Brookhaven Rehabilitation & Health Care Center LLC

Based on observation and staff interviews, during the recertification survey, the facility did not ensure that housekeeping and maintenance services maintained an orderly interior. Reference is made to the following:

1. Brown stained ceiling tiles on 4 of 6 resident floors.
2. Peeling wallpaper and brown splash stain in the corridor on 1 of 6 resident floors.

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

The findings are:

During environmental inspections 02/14/11 between 9:30am and 3:00pm the following was observed:

1. Brown stained ceiling tiles were observed in the following areas:

6th floor:
- 1 each in rooms 634, 633, and in the dining room.
- 1 each in the corridor in front of room 606, opposite the soiled linen room.
- 1 behind the nursing station.

5th floor:
- 3 in front of the elevator lobby

4th floor:
- 2 by the window in the dining room

2. Brown splash stains were observed on the corridor wall between rooms 630 and 631 of the 6th floor. The stains were observed multiple times throughout the Environmental survey. An approximate 3 feet section of peeling wallpaper was observed on the wall of the 6th floor elevator lobby.

In an interview on the same day at approximately 1:45 PM the Director of Maintenance stated that there are some isolated leaks from the ceiling that has to be addressed weather permitting. He further stated that the stained ceiling tiles would be changed and that the other identified areas would be addressed.

NYCRR 415.5(h)(2)
415.29

Based on observation, staff interview, and record review during the recertification survey, the facility did not store food, did not process and maintain food contact utensils/equipment, and did not maintain the kitchen environment under safe and sanitary conditions to prevent potential food contamination and food borne illness. Reference is made to the following:

1. Improper food storage.
2. Undated/unlabelled prepared food, and partially used food items.
3. Improper processing of food contact utensils.
4. Improperly maintained food contact and storage equipment, and food preparation areas.

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

The findings are:

During the kitchen inspection on 02/14/11 between 8:15am and 9:30am the following was observed:

1. Improper food storage was observed as follows:

- Approximately 6 trays of raw chicken were stored on a shelf above boxes of okra and wax beans in walk-in freezer #1
- 2 boxes of vegetable margarine (1 partially used) were stored directly on the floor in a 3-compartment cook's refrigerator.
- 2 cans of uncovered and partially used rosemary leaves were observed on a storage shelf adjacent to the cook's refrigerator.

In an interview on the same day at approximately 8:45am the Food Service Director (FSD) stated that the items were improperly stored and contacted a dietary employee to address the storage issues when they were pointed out.

2. (a) Undated/unlabelled prepared food was observed as follows:

- 3 trays of individual containers of cottage cheese, 1 tray of individual tray of Jello, and 1 tray of individual sliced cheese were not labeled/dated and stored in the cook's refrigerator.
- 1 tray of individual containers of pudding was not labeled and stored in walk-in refrigerator #1

2. (b) The following undated partially used food items were observed on a storage rack adjacent to the cook's refrigerator:

- 2 plastic containers of egg yellow
- 2 bags of creamy mashed potato
- 1 plastic container of granulated onion
- 1 plastic container of pure honey
- 1 plastic container of soy sauce
- 1 plastic container of white vinegar

In an interview on the same day at approximately 9:15am the FSD stated that all food items are supposed to be dated when placed in storage and that the individual containers of food items are supposed to be dated when they are opened. A review of the facility's policy and procedure for " rotation of foods " on the same day at approximately 12:45pm did not indicate dating of opened food, and dating of prepared food in storage. No additional documentation was provided to address the dating of prepared and opened foods.

3. Improper food contact utensil handling was observed during an observation of the dishwashing machine operating features. At approximately 9:00am a dietary employee was observed placing the soiled eating utensils in the dishwashing machine and retrieving the clean utensils with the same gloves/without changing cloves. The FSD immediately instructed the dietary employee to rewash the eating utensils and contacted another dietary employee to retrieve the clean utensils in order to prevent potential cross contamination.

4. Improperly maintained food contact and storage equipment, and an improperly maintained kitchen environment were observed as follows:

- 7 plastic food carts that are used for transporting food items within the kitchen contained scratch marks/crevices and discolorations on their outer surfaces.
- a three compartment cook's refrigerator contained sections of peeling gaskets with stains on all three doors, and one section of the door frame contained an approximate 3 feet section of a spongy/porous material.
- a light fixture each was not working by the toaster, by the dishwasher and in the porter's closet located in the kitchen.

In an interview on the same day at approximately 9:25am the FSD stated that all the plastic food carts would be inspected and replaced as necessary and that the refrigerator gasket and the light fixtures would be brought to the attention of the maintenance department to be addressed.

