Kirkhaven

Based on observations, staff interviews, and record reviews, it was determined that on two of four units the facility did not ensure that controlled substances were stored in separately locked, permanently affixed compartments (Unit 5), that an unlocked medication cart remained supervised at all times (Unit 4), and that expired medications (Tubersol - used to detect tuberculosis) were properly exposed in a timely manner (Unit 4). This resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. During an observation of Unit 5's medication refrigerator on 8/1/11 at 8:42 a.m., a metal box located in the refrigerator was not secured to the interior of the refrigerator. At this time, Licensed Practical Nurse (LPN) #1 removed this box from the refrigerator and stated that it held narcotic medications. LPN #1 stated that this box is locked after use and then stored in the refrigerator, which is also locked after use.

In a joint observation of the Unit 5 metal narcotic box on 8/3/11 at 8:41 a.m., the locked box was removed from the refrigerator by LPN #2. This box held 48 unopened vials of injectable Aptiva (narcotic medication, 2 milligram/milliliter vials) for three different residents. When interviewed at this time, LPN #2 said that the narcotics that need to be refrigerated and are kept in a locked metal box in the locked refrigerator. She reported that the metal box has never been secured to the refrigerator.

2. The Unit 4 medication room was inspected jointly with the surveyor and Registered Nurse/Nurse Manager (RN/NM) on 8/1/11 at 9:00 a.m. The medication refrigerator held two open vials of Tubersol (for tuberculosis detection). The first open vial was marked, "6/8," in black ink. The pharmacy label included a dispensing date of 5/7/11. The second open vial was not marked with a date. The pharmacy label included a dispensing date of 7/6/11 and an imprinted expiration date of 11/2/12. There were two vials of insulin labeled for a specific resident. Both vials of insulin (Humolog and Lantus) had a pharmacy label dispensing date of 7/22/11, with an attached label that read discard after 28 days, and the space for the date opened was blank.

In addition, there were two bottles of bismuth (Pepto Bismol) on the shelf in the medication room, unopened, that expired July 2011. When interviewed at that time, the RN/NM said that all of the insulin vials should be dated when opened and discarded in 28 days. He said that he was not sure how often the medication refrigerator was checked for expired medications. He added that if open medications are undated, then staff are not to use them.

When interviewed on 8/1/11 at 9:20 a.m., the Assistant Director of Nursing said that once a vial of insulin is open, it should be dated, and discarded in 28 days.

3. In an observation on 8/1/11 from 2:00 p.m. to 2:30 p.m., the medication cart on Unit 4 was unlocked, unsupervised, and stationed around the corner from the nurses' station. When interviewed at 2:30 p.m. and 2:50 p.m. that day, the RN/MN and LPN said that the medication cart should be locked at all times.

The facility's policy entitled, "Storage of Medications," dated September 2010, included that all medications will be stored in a locked room. Insulin is stored within the refrigerator in the medication room. When insulin is opened, the discard date is placed on the bottle by the nurse who opens the bottle. The discard date is 28 days from the date it is opened. Nightly audits for stickers and dates will be done by the Nursing Supervisor and recorded with glucometer calibration testing. Nursing will discard or remove any outdated medications as soon as possible.

[10 NYCRR 415.18 (d)]

Based on staff interview and record review, it was determined that for 1 of 17 residents reviewed for resident assessments, the facility had not completed the Minimum Data Set (MDS) Assessment to accurately reflect the resident's functional capacity. Specifically, Resident #35's MDS Assessment did not include an accurate assessment of pressure ulcers. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #35 was admitted to the facility on 11/9/10 with diagnoses including chronic venous ulcers and a healing Stage III pressure ulcer on the left heel.

Review of the MDS Assessment, dated 12/17/10, revealed the presence of one Stage III pressure ulcer, including dimensions of the ulcer. MDS Assessments, dated 3/11/11 and 4/29/11, documented the presence of one Stage II pressure ulcer and a healed Stage III pressure ulcer.

Review of the facility's skin book (log of residents with skin issues) revealed that the resident's left heel pressure ulcer was a Stage III upon admission. In April and May 2011, the pressure ulcer was unstageable, and in June and July 2011 it was a Stage III.

Review of the Nurse Practitioner (NP)/Wound Care Specialist progress note, dated 7/19/11, revealed the presence of a Stage III left heel pressure ulcer.

