Forest View Center for Rehabilitation & Nursing

Based on record review and staff interviews during the recertification survey, the facility did not ensure that all occurrences and injuries of unknown origin were thoroughly investigated for abuse, neglect or mistreatment. This was evident for six of ten residents reviewed for Accidents/Incidents (A/I) in a total of 24 sampled residents and three out of sample residents. Specifically, 1) Resident #2 was identified with a large ecchymotic area to the left knee during a wound observation and the LPN did not report the observation; 2) Resident #29 had three A/I Reports for observations of ecchymotic areas and the development of a skin tear without obtaining statements from staff on previous shifts, 3) Resident #30 was observed with a skin tear to her shin and no staff statements were obtained; 4) Resident #28 was noted with a Hematoma to her right forehead without the facility obtaining statements from staff that had cared for the resident; 5) Resident # 5 was observed on 2/9/10 with a discoloration to the left hip. There were no statements obtained from the 3:00 PM- 11:00 PM staff; and, 6) Resident #6 was observed with an ecchymotic area to his left side below his arm. There was no A/I Report generated for this unknown occurrence. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1) Resident #2 has diagnoses that include Leukemia, Diabetes Mellitus and Schizophrenia. The resident also had a Stage IV Sacral Decubitus Ulcer.

The Minimum Data Set (MDS) Assessment dated 7/28/10 documented the resident's cognition as severely impaired. The MDS also documented that the resident was a two person transfer with a Hoyer lift (mechanical lift).

On 8/9/10 at 10:20 AM during a sacral wound observation, a large ecchymotic area was observed on the resident's left knee and was brought to the Licensed Practical Nurses' (LPN) attention. The LPN stated that she would have to look into the finding.

On 8/10/10 at approximately 8:30 AM the nurse's notes for Resident #2 were reviewed. There was no documented evidence that the LPN had addressed the ecchymotic left knee that was identified the previous day.

The Certified Nursing Assistant (CNA) assigned to Resident #2 on the 7:00 AM- 3:00 PM shift was interviewed on 8/10/10 at 9:05 AM. The CNA stated that when she worked on 8/6/10 she had not observed the ecchymotic area and that she was off on 8/7/10 and 8/8/10. The CNA also stated that she did not recall the LPN asking her any questions about the ecchymotic area on Resident #2 on 8/9/10.

On 8/10/10 the RN Supervisor covering the 7:00 AM- 3:00 PM shift and also the 3:00 PM-11:00 PM shift on 8/9/10 was interviewed. The RN stated that he had not been made aware of a ecchymotic area on Resident #2. The Supervisor stated that had he been made aware, he would have assessed the resident and notified the physician.

The Director of Nursing Services (DNS) was interviewed on 8/10/10 at 9:15 AM. The DNS stated that nothing regarding Resident #2 had been brought to her attention on 8/9/10. The DNS further stated that the LPN should have notified the RN Supervisor and placed the resident on 24 hour report when the observation of the ecchymotic knee was identified. The 24 hour report was reviewed with the DNS and the observed ecchymosis had not been documented for Resident #2.

The LPN was interviewed on 8/10/10 at 10:50 AM. The LPN stated that she was an agency nurse and that she had not covered the unit where Resident #2 resided for a long time. The LPN acknowledged having observed the ecchymotic area on the left knee while doing her treatment on 8/9/10. The LPN stated that she did not know that the ecchymotic area was new and "she felt" that the facility was aware of the ecchymosis due to the resident's previous history of fractures. The LPN stated that she had assessed the resident for pain in that area and the resident denied pain.

The resident was transferred to the hospital on 8/10/10 with a suspected fracture of the left knee.

2) Resident #29 had diagnoses that include Osteoporosis and Cerebral Vascular Accident (CVA) with Left-Sided Hemiparesis.

The MDS Assessment dated 10/15/09 documented the resident's cognition as moderately impaired. The MDS also identified the resident was a two person transfer with a Hoyer Lift (mechanical lift).

A nurse's note dated 11/15/09 at 10:00 PM documented that a CNA observed a skin tear to the resident's right hand and was approximately 4 centimeters (cm) long.

The A/I Report dated 11/15/09 at 10:00 PM for Resident #29 was reviewed. There was no statement documented from the second CNA that might have assisted with transferring the resident to bed.

A nurse's note dated 2/24/10 at 1:00 AM documented that the resident was observed with ecchymotic areas to his left hand and right wrist.

