Boro Park Center for Rehabilitation and Healthcare

Based on observations, record reviews and staff interviews, the facility did not ensure that a resident who requires a wheelchair is provided leg rests. This was noted for 1 of 30 sampled resident. (Resident #7).

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

The finding is:

Resident #7 is an 89 year old female with diagnoses which include Hypertension, Seizure Disorder, Osteoporosis and Dementia.

On 2/25/10 at 9:15 AM, the resident was observed in the television area near the nursing station, sitting in the wheelchair with both feet unsupported. The resident's wheelchair was observed without footrests.

The Minimum Data Set 2.0 dated 12/17/09 documents that the resident has short and long term memory problems with severely impaired decision making skills and is totally dependent on staff in all activities of daily living.

On 3/1/10 at 11:00 AM, the Rehabilitation Nurse RN (Registered Nurse) stated that the resident has a tendency to "bang/move" her leg towards the wheelchair leg rest, and that was the reason why the leg rest was not being used.

On 3/1/10 at 1:30 PM the assigned Certified Nurses Aide (CNA) was interviewed and stated that it has been a long time since she saw the resident using a foot rest.

On 3/1/10 at 2:00 PM, the Physical Therapy Supervisor was interviewed and stated that when a wheelchair is issued it comes with a foot rest. He also stated that he was informed today that the resident has the tendency to drop her feet and hit the footplates. He further stated that a foot plate calf panel was needed to promote comfort and to maintain feet in a supported position.

415.5(e)

Based on observations, record review and interviews, the facility did not ensure that residents were treated with dignity and respect as evidenced by not waiting for the resident's response after knocking on the resident's door, not communicating with residents during dressing change observations and not ensuring that a resident has clothing to wear. This was evidenced for 3 of 30 sampled residents (Residents #15, #18 and #19).

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

The findings are:

1) Resident #15 has resided in the facility since 11/14/2001 with diagnoses including Diabetes, Peripheral Vascular Disease, and Dementia.

A Minimum Data Set (MDS) 2.0 assessment dated 1/20/10 documents that the resident has impaired skills for decision making, and has clear speech that is sometimes understood.
The MDS documents that the resident speaks and understands a language other than English.

On 3/1/10 at 11:30 AM, a Registered Nurse (RN) was observed during provision of wound care to the resident. The RN verbalized "knock-knock" without knocking on the door or waiting for a response from the resident. She entered the resident's room, assisted him to a side-lying position and performed the wound treatment. The nurse did not attempt to verbally communicate with the resident. During the treatment, the RN manager entered the room and assisted the RN with the wound care. The Registered Nurse manager did not have anyone translate for the resident or explain the treatment to him.

The Registered Nurse manager stated that the resident understands what he wants, whenever he wants and that she did not speak his language.

The resident was visited in his room on 3/2/10 at 10AM. An interpreter was asked to translate for the resident. The resident was observed interacting well with the interpreter and verbalized understanding of the purpose of the visit to his room. The resident also joined the interpreter in singing a religious song.

2) Resident #18 has resided in the facility since 7/11/2008 with diagnoses including Diabetes, Seizure Disorder and Aphasia.

A Minimum Data Set (MDS ) assessment dated 1/12/10 documents that the resident has severely impaired skills for decision making , rarely understands, and is rarely understood.

The resident was observed on 3/1/10 at 11 AM while receiving wound treatment.
The RN entered the resident's room while verbalizing "knock-knock".
The resident was positioned to one side by the RN who then proceeded to change his wound dressing. There was no verbal communication with the resident during the treatment.

The RN was immediately interviewed. She stated that the resident understood a language other than English, which she also spoke. She further stated that she did not speak to the resident due to being "nervous while being observed by the surveyor."

3) Resident #19 is a 78 year old male admitted to the facility on 11/17/09, with diagnoses which include Dementia, Depression and Coronary Artery Disease.

The Minimum Data Set (MDS) 2.0 dated 11/24/09 documents short and long term memory problems and moderately impaired decision making skills. The MDS further documents that the resident is sometimes understood and sometimes understands.

