Absolut Center for Nursing and Rehabilitation at Eden, LLC

Based on observation, record review and staff and resident interview, the facility did not provide care and services necessary to meet the needs of the resident in order to attain the highest practicable, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care. Specifically, for one (Resident #43) of one resident reviewed for quality of care the facility did not ensure effective pain management. This resulted in actual harm that is not immediate jeopardy.

The findings are:

1. Resident #43 has diagnoses including osteoarthritis and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 12/16/11 revealed the resident is cognitively intact.

Review of the Care Plan dated 12/27/11 included a plan for the resident to have decreased pain, five or less on the pain scale, with each administration of pain medication, offer heat along with other interventions.

During an interview on 1/31/12 at 11:06 AM, the resident answered approximately half of the interview questions then requested to stop the interview because he was in pain.

Observation on 2/2/12 at 9:34 AM during personal care, when the CNA assisted the resident to roll from one side to the other and back, revealed the resident moaned and called out "oh oh" with each movement. The Director of Nursing (DON) (who was present during the observation) asked if she could ask the Medication Nurse if the resident could have pain medication and left the room. The certified nurse aide (CNA) did not ask the resident if he needed something for pain or wanted her to stop moving him. The resident continued to moan and call out when moved until the Registered Nurse (RN) Medication Nurse administered Tylenol to the resident at 9:45 AM. When interviewed on 2/2/12 at 10:02 AM the resident stated he hurts all over.

When observed on 2/2/12 at 11:26 AM, two CNAs assisted the resident to the edge of the bed, applied a transfer sling, and attached it to the mechanical lift and started to raise the resident. The resident stated "ow, ow" and told the CNA not to raise the lift anymore. The resident was transferred from the bed to the wheelchair with his knees in a flexed position at approximately 90 degrees.

During an interview on 2/2/12 at 11:45 AM, the Physical Therapist stated the resident has a problem with the left hip and has "a lot of pain going on with the left hip". She stated the resident is in a "holding pattern" waiting to see if he can get his hip replaced. She stated she will monitor to see if the resident has any back slide and added she does not know if the resident has had any decline. The PT stated the resident is getting ROM to lower extremity as far as she knows.

During an interview on 2/2/12 at 12:26 PM, the Registered Nurse (RN) Resident Care Coordinator (RCC) stated the resident was admitted with hip pain and was on Oxycodone (narcotic - pain medication) 5 milligrams (mg) every (q) 8 hrs prn (as needed) and was taking the medication at least twice a day. She stated on 12/12/11 an order for Tylenol 650 mg q 4 hr prn was ordered and the resident was taking this one to two times a day. The RCC stated on 12/19/11 the resident's Oxycodone 5 mg was increased to q 6 hrs prn and then explained that the resident's pain was not any better because the resident would forget to ask for pain medication. On 1/5/12 the Oxycodone 5 mg was changed to q 6 hr around the clock (ATC) and the resident's pain was controlled for "a little bit". The RCC stated she spoke with the Nurse Practitioner (NP) and the NP informed her the dose could be increased if the pain was not controlled.

At the surveyor's request on 2/2/12 at 1:05 PM, the DON told the Physician the resident had pain on movement but if he does not move he is not in pain. During an interview on 2/2/12 at 1:06 PM, the Physician stated the resident is not at maximum dose for Neurontin or Oxycodone (narcotic- pain medication) and stated he will look at the resident today and evaluate his pain.

During an interview on 2/2/12 at approximately 1:30 PM, the CNA assigned to the resident revealed she has done the resident's care before and he is always in pain and it is hard to cleanse his genitals because of it. She stated "The resident is in pain when I transfer him and he cannot straighten out his legs".

Review of the Physical Therapy (PT) Progress Notes revealed the following:
- 12/19/11 the resident is able to ambulate 40 feet x 1 in parallel bars with assist of 1 and requires moderate assist of one for sit to stand.
- 1/9/12 the resident is non ambulatory due to pain.
- 1/16/12 the resident is non ambulating due to pain awaiting word from hospital for potential hip surgery.

Review of the Registered Physician Assistant 30 Day Visit dated 1/9/12 revealed the resident is currently participating in PT and ambulating with partial weight bearing with a wheelchair. Pain is controlled, requiring scheduled narcotic medication.

The Physical Therapy Rehabilitation Screening form dated 1/21/12 revealed the resident has contractures of left hip/knee recommendations for Passive Range of Motion (PROM - exercises performed on the resident by nursing staff) to bilateral lower extremities 5 x week.

