Heritage Green Nursing Home

Based on observation and staff interview, it was determined that the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included shower plumbing that lacked vacuum breakers on one (Woodside) of three resident units. This was a pattern with no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 3/30/10 at approximately 1:20 PM revealed that one of the showers in the Woodside Unit Resident Bath/Shower room located near resident room #336 lacked a vacuum breaker. Further observation at this time revealed the shower had a shower wand attached to it by a hose that allows the wand to lie flush with the shower floor. The length of the hose would allow the shower wand to be submerged if the shower did not drain properly. Interview with the Director of Environmental Services at this time revealed he was not sure if the shower's plumbing located above the ceiling tiles had a vacuum breaker attached to it. Observation above the ceiling tiles on 3/31/10 at approximately 9:33 AM in the Woodside Unit Resident Bath/Shower room located near resident room #336 revealed the shower plumbing lacked a vacuum breaker.

2. Observation on 3/30/10 at approximately 1:35 PM revealed that one of the showers in the Woodside Unit Resident Bath/Shower room located near resident room #332 lacked a vacuum breaker. Further observation at this time revealed the shower had a shower wand attached to it by a hose that allows the wand to lie flush with the shower floor. The length of the hose would allow the shower wand to be submerged if the shower did not drain properly. Interview with the Director of Environmental Services at this time revealed he was not sure if the shower's plumbing located above the ceiling tiles had a vacuum breaker attached to it. Observation above the ceiling tiles on 3/31/10 at approximately 9:33 AM in the Woodside Unit Resident Bath/Shower room located near resident room #332 revealed the shower plumbing lacked a vacuum breaker.

415.29(d)(f)(4)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 5/14/09.

Based on record review and staff and resident interview, the facility did not ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Three (Residents #10, 11, 15) of 21 residents reviewed for range of motion (ROM) had issues involving ROM that was not provided as planned and/or as recommended by therapy. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #10 has diagnoses that include diabetes mellitus, obesity, and fractures of the left (L) distal femur (lower portion of the thigh bone), and (L) ankle. Review of the Minimum Data Set (MDS) dated 2/13/10 revealed the resident is independent with decision making, has intact memory and has functional limitations in range of motion of his arms, hands, legs and foot.

Review of an initial "Initial Plan of Treatment for Physical Therapy (PT)" dated 2/9/10 revealed measurements and documentation that the resident had limitations of motion (joint mobility) of both hips, knees and ankles.

A "Discharge Services Plan for Treatment of Physical Therapy" dated 3/23/10 documented that the resident will stop PT services related to her non-weight bearing status, with a planned return on 4/2/10. The PT discharge recommendations documented "(L) knee contracture" (loss of joint mobility) with plans for staff to provide A/AROM (active assisted ROM - ROM provided with partial assistance by staff) to both lower extremities qd (each day).

Review of the current comprehensive Care Plan (updated 3/29/10) revealed the resident had contractures of both hips, both knees, the right ankle, and both shoulders. Additional review revealed there was no approach documented to address the lower extremity limitations.

Review of the unit "CNA (certified nurse aide) Assignment Sheet" dated 3/29/10 under the section entitled "ROM" revealed there was no plan to provide lower extremity ROM for Resident #10.

Interview with the Registered Nurse (RN) Unit Manager on 3/31/10 at 10:10 AM revealed that CNAs provide the residents' ROM services on the day and evening shifts and document the completed services in the unit "ROM" book.ne
Review of the ROM book from 3/22/10 through 3/29/10 revealed there was no documentation that the resident had received A/AROM to her lower extremities.

Further interview with the RN Unit Manager on 3/31/10 at 10:10 AM revealed the facility practice is for OT (Occupational Therapy) or PT (Physical Therapy) to send an email to the Unit Manager and/or the Unit Secretaries regarding updates or revisions for a resident's ROM services. When the revisions or recommendations are received from the therapy department, the Care Plan (and the CNA Assignment sheet) are revised/updated. Interview with the Unit Secretary on 3/31/10 at 10:10 AM revealed she could find no communication (email) from PT regarding any revision to Resident #10's ROM services. The Unit Manager stated he deletes all of his emails, therefore he could not review them to determine if he received any recommendations/revisions for Resident #10.