On 2/25/10 at approximately 10:25 AM, during the initial tour of the 8th floor, the resident was observed sitting in the dining area in a wheelchair with other residents present. The television was on and staff members were also present. The resident was wearing a hospital gown, brown nonskid socks and a white sheet covering his legs. The resident was also observed to have long brownish fingernails. Observation of the resident's room revealed that the he had no clothes or shoes in his closet and dresser.
On 3/2/10 at approximately 10:30 AM, the resident was observed sitting in the dining room. He was unshaven and had long uneven discolored fingernails.

The facility's Annual Clothing Inventory Form in the resident's medical record dated 11/24/09 documented "1 sweater, 3 pants, 2 shirts, 1 belt."
The facility's Annual Clothing Inventory Form dated 2/25/10 documented " 1 sweater, 4 pants, 4 shirts, 1 slipper and 2 socks."

On 2/25/10 at 10:25 AM, the resident was interviewed and stated that his clothes went out to be washed and hadn't come back yet.

On 2/25/10 at approximately 10:26AM, the Registered Nurse (RN) Manager was interviewed and stated that the resident's clothes had gone out on Monday (2/22/10) to be washed and had not come back yet. She further stated that the resident had no family.

On 2/25/10 at approximately 10:27 AM, the assigned Certified Nursing Assistant (CNA) was interviewed and stated that the resident did not have any clothes for 1 week and that she was not sure about prior to that time because she had been on vacation. She further stated that she did not notify anyone about the resident not having any clothes.

On 2/25/10 at approximately 10:30 AM, the Social Worker was interviewed and stated that the resident has been here for a few months now and has no family or friends and that the facility is working on obtaining guardianship. She further stated that she notified housekeeping to donate clothes to this resident and that clothes were donated in 11/09. She stated that the donated clothes were documented in the chart on the Clothing Inventory List.

415.5(a)

Based on observations, record review and staff interviews, the facility did not ensure that infection control policies and procedures during dressing changes and incontinent care.
This was evidenced for 3 of 30 sampled residents (Residents #15, #18, and #23).

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

The findings are:

1) Resident #18 has resided in the facility since 7/11/2008 with diagnoses including Diabetes, Seizure Disorder and Aphasia.

The Minimum Data Set (MDS ) assessment dated 1/12/10 documents that the resident has recently received treatment for a stage 3 pressure ulcer.

The resident was observed on 3/1/10 at 11 AM while receiving wound treatment.
The RN (Registered Nurse) transported the wound treatment cart to the doorway of the resident's room, removed a full box of gauze dressing and placed it on the resident's bedside table without use of a barrier. She entered the resident's room, assisted him to a side-lying position and removed the old dressing. The nurse then washed her hands, cleansed the wound with Normal Saline and changed her gloves. She applied Bactroban ointment and covered the wound with a gauze dressing . The RN then removed the box of remaining guaze dressings from the resident's bedside table and returned it along with the remaining Normal Saline to the top of the treatment cart. She then proceeded to the room of resident #15 with the treatment cart.

An interview was conducted with the RN Manager on 3/3/10 at 11 AM and stated that the nurse did not practice correct infection control techniques because she was "nervous".

2 ) Resident #15 has resided in the facility since 11/14//2001 with diagnoses including Diabetes, Peripheral Vascular Disease, and Dementia. The resident's most recent readmission to the facility was on 11/4/09 status post Left Above the Knee Amputation (L AKA).

The Minimum Data Set (MDS) 2.0 assessment dated 1/20/10 documents that the resident has impaired skills for decision making and requires extensive assistance of 2 persons for all activities of daily living.

