Ridge View Manor LLC

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 five errors for 54 observed medication opportunities involving Residents #39 and 173. This resulted in a medication error rate of 9.25 percent (%). The issues involved late administration of an anti-diabetic agent and proton pump inhibitor (medication used to reduce the production of gastric acid) that were ordered to be given before meals, medications that were crushed when contraindicated, and a medication ordered every other day given daily. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #39 has diagnoses including hypertension, macular degeneration and cerebral vascular accident (CVA-stroke)

Review of Physician's Orders dated 1/7/11 revealed the following orders:

- Preservision (vitamin supplement - used to treat macular degeneration), Areds Softgel 1 capsule by mouth every day.
- Aspirin Chewable 81 mg Tablet 1 tab by mouth every day for prophylaxis. Chew tablet before swallowing.
- Polyethylene Glycol 17 grams (GM)/1 dose powder (Miralax) 17 GM by mouth every other day with 4 ounces (oz) of juice or water for constipation.

a). During observation of the medication administration on 2/9/11 at 8:20 AM, the surveyor stopped the LPN (licensed practical nurse) CN (charge nurse) from crushing a Preservision Capsule prior to administration.

During an interview at the same time the LPN CN stated "I have not administered these before, so I haven't previously crushed the capsule. This is my second day here. I was going to crush all the meds because that's what the MAR (Medication Administration Record) instructions are for this resident. I did not read the pharmacy label that says Do Not Crush".

Review of the resident's blister pack dispensed by the pharmacy revealed a label, Preservision Capsule 1 cap by mouth every day for macular degeneration with an auxiliary label Do Not Crush affixed.

b). Continued observation of medication administration on 2/9/11 at 8:20 AM revealed the LPN CN crushed and gave the resident 1 tablet from a bottle labeled Aspirin 81 milligrams (mg) Enteric Coated (a coated tablet designed not to dissolve in the stomach).

On further interview at 9:00 AM, the LPN CM stated "I'll show you the bottle I took the Aspirin tablet out of, it was the last tablet so the bottle is empty." The LPN showed the bottle of Aspirin 81 mg Enteric Coated to the surveyor and stated "You're right, Enteric Coated is not the same as a Chewable Tablet."

c). During further observation of the medication administration on 2/9/11 at 9:15 AM, the observing surveyor stopped the LPN CN from administering Polyethylene Glycol.

Interview with the LPN CN at that time revealed the frequency of the dose for the Polyethylene Glycol is every other day as ordered by the doctor. The LPN stated "I gave this yesterday, so shouldn't be giving it today. I gave it yesterday 2/8/11, but it should have been skipped since the resident got a dose on 2/7/11."

Review of the resident's Medication Administration Record (MAR), for the period 2/1/11 through 2/8/11, revealed that the resident received this medication every day during this time period.

Interview with the Registered Nurse (RN) Nurse Manager (NM), on 2/9/11 at 9:20 AM revealed that the January MAR documents that the Polyethylene Glycol was administered correctly every other day. The RN further explained that the 11:00 PM to 7:00 AM shift nurses who do the 11:00 PM to 7:00 AM Med Check QD (daily) which is recorded on the MAR are supposed to check the MAR against the Physician's orders and cross out doses that are supposed to be skipped.

Further interview with the RN UM, on 2/9/11 at 10:05 AM, revealed that the resident has not had any adverse effects from the administration of the extra doses of the laxative.

2. Resident #173 has a diagnosis including diabetes mellitus (DM). Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS - a brief screen that aids in detecting cognitive impairment) dated 1/3/11 revealed the resident is cognitively intact.

Review of Physician's Orders dated 12/17/10 revealed orders for Glipizide ER 5 mg at 7:30 AM and Omeprazole 20 mg po at 9:00 AM. Review of the unsigned physician orders 2/1/11 to 2/28/11 revealed the orders included Glipizide ER 5 mg at 7:30 AM and Omeprazole 20 mg po at 7:30 AM.

Review of the Medication Administration Record (MAR) dated 2/4/11 is Glipizide ER 5 milligrams (mg) tab by mouth (po) before breakfast for DM and Omeprazole (proton pump inhibitor used to reduce gastric acid production) 20 mg po take before food/meal at 7:30 AM.

During the medication pass on 2/4/11 the LPN Medication Nurse was observed to administer Omeprazole and Glipizide ER at 10:09 AM, after breakfast.

During an interview on 2/4/11 at 10:13 AM the LPN Medication Nurse stated he tested the resident's blood sugar at 7:00 AM and it was 107. The LPN stated he was running late today and did not give Glipizide 5 mg and Omeprazole 20 mg at 7:30 AM. The LPN Medication Nurse explained he usually gives these medications at 8:00 AM because that is when breakfast comes.

When interviewed on 2/14/11 at 9:09 AM Registered Nurse (RN) Nurse Manager stated the LPN notified her that the Glipizide ER and Omeprazole 20 mg were given late on 2/4/11 and she notified the physician and obtained orders. The RN Manager stated the 12/17/10 orders are the most current and the physician would be signing new orders in 2/11. The RN Manager revealed the Medication Administration Record (MAR) documented the Omeprazole was administered at 9:00 AM 12/1/10 to 12/31/10. The MARs dated 1/1/11 to 2/4/11 documented the Omeprazole was administered at 7:30 AM. The RN stated the Pharmacy must have changed it to 7:30 AM because the Omeprazole it is supposed to be given before breakfast.

Review of the physician order dated 2/4/11 at 11:00 AM revealed an order to change the administration time of Omeprazole to 6:30 AM and repeat glucometer now times one.

Review of the facility policy for General Information about Drug Administration dated 12/11/07 revealed directions to compare medication labels with the medication administration record for correct drug, dose, time and the resident.

415.12(m)(1)

Based on observation, record review and staff interview, drugs and biologicals used in the facility were not labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. In addition, the facility did not store all drugs and biologicals under proper temperature controls and did not store medications in locked compartments in accordance with State and Federal laws. Three (Green Unit, Blue Unit, Yellow Unit) of three resident units had issues involving lack of secure storage of controlled substances, storage of open, outdated, undated and expired drugs and biologicals. In addition, medications requiring refrigeration were unrefrigerated. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. On 2/4/11 at approximately 11:45 AM the Blue Unit Med Carts on Lake Drive and Eckert Drive were observed to contain the following medications which were open and marked to expire:

- Travatan Z (used to treat glaucoma) ophth (ophthalmic - eye) gtts (drops) 0.004% - 1/10/11 and 1/29/11 - 2.5 milliliters (ml) each
- Brimonide Tartrate (used to treat glaucoma) Ophth soln 0.2 % - 10 ml (milliliter) - 1/19/11
- Timolol Maleate (used to treat glaucoma) ophth soln 0.5 % - 5 ml - 1/19/11
- Dorzolamide Hcl Timolol Maleate (used to treat glaucoma) ophth soln (solution) - 10 ml - 1/14/11
- Artificial Tears (lubricant)soln 1.4 % 15 ml - 2/3/11
- 2 opened bottles Acidophillus (supplement that aids in digestion) 60 capsules each stored in the med cart - Manufacturer's label reads Refrigerate after opening.
- One 10 ml multi-dose vial of Novolog insulin opened and not dated with date of opening.

