Oceanview Nursing & Rehabilitation Center, LLC

Based on observation and staff interview, the facility did not ensure that all portions of the resident call bell system were fully functional in that 1) the call bell from the B bed in resident room W4 did not work when tested; 2) a visible signal associated with resident rooms E5 & W3 could not be seen from the corridors; and 3) call bells did not activate a signal in the soiled utility rooms. This was noted on two of two units.

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

The findings are:

On 9/15/10 between 8:30am- 2:00pm during the recertification survey, portions of the resident call bell system were not fully functional. Examples are:

1) The call bell from the B bed in resident room W4 did not work when tested. There was no visible signal above the resident room door and the activated call bell did not annunciate at the nursing station.

2) Although a signal was received at the nursing station, a visible signal associated with resident rooms E5 & W3 could not be seen from the corridors. The entrances to rooms E5 & W3 are recessed from the corridor. This configuration prevents staff in the corridors from seeing the activated call signal above the resident room doors.

3) The soiled utility rooms on the East and West units were observed provided with audible nurse call annunciator panels. The annunciator panels did not work and no audible signals were observed when call bells were activated from resident rooms.

In an interview on 9/15/10 at approximately 10:30am, the Director of Maintenance stated that he would have the call bell system fixed immediately. He further stated that he would have visual signals installed in the corridors for resident rooms E5 & W3.

10NYCRR 415.29
10NYCRR 713-1.19(g)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed addressing medical concerns identified in their assessment. This was evident for one resident in a total of 19 reviewed. Specifically, Resident #11 had a diagnoses of Diabetes Mellitus and there was no documented evidence in the resident's medical record that a CCP had been developed related to the diagnosis. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #11 was admitted to the facility on 4/3/09 with diagnoses including Diabetes Mellitus (DM) and Hypertension. nene The Minimum Data Set (MDS) Assessments dated 4/3/09 through 7/4/10 documented that the resident was severely impaired with cognitive skills for daily decision making. The MDSs also documented that the resident had a diagnoses of DM.

Laboratory tests dated 5/10/10, 5/14/10, 5/26/10 and 7/7/10 documented that the resident had Blood Glucose levels of 127 milligrams/deciliter (mg/dl), 175 mg/dl, 182 mg/dl and 149 mg/dl, respectively (normal range 60 - 110 mg/dl).

There was no documented evidence in the resident's CCPs dated 4/6/10 through 9/17/10 that a CCP for DM had been developed.

An interview was conducted on 9/20/10 at 10:00 AM with the Registered Nurse (RN) Unit Manager responsible for Resident #11. The RN stated that she was responsible for implementing CCPs for the residents on her unit. The RN stated that the resident should have had a CCP for DM.

An interview was conducted on 9/20/10 at 10:40 AM with the Director of Nursing (DNS). The DNS stated that the resident should have had a CCP for DM to monitor for signs and symptoms of low and/or high blood sugar levels.

415.11(c)(1)

Based on observations, record review and staff interviews during the recertification survey, the facility did not ensure that supervision to prevent accidents was provided and that the residents' environment remained free from accident hazards. Specifically, 1 of 3 residents reviewed for smoking (Resident #1) in a total of 19 sampled residents was documented to have had four incidents of unsafe smoking and the interventions implemented were ineffective and other planned interventions were not implemented to prevent reoccurrence. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #1 has diagnosis including Seizure Disorder and Chronic Obstructive Pulmonary Disease.

An Admission Minimum Data Set (MDS) Assessment dated 7/10/10 documented that the resident had modified independence with cognitive skills for daily decision making and had no long or short term memory problems.

A facility safe smoking assessment form dated 6/29/10 documented that the resident was a smoker and that he needed encouragement to follow the cigarette policy.

A facility smoking agreement contract dated 6/29/10 documented that the resident agreed to smoke only under staff supervision in designated areas and at designated times.

A Social Work (SW) Progress Note dated 7/26/10 documented that Resident #1 was observed smoking outside the facility unsupervised and during the non-scheduled smoking times on 7/25/10 at 10:30 AM and 10:50 AM. The note also documented that the smoking policy was reviewed with the resident and that the resident was advised that he may lose his smoking privileges.

A SW Note dated 8/16/10 documented that Resident #1 was observed smoking outside the facility unsupervised and during the non-scheduled smoking time on 8/14/10, and the resident's smoking privileges were suspended for 24 hours.

A SW Note dated 8/31/10 documented that on 8/28/10 Resident #1 was observed to have exited another resident's room (Resident #22) smelling of cigarette smoke with ashes found on Resident #22's bathroom floor. The note further documented that a smoke detector was to be installed.

