Jewish Home Lifecare, Manhattan

Based on observations, record review and staff interviews, the facility did not ensure that 1 of 14 residents reviewed for weight loss/nutritional issues maintained acceptable parameters of nutritional status specifically, Resident #2 experienced a significant weight loss and the facility did not ensure that interventions including snacks, food preferences and supplements were consistently implemented to meet the resident's nutritional need.

This resulted in actual harm that is not immediate jeopardy.

The finding is:

Resident #2 has resided in the facility since 11/10 /08 with diagnoses including Hypothyroidism, Dementia, Diabetes, and Hypertension.

A Minimum Data Set (MDS) 2.0 assessment dated 12/30/09 documented that the resident has short and long term memory problems and severely impaired decision making skills. The MDS also documented that the resident requires extensive assistance of one person for eating.

The comprehensive care plan for dehydration dated 12/30/09 and 2/24/10 documented "poor PO (oral) intake" as a problem. The care plan documented interventions including: "Cater to food preferences within diet restrictions, provide assistance and encouragement at mealtimes, Glucerna 237 ml (milliliters), chocolate flavored 3 per day."

The resident was observed on 3/8/10 at 7:20 a.m., during initial tour of the facility. She was seated at a table near the nurses' station in a reclined wheel chair and sitting on a table too tall for her. Two cups of juice were observed on the table in front of the resident at approximately 8:20 a.m. The resident was not drinking the juice. The nursing staff present were not observed providing the resident any assistance to consume the juice. The resident was provided with breakfast at 9:00 a.m. She was assisted by a Certified Nursing Assistant (CNA) who fed her approximately 5-6 tablespoons of oatmeal, 1/3 hard boiled egg and 1/2 cup coffee.

A second observation of the resident was done during the lunch meal on 3/9/10 at 12:37 p.m. The resident stated, "yo tengo nausea, ay ,ay, no quiero," in Spanish that she did not want to eat and she was nauseated. The CNA then removed the uneaten meal of soup, pasta, vegetables, pie, and coffee from the resident's table and placed it on the serving cart. The Licensed Practical Nurse (LPN) reheated the soup from the resident's tray and encouraged the resident to eat. Three to four teaspoons of the soup was consumed by the resident.

The physician's orders for February 2010 documented no added salt, carbohydrate controlled, chopped diet. There was also an order dated 2/24/10 for Glucerna 237 cc (cubic centimeter) three times a day for supplement.

The nursing progress notes documented the following: On 2/25/10, 7-3 shift, "resident was fed by staff and ate very little meal." On 2/25/10, 3-11 shift, "appetite poor." On 2/26/10 "follow up poor intake/on calorie count, appetite remains poor....will continue to monitor." On 2/27/10, 7-3 shift, "appetite today poor fed by staff...fluids encouraged but only taken small amounts." On 2/27/10, 3-11 shift, "Appetite remains poor, refused all medications, fluids offered, refused to swallow...continue to monitor." On 2/28/10, 7-3 shift, "continues to have poor to fair intake...will continue feeding plan...on Glucerna 237 cc three times a day for supplemental nourishment"

The CNA "daily care assignment sheet" documented that the resident refused breakfast 5 of 6 mornings 2/22/10 to 2/28/10, had poor intake for lunch and dinner 2/11/10 to 2/28/10 and refused all meals 3/1/10 to 3/8/10. There was a blank space next to "nourishment." There was no documented evidence that the resident was provided with snacks.

Review of the Medication Administration Record (MAR) revealed documentation that the resident was given 1 can of Glucerna at 10 AM and 2 PM from 2/24/10 to 3/7/10. There were omissions for 10 AM and 2 PM on 3/8/10, 3/9/10, and 3/10/10. The Glucerna due at 6 PM was documented as given each day from 2/24 to 3/10 with the amount consumed to be between 50 and 100 ml.

Review of the resident's weight record documented the following:
During the week of 1/1/10 to 1/7/10 150 lbs
During the week of 2/1/10 to 2/7/10 146 lbs
During the week of 2/23/10 -2/29/10 141 lbs
On 3/10 /10, the resident's weight was 133 lbs

The resident had a severe weight loss from 2/1/10 (146.2 lbs) to 3/10/10 (133 lbs), approximately 13 lbs, greater than 5 %.

A Food and Nutrition (FN) note dated 2/18/10 documented that the resident had lost weight, prefers ethnic foods which would be provided when available. The FN note also documented "d/w MD (discussed with physician), son notified...offer alternatives during meals."

A calorie count was done for three days 2/25-2/27/10. The FN note dated 3/4/10 documented that the resident's average intake was only 158 kilocalories per day and that she required at least 1286 per day. The note also documented that the resident had "moderately depleted protein stores ...d/w MD (discussed with physician)." The documented plan included: "offer variation of meal choices...monitor biweekly weight...extra snacks pudding and soft sandwich added to meal trays."

There were no pudding, extra snacks or soft sandwich observed on the resident's meal trays on 3/8/10 or 3/9/10.

An interview was conducted with the Registered Dietician (RD) on 3/9/10 at 3:05 PM. The RD stated that she relied on the primary CNA and other floor staff to offer the resident snacks, puddings and soft sandwich. She was asked if any follow up was done to check the resident's intake. She stated that she visited the floor several times per week to observe meals but was not aware of any further problems with this resident. She stated that food preferences were according to resident and family request and she had spoken with the resident's son. The RD was asked if the resident's food preferences had been communicated to the kitchen staff. She stated that "I don't think I wrote it down anywhere." The RD then provided a sample of the facility's last 4 week menu. She stated that based on the variety of foods offered, there was always something that everyone eats.

The Licensed Practical Nurse (LPN) was interviewed on 3/10/10 at 4 p.m. and stated that the dietary supplements are documented as given on the resident's medication record (MAR) after the CNA reports how much the resident takes. The LPN also stated that "daily care assignment sheet" is the CNA's (certified nursing assistant) record of care and should have documented that the resident received supplements. The LPN also stated that there was no place for snacks to be documented except in the progress notes.

An interview was conducted with the resident's physician on 3/10/10 at 4:30 PM. He stated that he was aware of the resident's weight loss but believed she had adequate protein stores. He also stated that the resident had stopped eating in the past and resumed on her own. The physician was asked if there were recent labwork done to assess the resident's nutritional status. He stated that he checked the resident's albumin on 2/25/10 and believed the result to be 3.3. He further stated that he was aware that 3.3 was a little low but he will continue to observe the resident and give the supplements.

415.12(i)(l)

Based on observations, record reviews and staff interviews, the facility did not ensure that residents' dignity was maintained as evidenced by: 1) staff not speaking to a resident during care, 2) placing a resident in a hospital gown, 3) not maintaining dignity while toileting a resident. This was evident for 3 of 30 sampled residents. (Resident #2, #19, and #21)

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

The findings are:

1) Resident #2 has resided in the facility since 11/10 /08 with diagnoses including Hypothyroidism, Dementia. Diabetes, and Hypertension.

A Minimum Data Set (MDS) assessment dated 12/30/09 documented that the resident has short and long term memory problems and severely impaired decision making skills. The MDS also documented that the resident requires extensive assistance of one person for eating.

The resident was observed on 3/8/10 at 7:20 a.m. during initial tour of the facility. She was seated at a table near the nurses' station in a reclined wheel chair that was too low to reach the table. The resident was provided with a breakfast tray at 9:00 a.m. on 3/8/10. At this time a Certified Nursing Assistant (CNA) suddenly adjusted the back of the resident's chair from a reclining to upright position without providing an explanation. The resident responded by crying out in Spanish "aye, aye ,aye." The CNA then sat next to the resident, placed a spoon of oatmeal to the resident's mouth and stated, "open Mammy, comida (food)."

2) Resident #19 is a 74 year old female admitted to the facility on 12/21/09 with diagnoses which include Anemia, Schizo-affective, and History of (H/O) Falls.

The Minimum Data Set (MDS) 2.0 dated 1/27/10 documented that the resident has short and long term memory problems and modified independence in decision making skills.

The resident was observed on 3/8/10 at 10:00 a.m. during initial tour in the hallway, on 3/8/10 at 12:30 p.m. during meal observation and on 3/11/10 at approximately 2:00 p.m. in the hallway wearing a hospital gown and socks.