When interviewed on 2/4/11 at 12:00 PM, the Licensed Practical Nurse (LPN) stated that eye drops and insulin are to be discarded 28 days after opening.

Also observed on the Blue Unit in the Medication Refrigerator was a bottle of Lorazepam (Ativan - used to treat anxiety) oral concentrate 2 milligrams (mg)/ml 30 ml which contained 10 ml and a second bottle of Lorazepam liquid 2 mg/ml containing 26.50 mg per review of Narcotic Count Sheet stored in a locked metal box affixed to a removable shelf.

2. When observed on 2/4/11 at 1:13 PM, the Green Unit stock medication cupboard contained Biscodyl (laxative) 5 milligrams (mg) by mouth (po) tabs 100 mg tabs approximately 1/2 bottle left that expired 12/10.

When interviewed on 2/4/11 at 1:16 PM, the Nichols Lane (Green Unit) Licensed Practical Nurse (LPN) Medication (Med) Nurse stated the nurses obtain stock medications from a stock room down stairs. The LPN stated it is the 11:00 PM to 7:00 AM nurse's responsibility to check the medications for expiration dates. The LPN stated he would discard the expired Biscodyl.

When observed on 2/4/11 at approximately 1:20 PM the following medications were found in the refrigerator in the second floor Green Unit medication room:

- Lantus 100 units per milliliter (ml) one vial labeled with an illegible open date to discard on 2/2/11. During an interview at this time, the LPN Med Nurse stated he could not read when the vial was opened and would discard it.
- Novolog 70/30 100 units per ml opened and undated, Novolog 100 unit /ml opened and undated and a vial of Lantus 100 units/ml open and undated. When interviewed on 2/4/11 at 1:20 PM the Medication LPN stated the insulin vials are supposed to be dated when opened and discarded after 29 days.
- Intravenous (IV) medication Vancomycin (antibiotic) HCL 1.25 GM (grams) in 263 ml (milliliters) of normal saline two bags that outdated on 1/28/11 and 2/2/11 for Resident #190. When interviewed on 2/4/11 at 1:43 PM Medication LPN stated that Resident #190 is still receiving the Vancomycin and he would remove the the expired bags.

During an interview on 2/4/11 at 1:44 PM the Nichols Lane Registered Nurse (RN) Manager stated there is no policy for who checks outdated medication in the med room. The RN Manager stated when insulin vials are opened they are to be dated the day they are opened and then dated to be discarded after 28 days.

When observed on 2/4/11 at 1:50 PM the Fitzgerald Lane (Green Unit) medication cart had Biscodyl 5 mg laxative with an expiration date of 12/10. During an interview on 2/4/11 at 1:55 PM the Fitzgerald Unit LPN Med Nurse stated it is my responsibility to check the expiration dates and stated there are 15 or 20 tabs left in the Biscodyl bottle and she would discard the medication.

When observed on 2/4/11 at 2:05 PM the Nichols Lane Medication Cart had a opened bottle of Vitamin B 1 100 tab bottle approx 3/4 full with an illegible expiration date. When interviewed on 2/4/11 at 2:06 PM the Nichols Lane LPN Med Nurse stated the Vitamin B1 expiration date is illegible on the bottle and it should be discarded. During an interview on 2/4/11 at 2:12 PM the Nichols Lane RN Manager stated you cannot read the label on the B 1 and stated "I will flush it down the toilet".

When interviewed on 2/10/11 at 2:52 PM, the Consulting Pharmacist (RPH) stated it is her responsibility to check refrigerated medications, the medication carts and stock meds on a quarterly bases for expiration dates. She explained the nurses would check them the rest of the time. The RPH stated she checks the insulin vials monthly to see that they are dated when opened and expiration date if unopened. She stated when insulin is opened it should be dated to expire 28 days after opening. The RPH stated she checks IV antibiotics for expiration dates and medications stored on the medication carts quarterly for expiration dates. The RPH further explained the nurse should check the expiration date on the bottle before giving it and if the expiration date could not be read dispose of the medication and get a new bottle. The RPH stated when there is an expiration date on the bottle the bottle should be discarded at the end of the month that it expires.

Review of the facility policy Medication, Storage of Drugs and Biologicals dated 7/17/08 revealed that when the medication shelf life is expired such medications are disposed of or destroyed in accordance with State and Federal Regulations.

Review of the facility policy Multi-Dose Vials for Injection dated 8/24/07 revealed all multiple dose vials of injectible medications (including insulin) will be dated and initialed by the nurse at the time the first dose is used and discarded after 28 days.

3. On 2/4/11 at 1:06 PM a plastic, locked narcotic box was observed affixed to a removable shelf in the Medication Refrigerator on the Yellow Unit. The narcotic box contained 2 Lorazepam 2 mg/1 ml vials unopened with 1 ml each.

During an interview on 2/4/11 at 1:10 PM, the Nursing Supervisor stated the vials are for emergency use and if a resident has a refrigerated narcotic ordered, it would be stored in the Medication Refrigerator inside the plastic box.

415.18(d)(e)(2)(4)

Based on record review and staff interview, the facility did not provide evidence that the facility purchased a surety bond, or otherwise provided assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. The facility did not have a surety bond or similar protection with an amount equal to at least the current total amount of 61 of 61 residents' personal funds deposited with the facility. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Review of the Trust Fund "Active" account balance report dated 1/31/11 and printed 2/14/11 revealed that 61 residents had Resident Trust Fund balances held by the facility.

Interview with the Nursing Facilities Corporate Finance Officer (CFO) on 2/11/11 at 11:15 AM revealed that the nursing facility did not have a surety bond to secure the residents' personal funds. The CFO explained that the residents' personal funds are deposited in a trust fund in a Bank, the sole security being the FDIC (Federal Deposit Insurance Corporation). The CFO stated that monies are maintained as petty cash onsite at the nursing home in the amount of five hundred dollars

Review of an e-mail from the CFO to the Nursing Facility Administrator dated 2/11/11 at 2:46 PM and provided by the Administrator revealed "the Trust Fund petty cash is covered for anything over $500.00. The Trust Fund Accounts at [the bank] are covered by the FDIC for $250, 000 per account.

Review of a document titled "Property Coverage Part Declarations Policy Level Limits of Insurance" dated 10/15/10, provided by the Facility Administrator on 2/11/11 and confirmed by the Administrator as current, revealed the coverage for properties at the nursing home had a deductible ranging from $0 to $2500.00. The policy did not address the protection of residents' funds in the event of bankruptcy and includes deductibles for which there is no guaranteed coverage.

On 2/14/11 at 11:30 AM the Administrator provided a list of 61 residents who had personal account balances as of 1/31/11.

Additional review of the Trust Fund "Active" account balance report revealed residents' funds totaled $63,938.12.
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415.26(h)(5)(v)
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Based on observation, record review, resident and staff interview, the facility did not develop comprehensive care plans (CCP) for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Four (Residents #12, 44, 61, 166) of 20 residents who were reviewed for care plan development did not have a care plan to address Coumadin (anti-coagulant - medication used to prevent blood from clotting), ambulation by the certified nurse aides (CNAs), and pain management. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Resident #166 was admitted to the facility on 6/21/10 with diagnoses including diabetes mellitus, hypertension, hyperlipidemia (elevated fat levels in the blood) and deep vein thrombosis (DVT - formation of a blood clot in a deep vein).

