Cayuga County Nursing Home

Based on observation and staff interview conducted during the standard survey, it was determined for 3 of 4 meal observations on the East Unit, the facility did not promote care for residents in a manner that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality. Specifically, residents on the East Unit were consistently given their drinks in disposable cups and cartons. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During observation of meals on the East Unit, residents were served disposable cups for water, and drank milk from the cartons and juice from disposable cups, using straws. This was observed on:
- March 21, 2012 during lunch at 12:45 PM;
- March 22, 2012 during breakfast at 8:40 AM; and
- March 23, 2012 during breakfast at 8:55 AM.

On March 23, 2012 at 10:35 AM, the registered dietitian (RD) stated in an interview, the resident units were supplied with yellow, plastic cups in an attempt to move away from using disposable paper cups. She stated the unit staff were to use the yellow plastic cups when residents wanted drinks between meals and for nourishments. She stated paper cups were not to be used for meals as the kitchen sent clear plastic cups on the meal trays. She stated staff may be leaving residents' milk and juice in the containers as some resident preferred to drink from milk cartons and juice containers.

In summary, the residents were not provided a dignified dining experience as disposable cups were used as part of their regular meal service.

10 NYCRR 415.5 (a)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined for 2 of 2 residents (Residents #16 and 17) observed during the medication administration, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment, and to prevent the development and transmission of disease and infection. Specifically for Resident #16, staff did not observe proper infection control technique when cleaning the glucometer (device for measuring blood sugar levels) after a fingerstick blood sugar test. For Residents #16, and 17 proper infection control techniques were not used when dispensing oral medications and insulin. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The facility policy titled "Hand Washing revised "11/11" documented staff were to wash their hands when they came in contact with a resident.

The facility policy titled "Disposition and/or Cleaning of Equipment" revised "11/11" documented "All reusable equipment in the facility shall be cleaned and disinfected during and after use in order to prevent any transmission of infectious process." Licensed staff were to inspect and clean the glucometer with a decontaminated as necessary.

A sign was observed posted on the wall in the corridor outside the Director of Nursing's (DON) office and the in-service/infection control office on March 20, 2012 at 6:15 PM that documented "Effective immediately" glucometers could be cleaned with a 70% alcohol pad between each use. "This is an acceptable form of disinfection." The sign was dated January 9, 2012, and was signed by the DON.

A box labeled "Dynarex" was observed on the medication cart on March 20, 2012 at 6:55 PM. The licensed practical nurse (LPN) medication nurse #1 stated during an interview at that time the box contained 70% alcohol pads which could be used to clean glucometers.

During a medication administration observation on March 22, 2012 from 8 AM - 8:44 AM, and LPN medication nurse #2:
- at 8:08 AM, exited Resident #16's room wearing gloves and held a glucometer. She wiped the glucometer off with an alcohol pad, placed the glucometer in a pouch, and put the glucometer in the top drawer of the medication cart. The LPN removed the gloves from and typed information into the computer without engaging in hand hygiene. The LPN stated, to the surveyor, at that time, glucometers were cleaned with an alcohol pad between use;
- at 8:15 AM, dispensed medications for Resident #16 including 1.2 mg (milligrams) of Victoza (injectable insulin), 28 units of Humalog (injectable insulin), and 60 units of Lantus (injectable insulin);
- at 8:30 AM, entered Resident #16's room, without washing her hands, she administered the 3 insulin injections to the resident's abdomen. The LPN exited the resident's room did not engage in hand hygiene and typed information into the computer that was on the medication cart;
- at 8:37 AM, without employing hand hygiene dispensed Resident #17's medications including 94 units of Lantus; and
- at 8:44 AM, did not employ hand hygiene, did not don gloves, entered the resident's room and injected the insulin into the resident's abdomen.

During an interview with the LPN medication nurse #2 on March 22, 2012 at 8:50 AM, she stated:
- hands should be washed after the administration of medications, and she did not wash her hands, as the surveyor made her nervous; and
- insulin administration could be done with or with out gloves. It doesn't matter "if I know the resident".

The registered nurse (RN) in-service coordinator/infection control nurse stated during an interview on March 22, 2012 at 10:40 AM:
- her understanding was that glucometers could be cleansed with an alcohol pad;
- the DON posted a sign informing staff this was acceptable;
- staff should wash their hands after using the glucometer and after the administration of injectable medications;
- gloves should be worn when administering insulin;
- she was not aware staff did not wash their hands after they handled the glucometer and administered insulin, and did not wear gloves to administer insulin.

During an interview with the DON on March 22, 2012 at 11:12 AM, she stated the facility started using alcohol pads to cleanse the glucometers as the bleach clothes were "killing" the glucometers, and she was not aware of the CDC's recommendations for cleansing the glucometers. She was not aware staff were not washing their hands after the administration of insulin, and did not wear gloves to administer insulin.

In summary the facility did not ensure acceptable standards of infection control were maintained when they:
- did not properly cleanse the glucometer after each use;
- did not employ hand hygiene after administering insulin; and
- did not wear gloves to administer insulin.

10 NYCRR 415.19 (a)

Based upon observations and staff interviews conducted during the standard survey, it was determined the facility did not ensure the resident environment remained as free of accident hazards as is possible for 2 of 2 resident units (east and west), and did not ensure residents were provided adequate supervision and assistive devices to prevent accidents for 1 of 2 residents (Resident #4), reviewed for smoking and 1 resident outside of the sample (Resident #17). Specifically, hot coffee maker/dispensers were accessible to residents in the west wing lounge and east wing corridor, and hot water was accessible to residents at the staff's handwash sink located in the main dining room at temperatures that could potentially cause burns or scalds. For Resident #4, there was no clear plan of care for management of smoking materials and safe smoking. For Resident #17, who was on aspiration (taking foreign matter into lungs) precautions, the resident was observed eating in his room without supervision. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
Findings include:

1) During the building inspection conducted on March 21, 2012, between 9:15 AM and 3 PM, and on March 22, 2012 between 9:15 AM - 11:15 AM, which included a sampling of 13 resident rooms on 2 resident units, the following safety concerns were observed:
- a sign was posted in the main dining room above the handwash sink behind the steam table that read "water is very hot." The temperature was measured on March 21, 2012 at 9:15 AM as 140 degrees F (Fahrenheit); and
- hot coffee makers/dispensers were accessible to residents in the west wing lounge and in the east wing corridor.

The Director of Maintenance was interviewed on March 21, 2012 at 9:15 AM, and he stated the hot water supply to the hand wash sink in the dining room came from the kitchen supply rather than the domestic hot water supply and he did not believe there was easy access to domestic hot water supply lines in that area. He stated the sign was put up to alert residents not to use this sink. No rationale was provided for how this would work for residents who no longer had the ability to read and understand warning signs.

The east wing registered nurse (RN) unit manager was interviewed on March 22, 2012 at 10:20 AM, and she stated she had worked there for 9 months and no one had been scalded by the coffee. She stated they placed the coffee dispensers at the end of the corridor because they felt this area got the least amount of resident traffic.

The Director of Maintenance was interviewed on March 23, 2012 at 10:10 AM, and he stated he was on the safety committee and he was not aware of any incidents related to scalding.

In summary, the facility did not ensure residents did not have access to hot water temperatures or other hot liquids that could potentially cause burns or scalds.

2) Resident #4 had diagnoses including weakness of the arms and legs).

The "Skin Evaluation (Admission/Re-Admission) form dated January 5, 2012, documented the resident had "multiple" scars on his chest "from cigarette burns."

The physician's progress note dated January 10, 2012, documented the resident had a long history of smoking, he smoked 1 to 2 packs per day, and he refused a nicotine patch.

The resident's Minimum Data Set (MDS) assessment dated January 18,2012, documented the resident's cognition was intact and he did not smoke.