Interviews conducted on 8/3/11 are as follows:

a) At 11:15 a.m., the Registered Nurse/Nurse Manager (RN/NM) said that the resident had a Stage III ulcer on the left heel. The NM said he is new on the unit, did not know how long the resident had the pressure ulcer, and was not sure how the MDS Assessment is coded for pressure ulcers.

b) At 11:20 a.m., the Director of Nursing (DON) reported that wound care nursing documentation should be used to determine how to code the MDS section regarding pressure ulcers. In addition, the MDS handbook explains that pressure ulcers remain at the same stage until healed.

c) At 2:00 p.m., RN #1 said that she completed the 4/29/11 MDS Assessment and is not sure why the pressure ulcer was coded as a Stage II and a Stage III healed. RN #1 stated that she looks at the wound care specialist notes when completing the MDS Assessment and is aware that pressure ulcers are not downstaged during the healing process.

d) At 2:15 p.m., RN #1 contacted the NP/Wound Care Specialist and said that the left heel ulcer has always been a Stage III. She added that she would modify the 4/29/11 MDS Assessment that was submitted in April and pass the information on to the MDS Coordinator.

In an interview on 8/4/11 at 10:00 a.m., RN #2 said that she completed the 12/10/10 MDS Assessment and obtained the Stage III pressure ulcer information from a wound clinic note. She also stated that the pressure ulcer information on the MDS Assessments after 12/10/10 were inaccurate and that corrections will be made.

[10 NYCRR 415.11(a)(1)]

Based on staff interviews and record reviews, it was determined that for two of six employee files reviewed for Criminal History Record Checks (CHRC), the facility did not conduct a CHRC where required. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

When reviewed on 8/3/11 at 9:00 a.m., two employee personnel files lacked a CHRC result. Individual #5, hired as a food service employee on 5/6/11, and individual #4, hired as a food service employee on 6/6/11, were not submitted for a CHRC.

In an interview on 8/3/11 at 9:45 a.m., the Vice President of Human Resources and the employee recruiter said the two food service employees were not subject to a CHRC because they work in the kitchen, did not provide direct care, or have access to the resident's living area. When asked the duties of the food service employees, it was revealed they deliver the food carts to the residential unit kitchens and deliver food items to those units when necessary. When asked if these duties allowed for employee access to the residents' living quarters, the Vice President of Human Resources and the employee recruiter said, "Yes."

In an interview on 8/3/11 at 1:30 p.m., the facility's president stated that food service workers do not have independent access to the resident living area but do deliver the food carts to the units.

The facility's CHRC policy did not include a requirement for all dietary employees with access to the residents' living quarters to have a CHRC completed.

Part 402 of the CHRC expands the definition of an "employee in direct care and supervision" to include any unlicensed person employed by or used by a nursing home who has physical access to a resident's living quarters.

[10 NYCRR Section 402.6(a)402.3(i)(1)]

Based on staff interviews and record reviews, it was determined that for 1 of 17 residents reviewed for comprehensive care planning, the facility had not developed a care plan based on the resident's assessment. The care plan did not address the issue of aspiration risk for Resident #164. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #164 has diagnoses including Huntington's disease and chronic obstructive pulmonary disease.

Review of a nursing supervisor's progress note, dated 4/11/11, revealed that she was called to see the resident, who staff reported to be choking on food, and found the resident had cleared his throat and was able to speak. The Nursing Supervisor also documented that no intervention was necessary after the incident.

On 4/12/11, a Physician's Assistant documented in a progress note that the resident has dysphagia and is at risk for aspiration. A 4/13/11 progress note documented that the resident and family member were educated about the risk of aspiration and choking on regular food consistencies. At this time, the resident exhibited understanding of the risks explained and said he would refuse to eat pureed food.

Review of the current Interdisciplinary Care Plan revealed that the resident eats independently but requires supervision at meals. He receives a regular diet consistency as tolerated with thin liquids. The current Day/Evening Certified Nursing Assistant (CNA) Assignment Sheets included to provide the assistance of one to feed as needed with cueing, a regular consistency diet with thin liquid, and noted that the resident has frequently coughing/choking episodes during meals.