The resident's closet was observed on 3/8/10 at 10:15 a.m. and contained 3 pair of pants, 4 blouses, 1 dress, 1 winter coat, 1 pants set, 1 pair of shoes and 1 pair of slippers. All clothing items were in garment bags and neatly stored.

On 3/8/10 at approximately 10:20 a.m., the resident was interviewed and stated that none of her clothes fit and that they need to be altered because she had lost some weight.

On 3/8/10 at 10:25 a.m., the assigned Certified Nurses Assistant (CNA) was interviewed and stated that the resident has no clothes that fit her properly.

On 3/11/10 at 3:15 p.m., the Social Worker was interviewed and stated that she just found out that the resident's clothes are too big.

On 3/11/10 at 3:30 p.m., the Registered Nurse (RN) was interviewed and stated that the resident came in with clothes but wouldn't let the facility take them to label. She further stated that they didn't want to upset the resident so that they have been working on making her feel more comfortable before trying to get her something to wear.

On 3/11/10 at 3:40 p.m., the 3-11 p.m. CNA was interviewed and stated that sometimes residents come in without any clothing and that the facility would provide donated clothes so that the resident would have something to wear. She further stated that "we would go to the laundry department to get clothes for a resident as we don't like to have them walking around in a hospital gown."

3) Resident # 21 has resided in the facility since 1/29/08 with diagnoses including Dementia, Depression, and Spinal Stenosis.

A Minimum Data Set (MDS) assessment dated 1/4/2010 documented that the resident has short and long term memory problems and severely impaired decision making skills. The MDS also documented that the resident was occasionally incontinent of bladder and bowel and required assistance of one person for toileting.

A care plan for incontinence dated 10/15/09 documented "ensure resident privacy and dignity when providing care."

The resident was observed on 3/10/10 at 11:30 a.m. sitting with other residents in the dining area during a music activity. The resident was approached by a Certified Nurse Assistant (CNA) who stated at a volume that was audible to this surveyor and other residents close by,"come, you are probably wet you are usually wet by this time." The CNA then wheeled the resident to her room.

An interview was conducted with the CNA at 11:45 a.m. on 3/10/10. She stated that the resident has to be toileted 3 times on her shift. She further stated that she took the resident to sit on the toilet for a possible bowel movement before lunch. The CNA also stated that she was not aware anyone had heard her speak to the resident.

415.5(a)

Based on observations, record reviews and staff interviews, the facility did not ensure that residents who had chosen to execute advance directives were properly identified. Specifically, that residents designated as DNR (Do Not Resuscitate) status were wearing the appropriate color coded identification bracelets. This was evident for 2 (two) of 30 (thirty) sampled residents (Resident #6, #18) and 3 (three) of 10 (ten) residents in the expanded sample (Resident #101, #102, #107).

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

The findings are:

1) Resident #6 is a 93 year old female with diagnoses which include Multiple Vascular Ulcers, Anemia and Congestive Heart Failure.

The Minimum Data Set (MDS) 2.0 Assessment dated 2/4/10 documented that the resident has moderate cognitive impairment, and extensive assistance of staff for transfers, dressing and personal hygiene. The MDS further documents "Do Not Resuscitate."

Physicians orders dated 2/25/10 documented "DNR-Do Not Resuscitate Order."

On 3/11/10 at 2 p.m., the resident was observed wearing a white beaded bracelet on the right wrist and a yellow metal bracelet on the left wrist. During the observation the resident was not wearing an identification bracelet to inform the staff of her name and/or her code status.

An interview was immediately conducted with the unit Certified Nurse Assistant (CNA) who stated that all the residents are supposed to wear identification bands, and that she didn't know what happened to the residents wristband.

The unit Licensed Practical Nurse (LPN) was interviewed on 3/11/10 at 2:30 p.m. The LPN stated that the residents who are designated as DNR status are supposed to be wearing a purple armband that also includes their name and room number. The LPN further stated that both identification measures were important and would ensure that the resident received the appropriate identification.

2) Resident #18 is a 94-year-old with diagnoses which include Dementia with Behaviors, Coronary Artery Disease, and Hypertension.

The Minimum Data Set 2.0 Assessment (MDS) dated 12/12/09 documented that the resident had long and short-term memory impairment and is moderately impaired in decision making. The MDS also documented that the resident displays verbally and physically abusive behaviors and resists care at times and is able to move with limited assistance of one person in the wheelchair on the unit. .

On 3/11/10 at 4:30 p.m., the resident was observed sitting in her wheelchair in the hallway in front of her room. She did not have her identification (ID) band on.

On 3/11/10, at 4:32 p.m., the Unit Coordinator located the resident's ID band on top of her dresser. He applied the band to her wrist.

The physician's monthly orders dated 3/3/10 documented that the resident has a Do Not Resuscitate (DNR) order.

The facility policy for ID bands, effective 10/1/08, documented that residents with a DNR order should have a purple band.

The Unit Coordinator was interviewed on 3/11/10 at 4:32 p.m. He stated that he would have another ID bracelet made for the resident's wheelchair as a back-up.

3) Resident #101 is a 100 year old female with diagnoses which include Dementia, Angina, and Chronic Kidney Disease.

The Minimum Data Set (MDS) 2.0 Assessment dated 2/16/10 documented that the resident has moderate cognitive impairment.

Physicians orders dated 2/17/10 documented "DNR"-Do Not Resuscitate Order.

On 3/11/10 at 5 p.m., the resident was observed sitting in a wheelchair in the hallway of her unit. The resident was not wearing an identification bracelet to inform the staff of her name and/or her code status.

The unit Licensed Practical Nurse (LPN) was immediately interviewed and stated that the resident's identification bracelet was on her walker per the residents preference of not wearing the bracelet on her arm. The LPN further stated that if the resident were to "code" while in the hallway the staff would go to her chart to determine her "code status." The LPN also added that she would obtain another identification bracelet from the unit manager right away and attach the new bracelet to the residents' wheelchair.

The unit Registered Nurse (RN) was interviewed on 3/11/10 at 5:15 p.m. The RN stated that the nurses are ultimately responsible for checking each residents identification band at least daily as part of the medication pass to ensure accurate identification. The RN further stated that once the resident is found to be without an armband, the unit manager is to be informed so that another appropriately color-coded armband can be made and provided to the resident.

4) Resident #102 has resided in the facility since 6/25/07 with diagnoses including Dementia, Pneumonia, and Seizure Disorder.

A Minimum Data Set (MDS) assessment dated 1/10/10 documented that the resident has short and long term memory problems and severely impaired decision making skills.

The resident was observed sitting in a wheelchair near the nurses station on 3/11/10 at 4:50 p.m. The resident was wearing a white ID (Identification) bracelet. She had been previously identified from a list to have a Do Not Resuscitate (DNR) order.

There was a "Medical Orders for Life Sustaining Treatment" (MOLST) form in the resident's record dated 8/19/09. The MOLST form documented that the resident was DNR.

The monthly physician's orders last updated 2/19/10 document "yes " in the area checked for DNR.

An interview was conducted with the Licensed Practical Nurse (LPN) on 3/11/10 at 4:45 p.m. She stated that residents who are DNR are identified by a purple band, the MOLST form and physician's orders. The LPN also stated that a list of residents who are DNR is kept at the nurses' station. She stated that any unresponsive resident wearing a white bracelet would be resuscitated.

A Certified Nursing Assistant (CNA) was interviewed on 3/11/10 at 4:57 p.m. and stated that the nurse informs the CNA during shift report which residents are DNR. The CNA further stated that any resident found unresponsive would to be called to the nurses' attention right away. The CNA was not able to state the color bracelet worn by residents who are DNR.

The Unit Coordinator was interviewed on 3/12/10 at 10:15 a.m. He stated that the physician's order and MOLST form information regarding DNR status is first reviewed by the nurse. The information is then communicated to the Unit Manager who updates the facesheet and makes a new bracelet. He further stated that in the case of this resident, there had been a communication error to explain why the resident's bracelet had not been updated.

5) Resident #107 is a 92 year old female with diagnoses which include Alzheimer's Disease, Senile Dementia, and Failure to Thrive.

