New Vanderbilt Rehabilitation and Care Center, Inc

Based on observation and interview, the facility did not maintain the following mechanical and patient care equipment in a safe operating manner as evidenced by numerous bedpan flushers were noted to either lacking hoses, broken or the water supply shut off.

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

During the annual recertification survey conducted on 1/9/12 and 1/11/12 it was noted during the rounds that the facility is not equipped with a soiled utility room that has a flushing rim sink on each resident unit, as an alternative for flushing bedpan disposals each resident room is equipped with a toilet room that was built with a bedpan flusher. In numerous toilet rooms the bedpan flushers were not working in that they were either lacking water supply, lacking a hose or the hose was broken. Some examples include but are not limited to rooms 601, 605, 607, 708, 709,710,721,718,715,722,715,722,819,820,808,921,915,922,920 and 705.
In an interview with the maintenance director on 1/11/12 at approximately 2:30 pm he stated that the bedpan flushers are seldom used and they are somewhat cumbersome for the residents as the hoses get in the way of using the toilet therefore some hoses were removed because residents requested that they be removed and the water turned off in some cases because of none usage.

483.70 (c)(2)

Based on observation and staff interview, the facility did not ensure that sufficient housekeeping and maintenance services were provided to ensure resident's health and safety. This was evidenced by numerous splinted and broken furnishings, non-functional night lights and poignant urine/fecal odors on 7th floor resident unit.

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

The findings are:
During the annual recertification survey conducted on 1/9/12 and 1/11/12 it was noted that numerous food tray tables, night stands and closet on the 6th and the 7th floor were noted to be chipped and splinted in resident's rooms included but are not limited to 709,710, 708, 702, 605, 605 and 602.
Numerous night lights were not functional when tested on the 6th floor, some examples of rooms where night lights were not working, include but are not limited to606, 605, 604, 601, and 602.
In an interview on 1/11/12 at approximately 1:30 pm the Maintenance Director stated that, as these splinted, chipped or broken furnishings are noted they are usually taken out of the resident's room either for repair or replacement and these just have not come up for repair or replacement. He further stated that these would be removed from the resident's rooms immediately and all other rooms checked to ensure that there are no splinted or broken furniture in them. He further stated that the electrician on staff checked into the matter of the non-working night lights on the 6th floor and found that the circuit breaker had tripped and he rectified the problem and the night lights are now working.
At approximately 12:05 p.m. on 1/11/12, while touring the West wing of the 7th floor it was noted that the corridor reeked with the smell of urine/feces, upon intense inspection it was noted that the smell was emanating from room 708. The resident in bed 708A was in bed at the time and appeared to be clean and the 'A' area was noted in good sanitary condition. The 'B' bed resident was not in the room at the time, however it was noted that the bed was unmade and there were numerous of the residents' personal items on the bed and side table. The linen appeared heavily soiled and the smell got stronger closer to the bed.
In an interview with the Housekeeping Director at approximately 12:25 pm on the same day he stated that the bed linens are changed twice weekly but sometimes more frequently for said resident (708B) based on request by the staff on the unit. He further indicated that this resident does not only carry a smell whilst in the room but anywhere the resident is the area smells of urine/feces. In an interview with the Registered Nurse in charge of the unit at approximately 12:45 pm she stated that the resident is scheduled to take a shower twice weekly, on Sundays and Wednesdays but he is very non-compliant and most times refuse to take a shower. She further indicated that the resident is continent and according to the residents care plan he is not any toileting schedule but requires some assistance in setting up for showers.

483.15 (h)(2)

Garbage disposal

Based on observation and interview it was determined that the facility did not ensure that the refuse container (compactor) located in the exterior of the building was maintained in the closed position and the surrounding area kept clean so as to prevent pest movement and to assure proper disposal.