The MDS assessment dated February 2, 2012, documented the resident's cognition was intact, he was dependent upon others for transferring, bed mobility, dressing, toileting, and personal hygiene.

The comprehensive care plan (CCP) documented a new entry dated February 9, 2012 regarding smoking. The plan included the resident was to smoke 35 feet away from the building; staff were to light the resident's "cigarette" if it was windy; and cigarettes and lighters were to be stored in the locked medication room. The CCP did not specify when the lighter was to be stored in the locked medication room. There was no documented evidence an assessment was done to determine if the resident could safely smoke and the manage his smoking materials.

The nursing progress note dated February 11, 2012, documented the resident went out to smoke twice. The note recorded when the resident returned from smoking, nursing staff went to the resident's room to retrieve his lighter. The staff explained to the resident when he returned from smoking, he had to return the lighter to nursing staff, "even if he was going" out to smoke later. The note recorded the resident voiced his understanding and gave the lighter to nursing staff.

The was no documented evidence the resident's care plan was updated to include when resident needed to return his lighter to nursing staff.

The nursing progress note dated February 28, 2012, documented the resident was in the vestibule (small area between an outer door and the main part of a building) trying to light his cigarette. The note recorded the resident had been informed "several times that he can't light his cigarette" inside the building. There was no documented evidence the facility re-assessed the resident's ability to safely smoke independently.

A nursing progress note dated February 28, 2012, documented staff talked to the resident about the need to light his cigar for him. The note recorded the resident was not happy about that initially. The note documented after discussion, the resident "seemed" to understand, and he agreed to it.

The resident's CCP was updated on February 29, 2012, and documented the resident would light his "cigarette" outside the building.

The nursing progress note dated March 1, 2012 at 6:14 AM, documented when the nurse went to light the resident's cigar at the beginning of the shift and he stated he was able to light his own cigar now. The note recorded the resident stated he demonstrated to the administrator how he was able to light his own cigar. The progress note documented the nurse was unable to find record of that change in the resident's smoking status.

The nursing progress note dated March 1, 2012 at 10:49 PM, documented the resident became "very belligerent with staff", after he asked for a cigar and lighter to be left in his room. When the nurse left the resident's room, without leaving the cigarettes and lighter, the resident began swearing, screaming,and hollering. The Administrator was notified and "spoke with the resident." The note recorded the resident was aware he could not have smoking materials left in his room and was able to go outside to smoke independently. The note documented the resident "must" return his lighter to staff, the resident stated he understood, and would comply.

The smoking plan for the resident dated March 2, 2012, documented the resident was evaluated and assessed as safe for smoking. The plan included no lighters, cigars or cigarettes were to be in the resident's room. There was no documentation of who assessed the resident or how the resident was assessed.

On March 20, 2011 at 5:55 PM, the resident was observed in his room with a cigar on the over the bed table. When asked the resident stated it was a cigar.

On March 21, 2012, the surveyor made the following observations and interviews:
- at 10:35 AM, the Cigar/Smoking List documented the resident signed 1 cigar and 1 lighter in the locked medication room;
- at 12:50 PM, the resident was observed by the storage building, which was outside the facility. The resident stated he stayed outside from the time he got up until the time he went to bed;
- at 2 PM, the resident went to the nursing station and requested 2 cigarettes;
- at 3:30 PM, the the resident was observed in his room and denied having a lighter. Licensed practical nurse (LPN) stated 1 of the resident's 2 cigarette lighters were in the locked medication room. The resident's Cigar/Smoking List did not contain documented evidence the resident's lighter was returned to the locked medication room;
- at 3:35 PM, registered nurse (RN) unit manager went to the resident's room, and returned with a cigarette lighter; and
- at 3:40 PM, LPN #2 stated there was a form to sign when the resident's smoking materials were taken from the locked medication room. She stated the lighter had not been signed out that morning as staff "must have been busy."

The Cigar/Smoking List documented on March 21, 2012 at 4:45 PM, 6:30 PM, and 8 PM the resident was given smoking materials, including a lighter. The form did not include documented evidence the lighter was returned to nursing staff.

The Cigar/Smoking List dated February 7, 2012 documented 164 entries from February 7, 2012 - March 22, 2012 when cigarettes, cigars and/or lighters were given to the resident by staff. Sixteen of the 164 entries documented the lighter was returned to staff.

During an interview with the RN unit manager on March 22, 2012 at 9:14 AM, she stated the CCP did not include signing the Cigar/Smoking List. She said it was mandatory to sign in and out the resident's smoking materials, and she did not believe everyone signed the form, as "we trust him" to bring the lighter back "he's an adult."

The Director of Nursing (DON) was interviewed on March 22, 2012 at 12:45 PM, and stated the RN unit manager assessed the resident's ability to smoke, and there was no documented evidence this was done. She stated between January 9, 2009 -March 9, 2012, there were no changes made to the smoking interventions. The DON stated the resident's smoking materials were kept in the locked medication room. She stated the process was the resident would return the lighter after using it.

During an interview with the Administrator on March 22, 2012 at 2:35 PM, she stated:
- the resident was not to have smoking supplies in his room;
- she did not see a written plan for the resident's smoking prior to March 2, 2012;
- the resident was supposed to return the lighter to the nurse after using it;
- the incident on January 29, 2012, was a misunderstanding on the resident's part as he thought he had to smoke off the premises;

The facility's "Smoking by Residents" policy, revised "3/12" (date unspecified) documented residents admitted after April 1, 2011, would be able to smoke if they were assessed to be an independent smoker. The policy documented independent smokers may smoke outside the facility only, and smoking materials "must be" kept in the the medical storage room, or the east unit nurse's Station.

In summary the facility did not document an assessment of the resident's ability to smoke safely/independently, and safely manage his smoking materials.

3) Resident #17 had diagnoses including dementia, seizure disorder, hemiplegia and gastroesophageal reflux disease (GERD).

An Aspiration Precautions list dated March 6, 2012 was observed posted at the nurse's desk throughout the survey (March 20 - 23, 2012). Resident #17 was included on the list.

Resident #17's Minimum Data Set (MDS) assessment dated March 8, 2012 identified the resident with severe cognitive impairment. He was on a mechanically altered diet, required set up assistance and fed himself independently.

The current comprehensive care plan (CCP) documented an ongoing nutrition/hydration concern (effective March 17, 2010) related to the resident's diagnoses, including dementia, aneurysm and GERD. The resident was on an unmodified ground meat only diet. The goal included the resident not showing any signs or symptoms of aspiration. The CCP did not address a plan in place related to the resident's risk for aspiration.

The current Resident Nursing Instructions documented the resident was to eat in the main dining room (MDR), unit lounge "or doorway."

On March 22, 2012, the resident was observed at 5:30 PM eating by himself in his room sitting on the edge of his bed with a tray table in front of him. No staff were observed in the area at that time.

The registered dietitian (RD) was interviewed on March 23, 2012 at 11 AM. She stated if a resident was on aspiration precautions, they would be monitored when eating. She said resident's on aspiration precautions should not eat alone in their room. The RD stated the resident's CCP was for him to eat in the lounge or the doorway of his room, as he was on the list for aspiration precautions.

In summary, for this resident who was documented at risk for aspiration, the resident did not receive adequate supervision as planned when he was eating alone in his room.