When interviewed on 2/2/12 at 11:18 AM, the Director of Nursing (DON) stated the resident is no longer going to PT. The DON said she talked with the Physician last week about ordering an anti-inflammatory medication for the resident but no order was obtained and she does not know if the Physician has seen the resident.

When interviewed on 2/2/12 at 11:35 AM, the Range of Motion (ROM) CNA stated she is filling in for the regular ROM CNA. She revealed the resident refused ROM because he is in too much pain.

When observed on 2/2/12 at 11:38 AM, the ROM CNA approached the resident and he agreed to do ROM. The resident moaned during the PROM to the right leg and the CNA asked if she should stop and the resident said no. The CNA then informed the resident she was going to do PROM on the left leg and the resident stated he cannot put the left leg flat. The left leg is in a flexed position. When the CNA picked up the resident's left leg the resident said "ow, ow, ow" and stated it is too painful. The ROM CNA stopped and did not perform ROM to the left leg. When interviewed at this time the ROM CNA stated "The left leg is so stiff and painful I cannot do ROM".

When interviewed on 2/3/12 at 11:09 AM, the PT stated the resident has not been on ROM long and no one reported there was any problem with the resident participating in ROM. She stated nursing would communicate to PT if there was a problem with the resident tolerating ROM.

During an interview on 2/3/12 at 11:49 AM, the Director of Rehabilitation stated the resident rated his hip pain a 9 out of 10 (10 being the worse). She further revealed at one point the resident was able to transfer with limited assist of 1 person then the resident started complaining of more pain, plateaued in PT, and is now wheelchair bound. She stated the resident's pain was discussed at morning report.

When interviewed again on 2/3/12 at 1:55 PM, the Director of Rehabilitation stated the resident was discharged from PT on 1/23/12 but was not put on ROM until 2/1/12. She explained she had hoped the resident was going out for surgery and when the resident did not go out she put him on ROM. The Director of Rehabilitation stated the ROM CNA mentioned to her that the resident was having pain and refused ROM to the left leg. She stated she talked with the resident today and the resident told her his pain was worse than it has ever been.

When interviewed on 2/2/12 at 12:53 PM, the Director of Nursing (DON) stated she had just started to introduce the pain scale, 1 (no pain) to 10 (worse pain) in the facility. She stated she assessed the resident using the pain scale and his pain was a 5 and acceptable to him.

Review of the facility form entitled Pain Assessment Draft dated 12/9/11 revealed the resident occasionally has pain and on a pain scale of zero to ten the pain is a five.

Review of the Pain Assessment Draft dated 1/4/12 revealed the resident almost constantly has pain and the pain is a ten on a scale of zero to ten.

Review of the Nurses Notes 12/9/11 to 2/3/12 and the Medication Administration Records (MARs) dated 12/1/11 to 2/3/12 revealed no documented evidence that the resident's pain was assessed using the pain scale zero (no pain) to ten (worse pain).

Review of Physician's Progress Notes from 1/19/12 through 2/1/12 revealed no documented evidence that the physician was aware of the resident's increased pain.

Review of the MAR dated 1/1/12 to 1/31/12 revealed no documented evidence that the resident was administered Tylenol as ordered by the physician.

Review of the Physician's Orders dated 2/2/12 included orders for Oxycodone 5 mg q 4 hrs while awake and q 4 hr prn at night, and x-ray of the left hip.

When interviewed on 2/3/12 at 10:45 AM, the resident stated his pain has not been controlled. He stated he has pain all over and pain in the left hip even with the pain medication. The resident stated even though they changed the pain medication yesterday his hip still hurts and he does not know if it has made a difference yet.

During an interview on 2/3/12 at 1:27 PM, the Director of Nursing (DON) stated the resident was discontinued from PT because of pain and explained that pain was always an issue.

When interviewed on 2/6/12 at 11:28 AM, the RN RCC stated the resident's pain was discussed during morning report and it was decided to discontinue the resident from PT because of pain and lack of his progress. The RCC stated there is no documentation that the physician was notified about the resident's pain after 1/9/11 and "guesses" because he had routine Oxycodone, the Physician was not notified because the resident's pain was in PT.

When interviewed on 2/6/12 at 11:00 AM, CNA #2 stated the resident has pain when she does his care. She stated the resident was always in pain and particularly when he moved his legs. The CNA stated when the resident was in pain she would ask the resident if he wanted her to come back and do care later. She stated during 1/2012 she notified the nurse that he was in pain and was told he already had pain medication. The CNA stated the resident always had pain in his legs so she would notify the nurse later in the day that the resident was in pain so he could be given something for pain.