Interviews conducted on 8/4/11 are as follows:

a) At 9:00 a.m., the Registered Nurse (RN)/Nurse Manager (NM) stated that a resident at risk for aspiration should sit at a 90 degree angle and be supervised. The RN/NM reported that the facility does not have a written policy regarding aspiration precautions.

b) At 11:00 a.m., the Registered Dietitian said that the Interdisciplinary Care Plan should have included proper positioning and supervision during meals.

c) At 6:00 p.m., the RN/NM provided a revised Interdisciplinary Care Plan that addressed the resident's frequent coughing while drinking fluids and risk for aspiration. The NM also provided an updated CNA assignment sheet that included that the resident is at risk for aspiration, supervision with meals, and assist of one to feed as needed with cueing.

[10 NYCRR 415.11(c)(1)]

Based on observations, staff interviews, and record reviews, it was determined that for 2 of 17 residents reviewed for comprehensive care planning, the facility did not revise the care plans to reflect the residents' current status. The issues involved lack of care plan revisions to address pain (Resident #99), and nutritional supplements (Resident #171). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #99 has diagnoses including failure to thrive, dementia, cerebral vascular accident, and depression.

Review of the resident's Minimum Data Set Assessment, dated 3/7/11, revealed that the resident has frequent episodes of moderately intense pain and currently receives hospice services.

Review of the physician documentation, dated 7/13/11, revealed the resident's daughter expressed concern over her mother's anxiety and restlessness and requested medication be increased. The resident's Xanax (anti-anxiety) was increased to twice a day with a goal for symptom control and comfort.

Review of the Interdisciplinary Care Plan, dated 7/26/11, revealed that the resident was receiving hospice services/end of life care. Staff was to observe for signs and symptoms of discomfort and restlessness and to promote the use of both pharmacological and non-pharmacological interventions to keep the resident comfortable. This care plan did not address the presence of, or include interventions, in an individualized treatment for pain, including pharmacological and non-pharmacological interventions.

During an observation of care on 8/4/11 at 9:15 a.m., the resident moaned, complaining of severe back pain while moving to a sitting position and while getting up from the bed. When asked at this time if the resident had received pain medication recently, the hospice aide reported that she had informed the nurse of the resident's pain. At 9:17 a.m., a medication nurse entered the room to give the resident her routine medication, which included 650 milligrams of Tylenol. The resident continued to complain of pain and then abruptly walked out of the room and down the hall.

Interviews conducted on 8/4/11 at 9:47 a.m. revealed the following:

a) The Assistant Director of Nursing (ADON) and Licensed Practical Nurse both said they were not aware that the resident was experiencing pain. The ADON stated that if pain was occurring, this should be assessed.

b) The hospice aide stated that the resident has severe pain before she receives her morning medications on a regular basis, and this has been reported to the primary nurse, the unit nurses, and the hospice nurse. The hospice aide stated that the resident usually gets anxious and walks when she is in pain.

During an interview on 8/4/11 at 4:35 p.m., a family member reported that she has spoken to the nurses about her mother's pain, which has increased lately. The family member reported the back pain on 8/1/11 and said she documents her mother's pain or anxiousness daily when she visits.

The facility's Pain Management policy, dated June 2011, revealed nursing should review the resident's medication to identify routine/daily pain medications for effectiveness. If pain is not relieved, the nurse will notify the physician/Nurse Practitioner and clinical care team manager to follow-up for more effective pain management.

2. Resident #171 has diagnoses of Alzheimer's dementia, osteoarthritis, and gastro-esophageal reflux disease.

The Interdisciplinary Care Plan, dated 7/5/11, describes the resident as at risk for alteration in nutrition and hydration, and approaches include to administer medication pass program and to provide Ensure Plus (nutritional supplement) three times a day.

Review of the medical record revealed that the medication pass program was discontinued on 5/16/11, and the Ensure Plus was discontinued on 7/22/11.

During an interview on 8/4/11 at 11:30 a.m., the Nurse Manager (NM) stated that the resident's Interdisciplinary Care Plan should have been updated and did not know why this had not happened. At 1:25 p.m. that day, the NM reported that the Interdisciplinary Care Plan should have been revised to reflect the discontinuation of the medication pass program and the Ensure Plus.

[10 NYCRR 415.11(c)(2)(iii)]

Based on staff interviews and record review, it was determined that for 1 of 12 residents reviewed for accidents, the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, facility staff did not confiscate Aleve (anti-inflammatory medication which can cause bleeding) after they discovered and prevented Resident #50 from selfadministering the medication. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #50 has diagnoses including dementia, hypertension, and history of upper gastrointestinal bleed.