10 NYCRR 415.12(h)(1)(2)

Based upon observations and staff interviews conducted during the standard survey, it was determined for 2 of 2 resident units (east and west wings), which included a sampling of 13 resident rooms, the facility did not provide effective housekeeping and maintenance services to maintain a sanitary and orderly environment. Specifically, the facility did not maintain the building in good repair or sanitary manner in regard to windows, equipment, and walls. This resulted in no actual harm with potential for minimum harm.
Findings include:

During the initial building tour conducted on March 20, between 6:45 PM - 7:45 PM, the building inspections conducted on March 21, 2012, between 9:15 AM - 3 PM, and on March 22, 2012 between 9:15 AM - 11:15 AM, which included a sampling of 13 resident rooms on 2 nursing units, the following building deficits and concerns were observed:

WINDOWS
- the window tracks were dusty and filled with dust and debris in resident rooms 19, 25, 27, 77, 78, 79, and 82.

The Director of Housekeeping was interviewed on March 21, 2012 at 1:40 PM, and she stated the window tracks were supposed to be cleaned monthly.

EQUIPMENT
- a clean suction machine was stored in the east toilet room, which is considered a soiled area;
- the ceiling paint in the personal laundry room was peeling and the overhead pipes and wires were dust laden;
- the weight scale in the east bathroom was rusty;
- the interior of the microwave in the east kitchenette was not clean;
- the interior of the east kitchenette's freezer had spilled chocolate ice cream in it;
- the ice tray in the west kitchenette was mineral encrusted;
- 2 of 4 wheelchairs in the east equipment room had ripped armrests;
- 1 of 5 wheelchairs in the west equipment room had ripped armrests;
- 2 hair dryers heads and filters in the beauty shop were not clean;
- shower hoses in the east and west bathrooms lacked backflow prevention devices; and
- the cart wash hose in the kitchen lacked a backflow prevention device.

The Director of Housekeeping was interviewed on March 22, 2012 at 10 AM, and she stated they tried to reach the pipes with a high duster, but it was very difficult to reach.

The Director of Maintenance was interviewed on March 22, 2012 at 10:30 AM, and he stated the nursing staff told him they normally kept the clean suction machine in the toilet room because it was convenient.

The Director of Maintenance was interviewed on March 22, 2012 at 10:35 AM, and stated he was not aware of the missing backflow prevention devices on the hoses.

The Director of Maintenance was interviewed on March 22, 2012 at 10:40 AM, and stated maintenance was responsible for the upkeep on the weight scale and it was calibrated annually by Weighs and Measures.

The Director of Housekeeping was interviewed on March 22, 2012 at 10:55 AM, and she stated the microwave ovens are supposed to be cleaned daily by housekeeping.

The Director of Maintenance was interviewed on March 22, 2012 at 11:15 AM, and he stated he only repairs wheelchair arm rests if staff report a problem and staff had not reported any of the torn arm rests to him.

WALLS
- scraped walls were present in resident rooms #25, 27, 78, and 79; and
- the dining room wall was stained behind the steam table; and
- the east wing television lounge had one wall scraped.

The Director of Housekeeping was interviewed on March 21, 2012 at 1:30 PM, and she stated the wall behind the steam table in the dining room was permanently stained.

The Director of Maintenance was interviewed on March 22, 2012 at 10:10 AM, and he stated the wall in the television lounge was scraped by a chair in that room.

OTHER OBSERVATIONS
On March 21, 2012 between 9:15 AM and 10:15 AM, the east unit kitchenette was observed. There were spills and stains on the inside of the freezer and the ice machine had mineral encrustation.

On March 21, 2012 between 9:15 AM and 10:15 AM, the west unit kitchenette was observed. The inside of the microwave was soiled with spills that had not been cleaned up.

In summary, the facility did not maintain the building in good repair in regard to windows, equipment, and walls.

10 NYCRR 415.5(h)(2)

Based on record review and staff interview conducted during the standard survey, it was determined for 4 of 13 sampled residents (Residents #4, 10, 11, and 14), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated. Specifically, a staff member was not removed from resident care after an alleged incident of verbal abuse towards Resident #4 and the investigation was not initiated in a timely manner. Residents #10, 11 and 14 had bruising and a complete and thorough investigation was not done to determine of whether possible abuse occurred. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE JANUARY 31, 2011, MARCH 17, 2010 AND JANUARY 8, 2009 SURVEYS.

Findings include:

The facilities "Resident Abuse" policy, last revised "11/09" (date unspecified) documented the intention of the policy was to ensure residents were "afforded" the right to be free from verbal and physical abuse. The policy defined abuse as willful infliction of injury, intimidation, or punishment, with resulting harm, pain, or mental anguish by an individual, including a caregiver. The policy included:
- verbal abuse was defined as any oral, or gestured language that included disparaging and derogatory terms to residents;
- employees would not use or permit verbal abuse to its residents;
- any one who witnessed abuse was to report the event immediately;
- the individual observing the abuse should complete an incident report as soon as possible after the event; and
- the investigation would begin immediately by the supervisor, Director of Nursing (DON), or administrator.

1) Resident #4 had diagnoses including quadriplegia (paralysis to upper and lower extremities).

The nursing progress notes dated January 5, 2012 through January 17, 2012, were reviewed and revealed the resident refused care and was verbally abusive.

The comprehensive care plan (CCP) dated January 17, 2012, documented the resident had difficulty adjusting to the facility, and was "constantly" resisting care, medications, and therapy services. The planned interventions included:
- staff to monitor mood and encourage coping skills to decrease agitation and verbal outbursts;
- documentation of the intensity, duration and frequency of his behaviors;
- redirection of the resident's negative behaviors; and
- identify a pattern of the resident's verbal aggression and resistance of care.

The nursing progress note dated January 25, 2012, documented the social worker asked nursing staff to address the certified nurse aide (CNA) assignments, as the resident stated:
- there were only a "few" that could take care of him "sufficiently";
- the issue was on the day shift;
- the resident was approached and "attempted to explain" to the resident many staff "needed to learn how to meet" the resident's needed on a "daily and consistent basis." He stated he was not going to "train your" CNAs" and verbalized expletives; and
- the Administrator was aware of the interaction.

The Minimum Data Set (MD'S) assessment dated February 2, 2012, documented the resident's cognition was intact. The MDS recorded the resident was dependent upon others for transferring, bed mobility, dressing, toileting, and personal hygiene. He was assessed as verbally and physically abusive, and refused care 1 - 3 days during the assessment period.

The progress notes dated February 3, 2012 through March 20, 2012, revealed the resident refused care, and was verbally and physically abusive. CNAs were instructed to leave him alone and reproach at a later time.

Licensed practical nurse (LPN) #3's progress note dated March 20, 2012 at 1:56 PM, documented "during AM care" the resident called CNA #1 expletive names and threatened to kick her. The CNA provided care to the resident which he had refused. The CNA "continued to be mouthy and degrading to the resident" and the resident "retaliated by threatening to kick her and call her names." "Foul language" was exchanged between the resident and the CNA #1, which was observed by CNA #2.

CNA #1's time card documented she worked March 20, 2012, from 6:56 AM - 11:16 AM, and March 21, 2012, from 6:59 AM -2:56 PM.

The "Nursing Assignments" form dated March 21, 2012, documented CNA #1 was assigned to care for the resident on that date.

During an interview with LPN #3 on March 22, 2012 at 1:45 PM, she stated CNA #1 informed her the resident was verbally abusive and threatened to kick her. The LPN stated the actions she took included:
- she notified the registered nurse (RN) supervisor, who instructed her to interview the resident;
- she interviewed the resident, who stated CNA #1 was doing care that he did not want, he asked her to stop, and when she did not stop he started swearing;
- CNA #2 was in the resident's room at the time of the incident and provided the same information the resident did. There was no documented evidence he (CNA #2) reported the incident at the time of the occurrence.
- she did not initiate an incident report, as she "was under the impression" incident reports were done for physical abuse.

CNA #2 was interviewed on March 22, 2012 at 1:50 PM, and stated he was present during the interaction between the resident and CNA #1 on March 20, 2012. He stated CNA #1 was verbally abusive to the resident. CNA #2 said he had not given a statement regarding the incident to facility staff.