A SW Note dated 9/13/10 documented that Resident #1 was observed smoking on 9/11/10 unsupervised. The note further documented that an empty carton of cigarettes was found in the resident's closet and that the residents' smoking privileges were suspended for the day.

A Smoking Comprehensive Care Plan (CCP) dated 6/30/10 documented that resident was a smoker and needed supervision. The interventions on the CCP included: orient resident with smoking safety rules and regulations, smoking hours and re-evaluate smoking privileges at least quarterly and as needed. The evaluation section of the CCP documented that on 7/26/10 that the resident was counseled regarding safe smoking: that on 8/16/10, the resident was placed on 30 minute monitoring. There was no documented evidence of new interventions on the CCP after the 8/16/10 evaluation.

An undated facility policy titled Smoking Policy documented that an Interdisciplinary Team will develop a plan for all smoking residents and evaluate as necessary.

Observations of Resident #1 and Resident #22's rooms were conducted on 9/17/10 at 1:30 PM. There was no evidence of smoke detectors in the rooms.

The Director of Housekeeping was interviewed on 9/17/10 at 1:35 PM. The Director stated that she was not responsible for installing the smoke detectors and that she recalled informing the Maintenance Department that the smoke detectors needed to be installed. The Director further stated that she assumed that they had been installed by the Maintenance Department when she asked for it to be done.

The Maintenance employee responsible for installing the smoke detectors was interviewed on 9/17/10 at 1:55 PM. The employee stated that the smoke detectors had not been installed in the residents' rooms because the facility had to order them. The employee further stated that the smoke detectors had arrived today (9/17/10).

The Director of Social Services was interviewed on 9/20/10 at 10:00 AM. The Director stated that the Recreation Director is responsible for updating the CCP for smoking. The Director stated that she was unaware of who is responsible to search resident's rooms after an unsafe smoking incident is noted.

An interview was conducted with the Director of Recreation on 9/20/10 at 10:05 AM. The Director stated that she was responsible to update the CCP for smoking. The Director stated that she may not have been notified each time the resident had an unsafe smoking incident. The Director also stated that if a resident is identified to be smoking in a room that a smoke detector would be put in the room. The Director further stated that Social Services would be responsible for documenting room searches when completed.

415.12(h)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that the Preadmission Screening and Resident Review (PASRR) was completed as required for 1 (Resident #15) of four residents reviewed for PASRR Screen accuracy in a total of 18 sampled residents. Specifically, Resident #15's medical record review revealed that there was no documented evidence that the resident's PASRR Screen was completed. This resulted in no actual harm with a potential for more than minimal harm that is not an immediate jeopardy.

The finding is:

Resident #15 was admitted on 4/8/10 and has diagnoses including Psychosis and Developmental Delay.

Resident #15's medical record review revealed that there was no documented evidence that the resident's PASRR Screen was completed.

The facility provided a copy of a completed PASRR Screen bearing another patient's name. The name was blackened out and hand written Resident #15's name instead.

The Admission Director was interviewed on 9/20/10 at 1:20 PM and stated that she usually checks the residents pre-admission papers and then the Director of Nursing Services (DNS) checks the resident's pre-admission papers like the PASRR Screen for accuracy. The Director stated that she should have checked that the Screen was filled out for another patient's name.

The DNS was interviewed on 9/20/10 at 1:25 PM. The DNS stated the facility received the PASRR Screen from the hospital and probably received the wrong patient's PASRR Screen.

The facility's policy dated 8/23/10 titled Patient Review Instrument (PRI) and PASRR Screen documented "...A PASRR is required by Federal law that states a level I Screen PASRR (for those with mental illness, mental retardation, or developmental disability) is completed (with limited exceptions) on all patients (home or in a hospital) who seek nursing home admission..."

400.11

Based on record review, observation and staff interviews during the recertification survey, the facility did not ensure that the prescribed treatments were provided in accordance with the physician's orders and written Plan of Care. This was evident for 1 of 2 Pressure Ulcer Treatment observations out of 4 residents reviewed for Pressure Ulcers in a total resident sample of 19. Specifically, Resident #4 was observed to have received the incorrect treatment to four of five Pressure Ulcers (P/U) which was not in accordance with the physicians orders and written plan of care.

The finding is:

Resident #4 has diagnoses which include Peripheral Vascular Disease and Dementia.

The Quarterly Minimum Data Set (MDS) Assessment dated 7/7/10 documented that the resident had severely impaired cognition for daily decision making. The MDS also documented that the resident was dependant on staff for all activities. The MDS documented that the resident had three Stage III P/Us and four Stage 4 P/U.

