Clove Lakes Health Care and Rehabilitation Center, Inc

Based on observations, record review, and staff interviews, the facility did not ensure that the residents' plan of care were implemented as evidenced by not applying TED (Thromboembolic deterrent) stockings to the resident's lower extremities as ordered by the physician and not providing a tube feeding supplement at the correct rate. This was evident for 1 of 30 sampled residents (Residents #8 and #26).

The findings are:

1) Resident #26 a 87 years old female admitted to the facility with diagnoses including Transient Ischemic Attack, Spinal Stenosis, Hypothyroidism, Diabetes Mellitus, and Rheumatoid Arthritis.

The Minimum Data Set dated 2/24/10 identified the resident with short term and long term memory problems and moderately impaired with decision making.

The physician's order dated 11/21/09 and renewed on 3/16/10
documented "TEDS Knee High to both legs, On in AM (morning) and Off at bedtime. Keep legs elevated in bed and on wheelchair."

On 3/19/10 at 4:30 p.m., the resident was observed seated in her wheelchair in her room. The resident's legs were elevated wearing socks. On 3/22/10 at 11:30 a.m., the resident was again observed in her room in her wheelchair, wearing socks.

The Charge Licensed Practical Nurse (LPN) was interviewed on 3/22/10 at 12:00 pm and stated that the resident is wearing the TED stockings. The LPN went to the resident's room and there were no stockings in the resident's bedside stand or closet.

On 3/22/10 at 1:00 p.m., the CNA assigned to the resident was interviewed and stated "when I dressed the resident, she did not have the TEDS on because there was none available since Wednesday. I was her CNA from last week and I told my nurse that the resident has no TED."

The Charge LPN and the RN (Registered Nurse) Unit manager then stated, they will follow up with central supply and a requisition slip documented that on 3/17/10, two pairs of TEDS stockings were issued.

2) Resident #8 is an 82 year old admitted to the facility on 1/6/03 with the diagnoses, which include Diabetes Mellitus, Dementia, Cerebrovascular Accident, Hypertension and Peripheral Vascular Disease.

The Minimum Data Set 2.0 Assessment dated 3/17/10 documented that the resident has moderate cognitive impairment, and is totally dependent on staff for eating, dressing, transfers, and personal hygiene.

The physician order dated 3/15/10 documented that the resident is to receive Diabetisource AC (Advance Control) via gastrostomy tube at 75 ml/hr (millitersper hour).

On 3/19/10 at 11:20 a.m., the resident was observed receiving Diabetisource AC at a rate of 63 ml/hr (milliliters per hour).

The Registered Nurse (RN) was interviewed immediately after the observation and stated that at 9am she checked the resident's tube feeding and the rate was set at 75. The RN further stated that when she returned to the resident the rate was at 63. The RN stated that she does not know how the rate was changed.

415.11(c)(3)(ii)

Based on record review and staff interviews, the facility did not ensure that professional standards of practice were adhered to as evidenced by the licensed nurse not notifying the physician when a resident refuses medication. This was evident for 1 of 30 sampled residents (Resident #2).

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

The finding is:

Resident #2 an 81 year old male admitted to the facility with diagnoses which include status post fall with Fracture of the Neck of the Femur, Gait Disturbances, Essential Hypertension, Diabetes Mellitus, and Atrial fibrillation.

The Minimum Data Set (MDS) 2.0 with assessment reference date of 12/22/09 and 3/12/10 identified the resident with no short or long term memory problems and independent in decision making. The resident is able to make needs known and requires 1 person assist in all activities of daily living (ADL).

The physician's order dated 12/18/09 at 5:19 p.m. documented discontinue Lactulose PRN (whenever necessary), Lactulose 30 ml (milliters) by mouth 1 time a day at bedtime, CBC (Complete Blood Count), and Ammonia level.

The physician's order dated 12/19/09 at 4:59 p.m. documented to discontinue Lactulose one time a day at bedtime, and give Lactulose 30 cc by mouth 2 times a day.

The MAR (Medication Administration Record) dated 12/29/09 to 2/9/10 documented that Lactulose 30 cc (cubic centimeters) was scheduled to be administered at 8 a.m. and 8 p.m. Lactulose 30cc was not administered to the resident with staff signatures circled, on the following dates: 12/29/09 at 8 am, 1/2/10 at 8 am, 1/3 at 8am, 1/4 at 8am and 8 pm, 1/5 at 8 am and 8 pm, 1/6 at 8 pm, 1/13 at 8pm, 1/14 at 8 pm, 1/15 at 8 pm, 1/16 at 8 pm, 1/20 at 8 pm, 1/21 at 8pm, 1/24 at 8 pm, 1/26 at 8pm, 1/27 at 8 pm, 1/28 at 8 pm, 1/29 at 8 pm, 1/30 at 8 pm, 1/31 at 8 pm and on 2/17/10 at 8am (a total of 22 doses not administered to the resident). There was no documented evidence of any explanations/reasons of the circled signatures of the staff on the MAR.