During an interview on 2/6/12 at 2:00 PM, the Licensed Practical Nurse (LPN) Medication Nurse stated that on occasion the CNA would come to her and report the resident had pain and she would go and see the resident. She explained that the resident would tell her he only had pain when he moved his legs and stated that when the resident moved his legs you could hear a cracking sound. In addition the LPN stated the resident was on scheduled Oxycodone and at one point she told the resident he needed the pain medication increased and reported it to the RN RCC.

415.12

Based on record review and staff interview, the facility did not ensure that clinical records were maintained on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. One (Resident #47) of two residents' clinical records reviewed was not complete as it did not contain a record of the monitoring and assessment of the resident's Stage 2 pressure sore. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #47 has diagnoses including cerebral vascular accident (CVA - stroke) with left (L) hemiparesis (paralysis on one side of body), spinal stenosis of the lumbar spine, pathological compression fracture 2nd lumbar vertebrae (L2), and diabetes mellitus. Review of the initial Minimum Data Set (MDS) dated 8/22/11 revealed the resident was admitted with a Stage 2 pressure sore. Review of a quarterly MDS dated 11/9/11 and 12/2/11 documented that the resident's cognition is moderately impaired and that she no longer has a pressure sore.

Review of the initial Care Plan dated 8/16/11 revealed the resident has an alteration in skin integrity with a Stage 2 pressure ulcer (sore) on the right (R) buttock. The subsequent Care Plan dated 8/24/11 documented approaches to include a weekly skin assessment.

During an interview on 2/2/12 at 10:45 AM, the Director of Nursing (DON) identified herself as the Skin Rounds Nurse. She revealed the facility documented the monitoring and assessment of the resident's pressure sore on the "Wound Documentation Flowsheet(s)".

Interview with the DON on 2/3/12 at 1:33 PM revealed that she was unsure if the same pressure sore on the resident's right buttocks had healed and reopened, or if it had healed and another open area on the right buttock had developed.

Review of the Nurses Notes dated 9/6/11 to 10/22/11 revealed occasional pressure sore notation on the following dates:

- 9/6/11 - Open area on right buttock healed, discontinue (d/c) Optifoam. Continue with barrier of A&D.
- 9/21/11 - certified nurse aide (CNA) reported an open area on resident's buttocks. Resident Care Coordinator (RCC)/DON aware. Cleansed buttock, A&D applied until Registered Nurse (RN) assess.
- 9/28/11 - Buttocks examined, slightly reddened, no open areas.
- 10/22/11 - Writer assessed resident's buttocks, No Optifoam treatment, no open areas. CNA may use A&D.

Review of the resident's medical record dated 8/22/11 to 2/2/12 revealed no documented evidence of monitoring and assessment of the resident's Stage 2 pressure sore on the Wound Documentation Flowsheets.

During an interview with the RN DON on 2/2/12 at 9:15 AM, the DON stated the resident was admitted with a Stage 2 pressure sore on the right buttock. The DON explained she documented all of the skin/pressure sore notes on the facility's "Wound Documentation Flowsheet", but the sheets are missing/lost. The DON said she looked for them, but cannot find them anywhere. The DON stated that from now on, she is planning on keeping a second copy of skin sheets in her office, in addition to their being kept in the medical record.

415.22(a)(1)(2)(c)

Based on observation, record review and staff and resident interview, the facility did not develop a comprehensive care plan that includes measurable objectives and timetables to meet a resident's medical needs, to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Two (Residents #38, 51) of three residents reviewed for comprehensive care plans for vision did not have a care plan developed for impaired vision. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #38 has diagnoses that include diabetes mellitus, congestive heart failure, hypertension, and dementia. Review of the annual Minimum Data Set (MDS) dated 11/16/11 revealed the resident understands and is understood, has severely impaired cognition and impaired vision.

Review of the Care Plan dated 1/31/12 and Care Guide (used by certified nurse aides (CNAs) to provide care) modified 12/21/11 revealed no documented evidence that a care plan for vision was developed.

During an interview on 2/6/12 at 8:45 AM, the DON stated the certified nurse aides (CNAs) would use the Care Guide to ensure the resident was wearing her glasses. She further stated the resident's need for glasses should have been on both the Care Plan and Care Guide.

2. Resident #51 has diagnoses that includes dementia. Review of the Minimum Data Set (MDS) dated 1/23/12 revealed the resident understands and is understood, and has severely impaired cognition. In addition, the resident has impaired vision and requires glasses for some activities, such as reading, watching television and some activities.