Review of the most recent monthly Physician's Orders dated 1/17/11 revealed an order for Coumadin 7 milligram (mg) by mouth (po) at bedtime (hs). Further review of Physician's Orders revealed the following orders:

- 1/22/11 - Increase Coumadin to 7.5 mg by mouth at bedtime every night,
- 1/26/11 - Increase Coumadin to 8 mg by mouth at bedtime,
- 2/4/11 - Increase Coumadin to 8.5 mg by mouth daily at bedtime.

Review of the Comprehensive Care Plan (CCP) last reviewed 12/2/10 revealed there was no care plan developed regarding anticoagulant therapy.

Interview with the Registered Nurse (RN) Unit Manager (UM) on 2/9/10 at 4:00 PM revealed the resident was diagnosed with a DVT on 12/5/10 and started anticoagulant therapy on 12/5/10. The RN UM stated "we should have revised the care plan to include the anticoagulant therapy within a reasonable time, within a week at most. We were doing the monitoring of the Coumadin on a regular basis, I just missed revising the care plan. In the care plan for anticoagulant therapy, I would include monitoring of signs and symptoms of bleeding, administration sites, and lab values. There is a section in the Resident Care Plans for us to personalize the care plan regarding anticoagulants".

2. Resident #12 has a diagnosis of hip pain secondary to a fall. Review of the Minimum Data Set Assessment (MDS) 3.0 dated 1/24/11 revealed the Brief Interview for Mental Status (BIMS-a brief screen that aids in detecting cognitive impairment) indicated the resident is cognitively intact and has occasion mild pain.

Review of the Comprehensive Care Plan (CCP) dated 2/3/11 revealed there was no care plan to address pain.

Review of Physician's Orders dated 12/8/10 revealed orders for:

- Acetaminophen (Tylenol) 325 milligrams (mg) 2 tablets (650 mg) by mouth (po) every 4 hours prn (as necessary) for pain or temp (temperature) > (more than) 101 with a maximum of 12 tabs (tablets) in 24 hours,
- Acetaminophen suppository 650 mg (1) rectally every 4 hours prn for pain/ discomfort/ Temp > 101 if no po
- Darvocet N (narcotic pain medication) 100 1 tab by mouth every 4 hours as needed.

A Physician Progress Note dated 12/8/10 documented a plan to "assess (the resident's) pain management needs more fully at the next visit. Will need to stop Darvocet soon".

A Nurse's Note dated 12/29/10 documented "due to recall of Darvocet, Ultram (narcotic like pain reliever) 50 mg one po q (every) 6 hours prn for pain ordered". Review of a Physician's Order dated 12/29/10 revealed an order for Ultram 50 mg q 6 hours po for pain.

Review of the Medication Administration Record (MAR) dated 12/1/10 to 12/31/10 revealed Darvocet N 100 mg was administered 13 times for pain. Review of the MAR dated 1/11 revealed Ultram 50 mg and Acetaminophen 650 mg was administered for pain on 1/1/11.

When interviewed on 2/10/11 at 12:09 PM, the resident stated she fell before coming to the nursing home, she has back pain when she sits in the chair and takes pain pills only when she has a lot a pain. The resident stated she has pain every day when she gets up in the chair and stated "when my back hurts real bad I have them put a pillow behind me".

Observation on 2/10/11 at 12:13 PM revealed certified nurse aide (CNA) #2 and CNA #3 transferred the resident out of bed with a mechanical lift and the resident stated "my back hurts". CNA #3 stated "do you want a pain pill" and the resident replied "yes".

During an interview on 2/10/11 at 12:25 PM, the Nichols Lane Licensed Practical Nurse (LPN) stated he was going to give the resident Ultram for back pain.

When interviewed on 2/10/11 at approximately 12:30 PM, the Nichols Lane Registered Nurse (RN) Manager stated a pain assessment is done on admission and quarterly. After review of the current care plan dated 2/3/11, the RN Manager stated the resident occasionally has pain in her left shoulder but she did not know that the resident had back pain. The RN Manager explained that the CCP meeting was 2/3/11, the pain assessment was not done until 2/8/11 and she did not use the MDS to do the care plan. The RN Manager stated all residents have a potential for pain and further explained that she dated the pain section on the care plan but must have gotten distracted and did not do a pain care plan. The RN Manager stated she will have the Physician reassess the resident's pain tomorrow.

During an interview on 2/10/11 at 1:25 PM, the RN MDS Coordinator explained that the MDS is in the computer system and is not printed and the RN Manager would have to ask her for a specific section or have her print it (MDS) for information for the care plan.

3. Resident #61 has a diagnosis of status post shunt (bypass of blood directly from arteries to vein) for hydrocephalus (excessive accumulation of cerebrospinal fluid on the brain) and was admitted to facility for rehabilitation on 10/7/10. Review of the Minimum Date Set (MDS) 3.0 dated 10/17/10 revealed the Brief Interview for Mental Status (BIMS-a brief screen that aids in detecting cognitive impairment) indicated that the resident is cognitively intact and requires limited assistance of one to walk in her room and the hall.

Review of the Comprehensive Care Plan (CCP) dated 1/18/11 and the Personal Care Plan used by CNAs to provide care, dated 1/20/11 revealed the resident is on the Unit Ambulation Program with supervision 5 times a week, once a day. Additional review of both care plans revealed there was no care plan for staff to ambulate the resident on the unit.

Observation on 2/8/11 at 1:47 PM revealed the resident was sitting in a wheelchair and was pulling herself along by using the hand rail. When there was no hand rail, the resident was observed to use her feet and lunged forward with her upper body to propel the wheelchair.

When interviewed on 2/8/11 the resident stated that she walks with a Therapy Aide. The resident stated she would "rather walk then sit in the chair to get around" and is "willing to try to walk" with the CNAs.

During an interview on 2/8/11 at 2:30 PM, the Physical Therapist (PT) Rehabilitation Coordinator stated that Resident #61 is on an ambulation program 5 days a week with the Rehab (rehabilitation) Aide and there is no protocol for the unit CNAs to walk the resident. The PT Rehabilitation Coordinator stated that Resident #61 can be ambulated to the dining room and the bathroom and the CNAs know this from the inservice training he does with them.

When interviewed on 2/8/11 at 2:48 PM the Fitzgerald Lane RN Manager stated that Resident #61 is walked by the ROM (range of motion) CNA only and that PT decides what the resident's ambulation status is on the unit. The RN Manager stated she did not know why the resident does not ambulate on the unit.

When interviewed on 2/8/11 at 3:15 PM, CNA #1 stated she puts the resident in the wheelchair and takes her to the bathroom and transfers the resident to the toilet. The CNA stated she does not walk the resident.