NYCRR 415.14(h)
Chapter 1 SSC Subpart 14-1

Based on record review and staff interviews during the recertification survey, the facility did not ensure that all residents received appropriate and timely treatment and services to address documented mental and psychosocial difficulties. This was evident for 1 of 30 sampled residents reviewed for psychosocial assessment. Specifically, Resident #11 was identified by the facility's Social Worker (SW) to have had Suicidal Ideations upon admission and was referred to Psychology on 1/5/11. The resident was not seen by the Psychologist until 1/10/11. There was no documented evidence of a Comprehensive Care Plan (CCP) developed related to the resident's Suicidal Ideation and the resident was not seen by a Psychiatrist until 2/8/11 when medication was recommended for a new diagnosis of Depressive Disorder. 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 1/4/11 with diagnoses including Morbid Obesity and Status Post Tracheostomy placement.

A Psychosocial Assessment dated 1/4/11 completed by a facility SW (SW #1) was reviewed. The SW documented that Resident #11 was oriented to person, place, and time and had no long or short-term memory problems. The SW documented that the resident was fearful and emotional and did not present with any behavioral symptoms during the assessment. The SW documented that the Mood interview from the MDS 3.0 had been completed.

A SW Note dated 1/5/11 documented that Resident #11 was tearful and admitted to having thoughts of hurting herself. The SW documented that the Nursing Supervisor was made aware of the suicidal ideation and a "Psych" (psychiatric) consultation was initiated.

A Patient Referral Form for Psychological Services dated 1/5/11 completed by the facility SW was reviewed. The sections on the referral form designated to document psychological symptoms and the section for behavorial health concerns was blank.

A CCP titled Mood dated 1/5/11 documented that Resident #11 indicated that they felt bad about themselves. Interventions on the CCP included Psychiatry consults as needed, emotional support as needed, and SW to provide 1 on 1 visits. There was no documented evidence on the CCP of Resident #11's suicidal ideations.

An Interim Physician's Order Form dated 1/6/11 documented an order for a Psychodiagnostic Evaluation and Psychotherapeutic Services as needed.

An Interim Physician's Order Form dated 1/8/11 documented an order for a Psychiatric Evaluation for Anxiety.

A Psychologist Initial Diagnostic Interview dated 1/10/11 documented that Resident #11 was referred for services by the SW for Suicidal Ideation, Difficulty Sleeping, Depression, and Anxiety. The Psychologist documented that the resident presented with Adjustment Disorder with Depressed Mood.

A SW Note dated 1/13/11 documented that the resident was transferred to another unit at the resident's request and was assigned a new SW (SW # 2).

An Minimum Data Set (MDS) 3.0 Assessment dated 1/17/11 documented that Resident #11 was cognitively intact. The section of the MDS titled Mood documented that the resident presented with the following symptoms 12-14 days during the past two weeks: feeling down, depressed, or hopeless, thought that they would be better off dead, and thought of hurting themselves in some way. The section of the MDS titled Behavior documented that the resident presented with physical behavioral symptoms toward others and other behavioral symptoms 1 to 3 days and verbal behavioral symptoms 4-6 days. The MDS documented that the behavioral symptoms significantly interfered with the resident's care and participation in activities and or social interactions. The MDS also documented that the behavioral symptoms significantly impacted others and put others at risk of physical injury, intruded on the privacy of others and disrupted care or living environment.

There was no documented evidence in the resident's medical record or 24 Hour Nursing Reports between 1/4/11 and 2/18/11 that the Nursing Department was aware or implemented interventions related to the resident's suicidal ideations. However, The MDS dated 1/17/11 documented in Section D Mood that the resident had thoughts that they would be better off dead, or of hurting themselves in some way.

A Psychiatric Evaluation dated as completed on 2/8/11 (one month after being ordered on 1/8/11) documented that Resident #11 was diagnosed with Depressive Disorder. The Psychiatrist documented an intervention including to add Celexa (an antidepressant medication) 10 milligrams by mouth every morning. The Psychiatrist did not mention the suicidal ideation.

An interview was conducted on 2/18/11 at 9:30 AM with the SW (SW #2) responsible for Resident # 1 as of 1/13/11. The SW stated that she was not aware that the resident had a history of suicidal ideation. The SW stated that the SW that completed the admitting Psychosocial Assessment (SW #1) should have informed her of the resident's suicidal ideations. The SW stated that the SW department was responsible for developing CCPs addressing mood and that there should have been a CCP developed specifically to address Resident #11's suicidal ideations.

An interview was conducted on 2/18/11 at 10:00 AM with the Registered Nurse (RN) Charge Nurse responsible for Resident #11. The RN stated that she was not aware of Resident #11's suicidal ideations. The RN also stated that if any resident made a statement related to suicidal thoughts, the resident should be seen by a Psychologist or Psychiatrist the same day.

An interview was conducted on 2/18/11 at 10:20 AM with the SW that was responsible for Resident #11 from admission on 1/4/11 through 1/13/11 (SW #1). The SW stated that she recalled completing the Psychology referral for Resident #11's suicidal ideations and that she should have also added a CCP for suicidal ideations with interventions related to the statements the resident had made. The SW stated that Nursing was made aware and that they should have implemented their own plan related to the suicidal ideations.