The Minimum Data Set (MDS) 2.0 dated 1/4/10 documents short and long term memory problems and severe cognitive impairment.

On 3/12/10 at approximately 10:10 a.m., the resident was observed lying in bed without an identification arm band.

The monthly physician order for March 2010 documented: "Do Not Resuscitate (DNR)."

The Licensed Practical Nurse (LPN) was interviewed on 3/12/10 at 10:00 a.m. and stated that residents who are DNR are identified by a purple arm band and a MOLST form in the chart. She further stated that the arm bands are checked monthly and the unit manager is responsible for replacing the missing arm bands. The LPN also stated that there is a list of DNR residents but that she couldn't locate the list.

The LPN was interviewed immediately after observing the resident without a arm band and stated that this resident normally has a purple arm band. She further stated that she last saw a purple arm band on this resident approximately one and a half weeks ago.

The assigned Certified Nursing Assistant (CNA) was interviewed on 3/12/10 at approximately 10:20 a.m. and stated that she checks the resident's arm band every day and that if the arm band is missing she will tell the nurse and that the unit manager is responsible for replacing the arm bands. She further stated that the resident had her purple arm band on earlier when she fed her breakfast.

415.3(e)(2)(iii)

Based on record reviews and staff interviews, the facility did not ensure that services were provided by qualified persons in accordance with the residents written plans of care. Specifically, the nurses did not: 1) monitor the pulse oximetry readings/oxygen saturation of a resident on oxygen therapy, 2) administer the Glucerna supplement or ensure that labwork was done as per the Physicians order. This was evident for 4 of 30 sampled residents. (Residents #1, #2, #6 and #23)

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

1) Resident #1 has resided in the facility since 1/13/03 with diagnoses including Diabetes, Congestive Heart Failure, Arthritis, Cerebrovascular Accident and Neuropathy.

A Minimum Data Set (MDS) assessment dated 2/26/10 documented that the resident has short term memory problems and modified independence in decision making skills. The MDS also documented that the resident had been receiving Oxygen therapy.

The resident was observed in bed on 3/8/10 at 11:30 a.m. and on 3/9/10 at 2 p.m. There was an oxygen concentrator next to the resident's bed, with nasal canula tubing attached.

A physicians order dated 2/16/10 documented Oxygen at 2 liters per minute via nasal canula.

A care plan for Oxygen dated 2/18/10 documented an approach of "pulse ox (oximetry for oxygen saturation check) every shift."

A policy for oxygen therapy dated 6/2004 documented a requirement for the staff to "observe every 4 hours for impaired gas exchange...charted on medication administration record, care plan, nurses aide accountability record, and the 24 hour report."

Review of the resident's record revealed no documented evidence that the resident's pulse oximetry readings was measured every shift.

An interview was conducted with a Registered Nurse (RN) on 3/9/10 at 12:50 p.m. She stated that the results of oxygen saturation measurements are usually written in the resident's progress notes each shift when they are obtained.

2) Resident #2 has resided in the facility since 11/10 /08 with diagnoses including Hypothyroidism, Dementia, Diabetes, and Hypertension.

A Minimum Data Set (MDS) assessment dated 12/30/09 documented that the resident has short and long term memory problems and severely impaired decision making skills. The MDS also documents that the resident requires assistance of one person for eating.

The resident was observed on 3/8/10 at 7:20 a.m. during initial tour of the facility. Two cups of juice were observed on the table in front of the resident at approximately 8:20 a.m. The resident was not drinking and was not offered or assisted to drink the juice.

A second observation of the resident was done during the lunch meal on 3/8/10 at 12:37 p.m. The resident stated ("yo tengo nausea, ay ,ay, no quiero") in Spanish that she did not want to eat and stated she was nauseated. The CNA then removed the uneaten meal from the resident's table and placed in on the serving cart.

The Licensed Practical Nurse ( LPN) reheated the soup from the resident's tray and encouraged the resident to eat. Three to four teaspoons of the soup were consumed by the resident.

The resident's weight record documented the following:
During the week of 1/1/10 to 1/7/10 150 lbs
During the week of 2/1/10 to 2/7/10 146 lbs
During the week of 2/23/10 -2/29/10 141 lbs
On 3/10/10 the resident's weight was 133 lbs

This was a significant weight loss of over 8% in 1 month and over 11% in 2 months.

Nursing care plans for Hydration and nutrition were reviewed.
There was a care plan initiated on 12/30/09 for potential for dehydration. This care plan was updated on 2/24/10 with "poor PO (oral) intake identified as a problem.
Approaches included: Cater to food preferences within diet restrictions,provide assistance and encouragement at mealtimes, Glucerna 237 ml,chocolate flavored 3 per day.

There was no written evidence that the resident received Glucerna at 10 AM and 2 PM on 3/8, 3/9, and 3/10.

An interview was conducted with the Licensed Practical Nurse (LPN) on 3/10/10 at 4 p.m. She stated that the dietary supplements are documented on the resident's medication record (MAR). The LPN also stated that "daily care assignment sheet" which is the CNA documentation record should document that the resident is receiving supplements. There was no evidence on these documents that the supplement had been provided.

An interview was conducted with the resident's physician on 3/10/10 at 4:30 p.m. He stated that he was aware of the resident's weight loss but believed she had adequate protein stores. He stated that he checked the resident's albumin on 2/25/10 and believed the result to be 3.3. He further stated that he was aware that 3.3 was a little low but he will continue to observe the resident and give the supplements.

The physician was asked if he was aware that the supplements were not being given as ordered. He stated that he was not.

3) Resident #6 is a 93 year old female with diagnoses which include Multiple Vascular Ulcers, Anemia and Congestive Heart Failure.

The Minimum Data Set (MDS) 2.0 Assessment dated 2/4/10 documented that the resident has moderate cognitive impairment, and extensive assistance of staff for transfers, dressing and personal hygiene.

Physicians orders dated 2/25/10 documented to "check CMP(Comprehensive Metabolic Panel) on 3/9/10."

A review of the residents medical record revealed no documented evidence that the lab work had been done.

An interview was conducted with the unit Licensed Practical Nurse (LPN) on 3/11/10 at 11:50 a.m. The LPN stated that the Physician writes the order, fills out the lab slip and leaves both documents flagged on the residents chart for the nurse. The nurse is then responsible for noting the order and entering the residents room number, name, if "MD order indicates SMO (slip made out), test ordered and date specimen to be collected on the "Laboratory Requisition Tracking Log."

The LPN further stated that she was unable to explain why the resident's bloodwork had not been done as ordered.

An interview was conducted with the unit Physician on 3/11/10 at 12 noon. The Physician stated that she was not aware that the resident's lab work had not been done and had been awaiting the results.

At 3/11/10 at 3:30 p.m., the Nurse Practitioner (NP) informed the SA (State Agency) that the lab had been called and had no record that the blood had been drawn. The NP further stated that the residents blood would be drawn today (3/11/10).

415.11(c)(3)(ii)

4)
Resident #23 is a 68-year-old whose diagnoses include status post Right Femur Removal of Hardware 2/17/10, Osteoarthritis, Anxiety, and Depression.

The Minimum Data Set 2.0 Assessment (MDS) dated 3/5/10 documented that the resident is independent in decision making.

A progress note from the Nurse Practitioner (NP) dated 2/22/10 documented that the resident had watery diarrhea from the hospitalization with no fever and mild abdominal cramping.

An Interim Physician's Order dated 2/22/10 documented laboratory orders for a Complete Blood Count, Complete Metabolic Panel, and Thyroid Stimulating Hormone levels to be completed on 2/23/10.

The Laboratory Requisition Tracking Log dated 2/23/10 did have the resident's name written on it. There was no initial by the lab technician to document that a specimen was collected.

The lab slip dated 2/23/10 for the ordered labs was still in the laboratory book.

There was no documented evidence in the medical record that the labwork was done.

The NP was interviewed on 3/12/10 at 6:27 pm. The NP stated that she contacted the lab and they did not have any results for the bloodwork, and she will re-order the labs to make sure everything is okay.

The Physician (MD) was interviewed on 3/12/10 at 6:32 pm. The MD stated that all labs are reviewed by the NP and MD together. The MD said he was not aware that the lab was not done. The MD further stated that it was an oversight that they did not follow-up to see if the lab was done.