During an interview on 2/10/11 at 3:30 PM, the Corporate Director of Recovery Care stated that PT is responsible to do the care plan for ambulation. The Director stated that Resident #61 is ambulated 150 feet with a RW (rolling walker) and supervision once a day, 5 times per week and this is done by the ROM CNA who is under PT. The Corporate Director of Recovery Care stated that the unit CNAs get general orientation and would know that any resident that ambulates can be ambulated. The Director further explained that the unit CNAs would follow the care plan. The Corporate Director of Recovery Care stated he talked to the Director of Rehabilitation and the care plan can be made clearer regarding when the unit CNAs can ambulate the resident and how far.

During an interview on 2/11/11 at 10:49 AM, CNA #1 reviewed the Personal Care Plan dated 1/20/11 and stated the ROM CNA walks the resident CNA #1 stated "The care plan does not say I can walk the resident and I don't".

During an interview on 2/11/11 at 10:41 AM, CNA #2 stated he usually takes care of Resident #61, he follows the Personal Care Plan to provide the care and he does not walk the resident because the ROM CNA aide usually gets the resident in the morning and walks her on the unit.

When interviewed on 2/11/11 at 11:00 AM, the Corporate Director of Recovery Care stated they are revising Resident #61's care plan so the CNAs knows when to ambulate the resident. The Director explained that the CNAs get orientation, but realizes there should be a specific care plan. The Director stated he thought that the resident was being ambulated on the unit.

Review of a facility policy and procedure (P&P) entitled Ambulation dated 12/18/07 revealed "PT will provide Nursing with recommendations for ambulation on the unit, including the amount of assistance and devices needed for ambulation. These recommendations will be included in the resident's care plan".

415.11(c)(1)
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Based on record review and staff interview, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs and that residents received gradual dose reductions unless clinically contraindicated, in effort to discontinue the drugs. One (Resident #111) of three residents reviewed for Benzodiazepine use had an issue with the facility not acting upon a Consultant Pharmacist's recommendation to attempt a Gradual Dose Reduction (GDR) for a resident receiving Ativan twice a day for anxiety. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #111 has diagnoses which include depressive disorder and senile dementia. Review of the Minimum Data Set (MDS) dated 12/20/10 revealed the resident has moderately impaired cognition and no behavior problems for the seven days prior to the completion of the MDS.

Review of the resident's Behavior Modifying Agent and Review Committee (BMARC) sheet, dated 9/24/10, revealed current psychotropic medications include Ativan (Lorazepam) 0.5 milligrams (mg) by mouth twice a day for anti-anxiety and recommendations to attempt GDR (Gradual Dose Reduction) of Ativan or provide contra-clinical indicator for continued use which is signed by the Social Worker, Unit Manager, Director of Nursing (DON), Pharmacy Consultant.

Review of the Physician's Orders dated 10/21/10 and 12/9/10 revealed an order for Lorazepam 0.5 mg tablet 1 tab by mouth twice daily for anxiety. Review of the Medication Administration Record (MAR), for the period 10/1/10 through 2/13/11, revealed that the resident continued to receive Lorazepam 0.5 mg tablet 1 tab by mouth twice daily for anxiety.

Review of the resident's History and Physical, dated 10/21/10, revealed the physician's Assessment and Plan includes Monitor Ativan, behavior, and mood, Care Plan Review.

When interviewed on 2/10/11 at 3:45 PM, the Registered Nurse (RN) Unit Manager stated the resident still has periods of anxiety and is resistive to hands on care, including oral care. In addition, when out of bed, the resident becomes anxious, apprehensive, and cries. The RN further stated "there is no documentation of this behavior".

Additional review of the BMARC dated 9/24/10 revealed the covering Physician initialed the BMARC report on 10/6/10. During the interview of 2/10/11 at 3:45 PM the RN stated "I think the report was in his folder by mistake. I probably put the initialed sheet in the resident's Physician's folder for review, which resulted in his notation on 10/21/10 for the "plan-monitor Ativan behavior and mood, care plan review". I missed this note, we have not done any behavior monitoring to support a GDR".

415.12(l)(2)(ii)

Based on observation, record review and staff interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #25) of four residents reviewed for accidents had issues involving incomplete investigations of resident falls and lack of investigation of two falls. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #25 has diagnoses including dementia with depressive features, and hemiplegia (paralysis on one side of body) secondary to cerebrovascular accident (stroke). Review of the Minimum Data Set (MDS) 3.0 dated 1/3/11 revealed the resident has both short and long term memory problems, is usually understood and usually understands, and has moderately impaired cognitive skills for daily decision making. The MDS documented a history of a fall in the last 2 to 6 months, and "two or more" falls without injury since admission on 12/13/10. Review of a "Fall Risk Assessment Tool" dated 12/13/10 revealed a high risk score for falls of 21 (11 to 24 = high risk).

Review of the resident's untitled care plan (comprehensive care plan), confirmed on 2/9/11 at 2:30 PM, by the Licensed Practical Nurse (LPN) Nurse Manager as the most recent, revealed approaches for the resident to transfer and ambulate with contact guard of one staff and rolling walker. Additional review of the CP revealed the resident is at risk for falls. Review on 2/8/11 with the LPN Nurse Manager revealed the following approaches:

- call light in reach (undated, on interview 2/8/11 at 2:30 PM, the LPN Unit Manager stated this was implemented on 12/13/10)
- toilet every 2 hours, incontinence care every 2 hours and prn (12/13/10)
- bilateral floor mats (undated; on interview 2/8/11 at 2:30 PM, LPN Unit Manager stated this was implemented 12/13/10)
- dycem (non-slip material that grips on both sides to prevent movement) to seat of wheelchair (12/28/10)
- toilet before and after meals (undated; on interview 2/8/11 at 2:30 PM, LPN Unit Manager stated this was implemented 12/28/10)
- clip alarm at all times (12/30/10)
- sent to ER for evaluation of head wound, CAT, MRI, x-rays negative, neurochecks per policy (undated; on interview 2/8/11 at 2:30 PM, LPN Unit Manager stated this was implemented 1/6/11)
- d/c (discontinue) clip alarm in bed; bed alarm in bed (1/7/11)
- gerichair (1/18/11)
- Found on Floor 1/19/11 - sent to ER - 7 staples, chair alarm, ambulate with 1 assist with rolling walker, treatment per MD order, monitor laceration for signs and symptoms of infection, remove staples 7 to 10 days, OT (Occupational Therapy)/PT (Physical Therapy) screen for positioning, bed alarm, q15 minute checks in bed, low bed, mats to floor, ambulate to bathroom every 2 hours, before and after meals with rolling walker and 1 assist (1/19/11).

It was confirmed on interview, on 2/9/11 at 1:10 PM with the Director of Nursing (DON), that the date of this fall as documented on the care plan was an error and was actually a fall on 1/15/11. Review of Nurses Notes from 1/15/11 to 1/19/11 revealed no fall documented on 1/19/11, and a fall documented on 1/15/11.

Review of the Pocket Care Plan used by the certified nurse aides (CNAs) to provide care, dated 2/6/11 which was confirmed on 2/8/11 as the most current for this resident by the LPN Nurse Manager, revealed plans to toilet before and after each meal, ambulate every 2 hours by nursing to and from toilet, low bed, mats on floor, every 15 minute checks in bed, bed alarm in bed, will self transfer, check frequently, keep at nurses station for close observation when out of bed, may use gerichair while out of bed for safety, visual checks every 15 minutes, and seat alarm.