The Director of Nursing (DON) was interviewed on March 22, 2012 at 1:55 PM, and stated the Administrator notified her of the alleged verbal abuse on March 21, 2012. The DON stated she did not notify the New York State Department of Health (NYSDOH) of the alleged abuse, as she had 5 days to complete the investigation and she thought the investigation had to be substantiated prior to notifying the NYSDOH.

The RN supervisor was interviewed on March 22, 2012 at 2 PM, and she stated was not aware of the alleged verbal abuse between the resident and CNA #1, as she went "on what I see." She stated all she knew was that there was a confrontation.

During an interview on March 22, 2012 at 2:20 PM, the Administrator stated she was notified of the alleged verbal abuse on the evening of the March 22, 2012, and:
- the individual who was initially involved with the incident should have initiated an incident report;
- LPN #3 and the RN supervisor should have communicated with each other concerning the resident's interview, and the presence of a witness; and
- after notification of the alleged abuse, discipline for CNA #1 was the priority.

CNA #1 was not available for an interview.

In summary, the facility did not ensure:
- the resident was protected form further abuse when CNA #1 was not removed from resident care after an alleged incident of verbal abuse towards the resident; and
- the investigation of alleged abuse was not initiated in a timely manner.

2) Resident #10 had diagnoses including Alzheimer's disease, nutritional deficiencies, depression, psychosis, and anxiety.

The nursing progress note dated January 12, 2012, documented the resident had a 6 centimeter (cm) x 6 cm "dark purple" bruise from the top of her left hand to the base of the thumb. The resident was unable to state how the bruise occurred, and an incident report was filled out.

The "Initiation of Investigation" portion of the incident report was dated January 12, "2011", was signed by the reporter of the incident, the supervisor and Director of Nursing (DON) as 2012, and was not initiated. The interdisciplinary team review of the incident documented the resident propelled herself independently in the wheel chair. The report recorded the resident's bruise was consistent with the resident wheeling and propelling the wheel chair. The report documented the investigation was completed by the "Administrator/DON and staff witness statements were not obtained for the the determination that abuse/neglect did not occur.

The Minimum Data Set (MDS) assessment dated January 23, 2012, documented the resident had moderately impaired cognition, was unsteady during during transfers, pivoting (turning around), and walking.

The nursing progress note dated January 25, 2012, documented the resident had a "large bruise" on her left hand, the bruise was noted on January 12, 2012 and "appears" to have not changed since then. There was no documented evidence an investigation was done to determine if the bruise was the same bruise noted on January 12, 2012 (13 days earlier). The was no documentation to determine if abuse or neglect had occurred.

The nursing progress note dated February 2, 2012, documented the resident was found on the bathroom floor, and stated she hit her head. The note recorded the back of the resident's head was "reddened" with no hematoma (collection of blood under the skin)noted. There was no documented evidence an investigation was done to determine if abuse or neglect had occurred.

The nursing progress note dated February 25, 2012, documented the resident was found on the floor. The resident was "pleasantly confused" and "did not understand that she" was unable to walk without assistance. There was no documented evidence an investigation was done to determine if abuse or neglect had occurred.

The incident report dated March 1, 2012, documented the resident had a 6 cm x 5 cm bruise on her right lateral calf. An entry dated March 2, 2012, documented the resident had fallen on February 25, 2012, and the "probable cause" of the bruise was that fall. The report documented the investigation was completed by the "Administrator/DON" and staff witness statements were not obtained.

The nursing progress note dated March 2, 2012, documented the resident had a 6 cm x 5 cm bruise on her right outer thigh. The resident stated she did not know how the bruise happened, and the "Bruise paperwork" was filled out.

The March 4, 2012, nursing progress note documented the resident was on the floor.

The incident report dated March 4, 2012, documented the resident had a 3 cm x 4 cm bruise on her right buttock. The report documented the cause of the bruise was "unknown with no probable cause." The report documented The RN supervisor told the Administrator the resident's bruise"looked" fresh and was not consistent with the fall on February 25, 2012. The report documented the investigation was completed by the Administrator and DON. Staff/witness statements were not obtained to determine if abuse/neglect occurred.

The nursing progress note dated March 5, 2012, documented the resident had a 3 cm x 3 cm bruise on her hand, at the base of the thumb, of "unknown origin" and the resident was unable to state how the bruise occurred. The note recorded an incident report was done.

The incident report dated March 5, 2012, documented a 3 cm x 3 cm bruise was found on the resident's right hand, at the base of her thumb, and the resident stated "I banged it when I was standing in my kitchen making a sandwich." The report documented the investigation was completed by the "Administrator/DON" and staff witness statements were not obtained.

The nursing progress note dated March 7, 2012, documented the resident had a 3 cm x 4 cm bruise on her right hip, which "May be related to a fall she had on 3/4/12." The note recorded the resident was unaware of any other way she may have acquired the bruise.

The incident report dated March 7, 2012, documented a 3 cm x 4 cm bruise was noted on the resident's hip. The report documented the bruise "may" be "related to" the fall she had on March 4, 2012, "refer" to March 5, 2012 incident for the resident's history. The report recorded the investigation was completed by the "Administrator/DON" and staff witness statements were not obtained.

The nursing progress note dated March 9, 2012, documented the resident's right eye lid and under her right eye had "old" ecchymotic areas. The resident stated "it maybe from when she fell."

The incident report dated March 9, 2012, documented an old bruised area on the resident's right eye lid and under her eye possibly" from a previous fall. The report documented the investigation was completed by the "Administrator/DON" and staff witness statements were not obtained.

During an interview with the DON on March 23, 2012, between 12:15 PM and 12:40 PM, she stated:
- all incidents do not have witness statements;
- the process for bruises of unknown origin was for the interdisciplinary to discuss the bruise to determine if abuse or neglect had occurred;
- the Administrator was informed of injuries of unknown origin and would meet with the supervisor to determine if witness statements were needed;
- staff had been instructed to notify the Administrator if a resident had a bruise;
- an incident report would be started by the person who found the concerns;
- the nursing supervisor would assess the resident and determine if the Administrator needed to be notified;
- after the Administrator spoke to the supervisor she would make the decision to do a further investigation; and
- based on the Administrator's observation witness statements were not needed to rule out abuse or neglect as she had prior training regarding abuse.

During an interview with the Administrator on March 23, 2012 at 12:50 PM, she stated bruises of unknown origin would require witness statements and further investigation, if there was not reasonable cause for the bruise as determined by a prudent person.

In summary the facility did not conduct a thorough investigation, of injuries of unknown origin, to rule out abuse/neglect, as they did not conduct thorough interviews with all staff involved with caring for the resident.

3) Resident #14 had diagnoses including a history of a cerebral vascular accident (CVA), osteoporosis, and ocular hypertension.

The Minimum Data Set (MDS) assessment dated January 25, 2012 documented the resident had severe cognitive impairment and required total assistance with all activities of daily living.

The current comprehensive care plan (CCP) identified an ongoing need (effective July 8, 2009) for maximum assistance of one person for personal hygiene, grooming, dressing and daily care. The interventions included providing nail care as indicated. The CCP documented the resident's visual impairment (effective January 7, 2010), and interventions included eye drops as ordered (effective April 9, 2010).

The CCP documented the resident bruised easily related to poor nutritional intake (effective March 6, 2011). The interventions included handling the resident gently during all care and transfers. Several bruises were documented on the CCP and included a bruise noted under the resident's right eye on February 22, 2012.

A nursing progress note dated February 22, 2012 documented staff noted a 1 centimeter (cm) by 1.5 cm bruise under the resident's right eye. The resident denied discomfort. The note documented the resident received routine eye drops in the morning and evening.