An interview was conducted on 2/18/11 at 10:30 AM with the Director of Nursing Services (DNS). The DNS stated that she was not aware of Resident # 11's suicidal ideations and that she should have been. The DNS stated that the resident should have been placed on 24 Hour Report and that one on one monitoring should have been implemented until the resident was cleared by a Psychiatrist. The DNS further stated that the Psychiatry evaluation should have been completed within 48 hours.

415.12(f)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that residents' Comprehensive Care Plans (CCPs) are periodically reviewed and revised by a team of qualified persons after each assessment. This was evident for 1 of 30 sampled residents reviewed for plan of care. Specifically, Resident #21 had a Urinary Tract Infection (UTI) on 2/5/11 and was treated with an antibiotic. There was no documented evidence that the CCP for UTI was revised to reflect the resident's current health status. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #21 has diagnoses including UTI and Urosepsis.

The Minimum Data Set (MDS) Quarterly Assessment dated 1/28/11 documented that the resident was independent in cognition.

The urine culture specimen laboratory report collected on 2/4/11 and reported on 2/7/11 revealed that the urine collected had a positive culture for \i Escherichia coli (a microorganism commonly found in the lower intestine) with greater than 100,000 colonies observed and provided a list of sensitive and resistant antibiotics.

The Physician's Order dated 2/5/11 documented Rocephin (an injectable antibiotic) 1 gram (gm) intramuscularly (IM) once daily for 7 days for UTI.

The Nurse's Note dated 2/5/11 documented that the resident had a temperature of 101.5 Fahrenheit (F) and 102.5 F. The Note also documented that Rocephin 1 gm IM once daily for 7 days was ordered.

The February 2011 Medication Administration Record (MAR) documented that the resident was administered with Rocephin 1 gm IM once daily for 7 days with a diagnosis of UTI from 2/5/11 through 2/11/11.

The Comprehensive Care Plan (CCP) developed for Acute Condition Related to UTI was last updated 1/13/11 and documented that the resident completed Augmentin (an antibiotic) treatment for UTI. There was no documented evidence that the CCP was updated for the 2/5/11 UTI.

The Registered Nurse (RN) Charge Nurse was interviewed on 2/18/11 at 9:30 AM and stated that there was no update of the CCP related to UTI for the 2/5/11 UTI episode. The RN further stated that the CCP should have been updated for the 2/5/11 UTI.

The RN MDS Coordinator was interviewed on 2/18/11 at 9:45 AM and stated that it was the responsibility of the Unit Charge Nurse to update the CCP for an acute condition.

483.10(k)(2)

Based on observations, record review and staff interviews during the recertification survey the facility did not ensure that interventions were implemented to prevent accident hazards after identifying that resident's were at risk for accidents. This was evident for 1 of 30 residents reviewed in a total of 30 records. Specifically, Resident #4 sustained a fall on 11/28/11 without documented new interventions 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 #4 has diagnoses including Dementia and Hypertension.

The Minimum Data Set (MDS) Assessments dated 8/10/10 and 1/28/11 documented that Resident #4 had moderately impaired cognitive skills for daily decision making and both long and short-term memory problems. The MDS's documented that the resident required extensive assistance and staff support for transferring. The MDS's documented the resident did not walk in the room or the corridor. The MDS dated 8/10/10 documented that the resident sustained a fall within the past 30 days. The MDS dated 1/28/11 documented that the resident had sustained a fall with an identified injury during the past assessment period.

A Comprehensive Care Plan (CCP) dated 6/1/09 an updated through 1/31/11 documented that Resident #4 was at risk for falls secondary to visual impairment, history of falls and dementia. Interventions documented on the CCP included one person assistance with transfer, bed alarm, chair alarm and resident education.

Five Fall Risk Assessments dated 8/2/10 through 1/28/11 for Resident # 4 were reviewed and documented that Resident #4 had intermittent confusion, poor vision and received a total risk score between 13 through 19 (Note: total score of 10 or above represents high risk).

A Nurse's Note dated 11/28/10 documented that a staff nurse heard an alarm and responded to Resident #4's room and found the resident on the floor at the side of the bed at 7:00 PM. The note documented that the resident was noted with period of confusion and was noted with abrasion on right upper arm. New interventions added after the occurrence where to remind the resident to use the call bell. Physical Therapy was to assess the transfer status however, the resident's fall was not related to a transfer. Additionally, the resident was to be toileted every two hours however, the resident was already on a toileting schedule.

On 2/17/11 at 11:50 AM the Director of Nursing Services (DNS) was interviewed. The DNS stated that education would not be enough
to prevent falls from reoccurring. The DNS further stated that a low bed or matts should have been added to the plan of care.

On 2/17/11 at 2:00 PM the Director of Physical Therapy (PT) was interviewed. The PT stated that addressing the transfer status of Resident #4 would not have been appropriate because the fall did not occur during a transfer.