Review of Resident/Visitor Accident & Incident Reports (A&Is) on 2/9/11 at 1:00 PM with the DON, dated 12/13/10 through 1/15/11 revealed the following:

- On 12/13/10 at 8:30 AM, the resident was found on the floor on her back next to the bed without injury. The resident statement documented "unable". A contributing factor was documented as "agitated had just returned from hospital". The "Care Plan Changes to be Instituted" were documented as bilateral floor mats while in bed. There was no documentation regarding when and where the resident was last seen.
- On 12/19/10 at 3:15 PM the resident was found on the floor in the dining room in front of her wheelchair without injury. The resident's statement was documented as, "I wanna get up". A contributing factor was documented as the resident "is noncompliant and confused, will not ask for assistance". The "Care Plan Changes to be Instituted" were documented as clip alarm at all times. Interview on 2/9/11 at 1:10 PM with the DON revealed no explanation for the discrepancy between the 12/19/10 A&I care plan change to be instituted and the care plan documentation for a clip alarm at all times as implemented on 12/30/10. There was no documentation regarding whether staff was in the dining room at the time of the fall, and what the resident was doing in the dining room at that time.
- On 12/30/11 at 12:00 PM the resident slid out of her wheelchair to the floor on her buttocks while scooting forward without injury. The A&I documented the care plan in place prior to the incident as clip alarm at all times, standard wheelchair with pressure relief cushion and dycem, and foot pedals removed to propel wheelchair. The documented "Care Plan Changes to be Instituted" were to ambulate with contact guard with 1 assist and rolling walker, clip alarm at all times. The "Summary of Investigation" documented the resident scoots wheelchair forward by thrusting body weight in chair, despite dycem, slides ahead of chair and sits on floor. There was no documentation if the incident was observed and where the fall occurred, other than she was at the nurses station and then "moving wheelchair about" and found in "hallway".
- On 1/6/11 at 6:30 AM the resident was found on the floor in the bathroom (of her room) on her knees trying to get back up. Assessment revealed a hematoma over the resident's left eye. A CNA statement documented the resident was checked on every 15 minutes prior to the alarm sounding. The A&I "Summary of Investigation" documented "Clip alarm on while in bed. Clip alarm sounding". When asked on 2/9/11 at 1:10 PM if anyone questioned that the alarm sounded while the resident was in bed and was not found until she had made her way into the bathroom, and how the resident got to the bathroom, the DON stated, "Apparently not". The documented "Care Plan Changes to be Instituted" were to continue current plan, and bed alarm to bed.
- On 1/15/11 (Saturday) at 6:40 AM the resident was found lying on her right side on the floor at the nurses' station, with the "alarm in chair in place", and assessed with bleeding from posterior of head. Documentation included that the resident had been sitting in a chair at the nursing station with "alarm engaged". "Care Plan Changes to be Instituted" were low bed, PT to reassess, consider gerichair alternating with 1:1 for ambulation.

On interview 2/9/10 at 1:25 PM, the DON was asked about any other A&Is as the LPN Nurse Manager had stated to the surveyor there were falls on 12/28/10 and 1/7/11. The DON stated there were no other A&Is.

Review of Nurses Notes dated 12/28/10 revealed a note at 11:10 AM by a Registered Nurse (RN). The RN documented she observed the resident self-propel in her wheelchair around the atrium, then reach forward and "slowly slid to the floor landing on her buttock. Clip alarm intact, functioning".

Review of Nurses Notes dated 1/7/11 revealed a note at 11:30 AM by an RN. The RN documented the resident was found sitting on a mat next to her bed on her buttocks.

Observation on 2/9/11 at 11:00 AM and 2/11/11 at 3:30 PM revealed the resident sitting in her gerichair with seat alarm in place. The resident was moving all extremities and did not appear agitated.

In summary, not all investigations were complete for resident falls, and there was no evidence of investigation of falls on 12/28/10 and 1/7/11.

415.12(h)(2)

Based on record review and staff interview, the pharmacist did not report any irregularities to the Attending Physician and the Director of Nursing for their action. Two (Residents #111, #166) of twelve residents reviewed for drug regimen reviews had issues involving the lack of facility action to address a Consultant Pharmacist's recommendation to attempt a Gradual Dose Reduction for a resident receiving Ativan 0.5 milligrams (mg) twice a day for anxiety. In addition, the Consulting Pharmacist did not identify or report errors, in the signed Physician's Orders dated 1/17/11, to the Attending Physician or Director of Nursing as required. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. ne
The findings are:

1. Resident #166, admitted to the facility on 6/21/10, has diagnoses including diabetes mellitus, hypertension, hyperlipidemia (elevated fat levels in the blood) and deep vein thrombosis (DVT - blood clot).

Review of the resident's Comprehensive Physician's Order Sheet For: Telephone/ Standing/ Clarified Orders revealed the following orders:

- 12/23/10, clarification order: Compazine 10 mg IM (intramuscularly) every 8 hours as needed for nausea and vomiting. The previous order written earlier 12/23/10 was for Compazine 1 mg.
- 1/10/11 D/C (discontinue) Lovenox 80 mg twice a day.

Review of the resident's monthly renewal Physician's Orders, dated 1/17/11, revealed orders for the following:

- Lovenox (an anti-coagulant-blood thinner) 80 milligrams (mg)/0.8 mg Inject 0.8 cubic centimeters (cc) (80 mg) subcutaneously (beneath the skin) twice daily for LLE (LowerLeft Extremity) DVT (Deep Vein Thrombosis)
- Compazine 1 mg every 8 hours as needed for nausea and vomiting.

Review of the resident's Medication Administration Record (MAR), for the period 1/1/11 through 2/9/11, revealed that the Lovenox was discontinued on 1/10/11 and that the resident did not receive the Compazine.

Review of the Medication Regimen Review (MRR) revealed that the last review by the Consultant Pharmacist was done on 1/21/11. Further review of the MRR revealed there is no recommendation regarding the errors in the signed orders dated 1/17/11 for Lovenox or Compazine.

During an interview with the Registered Nurse (RN) Manager, on 2/9/11 at approximately 11:00 AM, the RN stated with new monthly orders for someone in the facility, the orders will come from the pharmacy around the 15th of the month. The new orders are checked against the orders in the chart before the orders are placed in the chart for MD signature. These orders were initially checked on 12/22/10 and again on the night of change over to the new month on 12/31/10. Both of those checks should have caught the clarification order for the Compazine order on 12/23/10 and made sure that it was written correctly for the MD signature on 1/17/11. The RN Manager further explained that when the order to D/C the Lovenox was taken on 1/10/11, the nurse taking the new order should make the change on the MAR and also make the change on the new set of monthly orders waiting for the MD signature. In this case the MAR was corrected but the orders were not corrected resulting in the Lovenox order being carried over in error.