415.11(c)(3)(ii)

Based on observations, record reviews and staff interviews, the facility did not ensure that services provided met professional standards of care. This was evidenced by: 1) The licensed nurse did not verify the accuracy of the treatment that was ordered to the inappropriate site of the body; 2.) The licensed nurse did not clarify the physician's order for the skin condition treatment that was already healed; 3.) The licensed nurse did not monitor the bruit and thrill of a resident with hemodialysis access site to the left upper arm; 4.) The nurse did not follow the procedure in medication administration by signing the Medication Administration Record (MAR) prior to giving the medication to the resident. This is evidenced for 4 out of 38 sampled residents. (Resident # 6, #9, #25, and # 37)

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

The findings include but are not limited to:

1) Resident #6 is a 93 year old female with diagnoses which include Multiple Vascular Ulcers, Anemia, and Congestive Heart Failure.

The Minimum Data Set (MDS) 2.0 Assessment dated 2/4/10 documented that the resident has moderate cognitive impairment, and required extensive assistance of staff for transfers, dressing and personal hygiene.

The physician's orders dated 2/25/10 documented "cleanse right and left feet dorsal (top of feet) pressure ulcers with Normal Saline Solution, apply Bacitracin and cushion dressing daily."

During wound care observations on 3/10/10 between 10:05 a.m.-11:30 a.m. the Licensed Practical Nurse (LPN) removed the kling and the old dressings from the residents right and left feet.

On 3/11/10 during the wound care observations, the SA (State Agency) observed the dorsal aspects of the residents right and left feet to have clean, pink, fully granulated skin. The LPN was not observed providing treatment to the dorsal aspects of the resident's feet.

The LPN was interviewed on 3/10/10 at 12 noon. The LPN stated that she didn't provide the treatment to the dorsal aspects of the resident's feet because the areas were healed.

The Registered Nurse Supervisor (RNS) was interviewed on 3/10/10 at 12:10 a.m. The RN stated that the nurses should have notified the Physician when they noted that the ulcers had healed, so that the Physician could re-evaluate the resident and change or discontinue the treatment.

2) Resident #9 is an 82-year-old whose diagnoses include Senile Dementia, Cerebrovascular Accident (CVA) with Left Hemiparesis, and Atrial Fibrillation.

The Minimum Data Set 2.0 Assessment (MDS) dated 12/18/09 documented that the resident has long and short-term memory impairment and moderately impaired cognition. The MDS also documented that the resident did not ambulate and required total assistance of one person for wheelchair locomotion.

The physician's orders dated 1/11/10, 2/8/10, and 3/8/10 documented the following treatment order: "Thermazene 1% Cream-Apply to affected area twice daily."

The treatment sheets dated 1/11/10 - 2/11/10, 2/8/10 - 3/8/10, and 3/8/10 - 4/8/10 documented that the treatment was not given. "D/c'd (discontinued) 12/17/09" was written on the treatment sheet next to the Thermazene 1% Cream.

The physician (MD) was interviewed on 3/10/10 at 3:30 p.m. about the order for Thermazene 1% Cream. When asked if the Thermazene 1% Cream was supposed to be discontinued, the MD stated that he would like the cream applied to the buttocks and sacral areas to prevent breakdown. The MD said he did want the Thermazene 1% Cream applied as ordered.

The Registered Nurse (RN) who reviewed and signed the physician's orders dated 3/8/10 and 2/8/10 was interviewed on 3/10/10 at 4:00 p.m. The RN reported that she reviewed the orders and wrote "D/c'd 12/17/09" on the treatment sheet. The RN stated that she had put notes in the MD's communication box so that he could clarify or discontinue the Thermazene 1% Cream order. When asked why she did not call the physician to clarify the order, the RN stated that the MD does not like the evening nurses to contact him and has told her to let the day shift nurses communicate with him when she has called him in the past.

The Assistant Director of Nursing (ADON) was interviewed on 3/10/10 at 4:45 p.m. The ADON stated that the nurse should have clarified the treatment orders. The ADON further stated that Thermazene 1% Cream is not usually used for prophylaxis, but the order should have been clarified with the MD so it could be discontinued or followed. The ADON reported that she informed the medical director and he will discontinue the Thermazene and order periguard.

3.)Resident #25 is an 88 year old male with diagnoses which include End Stage Renal Disease, Hypertension, and Congestive Heart Failure.

The Minimum Data Set (MDS) 2.0 Assessment dated 1/20/10 documented that the resident has modified independence in decision making.

The physician's orders dated 2/3/10 and 3/4/10 documented "Hemodialysis-Schedule & Care Orders" ...AV (Arterio-Venous) Access...LUE (Left Upper Extremity)...Three times a week."

Comprehensive Care Plans dated 10/21/09 (and 1/17/10) documented:
1) Problem: Complications from Hemodialysis r/t (related to) ...Potential AV shunt infection;
2)Goal: Resident will no experience complications related to dialysis...AV shunt free from infection;
3)Interventions: Assess and monitor for s/s (signs and symptoms) of complications...Observe for: Infection, Leakage, Coolness, Redness, Skin discoloration, Swelling..."

A review of the medical record from 10/23/09 through 3/12/10, revealed no documented evidence that the resident's left upper arm dialysis access site had been monitored for bruit and thrill.

An interview was conducted with the unit Physician on 3/12/10 at 5 p.m. the Physician stated she monitors the residents dialysis access site on a monthly basis. The Physician further stated that the nurses in the dialysis center monitor the resident's site three times per week and that she was not aware that the nurses in the facility needed to monitor the residents access site.

An interview was conducted with the unit Licensed Practical Nurse (LPN) on 3/12/10 at 5:15 p.m. The LPN stated that the resident's access site is checked for bleeding when he returns from dialysis. The LPN further stated that the nurses do not check the residents' hemodialysis access site for bruit and thrill.

An interview was conducted with the unit Registered Nurse Supervisor (RNS) on 3/12/10 at 5:40 p.m. The RNS stated that monitoring the residents bruit and thrill should be standard nursing practice. The RNS further stated that the nurses were using the old forms to document the residents pre/post hemodialysis care and should be using the revised pre/post hemodialysis care forms "in use for a year," to document the residents bruit and thrill.

4) Resident #37 is an alert and oriented male resident with diagnoses which include: Hypertension, and Hyperlipidemia.

Review of the current medical record documented that the resident's short and long term memory problem is intact and independent in decision making skills.

On 3/9/10 at 9:55 a.m. during the medication pass the Licensed Practical Nurse (LPN) was observed signing the Medication Administration Record (MAR) prior to medication administration.

On 3/10/10 at 11:00 a.m., the LPN was interviewed and stated that she usually signs after giving the medications, and could not offer an explanation why she pre-signed the MAR at that time.nene On 3/10/10 at 12:00 Noon, the Clinical Coordinator was interviewed and stated that the LPN was supposed to administer the medication first before signing the MAR.

415.11(c)(3)(i)

REPEAT DEFICIENCY

Based on observation and staff interview, it was determined that the facility did not ensure that food was stored, prepared, distributed and served under sanitary conditions. Reference is made to:
1) Mechanical exhaust grills that were encrusted with dust.
2) Undated canned foods.
3) Dented canned food items that were not separated from regular storage.

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

The findings are:

During the annual survey conducted on 3/08/10 between 8:4am and 11:00am, the following was noted:
1) The mechanical exhaust vents were heavily encrusted with dust. This was observed in locations which include by the food (raw meat and vegetable) prep sink, the tray line section and the clean storage room.
In an interview with the Director of Food and Nutrition on the same day at approximately 9:15am, he stated that they have facility staffs that clean the vents and that there is a schedule maintained for cleaning the mechanical exhaust vents in the kitchen.

2) Canned food items stored in the daily usage shelves were not dated. Examples of the canned food items noted were fancy shredded Sauerkraut, Chick peas, Chocolate pudding and Tropical fruit Salad (a minimum of 3 cans of each item was noted and examples are not all inclusive).
In an interview with the Director of Food and Nutrition on 03/08/10 at approximately 9:20am, he stated that he will instruct kitchen staff to date the canned food items immediately.