415.12 (h)(1)(2)

Based on a resident group interview and test tray results during the recertification survey, the facility did not consistently serve hot and cold food items at their proper temperatures to assure palatability. Specifically, 7 of 9 residents present for a group interview complained that food intended to be hot was served cold and food intended to be cold was served warm. Test tray temperatures were conducted on 3 of 5 units in addition to the Main Dining Room. Two of the three units tested (the 4th and 6th Floor Units) were noted to have food temperatures as not being palatable. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) On 2/15/11 at 11:00 AM during a group meeting with 9 residents, identified as alert and oriented by the facility, 7 residents complained that food intended to be served hot was often served cold and food intended to be cold was often served warm.

2) On 2/16/11 at 6:30 AM in the facility kitchen, test trays were requested for 4 of the dining areas available for service during the breakfast meal. The Food Service Director (FSD) calibrated thermometers that were used during the breakfast meal observations that followed.

a) The 4th Floor 2nd meal tray service arrived on the unit at 8:00 AM and meal service began at 8:00 AM. The last resident was served at 9:10 AM, 1 hour and 10 minutes after the 2nd meal tray service arrived to the 4th Floor Unit. The test temperatures were taken at 9:10 AM in the presence of the Registered Nurse (RN) Supervisor.

Regular Food Items Temperature in degrees Farenheit (F)

-milk 60 degrees F
-orange juice 58 F
-sausage 106 F
-egg 102 F
-oatmeal 102 F

Pureed Food Items Temperature Farenheit (F)

-milk 62 degrees F
-orange juice 60 F
-sausage 102 F
-egg 112 F
-oatmeal 102 F

b) The 6th floor 3rd meal truck arrived on the unit at 7:20 AM. At 7:40 AM the last resident was fed. The test tray temperatures were taken at 7:40 AM with the RN present. The orange juice on the test tray was recorded at 51.8 F.

The Food Service Director was interviewed on 2/18/11 at 9:30 AM and stated that he seldom gets complaints regarding cold food. The FSD also stated that the hot food items should reach the residents at no less than 120 F. The FSD further stated that the problem was the meal tray distribution on the floor/Unit by the nursing staff that could result in lowering or raising the food temperatures by the time the meal tray was served to the resident.

415.14(d)(1)(2)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that the physician reviewed the total program of care. This was evident for one of thirty sampled residents reviewed. Specifically, Resident #20 was identified by the physician as being non-compliant with a prescribed therapeutic diet, and there was no documented evidence in the medical record of the resident's non-compliance. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1) Resident #20 has diagnoses including Uncontrolled Diabetes Mellitus and End Stage Renal Disease.

The Quarterly Minimum Data Set (MDS) Assessment dated 9/2/10 documented that the resident had long and short-term memory problems and had moderately impaired cognitive skills for daily decision-making.

Physician's Orders dated 10/11/10 through 1/3/11 documented a Renal, No Concentrated Sweets diet.

An Endocrinology Consult dated 9/17/10 documented that Resident # 20 had Type 2 Uncontrolled Diabetes Mellitus and recommendations included to return to the Endocrinology Clinic in December for a follow-up.

A Physician's Order dated 10/13/10 documented to discontinue the Endocrinology consult. There was no further documented evidence that the resident returned to the Endocrinology Clinic.

A review of the Medication Administration Record (MAR) between 11/5/10 and 2/16/11 documented nineteen episodes of Hyper/Hypoglycemia requiring notification to the Physician for intervention.

A telephone interview was conducted on 2/18/11 at 10:00 AM with the Physician responsible for Resident #20. The Physician stated that the Endocrinology Clinic appointment was canceled because the resident has a history of non-compliance with his diet, and until the resident follows his diet, recommendations made by the Endocrinologist would not help him. The Physician further stated that the resident was observed with snacks and he also took food to dialysis and the Physician had repeatedly counseled the resident with no improvement in compliance.

A review of the Physician Medical Progress Notes from 10/11/11 through 2/7/11 documented that Resident #20 had no complaints and was comfortable. There was no documented evidence of Resident #20's non compliance with the therapeutic diet prescribed.

A review of the Comprehensive Care Plan (CCP) dated 4/7/08 and updated 11/29/10 titled Nutritional Assessment Interdisciplinary Care Plan documented that Resident #20 often has a very good appetite and was compliant with medications. There was no documented evidence on the CCP that the resident was non-compliant with his diet.

A CCP titled Diabetes dated 4/7/08 and updated 1/12/11 documented diet as ordered and monitor appetite and for signs and symptoms of Hypo/Hyperglycemia. There was no documented evidence on the CCP that Resident #20 was non-compliant with his diet.

A CCP titled Behavior dated 4/17/09 and updated 11/29/10 documented that the resident was socially inappropriate at times and verbally disruptive. There was no documented evidence on the CCP that the resident was non-compliant with his diet.