The Physician's Orders dated 9/13/10 documented the following treatment of Santyl Ointment 250/Grams after cleansing with Normal Saline Solution -Pat dry-and cover with dry dressing to the following Stage IV Pressure Ulcers: (1) Left Buttock Pressure Ulcer,(2) Left Heel, (3)Left Outer Calf and (4) Right Heel.

The Physician's Order dated 9/13/10 documented that the Stage IV Pressure Ulcer to the resident's upper back was to be cleansed with Normal Saline-pat dry-apply Santyl Ointment followed by Calcium Alginate on the undermining area.

The Treatment Administration Record (TAR) dated 9/2010 was reviewed. The physician's treatment orders were documented as he had prescribed on 9/13/10.

During treatment observation on 9/15/10 at 11:00 AM the Licensed Practical Nurse (LPN) was observed to remove Calcium Alginate packing from each of the five P/Us. There was no physician's order for packing all the wounds.

The LPN/Treatment Nurse confirmed during an interview on 9/15/10 at 11:00 AM that the Calcium Alginate packing was ordered by the physician for the upper back P/U only.

The LPN/Treatment Nurse who signed that the treatments were completed as ordered on 9/14/10 was interviewed on 9/20/10 at 11:00 AM. The LPN was unable to explain why all the P/Us had the Calcium Alginate packing.

During an interview with the Director of Nursing Services/DNS on 9/20/10 at 11:30 AM, the DNS stated that she would expect the nurses to follow the doctor's orders as written.

415.12 (c)(1)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that reassessments of low blood sugars were completed after treatment was administered for 1 (Resident #15) of 19 total sampled residents reviewed. Specifically, Resident #15 had 9 episodes of low fingerstick (FS) blood sugar level ranging from 42 milligram per deciliter (mg/dl) to 56 mg/dl during the period from 4/9/10 through 5/13/10 at 6:00 AM and 9/7/10 at 4:30 PM. There were no documented evidence that a repeat fingerstick was done to determine the clinical status of the resident. There were also no documented evidence that the licensed nursing staff notified the Physician of the low FS in a timely manner. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. (Resident #15)

The finding is:

Resident #15 has diagnoses including Hypoglycemia, Diabetes Mellitus (DM) and Mental Retardation.

The Admission Minimum Data Set (MDS) Assessment dated 4/15/10 documented that the resident had moderately impaired cognition and was diagnosed as Developmental Delay Mental Retardation and DM.

The Comprehensive Care Plan (CCP) for DM dated 4/8/10 documented to monitor blood sugar four times daily and to administer Lantus 20 Units at 9:00 AM daily.

The Physician's orders dated 4/9/10 through 5/11/10 had frequent changes made to the times of FS completions and insulin coverage.

The resident's Blood Glucose Testing and Insulin Coverage Form from 4/8/10 through 5/13/10 contained the following documented FS below 60 at 6:00 AM monitoring:
4/09/10- 56 mg/dl
4/29/10- 44 mg/dl
5/02/10- 45 mg/dl
5/05/10- 48 mg/dl
5/06/10- 53 mg/dl
5/08/10- 42 mg/dl
5/09/10- 44 mg/dl
5/11/10- 50 mg/dl
5/13/10- 43 mg/dl
Additionally, on 9/7/10 at 4:30 PM with FS at 49 mg/dl.

The nurses' notes reviewed from 4/9/10 through 5/13/10 revealed no documented evidence that repeat of FS monitor was obtained to determine if the treatment administered for the low FS was effective or not. There was also no documented evidence that the Physician was notified in a timely manner once the low FS was established.

The 4/9/10 Nurse's Note at 6:30 AM documented that the resident's FS was at 39 mg/dl. The Physician was notified after orange juice was administered. A repeat FS was done at 7:00 AM with 56 mg/dl. There was no further documented evidence that a follow up of FS or that the Physician was made aware of the resident's clinical status after the second low FS.

The Unit's 24 Hour Report did not have documented evidence that these low FS on the above mentioned dates were addressed, or a repeat FS was done or that the Physician was notified.

The Registered Nurse (RN) Unit Supervisor was interviewed on 9/20/10 at 10:00 AM. The RN stated that a recheck fingerstick blood of a previously low FS is not completed unless there was a Physician's order to do so.

The Unit Licensed Practical Nurse (LPN) was interviewed on 9/20/10 at 12:35 PM. The LPN stated that the facility's practice whenever the FS blood sugar is low was to administer orange juice/sugar packets or glucose gel and then inform the nursing supervisor. The LPN further stated that there was no further rechecking of the resident's FS blood sugar unless they were instructed to do so by the nursing supervisor.