3) Dented canned food items (3 cans) were observed stored on the daily use food storage shelves and not in the location that the facility had designated for the storage of dented food cans.
In an interview with the Director of Food and Nutrition on the same day at approximately 9:25am, he stated that he will instruct the kitchen staff to inspect the daily use food storage shelves and remove any dented can found.

415.14(h)

Based on observations, record reviews and interviews, the facility did not ensure that the residents' needs were accommodated. Specifically, the facility did not: 1) provide a resident with clothes that fit, 2) place the resident's call bell within reach, and 3) change the date on the reality orientation calender to reflect the current date. This was evident for 2 of 30 sampled residents and 1 of 16 resident units. (Resident#19, #20, and Frank 2 unit)

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

The findings are but not limited to:

1) Resident #19 is a 74 year old female admitted to the facility on 12/21/09 with diagnoses which include Anemia, Schizo-affective, and History of Falls.

The Minimum Data Set (MDS) 2.0 dated 1/27/10 documented that the resident has short and long term memory problems and modified independence in decision making skills.

The resident was observed on 3/8/10 at 10:00 a.m. during initial tour, on 3/8/10 at 12:30 p.m. during meal observation and on 3/11/10 at approximately 2:00 p.m. wearing a hospital gown and socks in the hallway.

The resident's closet was observed on 3/8/10 at 10:15 a.m. and contained 3 pairs of pants, 4 blouses, 1 dress, 1 winter coat, 1 pants set, 1 pair of shoes, and 1 pair of slippers. All clothing items were in garment bags and neatly stored.

On 3/8/10 at approximately 10:20 a.m., the resident was interviewed and stated that none of her clothes fit and that they need to be altered because she had lost some weight.

On 3/8/10 at 10:25 a.m., the Certified Nurses Assistant (CNA) was interviewed and stated that the resident has no clothes that fit her properly.

On 3/11/10 at 3:15 p.m., the Social Worker was interviewed and stated that she just found out that the resident's clothes are too big.

On 3/11/10 at 3:30 p.m., the Registered Nurse (RN) was interviewed and stated that the resident came in with clothes but wouldn't let the facility take them to label. She further stated that they didn't want to upset the resident so that they have been working on making her feel more comfortable before trying to get her something to wear.

2)Resident #20 is a 77 year old female with diagnoses which include Multiple Sclerosis (MS), Alzheimer's Disease, and Major Depressive Disorder.

The Minimum Data Set (MDS) 2.0 dated 1/17/10 documented that the resident has short and long term memory problems and modified independence in decision making skills. The MDS also documents no limitation or loss of movement in resident's hands.

The resident was observed on 3/8/10 at 10:30 a.m. during initial tour, lying in bed with the call bell wire behind the head of the bed and call bell on the floor.

The Licensed Practical Nurse (LPN) was immediately interviewed and stated that the call bell should be within resident's reach and that the Certified Nursing Assistants (CNA) should check the call bells when they do rounds and after care. She further stated that the CNAs should check the call bells to ensure that the they are within the resident's reach.

The CNA was interviewed on 3/8/10 at approximately 11:30 a.m. and stated that she checks the call bells when she comes on duty and then again after giving care. She further stated that she checks the call bells anytime she puts a resident in a chair or bed.

415.5(e)(1)

Based on observation, record review and staff interview, the facility did not ensure that a resident's clinical record was accurately documented. This was evident for 1 of 30 sampled residents (# 10).

The finding is:

Resident #10 has resided in the facility since 2/12/2004 with diagnoses including Cerebrovascular accident (CVA), Diabetes, Dementia, and Dehydration.

Minimum Data Set (MDS) assessment dated 1/19/10 documented that the resident has short and long term memory problems and is severely impaired in decision making. The MDS also documents that the resident has limitation in range of motion and is fully dependent on staff for activities of daily living.

The resident was observed in bed on 3/11/10 at 2:50 p.m. She was receiving IV (intravenous) fluid of D5 0.2 nacl (Sodium Chloride) with 20 meq (milliequivalents) pottassium/litre. The infusion was controlled by Dial -A Flow device at 70 milliliters (ml) per hour via the left hand. The resident's left arm was resting on the bed with grossly swollen fingers, palm and entire forearm. The Resident Assessment Utilization Management (RAUM) registered nurse (RN) was asked to assess the resident's arm. The RN removed the tape from the IV site to inspect the resident's hand. During the RN's handling of the arm, the resident was grimacing and moaning. The resident was also asked by the RN to move her fingers. She (resident) did not do so. The IV infusion was stopped by the nurse who called the condition of the resident's arm to the attention of the physician who was present on the unit. The physician instructed the nurse not to discontinue the IV site as the resident was "a difficult stick" and the IV was possibly salvageable. The physician then examined the resident's arm and tried to reposition the IV canula. During the manipulation of the IV site the resident was observed grimacing and heard moaning. The IV was then discontinued by the physician and relocated to the resident's left foot.

The resident's record was reviewed with the following documentation noted:

Physician's orders dated 3/5/10 and 3/11/10 for: IV fluids of Dextrose 5% with normal saline 0.2 %with Potassium additive of 20 milliequivalents (MEQ) per liter at 70 ML per hour.

A nursing readmission note dated 3/11/10 at 5:10 a.m. which documented no skin abnormalities except for a sacral decubitus.

A physician's return from hospital" note dated 3/11/0 at 7:10 a.m. documented "no edema, no joint swelling."

A physician's "admission follow up" note dated 3/11/10, (untimed) documented "+ (positive) mild edema L (left) forearm."

The physician's "admission follow up " note dated 3/11/10 was again reviewed on 3/12/10. There was additional documentation to "elevate L (left) UE (upper extremity)."

There was a nursing note dated 3/11/10 4:05 p.m. (late entry). A 10 a.m. entry documented "...infusing and dripping well ... Seen and examined by Dr " and a 3 p.m. entry that documented "stopped by RN for infiltration."
There was no documentation regarding the status of the resident's IV site at any time.

An interview was conducted with the physician on 3/11/10 at 3 p.m. She stated that the resident's arm was slightly swollen when she first saw her that day but that the arm was "definitely much more swollen now."

The Licensed Practical Nurse (LPN) assigned to the resident was interviewed on 3/11/10 at approximately 3:05 p.m. She stated that she has had IV training and was the person who hung the bag of fluids for the resident at 10 a.m. She also stated that the resident's arm "did not look like that" referring to the swollen arm, when the fluid was hung.

415.22(a)(1-4)

Based on record review and staff interviews, the facility did not ensure that the comprehensive care plan was reviewed and revised with new interventions after a resident had a fall. This was evident for 1 out of 30 sampled residents (Resident #9).

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

The finding is:

Resident #9 is an 82 year-old whose diagnoses include Senile Dementia, Cerebrovascular Accident (CVA) with Left Hemiparesis, and Osteoporosis.

The Minimum Data Set 2.0 Assessment (MDS) dated 12/18/09 documented that the resident has long and short-term memory impairment and moderately impaired cognition. The MDS also documented that the resident did not ambulate and required total assistance of one person for wheelchair locomotion.

The Nursing Admission Assessment dated 11/11/09 documented an incomplete Falls Risk Assessment.

The Comprehensive Care Plan (CCP) for falls was implemented 11/11/09. It documented that the resident had a potential high risk for fall due to cognitive impairment, diagnosis of Cerebrovascular Accident (CVA) with Left Hemiparesis, impaired balance, and history of falls. The initial interventions were to anticipate activities of daily living (ADL) needs, place call bell in reach, low bed, refer to physical therapy (PT), and refer to occupational therapy (OT).

A progress note written by the Nurse Practitioner (NP) on 12/11/09 documented that the resident fell and had been found on the floor between the wheelchair footrests. The note further documented that the resident stated that she was trying to get into bed. Interventions mentioned in the NP note were bed and chair alarms and monitor vital sings every 4 hours for 24 hours then every shift for 48 hours. The resident was transferred to the hospital for x-rays at the request of her family.

The CCP for falls was updated on 12/11/09 to document the fact that the resident fell. A new goal that the resident would be free of falls with serious injury in 3 weeks was added. No new interventions were added to the CCP.