During an interview on 2/10/11 at 2:55 PM, the Consultant Pharmacist stated, "I did do the Monthly Regimen Review on 1/21/10 after the physician orders were signed on 1/17/10. I check the monthly orders against the interim orders for accuracy. I check the new written orders against the pharmacy orders and the MAR. And I would make any recommendations either to the Doctor or I could make a recommendation to nursing regarding a lesser change in the orders. I was aware of the discontinuation of the Lovenox and the clarification of the Compazine. I checked the MAR and it was accurate. The Pharmacy has the correct orders. I just missed commenting on the error in the signed orders of 1/17/11."

Review of the undated facility policy entitled Monthly Doctor Orders & MARS Change-Over revealed all medication sheets must be reviewed for accuracy and comparison with all current orders. New med sheets are checked against last signed doctor orders for any discrepancies. Then check for verbal orders to see if any changes have occurred in last 30 to 60 days.

Review of the facility policy Medication Administration Record (MAR), with a revised date of 11/14/08, revealed the 11:00 PM to 7:00 AM Nurse will check the MAR on a daily basis against the physician orders. If any discrepancies are found, the Nurse will notify the Nurse Supervisor, who will contact the physician to notify him/her of all medication discrepancies for clarification and further orders.

2. Resident #111 has diagnoses which include depressive disorder and senile dementia. Review of the Minimum Data Set (MDS) dated 12/20/10 revealed the resident has moderately impaired cognition and no behavior problems for the seven days prior to the completion of the MDS.

Review of the resident's Behavior Modifying Agent and Review Committee (BMARC) sheet, dated 9/24/10, revealed current psychotropic medications include Ativan 0.5 milligrams (mg) by mouth twice a day for anti-anxiety and recommendations to attempt GDR (Gradual Dose Reduction) of Ativan or provide contra-clinical indicator for continued use which is signed by the Social Worker, Unit Manager, Director of Nursing (DON), Pharmacy Consultant.

Review of the Physician's Orders dated 10/21/10 and 12/9/10 revealed an order for Lorazepam (Ativan) 0.5 mg tablet 1 tab by mouth twice daily for anxiety. Review of the Medication Administration Record (MAR), for the period 10/1/10 through 2/13/11, revealed that the resident continued to receive Lorazepam 0.5 mg tablet by mouth twice daily for anxiety.

Review of the resident's History and Physical, dated 10/21/10, revealed the physician's Assessment and Plan includes Monitor Ativan, behavior, and mood, Care Plan Review.

When interviewed on 2/10/11 at 3:45 PM, the RN Manager stated the resident still has periods of anxiety and is resistive to hands on care, including oral care. In addition, when out of bed, the resident becomes anxious, apprehensive, and cries. The RN further stated "there is no documentation of this behavior".

Additional review of the BMARC dated 9/24/10 revealed the covering Physician initialed the BMARC report on 10/6/10. During an interview on 2/10/11 at 3:45 PM, the RN Manager stated "I think the report was in his folder by mistake. I probably put the initialed sheet in the resident's Physician's folder for review, which resulted in his notation on 10/21/10 for the "plan-monitor Ativan behavior and mood, care plan review". I missed this note, we have not done any behavior monitoring to support a GDR".

During an interview on 2/10/11 at 4:00 PM the Director of Nursing (DON) stated "I review the Pharmacist Consultation Report. I don't get the BMARC recommendations, that is driven by Social Worker. I agree that there had to be a follow up to the recommendation to attempt a GDR of the Ativan. The physician's response to monitor Ativan behavior and mood, care plan review should have resulted in a record of resident behavior to support either an attempt to reduce the medication or the physician's decision to continue the medication as ordered."

When interviewed on 2/11/11 at 9:20 AM the DON stated "I expect the pharmacy consultant to follow up on recommendations that they make. In this case the recommendation for the GDR was made in September and the Pharmacist should have followed up in October or November."

Review of the resident's Medication Regimen Review sheet for the dates 9/24/10,10/27/10, 11/22/10, 12/24/10, and 1/17/10 revealed no documented evidence of a follow up recommendation to the 9/24/10 BMARC recommendation to attempt GDR of Ativan.

During an interview on 2/11/11 at 9:12 AM the Pharmacy Consultant stated "I have a GDR tracking component in my computer program. I have had responsibility for this home for only 1 month and have not gotten all the information in on all of the residents yet. Yes, the pharmacy consultant should have followed up on the recommendation to GDR the Ativan."

415.18(c)(2)

Based on observation, record review and staff and resident interview, the facility did not ensure that a resident was given the appropriate treatment and services to maintain or improve his or her transfer and ambulation abilities. One (Resident #61) of four residents reviewed for activities of daily living was not assisted with ambulation on the unit by unit staff. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #61 has a diagnosis of status post shunt (bypass of blood directly from arteries to vein) for a normal pressure hydrocephalus (excessive accumulation of cerebrospinal fluid on the brain) and was admitted to the facility for rehabilitation on 10/7/10. Review of the Minimum Data Set (MDS) 3.0 dated 10/17/10 revealed the Brief Interview for Mental Status (BIMS-a brief screen that aids in detecting cognitive impairment) indicated that the resident is cognitively intact and walks in her room and the corridor with limited assistance.

Review of the Comprehensive Care Plan (CCP) dated 1/18/11 and the Personal Care Plan, used by certified nurse aides (CNAs) to provide care, dated 1/20/11 revealed the resident is on the Unit Ambulation Program using a RW (rolling walker) once a day, five times a week for a distance of 150 feet.

Review of a Physician Progress Note dated 10/20/10 revealed the resident was evaluated by Occupational Therapy (OT)/Physical Therapy (PT) and scheduled for a 4 week course of treatment. A Physician Progress Note dated 1/7/11 documented that the resident completed OT/PT on 11/29/11 and the resident showed improvement in her general abilities and activities of daily living (ADLs).

Review of a Physical Therapy Discharge Summary dated 11/29/10 and a PT Screen dated 1/4/11 revealed Nursing Recommendations included supervised ambulation with a RW once a day, 5 times a week for a distance of 150 feet.

When observed on 2/8/11 at 12:54 PM, the resident was sitting in a wheelchair without leg rests on and at 1:47 PM the resident was pulling herself down the hall using the hand rail. When no hand rail was present, the resident was observed to use her feet and lunged her upper body forward to propel the wheelchair.

During an interview on 2/8/11 at 2:00 PM, the resident stated she previously lived at home, was hospitalized and was then admitted to the facility. The resident stated that she walked with a cane at home and drove a car. The resident stated that she is walked by a Therapy Aide, but the unit CNAs do not want her to walk. The resident stated she did not know why she is in the wheelchair and stated "I would rather walk then sit in the chair to get around. I am willing to try to walk. I am not sure I want to stay here for the rest of my life".

During an interview on 2/8/11 at 2:09 PM, the Fitzgerald Unit Registered Nurse (RN) Manager explained that the resident came in for rehabilitation and the family thought it was best if the resident stayed in LTC (Long Term Care). The Fitzgerald RN Manager stated she did not know why the resident is in a wheelchair and why she does not walk to dining and other destinations.