An incident report initiated on February 22, 2012 and documented the resident had an ecchymotic area under her right eye, found by the certified nurse aide (CNA) on first rounds, and the CNA was interviewed. The report recorded the interdisciplinary team reviewed the incident and documented the resident continued to receive eye drops and questioned if the application of the eye drops traumatized the resident's skin. The plan documented the bruise was "probable trauma" from the medication administration. It was concluded by the Administrator/Director of Nursing, no statements were needed from staff and there was no evidence of abuse/neglect. The cause of the injury was described as "maybe with administration" of eye drops. The report recorded no corrective action was necessary. There was no documented evidence the nurse who administered the eye drops was interviewed, and no evidence the nurse was re-educated on administering the eye drops in a manner that would prevent further injury to the resident.

The resident was identified on the current CCP as high risk for skin breakdown (effective October 14, 2009) and interventions included the certified nurse aides (CNAs) would assess the resident's skin condition daily during care and report any abnormalities to the nurse. The CCP documented several bruises of unknown origin from May 25, 2010 through the present, including a scratch to the outer aspect of the resident's right buttocks on February 27, 2012.

A nursing progress note dated February 27, 2012 documented a 1.5 cm scratch on the resident's right buttock was noted during PM care.

An Incident Report dated February 27, 2012 documented a 1.5 cm scratch was noted on the resident's buttocks. The report recorded the staff member who found the bruise was interviewed. The interdisciplinary team review documented the CNA followed the plan of care instructions and no long fingernails were observed on the the "staff reporter." The report documented team questioned if the scratch was self inflicted by the resident while in bed. There was no documented evidence the length of the resident's fingernails was observed to determine if nail care was provided as planned. No other statements from staff were obtained.

When the Director of Nursing (DON) was interviewed on March 23, 2012 at 12:15 PM, she stated not all incidents had witness statements. Incidents (bruises) of unknown etiology were discussed with the interdisciplinary team to determine if abuse occurred. The supervisor completed an assessment and discussed her findings with the administrator. Based on this information, the administrator made the determination if "they"needed to go further with the investigation and if witness statements were needed. The staff were instructed to call the administrator if any bruising was found on any residents.

In summary, the facility did not ensure:
- all injuries of unknown origin were thoroughly investigated: and
- a plan of care was implemented to prevent further abuse.

10NYCRR 415.4 (b)(1)(i)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 4 of 4 residents (Residents #2, 8, 12, and 13), observed being fed by paid feeding assistants, the facility did not ensure resident were fed by appropriate staff. Specifically, Residents #2, 8, 12, and 13 were fed by paid feeding assistants and the facility did not complete assessments deeming the practice was appropriate; did not base the selection of those residents on their plans of care; did not ensure paid feeding assistance received direction from licensed nurses; and did not ensure paid feeding assistants fed only those residents without complicated feeding problems. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facility's January 2008 Training Non-Nursing Personnel to Assist in Resident Feeding did not document how residents were to be assessed and/or deemed safe to be fed by paid feeding assistants. The policy did not include where the assessments were to be documented and did not document that paid feeding assistants worked under the direction of a licensed nurse.

1) Resident #2 had diagnoses including dementia and reflux.

At the time of survey, the resident's most recent swallowing evaluation was dated August 30, 2011 and documented the evaluation was ordered as the resident developed a congested cough. The speech language pathologist (SLP) documented the resident required 1:1 feeding to control bolus (bite) size. The resident was assessed as high risk for choking and aspiration (taking foreign matter into the lungs). Recommendations included a puree diet, staff to add gravy to "sticky dry pureed solids" and staff to feed the resident 1/2 teaspoons of solid food at a time. The Dysphagia (difficulty swallowing) Medical Workup, dated August 30, 2012, filed with the swallowing evaluation, documented the resident had oral and pharyngeal dysphagia (types of swallowing difficulties).

The comprehensive care plan (CCP) dated as "active" since December 23, 2011 documented a goal for the resident included exhibiting no signs or symptoms of aspiration during meals. Interventions included monitoring tolerance to pureed foods. The CCP did not document the the resident was assessed as appropriate to be fed by a paid feeding assistant.

The January 5, 2012 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was dependent on staff for eating and was on a mechanically altered diet.

The January 5, 2012 nutrition assessment documented the resident was on a puree diet, had chewing problems, did not have swallowing problems and was dependent on staff for eating.

The resident was observed at the lunch meal on March 21, 2012 at 12:55 PM being fed by an activities staff person.

On March 21, 2012 at 1:20 PM, the activities staff person stated in an interview, she could feed anyone who was not on thickened liquids. She stated she knew who to feed as she always fed the residents at that table.

On March 21, 2012 at 2:20 PM, registered nurse (RN) #1, the Head Nurse of the resident's unit, stated in an interview, the Director of Activities told the paid feeding assistants who they could feed. RN #1 stated she was not involved in supervising the paid feeding assistants or directing them regarding who they could feed.

On March 21, 2012 at 2:33 PM, the Director of Activities stated in an interview, the paid feeding assistants always fed residents at the same table. She stated the resident sat at that table for breakfast and lunch, and could be fed those meals by a paid feeding assistant. She stated the resident did not do as well at night and was fed supper by nursing. The Director of Activities stated paid feeding assistants could feed any resident who was not on thickened liquids.

On March 21, 2012 at 2:50 PM, RN #3, who was the Staff Educator, stated in an interview, the paid feeding assistants could feed anyone who was not on thickened liquids. She stated the facility had a list of residents on aspiration precautions and those residents were also the ones on thickened liquids. She stated the list was in the dining room and the paid feeding assistants knew not to feed anyone on that list. RN #3 stated she did not provide supervision or direction to the paid feeding assistants as they received direction from the Director of Activities.

On March 22, 2012 at 10:30 AM, the Director of Nursing (DON) stated in an interview, the facility kept a list of residents on aspiration precautions and the paid feeding assistants could not feed those residents. The list was reviewed at team meetings and updated monthly. The DON provided a copy of the list dated March 6, 2012 and Resident #2 was not listed as being on aspiration precautions. The DON stated she did not know who determined or how it was determined the resident was safe to be fed by a paid feeding assistant when she had a diagnosis of dysphagia. The facility was in the process of developing an aspiration precautions policy and a policy was not in place presently.

In summary the facility:
- did not ensure paid feeding assistants fed only those residents without complicated feeding problems;
- did not ensure the selection residents to be fed by a paid feeding assistant was based on the licensed nurse's last assessment and the resident's CCP; and
- did not ensure the paid feeding assistants received direction from a licensed nurse regarding which residents they were able to feed.

2) Resident #8 had diagnoses including dementia.

The Minimum Data Set (MDS) assessment dated December 21, 2011 documented the resident had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADLs), including total assistance of 1 person for eating. The resident was on a mechanically altered diet.

The current undated physician "standing orders" documented the resident was on a ground consistency diet.

A list was observed at the nurses' desk labeled "Aspiration Precautions to be noted on the following Residents" and Resident #8 was not on the list. The list was dated on March 6, 2012.

A dietary progress note dated March 19, 2012 documented the resident had increased difficulty chewing and a pureed diet was requested. The note recorded the resident remained at moderate nutritional risk.

The comprehensive care plan (CCP) dated March 19, 2012 documented the resident had increased difficulty chewing and the diet was changed to pureed. The CCP documented the resident's need for the assistance of 1 person at meals and a need to remind the resident to swallow.

The "Resident CNA (certified nurse aide) Documentation History Detail" for March 5 - March 20, 2012 recorded the resident was totally dependent for eating at all meals.

The dietary progress note dated March 20, 2012 documented the resident received pureed consistency at lunch and dinner as a trial. The note recorded the resident continued with a chewing motion even with pureed consistency.