The Dietitian responsible for Resident #20 was interviewed on 2/28/11 at 1:00 PM and stated that she was not aware that Resident #20 was non-compliant with his diet. The Dietitian further stated that if the resident was non-compliant, it would be documented on the Nutritional Assessment CCP.

The Registered Nurse (RN) Charge Nurse responsible for Resident #20 was interviewed on 2/18/11 at 1:00 PM and stated that she was not aware that Resident #20 was noncompliant with his diet and never saw Resident #20 bring in food from outside the facility. The RN stated that if the resident was non-compliant, it would be documented on the Nutritional Assessment CCP.

The Certified Nursing Assistant (CNA) responsible for Resident #20 was interviewed on 2/18/11 at 1:30 PM and stated that she was not aware of Resident #20 bringing in food from outside the facility.

415.15(b)(2)(iii)

Based on record review and staff interviews during the recertification survey, the facility did ensure that all residents received the necessary care and services necessary to attain or maintain their highest practicable wellbeing. This was evident for 1 of 30 sampled residents reviewed for plan of care. Specifically, there was no documented evidence that Resident #19, who had no bowel movement for 4 days and one shift, that the assigned Certified Nursing Assistant (CNA) notified the Nurse. There was also no documented evidence that the Nurse notified the Physician for further bowel management per facility policy for Resident #19. This resulted in no actual harm with the [potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #19 has diagnoses including Chronic Constipation, Hypothyroidism, and Dementia.

The MDS Annual Assessment dated 1/6/11 documented that the resident was severely impaired in cognition, required total dependence of one person assist for toilet use and personal hygiene, and always had bowel incontinence.

The Comprehensive Care Plan (CCP) developed for Constipation dated 1/12/11 documented to refer to the Physician if the resident had no bowel movement after 3 days.

The Physician Order's dated 1/30/11 documented medications including Colace 200 milligrams (mg) orally at bedtime, Senokot 2 tablets orally at bedtime, and Lactulose 20 grams orally twice daily, all for Constipation.

The February 2011 CNA Accountability Record (CNAAR) documented that the resident had no bowel movement from 2/12/11 through 2/16/11 for a total of 4 days and one shift.

The February 2011 Treatment Administration Record (TAR) documented a Fleet enema (laxative) to be inserted rectally every other day as needed for Constipation. The TAR contained no documented evidence that the resident was offered a Fleet enema from 2/14/11 through 2/16/11.

The Unit's 24 Hour Report from 2/14/11 through 2/16/11 contained no documented evidence that the resident's bowel status was addressed.

The Nurse's Notes from 2/14/11 through 2/16/11 revealed no documented evidence that the assigned CNAs had notified a Nurse that the resident did not have a bowel movement in 3 days, that a Fleet enema was offered to the resident, or that the Physician was notified of the resident's bowel status.

The assigned CNA for the 7-3 PM shift that worked on 2/15/11 and 2/16/11 was interviewed on 2/17/11 at 9:30 AM. She stated that she could not recall if she had notified the Nurse on 2/15/11 or 2/16/11 that the resident had no bowel movement for 3 days. The CNA also stated that the other shift's CNA's could have reported that the resident did not have a bowel movement to their respective Charge Nurse.

The Registered Nurse (RN) Medication and Charge Nurse were interviewed on 2/17/11 at 9:45 AM and stated that the CNAs did not report or notify them that the resident had no bowel movement for 3 days. The RN Charge Nurse also stated that the 11:00 PM-7:00 AM shift Charge Nurse reviews and monitors the residents' bowel movements.

The Director of Nursing Services (DNS) was interviewed on 2/18/11 at 11:00 AM and stated that the CNA should have reported to the Nurse that the resident did not have a bowel movement for 3 days so the Physician could be notified for further appropriate bowel management.

The facility's policy revised 9/2009 Titled Bowel Management Policy and Procedure documented "... The 11-7 nurse will review the documentation of bowel function daily and will inform the 7-3 nurse if follow up is needed ... The CNA on all shifts alerts the charge nurse if resident has not had a bowel movement in 3 days ...The Charge nurse when informed by CNA of residents who have not had a bowel movement in 3 days will monitor the resident and if no BM by the 4th day, give resident Milk of Magnesia 30 cubic centimeter (cc) ... Places the resident on the 24 hour report ... Revises and updates the care plan ... notifies the Physician for further orders ...".

483.25

Based on record review and staff interviews during the recertification survey, the facility did not ensure that all residents were provided with interventions to maintain documented declines of acceptable parameters of nutritional status. This was evident for one of nine residents reviewed for Nutrition in a total sample of 30. Specifically, Resident #9 had documented Prealbumin (a laboratory blood test used to determine current levels of protein status) values that were identified to have been below normal limits and/or have declined between 9/15/10 and 2/18/11 without new nutritional interventions attempted to prevent a further decline in Prealbumin status. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #9 has diagnoses which include Failure to Thrive, Dementia, and a Stage IV Decubitus/Pressure Ulcer (P/U).

