Evergreen Valley Nursing Home

Based on medical record review, observation and interviews, the facility did not maintain an accurate and complete record of the care provided for 4 (# 21, 38, 65, 86) of 18 residents reviewed during the standard recertification survey. Specifically, the facility did not maintain complete and accurate documented records for meal nourishment consumption, care administered and documentation for checking/trimming toe/fingernails. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Resident #65
The facility did not maintain complete documentation of the resident's "Rehab/ADL sheet", (documented care administered to the resident) and the "Meal Nourishment Consumption Form" (documented amount of food and fluid the resident consumed)

The resident was admitted on 9/10/07 with diagnoses of dementia, hypertension and congestive heart failure. The Minimum Data Set dated 2/16/11 assessed the resident rarely understands and was rarely understood, had impaired short and long term memory and severely impaired cognitive skills for daily decision making.

There were multiple blanks noted on the "Meal Nourishment Consumption Form"s dated November 2011 and December 2011.

There were multiple blanks noted on the"Rehab/ADL sheet"s dated October 2011, November 2011 and December 2011.

During interview on 1/25/12 at approximately 9:30am, the registered nurse unit manager (RNUM) stated the certified nurses aides (CNAs) are responsible for completing the Rehab/ADL sheets for the residents they care for, and whoever assists the resident with their meals is responsible for completing the "Meal Nourishment Consumption Form". The nurses are responsible for verifying the above forms are completed. The RNUM acknowledged the above forms were not completed.

Resident #86
The facility did not maintain complete documentation of residents toenails as being trimmed.

The resident was admitted on 8/25/10 with diagnoses of high blood pressure, osteoporosis and cerebral vascular accident.. The Minimum Data Set (MDS) dated 1/4/12 assessed the resident as being moderately impaired.

Review of the Nurse Action Sheets, documented check and trim toenails with bath (Tues.). For the months of September, October and December 2011 there is no documented evidence that resident's toenails were trimmed during these months.

During an interview on 1/25/12 at 1:45 pm with the Director of Nursing (DON) and the DON in training, the DON stated if a podiatrist cannot come and cut the residents toenails then it is the responsibility of the nurse to do and document that this was done.

Resident # 21
The facility did not maintain complete documentation of the resident's Meal Nourishment Consumption Form.

The resident was admitted to the facility on 8/8/11 with the diagnoses of dementia, gastroesophageal reflux and anxiety. The MDS, dated 11/30/11, assessed the resdient to have been cognitively impaired.

The Nurse's Notes (N/N) , dated 12/20/11, documented the resident was seen in the hospital's Emergency Department due to an episode of unconsciousness. The resident was diagnosed with mild dehydration, was given intervenous fluids and sent back to the nursing home. The discharge instructions documented to monitor oral fluid intake.

The Meal Nourishment Consumption Form, dated 12/20/11-12/31/11, did not document fluid intakes for dinner on 12/21, lunch and dinner on 12/22, lunch meals on 12/23 and 12/24, breakfast and lunch on 12/25, and dinner meals on 12/27,12/30 and 12/31/11.

During interview on 1/25/12 at approximately 9:30am, the RNUM stated that whoever assists the resident with their meals is responsible for completing the "Meal Nourishment Consumption Form". This could include a nurse, CNA, or paid feeding assisitant. The RNUM further stated that the nurses were then responsible for verifying the forms are completed. The RNUM acknowledged the above forms were incomplete.

10NYCRR 415.22(a)(1-4)

Based on medical record review, observation and interviews, the facility did not ensure that residents received necessary care and services regarding activities of daily living (ADL) for 1(#86) of 3 residents reviewed during the standard recertification survey. Specifically, the facility did not maintain good foot care for resident #86. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Finding:
During the group interview on 1/24/12 at 10:00am, 2 of the residents stated their toenails needed to be trimmed, and had not been trimmed for a long time. One of the resident's stated she did bring her concerns up at resident council a couple months ago, and has not heard back from the facility about getting her toenails trimmed.