Resident #51 was observed on 2/2/12 at approximately 9:30 AM, and he was not wearing glasses. During an interview at the same time, the resident stated he needs glasses for reading, watching television and if he goes to any activities. He further stated doesn't attend many activities. He then stated he has his glasses with him all the time.

During an interview on 2/6/12 at 8:45 AM, the Director of Nursing (DON) stated the certified nurse aides (CNAs) would use the Care Guide to ensure the resident was wearing their glasses. She further stated the resident's need for glasses should have been on both the Care Plan and Care Guide.

Review of the resident's most recent Care Plan dated 1/12/12 revealed it did not address the resident's impaired vision including his need for corrective lenses. Review of the Care Guide modified 1/24/12 used by the CNA to provide ADL (activities of daily living) care revealed no interventions to address the resident's impaired vision and the need for corrective lenses.

415.11(c)(1)

Based on observation, record review and staff interview, the facility did not ensure that the comprehensive care plan was periodically reviewed and revised by a team of qualified persons after each assessment. Two (Residents #8, 43) of 24 residents reviewed for care plan revision had issues that included a lack of interventions to address repeated falls and a lack of clear transfer directions after a change in the resident's transfer status. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #8 has a diagnosis of dementia, right humeral (upper arm bone - humerus) fracture and a history of falls. Review of the Minimum Data Set (MDS) dated 12/2/11 revealed the resident's cognition is severely impaired. The "Comprehensive" Care Plan dated 12/13/11 documented that the resident has a history of falls. Review of the Care Guide, used by the CNAs (certified nurse aides) to provide care, dated 5/5/11 revealed a plan for the use of a personal alarm, wheelchair seat belt in wheelchair and release q (every) 2 hours and Merriwalker (ambulation device) to be used for agitated periods, not to exceed 2 hours and supervise at all times.

Review of the Incident Reports dated 8/25/11, 9/9/11, 9/10/11, 9/17/11, 9/18/11, 9/18/11, 10/10/11, and 10/17/11 revealed the resident was found and or fell on the floor. There was no documented evidence that the care plan was revised to address the resident's falls.

When interviewed on 2/6/12 at 9:07 AM, the Registered Nurse (RN) Resident Care Coordinator (RCC) stated the Incident Reports are made out by the nurse that is on at the time of the incident. She explained that the RN or the Licensed Practical Nurse (LPN) can change the Care Plan to put interventions in place to prevent further incidents.

When interviewed on 2/6/12 at 9:17 AM, the Director of Nursing (DON) stated if the resident had a fall the LPN can put interventions in place to prevent further falls but the RN is the only one that can update the Care Plans.

On 2/6/12 at 9:22 AM, the DON was observed to review the following Incident Reports:

- 9/9/11 - Found on the floor - alarm sounding,
- 9/10/11 - Fell into wall and slid down the wall,
- 09/17/11 - Resident crawled out wheelchair (w/c) and landed on all "4's",
- 9/18/11 - Resident in wheelchair and fell to floor,
- 9/18/11 - resident climbed out of wheelchair,
- 10/10/11 - found on the floor,
- 10/17/11 - resident found on floor.

When interviewed on 2/6/12 at 9:30 AM, the Director of Nursing (DON) stated the incidents were all in the afternoon and there were no new care plan interventions to address the falls.

2. Resident #43 has a diagnosis of osteoarthritis and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 12/16/11 revealed the resident is cognitively intact. The "Comprehensive" Care Plan dated 12/27/11 revealed a plan for the extensive assist x 1 for functional transfers with gait belt and rolling walker, extensive assist of one with ambulation with rolling walker and gait belt for up to 15 feet. Review of the Care Guide dated 1/30/12 revealed the resident is non ambulatory with a plan for sit to stand transfer aid with one assist if having pain and extensive assist of one person with rolling walker and gait belt.

Review of the Physical Therapy Rehabilitation Screening dated 1/21/12 revealed a plan to transfer the resident with extensive assist of one person or Sara Lift (sit to stand mechanical lift) with one person if needed. The resident is non ambulatory, and has poor balance.

When observed on 2/2/12 at 11:26 AM during transfer with the Sara Lift, the Primary certified nurse aide (CNA) applied the lift sling and raised the resident until his knees flexed at approximately 90 degrees at which time the resident indicated he had pain. The CNA then transferred the resident from the bed to the wheelchair.