The A/I Report dated 2/24/10 at 12:00 AM documented that the 11:00 PM- 7:00 AM CNA observed the ecchymotic areas while doing her changes. There were no statements obtained from staff caring for the resident on previous shifts.

A nurse's note dated 3/31/10 at 1:00 PM documented that the resident was observed with a 7.0 cm X 4.0 cm bluish discoloration on his right wrist.

The A/I Report dated 3/31/10 at 4:00 PM documented that during PM care the CNA observed the bluish discoloration on the resident's wrist. There were no additional statements obtained from staff that had cared for the resident on previous shifts.

3) Resident #30 has diagnoses that include Pneumonia and Cerebral Vascular Accident.

The MDS Assessment dated 6/9/10 documented the resident's cognition as independent.

A nurse's note dated 6/23/10 at 6:30 AM documented that the CNA observed the resident with a skin tear on her right shin. The note further documented that the resident stated that she sustained the skin tear yesterday when she was being changed.

The A/I Report dated 6/23/10 at 6:30 AM contained no statements from staff who had cared for this resident.

The Director of Nursing Services (DNS) was interviewed on 8/9/10 at 10:00 AM. The A/I Reports were reviewed with the DNS. The DNS stated that the responsible person for the completion of the reports was on vacation. The DNS acknowledged that statements should have been obtained to rule out abuse neglect or mistreatment for the above resident's.

415.4 (b) (1) (ii)

Based on observation, record review and staff and resident interviews during the recertification survey, the facility did not ensure that all residents received treatment and services for psychosocial difficulties to improve psychosocial functioning. This was evident for 1 of 12 residents reviewed for behavior in a total of 24 residents reviewed. Specifically, Resident #12 was documented to have had experienced behavioral problems between 5/2010 and 7/17/10 without Psychiatry Evaluations completed as ordered, Psychological Services, Social Services Assessments, or a Comprehensive Care Plan completed related to the behavior problems identified. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #12 was admitted to the facility with diagnoses including Depression and Osteoarthritis.

The Minimum Data Set (MDS) Assessments dated 11/27/09 through 5/26/10 documented that the resident had modified independence with cognitive skills for daily decision making and had some difficulty in new situations only. The MDSs also documented that the resident presented with the following indicators of Depression, Anxiety and Sad Mood up to five times per week: persistent anger with self or others; expressions of what appear to be unrealistic fears; repetitive anxious complaints/concerns; sad, pained, worried facial expressions; and, crying, tearfulness.

During a group interview on 8/6/10 at 10:00 AM Resident #12 complained that other residents talk about her in front of her and behind her back. The resident stated that other residents are mean to her and curse at her when she is in the Penthouse (PH) room/activity room. The resident became visibly upset and began to raise her voice and continued to complain about how other residents were ganging up on her.

The Physician's Orders dated 12/31/09 through 7/14/10 documented an order for a Psychiatry Evaluation every three months. The last Psychiatry Evaluation completed for Resident #12 was documented to have been completed on 9/12/09.

The Physician's Orders dated 11/20/09 through 7/14/10 documented an order for Psychotherapy 1-2 times per month or as needed.

A Comprehensive Care Plan (CCP) dated as initiated on 9/1/09 and updated through 5/25/10 titled Individual Coping/Impaired Adjustment was reviewed. The CCP documented that the resident had impaired ability to cope with life's demands causing maladaptive behavior secondary to Depression and life changes. Interventions on the CCP included: acknowledge behavior as an attempt to communicate needs; assess for risk of violence toward self/others; monitor relationship with roommate. Evaluations completed on the CCP dated 11/30/09 through 5/25/10 documented that the resident had been well adjusted to the facility.

The Social Services notes completed by a facility Social Worker (SW) dated 11/23/09 through 5/25/10 were reviewed and revealed the following: on 11/23/10 Resident #12 was documented to have had been physically aggressive with another resident on her unit and the residents were kept apart; on 11/30/09 Resident #12 was moved to another unit in the facility as a result of the altercation that occurred on 11/23/10. Resident #12 was documented to have not been in agreement with the move but, expressed understanding; Social Services notes dated 2/24/10 and 5/25/10 documented that the resident had not presented with any behavior problems and that the resident's mood had been stable.