Resident #86

The resident was admitted on 8/25/10 with diagnoses of high blood pressure, osteoporosis and cerebral vascular accident.. The Minimum Data Set (MDS) dated 1/4/12 assessed the resident as being moderately impaired.

During an interview on 1/25/12 at 1:10 pm the Certified Nurses Assistant (CNA) stated nail care on the Rehab/ADL sheet means to clean and cut toe/finger nails. The CNA also was providing care for this resident and stated she would not cut the resident's toenails as they are very long and thick. The nurses would cut them.

During observation off both feet on 1/25/12 at 1:15 pm the toenails were long, thick and starting to slightly to curl under.

During an interview on 1/25/12 at 1:20 pm with the resident stated that she had not had her toenails cut in over a year. She had asked repeatedly for them to be cut.

During an interview on 1/25/12 at 1:30 pm the licensed practical nurse stated that the "Nurse Action Sheets" is where you would find if a residents nail care was to be performed by a nurse instead of a CNA.

During an interview on 1/25/12 at 1:45 pm the Director of Nursing (DON) stated if a podiatrist cannot come and cut the residents toenails then it is the responsibility of the nurse to do it and document that this was done.

Review of the Nurse Action Sheets 2011, for the months of September, October and December there is no documented evidence that resident's toenails were trimmed.

10NYCRR 415.12(a)(3)

Based on medical record review and staff interview the facility did not ensure that all alleged violations were thoroughly investigated, and must prevent further potential abuse while the investigation is in progress for 1 (#66) of 8 residents reviewed during the standard recertification survey. Specifically, the facility did not thoroughly investigate the circumstances regarding a resident's fall to determine if the resident's plan of care was followed. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Resident #66

The resident was admitted on 6/17/10 with diagnoses of COPD, a history of falls, and anxiety. The Minimum Data Set dated 6/10/11 assessed the resident usually understands and is usually understood, and had severe cognitive impairment for daily decision making skills.

The nurse's notes dated 10/28/11 at 7:50pm documented the resident was lying on her left side, blocking the bathroom doorway. The resident was bleeding from the left side of her head, her wheelchair was in front of the open bathroom door, and the resident's oxygen tubing was on the floor. The resident's pants were around her ankles, her shoes were off, and she was alert and responsive. The nurse's notes also documented the resident stated she was going to the bathroom. The registered nurse (RN) supervisor was called to assess the resident, 911 was called and at 7:15pm the resident was transferred via ambulance to the ER.

The nurse's note dated 10/28/11 at 11:10pm documented the resident returned via ambulance at 11:00pm with a left hematoma and a small laceration over the left eyebrow.

The Resident Care Plan entitled "Falls", which was initiated 9/16/10 and most recently updated 1/17/12, documented on 9/6/11 resident was "not to be left unattended in room unless in bed". There was no documentation on the resident's care card indicating the resident was "not to be left unattended in room unless in bed".

The "Quality Improvement Incident Report" dated 10/28/11 documented no statement from staff to determine where the resident was prior to the fall.

During interview on 1/25/12 at 1:30pm, the Director of Nursing (DON) stated, after reviewing the "Quality Improvement Incident Report", she could not determine where the resident was prior to the fall. The DON acknowledged the resident's care plan documented the resident was not to be left alone in her room unless she was in her bed. The DON stated there should have been more information obtained in the staff's statements, to determine if the resident's plan of care was followed.

10NYCRR415.4(b)(1)(ii)

Based on medical record review and staff interview, the facility did not ensure services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care for 1 (#66) of 2 residents reviewed during the standard recertification survey. Specifically, the resident's care plan documented the resident should use the wheelchair for transportation only. The resident was transferred from the toilet to the wheelchair, left unattended, and subsequently fell. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Resident #66

The resident was admitted on 6/17/10 with diagnoses of chronic obstructive pulmonary disease (COPD), a history of falls, and anxiety. The minimum data set dated 6/10/11 assessed the resident usually understands, is usually understood, and had severe cognitive impairment for daily decision making skills.