When interviewed on 2/2/12 at approximately 12:00 PM the Physical Therapist (PT) stated the resident has a problem with the left hip and is non ambulatory. She stated the resident needs extensive assist of 2 people to stand pivot or "if he is having a bad day" the CNA can use the Sara lift. The PT revealed the resident can tell them how he wants to be transferred. She stated the CNA Care Guide documents 2 people or Sara lift and the CNA decides which to use.

When interviewed on 2/3/12 at 11:09 AM, the PT stated it should not be up to the CNA to decide whether the resident is a stand pivot or Sara lift (transfer) and she changed the Care Guide today to Sara Lift (transfer) only.

When interviewed on 2/6/12 at 9:46 AM, the CNA stated PT decides how the resident should transfer. The CNA stated she does not assess and the Care Guide was confusing because there were two ways to transfer the resident. She stated when she tried to stand pivot the resident, the resident was in too much pain so she has transferred the resident with the Sara lift. The CNA explained she felt more comfortable transferring the resident with the lift.

415.11(c)(2)(iii)

Based on observation, record review and staff interview, the facility did not maintain an infection control program designed to provide safe, sanitary and comfortable environment and to prevent the development and transmission of disease and infection. Two (Residents #8, 43) of three residents had improper hand washing after peri rectal care for residents with urinary tract infections and indwelling Foley catheters (a tube inserted into the bladder to drain urine). There was no actual harm with potential for more than minimum harm that is not immediate jeopardy.

The findings are:

1. Resident #8 has a diagnosis of dementia, has a Foley catheter and urinary tract infection (UTI). Review of the Minimum Data Set (MDS) dated 12/2/11 revealed the resident's cognition is severely impaired. Review of the Care Guide (Certified Nurse Aide Care Plan) dated 5/5/11 revealed the resident requires extensive assist of one for bathing.

When observed on 2/2/12 at 8:51 AM during personal care, the certified nurse aide (CNA #1) applied gloves and removed the resident's brief and washed and dried the resident's arms then proceeded to look through the resident's drawer, found and applied deodorant under the resident's arms. CNA #1 then pulled the bed sheet around the resident's waist and cleansed the female genitalia and down the Foley catheter. The CNA was observed to drop a washcloth on the floor and picked it up with her gloved hand. The CNA then removed gloves, emptied the wash basin, washed hands for 4 seconds and reapplied gloves. The CNA then disconnected the Foley catheter from the Foley drainage bag and attached a leg bag to the Foley catheter. The CNA rolled the resident to the left side, cleansed the rectal area and left buttock then turned the resident to the right side and cleansed the left hip and the rectal area with the same washcloth. The CNA then removed her gloves and did not wash her hands.

The CNA then assisted the resident to sit on the edge of the bed and applied bra and shirt, brief, adjusted the leg bag, applied pants and gait belt. She obtained the resident's walker, stood the resident, pulled her brief and pants up, transferred the resident to wheelchair, removed the gait belt and applied the safety seat belt.

The resident then removed her dentures and placed them in a denture cup. The CNA obtained a tooth brush from the resident's drawer and placed it on the over bed table and then emptied the wash basin before she washed her hands for 14 seconds. The CNA then left the resident's room, went to the maintenance room, opened the door and obtained toothpaste off a shelf and returned to the resident's room. Without washing her hands the CNA put on gloves and brushed the resident's teeth. The CNA removed her gloves and assisted the resident in the wheelchair to the sink. The CNA left the resident's room and obtained a plastic cup from the medication cart, returned to the resident's room, filled the cup with water and gave it to the resident to rinse her mouth. The CNA gave the denture cup to the resident and the resident placed the dentures into her mouth. The CNA then washed her hands 9 seconds, put on gloves, removed the cap from the Foley drainage bag, emptied urine from the bag and wiped the tip of the drainage bag with alcohol and reapplied the cap. The CNA took the container of urine to the dirty utility room and emptied it, removed her gloves and washed her hands 13 seconds, returned to the resident's room and combed the resident's hair.

When interviewed on 2/3/12 at 12:07 PM, the CNA stated after peri rectal care she should have washed her hands before she changed the Foley bag to the leg bag and did not. The CNA stated she thought 5 to 10 seconds was long enough to wash her hands.

When interviewed on 2/3/12 at 1:08 PM, the Director of Nursing (DON) stated the CNA should have removed her gloves and washed her hands 20 seconds after providing peri rectal care, before doing other care and touching items in the room. She stated the CNA should have washed her hands 20 seconds and did not wash her hands long enough.