An Accident/Incident Report dated 12/11/09 documented the corrective action taken as adding the resident to the Fall Performance Improvement (PI) for ongoing monitoring and refer to OT/PT as previously ordered and continue therapy.

The progress notes on 12/15/09 documented that the resident returned to the facility on 12/15/09 with no fracture diagnosed.

An Interim Physician's Order Form dated 12/21/09 documented transfer orders written by the Nurse Practitioner (NP). The orders documented bed and chair alarms and fall precautions.

The Resident/Patient Review dated 1/12/10 documented an incomplete falls review.

A Registered Nurse (RN) was interviewed on 3/10/10 at 5:00 p.m. The RN stated that the Resident #9 has never had bed or chair alarms since transferring to her unit on 12/21/09.

The NP was interviewed on 3/11/10 at 1:14 p.m. The NP stated that when the resident fell on 12/11/09, she decided to order a bed and chair alarm. She did not add any interventions to the CCP because that is to be done by nursing. The NP stated that on the resident's previous unit they were doing a pilot project to reduce falls, and it was up to the new unit to determine if the resident was still a fall risk after an adjustment period.

The Registered Nurse Supervisor (RNS) was interviewed on 3/11/10 at 2:35 p.m. The RNS stated that the resident was put on the Fall PI which means the resident is offered to be toileted before and after meals and at the end of each shift. The RNS further stated that the Certified Nursing Aides are trained to be more encouraging when trying to toilet the residents. The RNS stated that she would not have recommended a chair or bed alarm for the resident because she has Dementia. The RNS said that there is no documentation in the resident's CCP or medical record about the Fall PI interventions because it was a pilot program. The RNS further stated that the Fall PI interventions would not have continued after transfer because the Fall PI was a project on one unit. The RNS stated that they will consider documenting interventions for the Fall PI project in the future.

Based on observations, record review and staff interviews, the facility did not ensure that 1) infection control procedures were adhered to during dressing change, 2) equipment and linens were handled in a manner to reduce the spread of infection. This was evident for one (1) of thirty (30) sampled residents. (Residents #6) and on 1 of 16 units (Frank 5)

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

The findings are:

1) Resident #6 is a 93 year old female with diagnoses which include Multiple Vascular Ulcers, Anemia and Congestive Heart Failure.

The Minimum Data Set (MDS) 2.0 Assessment dated 2/4/10 documented that the resident has moderate cognitive impairment, and extensive assistance of staff for transfers, dressing and personal hygiene.

The physician's orders dated 2/25/10 documented "cleanse right and left heel pressure ulcers with Normal Saline Solution, apply dry sterile dressing and kling daily."

During a wound care observation on 3/10/10 at 10:05 a.m. the unit Licensed Practical Nurse (LPN) removed the kling and old dressing from the residents left foot. The LPN did not remove her gloves and wash her hands, and proceeded to cleanse the resident's left foot with normal saline. The LPN was immediately interviewed and stated that she should have stopped and washed her hands after removing the old dressings before proceeding with cleansing the area.

An interview was conducted with the Registered Nurse Supervisor (RNS) on 3/10/10 at 11:30 a.m. The RNS stated that the nurse should have known to wash her hands after removing the old dressings because the LPN had recently been inserviced on wound care. The RN further stated the LPN clearly needed and would be re-inserviced on wound care.

2) During an initial tour of the facility's Frank 5 unit on 3/8/10 at 11 a.m. the following was observed:

There was a laryngoscope locked inside the outer narcotic cabinet on top of the inner cabinet. There was a large amount of dry, yellow and brown material encrusted on the blade of the laryngoscope.

The Licensed Practical Nurse (LPN) who accompanied during the tour was also identified as the facility's infection control nurse. She was immediately interviewed and stated that she did not know what that was (laryngoscope) or where it should have been kept.

An interview was conducted with the unit coordinator on 3/8/10 at 11:30 a.m. She stated that any equipment needed for an emergency was kept on the code cart on the 4th floor and that she was not sure why the dirty laryngoscope had been left in the medication cabinet.

3) During an initial tour of the facility's Frank 5 shower room on 3/8/10 at 10:35 a.m., a cart with clean linen was observed in front of the toilet located there. A resident entered the shower room to use the toilet. She attempted to push the cart away and stated "I want to go really bad." The cart was pushed closer to the tub area by the unit coordinator who accompanied on the tour.

An interview was immediately conducted with the unit coordinator who stated that the CNA always kept the cart with extra linen in the bathroom to keep it out of the way.

415.19(a)(1-3)

Based on observation, record reviews and staff interviews, the facility did not ensure that the residents' environment remained free of accident hazards as evidenced by: an unlocked porter's closet with cleaning agents, disposable razors, a linen cart obstructing access into the residents' bathroom, and unsupervised medication cart. This was noted for 4 of 16 units (Friedman 2 and 5, Frank 2 and 5), and 1 of 30 sampled #22, One out of sample resident #38.

This resulted in no actual harm with potential for more than minimal harm for Residents #22 and #38 that is not immediate jeopardy.

The findings are:

1) Resident #22 has resided in the facility since 10/2/06 with diagnoses including Dementia,and Hypertension.

A Minimum Data Set (MDS) assessment dated 2/16/10 documented that the resident has short and long term memory problems and moderately impaired decision making skills. The MDS also documents that the resident is occasionally incontinent and requires assistance of one person for toileting.

The resident's record also documents that she sustained a fall in her room on 4/8/10.

A nursing care plan for falls updated on 2/18/10 documents an approach to "keep environment clutter free."

The resident was observed during initial tour on 3/8/10 at 10:35 a.m. She entered the shower room to use the toilet located there. There was a cart with clean linen on it obstructing the resident's access to the toilet. The resident attempted to push the cart away and stated "I want to go really bad." The cart was removed by the unit coordinator who accompanied on the tour.

An interview was immediately conducted with the unit coordinator who stated that the CNA always kept the cart in the bathroom to keep it out of the way.

The resident was again observed on 3/12/10 at 5:30 p.m. She entered the shower room to use the toilet.

An interview was immediately conducted with a CNA. The CNA stated that the resident always goes to the toilet unassisted and likes using the toilet in the shower room whenever she is up and about.

2) Resident #38 is a 78-year-old whose diagnoses include Dementia, Anxiety, and Schizophrenia with Mild Tardive Dyskinesia.

The Minimum Data Set 2.0 Assessment (MDS) dated 1/13/10 documented that the resident has short-term memory impairment and modified independence in decision-making. Resident #38 requires supervision with set-up for locomotion on the unit.

The Comprehensive Care Plan dated 7/21/09 documented that the resident is at risk for unsafe wandering/elopement evidenced by verbalized intent to leave the facility, impaired cognition/judgment, and attempts to leave the unit.

On 3/11/10, at 4:48 p.m., the resident was observed on his unit standing by an unattended medication cart. The resident was pulling on the cart shelf where a glucometer kit was placed. The surveyor noticed and the resident was redirected by the Licensed Practical Nurse (LPN 1) that was assisting the surveyor. The medication cart had the following items on top of it: 1 open bottle of Calcium and Vitamin D tabs, 1 open bottle of Senna, 1 open bottle of Pro-Stat 101, 3 Insulin vials in a cup.

On 3/11/10 at 4:50 p.m., LPN 1 was interviewed. LPN 1 said that the nurse who was using the medication cart was in the bathroom. LPN 1 pointed out that the medication cart was locked.

On 3/11/10 at 4:51 p.m., the Licensed Practical Nurse (LPN 2) that was using the medication cart was interviewed. LPN 2 stated that she went to the bathroom and locked the cart before she went. The surveyor pointed out all the medications left on top.

On 3/12/10 the Community Coordinator/Registered Nurse (CC-RN) in charge of the unit was interviewed at 8:56 p.m. The CC-RN stated that there is a potential for injury if the medication cart has items left on top, and medications carts should be locked with no items left on top when unattended. The CC-RN further stated that the resident is probably more confused in the evenings. The CC-RN said she would review the tapes and speak to LPN 2 if teaching or disciplinary action is needed.