On 3/1/10 at 11:30 AM, a Registered Nurse (RN) was observed during provision of wound care to the resident. She transported the wound treatment cart to the doorway of the resident's room, removed a full box of gauze dressing and placed it on the resident's bedside table without a barrier. She entered the resident's room, assisted him to a side-lying position washed her hands, donned gloves and removed the old dressing and packing from the wound. A stage 4 sacral ulcer was observed with brown, foul-smelling drainage. The wound was irrigated and patted dry. The RN then applied Santyl ointment to a gauze pad that was used to pack the wound. A second gauze pad was prepared with Santyl ointment, it was dropped on the resident's bed on top of the open diaper which the resident was wearing. The nurse picked up the gauze and used it to pack the wound.

3) Resident #23 was admitted to the facility in June 2008 with diagnoses including Diabetes, Cerebrovascular Accident (CVA), and Asthma.

A MDS 2.0 assessment dated 11/19/09 documents that the resident was incontinent of bladder and bowel and had been treated for a urinary tract infection (UTI) within the past 30 days.

An observation was made of the resident during incontinence care on 3/2/10 at 3:30 PM.
The Certified Nursing Assistant (CNA) removed the resident's incontinence brief, wiped the outer labial folds with soap and water, turned the resident to the side and cleaned the perianal area with soap and water. The resident was patted dry and a clean brief placed under the resident. The CNA then wiped the resident's inner labial folds. This was done in a back to front direction. The washcloth was observed to contain yellow material.

During an interview with the facility's Director of Nursing Services (DNS) on 3/3/10 at 11:30 AM, the DNS stated that the CNA was counseled and on correct incontinence care and there was no excuse for the observed practice.reinserviced
415.19(a)(1-3)

epn CFR STATE DEFICIENCIES ONLY
415.18 Pharmacy Services

Storage of drugs and biologicals

The facility shall store all drugs and biologicals in locked compartments under proper temperature controls, and permit access only to authorized personnel.

The facility shall provide separately locked, permanently affixed compartments for storage of controlled drugs and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stores is minimal and a missing dose can be readily detected. Storage of controlled substances shall be in accordance with Article 33 of the Public Health Law and Part 80 of this Title.

Poisons and medications for " external use only " shall be kept in a locked cabinet and separate from other medications; and

Medications whose shelf life has expired or which otherwise no longer in use shall be disposed of or destroyed in accordance with State and Federal law and regulations.

This REQUIREMENT was not met as evidenced by:

Based on observations, record reviews, and staff interviews, the facility did not ensure that multi-dose vials medication was properly labelled once opened or that expired medications were discarded. This was evident for two (2) of nine (9) units toured. (Units 7 East, and 9)

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

The findings are:

1) On 2/25/10, at 9:20 A.M., during the initial tour in the 7 East medication room, the medication refrigerator was observed to have an open vial of Tuberculin, Purified Protein Derivative, Diluted (PPD) approximately .50 ml (milliliter) remaining dated 1/22/10 which was 5 days expired and was not discarded.

On 3/1/10, at 10:00 A.M., the Registered Nurse (RN) was interviewed and stated that the expired vial of PPD should have been discarded.

2) During an initial tour of the facility's 9th floor medication room on 2/25/10 at approximately 10 AM the following, it was observed that the medication storage refrigerator contained an open vial of Apidra (Insulin analog) that was not labeled with the date when the vial was opened.

The Registered Nurse manager who accompanied on the tour was interviewed at that time and stated that there should have been a label with an opening date on the vial and that the vial should be discarded.

Based on record review, and staff interviews, the facility did not ensure that the physician reviews the resident's total plan of care as evidenced by note ensuring that the resident receives the correct dosage of medication. This was evident for one (1) of thirty (30) sampled residents. (Resident #16)

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

The findings are:

Resident #16 is an 82 year old female with diagnoses which include Dementia, Hypertension, Cerebrovascular Accident, and Constipation.

The Minimum Data Set (MDS) 2.0 Assessment documented resident has severely impaired cognition, and is dependent on the staff for all of her activities of daily living.

The physician's admitting order dated 1/22/10 documented "Colace 200 mg (milligrams) Liquid peg (Percutaneous Enteral Gastrostomy) Q (every)AM (morning) Constipation."