Review of the Interdisciplinary Care Plan, dated 5/17/11, revealed that the resident does not selfmedicate due to dementia, a history of taking medications incorrectly, and taking over the counter medications that were not prescribed. Review of a physician order, dated 6/30/11, revealed that the resident may keep a bottle of Tums at bedside.

Review of a nursing note, dated 7/21/11, revealed that the resident was observed to have a medicine bottle at the lunch table from which she had taken out a blue pill and proceeded to swallow it. The nurse noted several blue pills in the bottle, and the resident verified it was Aleve (an over-the-counter anti-inflammatory medication that can cause bleeding). The Nursing Supervisor and the Physician Assistant (PA) were notified.

A PA note written on 7/22/11 documented that the resident was not to use Aleve secondary to history of gastrointestinal bleeding and that it had not been ordered for the resident's use.

During an interview on 8/4/11 at 11:00 a.m., the Nurse Manager (NM) stated that the bottle of Aleve had not been taken from the resident and that she would take care of it immediately.

After surveyor intervention, nursing documented in a progress note on 8/4/11 that the bottle of Aleve was removed from the resident's room that day. The family was notified of the incident and were informed that the resident is not to have over-the-counter medications.

When interviewed on 8/5/11 at 9:00 a.m., the NM reported that the only medication the resident can have at her bedside is Tums.

[10 NYCRR 415.12(h)(2)]

Based on observations, staff interviews, and record reviews, it was determined that for one of seven residents reviewed for abuse and neglect, the facility did not thoroughly investigate injuries of unknown origin or ensure the resident's safety while ruling out resident abuse, neglect, or mistreatment. The issues involved the lack of a thorough investigation of a bruise of unknown origin (Resident #99). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

The facility's policy entitled, "Abuse Reporting Policy and Procedure," dated September 2010, documented that the Clinical Care Manager/Supervisor is responsible for follow-up and investigation of injuries of unknown origin, including bruises. The Director of Nursing/Designee is expected to complete a thorough investigation within 48 hours.

Resident #99 has diagnoses including dementia, and has been receiving end of life hospice services since March 2011.

The Minimum Data Set Assessment, dated 3/7/11, shows evidence that the resident has severely impaired cognitive skills for daily decision making, has disorganized thinking, and difficulty focusing attention. Additionally, the resident requires extensive assistance of one with dressing, toilet use, and personal hygiene.

Review of the Incident and Accident (I&A) Report, dated 7/28/11, revealed that at 3:15 p.m. that day, an ecchymotic area was identified above the resident's left eyebrow. A staff statement, dated 7/28/11, attached to this I/A report, documented that the hospice aide was caring for this resident between 9:00 a.m. to 11:00 a.m., during which time a bruise was discovered on the resident's forehead. The report showed that the resident was not able to say what caused the bruise and did not show any evidence of interviews with additional staff members, of a possible time the bruise occurred, or of a potential cause of bruising.

The facility's investigation of injury of unknown origin report, dated 7/28/11, indicates the resident's environment and equipment were not checked for unsafe features. It described the condition that contributed to the injury as independent ambulation on the unit. The conclusion on the I&A Report determined there was no abuse or neglect suspected in regard to this incident. The report did not indicate how the conclusion was reached.

Review of the progress notes for 7/28/11 and 7/29/11 did not reveal any added information.

During an observation on 8/1/11 at 1:06 p.m., the resident had a large bruise around the left eye and cheek.

Interviews conducted on 8/4/11 revealed the following:

a) At 11:00 a.m., the Assistant Director of Nursing said she was not involved with the investigation, and the resident's primary nurse would have information.

b) At 11:03 a.m., the primary Licensed Practical Nurse said the bruise was not present when the resident received her morning medication. At that time, the hospice aide said the bruise was present when she did morning care.

c) At 4:35 p.m., a family member said she noticed the bruise and reported it to the nurse.

d) At 6:30 p.m., the Director of Nursing said the incident was reviewed. No further information about the incident was provided.

[10 NYCRR 415.4(b)(3)]

Based on record review and staff interviews, it was determined that for one of one resident reviewed for hospice services, the facility did not provide the necessary care and services to attain or maintain the resident's highest practicable physical and psychosocial well-being. The issue involved Resident #99, who has not been reassessed to determine if the resident's behaviors are pain related. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #99 has diagnoses including failure to thrive, dementia, cerebral vascular accident, and depression.