3) Observation of Frank 5 on 3/10/10 at 9:55 a.m., the following was noted:

The door to the porter's closet was observed ajar. There were several containers of cleaning supplies on a shelf inside. These included: 2 cans of scouring powder with bleach, 1 bottle of spray glass cleaner, 2 full cans of spray stainless steel polish and a full can of spray furniture cleaner. These had warning labels attached of "irritant to eyes, skin and mucous membranes."

Unit Frank 5's population was identified during initial tour as including 27 residents with cognitive impairment, 4 of whom were ambulatory and prone to wandering.

The porter's closet remained open until brought to the attention of the floor's housekeeper at 10:05 a.m. during an interview. She stated that she opened the closet to remove paper towels and forgot to close it. She further stated that the closet should have been kept locked.

4) On 3/8/10 at 6:40 a.m. on Friedman 2 during the initial tour the residents' shower room was observed with a disposable scissors hanging on a hook on the wall.

The Registered Nurse (RN) Clinical Coordinator was interviewed immediately and stated that the disposable scissors should have been disposed in the sharps container.

5) During the initial tour of the Freidman 5 on 3/8/10 from approximately 8:30 a.m. until 9:20 a.m., 2 disposable razors were observed in the medicine cabinet in room 527 where 2 residents reside and 1 disposable razor was observed in the medicine cabinet in room 529 where 2 residents reside.

The Assistant Director of Nursing (ADON) who assisted with the tour was interviewed on 3/8/10 at approximately 8:35 a.m. and stated that Friedman 5 is a Dementia unit and there are 7 residents who wander on the unit, 3 of whom are ambulatory. The ADON stated that the disposable razors do not belong in the residents' rooms.

415.12(h)

Based on observations, record review, and staff interviews, the facility did not ensure that the resident was provided with medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, a resident admitted to the facility with clothes that did not fit properly and had to wear a hospital gown. This was evident for one (1) of thirty (30) sampled residents. (Resident #19)

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

The finding is:

1) Resident #19 is a 74 year old female admitted to the facility on 12/21/09 with diagnoses which include Anemia, Schizo-affective, and History of (H/O) Falls.

The Minimum Data Set (MDS) 2.0 dated 1/27/10 documented that the resident has short and long term memory problems and modified independence in decision making skills.

The resident was observed on 3/8/10 at 10:00 a.m. during initial tour, on 3/8/10 at 12:30 p.m. during meal observation, and on 3/11/10 at approximately 2:00 p.m. wearing a hospital gown and socks in the hallway.

The resident's closet was observed on 3/8/10 at 10:15 a.m. and contained 3 pairs of pants, 4 blouses, 1 dress, 1 winter coat, 1 pants set, 1 pair of shoes and 1 pair of slippers. All clothing items were in garment bags and neatly stored.

On 3/8/10 at approximately 10:20 a.m., the resident was interviewed and stated that none of her clothes fit and that they need to be altered because she had lost some weight.

On 3/8/10 at 10:25 a.m., the Certified Nurses Assistant (CNA) was interviewed and stated that the resident has no clothes that fit her properly.

On 3/11/10 at 3:15 p.m., the Social Worker was interviewed and stated that the resident came in with clothes but they are too big and that the seamstress comes once a week to alter any resident's clothes. The Social Worker also stated that she found out just last week that the resident's clothes were too big.

On 3/11/10 at 3:30 p.m., the Registered Nurse (RN) was interviewed and stated that the resident came in with clothes but wouldn't let the facility take them to label. She further stated that they didn't want to upset the resident so that they have been working on making her feel more comfortable before trying to get her something to wear.

415.5(g)(l)(i-xv)

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 expired medications were discarded. This was evident for one (1) of sixteen (16) units toured. (Unit Frank 2)

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

The finding is:

1) On 3/8/10, at 8:20 a.m., during the initial tour in the Frank 2 medication room, the medication refrigerator was observed to have an open vial of Lantus dated 2/1/10 which was 7 days expired and was not discarded.

The Registered Nurse (RN) was immediately interviewed and stated that the expired vial of Lantus should have been discarded.

Based on observations, record reviews and staff interviews, the facility did not ensure that the physician reviewed the residents total program of care. Specifically, that the physician's orders accurately reflected the part of the resident's body requiring treatment. This was evident in 1 of 30 sampled residents. (Resident #6)

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

The findings is:

Resident #6 is a 93 year old female with diagnoses which include Multiple Vascular Ulcers, Anemia and Congestive Heart Failure.

The Minimum Data Set (MDS) 2.0 Assessment dated 2/4/10 documented that the resident has moderate cognitive impairment, and extensive assistance of staff for transfers, dressing and personal hygiene.

The physician's orders dated 2/25/10 documented cleanse right and left feet dorsal (top of feet) pressure ulcers with Normal Saline Solution, apply Bacitracin and cushion dressing daily.

During wound care observations on 3/10/10 between 10:05 a.m-11:30 a.m, the unit Licensed Practical Nurse (LPN) removed the kling and the old dressings from the residents right and left feet.

During the wound care observation, the residents right and left feet dorsal areas were observed by the SA (State Agency) to have clean, pink, fully granulated skin. The LPN was not observed providing treatment to the dorsal aspects of the residents feet.

The LPN was interviewed on 3/10/10 at 12 noon. The LPN (Licensed Practical Nurse) stated that she didn't provide the treatment to the dorsal aspects of the residents' feet because the areas were healed.

The unit Physician was interviewed on 3/10/10 at 12:05 p.m. The Physician stated that she meant for the treatment to be applied to the soles of the residents feet and that she "made a mistake," and would "change the order now."The Physician further stated that she would also discontinue the treatments to the dorsal aspects of the residents feet since those areas were healed.

415.(h)(2)(iii)

Based on record review, and staff interviews, the facility did not ensure that the nurse aide demonstrated competency in skills and techniques necessary to care for the resident's needs. Specifically, the Certified Nurse Assistant (CNA) did not utilize "two person assist" while transferring the resident from the bed to the chair, or from the wheelchair to the toilet according to the plan of care. This was evident for one (1) of thirty (30) sampled residents. (Resident #6)

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

Resident # 6 is a 93 year old female with diagnoses which include Multiple Vascular Ulcers, Anemia and Congestive Heart Failure.

The Minimum Data Set (MDS) 2.0 Assessment dated 2/4/10 documented that the resident has moderate cognitive impairment, and required extensive assistance of two staff for transfers.

On 3/10/10 at 10:45 a.m. the unit CNA assigned to care for the resident was observed transferring the resident from the bed to her wheelchair and then onto the toilet. The CNA then transferred the resident from the toilet to her wheelchair and then back to bed without the assistance of another staff member.

The Comprehensive Care Plan for "Activities of Daily Living (ADL)" dated 1/26/10,documented "ADL deficit related to: upper and lower extremity weakness..."
Interventions: "transfer...self performance-extensive assistance, support-two + (plus) persons physical assist..."

A review of the "Resident 24 Hour Daily Care Assignment Sheet" for March 2010 documented "support provided" for transfers as "3" for "two person-physical assistance."

An interview was conducted with the unit Certified Nurse Assistant (CNA) assigned to care for the resident on 3/10/10 at 11:00 a.m. The CNA stated that sometimes the resident needs two people to transfer and sometimes she needs one person.

An interview was conducted with the unit Registered Nurse on 3/10/10 at 11:45 a.m. The RN stated that the CNA should follow the residents written plan of care as it is documented on the resident's daily care assignment sheet. The RN further stated that the residents ability to participate in transfer activity may fluctuate from day to day and she would update the care plan and CNA assignment sheet with this information and inservice the CNA's accordingly.

415.26(c)(l)(iv)

Based on observation, record review and staff interviews, the facility staff did not provide proper care for a resident receiving intravenous (IV) fluids. This was evidenced for one (1) of thirty (30) sampled residents. (Resident #10)

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

The finding is:

Resident #10 has resided in the facility since 2/12/2004 with diagnoses including Cerebrovascular accident (CVA), Diabetes, Dementia, and Dehydration.

The Minimum Data Set (MDS)2.0 assessment dated 1/19/10 documented that the resident has short and long term memory problems and is severely impaired in decision making. The MDS also documented that the resident has limitation in range of motion and is dependent on staff for all activities of daily living.