The Resident Care Plan entitled "Falls", which was initiated on 9/16/10 and most recently updated on 1/17/12 documented resident should be in a straight back chair or recliner and placed at nursing station or in the activities room when out of bed.

The Nursing Assistant Care Sheet (utilized by the certified nurses aides to direct resident's care), which was most recently updated 11/1/11, documented the resident's wheelchair was to be used for transfers only.

The Nurse's Notes dated 12/31/11 at 9:52 am documented the resident was found on the floor by the B-wing whirlpool tub room. The resident was on her left side and stated she hit her head. There was no visible bleeding noted, however, per the Director of Nursing and the resident's history of falls, the resident was transferred to the emergency room (ER).

The Nurse's Notes dated 12/31/11 at 2:30pm documented the resident returned from the ER with no new orders.

The Quality Improvement Incident Report dated 12/31/11, documented that the resident was discovered by the nursing staff on her left side by the door of the whirlpool tub room with her legs out towards the bathroom. Attached to the Incident Report was a statement from a certified nurses' aide (CNA), which documented the housekeeper told the CNA that the resident was alone in the bathroom. The CNA rushed to the bathroom and found the resident on the toilet. When asked why she went to the bathroom alone, the resident stated she had to. This report also documented the CNA toileted the resident, put her in the wheelchair, brought her outside the door and went to answer another resident's call light. The CNA stated after he assisted the other resident to the bathroom, he heard a nurse shout that someone had fallen. The CNA left the second resident and went to discover resident #66 on the floor.

During interview on 1/25/12 at 1:30pm, the Director of Nurses(DON) stated she reviewed and signed the above Incident Report, but did not realize the resident's care plan was not followed. The DON stated there was no education or counseling completed for the staff member involved.

10NYCRR415.11(c)(3)(ii)

Based on observation and staff interview during the standard recertification survey, it was determined that the exit discharges to the public way were not free of all impediments for full instant use. NFPA 101 Life Safety Codenone 2000 edition section 7.10.1 states 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. Specifically, the west exit from the beauty parlor corridor, one of 7 exits, was closed by the facility due to a sunken sidewalk. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The west exit discharge by the beauty parlor was inspected on 01/23/2012 at 10:00 am and the exit door was inspected at 10:05 am. On the door to the exit a sign was posted that read " SIDEWALK CLOSED UNTIL FURTHER NOTICE. " The sidewalk is the exit discharge to this exit. An accumulation of water was noted on the sidewalk.

The director of environmental services stated in an interview conducted on 01/24/2012 at 10:05 am that the sign was posted on the exit door because the sidewalk in sunken in places, water accumulates and freezes, and becomes unsafe for passage during the winter months.

2000 NFPA 101 7.10.1; 1997 NFPA 101 5-1.9; 10 NYCRR 415.29, 711.2(a)(1)

dowctrlrmshadectd ain Based on observation and interview during the standard recertification survey, it was determined that the facility did not meet the minimum requirements for safeguarding hazardous areas. NFPA 101 ain Life Safety Codeain 2000 edition section 19.3.2.1 requires that boiler rooms shall be safeguarded by a fire barrier having a 1-hour fire-resistance rating and that the doors to boiler rooms be self-closing. Specifically, the fire-resistance rating of the fire barriers enclosing 2 of 2 boiler rooms are not maintained and all the doors to the boiler rooms are not self-closing. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The fuel-oil boiler room was inspected on 01/24/2012 at 2:30 pm. An unsealed 3-inch penetration for an electrical conduit was found in the fire barrier.

The electric boiler room was inspected on 01/25/2012 at 9:30 am. Two of the 3 doors in the electric boiler room fire barrier, a door to the oxygen storage room and a door to the mop room, are not self-closing.

The director of environmental services stated in an interview conducted on 01/25/2012 at 9:30 am that the doors to the oxygen storage room and the mop room were not equipped with self-closing devices when the electric boiler room fire barrier was originally constructed.