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

The findings are:
During the annual life safety and environmental survey on 1/9/12, it was noted that at approximately 11:45 am on 1/9/12, that there was 1 large compactor located in the exterior alley way of the facility. The lid for the compactor was noted to be tied on to the compactor in the open position. There were a few flies within the vicinity of the container. It was also noted that the area was in a deplorable condition in that there were numerous pieces of cardboard boxes, leaves, soiled medical gloves and other debris in the area surrounding the compactor.
In an interview with the Director of Maintenance he stated that the area is usually cleaned daily and the staff must not have cleaned this location as yet for the day. He further indicated that he would bring this to the attention of the House keeping director immediately.

483.35 (I) (3)

Based on observations and staff interviews it was determined that the facility did not ensure that: Residents' personal items were stored in accordance with infection control procedures. This was evidenced by residents' clothing, basins and bedpans being stored directly onto the closet floor.

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

The findings are:

On 1/9/12 and 1/11/12, during the Annual Recertification Survey, it was noted that some storage closets off the corridor on the 3rd , 5th and 6th floors East wing were observed to have some of the resident's clothing in clear plastic bags stored on the floor. Numerous resident rooms were noted to be cluttered with personal items stored directly onto the floor. Examples include but are not limited to room #s 702,701, 706, and 606.

In an interview with the Maintenance Director he stated that these items would be removed as soon as possible. He also indicated that this is not normally the way items are stored, they are usually shelved.

483.65

Based on record review and staff interviews, the facility did not ensure that medically related social services were provided for a resident who requested to live in a group or adult home. This was noted in 1 of 9 sampled residents reviewed for social services related issues. Resident # 23.
This resulted in no actual harm with potential for more than minimal harm.
The finding is:
Resident #23 is a 54 years old female admitted to the facility with diagnoses including Mental Retardation, Myopia , Asthma and Osteoporosis.
The minimum data set 3.0 ( MDS ) assessment dated 12/01/2011 assessed the resident BIMS (Brief interview for Mental Status) score as 15 which indicates that the resident has intact cognition. This MDS further documented that the resident requires minimal assistance with activities of daily living and is independent in the use of her wheelchair.
The resident was observed in her wheelchair, independently propelling it to her room. During an interview with the resident on 01/12/2012 at 11:10 AM she stated that she expressed a desire to live in a group home or an adult home several years ago . The resident further stated that there was no assistance given. She stated that there was one place she wanted to visit but she was not able to go because there was no transportation available. When the resident was asked if she is wanted to go to a group or adult home, she stated "Yes, I really want to live in a group or adult home. I am capable of taking care of myself and I would be with people of the same age."
The PASRR (Pre-admission screening and resident review) dated 7/26/07 documented "Consumer may continue staying in the facility until an appropriate placement is available."
The social worker notes dated 3/26/09 to 1/11/12 did not document any evidence that the resident was assisted in finding a suitable group or a adult home placement.
The resident's current Social Worker was interviewed on 1/12/12 at 10 am who stated that she did not know that the resident wanted to go to a group or adult home. The Social Worker stated that she would talk with the resident and also contact the resident's former social worker.
The social worker previously assigned to the resident was interviewed on 01/12/2012 at 10:20 AM and stated that she remember that a representative from a group home came. However, the resident did not agreed to go this group home.
415.5 (g)(l)(i-xv)

NYCRR 713-1.18(d) (VI) (b)

A manometer shall be installed across each filter bed serving central air systems.

Based on observation and interview it was determined that the facility did not ensure that manometers were installed across filter beds serving the central air handling equipment units located in the basement of the building.

The findings include:

During the environmental rounds conducted on 1/9/12 between 9:00am and 3:00pm, it was observed that two (2) of the two (2) air handling units located within the mechanical rooms in the basement lacked manometers.
In an interview with the Director of Maintenance on 1/9/12 at approximately 11:55am, he stated that he was unaware that manometers were required because the filters are checked monthly to ensure that clean air is being circulated and replace them when needed.