The resident was observed in bed on 3/8/10 at 11 a.m. There was an IV (intravenous) of D5 (Dextrose) 0.2 Nacl (Sodium chloride) with 20 meq(milliequivalent) potassium/liter via the resident's left hand. The infusion was controlled by Dial-A Flow device at 70 milliliters (ml) per hour. There was no swelling to the hand or arm.

The "Admission Follow Up Note/Return From Hospital" dated 3/11/10, untimed, documented that the resident was readmitted from hospital for persistent fever/UTI not responding to antibiotic. The resident had possible pyelonephritis on CT (computerized tomography). The record further documented that the resident had positive mild edema of left forearm, elevate left upper extremities. Diagnoses included fever/possibly pyelonephritis, Electrolyte imbalance, hypertension, Diabetes mellitus, status post cerebrovascular accident.

Review of the nurses' note by Registered Nurse (RN) dated 3/11/10 documented that the resident returned to the nursing home at 5:10 a.m. from the hospital.

The physician's progress note dated 3/11/10, at 9:30 a.m., documented the resident returned from the hospital for high fever felt to be secondary to acute pyelonephritis. The resident was assessed to be noncommunicative, lungs clear, abdomen soft, no edema and others.

Review of the physician's order dated 3/11/10 documented, "IV fluid D5W
.2 NS + 20 meq/lit KCL (potassium chloride) to run at 70 cc/hr, and start Azactan 1 Gm (gram) q (every) 24 h (hours) q d (every day) via 50 cc IV piggy back to run over 30 minutes."

On 3/11/10, at 2:50 p.m., the resident was observed in bed. She was receiving IV fluid of D5 0.2 NaCl with 20 meq potassium/liter. The infusion was controlled by Dial-A Flow device at 70 milliliters (ml) per hour via the left hand. The resident's left arm was resting on the bed with grossly swollen fingers, palm and entire forearm. The Resident Assessment Utilization Management (RAUM) Registered Nurse (RN) was asked to assess the resident's arm. The RN removed the tape from the IV site to inspect the resident's hand. During the RN's handling of the arm, the resident was grimacing and moaning. The resident was also asked by the RN to move her fingers. She did not do so. The IV infusion was stopped by the nurse who called the condition of the resident's arm to the attention of the physician who was present on the unit. The physician instructed the nurse not to discontinue the IV site as the resident was "a difficult stick" and the IV was possibly salvageable. The physician then examined the resident's arm and tried to reposition the IV canula. During the manipulation of the IV site the resident was observed grimacing and heard moaning. The IV was then discontinued by the physician and relocated to the resident's left foot.

The physician's progress note dated 3/11/10 at 3:25 p.m. documented, "Res. (resident) noted c (with) ^ (increased edema LUE (Left Upper Extremity)/L Hand. IV (Intravenous) still running, however, unable to get blood action via angiocath. D/ced (discontinued) IV L (left) forearm. IV situ, no redness, no localized swelling. Keep LUE elevated. IV resumed on L leg. infusing well..."

The nursing progress note dated 3/11/10, late entry, from 4:05 p.m.-7:30 a.m. documented: "...Resident seen and examined by (name of) physician. All due meds given & (and) tolerated via peg (tube inserted into stomach). IVF...infusing & dripping well. Noted to have swollen arms. Seen by physicians...IVF stopped by RN for infiltration. IVF reinserted by (name of) physician..."

There was no documentation regarding the status of the resident's IV site.

An interview was conducted with the physician on 3/11/10 at 3 p.m. She stated that the resident's arm was slightly swollen when she first saw her that day but that the arm was "definitely much more swollen now."

The Licensed Practical Nurse (LPN) assigned to the resident was interviewed on 3/11/10 at approximately 3:05 p.m. She stated that she had IV training and was the person who hung the bag of fluids for the resident at 10 a.m. She also stated that the resident's arm "did not look like that at 10 o'clock," referring to the swelling of the resident's arm.

The resident was observed on 3/12/10 at 5:20 p.m. She was in bed with her left arm elevated on a pillow. She was receiving IV fluid of D5 0.2 NaCl with 20 meq potassium/liter at 70 ml per hour via the left foot. There was no swelling observed. The resident was alert and smiling when spoken to by the nurse. She was able to follow commands to move her left hand.

The facility's policy for IV therapy was reviewed. The policy documented a requirement for "no less often than hourly" checks of the IV site for infiltration. There was no documented evidence that these hourly checks were done.

415.12 (k)(1)

Based on observation, it was determined that the facility did not ensure that the exit stair "I" enclosure, at the first floor level, in the Frank building, the "Frank"/Friedman exit stair enclosure leading to 106th street in the basement, and the exit stair "L" enclosure in the "Sutro" building basement, are free from the passage of unenclosed drain pipes or other utility pipes, which were not meant to serve the exit stair enclosures, 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 March 8, 2010 and March 9, 2010, at 10:00 AM to 2:30 PM, it was observed that the exit stair enclosure to stair "I" on the first floor level in the "Frank" building basement, the "Frank"/Friedman exit stair leading to 106th street, and the exit stair "L" enclosure in the basement of "Sutro" building, are penetrated by overhead drain/sewage pipes and other miscellaneous utility pipes of varying sizes. These pipes lack an enclosure of the same fire resistance rating, as the exit stair enclosure. Any accidental water leakage from the drain pipes in the exit stairways would interfere with the safe usage of the stairways by the occupants during fire or other emergency. On March 9, 2010 at approximately 2:00 PM, the facility's director of maintenance stated that the drainage pipes and the utility pipes penetrating the exit stair enclosures will be either enclosed/boxed or properly insulated with material having at least 1-hour fire resistance rating construction.

711.2 (a)(1)

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

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the egress door from the room identified as "IT" room/office area, in the basement of "Friedman" building, is equipped with latching/locking devices which could be released with only one releasing operation from the egress side and that the door releasing devices are the familiar type of releasing devices.

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

The findings include:
On March 8, 2010 and March 9, 2010, at 10:00 AM to 2:30 PM, it was observed that the door to the "IT" room , in the basement of "Friedman" building, is equipped with 2 dead bolt type locks, in addition to the conventional door knob type latching device. These door fastening devices, when engaged, would require more than one operation to open the door from the egress side (the twisting of the two thumb twist devices to open the dead bolt locks and then turning the door knob to release the conventional door latching device). Also, the thumb twist type lock releasing devices are not the familiar type lock releasing devices and would be difficult to locate and operate during darkness. On March 9, 2010, at approximately 2:30 PM. during the exit conference, the facility director of maintenance stated that the
dead bolt locks will be removed from the "IT" room egress door.

711.2 (a)(1)

The following requirement has been waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed.

Please indicate if the facility wishes the waiver to be continued or provide a plan of correction.

42 CFR 483.70 (a)

K 038 S/S=B
Where accumulation of snow or ice is likely because of the climate, the exterior exit access shall be protected by a roof. The access to the alternate exit on the 8th floor of the Friedman Building is via an unprotected roof area. 5-5.3.8

NYCRR 711.2 (a)(1)

Section 5.2.2.2, NFPA25, requires 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 tank room #125 and in the corridors of the basement of "Sutro" building are maintained free from the miscellaneous utility pipes, cables and conduits either tied or resting on the pipes.

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

The findings include:
On March 9, 2010 at 10:00 AM to 2:30 PM, it was observed that in the hot water tank room #125, in the "Sutro" building basement, two utility pipes were tied to the sprinkler pipe, a loose metal pipe and a number of miscellaneous cables were either tied or were resting on the sprinkler piping. Also, in the corridors of the "Sutro" building basement, 6 - 8 inch thick conduits/cables were resting on the sprinkler piping. All sprinkler piping must be maintained free from materials hanging or resting on the pipes. On March 9, 2010, at approximately 2:10 PM, the facility director of maintenance stated that all utility pipes, cables/conduits will be removed from the sprinkler piping systems.

711.2 (a)(1)

The following requirement has been waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed.

Please indicate if the facility wishes the waiver to be continued or provide a plan of correction.

42 CFR 483.70 (a)

K 017 S/S=B
Television Rooms/Dining rooms on patient floors in the Sutro Pavilion are not separated from the Corridor.

NYCRR 711.2(a)(1)