Interview with the Physical Therapist on 3/31/10 at 11:50 AM confirmed that therapy (OT/PT) recommendations are first documented in AOD (Answers on Demand-the facilities computerized interdisciplinary department note system), and then an email is sent from the Therapist to the Unit Manager to communicate these revisions. After reviewing her email communications to determine if she sent the recommendations dated 3/23/10 for A/AROM services for Resident #10's lower extremities, the Physical Therapist stated "I guess I forgot to send it".

2. Resident #11 has diagnoses that includes dementia, and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) dated 2/15/10 revealed the resident has moderate cognitive impairment, short and long term memory problems, and functional limitations in range of motion of the hands, leg and feet.

Review of an initial "Initial Plan of Treatment for Physical Therapy (PT)" dated 2/10/10 reveals measurements and documentation that the resident has limitations of motion (joint mobility) of the right (R) knee and both ankles.

A "Discharge Services Plan for Treatment of Physical Therapy" dated 2/25/10 documented that the resident was discharged from PT services. The PT discharge recommendations documented "(R) knee contracture and (B) ankle contractures" with plans for staff to provide A/AROM to both lower extremities qd (each day).

Review of the current comprehensive Care Plan dated 2/11/10 (updated 3/23/10) revealed the resident had contractures of the "right knee and bilateral ankle" with an approach for staff to "Record ROM participation" and notify the charge nurse/NP (nurse practitioner)/MD (medical doctor)/PT/OT for any decline/changes". Additional review revealed there was no Care Plan approach listed to address the lower extremity limitations.

Review of the unit "CNA Assignment Sheet" dated 3/29/10 under the section entitled "ROM" revealed there was no plan to provide lower extremity ROM for Resident #11.

Interview with the RN Unit Manager on 3/31/10 at 10:10 AM revealed that CNAs provide ROM services on the day and evening shifts and document the completed services in the unit "ROM" book.

Review of the ROM book from 3/4/10 through 3/29/10 revealed there was no documentation that the resident received A/AROM to her lower extremities.

During an interview on 3/31/10 at 11:50 AM the Physical Therapist produced an email dated 2/25/10 that documented her communication to the Unit Manager that A/AROM services were to begin for Resident #11's lower extremities.

Interview with the Unit Secretary on 3/31/10 at 10:10 AM revealed she was unable to find any communication (email) from PT regarding revision to Resident #11's ROM services. Interview with the RN Unit Manager on 3/31/10 at 10:10 AM revealed he deletes all of his emails and therefore could not determine if he received any revisions to Resident #11's ROM recommendations.

3. Resident # 15 has diagnoses including Parkinson's disease and congestive heart failure. Review of the Minimum Data Set (MDS) dated 2/4/10 revealed the resident has modified independence for daily decision making skills, always understands, is always understood and has impaired short term memory.

Review of an OT Interdisciplinary Note dated 2/12/10 revealed the resident was discharged from therapy with recommendations for AAROM for upper extremity contractures twice a day.

Review of the current, undated comprehensive Care Plan (CCP) revealed the resident has musculoskeletal pain with bilateral shoulder contractures and a history of a compression fracture (a fracture caused by compression, pressing together). CCP approaches included a plan for staff to provide range of motion (ROM) per Occupational Therapy/Physical Therapy (OT/PT) recommendations.

Review of ROM accountability sheets, used by CNAs to document ROM dated 3/1/10 through 3/31/10 revealed Resident #15's recommended ROM included AAROM to upper extremities twice a day and AAROM to lower extremities once a day. Additional review of the ROM Sheets revealed no documented evidence ROM was provided as planned on 16 of the 31 days.

Interview with the Registered Nurse Unit Manager (RN UM) on 3/31/10 at approximately 10:00 AM revealed he did not know the specific reason for the omissions.

4. Interview with Residents A, B, and C during the Standard survey from 3/29/10 to 4/1/10 revealed they did not routinely receive ROM exercises as recommended by therapy.