The Minimum Data Set (MDS) Assessments dated 2/8/10 through 1/20/11 documented that the resident was severely impaired with cognitive skills for daily decision-making. The MDS's also documented that the resident had P/U's including one Stage IV.
The MDS also documented the resident's eating status as total dependence on one person.

A Comprehensive Care Plan (CCP) titled Nutritional Interdisciplinary Care Plan dated 6/17/09 documented that Resident #9 had compromised nutritional status secondary to issues including: poor appetite, P/Us, Failure to Thrive, and Dementia. The CCP interventions included liquid nutritional and protein supplementation, monitor labs as per Physician's Orders, and monitor food/liquid intake.

A Dietary Assessment dated 8/4/10 documented that Resident #9 was on a pureed diet, received Ensure (a liquid nutritional supplement) 240 milliliters (ml) four times per day, ice cream added to lunch and supper, and received an appetite stimulant. The Assessment documented that the resident had an Albumin of 3.7 grams/deciliter (g/dl) (reference range 3.2-4.7) and a Prealbumin of 12.27 milligrams/deciliter (mg/dl) (reference range 17.00-42.00) indicative of moderate visceral protein depletion. The Assessment documented that the resident had poor-fair intake and received supplements to increase micro/macro nutrient intake. The Assessment also documented that the resident's family visits often and assisted with meals and snacks to increase consumption.

A Laboratory (Lab) for Resident #9 dated 9/15/10 documented that the resident had a Prealbumin of 10.80 mg/dl and an Albumin level of 3.3 g/dl (reference range 3.2-4.7).

A subsequent Nutrition Services Pressure Ulcer Assessment dated 10/25/10 documented that the resident was receiving a pureed diet, Ensure 240 ml three times per day and ice cream at lunch and supper. The Assessment documented that the resident's lab work was obtained on 9/15/10. The Assessment documented that the resident had a protein requirement of 92- 123 g protein per day and that the resident consumed approximately 60 g of protein per day.

There was no documented evidence in the 10/25/10 Nutrition Assessment or in the evaluation section of the CCP for Nutrition of new interventions attempted as a result of the documented decrease in protein consumption and decline in protein related lab values obtained on 9/15/10.

Subsequent Nutritional Assessments dated 11/4/10 and 12/28/10 documented that the resident's protein intake continued to be below their estimated needs. The Assessment dated 12/28/10 documented a recommendation for a Prealbumin to further assess the resident's nutritional status.

A lab for Resident # 9 dated 12/29/10 documented that the resident had a Prealbumin of 12.20 mg/dl and an Albumin level of 2.5 g/dl, both below normal limits.

A Nutritional Assessment dated 1/11/11 documented that Resident #9 had lab values as indicated on 12/29/10 lab tests. The Assessment documented that the resident had an increase in meal consumption (greater than or equal to 75 percent of meals taken). There were no documented new interventions or recommendations made for the decline in the resident's Albumin level or continued Prealbumin below normal limits.

A review of the Certified Nursing Assistant Accountability Record (CNAAR) for Resident #9 revealed that 19 of the 33 possible meals between 1/1/11 and 1/11/11 were taken at less than or equal to 50 percent.

A Monthly Physician's Order Form dated 1/17/11 documented an order for a Prealbumin and a Comprehensive Metabolic Panel (CMP - a routine lab blood test that includes an Albumin level) to be obtained.

There was no documented evidence in the medical record that the 1/17/11 lab was completed until 2/16/11.

The lab for Resident #9 dated 2/16/11 documented that the resident had a Prealbumin of 4.74 mg/dl and an Albumin level of 2.3 g/dl, both showing a deterioration from the prior Lab dated 12/19/10.

An interview was conducted on 2/16/11 at 12:30 PM with the Registered Dietitian (RD) responsible for Resident #9. The RD stated that she had been assigned to work with the resident for over one year. The RD stated that she previously tried other protein supplements, but the resident had a history of refusal. The RD stated that she never tried any other type of supplement or the addition of different food items for the resident.

An interview was conducted on 2/17/11 at 10:00 AM with the 7:00 AM-3:00 PM CNA responsible for Resident #9. The CNA stated that for at least the last three months, the resident ate between 25% and 50% of her breakfast and lunch meals.

An interview was conducted on 2/17/11 at 1:30 PM with the facility's Chief Clinical Registered Dietitian (RD). The RD stated that she would have expected that the RD responsible for Resident #9 would have added more calories to the diet, provided that a Prealbumin was identified below normal limits. The RD further stated that if the interventions attempted previously were ineffective, the RD should have attempted other ways to increase the resident's caloric intake.

There was no documented evidence in the resident's medical record of new nutritional interventions related to the documented declines in lab values which indicated a decline in the resident's nutritional status.