A review of Resident #12's Patient Activities Progress Notes and Evaluations dated 12/1/09 through 7/27/10 revealed the following: on 12/1/09 the resident was recently moved to another unit and has become erratic which has given rise to arguments with her peers; on 3/1/10 the resident gets upset easily and can be temperamental, irritable and often explosive and stubborn; on 5/31/10 the resident had occasional episodes of excitement and either misunderstands or over-reacts and becomes vocal; on 7/12/10 the resident was documented to have had behaviors and relationships with her friends and peers that had greatly soured. The note also documented that as a result, the resident has become ashamed and depressed.

There were no Psychological Services notes documented in the resident's medical record between 4/18/10 and 7/17/10.

A Psychological Service Note dated 7/18/10 documented that the resident had presented with "irritability, verbal hostility towards others and mild paranoid ideations". The Psychologist documented clinical interventions including: "identifying affects (of hurt secondary to received threats) underlying the residents anger and recent hostility towards others." The Psychologist also documented that the resident had poor insight about her own contribution to the conflicts and the resident's severe anger was noted.

An interview was conducted on 8/10/10 at 9:30 AM with the Licensed Practical Nurse (LPN) Charge Nurse responsible for Resident #12. The LPN stated that she had only worked with the resident for the past two months and that she had not noticed any behavioral or verbal concerns between Resident #12 or any of the other residents. The LPN stated that she is not with the resident when she is in the PH.

An interview was conducted on 8/10/10 at 9:35 AM with a 7:00 AM - 3:00 PM Certified Nursing Assistant (CNA) that has worked with Resident #12. The CNA stated that she had not noticed any behavior problems with Resident #12. The CNA stated that she does not accompany the resident for meal or activity programs in the PH.

An interview was conducted on 8/10/10 at 9:45 AM with the Director of Recreation. The Director stated that she had noticed that Resident #12 has had "melt-downs" as a result of communication problems with other residents for the past three months. The Director stated that Resident #12 curses and has been racially derogatory towards others. The Director stated that there is a clique of women that have been ganging up on the resident and they taunt, ignore and fight with her at times during the past three months when they are in the PH. The Director also stated that she recalled telling a Social Worker (SW) who told the Director that they would look into getting a Psychiatry evaluation for the resident.

An interview was conducted on 8/10/10 at 10:21 AM with the SW responsible for Resident #12. The SW stated that the SW who was assigned to the resident during the past three months is no longer employed by the facility. The SW stated that he had not been made aware of the resident's behaviors. The SW also stated that if the SW that had worked with the resident was aware of the behaviors that they should have documented it in the medical record.

An interview was conducted with the Director of Nursing Services (DNS) on 8/10/10 at 3:30 PM . The DNS stated that the Psychiatry consults should have been completed as per the Physician's Order. The DNS also stated that the resident should have had a CCP developed that addressed the resident's behaviors. The DNS stated that the SW should have been notified of Resident #12's behaviors and a request for a follow Psychologist visit should have followed.

An interview was conducted on 8/10/10 with the Psychologist responsible for Resident #12. The Psychologist stated that had he been aware that the resident had been presenting with behavior problems that he would have seen the resident sooner and started to visit the resident on a more regular basis.

A Psychiatry Evaluation was documented as completed on 8/10/10. The Psychiatrist documented that the resident presented with Dementia due to Behavioral Disturbance due to General Medical Condition. The recommendations included: Dementia work-up, Namenda (drug to treat moderate to severe Alzheimer Dementia) 5 milligrams by mouth two times per day and follow-up as needed.

415.12 (f) (1)

Based on record review and staff interviews during the recertification survey, the facility did not consistently develop or review and revise Comprehensive Care Plans (CCP) for all residents. This was evident for 2 residents in a total of 24 reviewed. Specifically, 1) Resident #5 had multiple documented falls and the resident's CCP for falls was not documented as revised after each incident; 2) Resident #21 was documented to have had sustained a swollen discolored left hand and there was no revision documented on the CCP related to the episodic event. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #5 was admitted to the facility on 9/23/09 with diagnoses including Schizophrenia and Dementia.

The A/I reports dated 9/24/09 through 7/25/10 documented that Resident #5 had sustained 7 falls that originated from his wheelchair.

The CCP implemented on 9/24/09 and updated through 7/25/10 titled Falls was reviewed. The CCP documented that the resident was at risk for falls related to cognitive deficits, impaired safety awareness and impaired mobility. The interventions documented on the CCP included: toilet resident per schedule and request, assess the need for fall interventions such as: low bed, bed or chair alarms, raised toilet seat, padded floor next to bed, wedge in chair. The evaluation section of the CCP contained no documented evidence that new and effective interventions were implemented after each fall had occurred.