2000 NFPA 101 19.3.2.1; 1997 NFPA 101 13-3.2.1; 10 NYCRR 415.29, 711.2(a) (1)

Based on observation and staff interview during the standard recertification survey it was determined that the facility did not maintain the integrity of 1 of 1 smoke barriers observed. NFPA 101 Life Safety Codenone 2000 edition section 8.3.2 requires that smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling. Specifically, the smoke barrier separating fire zones 4 and 5 was not continuous above the ceiling. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The smoke barrier separating fire zones 4 and 5 was inspected on 01/25/2012 at 1:00 pm, and the observations noted below are of this smoke barrier. A 3-inch by 3-inch unfilled penetration and a 2-foot by 3-inch section of loose fill material were observed in the corridor. An unfilled 12-foot by \'bd-inch space next to the underside was observed in the B-wing employee break room.

The director of environmental services stated in an interview conducted on 01/25/2012 at 1:00 pm that the penetrations noted above require sealing.

2000 NFPA 101 19.3.7.3, 8.3; 1997 NFPA 101 13-3.7.3, 6-3; 10 NYCRR 415.29, 711.2(a) (1)

Based on staff interview and review of inspection records during the standard recertification survey, it was determined that the automatic sprinkler system was not tested in accordance with adopted regulations. NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systemsnone 1998 edition section 2-3.3 requires that alarming devices servicing sprinkler systems shall be tested quarterly. Specifically, 3 of the past 4 required sprinkler system flow alarm device tests was not conducted. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The sprinkler system inspection records were reviewed on 01/24/2012. The records showed that the flow alarm devices were not tested during the second, third, and fourth quarters of 2011.

The director of environmental services stated in an interview conducted on 01/24/2012 at 11:00 am that the sprinkler system flow alarms were tested once during 2011.

2000 NFPA 101 19.7.6, 4.6.12, 9.7.5; 1998 NFPA 25 2-3.3; 1997 NFPA 101 7-7.6; 1995 NFPA 25 2-3.3; 10 NYCRR 415.29, 711.2(a)(1)

dowctrlrmshadectd ain Based on record review and staff interview during the standard recertification survey, it was determined that the facility did not test the fire alarm system in accordance with adopted regulations. NFPA 72 ain National Fire Alarm Codeain 1999 edition section 7-3.2 and Table 7-3.2 require that components of the fire alarm system, such as batteries, be tested semiannually. Specifically, the fire alarm system testing records indicated that the fire alarm system batteries were not tested in the past year. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The fire alarm system testing records were reviewed on 01/24/2012. The documents did not show that the batteries servicing the fire alarm panel were tested.

The director of environmental services stated in an interview conducted on 01/24/2012 at 11:45 am that the batteries servicing the fire alarm panel were not tested in the past year.

2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-3.2, Table 7-3.2; 1997 NFPA 101: 7-6.1.4; 1996 NFPA 72: 7-3.2; 10 NYCRR 415.29, 711.2(a) (1)ain

The following requirement of the Life Safety Code has been previously waived. The results of the current survey and review of the facility's previously submitted justification reaffirm that adequate safeguards remain in place to safeguard residents, staff and visitors and that correction would pose an undue hardship. The continued waiver of the following is recommended. Please indicate your request for renewal or submit a plan of correction in the space provided on this form.

Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

42 CFR 483.70 (a) (1); 2000 NFPA 101 19.2.2.2.4 exception #2, 7.2.1.6.1; 10 NYCRR 415.29 (a) (2); 10 NYCRR 711.2 (a) (1); 1997 NFPA 101 13-2.2.2.4 exception: #2, 5-2.1.6.1
\i The facility had installed delayed egress locking devices on six emergency exit doors. The facility did not meet the requirements as the building is not fully protected throughout by an approved automatic fire detection system or an approved automatic sprinkler system.

The delayed egress locks were installed on the emergency exit doors to protect confused and/or wandering residents from possible harm that may occur during elopement. Residents' sleeping rooms have smoke detectors, corridors have partial smoke detectors and there is a partial sprinkler system for the hazardous areas. In addition, the residential areas are separated from the other facility areas by smoke barriers.