When interviewed on 2/8/11 at 3:11 PM, the Social Worker stated that Resident #61 was admitted for rehabilitation and prior to admission was living alone at home. The Social Worker stated the resident's son had considered remodeling his home so the resident could move in, but decided not to do that. The Social Worker stated she did not write a note that she discussed discharge options with the resident. The plan is now for the resident to remain in LTC and that PT would determine if the resident is able to function at a different level of care.

When interviewed on 2/8/11 at 2:30 PM, the Physical Therapist (PT) Rehabilitation Coordinator stated that Resident #61 came in for short term rehabilitation and progressed to ambulating 150 feet with the rolling walker (RW) with supervision. The PT Rehabilitation Coordinator stated that the resident is on an ambulation program and is ambulated by the ROM CNA once a day, 5 days a week. The PT Rehabilitation Coordinator stated there is no "protocol" for the unit CNAs to walk the resident on the unit and the resident can be ambulated to the dining room and the bathroom. The PT Rehabilitation Coordinator explained that the CNAs should know they can ambulate the resident from the inservice training he does with them. The PT Rehabilitation Coordinator also stated that he did not know if the resident was being walked to the bathroom or the dining room.

During an interview on 2/8/11 at 2:48 PM, the Fitzgerald Unit RN Manager stated that Resident #61 is walked by the ROM Aide only. The RN Manager stated that PT decides when the resident's ambulation status is on the unit and she did not know why the resident does not ambulate on the unit.

When interviewed on 2/8/11 at approximately 3:00 PM, the day shift CNA (CNA #1) stated she transfers the resident per the care plan but does not walk the resident. On 2/11/11 at 10:49 AM, CNA #1 reviewed the Personal Care Plan dated 1/20/11 and stated that the ROM CNA walks the resident and "the care plan does not say I can walk the resident and I don't".

When observed on 2/9/11 at 10:42 AM, the resident was ambulated in the hall by ROM CNA #1 using a RW. At 10:48 AM, the resident asked to sit down and rest. At 10:50 AM, the ROM CNA assisted the resident to stand and the resident stated "I thought I would go around again". The ROM CNA was observed to walk the resident a short distance and then had the resident sit in the wheelchair.

During an interview on 2/9/11 at 10:55 AM, the ROM CNA #1 stated he ambulates the resident twice "around" (from the elevator, past PT around the corner and back to the elevator) and thinks this is 150 feet or maybe 300 feet. The ROM CNA stated the resident is supposed to be walked 150 feet and that the resident does not walk more than that. The ROM CNA stated that the resident did want to walk more when he ambulated her but the resident is only supposed to walk 150 feet, "I wasn't going to let the resident walk around again and if the resident wanted to do it walk around again I would have had to tell PT".

Observation on 2/9/11 at 3:20 PM revealed the resident was sitting in the wheelchair in the hall. When observed on 2/10/11 at 11:50 AM, the resident was in the wheelchair and was wheeled into the unit bathroom by the ROM CNA #2.

During an interview on 2/10/11 at 3:30 PM, the Corporate Director of Recovery Care stated that PT is responsible to do the care plan for ambulation. The Director stated that Resident #61 is ambulated 150 feet with a RW and supervision once a day, 5 times per week and this is done by the ROM CNA, who is under PT. The Corporate Director of Recovery Care confirmed the that resident should be ambulated 150 feet with supervision once a day, 5 times per week by the ROM CNA. The Corporate Director explained that the unit CNAs get general orientation and would know that any resident that ambulates can be ambulated. The Director further explained that the Unit CNA would follow the care plan. The Corporate Director of Recovery Care stated he talked to the Director of Rehabilitation and the care plan can be made clearer when the Unit CNA can ambulate the resident and how far.

When interviewed on 2/11/11 at approximately 11:00 AM, the Corporate Director of Recovery Care stated they would revise the care plan so the unit CNAs will know when to ambulate the resident.

415.12(a)(2)

Based on observation, record review and staff and resident interview, the facility did not ensure that services provided by the facility are provided by qualified persons in accordance with each resident's written plan of care. One (Resident #166) of twenty residents reviewed for care plan implementation did not have a pressure reduction cushion when out of bed in the wheelchair, according to the plan of care. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #166 has diagnoses diabetes mellitus and a perirectal abscess. Review of the Minimum Data Set (MDS) dated 12/13/10 revealed the Brief Interview for Mental Status (BIMS-a screen that aids in detecting cognitive impairment) indicated the resident is cognitively intact.

Review of an Occupational Therapy (OT) Consultation dated 10/27/10 revealed the resident was issued a standard pressure reduction (relief) cushion. An OT Evaluation dated 12/10/10 documented equipment recommendations for a power wheelchair and a pressure reduction cushion.

Review of the Comprehensive Care Plan (CCP) dated 12/21/10 revealed the resident had a recurrent perirectal abscess and an approach to use a pressure reduction cushion in the chair when out of bed. The Personal Care Plan, used by certified nurse aides (CNAs) dated 1/18/11, documented a plan for a wheelchair cushion.

Observations on 2/7/11 at 8:48 AM, 2/8/11 at 1:20 PM and 2/10/11 at 8:15 AM revealed the resident was sitting in an electric wheelchair and there was no cushion in the chair.

Observation on 2/9/11 at 8:58 AM revealed the Registered Nurse (RN) Manager and Certified Nurse Aide (CNA) assisted the resident to stand up from the wheelchair and there was no cushion in the chair. The CNA was observed to remove the resident's brief and the RN Manager measured a 2.7 centimeter (cm) long by 0.8 cm wide macerated (softened skin as a result of moisture) area on the right inner buttock.

During an interview on 2/9/11 at 9:05 AM, the resident stated he did not have a cushion in his chair and has never had one.

When interviewed on 2/10/11 at 8:35 AM, RN Manager stated the area on the resident's buttock looks macerated and is "bigger" this week than last but that the area does fluctuate up and down in size.

When interviewed again on 2/10/11 at 9:06 AM, the RN Manager reviewed the care plan for skin integrity which included the approach for the pressure reduction cushion in the chair when out of bed. The RN Manager stated she thought the electric wheelchair had pressure relief cushion in the wheelchair and she would check the wheelchair instruction booklet. At 9:15 AM, the RN Manager stated the care plan is for a cushion in the wheelchair and explained that the resident had a cushion in a standard wheelchair when he first was admitted 6/10, but has not had one since. The RN stated that therapy had recommended a cushion and she would ask them to provide one.

During an interview on 2/10/11 at approximately 10:00 AM, the Certified Occupational Therapy Assistant (COTA) stated that the OT recommendation dated 12/10/11 for a pressure relief cushion in the chair was because the resident has a "pressure ulcer". When informed that the resident did not have a pressure relief cushion in his wheelchair, the COTA stated "Oh, he doesn't have one?".

When observed on 2/10/11 at approximately 10:30 AM, the resident was approached by the Director of Rehabilitation who was carrying a gel/foam cushion in his hand.

Observation on 2/10/11 at 10:44 AM revealed the resident had a cushion in his wheelchair.

Review of a facility policy and procedure entitled "Care Plans, Using the Care Plan" dated 11/5/10 revealed daily care and documentation must be consistent with the resident's care plan.