An interview was conducted with the Director of Nursing (DNS) on 8/10/10 at 3:20 PM. The DNS stated that the Assistant DNS who is responsible to complete and ensure that the CCPs are updated and interventions are implemented was unavailable for interview. The DNS stated that the resident's CCP should have documented new interventions each time an occurrence was identified.

2) Resident #21 has diagnoses that include Dementia and Status Post Left Hip Fracture.

The MDS Assessment dated 5/5/09 documented that the resident's cognition was moderately impaired.

A nurse's note dated 7/4/10 documented that the resident was observed to have had a swollen left hand. A review of nurse's notes between 7/4/10 and 8/3/10 documented that the discoloration persisted.

There was no documented evidence in the medical record that a CCP had been developed for this episodic event.

415.11 (c) (1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that one resident, who refused a Purified Protein Derivative (PPD) test [a skin test to identify if a person has Tuberculosis (TB)], was adequately monitored until a determination was made that the resident was not an active carrier of TB. This was evident for 1 (Residents #13) of 9 residents reviewed for infection control in a total of 24 records reviewed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #13 was admitted to the facility on 7/29/10 and has diagnoses including Hip Fracture and Fracture of the Left Humerus.

A Physician's Order dated 7/29/10 documented to administer a PPD skin test.

A review of Resident #13's Medication Administration Record was completed on 8/5/10 and documented that the resident was offered a PPD 7/30/10 and again on 8/3/10 and the resident refused the PPD test on both occasions.

The Nurse's Notes reviewed from 7/29/10 through 8/4/10 did not contain documented evidence that the Attending Physician was notified that the resident refusal of the PPD test.

A review of the current medical and hospital records for Resident #13 revealed no documentation pertaining to a previous history of a PPD.

A facility Policy and Procedure dated 1/2010 titled Resident PPD Program documented that "any resident who refuses to have a PPD despite appropriate counseling and education must be referred to the physician for prompt follow up."

An interview was conducted on 8/5/10 at 1:00 PM with the Licensed Practical Nurse (LPN) medication nurse. The LPN stated that she had notified the Infection Control nurse on 8/3/10 that the resident had refused the PPD test.

An interview was held on 8/5/10 at 1:05 PM with the physician. The physician stated that if he had been notified of the resident's refusal of the PPD test he would have ordered a Chest X-Ray immediately.

An interview was conducted on 8/10/10 at 1:35 PM with the Infection Control Registered Nurse (RN). The RN stated that she had been notified of the resident's PPD refusal on 8/3/10 and she obtained a telephone order for a Chest X-Ray. The RN stated that the Attending Physician should have been notified when the resident refused the PPD test.

A review of the Physician's Orders dated 7/29/10 through 8/5/10 documented that a chest X-ray was ordered on 8/5/10.

An interview was held on 8/10/10 at 3:20 PM with the Director of Nursing Services (DNS). The DNS stated that the Attending Physician should have been notified within two days of the resident's refusal of the PPD test.

415.19 (a) (1-3)

Based on record review, and staff, resident and group interviews during the recertification survey, the facility did not ensure that resident complaints of interrupted sleep, disrupting noise at night, and opened mail were promptly addressed to prevent recurrence. This was evident for 4 out of sample residents. This resulted in no actual harm with the potential for minimal harm that is not immediate jeopardy.

The findings are:

1) During a group interview conducted on 8/6/10 at 10:00 AM with 11 alert and lucid residents selected by facility, 2 (Resident #32 and #33) of the 11 residents complained that they have had interrupted sleep 3 or more times per week because of another resident (Resident #19) screaming and yelling on their unit at night. The two residents stated that they have informed both the day and night nursing staff on two or more occasions and have not noticed any improvement in the screaming in the last two to three months. One of the 11 residents (Resident #34) stated that they have heard the screaming and yelling but, it had no effect on their sleeping patterns.

A individual interview was held on 8/9/10 at 9:55 AM with Resident #32. The resident stated that he was transferred to the third floor about two months ago and since then he has not been able to get a good night sleep most nights because of Resident #19 screaming and yelling. The resident also stated that when he complains to the nursing staff the nurses close his door but it does not help. The resident also stated that he would prefer his door to remain opened and had not asked for the nurses to close his door. The resident also stated that he could not recall which nurses he specifically told but no one has gotten back to him about his complaints of interrupted sleep.