415.12(e)(2)

Based on record review and staff interview, the facility did not ensure that services provided met professional standards of quality. Two (Residents #9, 25) of two residents reviewed for peritoneal dialysis (a dialysis method to remove waste products from the body of an individual with severe, chronic kidney failure. Fluid is washed in and out of a space in the abdomen) did not have physician's orders for dialysate solutions (fluid instilled into the abdominal space during peritoneal dialysis) used during peritoneal dialysis treatments. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident # 9 has diagnoses of chronic kidney disease on peritoneal dialysis and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 2/18/10 revealed the resident is cognitively intact, always understands and is always understood.

Review of the current, undated comprehensive Care Plan (CCP) revealed the resident receives in house peritoneal dialysis with an approach to administer peritoneal dialysis per physician, nurse practitioner or peritoneal dialysis nurse order.

Review of a Contract Agreement for the Provision of Dialysis Services between the Dialysis Provider and the Nursing Home dated 4/27/05 revealed the dialysis provider "shall provide faxed signed physician orders for all initial and changed dialysis orders". The Contract Agreement documented that the nursing home is responsible for ensuring "timely implementation of all nephrologists orders".

a). Review of Physician's Orders dated 11/16/09 revealed an order originally initiated on 9/2/09 for the resident to receive peritoneal dialysis solution per the hospital dialysis provider and to hook up at bedtime and disconnect in the morning when completed. A Physician's Telephone Order from the Nurse Practitioner dated 11/19/09 documented "peritoneal dialysis order per hospital peritoneal dialysis".

Review of an (Out of Office) Physician Visit Form dated 12/28/09, for a follow-up nephrology appointment revealed there were no orders for the peritoneal dialysate solution.

Review of CCPD (continuous cycling peritoneal dialysis) Daily Flow Sheets dated 12/29/09 through 1/20/10 revealed documentation that 2.5/2.5% (percent) dialysate solution was instilled for 10 peritoneal dialysis treatments and 2.5/1.5% dialysate solution was provided for 11 treatments. Additional review of the CCPD Daily Flow Sheets revealed a handwritten notation, "per xxxx" (name of hospital dialysis nurse) was written in the section entitled "% of solution". Review of the medical record, including Physician's Orders and Consultation Sheets dated 12/29/09 through 1/20/10 revealed no documented evidence that physician's orders were obtained for the daily dialysate solutions that were provided.

b). Review of a Physician Visit Form dated 1/20/10 revealed an order to "use 2.5/1.5 % dialysate solution tonight". The CCPD Daily Flow Sheet for 1/20/10 documented that this dialysate solution was instilled on 1/20/10 per the physician's order.

Review of the CCPD Daily Flow Sheets dated 1/21/10 through 2/16/10 revealed the following:

- 2.5/1.5 % dialysate solution was documented as used for 9 treatments
- 2.5/2.5% solution was used for 10 treatments
- 1.5/2.5% solution was used for 4 treatments
- 1.5/1.5% solution was used for 5 treatments

Additional review of the CCPD Daily Flow Sheets revealed occasional documentation that the "% of solution" was "per xxxx" (hospital dialysis nurses). There was no documented evidence of physician's orders for the changing dialysate solution in the medical record.

c). Review of an order sheet entitled "Standing Orders for Peritoneal Dialysis" that was faxed to the nursing home from the dialysis provider dated 2/16/10 revealed orders for CCPD Homechoice (type of peritoneal dialysis) using 1.5/2.5/4.25 % dialysate solution "varies", with 6 exchanges per 24 hours (the number of complete treatments within 24 hours).

Review of CCPD Daily Flow Sheets dated 2/17/10 through 3/16/10 revealed:

- 1.5/2.5% dialysate solution was used for 6 treatments
- 1.5/1.5% solution was used for 7 treatments
- 2.5/1.5% solution was used for 11 treatments
- 2.5/2.55 solution was used for 4 treatments

Additional review of the CCPD Daily Flow Sheets revealed there were handwritten notations documenting that the "% of solution" was "per xxxx" (hospital dialysis nurses). Review of the medical record including Physician's Orders and Consultation Sheets from 2/17/10 to 3/16/10 revealed no documented evidence physician orders were obtained for the daily dialysate solutions.

d). Review of an (Out of Office) Physician Visit Form for a follow-up nephrologist appointment dated 3/16/10 revealed an order to "use all 1.5% peritoneal dialysis solution tonight". A Physician's Telephone Order dated 3/23/10 revealed an order for "peritoneal dialysis daily per nephrology protocol".