The resident was observed on March 21, 2012 at 12:55 PM, being fed lunch by an activities staff person.

On March 21, 2012 at 2:15 PM, registered nurse (RN) #1, who was the Head Nurse of the resident's unit stated in an interview, to her knowledge, activities staff were not trained to feed residents. At 2:30 PM, RN #1 returned to the surveyor and stated there were some activities staff who were trained to feed residents. RN #1 stated they could feed any resident who was not on the aspiration precautions list. She said she did not direct the paid feeding assistants regarding who they could feed and thought that was done by the Director of Activities.

On March 21, 2012 at 2:33 PM, the Director of Activities stated in an interview, the paid feeding assistants always fed residents at the same table in the dining room. She stated the resident sat at that table for all 3 meals and could be fed all 3 meals by a paid feeding assistant. She stated the paid feeding assistants could feed any resident who was not on thickened liquids.

On March 21, 2012 at 2:50 PM, RN #3, who was the Staff Educator, stated in an interview, the paid feeding assistants could feed anyone who was not on thickened liquids. She stated those residents were on the aspiration precautions list and the list was kept in the dining room where the paid feeding assistants could refer to it. RN #3 stated she did not provide supervision or direction to the paid feeding assistants as that was done by the Director of Activities.

On March 22, 2012 at 10:30 AM, the Director of Nursing (DON) stated in an interview, the facility had a list of residents on aspiration precautions and the paid feeding assistants could not feed those residents. The DON provided a copy of the aspiration precautions list dated March 6, 2012 that included Resident #8. The DON stated the facility was in the process of developing an aspiration precautions policy and did not have one at this time.

The registered dietitian (RD) was interviewed on March 23, 2012 at 11 AM. She did not recall why the resident was on the aspiration precaution list, but thought she may have gone on the list when she was changed from a regular consistency diet to a ground consistency because of her continual chewing.

In summary the resident was fed by a paid feeding assistant without an assessment documenting the resident was appropriate to be fed by the paid feeding assistants.

3) Resident #13 had diagnoses including reflux and diabetes.

At the start of the survey, the most recent swallowing evaluation in the medical record was dated March 9, 2009 and documented the resident exhibited disorganized bolus manipulation and oral food residue was present in the mouth after eating. The resident's diagnosis included mild oropharyngeal dysphagia (difficulty swallowing) secondary to pharyngeal weakness. The recommended diet was ground/mechanical soft.

The current comprehensive care plan (CCP) with an "active" date of December 23, 2011 documented the resident was on a ground consistency diet, required assistance with eating, and had dental impairments. Interventions included monitoring tolerance to the diet order, assisting the resident with eating, encouraging the resident to feed herself finger foods, and referrals to dental services when needed. The CCP did not document the resident was assessed to be fed by a paid feeding assistant.

The February 22, 2012 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance with eating, and was on a mechanically altered diet.

The resident was observed at the lunch meal on March 21, 2012 at 12:55 PM being fed the lunch meal by an activities staff person.

On March 21, 2012 at 2:15 PM, registered nurse (RN) #1, who was the Head Nurse of the resident's unit stated in an interview, to her knowledge, activities staff were not trained to feed residents. At 2:30 PM, RN #1 returned to the surveyor and stated there were some activities staff who were trained to feed residents. RN #1 stated they could feed any resident who was not on the aspiration precautions list. She stated she did not direct the paid feeding assistants regarding who they could feed and thought that was done by the Director of Activities.

On March 21, 2012 at 2:33 PM, the Director of Activities stated in an interview, the paid feeding assistants always fed residents at the same table in the dining room. She stated the resident sat at that table for all 3 meals and could be fed all 3 meals by a paid feeding assistant. She stated the paid feeding assistants could feed any resident who was not on thickened liquids.

On March 21, 2012 at 2:50 PM, RN #3, who was the Staff Educator, stated in an interview, the paid feeding assistants could feed anyone who was not on thickened liquids. She stated those residents were on the aspiration precautions list and the list was kept in the dining room where the paid feeding assistants could refer to it. RN #3 stated she did not provide supervision or direction to the paid feeding assistants as that was done by the Director of Activities.

On March 22, 2012 at 10:30 AM, the Director of Nursing (DON) stated in an interview, the facility had a list of residents on aspiration precautions and the paid feeding assistants could not feed those residents. The DON provided a copy of the aspiration precautions list dated March 6, 2012 and the resident was not on the list. The DON stated she did not know who determined or how the determination was made that the resident was safe to be fed by a paid feeding assistant when she had a diagnosis of dysphagia. The DON stated the facility was in the process of developing an aspiration precautions policy and did not have one at this time.

The resident was observed on March 22, 2012 at 12:45 PM being fed lunch by an activities staff person.

In summary the facility:
- did not ensure the selection of the resident as safe to be fed by a paid feeding assistant, was based on the licensed nurse's last assessment and the resident's CCP;
- did not ensure paid feeding assistants fed only those residents without complicated feeding problems; and
- did not ensue paid feeding assistants received direction from a licensed nurse as to which residents they were able to feed.

10 NYCRR 415.13(d)

.

Based on record review and staff interview conducted during the standard survey, it was determined for 4 of 6 residents (Residents #4, 10, 11, and 14) reviewed for falls, fractures, abrasions and bruising, the facility did not operationalize written policies and procedures that prohibit mistreatment, neglect, and abuse of residents. Specifically, for Residents #4, 10, 11, and 14 staff did not operationalize the facility's written policy and procedure for resident abuse/neglect reporting and investigation. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facilities "Resident Abuse" policy, last revised "11/09" (date unspecified) documented the intention of the policy was to ensure residents were "afforded" the right to be free from verbal and physical abuse. The policy defined abuse as willful infliction of injury, intimidation, or punishment, with resulting harm, pain, or mental anguish by an individual, including a caregiver. The policy included:
- verbal abuse was defined as any oral, or gestured language that included disparaging and derogatory terms to residents;
- employees were not to use or permit verbal abuse to its residents;
- any one who witnessed abuse was to report the event immediately;
- the individual observing the abuse should complete an incident report as soon as possible after the event; and
- the investigation would begin immediately by the supervisor, Director of Nursing (DON) or administrator.

1) Resident #4 had diagnoses including quadriplegia (paralysis to upper and lower extremities).

The Minimum Data Set (MDS) assessment dated February 2, 2012, documented the resident's cognition was intact, and he was dependent upon others for transfers, bed mobility, dressing, toileting, and personal hygiene. He was assessed as verbally and physically abusive 1 - 3 days during the assessment period. Care was refused 1 - 3 days during the assessment period.

Licensed practical nurse (LPN) #1's progress note dated March 20, 2012, at 1:56 PM, documented "during AM (morning) care" the resident called certified nurse aide (CNA) #1 expletive names and threatened to kick her. The CNA provided care to the resident which he had refused. The CNA "continued to be mouthy and degrading to the resident" and the resident "retaliated by threatening to kick her and call her names". Foul language was exchanged between the resident and the CNA, and this was observed by CNA #2. There was no documented evidence an incident report was instituted.

CNA #1's time card documented she worked March 20, 2012, from 6:56 AM - 11:16 AM,and March 21, 2012, from 6:59 AM - 2:56 PM. The time card did not specify why the CNA left early.

The "Nursing Assignments" form documented CNA #1 was assigned to provide care for the resident March 21, 2012.

During an interview with LPN #3 on March 22, 2012 at 1:45 PM, she stated CNA #1 informed her the resident was verbally abusive and threatened to kick her. The LPN stated after the CNA reported this she:
- notified the registered nurse (RN) supervisor, who instructed her to interview the resident;
- interviewed the resident, who stated CNA #1 was doing care that he did not want, he asked her to stop, and when she did not stop he started swearing;
- determined CNA #2 was in the resident's room at the time of the incident and provided the same information the resident did; and
- did not start to fill out an incident report, as she "was under the impression" an incident report was for physical abuse.