An interview was conducted on 8/9/10 at 9:50 AM with the 7:00 AM - 3:00 PM Licensed Practical Nurse (LPN) Charge Nurse responsible for Residents #19, #32, #33 and #34. The LPN stated that today (8/9/10) was the first time she had heard any complaint of other resident's not being able to sleep because of screaming/yelling. The LPN also stated that she was unaware that Resident #19 had been presenting with disruptive behaviors at night.

An interview was conducted on 8/10/10 at 3:00 PM with the 11:00 PM - 7:00 AM CNA responsible for Resident #19. The CNA stated that the resident yells and screams at times during the night. The CNA stated that a few residents have complained that the resident is too loud and when she told the nurse that the nurse told her to close their doors. The CNA also stated that she tries to calm the resident by talking to him but, it only works for a short while.

The regular 11:00 PM - 7:00 AM LPN responsible for Residents #19, #32, #33 and #34 was unavailable for interview.

An interview was conducted on 8/10/10 at 3:05 PM with the 11:00 PM - 7:00 AM LPN covering the unit during the past two weeks. The LPN stated that sometimes the resident would talk loudly but, he did not really scream. The LPN also stated that she had not received any complaints from other residents.

An interview was conducted with the Director of Nursing Services (DNS) on 8/10/10 at 3:20 PM. The DNS stated that resident's should not be awakened by other residents because of screaming/yelling. The DNS also stated that the behaviors specific to the night should have been brought to the Physician's attention for follow up.

2) During a group interview conducted on 8/6/10 at 10:00 AM with 11 alert and lucid residents selected by facility, Resident #31 complained that she had received mail that had been previously opened by the facility staff on two occasions.

A subsequent individual interview was conducted with Resident #31 on 8/9/10 at 9:25 AM. The resident stated that she was expecting a disability check and called the disability company early in June 2010 and was told it had been sent to the facility on 5/26/10. The resident stated that she then asked the facility staff on 6/10/10 where her mail was and that she was expecting a check. The resident stated that she was told to wait until Monday 6/13/10 for the bookkeeper to investigate the problem. The resident stated that on 6/14/10 that she was told that the bookkeeper mistakenly opened and deposited her check and she was provided with a check on 6/14/10 for reimbursement of her disability check. The resident stated that she was told that the problem with the mail would not happen again. The resident further stated that about a month ago (7/2010) that a facility staff member showed her that a Social Security (SSI) acceptance letter had been received and opened by the facility at the beginning of the month. The resident stated that she had requested a copy of her SSI acceptance letter and that she had not received a copy of her letter since she had requested it in July.

An interview was conducted with Bookkeeper #1 on 8/9/10 at 10:50 AM. The Bookkeeper stated that alert and oriented residents like Resident #31 should get their mail unopened and that he knows who is not alert because they are the Long Term Care residents.

An interview was conducted with Bookkeeper #2 on 8/9/10 at 11:05 AM. The Bookkeeper stated that the mail for alert residents goes to the Activities Department to be handed out to the residents. The Bookkeeper also stated that he thought that Resident #31 was not alert so he opened her mail.

A SSI Notice of Award letter dated 6/21/10 was presented to Resident #31 on 8/9/10.

An interview was conducted with the facility Recreation Director on 8/9/10 at 1:10 PM. The Director stated that she gets mail from the bookkeeping office and makes sure that the residents receive the mail. The Director also stated that she did not know how the bookkeepers determine who is or is not alert and oriented to determine who should receive their mail unopened.

415.3 (c) (1) (ii)

Based on record review and staff interview during the recertification survey, the facility did not provide medically related social services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being for one of five residents reviewed for Advance Directives in a total of twenty four sampled residents. Specifically, Resident #2's medical record had no social work interventions to ensure that Advance Directive information had been provided to the resident or the resident's designated representative. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is :

Resident #2 has diagnoses including but not limited to Leukemia, Schizophrenia and Dementia.

The Minimum Data Set (MDS) Assessment dated 7/28/10 documented the resident's cognition for daily decision making as severely impaired with short and long term memory problems.

A Social Work Assessment completed on admission in 2006 documented that the resident had a court appointed guardian who did not want to decide on the resident's Advanced Directives at that time.