The physician's order dated 2/1/10, and the Medication Administration Record documented "Doss (Colace) 50 mg/5 ml (milliliter) lig (liquid). ...10 ml = (equal) 200 mg via peg every morning." The order was reviewed and signed by 2 nurses, and the Medical Doctor.

On 2/26/10, at 12:25 P.M., the Physician was interviewed and said that the order for Colace should be 20 ml, not 10 ml. The physician said that he had reviewed the order but had missed the error.

On 2/26/10, at 12:30 P.M., the Registered Nurse Supervisor was interviewed and stated that the order had been reviewed by 2 nurses and the physician, and not one had picked up on the error.

On 2/26/10, at 2:30 P.M., the Licensed Practical/Medication Nurse was interviewed and she stated that the Colace bottle states 50 mg/5 ml. "I know to give 20 ml. Normally, I would notify the MD (Medical Doctor) and correct the order."

415.22(a)(1-4)

Based on observation, record review and interview, the facility did not ensure that the CNA (Certified Nurse Assistant) was competent in providing incontinence care to a resident. This was evident for 1 of 30 sampled resident (Resident #23).

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

The finding is:

Resident #23 was admitted to the facility in June 2008 with diagnoses including Diabetes, Cerebrovascular Accident (CVA), and Asthma.

A MDS (Minimum Data Set) 2.0 assessment dated 11/19/09 documents that the resident was incontinent of bladder and bowel and had been treated for a urinary tract infection (UTI) within the past 30 days.

An observation was made of the resident during incontinence care on 3/2/10 at 3:30 PM.
The certified Nursing Assistant (CNA) removed the resident's incontinence brief, wiped the outer labial folds with soap and water, turned the resident to the side and cleaned the perianal area with soap and water. The resident was patted dry and a clean brief placed under the resident. The CNA then wiped the resident's inner labial folds. This was done in a back to front direction. The washcloth was observed to contain yellow material.

During an interview with the facility's Director of Nursing Services (DNS) on 3/3/10 at 11:30 AM, the DNS stated that the CNA was counseled and reinserviced on correct incontinence care and there was no excuse for the observed practice.

415.26(c)(1)(iv)

Based on record review and staff interviews, the facility did not ensure that the Pharmacist Consultant identify irregularities in the resident's medication regime. This was noted for one (1) of thirty (30) sampled residents. (Resident #16)

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

The finding is:

Resident #16 is an 82 year old female with diagnoses which include Dementia, Hypertension, Cerebrovascular Accident, and Constipation.

The Minimum Data Set (MDS) 2.0 Assessment documented she has severely impaired cognition, and is dependent on the staff for all of her activities of daily living.

The physician's admitting order dated 1/22/10 documented, "Colace 200 mg (milligrams) Liquid peg (Percutaneous Enteral Gastrostomy, tube inserted into stomach) Q (every) AM (morning) Constipation."

The physician's order dated 2/1/10, and the Medication Administration Record documented "Doss (Colace) 50 mg (milligrams)/5 ml (milliliter) lig. (liquid) ...10 ml= 200 mg via peg every morning." The order was reviewed and signed by 2 nurses, and the physician.

The Medication Regimen Review Consultant Pharmacist Signature and Notation page documented that the consultant was in the facility on 2/22/10 and she reviewed the resident's medications. In the comments section, she checked off "No Comments."

On 2/26/10, at 12:25 P.M., the Physician was interviewed and said that the order for Colace should be 20 ml, not 10 ml. He said that he had reviewed the order but had missed the error.

On 2/26/10, at approximately 3:00 P.M., the Pharmacy Consultant was interviewed and she stated that she had reviewed the Medication Administration Record but she had missed the error for Colace. It was brought to her attention that day by the facility staff.

415.18(c)(1)

Based on observation, record review, and staff interviews, the facility did not ensure that acceptable parameters of nutritional status were maintained. Specifically, the facility did not timely identify residents as having a significant weight loss, did not communicate an insufficient intake in a timely manner to the dietician and the dietician did not develop and implement timely interventions. The residents experienced unplanned significant weight loss. This was evident for three (3) of 30 sampled residents. (Residents #4, #22, and #28)

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

The findings are:

1) Resident #4 is a 51 year old male initially admitted to the facility on 1/27/93 with diagnoses which include Mental Retardation, Dementia, and Blindness.