Review of the Minimum Data Set Assessment, dated 3/7/11, revealed that the resident experiences frequent episodes of moderate pain and is currently receiving hospice services. Review of the Pain Assessment Tool, dated 3/7/11, revealed that the resident's pain score is a zero. Review of the current Home Health Aide Care Plan revealed that the aide is to advocate for comfort.

The physician documentation, dated 7/13/11, revealed the resident's daughter expressed concern over her mother's anxiety and restlessness and requested medication be increased. The resident's Xanax (anti-anxiety) was increased to twice a day with a goal for symptom control and comfort.

Review of the Interdisciplinary Care Plan, dated 7/26/11, revealed the following approaches for hospice/end of life care: observe for signs and symptoms of decline or discomfort; observe for facial, postural, and verbal indications of discomfort or restlessness; and to advocate for comfort through pharmacological and non-pharmacological interventions.

Hospice nurse routine visit documentation from 7/5/11 through 7/29/11 revealed no current pain and no history of pain, resistiveness to care, and use of the as needed Xanax medication seven times in July 2011. It also revealed that the resident's condition and medication discussed with primary caregivers.

The hospice aide communication notes revealed that on 7/28/11, the resident said she felt like she was going to vomit and complained of pain in her legs. She ate a few bites of oatmeal but did not drink much. The 7/29/11 note revealed the resident seemed very anxious that day, complained of pain, and being tired. On 8/1/11, the resident was very anxious and refused breakfast.

When interviewed on 8/3/11 at 11:00 a.m., the hospice nurse said that hospice is a coordinated effort between the facility and hospice case management. She said they work together to provide the resident's care. If there are any concerns, the staff communicate this to her and she will also communicate with the staff. She stated that hospice personnel have communication books on the unit that the staff can review. She said the resident has a hospice aide from 9:00 a.m. to 11:00 a.m. If there are any areas of concern, the staff communicate this to her, and they also have notes that are in a notebook on the unit.

During an observation of care on 8/4/11 at 9:15 a.m., the resident complained of severe back pain while sitting up in bed and getting up from the bed. In an interview at this time, the hospice aide stated that the nurse had been informed about the resident's pain. She also stated that a nurse entered the resident's room at 9:17 a.m., and gave the resident 650 milligrams (mg) of Tylenol. The resident continued to complain of pain and then abruptly left the room and walked down the hall and around the entire unit.

Interviews conducted on 8/4/11 are as follows:

a) At 9:47 a.m., the Assistant Director of Nursing (ADON) said she was not aware the resident was experiencing pain and that a pain assessment is done when a resident complains of pain. The hospice aide said she had informed the primary nurse, hospice nurse, and unit nurses that the resident has severe pain before she gets her medication every morning. She said the resident walks and gets anxious when she has pain. The LPN said she was not aware the resident was experiencing pain and has not done an assessment for pain. The ADON reported that the last pain assessment was done on 3/7/11. She also said the resident would tell them she was having pain. The ADON also said that facility staff do not review the hospice communication book; they rely on the hospice nurse to let them know when there is a problem. When asked if hospice is informed of any change in condition or medication needs, she said "yes."

b) At 11:27 a.m., the Acting Nurse Manager provided a progress note completed on 7/18/11 that included a reference to a staff interview for pain information and behaviors. This note documented that the resident was not interviewable.

c) At 4:35 p.m., the resident's daughter reported that the resident had been more uncomfortable lately and that she (daughter) reported the back pain to nursing staff on 8/1/11. The daughter said that she documents her mother's pain/anxiousness daily when she visits and when the resident has pain. She reports this to the nursing staff.

After surveyor intervention, nursing staff documented in an 8/4/11 progress note that the resident's back pain was not relieved with the as needed Tylenol. Also, the resident would be seen by medical for assessment and treatment for back pain.

The facility's policy entitled, "Hospice Care," dated January 2008, directs that the facility will notify the hospice team immediately of any changes to the resident's condition, pain needs, or changes in symptoms.

The facility's policy entitled, "Pain Management," dated June 2011, directs nursing staff to review the resident's medication to identify routine/daily pain medications for effectiveness. If pain is not relieved, the nurse will notify the physician/Nurse Practitioner and clinical care team manager to follow-up for more effective pain management.