A review of the medical record revealed no documented evidence that the Social Service Department reviewed Advance Directives with the guardian since November of 2006.

Review of the undated facility policy and procedure (P&P) entitled "Advance Directives" documented to provide information to all residents and families about their right to refuse medical treatment and formulate Advance Directives. The policy documented that the Social Worker will provide written notification to residents on an annual basis and to families and designees about Advanced Directives.

An interview with the Social Worker (SW) was held on 8/10/10 at 11:40 AM and revealed that Advanced Directives should be reviewed every quarter (3 months) with the families and residents. The SW stated that there was no documented evidence in the residents medical record that Advance Directive decisions were discussed with the resident's guardian since November 2006. The SW also stated that the resident's regular SW is no longer employed with the facility and the resident's current SW has only been employed for 2 weeks. The SW was unable to explain why the resident's guardian was not contacted regarding Advanced Directives since 2006.

415.5 (g) (1) (ii,iii)

Based on record review and resident and staff interviews during the recertification survey, the facility did not provide a resident's family member with access into the facility to visit a resident. This was evident for one out of sample resident (Resident #32). Specifically, Resident #32 complained that a family member was denied entrance into the facility because it was after visiting hours. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

During a group interview on 8/6/10 at 10:00 AM with eleven alert and lucid residents chosen by the facility, all the residents' present acknowledged that they were aware that the facility visiting hours were 10:00 AM - 9:00 PM. During the meeting Resident #32 complained that a few days ago a family member attempted to drop off some clothing after 9:00 PM and was denied entrance into the facility because visiting hours were over.

On 8/9/10 at 9:55 AM, the resident further stated that his family member called him a few days ago after being refused entry to the facility. The resident stated that he felt bad that his family member could not come to see him because they travel at least 20 minutes via public transportation to the facility. The resident also stated that he was told by his family member that a facility employee refused to let them in to see him but, he did not know specifically who the employee was.

A facility Admission Agreement/Packet documented that "recommended visiting is from 10:00 AM to 9:00 PM daily".

An interview was conducted on 8/10/10 at 9:50 AM with the 3:00 PM - 11:00 PM shift Registered Nurse (RN) Supervisor. The RN stated that she was unaware of any incident of a family member trying to enter the facility to drop off clothes for a resident. The RN stated that visiting hours end at 9:00 PM during the 3:00 PM - 11:00 PM shift. The RN further stated that after 9:00 PM families can enter the facility only if there is an emergency. The RN further stated that visitors ring the bell at the front of the building and sometimes staff on the first floor go to the door.

An interview was conducted on 8/10/10 at 10:20 AM with a 11:00 PM - 7:00 AM shift RN Supervisor. The RN stated that all visitors are required to call and pre-arrange a visit. The RN also stated that in an emergency they may make an exception if the visit is after 9:00 PM.

An interview was conducted on 8/10/10 at 3:30 PM with the Director of Nursing Services (DNS). The DNS stated that the visitation hours are only recommendations and that all families should be allowed entrance into the facility if the resident desires the visit and it does not interrupt other residents. The DNS stated that there are areas within the facility that residents and visitors can meet privately before and after recommended visiting hours.

415.3 (c) (2) (iv)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that a pre-admission Screen had been completed as required for 3 of 7 residents reviewed for pre-admission Screen accuracy in a total of twenty four residents. Specifically, 1) Resident #3 was admitted to the facility on 3/3/10 and the Screen completed for the resident did not document the appropriate 10 digit identification number; 2) Resident #10 was admitted to the facility on 7/26/10 and the Screen was incomplete and had not been signed; 3) Resident #23 was admitted to the facility on 6/8/10 and the Screen was not signed and did not document a 10 digit identification number. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #3 was admitted to the facility on 3/3/10 and had diagnoses that included Altered Mental Status and Depression.

There was documented evidence in the medical record that the completed Screen dated 3/2/10 was signed but, did not contain the 10 digit screener identification number.

2) Resident #10 was admitted to the facility on 7/26/10 and had diagnoses that included Hypertension and Diabetes Mellitus.

The Screen was missing two pages, a signature and the identification number required.

3) Resident #23 was admitted to the facility on 6/8/10 and had diagnoses that included Cellulitis of the Leg and Organic Brain Syndrome (OBS).

The Screen documented in the resident's medical record was did not contain a signature or the 10 digit identification number of the person who had completed the form.