Review of CCPD Daily Flow Sheets dated 3/17/10 through 3/30/10 revealed 1.5/1.5% dialysate solution was used for 10 treatments and 1.5/2.5% solution was used for 3 treatments. "Per xxxx (name of hospital dialysis nurses) was documented on the CCPD Daily Flow Sheets in the section entitled "% of solution". There were no physician's orders for the changing dialysate solutions in the medical record.

Interview with the Parkside Unit Registered Nurse (RN) Unit Manager on 3/31/10 at approximately 9:00 AM revealed that the daily orders for the resident's peritoneal dialysate solution are obtained from nurse practitioners at the dialysis center in the morning and are noted on the dialysis flow sheets. The RN Unit Manager confirmed there were no other orders for the dialysate solutions.

Interview with the RN Assistant Director of Nursing (ADON) on 3/31/10 at approximately 10:30 AM revealed Resident #9 should have standing orders for dialysis from the dialysis provider which are then countersigned by the nursing home Physician. The ADON explained that dialysis residents are seen monthly at the dialysis center and any changes in treatment are documented on the Physician Visit Form which is sent back to the nursing home with the resident. The ADON stated that peritoneal dialysis residents are weighed daily at the same time and the resident's weight is communicated to the dialysis center if there is a fluctuation of three pounds to determine potential changes in the dialysate solution. The ADON further explained that the nursing home Charge Nurse calls the dialysis center and speaks to the dialysis nurse who informs them of the required dialysate solution which is documented on the dialysis flow sheet only.

Interview with the RN Director of Nursing (DON) on 3/31/10 at approximately 12:30 PM revealed the nurses at the dialysis center who are providing the treatment orders are RNs and not nurse practitioners.

In summary, there is no documented evidence that peritoneal dialysis orders are routinely provided by a Physician, Nurse Practitioner (NP) or a Physician's Assistant (PA).

2. Resident #25 has diagnoses of chronic kidney disease on peritoneal dialysis, congestive heart failure and coronary artery disease. Review of the Minimum Data Set (MDS) dated 1/21/10 revealed the resident has modified independence for cognitive skills in daily decision making, always understands, is always understood and has short term memory problems.

Review of the current, undated comprehensive Care Plan revealed the resident was identified with chronic kidney disease on 1/19/10 with planned approaches to provide peritoneal dialysis per MD/NP/PD nurse order.

Review of a Contract Agreement for the Provision of Dialysis Services between the Dialysis Provider and the Nursing Home dated 4/27/09 revealed the dialysis provider "shall provide faxed signed physician orders for all initial and changed dialysis orders". The Contract Agreement documented that the nursing home is responsible for ensuring "timely implementation of all nephrologists orders".

Review of Physician's Orders dated 12/23/09 revealed an order for a PD (peritoneal dialysis) cycler (an automated machine that instills and drains dialysate solution) every evening with specific instructions for the dialysate solution to be used.

Review of Inpatient CCPD Daily Flowsheets dated 12/29/09 through 3/25/10 revealed:

- 2.5/2.5% dialysate solution was used for 20 treatments
- 1.5/2.5% solution was used for 26 treatments
- 1.5/1.5% solution was used for 21 treatments
- 2.5/1.5% solution was used for 18 treatments
- 2.5/4.25% solution was used for 2 treatments.

Review of an (Out of Office) Physician Visit Form from the Nephrologist dated 3/25/10 revealed a New Treatment Order for specific dialysate solutions to be used "tonight".

Review of Physician's Telephone Order dated 3/31/10 revealed a specific dialysate order was obtained from a dialysis nurse and not from a Physician, NP or PA.