415.12(i)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that services provided by qualified persons were in accordance with each residents' written plan of care. This was evident for 3 of 30 sampled residents reviewed for plan of care. Specifically, 1) Resident #26 had a Physician's Order dated 1/21/11 for a repeat Prothrombin Time/International Normal Ratio (PT/INR - measures the extrinsic pathway for blood coagulation) to be done on 2/7/11 which was never completed as ordered, 2) Resident #27 had a Physician's Order for a Urine Analysis and Culture/Sensitivity dated 1/27/11 that was not completed, and 3) Resident #9 had a Physician's Order for a Prealbumin and a Complete Metabolic Panel (CMP) dated 1/17/11 that was not completed until 2/16/11. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding are:

1) Resident #26 has diagnoses including Venous Embolism and Left Femoral Deep Vein Thrombosis (DVT).

The Comprehensive Care Plan (CCP) developed for Anticoagulant Therapy Secondary to DVT dated 12/21/10 documented to monitor laboratory as per Physician. The CCP also documented that the resident was on Coumadin (a prophylaxis and/or treatment for Venous Thrombosis to prevent blood clotting) treatment and that the Coumadin dose should be adjusted accordingly based on PT/INR.

The Physician's Order dated 1/21/11 documented to repeat PT/INR on 2/7/11. It also documented that the previous INR was 1.5 (normal range 0.8-1.2).

The Laboratory Report section of the resident's medical record did not show documented evidence that a PT/INR was completed on 2/7/11 as ordered by the Physician.

The Nurse's Notes reviewed from 2/5/11 through 2/9/11 contained no documented evidence a PT/INR was completed on 2/7/11 as ordered by the Physician.

The Unit's Laboratory Request Log Book did not contain documented evidence that a PT/INR was requested and logged on 2/7/11 for the laboratory technician to draw the resident's blood.

The Registered Nurse (RN) Supervisor was interviewed on 2/18/11 at 10:00 AM and stated that after verification with the laboratory provider and review of the resident's medical record file, the PT/INR was not completed on 2/7/11.

The Physician's Order dated 2/9/11 documented a PT/INR on 2/10/11.

The Laboratory Report dated 2/10/11 documented INR at 1.8.

The facility's policy revised 12/2010 Titled Coumadin Monitoring documented that residents who require anticoagulation with Coumadin will have PT/INR monitoring to ensure therapeutic range.

2) Resident #27 has diagnoses including Urinary Tract Infection (UTI).

A Physician's Order dated 1/21/11 documented Cipro (an antibiotic) 500 milligrams (mg) by mouth twice a day for seven days and Acidophilus (a probiotic) one capsule by mouth twice a day for seven days for UTI.

A Physician's Order dated 1/27/11 documented Urinalysis (U/A) and Culture and Sensitivity (C/S). There was no documented evidence that the U/A and C/S was completed.

The Registered Nurse (RN) Charge Nurse responsible for Resident #27 was interviewed on 2/17/11 at 1:05 PM and stated that when an order for a laboratory test is written, it is put in the laboratory log with a notation of the date to be completed, and when completed, it is noted on the log. The RN further stated that the order for Resident #27's laboratory tests was not transcribed to the log and should have been.

A review of the laboratory log documented no evidence that the Physician's Order for the U/A and C/S for Resident # 27 was transcribed or completed.

The Physician responsible for Resident #27 was interviewed on 2/18/11 at 12:25 PM and stated that the expectation would be that after an order for a laboratory test is written, it should be completed.

3) Resident #9 has diagnoses which include Dementia and Failure to Thrive.

The monthly Physician's Order Form dated 1/17/11 revealed an order for a Prealbumin and Complete Metabolic Profile (CMP) to be completed.

Review of the resident's medical record revealed no documented evidence that the laboratory tests were completed.

The RN Charge Nurse was interviewed on 2/15/11 at 10:35 AM and acknowledged that the laboratory tests were never completed. The RN also stated that after the order was picked up, it should have been written in the laboratory book, but it was never written there, and that was why the tests were never completed. The RN further stated that she would call the resident's Physician and get a new order for the laboratory tests to be completed right away.

The Director of Nursing Services (DON) was interviewed on 2/18/11 at 1:15 PM and stated that after laboratory tests are ordered, they should be completed the next time a laboratory technician comes to the facility and they come daily Monday through Friday.

The facility's undated policy titled Laboratory Tests documented laboratory testing will be done when ordered by a Physician.

483.20(k)(3)(ii)

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that charges were not imposed for items determined as necessary by the facility and not requested by the resident/family. This was noted for 1 of 1 resident reviewed for security-suit/jumpsuits in a total sample of 30 residents. Specifically, a review of the monthly financial statements for Resident #19 documented that charges were made to the resident's personal fund to purchase jumpsuits. This resulted in no actual harm with the potential for minimal harm that is not immediate jeopardy.

The finding is:

Resident #19 has diagnoses including Hypothyroidism and Dementia.