The Admissions Coordinator was interviewed on 8/9/10 at 12:15 PM. The Coordinator stated that Screens should be received prior to the resident being admitted to the facility. The Coordinator also stated that it has been difficult receiving the Screens timely.

The Director of Nursing Services (DNS) was interviewed on 8/9/10 at 12:30 PM. The DNS that the Screens are not always sent with the resident. The DNS stated that she reviews the Patient Review Instrument (PRI) prior to admission and clears the resident medically. The DNS also stated that she does not review the Screens for the residents.

The undated facility policy that included "Admission policies" was reviewed. The policy documented that a Screen shall be completed for all admissions by a professional who has successfully completed a New York State Health Department approved Screen training program.

415.11 (e)

Based on observation and staff interview the facility did not ensure that smoke detectors, at the minimum of single station battery-powered, were installed in all required locations for an existing nursing home that is not fully sprinklered. This was evidenced by the lack of smoke detectors in the resident dayrooms/dining rooms on the 5 of 6 resident sleeping floors.

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

The findings are:

During the recertification survey on 8/05/10 between 8:15am and 2:30pm, it was observed that the building is partially sprinklered by the absence of sprinkler coverage for an Administrative room and a closet located within the room, and a telephone closet located within the dry goods storage room in the basement. The required smoke detectors (at the minimum of single station battery-powered) were not provided in all the resident public areas (dayrooms/dining rooms) on the 2nd , 3rd , 4th , 5th and 6th floors.

In an interview at approximately 2:30pm the Administrator stated that the sprinkler coverage would be provided in the identified areas.

10 NYCRR 711.2(a)(1)
2000 NFPA 101

Based on observation, and staff interview, that facility did not ensure that doors protecting corridor openings positively latch, in that double leaf doors were not secured in their frames on 5 of 6 resident use floors.

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

The findings are:

During the recertification survey on 8/05/10 between 8:15am and 1:30pm it was observed that the double leaf corridor doors to the common bathrooms, and tub rooms on 5 of 6 resident use floors and the staff locker rooms on 2 of 6 resident use floors were not positively latching. One leaf of the double leaf doors are equipped with a latching mechanism that was not engaged in order for the other leaf to be positively latching. The latching devices on the doors did not function when tested on the 5th floor tubroom, and the 3rd floor locker room.

The common areas and staff locker rooms were observed to be periodically unattended during the observations.

In an interview at approximately 11:00am a maintenance employee stated that the issues would be brought to the attention of the Maintenance Director and Administrator to be addressed.

711.2(a)(1)

2000 NFPA 101 Life Safety Code(LSC) states:

Chapter 7.2.1.6.1 -7.2.1.6 Special Locking Arrangements.
7.2.1.6.1 Delayed-Egress Locks.
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:

PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

2000 NFPA 101, Section 19.2 Means of Egress Requirements, 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

7.1.10 Means of Egress Reliability. 7.1.10.1 Requires that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This Requirement is not met as evidenced by:

Based on observation and staff interview the facility did not ensure that approved, listed, delayed-egress locking mechanism is installed on the main entrance door in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and did not ensure that exit access is arranged so that exits are readily accessible at all times in the activities department.

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

The findings are:

During the recertification survey on 8/05/10 between 8:15am and 1:30pm the following was observed:

1. At approximately 10:25am, it was observed that the facility's main entrance swing type door is equipped with a proximity locking mechanism that is activated by a wander guard bracelet. The locking mechanism did not release when pressure was applied to the door. In addition, the door was not provided with the instructions to be used in an emergency. The building was observed not provided with a complete automatic sprinkler or smoke detection system in all areas.

In an interview at this time, the Administrator stated that the door locking mechanism would be either removed or installed according to the regulations.

2. At approximately 9:15am, a visit to the penthouse level revealed an exit sign that was placed over a door leading from the activities department into an enclosed exterior patio. There were no exits to the public way from the enclosed patio area. In an interview at this time a maintenance employee stated that the penthouse was recently renovated and that the exit sign was placed in the wrong location. He further stated that he would bring it to the Administrator's attention in order to be timely addressed.

10 NYCRR 711.2(a)(1)
2000 NFPA 101

7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.2* Directional Signs.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation and staff interview the facility did not ensure that all exit access were provided with readily visible exit signs on 5 of 6 resident sleeping floors.