Review of the medical record including Physician's Orders and Consultant Sheets dated 12/29/09 through 3/25/10 revealed no documented evidence that physician's orders were obtained for the changing dialysate solutions that were provided.

Interview with the Registered Nurse (RN) Assistant Director of Nursing (ADON) on 3/31/10 at approximately 10:30 AM revealed Resident #25 should have standing orders for dialysis from the dialysis center, which are then countersigned by the nursing home physician.

Interview with the RN Director of Nursing (DON) on 3/31/10 at approximately 12:30 PM revealed the nurses at the dialysis center who are providing the dialysate solution treatment orders are RNs.

In summary, there is no documented evidence that peritoneal dialysis orders are routinely provided by a Physician/NP/PA.

415.11(c)(3)(i)

Based on observation, record review and staff interview, the facility did not ensure that the resident environment remains as free of accident hazards as is possible. One (Resident #6) of five residents observed for side rail use had an issue involving the use of side rails which was not in accordance with the resident's Side Rail Assessment form. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #6 was admitted on 3/17/09 with diagnoses including diabetes mellitus, hypertension and dementia. Review of the Minimum Data Set (MDS) dated 12/31/09 revealed that the resident has moderately impaired cognition, short and long term memory problems, is understood and usually understands.

Review of a Side Rail Assessment form, done at the time of admission, dated 3/17/09, revealed that Resident #6 did not want or need side rails. The Assessment documented a conclusion of "No SRs" (side rails).

Review of Side Rail Assessments dated 6/11/09 and 9/8/09 revealed a plan for "No Side Rails".

Review of the most recent Side Rail Assessment form dated 12/26/09 revealed the resident is alert with confusion, does not understand the risks (of side rails), has a history of falls and should have "no side rails". The Assessment documented that the risks (of side rails) outweighed the benefits for Resident #6.

Observations on 3/30/10 at 2:15 PM and on 3/31/10 at 10:30 AM revealed Resident #6 was laying in bed with two 1/2 side rails in the up position at the head of the bed.

Review of the comprehensive Care Plan, under the heading ADL (activities of daily living) Functional/Rehab (rehabilitation) Potential dated 2/26/10, revealed the resident requires assistance with ADLs due to diagnoses of legal blindness, dementia, weakness from a recent GI (gastrointestinal) bleed and depression. The CCP documented an approach for the resident to have 2 1/2 side rails at the head of the bed to assist with turning and positioning.

Review of the unit CNA (certified nurse aide) Assignment Sheet dated 3/29/10 revealed a plan for the use of two half side rails.

Interview with the Registered Nurse (RN) Unit Manager (UM) on 3/30/10 at 2:30 PM revealed that the Care Plan was changed on 2/26/10 to include two 1/2 side rails and he did not know why a side rail assessment was not done. The RN UM explained that the next quarterly assessment has not been done yet and the resident has never had side rails according to the previous assessments.

Interview with the RN UM on 3/31/10 at 11:15 AM revealed that he fixed the Care Plan and the CNA Care Guide (CNA Assignment Sheet) and removed the side rails. The RN UM stated "there was no reason for me to add the side rails to the Care Plan on 2/26/10, it was a mistake, I put the wrong information on the resident's Care Plan". The RN UM stated "I called maintenance to remove or tie down the side rails and this will be done as soon as the resident gets out of bed".

Observation of the resident's bed on 3/31/10 at 12:05 PM revealed both side rails were zip tied in the down position and were unable to be put into the up position.

Review of a facility Nursing Policy and Procedure (P&P) entitled Side Rail Use dated 7/13/06 revealed the intent of the P&P is to provide a safe bed environment through the assessment and planning of each resident's needs. The P&P documented that RNs are responsible to conduct Side Rail Assessments which will be completed within one week of admission. The RNs will write a risk/benefit statement using the information gathered by the assessment to determine if side rails are not being used due to risk factors, or if risk factors are not present and the resident would benefit from the use of a side rail. Residents who are care planned to use side rails will be assessed with each quarterly MDS or significant change in condition. Residents using side rails will have their plan of care reviewed by the Interdisciplinary Care Plan Team minimally quarterly and more often if needed.

