Evergreen Valley Nursing Home

Based on observation ,medical record review and staff interview, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection, for 4 (#s 36, 40, 44, 46 ) of 6 residents reviewed during the standard recertification survey. Specifically, the facility did not ensure that nursing staff followed standards of practices for infection control during blood glucose monitoring and did not ensure tuberculosis testing (PPD) was performed as ordered. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Finding #1
The facility did not ensure that nursing staff followed standards of practices for infection control during blood glucose monitoring.

During an observation on 2/15/11 at 11:45 am, the licensed practical nurse(LPN) administering medications was observed checking Resident #36's blood sugar (BS) with a glucose meter. After the LPN completed the BS, she did not clean or disinfect the glucose meter.

On 2/15/11 at 11:55 am, the LPN was observed using the same glucose meter to obtain a BS on Resident #44. The LPN did not clean or disinfect the glucometer either before or after obtaining the BS.

On 2/15/11 at 12:05 pm, the LPN was observed using the same glucose meter to obtain a BS on Resident #40. The LPN did not clean or disinfect the glucometer either before or after obtaining the BS.

During interview on 2/15/11 at 12:15 pm, the LPN stated the outside of the glucometers should be cleaned with a germicidal wipe between resident use.

During interview on 2/15/11 at 4:45 pm, the Director of Nursing (DON) stated the glucose meters should be cleaned with a germicidal wipe between resident use.

Resident #46
The facility did not ensure tuberculosis testing (PPD) was performed as ordered by the physician.

The resident was admitted on 12/24/09 with diagnoses of dementia, depression and osteoarthritis. The Minimum Data Set, dated 12/29/10 assessed the resident had impaired short and long term memory, and cognitive skills for daily decision making was severely impaired.

The physician's orders dated 12/24/09 documented the resident was to receive PPD Mantoux (Tuberculosis testing) 0.1 ml intradermal injection, if negative, repeat in 1 week.

Review of the resident's medical record produced no evidence the PPD was administered as ordered.

During interview on 2/15/11 at 7:50 am, the DON stated the PPD must have been missed and never picked up by anyone. She stated she could not produce evidence that the PPD was ever completed on the resident.

Review of the Tuberculin and Immunization Record documented the PPD was administered on 2/15/11 after the above conversation with the DON.

10 NYCRR415.19(a)(1-3)

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Based on record review and staff interview it was determined that the facility did not test the fire alarm system in accordance with 1999 NFPA 72, National Fire Alarm Code. Section 7-2.2 Table 7-2.2 item 13.g.1 requires that smoke detectors be tested using smoke or a listed aerosol approved by the manufacturer. 33 of 33 smoke detectors were not tested by using smoke or a listed aerosol. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The director of environmental services stated in an interview conducted on 02/15/2011 at 10:20 am that the facility conducts all smoke detector testing internally and that none of these devices were tested using smoke or a listed aerosol approved by the manufacturer.

The maintenance supervisor stated in an interview on 02/16/2011 at 2:15 pm that the facility could not locate a copy of \i NFPA 72, The National Fire Alarm Code 1999 edition.

The fire alarm system test report, when reviewed on 02/15/2011, indicated that the facility has 33 smoke detectors.

2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-2.2 Table 7-2.2 item 13.g.1; 1997 NFPA 101: 7-6.1.4; 1996 NFPA 72: 7-2.2; 10 NYCRR 415.29, 711.2(a)(1)

The following requirement of the Life Safety Code (LSC) 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.

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.

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