[10 NYCRR 415.12\

Based on observations, staff interviews, and record reviews, it was determined that for 1 of 17 residents reviewed for professional standards, the facility did not provide services in a manner consistent with accepted standards of quality. The issue involved inaccurate physician orders and a lack of a physician order for pressure ulcer treatment (Resident #35). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #35 has diagnoses including chronic venous ulcer and a healing Stage III pressure ulcer on the left heel. The physician orders, dated 5/12/11 and 7/12/11, included to continue Allevyn dressing on left heel and use Ace wraps on both lower legs, on in the a.m. and off in the p.m.

Entries on the Treatment Administration Record (TAR) for June, July, and August 2011 included to cleanse left heel, gently apply Medihoney (therapeutic honey used for wound healing), and cover with a 2 x 2 dressing, tape, and change two times a week. There were no entries on these TARs that required the use of Ace wraps.

When interviewed on 8/3/11 at 9:15 a.m., the primary Licensed Practical Nurse (LPN) said that treatment orders are written on the physician order sheets and that the Medihoney treatment had been used for two to three months. After review of the physician orders at this time, the LPN stated that the Medihoney treatment had not been ordered.

During an interview on 8/3/11 at 11:15 a.m., the Registered Nurse (RN)/Nurse Manager (NM) stated that the resident currently\i receives a Medihoney treatment. The RN/NM reported that physician orders come preprinted from the pharmacy. The RN/NM did not know how to remove the Allevyn order from the physician order sheets and could not explain the facility's procedure for checking month-to-month physician orders.

Interviews completed on 8/4/11 are as follows:

a) At 10:00 a.m., the RN agreed that the physician's order for the Allevyn should be removed, since it is no longer being used.

b) At 1:35 p.m., the primary LPN said that the Ace wraps were discontinued about three months ago.

c) At 1:10 p.m., the Director of Nursing described the process for checking 60-day physician orders. The night nurse checks the new orders against current orders, the physician then visits the resident, reviews and signs the physician orders, and then the nurse checks the signed orders.

The facility's policy entitled, "Medication Administration Records (MAR) Treatment Sheet and Physician Order Sheets-Monthly Updating and Checking," dated September 2010, states that the first check is completed by the night nurse for accuracy and completeness by checking the new month's MAR and TAR with the current month's MAR and TAR and physician orders. The nurse then initials and dates the bottom of the MAR and TAR when the check is completed. The second check is completed by the day nurse the same way the night nurse has checked orders. The third check is done the last day of the month by the evening nurse. The nurse will check the old MAR and TAR to the new MAR and TAR.

[10 NYCRR 415.11(c)(3)(i)]

Based on staff interviews and record reviews, it was determined for one of one resident reviewed for personal funds (Resident #171) and all other residents with personal funds that exceeded $50.00 did not receive a statement that identified how much interest was paid on their personal account balances. This resulted in no actual harm with potential for minimal harm that is widespread, and is evidenced by the following:

When reviewed, the 7/1/11 to 7/31/11 facility Bank Checking Account Statement revealed that the pooled resident accounts had earned a total of $3.90 in interest and had $77.42 in service charges. Review of Resident #171's 1/4/11 to 8/4/11 Saving Statement for personal funds revealed that the resident's balance was $186.69. This statement did not include any interest paid to the resident during this period.

During interviews on 8/4/11 at 11:20 a.m. and 1:45 p.m., the Account Payable Representative and Vice President of Finance (VPF) stated that residents do not receive interest on personal funds accounts because the amount charged by the bank for service fees is greater than the interest earned. The facility incurs the remaining cost of the service fee. The VPF stated that resident accounts are pooled into one account, which leaves the facility unable to determine individual service fees and interest earned at this time for an individual resident.

When interviewed on 8/8/11 at 3:30 p.m., the CEO, when asked, could not provide evidence that the resident received a statement that included interest and service charges.

[10 NYCRR 415.26(h)(5)(i)]

Resident #188 was admitted on 2/11/11 with chronic obstructive pulmonary disease and congestive heart failure. A Pre-Admission Screening and Resident Review (PASRR) was not able to be located in the resident's closed record.

When interviewed on 8/2/11 at 11:00 a.m., the Director of Social Work stated she could not locate the PASRR.