The Director of Nursing Services (DNS) was interviewed on 9/20/10 at 12:40 PM. The DNS stated the when a resident's FS was identified as low, usually a follow up FS should be done within 10 minutes and notify the Physician. The DNS further stated that FS below 60 is significant. The DNS also stated that the licensed nursing staff should document what supplement was administered to the resident, that a repeat FS was done within 10 minutes and that the Physician was notified.

The Medical Director was interviewed on 9/20/10 at 1:35 PM. The Director stated that it will be according to the licensed nursing staff's nursing judgement to initially treat the resident's low FS blood sugar and to call the Physician. The Director further stated that there should be a follow up recheck of the resident's FS blood sugar to determine the clinical picture/status within 15-30 minutes after administering an orange juice/sugar packets or glucose gel.

The facility's policy dated 5/21/10 titled Blood Glucose Monitoring Using Blood Glucose Monitoring Meter documented "... Nurse will notify Physician or RN Supervisor if FS is below 60 or greater than 400. Nurse will use nursing judgment and repeat FS as necessary to ensure good care or as indicated by Physician order." The policy did not indicate as to what interventions were to be administered by the licensed nursing staff for FS below 60.

415.12

Based on record review and staff/family interviews during the recertification survey, the facility did not ensure that Advanced Directive wishes had been honored as requested by a resident's legal representative. This was evident for one resident in a total of 19 reviewed. Specifically, Resident #11's Health Care Proxy (HCP) designated representative requested on 4/6/10 that the resident have an order for Do Not Hospitalize (DNH). The resident was documented to have been transferred to the hospital on 5/16/10 without timely notification to the HCP agent. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. nene The finding is:

Resident #11 was admitted to the facility on 4/3/09 with diagnoses including: Diabetes Mellitus (DM) and Hypertension.

The Minimum Data Set (MDS) Assessments dated 4/3/09 through 7/4/10 documented that the resident was severely impaired with cognitive skills for daily decision making. The MDSs also documented that the resident had a diagnoses of DM.

A facility form titled Admission and Discharge Information dated 4/3/09 documented that the resident had a HCP and had other Advanced Directives including Do Not Hospitalize (DNH). The form also documented contact information for the resident's designated health care representative.

A facility memorandum completed by the Director of Nursing (DNS) addressed to "All Physicians & Nursing Staff" dated 1/15/10 documented that the resident's designated health care agent was to be contacted with any changes in the resident's condition. The memorandum also document that the resident was on Palliative Care and was DNH.

The Physician's Orders dated 5/7/10 documented that the resident had a HCP and an Advanced Directive including DNH.

A Nursing Note dated 5/16/10 at 10:00 PM documented that the resident was in no distress and was documented to have had a normal temperature, pulse and respirations.

A Physician's Order dated 5/16/10 at 11:30 PM documented an order to transfer the resident to the hospital to evaluate for Respiratory Distress.

A Nursing Note dated 5/17/10 at 1:10 PM documented that at 11:35 PM an ambulette was called to transfer the resident to the hospital because the resident was found congested, was suctioned and identified to have had an Oxygen Saturation of 85%-89% (normal range 95% - 100%). The note documented that the resident left the nursing unit at 12:43 AM. The note also documented that the resident's designated health care agent was called at 12:50 AM. The note further documented that the designated health care agent called back at 12:55 AM and requested that the resident be returned to the facility.

A Physician's Order dated 5/17/10 at 1:25 AM documented orders for Oxygen 2 liters/minute when the resident returns from hospital, and Tylenol 650 milligrams by mouth every 4 hours as needed for fever.

A Nursing Note dated 5/17/10 at 3:05 AM documented that the resident returned to the facility at 2:47 AM in no acute distress.

An interview was conducted on 9/17/10 at 1:40 PM with the 11:00 PM - 7:00 AM Registered Nurse (RN) Supervisor who completed Resident #11's hospital transfer on 5/17/10. The RN stated that she was aware that the resident was a DNH resident. The RN stated that when she told the Physician that the resident was DNH the Physician told her to send the resident out anyway. The RN also stated that she felt obligated to follow the Physician's order but, knew that the resident should not have been transferred to the hospital.

The Physician who gave the order to transfer the resident to the hospital no longer is employed by the facility.

An interview was conducted with the facility Medical Director on 9/20/10 at 10:00 AM. The Director stated that Resident #11 should not have been transferred to the hospital without prior consent of the designated representative.