415.12(h)(1)

Based on record review and staff interview, the facility did not develop policies and procedures that ensure that each resident is offered influenza and pneumococcal immunization, unless the immunization is contraindicated or the resident had already been immunized. Two (Residents #6, 13) of five residents reviewed for influenza and pneumococcal immunizations did not receive one of the two vaccines. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident # 13 has diagnoses including Alzheimer's disease and osteoarthritis. Review of the Minimum Data Set (MDS) dated 3/18/10 revealed the resident is severely impaired in cognitive skills for daily decision making, rarely/never understands, and is rarely/never understood.

Review of the Immunization Report revealed the resident received the seasonal influenza vaccine annually from 2005 through 2008.

An interview with the Social Work Director on 3/31/10 at approximately 10:00 AM revealed responsible parties are sent a letter prior to the influenza immunization requesting permission to administer it. If the form is not returned the responsible party is called to remind them to return the form granting permission.

During an interview with the resident's Social Worker on 3/31/10 at 10:45 AM she explained that the responsible party returned the H1N1 form but not the form for the seasonal flu vaccine. She did not follow up because she knew the responsible party "had a lot going on" as her spouse was in the hospital.

Review of the Social Work notes from 8/12/09 through 3/31/10 revealed on 3/31/10 the Social Worker wrote a note at 11:42 AM that she attempted to reach the responsible party at that time to obtain verbal consent for the flu shot.

The surveyor was approached by the Social Worker at 1:30 PM on 3/31/10 and revealed she phoned the responsible party after being questioned and revealed the responsible thought the form she returned covered both influenza vaccines and she wanted the resident to have the seasonal influenza vaccine.

2. Resident #6 has diagnoses which include diabetes mellitus, hypertension and dementia.

Review of the resident's Vaccination Request Form revealed that the facility offered a one-time pneumococcal vaccination (to protect against pneumonia) and the resident's Health Care Proxy consented at the time of the resident's admission to the facility, on 3/17/09.

Review of the resident's medical record, including the computerized Vaccination Record, revealed no documentation that the resident received the Pneumococcal vaccination.

Interview with the Registered Nurse (RN) Unit Manager (UM) on 3/31/10 at 11:00 AM, revealed that there is no record of the resident receiving the Pneumococcal vaccination and that there is no documentation in the record as to why she did not get it.

The RN UM further stated that the secretary usually reviews the Vaccination Request Forms at the time of admission and if the resident agrees to the Pneumococcal vaccination, the secretary calls the primary Physician to find out if there is a record of the vaccination. The RN UM stated that if the resident had received the Pneumococcal vaccination the secretary records it in the immunization record on the computer and if the resident has not received the vaccination, a resident evaluation is completed, an immunization order is obtained, and the vaccine is administered. The RN UM stated the resident was admitted prior to the RN UM managing the unit, and she did not know why the resident did not receive the vaccine.

Interview on 3/31/10 at 11:55 AM with the Director of Nursing (DON) revealed that the facility system for vaccination is to have the Unit Secretary keep an Immunization Roster which she should review for completion and question why a resident doesn't have an Immunization. The DON further stated that due to secretarial staffing changes there will be a policy change, "probably" making the Unit Managers responsible for periodic review of immunization through the Care Planning process.

Interview with the Temporary Unit Secretary on 3/31/10 at 2:30 PM revealed that the regular Unit Secretary is out on vacation and that the Temporary Secretary did not know about the Immunization Roster for the Unit.

Review of the Nursing Policy and Procedure "Standing Order for Provision of Influenza and Pneumococcal Vaccines", dated 1/3/06, revealed: "All residents, regardless of age and medical condition, should receive the pneumococcal vaccine at least once unless there is a documented contraindication, and in the section, "Admission Policy", that the "Pneumococcal immunization status of all residents will be determined on admission regardless of date. After being reviewed for possible contraindications for vaccination, immunization will be offered to all residents who cannot provide documentation of previous vaccination. Those who are unsure or do not know of their vaccination status will be immunized. Any immunization given will be recorded in the medical record".