In an interview on 8/4/11 at 10:48 a.m., the Admission's Director reported that she did not receive a PASRR when the resident was admitted to the facility.

The facility's policy for the PASRR portion of the screen, revised in March 2010, documented that the PASRR is to be completed prior to admission to the facility.

[10 NYCRR 415.11(e)]

Based on observations and a staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not maintain hazardous areas. The issues were related to doors and a door frame to hazardous areas and improper separation from corridors. This affected one (first floor) of five resident use floors and one of one basement, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

Observations on 8/2/11 from 1:00 p.m. to 2:30 p.m. revealed the following:

a) A set of double doors to the kitchen (first floor service wing) did not have latching hardware, and a single door to the kitchen did not automatically latch into the door frame. In both cases, the latching hardware had been removed.

b) The double doors to the basement laundry room did not properly close. One of the doors would not automatically close and became hung up on the floor, and the other door was obstructed from closing by a clothes rack and then a clothes hanger that was hung from a wall-mounted hook.

c) There was an approximately 30 x 30-inch square stainless steel panel on each side of the wall that separates the basement boiler room from the egress corridor. The boiler room is not protected by a sprinkler system. The Director of Facilities stated that the panels were installed to allow access to the hot water tank inside the boiler room.

d) The South basement record storage room door frame did not have a fire rating. No documentation was provided to demonstrate that this door frame was fire rated.

These conditions compromised the fire and/or smoke resistance of the hazardous area enclosures.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.3.2.1]

Based on observation, staff interview, and record review conducted during the Life Safety Code Survey, it was determined that the facility did not provide compliant interior finish material. The issue was related to a newly installed wall covering that was not Class A. This affected one (second floor) of five resident use floors, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

Observation on 8/2/11 at 12:10 p.m. revealed the second floor storage room of the North wing contained a vinyl wall covering on the interior walls. In an interview at this time, the Director of Facilities stated that the wall covering had been installed this year.

On 8/3/11 at 1:30 p.m., the Director of Facilities provided the surveyor with a specification sheet for the material, which showed the material to be Glasbord P, a Class C material.

The 2000 edition of NFPA 101, Life Safety Code, defines interior wall finish as the interior finish of columns, fixed or movable walls, and fixed or movable partitions. This standard requires newly installed interior wall finishes to be Class A, based on test results from NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.3.3.2(2)]

Based on observations, staff interview, and record review conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain vertical openings between floors. The issue was related to a vertical shaft that was not properly enclosed, and to an atrium that was not compliant with enclosure and sprinkler requirements. This affected three (first, second, and third) of five resident use floors, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

1. Observation on 8/2/11 at 11:00 a.m. revealed the third floor of the South wing has a mechanical room that is open to a vertical shaft. In an interview at this time with the Director of Facilities, he stated that this shaft extends from the basement to the third floor. The door frame to the mechanical room is not marked with a fire rating consistent with the requirements for enclosure of vertical openings. No documentation was provided by the facility to demonstrate that this door frame was fire rated.

Please include your Plan of Correction for this deficiency.

2. On 8/2/11, it was observed that the building has an atrium in the area of the main entrance, between the existing building and the South building. The atrium extends from the first floor to the third floor. The 2000 edition of NFPA 101, Life Safety Code, section 8.2.5.6(4) allows an atrium if, "The entire building is protected throughout by an approved supervised, automatic sprinkler system." Kirkhaven is only partially sprinklered. Additionally, the doors which enclose the atrium at all levels do not contain a fire rating consistent with the requirements for enclosure of vertical openings.

The Centers for Medicare and Medicaid Services recognizes the 2001 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety, (also known as the Fire Safety Equivalent System or FSES). This standard provides alternative approaches to life safety based on equivalent safety concepts. A building determined to have equivalent safety to the requirements of the NFPA 101, Life Safety Code, is deemed to be compliant for the identified deficient requirement.

Based on a review of the facility's FSES completed 5/10/05, and following observations conducted from 8/2/11 through 8/4/11, it has been confirmed that the facility has provided an equivalent level of safety and is, therefore, considered to be compliant with the Life Safety Code for this particular aspect of the identified deficiency.

Please include your Plan of Correction or your request for continuation of the FSES.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.3.1.1, 8.2.5.2, 8.2.5.6(4)]