The Minimum Data Set (MDS) 2.0 Assessment dated 8/16/09 documented short and long term memory impairments and severely impaired decision making skills. The MDS further documented total dependence on staff for eating, dressing, transfers, and personal hygiene.

On 2/26/10 at 12:06 p.m., and on 3/2/10 at 9 a.m., the resident was observed being spoon fed by a Certified Nurse Aide (CNA) in the dining room.

The Resident/Patient Weight Documentation Record documented the following weights:
12/23/09 107.4 lb
01/11/10 97.0 lb
01/13/10 96.4 lb
01/20/10 96.0 lb
01/28/28 95.6 lb
02/03/10 95.4 lb
02/08/10 93.8 lb
02/17/10 94.0 lb
02/24/10 95.4 lb

The Care Plan for Nutritional Status dated 9/9/09 and updated on 1/14/10 documented the following interventions "Provide therapeutic/regular diet as per MD order of: low cholesterol Provide mechanically altered diet as per MD order... puree Nutritional supplements as per MD orders: Ensure + (plus)...: Assess diet order for appropriateness. Monitor intake and assess appetite level. Encourage adequate food and fluid intake as tolerated. Monitor weight as per MD (Medical Doctor) order."

The Nutrition Assessment dated 12/09/09 documented that the resident is: on a low cholesterol puree diet, receiving Ensure Plus 8 oz (ounces) 3 cans per day, current weight is 107.6 lbs (pounds) and the resident's weight is stable with some fluctations noted, and that the resident is at risk of weight decline. This assessment documented a plan to adjust meal to provide additional favored foods secondary to increased pickiness, 3 day calorie count to assess intake and continue to monitor the resident's weight status.

The physician order dated 12/14/09 documented an order for low cholesterol puree diet and Ensure supplement one can 3 times a day.

The nutrition note dated 12/16/09 documented "Resident with some variation in po (per oral) intake noted c (with) decrease as compared to usual intake (good previously) to a fair/poor c good acceptance of supplements. Request 3 day calorie count to assess intake."

The 3 day calorie count was documented for 12/16/09, 12/17/09, and 12/18/09 on the Food Intake Sheet.

The nutrition note dated 12/20/09 documented "Results of 3 day calorie count...MD increased Ensure Plus 8 oz to 4 cans per day secondary to observed preference for Ensure Plus equals 1400 calories to prevent further weight loss. Weekly weights initiated to closely monitor for change in weight status. Team to follow up as appropriate."

The physician order dated 12/20/09 documented change order to Ensure Plus 8 oz 4 times a day and weekly weights.

The facility policy on "Weighing the Resident/ Patient" dated 10/2003 and updated on 2/2010 documented all weights are to be documented on the Resident/Patient Weight Documentation Record. Weekly weights are to be done every Wednesday.

The comprehensive care plan (CCP) for nutritional status outcome evaluation dated 12/20/09 documented that Ensure Plus was increased to four times a day secondary to the resident's preference and that weekly weights were initiated.

The Weekly Weight Record did not document weights for the weeks of 12/30/09 and 1/6/10.

The CNA (Certified Nurse Assistant) Assignment sheet dated 12/31/10 documented the resident's weight as 101 lbs. This is a 6.4lbs weight loss in the period 12/23/09 to 12/31/09. There was no documented evidence that the resident's weight of 101lbs. was communicated to the licensed nurse, dietitician or the physician in order to implement interventions to address the resident's weight loss.

Between 12/20/09 and 1/11/10, there were no additional interventions put in place to prevent further weight loss. During this time, the resident had a significant loss of 10.4 lbs which represents 9.6% of his body weight. There was no reassessment of the interventions until 1/11/10.