The Minimum Data Set (MDS) Annual Assessment dated 1/6/11 documented that the resident was severely impaired in cognition, required total dependence of one person for toilet use and personal hygiene, had an indwelling catheter, and used a one piece suit daily in chair or out of bed as a physical restraint.

The resident was observed on 2/17/11 at 10:00 AM seated in a wheelchair by the day room area. The resident was wheeled to his room by the Registered Nurse (RN) Charge Nurse and Certified Nursing Assistant (CNA) and noted that the resident was wearing a one piece suit underneath his sweat shirt and pants. The RN stated that the resident wears his one piece suit at all times to prevent pulling out his suprapubic catheter.

The Comprehensive Care Plan (CCP) developed for Physical Restraint dated 10/20/10 documented that the resident was to wear one piece suit at all times. The CCP also documented that the resident had a history of pulling out his suprapubic catheter.

An apparel company invoice for Resident #19 dated 12/29/10 documented a charge of $199.95 for 5 jumpsuits.

A Physician's Order dated 1/30/11 documented a one piece suit to be worn at all times.

A facility form dated 1/12/11 Titled Restraint Assessment Form documented that a one piece suit was used due to the resident's medical symptom of Dementia and Psychosis. The form also documented periods of agitation and combativeness during care as justification for the continued use of the restraint.

A review of the resident's personal financial account documented a charge of $199.95 on 1/4/11 for 5 jumpsuits.

The resident's Social Worker was interviewed on 2/17/11 at 11:40 AM and stated that she was not sure if the resident's jumpsuits could be charged to his personal account and would refer the issue to the Administrator.

The Administrator was interviewed on 2/17/11 at approximately 11:50 AM and stated that she did not know that it was not acceptable to charge the resident's personal account for the purchases of his jumpsuits.

415.26(h)(5)(vi)

NFPA 101, Life Safety Code section 19.1.6.2 requires that buildings containing Existing Health Care Occupancies that are built of unprotected non-combustible construction (i.e., NFPA 220, Standard on Types of Building Construction - Type II (000) building construction) are required to be provided with automatic sprinkler protection. Life Safety Code section 9.7.1 requires that sprinkler systems be installed in accordance with NFPA 13, \i Standard for the Installation of Sprinkler Systems. NFPA 13 section 5-1.1 requires that sprinklers be installed throughout the premises.
In addition, Life Safety Code section 19.1.6.2 and Table 19.1.6.2 limit the height of buildings that are built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000) building construction) to only two stories.

1. Based on observation, staff interview, and record review during the recertification survey, the facility did not ensure that buildings that are built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000) building construction) were not more than two stories in height and protected throughout with an automatic sprinkler system installed in accordance with NFPA 13-\i Standard for the Installation of Sprinkler Systems.

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

This is a repeat deficiency.

The findings are:

During life safety inspections on 02/14/11 between 9:30am and 3:00pm, observations of the suspended ceiling revealed that it was not maintained as a fire rated ceiling assembly. For example, the public address system speaker assemblies, and lighting fixtures on some floors were not protected above where they penetrate the suspended ceiling. In addition, the steel structural members (joists, beams) above the suspended ceiling assembly were not provided with fire proofing or enclosed with fire resistance rated construction.

Due to lack of fire proofing of the steel structural members and the lack of a fire resistance rated ceiling assembly, this building is considered a Type II (000) Unprotected, Non-combustible structure. The Life Safety Code prohibits Type II (000) buildings from being more than two stories in height with a complete automatic sprinkler system. The nursing home building is a six story building.

Observations of the kitchen on 02/14/11 between 8:15am and 9:30am revealed that the building is not provided with a complete automatic sprinkler system since the walk-in freezer and refrigerator boxes were not provided with sprinkler protection.

In an interview on the same day at approximately 1:00pm and a record review at approximately 1:15pm revealed that the facility was cited during the 03/31/10 recertification survey for being greater than the required two stories in height based on the building classification type, and not being provided with a complete automatic sprinkler system. A proposal from a consulting engineer was provided by the Administrator indicating that the corrective work would be provided in order to be in compliance with the NYS requirement for all nursing home to be fully sprinklered by 2013. There was no date indicated for the completion of the installation of the sprinkler heads in the locations identified in the deficiency for the 03/32/10 recertification survey. The Administrator stated that the engineering firm is responsible for completing the necessary work in order to bring the building in compliance with the regulations.

A review of the plan of correction for the K-12 deficiency cited during the 03/31/2010 recertification survey indicated that " the facility will install sprinklers where required to make the building fully protected " with a completion date of 5/30/10. There is no mention of an application for a waiver for the building classification.

NYCRR 711.2(a)
10 NYCRR 415.29

The following waiver is 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.

K 025 S/S=B
Resident rooms in the 07/08 and 26/27 lines contain toilets whose ventilation ducts cross the smoke barrier. These ducts contain no smoke dampers.

CFR 483.70 (a)
LSC 19.3.7.3; 19.3.7.5; 19.1.6.4;19.1.6.3; 711.2(a)(1)