2. Resident #43 has a diagnosis of urinary retention and urinary tract infection (UTI). Review of the Minimum Data Set (MDS)dated 12/21/11 revealed the resident is cognitively intact. Review of the Care Guide (Certified Nurse Aide Care Plan) dated 1/30/12 revealed the resident requires extensive assist of one for bathing.

Review of the Urine Culture report dated 1/26/12 revealed staphylococcus aureus 80,000 cfu/ml.

When observed on 2/2/12 at 9:34 AM during personal care, the certified nurse aide (CNA #2) applied gloves and removed the resident's brief. She cleansed the peri (area between the anus and genitalia) area and Foley catheter, removed and reapplied her gloves without washing her hands, washed the hip and rectal area. The CNA then removed her gloves without washing her hands, obtained the basin and tooth brush from the night stand and washed her hands 5 seconds. CNA #2 reapplied gloves, gathered the soiled linen and disposed of it in the dirty utility room, removed her gloves and washed her hands for 11 seconds. The CNA proceeded to the medication cart, poured the resident a glass of water and returned to the resident's room and the resident rinsed his mouth.

When interviewed on 2/2/12 at 1:30 PM, CNA #2 stated she changes gloves after cleaning the peri area and then after cleaning the rectal area and should wash her hands for 30 seconds. She explained she was nervous and thought she washed her hands for 30 seconds. The CNA stated "I just count 1, 2, 3. I know you can sing happy birthday twice but I do not do that".

When interviewed on 2/3/12 at 12:57 PM, the Director of Nursing (DON) revealed the CNA should wash hands before peri rectal care, remove gloves and wash hands 20 seconds before touching other items or providing oral hygiene.

415.19(a)(b)(4)

Based on observation, record review and staff and resident interview, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to restore as much normal bladder function possible. Three (Residents #8, 43, 47) of three residents reviewed for urinary catheter use had issues involving continuation of the catheter without medical justification and use of improperly secured Foley catheters. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #47 has diagnoses including cerebral vascular accident (CVA - stroke) with left hemiparesis (paralysis on one side of body), spinal stenosis of the lumbar spine, pathological compression fracture of the 2nd lumbar vertebrae (L2), and diabetes mellitus. Review of the Initial Minimum Data Set (MDS) dated 8/22/11 revealed the resident was admitted with a Foley catheter. A quarterly MDS dated 12/2/11 documented the resident's cognition is moderately impaired. This assessment also documented that the resident has not undergone a urinary voiding trial and does not have a current toileting program.

Review of the initial Care Plan dated 8/16/11 revealed the resident has impaired elimination - Foley catheter due to (urinary) retention. Approaches listed include: Evaluate for (Foley catheter) removal. Review of the Care Plan dated 8/24/11 continued to identify the resident's impaired elimination - (use of) Foley catheter due to retention. The approaches do not document a plan to remove the catheter. Care Plan revisions dated 12/13/11 and 1/9/12 continue to identify impaired elimination - Foley catheter due to retention, with approaches to include Monitor for s/s (signs & symptoms) of a UTI (urinary tract infection). These care plans do not document the medical reason/justification for the resident's urinary retention.

Review of a Urinary Continence Assessment form dated 8/14/11 revealed the resident had an indwelling catheter (tube inserted into the bladder to drain urine) upon admission, insertion date unknown, reason is "retention". Factors impacting urinary continence include depression, CVA, pain.

Review of the physician's progress notes dated 9/15/11 revealed no documentation regarding the resident's urinary catheter. A physician progress note dated 10/10/11, instructs to anchor 16 FR Catheter with a 10 cubic centimeter (cc) bulb (diagnosis retention). Review of the most recent physician progress note in the medical record dated 1/16/12 revealed no documentation regarding the resident's catheter.

Review of the resident's physician monthly orders from 8/11 to 2/12 revealed an ongoing, routine order for the resident's catheter use as: Anchor 16 FR catheter with 10 cc bulb using catheter insertion kit to continuous drainage with one UD bag.

Interview with the Registered Nurse (RN) Director of Nursing (DON) on 2/2/12 at 9:15 AM revealed it was her understanding that the resident's catheter was initiated in the hospital, previous to her admission to this facility, because of retention, but she does not know what is causing the retention. She stated that the facility has not tried to remove the resident's catheter, to see if her bladder could function normally without it.

During an interview with the DON on 2/2/12 at 1:32 PM, the DON said she would look for any information in the resident's medical record regarding the resident's diagnosis of urinary retention. The DON stated she believes the reason for the retention is related to a neurogenic bladder and added if she cannot locate the information in the medical record, she will contact the resident's neurologist for information.