On 12/19/09 at 4:00 p.m., the nurse's note documented "resident was extremely agitated, punching and cursing at the staff." MD (medical doctor) was informed and the latest Ammonia level=46 (Reference value: 11-35 umol/l-micromoles per liter)."

On 1/6/10 at 10am, the nurse documented that the resident refused to take Lactulose. This note further documented that the MD (medical doctor) ordered NH3 (Ammonia) level in the morning.

The nursing notes dated 1/9/10 to 2/9/10 did not document any evidence that the resident refused Lactulose. nor did the nurses note document that the physician was informed of the resident's refusal of Lactulose.

The attending physician was interviewed on 3/19/10 at 10:25 a.m. on the resident's refusal to take the medications and stated "it was mentioned to me, I think 3 - 4 times and I keep telling the nurses to have the resident take the Lactulose and increase fluid intake. I was not aware of the other times he was refusing the medication."

During an interview with the Licensed Practical Nurse (LPN) on 3/19/10 at 4:10 p.m. who worked on the days that the medication was encircled and stated,"the resident refuses the medication. So I tried to give it to him in parts, I come and give it - he takes a little, then I come back again and give it till he finishes the medication." When asked why she encircled her signature (which designates that the medication was not taken) and why the physician was not informed of his refusal, she did not answer. The LPN further stated that she did not report the resident's refusal of the medication to the registered nurse.
415.11(c)(3)(i)

Based on observation and interview it was determined that the facility did not ensure that the residents are smoking only in designated areas with ashtrays of noncombustible material and safe design in accordance with 19.7.4 (NFPA 101). This was evidenced by two residents smoking in an adjacent area in front of the facility;in addition, more than thirty (30) cigarette butts were observed in this non-smoking area. There was no ashtray of safe design observed in this area. Also, not observed was any containers where smokers can empty the cigarette butts/ashes.

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

The Finding is:

On 3/17/10 and 3/18/10 during the Life Safety Evaluation of the Skilled Nursing Facility, it was observed that an area adjacent to the front of the facility was littered with more than thiry cigarette butts in the grass and concrete area. Two resident's were observed to be smoking in this area on 3/17/10 at approximately 12:15pm.

Signs indicating "NO SMOKING IN THE AREA" were observed in various places in and adjacent to the front of the building.

In an interview with the maintenance staff on 3/17/10, he stated that family members and staff utilize this area and they should not have been smoking in this area at all. All the cigaretter butts were immediately cleaned from the front of the builing. He further stated that they have a separate area in the patio that is a DESIGNATED AREA to smoke.

NFPA 101(2000 edition)
NYCRR 10 415.29(a)(1)

NYCRR Section 713-1.18 - Mechanical requirements
713-1.18 Mechanical requirements

(1) Plumbing fixtures
(ii) The water supply spout for lavatories and sinks required in resident care areas shall be mounted so that its discharge point is a minimum distance of five inches above the rim of the fixture. All fixtures used by medical and nursing staff, and all lavatories used by residents and food handlers shall be trimmed with valves, which can be operated without the use of hands. Where blade handles are used for this purpose, they shall not exceed four and one-half inches in length, except that handle on clinical sinks shall be not less than six inches long.

Based on observation and interview, it was determined that the facility did not ensure that all hand-washing sinks used by staff as well as residents on six (6) out of six (6) resident units in the " A " building were equipped with faucets that were mounted at least five inches from the rim of the sinks.

This was evidenced by hand-washing sinks in the residents' common restrooms, toilet rooms, and staff restrooms that were equipped with faucets that discharged approximately one to two inches above the rim of the sink.

The findings are:

On 3/17/10 and 3/18/10 between 9:00 a.m. and 3:00 p.m. during the annual life safety code survey it was observed that the hand washing sinks on all residents' units in floors 1 through 6 in the"A" building were all equipped with the type of faucets that discharged approximately 1 to 2 inches from the rim of the sink. These types of faucets were found inside residents' rooms, residents' toilet rooms, restrooms, and staff restrooms.

In an interview with the Director of Support Services on 3/18/10 at approximately 2:10 p.m. he stated that the faucets were from original construction but that he will bring the issues noted to the attention of the administrator.

NYCRR 713-1.18(1)(ii)

The following waiver is on file with this office. Repeat waiver is granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waiver has been granted has not changed. Please indicate if the facility wishes the waiver to be continued.

The diameter of the linen chute located in Building A is 18 inches, not 24 inches as required.

NYCRR 711.2(a)(1)