415.11(c)(3)(ii)

Based on observation during a Life Safety Code survey, a smoke barrier door and a hazardous area door were held open by devices that were not arranged to automatically close these doors upon activation of the required manual fire alarm system, local smoke detectors and/or the automatic sprinkler system. This affected one (First Floor) of two resident use floors and one of one Basement. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the First Floor on 2/10/11 at approximately 12:27 PM revealed a medication cart was stored in front of and obstructing one of the smoke barrier doors that lead into Lake Drive on the Blue Unit.

2. Observation in the Basement on 2/10/11 at approximately 12:44 PM revealed a shopping cart was stored in front of and obstructing the door to the Soiled Laundry room closing.

10NYCRR 415.29(a)(2), 711.2(a)(1)
42 CFR 483.70(a)(1)
2000 NFPA: 19.2.2.2.6

Based on observation and staff interview during a Life Safety Code survey, smoke barrier doors were not properly maintained. Issues included smoke barrier doors that were not designed to resist the passage of smoke. This affected one (First Floor) of two resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the First Floor on 2/9/11 at approximately 9:15 AM revealed an approximate one quarter inch gap between the smoke barrier doors that lead into Colleen Drive on the Yellow Unit. Also at this time, interview with the Environmental Services Director revealed that one of the doors was replaced by an outside vendor in 7/10 or 8/10.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
42 CFR 483.70(a)(1)
2000 NFPA 101: 19.3.7.6, 8.3.4, 8.3.4.1

Based on observation and staff interview during a Life Safety Code survey, oxygen storage was not properly maintained. Issues included an oxygen storage room that lacked signage. This affected one (Second Floor) of two oxygen storage rooms. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 2/10/11 at approximately 10:35 AM revealed the Second Floor Oxygen Storage room lacked signage. Further observation at this time revealed this room contained 12 E sized oxygen cylinders and one D sized oxygen cylinder. Interview with the Environmental Services Director on 2/11/11 at approximately 3:00 PM revealed a member of the facility's Nursing staff had removed the sign from the Second Floor Oxygen Storage room to place it on the door frame of a resident room of a resident that was using oxygen because the state survey team was in the building.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
42 CFR 483.70(a)(1)
2000 NFPA 101: 19.3.2.4
1999 NFPA 99: 8.3.1.11.3

Based on observation and staff interview during Life Safety Code survey, smoke detectors were not properly maintained. Issues included the orifices (openings) on smoke detectors being obstructed. This affected one (Yellow Unit) of three resident units. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the First Floor on Colleen Drive on the Yellow Unit on 2/11/11 at approximately 8:01 AM in the presence of the Environmental Services Director revealed smoke detectors located in resident rooms #52, #54, #55 and the smoke detector located in the corridor near resident room #54 were covered with gray tape. Also at this time observation revealed the orifices (openings) that allow smoke and visible and invisible products of combustion to enter into these smoke detectors were covered with the gray tape. Covering the orifices of these smoke detectors with tape compromises the smoke detectors ability to function as it is designed. Further observation at this time revealed the smoke detector located in resident room #52 was covered with a dust mask that was designed to be worn on one's face and gray tape and the smoke detector located in the corridor located near resident room #52 was taped inside a black plastic bag. Covering the orifices of these smoke detectors with tape compromises the smoke detectors ability to function as it is designed. Continued observation at this time revealed that none of the staff for the outside vendor that was working in this area were on site.

Interview with the Environmental Services Director at this time revealed that she had discussed the fact that all of the smoke detectors in this area had to be uncovered by the outside vendor's staff before the outside vendor's staff left the site each day and that the outside vendor's staff must have forgotten to remove everything that was covering the smoke detectors in this area on 2/10/11 when they left the building. Further interview with the Environmental Services Director at this time revealed that this area of the building was affected by a roof leak on 12/31/10 and that this area of the building was currently being repaired due to water damage from the leak.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
42 CFR 483.70(a)(1)
2000 NFPA 101: 9.6.1.3, 4.6.10, 4.6.10.1
1999 NFPA 72: 7-3.1, 7-4, 7-4.1

Based on observation during a Life Safety Code survey, sprinkler piping was not properly maintained. Issues included sprinkler piping that was exposed to external loads. This affected two (First, Second Floors) of two resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation above the ceiling tiles on the Second Floor on 2/10/11 at approximately 10:40 AM revealed a metal clamp and copper wire were attached to and hung from sprinkler piping located in the Oxygen Storage room. Further observation at this time revealed the metal clamp and copper wire were being used as an electrical ground for television electrical lines.

2. Observation above the ceiling tiles on the First Floor on 2/10/11 at approximately 11:34 AM revealed an approximate 12 inch tall by 12 inch long by two inch wide electrical box was sitting on top of sprinkler piping near the Center Stairway door. Also at this time observation revealed an approximate four foot long by one half inch wide piece of metal conduit was attached to and hung from sprinkler piping with metal wire. Further observation at this time revealed this piece of metal conduit that was attached to and hung from the sprinkler piping had an electrical Exit sign attached to it and that the conduit was being used as an anchor to hold the Exit sign in place above the Center Stairway door.

3. Observation above the ceiling tiles on the First Floor on 2/10/11 at approximately 11:40 AM revealed two metal conduits and electrical wires were attached to and hung from sprinkler piping with metal wires. Further observation at this time revealed the sprinkler piping was located between the Atrium and the Yellow Unit Nurses station.

4. Observation above the ceiling tiles on the First Floor on 2/10/11 at approximately 12:25 PM revealed two metal conduits and one flexible metal electrical conduit were attached to and hung from sprinkler piping with metal wires. Further observation at this time revealed this sprinkler piping was located near resident room #15 of Eckert Lane on the Blue Unit.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
42 CFR 483.70(a)(1)
2000 NFPA 101: 9.75
1998 NFPA 25: 2-2.2

Based on observation and staff interview during a Life Safety Code survey, fire alarm pull stations were not properly maintained. Issues included fire alarm pull stations that were obstructed. This affected one (First Floor) of two resident use floors and one of one Basement. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the First Floor on 2/9/11 at approximately 9:20 AM revealed an air cleaning machine was stored in front of and obstructing the fire alarm pull station near resident room #54 on Colleen Drive of the Yellow Unit. At the time of the observation and interview with the Lead Maintenance Technician revealed he had spoken with the outside vendor's staff about not obstructing the fire alarm pull station located near resident room #54. Observation on 2/11/11 at approximately 8:02 AM revealed an approximate eight foot long by eight inch wide and an approximate four foot long by eight inch wide metal heater covers were stored in front and obstructing the fire alarm pull station located near resident room #54 on Colleen Drive of the Yellow Unit.

2. Observation in the Basement on 2/10/11 at approximately 12:45 PM revealed a chair was stored in the corridor in front of and obstructing the fire alarm pull station located near the Housekeeping Storage room door.

3. Observation on the First Floor on 2/11/11 at approximately 10:38 AM revealed an oversized wheelchair with a foot pedal attached to it was stored in front of and obstructing the fire alarm pull station located near resident room #15 on Eckert Lane of the Blue Unit.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
42 CFR 483.70(a)(1)
2000 NFPA 101: 9.6.1.4
1999 NFPA 72: 2-8.2.1