Interview with the DON on 2/6/12 at 10:25 AM revealed she had spoken with the resident's Neurologist, and the Neurologist indicated that he did not order the catheter, so he has not followed up on this. The DON said the facility will initiate a voiding trial with the resident in the immediate future (to determine if the resident can retain normal bladder function).

2. Resident #8 has a diagnosis of dementia and urinary tract infection (UTI). Review of the Minimum Data Set (MDS) dated 12/2/11 revealed the resident's cognition is severely impairment. Review of the "Comprehensive" Care Plan (CCP) dated 12/13/11 revealed a plan for Foley catheter (tube inserted into the bladder to drain urine) care every shift, keep catheter below the level of the bladder and empty the Foley every shift and as needed. Review of the Care Guide (Certified Nurse Aide Care Plan) dated 5/5/11 revealed Foley bag at night, leg bag with extension tubing on during the day, leg bag must hang to gravity while in bed.

During an observation of personal care on 2/2/12 at 8:51 AM, the resident's Foley catheter was not secured and moved up and down in the leg strap. The certified nurse aide (CNA #1) was observed to apply gloves and remove the resident's brief, washed the upper body and then cleanse the fold of the female genitalia and down the Foley catheter before she removed her gloves and washed her hands. CNA #1 then disconnected the Foley catheter from the Foley drainage bag and placed the uncovered end of the Foley drainage tube into the cloth bag that was covering the drainage bag. She then removed the end of the drainage bag tubing from the cloth bag and placed a cap on it. After the CNA attached the leg bag to the Foley catheter and secured it to the resident's right calf, the Foley tubing was observed to move in the leg strap. CNA #1 then assisted the resident to sit on the edge of the bed while the CNA dressed the resident. The catheter was observed to move up and down in the leg strap when the resident's pants were pulled up.

When observed on 2/2/12 at 1:50 PM, CNA #1 slid the Foley catheter tubing back and forth through the catheter leg strap. The CNA readjusted the strap on the Foley catheter tubing and secured it.

When interviewed on 2/3/12 at 12:07 PM, the CNA revealed she is responsible for adjusting the leg strap to secure the Foley. The CNA stated she did not adjust the leg strap to secure the Foley until 1:50 PM on 2/2/12. She further explained it is her responsibility to change the Foley drainage bag to the leg bag. The CNA explained she did not realize she put the tip of the Foley drainage bag in the cloth cover and then took it out and covered it and added she should not have done that.

When interviewed on 2/3/12 at 1:08 PM, the Director of Nursing (DON) stated the CNA should not have put the Foley drainage bag tip in the cloth bag cover and should have put an alcohol swab over the tip of the Foley drainage tubing. The DON further revealed the CNA should have checked the leg strap to make sure the Foley catheter was secured.

3. Resident #43 has a diagnosis of urinary retention and urinary tract infection (UTI). Review of the Minimum Data Set (MDS) dated 12/21/11 revealed the resident is cognitively intact and has an indwelling Foley catheter (tube inserted into the bladder to drain urine). The Physician order dated 1/9/12 revealed orders to anchor 16 fr with 10 cubic centimeters (cc) bulb using catheter insertion kit. Review of the Nurses' Note dated 12/10/11 revealed Foley yellow urine - blood clots in tubing and Nurses' Note dated 12/12/11 documented red hematuria noted in Foley.

When observed on 2/2/12 at 9:34 AM, certified nurse aide (CNA) #2 provided personal care to the resident while the resident was lying in bed. CNA #2 assisted the resident to roll to the left side and then the right side and then onto the resident's back to remove the resident's brief. The Foley catheter was observed unsecured and pulled taut. The resident moaned when moved. When the CNA performed Foley care, the Foley catheter was pulled taut. The resident said "oh oh or ow" while being cleansed. At 9:45 AM, the CNA had the resident turn to left side and cleansed the resident's hip and rectal area and had resident roll to right and cleansed the rectal area and then left hip and the Foley catheter remained taut. At 10:00 AM, the CNA applied the resident's brief and the resident said it felt like he had to urinate. The DON stated "It's flowing" (the urine).

When interviewed on 2/2/12 at 10:02 AM, the resident stated when the CNA cleansed him the catheter pulled and it hurt.

When interviewed on 2/3/12 at 12:57 PM, the Director of Nursing (DON) stated the resident should have had a leg strap on and confirmed it was pulled taut during bathing and it should have been secured. She further revealed the CNA should have moved the Foley bag from one side to the other when she was turned the resident.