CNA #2 was interviewed on March 22, 2012 at 1:50 PM, and stated he was present during the interaction between the resident and CNA #1 on March 20, 2012. He stated CNA #1 was verbally abusive to the resident and he did not report it at the time of the incident.

The Director of Nursing (DON) was interviewed on March 22, 2012 at 1:55 PM, and stated the Administrator notified her of the alleged verbal abuse on March 21, 2012. The DON stated she did not notify the New York State Department of Health (NYSDOH) of the alleged abuse, as she believed she had 5 days to complete the investigation and she thought the investigation must be substantiated before notifying the NYSDOH.

The RN supervisor was interviewed on March 22, 2012 at 2 PM, and stated she was not aware of the alleged verbal abuse between the resident and CNA #1. She stated all she knew was that there was a confrontation.

During an interview on March 22, 2012 at 2:20 PM, the Administrator stated she was notified of the alleged verbal abuse on the evening of the March 22, 2012, and:
- the individual who was initially involved with the incident should have instituted an incident report;
- LPN #3 and the RN supervisor should have communicated with each other concerning the resident's interview, and the presence of a witness; and
- investigation of the LPN and CNA #2 to rule out abuse and neglect was not done at the time, as after learning of the alleged abuse, the priority was discipline for CNA #1.

CNA #1 was not available for an interview.

In summary, the facility did not:
-operationalize facility policies regarding incident reporting and verbal abuse to ensure possible verbal abuse was investigated;
-conduct a thorough investigation to determine if verbal abuse occurred; and
- report this incident of potential abuse to the DON, Administrator and NYSDOH.

2) Resident #10 had diagnoses including Alzheimer's disease, nutritional deficiencies, depression, psychosis, and anxiety.

The nursing progress note dated January 12, 2012, documented the resident had a 6 cm (centimeter) x 6 cm "dark purple" bruise from the top of her left hand to the base of the thumb. The resident was unable to state how the bruise occurred, and an incident report was filled out.

The incident report dated January 12, "2011" (signed by the reporter of the incident report, the supervisor and Director of Nursing (DON) as 2012) documented the investigation was complete by the "Administrator/DON" The "Initiation of Investigation" portion of the report had not initiated. The report documented staff witness statements were not obtained for the the determination that abuse/neglect did not occur.

The Minimum Data Set (MDS) assessment dated January 23, 2012, documented the resident had moderately impaired cognition, was unsteady during during transfers, pivoting (turning around), and walking.

The nursing progress note dated January 25, 2012, documented the resident had a "large bruise" on her left hand, and the bruise was documented on January 12, 2012, and "appears" not to have changed since that date. There was no documented evidence an investigation was done to determine if the bruise was the bruise noted on January 12, 2012. The was no documented evidence to rule out if abuse or neglect had occurred.

The nursing progress note dated February 2, 2012, documented the resident was found on the bathroom floor, and stated she had hit her head. The back of the resident's head was "reddened". No hematoma (localized swelling filled with blood) was noted. There was no documented evidence an investigation was done to determine if abuse or neglect had occurred.

The nursing progress note dated February 25, 2012, documented the resident was found on the floor. The resident was "pleasantly confused" and "did not understand that she" was unable to walk without assistance. There was no documented evidence an investigation was done to determine if abuse or neglect had occurred.

The incident report dated March 1, 2012, documented the resident had a 6 cm x 5 cm bruise on her right lateral calf. An entry dated March 2, 2012, documented the resident had fallen on February 25, 2012, and the "probable cause" of the bruise was from the fall on February 25, 2012. The report documented the investigation was completed by the "Administrator/DON" and staff witness statements were not obtained for the determination that abuse/neglect did not occur.

The nursing progress note dated March 2, 2012, documented the resident had a 6 cm x 5 cm bruise on her right outer thigh. The resident stated she did not know how the bruise happened, and the "Bruise paperwork" was filled out. There was no documentation an investigation was started to determine if abuse or neglect had occurred.

The March 4, 2012, nursing progress note documented the resident was on the floor.

The incident report dated March 4, 2012, documented the resident had a 3 cm x 4 cm bruise on her right buttock. The report documented the cause of the bruise was "unknown and no probable cause". The report documented the investigation was completed by the "Administrator/DON" and staff witness statements were not obtained for the the determination that abuse/neglect did not occur.

The nursing progress note dated March 5, 2012, documented the resident had a 3 cm x 3 cm bruise on her hand, at the base of the thumb, of "unknown origin", the resident was unable to state how the bruise occurred, and an incident report was done.

The incident report dated March 5, 2012, documented a 3 cm x 3 cm bruise was found on the resident's right hand, at the base of her thumb. The "Initiation of Investigation" portion of the incident report had not be started, the "Administrator/DON" documented the investigation was complete, and staff witness statements were not obtained for the the determination that abuse/neglect did not occur.

The nursing progress note dated March 7, 2012, documented the resident had a 3 cm x 4 cm bruise on her right hip, which "May be related to a fall she had on 3/4/12". The resident was unaware of any other way she acquired the bruise.

The incident report dated March 7, 2012, documented a 3 cm x 4 cm bruise was noted on the resident's hip. The report documented the investigation was completed by the "Administrator/DON" and staff witness statements were not obtained for the the determination that abuse/neglect did not occur

The nursing progress note dated March 9, 2012, documented the resident's right eye lid and the area under her right eye had "old" ecchymotic areas. The resident stated "it maybe from when she fell".

The incident report dated March 9, 2012, documented the resident's right eye lid and the area under her eye had an old bruised area, "possibly" from a previous fall. The report documented the investigation was completed by the "Administrator/DON" and staff witness statements were not obtained to rule out abuse/neglect had occurred.

During an interview with the DON on March 23, 2012, between 12:15 PM and 12:40 PM, she stated:
- all incidents do not have witness statements;
- the process for bruises of unknown origin was for the interdisciplinary to discuss the bruise to determine if abuse or neglect had occurred;
- the Administrator was informed of injuries of unknown origin, would meet with the supervisor to determine if witness statements were needed;
- an incident report would be instituted by the individual who found a concern, or incident;
- the Supervisor would assess the resident and determine if the Administrator needed to be notified;
- after the Administrator spoke to the Supervisor she would make the decision to do a further investigation; and
- based on the Administrator's observation witness statements were not needed to rule out abuse or neglect as she had prior training regarding abuse.

During an interview with the Administrator on March 23, 2012 at 12:50 PM, she stated bruises of unknown origin would require witness statements and a further investigation, if there was not reasonable cause for the bruise as determined by a prudent person. She stated this information was provided in a DAL (Dear Administrator Letter).

In summary, facility policies were not operational as the incidents of unknown origin were not thoroughly investigated to determine if abuse/neglect occurred.

3) Resident #14 had diagnoses including a history of a cerebral vascular accident (CVA), osteoporosis and ocular hypertension.

On February 22, 2012 an incident report documented staff observed an ecchymotic area under the resident's right eye. The area was first observed by a certified nurse aide (CNA) on "first rounds" and the CNA was interviewed. The incident report documented the resident received eye drops twice a day and the cause of the injury was described as "maybe" from the administration of eye drops. No further interviews were completed and the determination was made that no corrective action was necessary.

On February 27, 2012 an incident report documented the resident was observed with a scratch on her buttock. The staff member (CNA) who found the bruise was interviewed and the determination was made that the plan of care instructions were followed and the "staff reporter" did not have long fingernails. The team (reviewing the incident) questioned if the scratch was self-inflicted, and no further action was taken.

