Forest Hills Care Center

Based on observation and staff interviews, the facility did not ensure that a resident who was unable to carry out ADL (Activities of Daily Living) received the necessary services to maintain the resident's grooming.
This was evident for 1 of 1 residents reviewed for activities, cleanliness and grooming. Resident #54.

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

The finding is:

Resident #54 is 81 years old with diagnoses which include:
Parkinson's Disease, Anemia, Spinal stenosis, and Osteoarthritis.

The Minimum Data Set 3.0 dated 6/8/11 documented that the resident's cognition is severely impaired, the resident is totally dependent on the staff for toilet use, and has a indwelling catheter.

On 6/30/11 at 9:45 AM, the resident was in bed and the resident's toe nails were observed to be long.

The CNA (Certified Nurse Assistant) assigned to the resident was interviewed on 6/30/11 at 9 55 AM and stated that she had noticed that the resident had long toe nails 2 days ago but forgot to inform the charge nurse. The CNA stated that she only cuts the resident's fingernails. The CNA stated that if the resident's toe nails are long, she informs the nurse.

On 6/30/11 at 10:29 AM, the Licensed Practical Nurse was interviewed and stated that she relies on the CNA's to tell her if the resident's nails are long.

415.12(a)(3)

Based on observations, record reviews and staff interviews, the facility did ensure that infection control procedures were adhere to as evidenced by: a Certified Nursing Assistant (CNA) #1 was observed washing her hands under running water and turning off the faucets without a barrier; and a resident's Foley catheter tubing and drainage bag was observed lying under the resident's bed. This was evident for 1 of 2 residents reviewed for pressure ulcers. Resident #54.

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

The finding is:

Resident #54 is 81 years old with diagnoses which include:
Parkinson's Disease, Anemia, Spinal stenosis, and Osteoarthritis.

The Minimum Data Set 3.0 dated 6/8/11 documented that the resident's cognition is severely impaired, the resident is totally dependent on the staff for toilet use, and has a indwelling catheter.

On 6/28/11 at approximately 4:20 PM, the CNA #1 was observed transferring the resident from the gerichair to the bed. After transferring the resident, the CNA handled the Foley catheter tubing and Foley catheter drainage bag while wearing gloves. She removed her gloves, discarded them, turned on the water at the sink and put soap on her hands. She immediately put her hands under running water and continued to wash her hands under the water. She then turned off both faucets without using a barrier between her hands and the faucets.

On 6/30/11 at approximately 9:45 AM, the resident's Foley tubing and Foley drainage bag was observed lying on the floor under the resident's bed. This was shown immediately to CNA #2 who placed it on the resident's bedframe.

On 6/28/11 at approximately 5:00 PM, the CNA was interviewed and she stated that she realized that she did not wash her hands long enough. She stated that she did not realize that she washed them under running water and that she did not use a barrier to turn off the water. She stated that she received inservices recently with the Director of Nursing regarding hand hygiene/infection control practices.

On 6/28/11 at approximately 6:00 PM the Director of Nursing Services was interviewed and stated that she has given inservices to the CNA regarding hand hygiene. She provided an Inservice sign-in sheet entitled: "Proper Handwashing Technique, Infection Control" dated 6/17 and 6/18/11 with documented evidence of the CNA's attendance.

On 6/30/11 at approximately 9:53 AM, an interview was conducted with the CNA #2 assigned to resident #54. She stated that she knows the resident has a Foley catheter for approximately 2 months. She stated that she readied the resident between 8 and 9 AM to be taken out of bed later in the morning. She stated that the Foley tubing and the Foley drainage bag were hanging on the bedframe when she left the resident. She stated that she knows that these medical devices must not touch the floor and she did not see them there. She stated that perhaps the housekeeper may have knocked it off when he cleaned the floor.

On 6/30/11 at approximately 10 AM, the charge nurse, a Licensed Practical Nurse was interviewed and she was made aware of the CNA's statement regarding the Foley catheter tubing and the drainage bag. She left to locate the Housekeeper and speak with him. When she returned a few minutes later, she stated that the housekeeper stated that he may have knocked it off while he was cleaning the resident's room.

415.19(a)(1-3)

STATE DEFICIENCIES ONLY
415.18 Pharmacy Services

Storage of drugs and biological's

1) The facility shall store all drugs and biological's in locked compartments under proper temperature controls, and permit access only to authorized personnel.

2) 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.

