor were held open with chocks or metal wedges wedged under the doors. Examples are: the door to the food storage room off the kitchen area the door to the medical supplies storage room the door to soiled linen room/central laundry area, and the door to the housekeeping supplies storage room. These door hold open devices are not the automatic release devices which will activate upon the activation of the fire alarm systems, sprinkler and smoke detection system, as required under 19.2.2.2.6 and 7.2.1.8.2. On September 21, 2011 at approximately 11:00 AM, the facility's director of maintenance stated that all chocks and metal wedges had been removed from the first floor hazardous areas.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that oxygen cylinders stored in the oxygen storage room, on the first floor are separated from combustible cardboard boxes, as per 8.3.1.11.2, of the NFPA99 -Health Care Facilities.

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

The findings include:
On September 20, 2011 and September 21, 2011, at 10:00 AM to 2:00 PM, it was observed that the utility closet, on the first floor, approximately 10-12, "E" size oxygen cylinders were stored along with the cardboard boxes (cartoned supplies). The oxygen storage must be separated from combustible storage, in accordance with NFPA99. On September 21, 2011, at approximately 1: 30 PM, the facility's director of maintenance stated that all cardboard boxes were being removed from the oxygen cylinders' storage closet.

711.2 (a)(1)

NYCRR 713-2.24 (d)(2)(vi):
(vi) All filter(s) efficiencies shall be average atmospheric dust spot efficiencies tested in accordance with ANSI/ASHRAE Standard 52.2 - 1999, Method of Testing Air-Cleaning Devices for Removal Efficiency by Particle Size, 1999 edition. Further details concerting this referenced material are contained in section 711.2 (b) of this Title (a). Filter frames shall be durable and carefully dimensioned and shall provide air-tight fit with the enclosing duct work. All joints between filter segments and the enclosing duct work shall be gasketed or sealed to provide seal against air leakage. A manometer shall be installed across each filter bed serving central air systems.

This requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the air handling equipment MUA #1, serving the kitchen areas, is equipped with filter segments which are dimensioned properly and provide an air-tight fit with the enclosing ductwork.

The findings include:
On September 20, 2011, at 10:00 AM to 2:00 PM, it was observed that the facility has installed an air handling equipment identified as MUA #1 on the first floor adjacent to exit door East. The air handler is designed to supply outside air to the kitchen areas. Although, the air handler is equipped with throw-in type rectangular filter segments, the outermost filter segments were observed placed approximately 5 inches away from the side door/duck work. The filters were not properly dimensioned to provide an air-tight fit with the equipment door/duct work so as to create seal against the air leakage. On September 21, 2011, at approximately 12:00 PM, the facility director of maintenance stated that the HVAC company has been contacted to provide properly dimensioned filters for all air handlers in the facility.

NYCRR 713- 3.4 (c)(6)
A soiled workroom that contain s a clinical sink or equivalent , flushing rim fixture, with a rinsing hose or bed pan sanitizer, handwashing facilities, work counter, and an area for soiled linen holding and waste receptacle (s) in a number and type as required by the functional program. The location of the soiled workroom shall be based on the functional program and the physical layout of the nursing unit. A soiled holding facility, if not provided within the workroom, shall be part of an approved system for collection and disposal of soiled materials .

This requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not e nsure that the soiled workroom /the soiled holding room which contains the handwashing facility is provided with a work counter as per 713-3.4.

The findings include:
On September 20, 2011 and September 21, 2011 at 10:00 AM to 2:00 PM, it was observed that the facility provided a combination of soiled workroom and soiled holding room on the nursing units. The soiled holding room/soiled workroom contains the handwashing facility. The room lacks a work counter as required under 713-3.4. On December 26 at approximately 4:30 PM, the facility's Director of Maintenance stated that work counters will be installed in all soiled workrooms.