The Director of Nursing (DON) was interviewed on March 23, 2012 at 12:15 PM and stated not all incidents had witness statements, and incidents of unknown origin were discussed by the interdisciplinary team to determine if abuse occurred. Based on the summary of all information gathered, the administrator made the determination that no further investigation was necessary.

In summary, facility policies were not operational as the incidents of unknown origin were not thoroughly investigated to determine if abuse/neglect occurred.

10NYCRR 415.4(b)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 3 residents (Resident #14), reviewed for activity of daily living (ADL) concerns the facility did not ensure a resident who required total assistance with ADLs received the necessary services to maintain good nutrition. Specifically, Resident #14 was fed by staff at meals, using interventions that were not assessed as appropriate for the resident. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #14 had diagnoses including a past cerebrovascular accident (CVA, stroke) and failure to thrive.

The October 21, November 30, and December 29, 2011 physician's progress notes documented the resident ate poorly, had failure to thrive and had lost weight.

A January 23, 2012 nutrition progress note documented the resident's condition as failure to thrive with no anticipation of improvement and she was on comfort care. The resident's intake varied based on the resident's acceptance and was primarily 0 to 25% at meals.

The comprehensive care plan (CCP) updated on January 23, 2012 documented the resident was fed by staff, received a puree diet with nectar thick liquids, and would clench her mouth closed when she had enough to eat/drink.

The January 25, 2012 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was fed by staff, and was on a mechanically altered diet.

The Nursing Instructions updated on January 27, 2012 documented the resident was dependent on staff for eating. No specific instructions were documented regarding feeding techniques.

The resident was observed on March 21, 2012 between 12:25 PM and 12:55 PM. The resident received pureed foods and was fed by a certified nurse aide (CNA). The CNA was observed adding thickened milk to the resident's pudding and stated at that time to the surveyor she had to "thin it down a little" as the resident did not have the energy to swallow the pudding otherwise.

On March 22, 2012 at 8:45 AM, the resident was fed in bed by the CNA. The resident received pureed fortified cereal, pureed toast and jelly, and nectar thick orange juice and milk. The CNA stated the food sometimes stayed on the resident's tongue. She said she needed to add fluid to the food to get the resident to swallow it. The CNA stated she had worked at the facility for many years and she "knows the tricks of the trade." She did not know how other staff fed the resident and was not aware of any specific documented instructions regarding feeding the resident.

In summary, the facility staff assisted the resident at meals, with no documented evidence the interventions used were assessed as appropriate.

10 NYCRR 415.12(a)(3)]

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 5 residents (Resident #7), reviewed for weight concerns the facility did not ensure acceptable parameters of nutritional status were maintained. Specifically, Resident #7 experienced a change in status with an acute infection coupled with decreased intake and the facility did not ensure the resident was weighed as recommended by the registered dietitian so that interventions could be implemented timely if necessary. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #7 had diagnoses including Alzheimer's disease.

The January 3, 2012 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, fed herself after set-up, weighed 122 pounds, did not have a significant weight change, and was on a therapeutic diet.

The February 6, 2012 diet technician's progress note documented the resident weighed 122 pounds, lost 3 pounds in 1 month, and the plan was to discontinue small portions.

The February 20, 2012 registered dietitian's (RD) progress note documented the resident was more lethargic. The plan was to provide the resident with whole milk in place of skim milk and add fortified potatoes at lunch and dinner.

The Resident Certified Nurse Aide (CNA) Documentation History Detail documented the resident weighed 121 pounds on March 1, 2012.

The March 14 and 15, 2012 nursing progress notes documented the resident's appetite was poor and she was refusing meals.

The March 15, 2012 physician's progress note documented the resident had a change in status with increased lethargy and mild anorexia. The plan was to check the resident's urine for an infection.

The March 16, 2012 nursing progress note documented the resident took "a few bites of egg" at breakfast.

The March 16, 2012 diet technician's progress note documented the resident's "intake was down." The plan was to provide donuts at breakfast and ice cream at dinner.

The March 19, 2012 RD's progress note documented the resident had 2 acute infections, a urinary tract infection and an eye infection. The RD recorded the resident's intake was decreased, and that may have been related to the infections. The RD recommended the resident be weighed.

Review of the medical record from March 19 through 21, 2012 revealed no documentation the resident was weighed or that staff had attempted to weigh the resident.

The resident was observed on March 21, 2012 at 12:15 PM at lunch. She was fed by a CNA and received meat loaf, macaroni and cheese, pears, milk, juice, and coffee. While feeding the resident, the CNA stated to the surveyor, the resident had not been eating well lately.

The Resident CNA Documentation History Detail for March 1 - 23, 2012 was reviewed and revealed the resident was weighed on March 1, 2012 (121 pounds) and no other weights were attempted or obtained. The facility's handwritten weight book documented the same information.

The physician's orders dated March 23, 2012 documented the resident was on a no extra salt (NES) regular consistency diet.

On March 23, 2012 at 9:17 AM, a CNA, while feeding the resident, was heard telling the RD the resident was not eating anything and this was "normal" for her. She stated, to the surveyor, the resident had also been eating very little at lunch. The CNA said she thought the resident was not feeling well.

On March 23, 2012 at 10:10 AM, the registered nurse (RN) Head Nurse stated in an interview, resident weights were obtained at the beginning of the month or each week depending on the resident. She stated the CNAs knew when to weigh residents based on how it was programmed into the electronic medical record. The RN and the Unit Clerk (who was present) stated they remembered dietary asking for the resident to be weighed on March 19, 2012. The Unit Clerk stated the resident had been combative that day so she had the staff consider that a refusal. Neither the RN nor Unit Clerk knew if staff actually attempted to weigh the resident that day and neither knew if a weight had been attempted since then.

On March 23, 2012 at 10:30 AM, the RD stated in an interview, the resident had been eating poorly and she felt it was due to acute illnesses. She stated her plan was to initiate Mighty Shakes with meals today until the resident's intakes improved. She stated she did not know whether a weight was obtained when she recommended it on March 19, 2012.

On March 23, 2012 at 11:52 AM, the RD stated to the surveyor, the staff weighed the resident today and she weighed 108 pounds (18 pounds/10% loss in less than 1 month).

The comprehensive care plan (CCP), printed by the facility on March 23, 2012 at 12:57 PM, documented the resident left 25% or more uneaten and a goal was to maintain her weight between 120 and 130 pounds. The CCP documented inconsistent interventions including providing supplements/fortified foods (Mighty Shakes) with meals related to acute illness, decreased intakes and an intervention to provide skim milk for weight control.

In summary the facility did not ensure the resident was weighed as recommended by the RD so that interventions could be implemented timely if necessary.

10 NYCRR 415.12(i)(1)

Based upon observation and staff interview conducted during the standard survey, it was determined for 2 of 3 building wings (east and west wings), the facility did not ensure that all hazardous storage areas were appropriately constructed and maintained. Specifically, the doors to the housekeeping storage room and the medical supply room did not have self-closing devices as required. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the building inspection conducted on March 21, 2012, between 1:30 PM and 3:00 PM, and on March 22, 2012 between 9:15 AM - 11:15 AM, the following life safety code violations were observed:
- the door to the housekeeping storage room lacked a self-closing device. The room measured approximately 12 X 6 feet (72 square feet): and
- one of the 2 doors to the medical supply room lacked a self-closing device. The room measured approximately 36 x 6 feet (216 square feet).

The Director of Maintenance was interviewed on March 22, 2012 at 11:15 AM and he stated the housekeeping storage room never had a self-closing device on the door and both the medical supply room and the housekeeping storage rooms are always kept locked except when being used.

In summary, the facility did not ensure that 2 rooms over 50 square feet in size, the housekeeping storage room and the medical supply room, which were being used for the storage of combustible supplies, were protected as required for hazardous areas with self-closing doors.

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