On 3/1/10 10:05 A.M., the Licensed Practical Nurse (LPN) was interviewed and stated that she worked on 12/30/09, and 1/6/10 and does not remember why the resident was not weighed. She further stated that if there was a problem she may have informed the Dietitian.

On 3/1/10, at 10:50 A.M., the Registered Dietitian was interviewed and stated that she initials the weights in the weight book but nursing is responsible to make sure the weights are being done. She stated she saw the 1/11/10 weight on 1/13/10 and asked for a reweigh the same day. She further stated the resident may have a high metabolism.

On 3/1/10, at 12:10 P.M., the CNA was interviewed and stated she weighed the resident on 12/31/09 wrote in on her assignment sheet and communicated it to the nurse.

On 3/1/10 at 12:15 P.M., the Registered Nurse Supervisor was interviewed and stated that the Resident should have been weighed on 12/30/09 and 1/6/10. She further stated that the 12/30/09 weight was done on 12/31/09 instead but the nurse did not follow up with the weight.

2) Resident #22 is a 90 year old female initially admitted to the facility on 7/27/08 with diagnoses which include Alzheimers and Depression.

The Minimum Data Set (MDS) 2.0 dated 1/20/10 documents short and long term memory impairments and moderately impaired decision making skills. The MDS further documents set up required for eating.

The Resident/Patient Weight Documentation Record documents the following:
12/9/09 98.4 lbs
12/17/09 92.6 lbs
12/23/09 93.8 lbs
12/31/09 93.2 lbs
1/6/10 92.2 lbs
1/13/10 97.8 lbs reweight under comments section
1/14/10 90.8 lbs
1/22/10 88.8 lbs
1/27/10 88.8 lbs
2/3/10 89 lbs
2/10/10 85.6 lbs
2/18/10 86 lbs
2/24/10 86.4 lbs

The Monthly Physician orders dated 11/19/09, 12/17/09, 1/14/10, 2/10/10 document diet order for No added Sugar, regular texture, Ensure Plus 8 oz 3 times a day. It further documents weekly weights and multivitamin daily.

The Nutrition note dated 12/29/09 documents that the resident's weight was 93.8 lbs, which represented a 7.7% decline in less than 90 days .The note further documents that the interdisciplinary team was made aware of the weight decline and would continue to monitor weights weekly.

The Weight Change Care Plan initially dated 12/29/09 and updated 1/26/10 documents resident has weight loss of 5% or more in last 30 days or 10% or more in last 180 days. Interventions include Provide diet as ordered by MD , weigh resident weekly, provide food likes, provide feeding set up, provide appropriate treatment to underlying behavioral and/ or medical problems contributing to the weight loss, monitor intake and assess appetite level, provide nutritional supplements as ordered.

The Nutrition note dated 1/4/10 documents:"weight of 93.2 lbs.... Gradual weight loss not significant. Continue to monitor weights weekly".

The Nutrition note dated 1/7/10 documents: "weight of 92.2 lbs. Team made aware. Weight loss significant".

The Nutrition note dated 1/14/10 documents: weight of 90.8 lbs. Weight decline significant x 30, 90, 180 days. Team aware continue weekly weights.

The Nutritional Status Care Plan initially dated 1/26/10 for Significant Change documents "Resident is underweight and/or at risk of unplanned weight loss secondary to dementia, fair PO intake". Interventions include
Ensure Plus, multivitamin, monitor weight, assess diet order for appropriateness, provide food preferences.

The Nutrition note dated 2/26/10 documents: weight of 86.4 lbs. Resident continues to have significant weight decline. Weight decline not desirable. Recommend Prostat 101 30 ML daily.

There are no new or additional interventions documented until the Physician order dated 2/26/10 which documents Prostat 101 30 ML daily for supplement.

On 3/3/10 at 9:40 AM the Dietitian was interviewed and stated she continued to monitor the Resident for weight loss and provided food preferences including egg salad sandwiches since 1/11/10. She further stated she added Prostat on 2/26/10 based on the decline in Albumin level lab of 1/27/10.