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

The findings are:

During the recertification survey on 8/05/10 between 8:15am and 1:30pm the following was observed:

1. Approved exit signs were not provided at corridor intersections that would direct egress from any direction to the exit access on 5 of 6 resident sleeping floors. Only one exit sign was provided and visible in the North and West corridors on the units.

In an interview at approximately 10:45am a maintenance employee stated the issue with the exit sign would be brought to the attention of the Maintenance Director and the Administrator in order to be addressed.

10 NYCRR 711.2(a)(1)
2000 NFPA 101

Based on observation and staff interview, the facility did not ensure that the seven story building was appropriately protected at a minimum of a Type II (222) construction in that 1) sections of the basement had penetrations in the solid fire-rated ceiling assembly and sections of exposed corrugated steel decking were lacking a fire-proofing material; and 2) areas in the 1st floor and basement were not provided with sprinkler coverage.

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

The findings were:

On 8/5/10 between 8:00am- 2:00pm during the re-certification survey, observations indicated that the facility is a seven story building with sections in the basement of an unrated floor-ceiling assembly, making the building Type II(000).

1) Reference is made to sections in the solid fire-rated ceiling assembly lacking fire-proofing material in rooms in the basement. Penetrations in the solid fire-rated ceiling assembly and sections of exposed corrugated steel decking lacking a fire-proofing material were noted in the fire pump room, maintenance office and housekeeping storage room in the basement. Buildings of Type II(000) construction are limited to two stories with a complete automatic sprinkler system.

2) The facility lacked a complete automatic sprinkler system in that areas in the 1st floor and basement were not provided with sprinkler coverage. Examples are: the 1st floor Administrator's office and closet within; and the telephone closet in the kitchen storage room in the basement.

In an interview on 8/5/10 at approximately 8:20am, the maintenance employee stated that he would inform the Administrator about the issues.

NFPA 101-2000: 19.1.6.2, NFPA 13, 711.2(a)(1)

2000 NFPA 101 Chapter 7.2- Means of Egress Components
7.2.1.8.2
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code\'ae.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

2000 NFPA 101 Chapter 19.2- Means of Egress Requirements
19.2.2.2.6*
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Based on observation and staff interview, doors to hazardous areas in the basement were held open with devices that are not tied into the fire alarm system.

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

The findings were:

On 8/5/10 between 8:00am- 2:00pm during the re-certification survey, doors to hazardous areas in the basement were observed held open with devices not tied into the fire alarm system. These devices are only released manually and are not automatically released upon activation of approved smoke detectors. Examples include but are not limited to:

1) The storage room adjacent to the North Stair.
2) Fire pump room.
3) Kitchen storage room in the vicinity of the maintenance office.
4) Suite of rooms including the laundry, soiled utility room and housekeeping storage room.

In an interview on 8/5/10 at approximately 8:45am, the maintenance employee stated that he would inform the Administrator about the issues.

NFPA 101-2000: 7.2.1.8.2, 19.2.2.2.6, 711.2(a)(1)

2000 NFPA 101 LSC Chapter 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation, staff interview and record review, there was no documentation regarding the annual 1hour test on battery-powered emergency lighting located at the generator set.

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

The findings are:

On 8/5/10 between 8:00am- 2:00pm during the recertification survey, battery-powered emergency lights were noted at the generator set. During facility record review at approximately 11:30am, there was no documentation of any 1hour tests of the battery-powered emergency lights provided during the survey.

In an interview on 8/5/10 at approximately 11:30am, the maintenance employee stated that he will look for the documentation. No documentation was provided by the exit date.

711.2(a)(1), 2000 NFPA 101: 7.9.2.1, 7.9.2.2, 7.9.3

2000 NFPA 101 Chapter 7.7- Discharge From Exits
7.7.3
The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Based on observation and staff interview, the North Stair continues to the basement level, more than one-half story beyond the 1st floor level of exit discharge. No partitions, doors or other effective means were provided to prevent travel beyond the 1st floor level of exit discharge. This was noted for one of two stairwells in the building.

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

The findings are:

On 8/5/10 at approximately 10:30am during the recertification survey, the North Stair was noted to continue down to the basement level. There were no partitions, doors or other effective means provided to prevent travel beyond the 1st floor level of exit discharge.

In an interview on 8/5/10 at approximately 10:30am, the maintenance employee stated that he would inform the Administrator about the issues.

2000 NFPA 101: 19.2.2.3, 7.7.3, 711.2(a)(1)