415.19(a)(1)
none

Based on observation, record review and staff interview, the facility did not ensure that it is free of medication error rates of five percent or greater. There were three errors for 47 observed medication opportunities involving Residents #16, 17. This resulted in a medication error rate of 6.38% (percent). The issues involved lack of following physician's medication orders with regard to the correct medication (Ecotrin - enteric coated aspirin) and crushing medications that are not to be crushed (Metoprolol extended release for hypertension). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #16 has diagnoses which include congestive heart failure, hypertension and peripheral vascular disease (poor circulation of the lower extremities).

During an observed medication pass on 3/30/10 at 7:10 AM, the Licensed Practical Nurse (LPN) Medication Nurse was observed to administer one Aspirin 81 milligrams (mg) Chewable Tablet to Resident #16, along with her other scheduled medications.

Review of Resident #16's current Physician's Orders dated 2/11/10 revealed an order for Ecotrin (Enteric Coated Aspirin - a special coated tablet designed to protect the stomach) 81 mg by mouth every day.

Interview on 3/30/10 at 9:30 AM with the LPN who administered the Aspirin revealed that she knew the difference between an enteric coated tablet and a regular tablet and "just grabbed the wrong one. I usually give the enteric coated tablet".

Interview with the Registered Nurse (RN) Unit Manager on 3/30/10 at 9:40 AM revealed that the resident has had no GI (gastrointestinal) upset.

2. Resident # 17 has diagnoses of atrial fibrillation (rapid contractions of the top section of the heart) and gastroesophageal reflux (backflow of gastric fluids into the esophagus).

Review of Physician's Orders dated 2/16/10 included orders for Toprol XL 50 milligrams (mg) (Metoprolol ER-extended release), take one tab by mouth daily for hypertension and Ecotrin (enteric coated aspirin) 81 mg one tablet by mouth daily (clot prevention).

During an observation on 3/30/10 at 8:30 AM the Licensed Practical Nurse (LPN) administered chewable Aspirin 81 mg and Metoprolol ER 50 mg after crushing the medications.

On interview 3/30/10 at 2:05 PM with the LPN Medication Nurse stated that he usually crushes the resident's medications and is aware ER medications should not be crushed because the release will not be extended if crushed. He further stated that he thought it would be all right to substitute the chewable Aspirin for the enteric coated Aspirin. The LPN stated he should have requested an order change if a medication can not be given as ordered.

Observation on 3/30/10 at 2:05 PM of the medication cart revealed both forms of Aspirin were available on the cart.

When interviewed at 1:45 PM on 3/31/10, the Pharmacist revealed he supplied the facility with an extensive list of medications not to be crushed and copies were placed in the front of the Medication Administration Record (MAR) binders. He further explained that chewable Aspirin should not be substituted for enteric coated Aspirin.

Review of the list utilized in the facility entitled "Drugs that Should Not Be Crushed", dated 2004, revealed Ecotrin and Toprol XL should not be crushed.

415.12 (m)(1)

Based on observation, record review and staff interview, the facility did not ensure residents received personal privacy during a medical treatment and personal care. Two (Residents #8, 10) of seven residents observed during personal care/treatments had issues involving window curtains not closed during a pressure sore treatment and privacy curtains not closed during personal care. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #8 has diagnoses including hemiplegia (paralysis on one side of the body) and Alzheimer's disease. Review of the Minimum Data Set (MDS) dated 1/14/10 revealed the resident has severe cognitive impairment and is dependent on staff for activities of daily living (ADLs).

Observation on 3/30/10 at approximately 8:30 AM revealed a certified nurse aide (CNA) was providing a bed bath to Resident #8 without the privacy curtain drawn at the foot of the resident's bed. During the observation, a Licensed Practical Nurse (LPN) knocked on the door and asked for permission to enter the room to go to the resident in the window bed. The CNA gave the LPN permission to enter and did not close Resident #8's privacy curtain. The CNA continued to provide pericare to the resident while the LPN walked by the bed. When the LPN left the room, the CNA was washing the resident's buttocks and the LPN was heard to say "excuse me" as she walked by.