On 3/3/10 at 9:50 AM the RN (Registered Nurse) was interviewed and stated the resident is a picky eater and the staff encourage and monitor her. She stated the staff do not record meal consumption amounts and only if a 3 day calorie count is requested. She stated staff verbally communicate how much the resident eats.

On 3/3/10 at 10:35 AM the Physician was interviewed and stated that the resident is a finicky eater and was given supplements of Ensure Plus 3 times a day since November 2010. He stated the Resident had a continued weight loss. He stated a lab was done 1/27/10 and Prostat started 2/26 due to drop in Albumin. He stated the staff observe the resident during meals and will inform him if is she is not eating or taking the supplements.

3) Resident #28 is a 79 year old male admitted to the facility on 1/27/10 with diagnoses which include Gastric Cancer, Status Post (s/p) Subtotal Gastrectomy, Hypertension (HTN) and Gastroesophageal Reflux Disease (GERD).

The Minimum Data Set (MDS) 2.0 dated 2/3/10 documented no memory problems and independent in decision making skills.

The Discharge Summary Instructions from the hospital dated 1/27/10 documented s/p Gastrectomy and Post Gastrectomy Diet (6 small meals/day).

The Physician's Order dated 1/27/10 documented NAS (no added salt) mechanical soft diet, Ensure Plus PO (by mouth) BID (twice a day) and Dietary Evaluation.

The Resident's Food Preference Sheet dated 1/27/10 documents "Current Diet Order: NAS low cholesterol mech. Soft, Ensure Plus 8 oz. BID .....Substitutions: No coffee, give tea."

The Dietary Department Diet Order Sheet dated 1/27/10 documents: " New or Re-admission, Diet: Mechanical Soft, no added salt, low cholesterol " .

The Initial Nutrition Assessment dated 1/28/10 documents: " See food preference sheet ... ...Resident is aware of small frequent meals, diet education provided. Resident is comfortable with current diet regime of 3 meals/day and 2 snacks. Will readjust as needed ..."

The Resident/Patient Weight Documentation Record documents the following weights:
Initial weight 146
2/2/10: weight 140
2/9/10: weight 128
2/9/10 weight 128 (reweigh)

The Interdisciplinary Progress Notes dated 2/3/10 documents: " Biweekly Note, Pt c/o N/V x 2 this AM after eating eggs for breakfast ... ...N/V, improved, ginger ale for upset stomach (probably secondary to eggs), Gastric Ca, s/p subtotal gastrectomy ... .... " .

The Interdisciplinary Progress Notes dated 2/7/10 documents: " Pt. reports nausea and vomiting after breakfast. Vomited x 2 ....reported vomiting after drinking cold water, ensure and a banana. Remaining nauseated throughout AM ... .... " .

The Nutrition Bi-Weekly Monthly Note dated 2/8/10 documented: " No Added Salt Low Cholesterol Mechanical Soft Diet ... ....tolerating diet as ordered, Ensure Plus 8 oz. 2 cans/day ....wt 140, lost 6 pounds (4%) in 1 week secondary to complaining of fullness, GERD ... ...Continue to address food preferences ... ... " .

The Nursing Assistant Accountability Record dated 1/27/10 through 2/10/10 documented supervision while eating.

There is no documented evidence that the interventions for small frequent meals were implemented.

On 3/3/10 at approximately 12:05 PM, the Registered Dietitian (RD) was interviewed and stated that she spoke to this resident about his diet and that this resident wanted small frequent meals. She further stated that 6 small meals would consist of breakfast, lunch, dinner and 3 snacks. She said that she was supposed to document on the Food Preference Sheet so that the dietary staff would know what to give this resident.

On 3/3/10 at approximately 12:30 PM, the Registered Nurse (RN) Manager was interviewed and stated that the Dietary Department is responsible for providing the appropriate meal plan. She further stated that if a resident is not eating well the Certified Nursing Assistant (CNA) will tell the nurse otherwise they don't document meal consumption.

On 3/3/10 at approximately 12:55 PM, the attending Physician was interviewed and stated that the dietitians make recommendations for the appropriate diet. He further stated that the dietitians document their recommendation on the Diet Order Sheet and then the doctor signs off.