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

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

This REQUIREMENT is not met as evidenced by:

Based on observation and staff interview, the facility did not ensure that medication that was stored in the medication refrigerator was dated after opening. Specifically, a vial of Lantus insulin was not labeled with the date that it was opened. This was evident for one of 3 resident care units reviewed for medication storage (3rd floor).

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

The finding is:

On 6/24/11 at approximately 9:42AM, during medication storage review conducted during the Initial Tour of the facility, the following was observed: a vial of Lantus Insulin (a medication that lowers blood sugar) was open but the label did not contain the date that it was opened.

The unit charge nurse, a Licensed Practical Nurse, was interviewed immediately. She stated that the medication nurse who opens it is responsible to date it.

Based on observation and interview it was determined that the facility did not ensure to maintain safety measures in securing approximately 18 oxygen "e" tanks from falling or being knocked over. This was observed in the basement oxygen storage room.

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

The Finding is:

On 06/24/11 at approximately 12:30 pm, during the Life safety rounds, it was observed that in the basement oxygen storage room, apprximately eighteen 18) oxygen "E" tanks were freely standing on the floor without being secured in rack or chained to prevent them from falling or being knocked over. One tank was observed on top of other oxygen tanks.

In an interview with the maintenance director on the same day at approximately 12:31 pm, he stated that he will immediately order some extra racks so as to secure the tanks. Later an invoice was provided that showed the facility had ordered the tank racks.

2000 LSC NFPA 101 19.3.2.4
10 NYCRR 415.29 (a) (1, 2)

Based on observation and interview it was determined that the facility did not ensure that all hazardous areas were protected as evidenced by the boiler room door in the basement not positively latching in its frame when closed. Also, the generator room wall had unsealed 2 inch circular hole on one of the walls.

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

The Findings are:

On 06/24/11 during the Annual Life Safety evaluation it was observed that the boiler room door did not positively latch on its frame when closed. A one inch gap between the frame and the door was observed. Also, the generator room was observed with an unsealed two (2) inch circular hole around a pipe that extends into ladies locker room.

In an interview with the Maintenance Director on 06/24/11 at approximately 11:45 am, he stated that he will immediately take care of the door and seal the penetration on the generator wall.

NFPA 101, 2000: 19.3.2.1; 19.3.5.4; 8.4.1.
711.2.(a)(1).

Based on observation and interview it was determined that the facility did not ensure that smoke barrier walls above the double smoke barrier doors were maintained to provide at least a half hour fire/smoke resistance rating. This was observed on the second and third floor.

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

The Findings are:

On June 24, 2011 between the hours of 10:00 am and 11:30 am, it was observed that the smoke barrier wall above the double smoke barrier doors on the third floor, near room 314 had an unsealed one(1) inch annular space around a cable penetration.

Also,on the second floor in close proximity to room 212, inch unsealed circular cable penetration was discovered. Both of these penetrations were visible from both sided of the barrier walls. These penetrations must be sealed with approved fire rated sealents in accordance with NFPA 101.

In an interview with the maintenance director on 06/24/11 at approximately 10:24 am, the penetrations will be sealed with approved sealants as soon as possible.

711.2(a)(1)

713-1.9 Mechanical requirements.

(d) Bathing rooms, soiled workrooms, soiled linen rooms and janitors' closets shall have mechanical exhaust ventilation or a wall or, if approved by the department, window exhaust fan with back-draft louvers.

Based on observations and interview it was determined that the facility did not ensure that the janitor's closet on the first floor was provided with an exhaust system or a window exhaust fan with back-draft louvers.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The Finding is:
On June 06/24/2011 during the annual life safety evaluation of the facility it was observed that the janitor's closet located on the first floor resident unit was not equipped with any outside window or window exhaust fan with back-draft louvers or a mechanical exhaust system.
In an interview with the maintenance director at approximately 11:30 am, he stated that the area was previously a continuation of the shower area and it was recently converted to a porters closet. This he said was the main reason for the lack of any mechanical exhaust in the room.

The following waiver(s) is (are) on file with this office. 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(s) to be continued.

K11, SS=B

The roof of a non-conforming building abuts an outer wall of the facility at the second floor level. There is no evidence that the required two-hour fire resistant rating is maintained.

711.2 (a) (1)

Arial Baltic;
The following waiver(s) is (are) on file with this office. 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(s) to be continued.

LSC 13-2.6.2; NYCRR 711.2(a)(1)
k36 S/S=C
A fifty foot dead end corridor is present on the first floor of the facility. Seventy foot dead end corridors are present on the second and third floors of the facility.