2. Resident # 10 has diagnoses including fractures of the left distal femur (lower section of the thigh bone) and left ankle and a stage two pressure sore on the left buttock.

Review of the Minimum Data Set (MDS) dated 2/13/10 revealed the resident is independent for daily decision making, understands and is understood.

Observation of a pressure sore treatment provided by the Licensed Practical Nurse (LPN) Treatment Nurse on 3/30/10 at 3:00 PM revealed the resident was lying in bed with her buttocks exposed during the treatment.

After cleansing the pressure sore with normal saline, the LPN left the bedside to go to the bathroom and wash his hands. The LPN returned to the bedside to apply an ointment to the area. The resident's exposed buttocks were facing the first floor double window in the resident's room. The blinds remained open for 15 minutes during the treatment and there was no attempt to close the blinds or cover the resident.

During an interview on 3/30/10 at 3:17 PM, the LPN explained that he should have closed the blinds.

415.3 (d)(1)(i)

Based on record review and staff interview during a Life Safety Code survey, one of one Kitchen Hood Suppression System was not inspected every six months. This was a pattern with no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Record review of Semi-Annual Kitchen Hood Suppression System Reports on 3/31/10 at approximately 1:12 PM revealed the Kitchen Hood Suppression System was inspected on 11/21/08 and that the next inspection occurred approximately 10 months later on 9/18/09.

Interview with the Director of Environmental Services on 3/31/10 at approximately 2:00 PM revealed that the outside vendor that inspected the facility's Kitchen Hood Suppression System confirmed that the suppression system was inspected on 9/18/09 and that they would check their records for the previous inspection.

Interview with the Maintenance Supervisor on 4/1/10 at approximately 10:21 AM revealed the outside vender that inspects the Kitchen Hood Suppression System had no record they had inspected the facility's Kitchen Hood Suppression System between 11/21/08 and 9/18/09. Further interview with the Maintenance Supervisor revealed the Director of Environmental Services reviewed the facility's purchase orders and that that were no purchase orders for the inspection of the facility's Kitchen Hood Suppression System between 11/21/08 and 9/18/09.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 1997 NFPA 101: 13-3.2.6, 7-2.3
2000 NFPA 101: 19.3.2.6, 9.2.3
1998 NFPA 69: 8-2

Based on observation during a Life Safety Code survey, sprinkler piping on three (Lakeside, Parkside and Woodside) of three resident units was not properly maintained. Issues included sprinkler piping that had electrical wiring zip tied to it, taped to it and/or metal grid-work for drop ceilings wired to it. This was a pattern with no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation above the ceiling tiles on the Woodside Unit on 3/31/10 at approximately 9:35 AM revealed electrical wiring was zip tied to sprinkler piping located near resident room #321.

2. O bservation above the ceiling tiles on the Woodside Unit on 3/31/10 at approximately 9:39 AM revealed electrical wiring was zip tied to sprinkler piping located near resident room #322.

3. Observation above the ceiling tiles on the Woodside Unit on 3/31/10 at approximately 10:01 AM revealed electrical wiring was taped to sprinkler piping located near resident room #336.

4. Observation above the ceiling tiles on the Lakeside Unit on 3/31/10 at approximately 10:37 AM revealed the metal grid-work for the corridor drop ceiling was wired to sprinkler piping located near resident room #113.

5. O bservation above the ceiling tiles on the Parkside Unit on 3/31/10 at approximately 10:59 AM revealed the metal grid-work for the corridor drop ceiling was wired to sprinkler piping located near resident room #217.

6. Observation above the ceiling tiles on the Lakeside Unit on 3/31/10 at approximately 11:05 AM revealed the metal grid-work for the corridor drop ceiling was wired to sprinkler piping located near resident room #120.

7. Observation above the ceiling tiles on the Lakeside Unit on 3/31/10 at approximately 11:10 AM revealed the metal grid-work for the corridor drop ceiling was wired to sprinkler piping located near the Resident Bath/Shower room #1.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 1997 NFPA 101: 7-7.5
2000 NFPA 101: 9.75
1998 NFPA 25: 2-2.2