415.12(d)(1)(2)

Based on record review and staff interview, the facility did not ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. One (Resident #38) of three residents reviewed for hearing and vision did not have an eye exam consult obtained since admission to the facility. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #38 has diagnoses that include diabetes mellitus and dementia. Review of the annual Minimum Data Set (MDS) dated 11/16/11 revealed the resident is cognitively impaired, understands and is understood, has clear speech, adequate hearing and impaired vision.

Review of the Care Plan dated 1/31/12 and Care Guide (used by certified nurse aides (CNAs) to provide care) modified 12/21/11 revealed no care plan for vision was developed. Review of the entire medical record revealed no documented evidence that the resident was seen by an eye specialist.

During an interview on 2/3/12 at 8:30 AM, the Director of Nursing (DON) stated she did not know if the resident has had any eye exams but she would attempt to find out.

During an interview on 2/3/12 at 11:15 AM, the DON explained that the resident was on a list to see the eye doctor on 6/11/11 but she could not locate any Ophthalmology (eye specialist) consults.

During an interview on 2/6/12 at 8:30 AM, the DON stated that the resident has not been seen by the eye doctor since her admission 12/11/08. She further stated she has initiated a log to ensure residents have annual eye exams. The log will be reviewed monthly.

415.12(3)(b)(1)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED 1/7/11 AND 4/1/10.

none Based on observation, record review and staff interview, structural components of the facility were not properly protected from fire. Issues include structural steel beams, located above the non-fire rated ceiling assembly, were not protected to meet minimum fire rated building construction type II (111) or type II (000). This affected one of one resident unit. This was widespread with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. The minimum acceptable construction type for this single story building is type II (000) per NFPA 101 Life Safety Code. Construction type II (000) requires the facility be fully sprinklered.

Observations in the facility on 2/3/12 from 8:15 AM until 11:45 AM revealed this building is not protected by a complete automatic sprinkler system. This facility is partially sprinklered only at select hazardous areas.

A review of historical records kept by the New York State Department of Health revealed the facility construction type is recorded as type II (111). This construction type requires that structural components (Beams, Columns, etc,) are protected with at least a one-hour fire resistive rating either by a physical one-hour fire rated protective covering on structural components or by maintaining a one-hour fire rated ceiling assembly.

Observations on 2/3/12 from approximately 12:30 PM until approximately 1:45 PM revealed the ceiling assembly located in the egress corridor and resident sleeping rooms consisted of lay-in ceiling tiles. These ceiling tiles were not clipped in place and the facility did not provide documentation of a one-hour fire resistive rated ceiling assembly. Observation made above the ceiling tiles at these same times revealed unprotected steel beams in several locations throughout the resident unit.

A Time Limited Waiver was applied for by this facility through a Plan of Correction from the Standard survey exit date 4/1/10. This Waiver was requested by the facility to extend their Plan of Correction date until 6/5/11 to consult an architect to formalize a plan to properly protect the steel beams, obtain bids, hire a contractor and perform the work to fully sprinkler this facility .

Observations in the facility on 2/3/12 from 8:15 AM until 11:45 AM revealed this building is not protected by a complete automatic sprinkler system.

An interview with the Corporate Director of Environmental Services on 2/3/12 at approximately 1:00 PM revealed the project should begin by 5/12.
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10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 2000 NFPA 101: 19.1.6.2, 19.1.6.3, 19.3.5.1
1999 NFPA 220: 3-2, Table 3-1

Based on record review of the Generator's Monthly Load tests, it was determined that the generator testing records did not adequately demonstrate monthly load tests were being conducted for at least 30-minutes (.5 hour) based on the recordings made from the generator's Hour Meter. This affected one of one resident unit. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. A review of facility records for the Monthly Load Tests of the Emergency backup generator on 2/3/12 revealed the facility records: Date of Test, Time of day the test was conducted and the Start and End Time of Load Test based on the Hour Meter on the Generator Unit. The testing was as follows for three months that did not meet the 30 minute (.5 hour) load test requirements.

- 3/25/11: (7:54 AM until 8:34 AM) Hour meter 47.5 to 47.9 (.4 hour)
- 4/29/11: (No time of day recorded) Hour meter 49.8 to 50.2 (.4 hour)
- 5/27/11: (7:13 AM; no end time recorded) Hour Meter 51.5 to 51.8 (.3 hour)

1999 NFPA 99; 3-4.4.1
1999 NFPA 110: 6.4.2
10 NYCRR 415.29(a)(2), 711.2(a)(1)