415.3 (e) (1) (ii)

Based on observation, resident and staff interviews during the recertification survey, the facility did not provide an environment that enhanced each resident's dignity and respect in full recognition of their individuality on 2 of the 2 facility units. Specifically, the facility did not promote residents' independence and dignity in dining as evidenced by the daily use of plastic cutlery and styrofoam dishware. In addition, the residents' were given plastic bibs daily as clothing protectors. This resulted in no actual harm with the potential for minimal harm.

The findings is:

During breakfast dining observations on 9/15/10 at 8:35 AM and subsequent lunch dining observations at approximately 12:00 PM on 9/15/10 through 9/17/10 and 9/20/10, residents were observed to have had their food placed in front of them served on trays with styrofoam plates. Plastic Utensils and plastic bibs as clothing protectors were also being utilized.

During the Group Interview on 9/15/10 at 1:30 PM with 10 alert and lucid residents, 9 of the 10 residents stated that they would prefer china plates and "real" utensils, not styrofoam and plastic. In addition, 10 of the 10 residents stated that this request had been brought up during the last two Food Committee Meetings without resolution.

The Administrator was interviewed on 9/20/10 at 11:30 AM. The Administrator stated that the order had been placed for the china to be used for the Dairy meal only and that the facility was still trying to pick out a pattern for the Meat meal.

415.5(a)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that, upon a resident's death, the funds were conveyed within 30 days as required. The was evident for 1 of 3 closed records in a total of 19 residents reviewed. Specifically, Resident # 17 who expired in the facility on 7/25/10 did not have their funds returned to the appropriate agency in a timely manner. This resulted in no actual harm with the potential for Minimum harm.

The finding is:

Resident #17 has diagnoses that include Dementia and Diabetes Mellitus.

The Resident was originally admitted to the facility on 5/22/96. According to the face sheet, there are two cousins identified as the Designated Representative and Health Care Proxy.

A review of the medical record documented that the resident had expired in the facility on 7/25/10.

A personal account ledger for Resident #17 dated 9/ 20/10 documented that as of 7/27/10 the resident had $786.20 in their account.

There was no documented evidence that the remaining funds in the resident's personal account were conveyed to the appropriate party for almost two months.

A Business Office staff member directly responsible for personal accounts was interviewed on 9/20/10 at 12:45 PM. The office staff member stated that the facility was looking for family of Resident #17 before closing out the person account. A letter to the family regarding closing the account could not be produced by the office staff member.

The Public Administrator of Queens County was contacted on 9/20/10 at 1:00 PM. The interview revealed that cousins do not qualify as family for Medicaid money remaining in a resident's account at the time of there demise. The interviewee further revealed that the money should have been forwarded to the Public Administrator within 30 days after the resident's demise.

The Administrator was interviewed on 9/20/10 at 2:00 PM. The administrator stated that she was unaware that the funds had not been conveyed to the appropriate agency. The administrator further stated that she would ensure that a check was issued immediately.

415.26 (h)(5)(iv)

1999 NFPA 99 Chapter 16-3.8.1 states that equipment shall conform to requirements for patient equipment in Chapter 8.

1999 NFPA 99 Chapter 8-3.1.11.2 states that: Storage for nonflammable gases less than 3000 ft3 (85 m3).
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

1999 NFPA 99 4-3.5.2.1 (b)(27) states that: Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation and staff interview, 1) three oxygen tanks were observed stored freestanding and directly on the floor unchained and not supported in a proper cylinder stand or cart; and 2) 11 oxygen tanks were stored in two plastic crates. This was noted in the main oxygen storage room located in one of two resident units.

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

The finding is:

On 9/15/10 at approximately 10:35am during the recertification survey, the following was noted:

1) Three oxygen tanks (e tanks) in the main oxygen storage room in the East unit were observed stored freestanding and directly on the floor unchained and not supported in a proper cylinder stand or cart.
2) The main oxygen storage room was noted not sprinklered. 11 e tanks were observed stored in two plastic crates. Storage of combustibles are required to be separated by a minimum distance of 20 feet.

In an interview on 9/15/10 at approximately 10:35am, the Director of Maintenance stated that he would inform staff to put the e tanks in the carts or stand. He further stated that he will order the appropriate rack immediately.

1999 NFPA 99: 4-3.5.2.1 (b)(27), 8-3.1.11.2
711.2(a)(1)

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued.

Include your request for renewal of this waiver, or plan of correction in the space provided on this form.

A soiled linen shed is located at the West Wing exit. If it became involved with fire, it could obstruct the exit. 7.1,19.2.1.

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued.

Include your request for renewal of this waiver, or plan of correction in the space provided on this form.

A copy machine is located in the alcove adjacent to the administration office. This alcove opens into the lobby. 19.3.2.1.