415.12(i)(l)

Based on observation, it was determined that the facility did not ensure that the doors to the resident room #503, and the other use areas such as the medical records room and room #5B2 are kept free of impediments to closing the doors and are maintained to close tightly in their frames.

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 25, 2010, at 9:30 AM to 2:00 PM, the following was observed:
(1) The corridor door to resident room #503, was hitting the door jamb and was not closing in its frame.

(2) The corridor door to the medical records room was impeded to closing on uneven floor under the door.

(3) The door to the general office room #5B-2, was equipped with the kick stand type of the door holding device. This type of device would impede the free closing of the door in case of fire or other emergency.

On February 25, 2010, at approximately 2:00 PM, the facility's director of maintenance during the exit conference, stated that doors to all use areas will be maintained free of impediments to closing.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the doors to the hazardous areas are only held open with he approved automatic release devices activated via the activation of the facility fire alarm systems, as per 7.2.1.8.2 and 19.2.2.2.6.

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 25, 2010, at 9:30 AM to 2:00 PM, it was observed that the doors to the hazardous area enclosures were held open with the regular magnatic devices, door check type devices or with miscellaneous objects wedged under the doors, examples are: storage room #5B-11,storage room #5B-2, soiled linen chute room #5B-9, garbage chute/compactor room #5B-8 and the central storage room #5B-3. These hold open devices are not the approved automatic release devices which will operate upon the activation of the facility's fire alarm systems, sprinkler system and the smoke detection system,as required under 19.1.1.4.3, 19.2.2.2.6 and 7.2.1.8.2. The fire doors protecting the openings in the hazardous area enclosures which need to be kept open for increased efficiency should only be held open by automatic hold open devices actuated by the facility's fire alarm systems, as described under 7.2.1.8 and 19.2.2.2.6. On February 25, 2010, at approximately 2:00 PM, the facility's director of maintenance stated that all doors to the hazardous areas will be kept closed and all unapproved door holding devices will be removed.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the doors to the central storage areas and the boiler room are self-closing or automatic closing and positively latching.

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 25, 2010, at 9:30 AM to 2:00 PM, it was observed that one of the two leaf doors to the central storage room #5B-3 was hitting the edge of the stationary door leaf and was not closing completely and was not latching. The door to the boiler room #B-19, was impeded to closing by uneven floor under the door. On February 25, 2010, at approximately 2:00 PM, the facility's director of maintenance stated that the doors to all hazardous areas will be maintained self-closing and latching.

711.2 (a)(1)

Section 5.2.2.2, NFPA25, states that the sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

This standard is not met as evidenced by :

Based on observation, it was determined that the facility did not ensure that the sprinkler piping located within the central storage area in the sub-basement are maintained free from metal/cable conduits resting on the pipe.

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 25, 2010, at 9:30 AM to 2:00 PM, it was observed that in the central storage room #5B-3, a metal conduit and heavy cables were either hung or resting on the sprinkler piping. All sprinkler piping must be maintained free from materials hanging or resting on them. On February 25, 2010, at approximately 2:00 PM, the facility director of maintenance stated that the sprinkler piping will be maintained from any materials resting on the pipes.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that exit stair "A" enclosure is free from the passage of overhead drain pipe, as per 7-1.3.2.1 and 7.1.3.2.3.

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 25, 2010, at 9:30 AM to 2:00 PM,it was observed that the enclosure to exit stair "A", at the garage level, is penetrated by an overhead drainage pipe of approximately 6 inch diameter. The drainage pipe lacks an enclosure of at least 1 hour fire resistance rating. Any accidental water leakage from the drain pipe in the exit stairway would interfere with the safe usage of the stairway by the occupants during fire or other emergency. On February 25, 2010, at approximately 2:00 PM, during the exit conference, the facility's director of maintenance stated that the drainage pipe penetrating the exit stair enclosure will be enclosed with at least 1 -hour fire resistance rating construction.

711.2 (a)(1)