Rosewood Rehabilitation and Nursing Center

Based on medical record review and staff interview during the standard recertification survey the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, for one (Resident # 11) of three residents reviewed, the facility did not develop a care plan after a resident experienced an episode of suicidal ideation and was transferred to the emergency room for treatment. This caused no actual harm but has the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following information:

Resident # 11 :
The resident was admitted to the facility on 11/30/10 with a diagnosis of gout and diabetes mellitus. The Minimum Data Set ( MDS) assessed the resident had intact memory and no problems with decision making ability.

The nurse notes dated 12/31/10 documented the resident stated he was having thoughts of suicide and that he had these thoughts before.

The nurses note dated 1/1/11 at 12:30 am documented the resident stated he wasn't feeling right and he was more depressed than usual. The resident was sent to the emergency room for treatment.

The psychological interview by the psychologist dated 12/20/10 had documented interventions to use humor and to avoid giving orders to the resident.

The entire comprehensive care plan was reviewed and there was no documented interventions to address the situation or interventions mentioned by the psychologist

During interview on 2/3/11 at approximately 3:30 pm .The Registered Nurse Manager (RNM) stated she would develop a care plan. The RNM was shown the psychological interview and was not familiar with it. She stated she does not see every consult and she should. The RNM stated the interventions listed could help the resident.

10NYCRR415.11(c)(1)

Based on observation, staff interview and review of facility documents the facility did not establish and maintain an Infection Control Program designed to prevent the development and transmission of disease and spread of infection for one (# 35) of two residents reviewed during the standard recertification survey. Specifically, the facility did not ensure that the glucose meter (a machine used to measure blood sugar readings), that was being used for multiple residents, was disinfected between use on each resident. This resulted in no actual harm with the potential for than minimal harm that is not Immediate Jeopardy. This was evidenced by :

Resident #35:
The resident was admitted on 1/28/11 with a diagnosis of diabetes, chronic obstructive pulmonary disease, and a history of stroke. The Minimum Data Set (MDS) assessed the resident to have had no cognitive impairment.

The policy and procedure (P&P) for Finger Sticks, dated 5/2004, documented the equipment to be used for taking a finger stick, and for the Procedure portion of the P&P staff were directed to read the manual before using the glucometer.

The Blood Glucose Monitoring System (glucose meter) Owner's Manual, Version 1.0 dated 10/2008, and was the manual in use by the facility at the time of the recertification survey, documented that the glucometer was to be cleaned with tap water or a mild cleaning agent. Organic solvents (alcohol is an organic solvent) were not to be used.

On 2/4/11 at 4:34 pm, Licensed Practical Nurse (LPN) #1 was observed performing a finger stick blood sugar (FSBS) on resident #11. LPN#1 exited Resident #11's room with the glucose meter and returned it to the medication cart. LPN#1 then performed a FSBS on this resident (#35). The LPN did not disinfect the glucose meter prior to completing the FSBS.

During an interview with LPN#1 on 2/4/11 at 4:40 pm, she stated that she did not disinfect the glucose meter between residents, but that she usually did by wiping it with an alcohol swab.

During an interview on 2/4/11 at 5:15 pm, Registered Nurse Manager (RNM) #1, stated that she did not know how the glucose meters are disinfected or cleaned between resident use. She stated that she would expect the nurses to wipe the glucose meter with at least an alcohol wipe after each use, but that she would have to speak with the nurses to confirm what was being done. She stated that she did not have knowledge of the facility's practice on the cleaning or disinfecting of the glucometer.

During an interview the Infection Control Nurse on 2/4/11 at 5:30 pm, stated that the best practice for infection control and to prevent the spread of infection from resident to resident would be for the glucometer to be cleaned before and after each use with either an alcohol wipe or a germicidal wipe.

During an interview on 2/4/11 at 5:50 pm, with LPN #2, he stated that he wiped the glucometer off with an alcohol wipe between resident use and that he tried to do this on a consistent basis. LPN#2 stated that he used germicidal wipes if the glucometer came in contact with blood, otherwise he used alcohol wipes.

10 NYCRR 415 .19 (a) (b)

Based on medical record review and staff interview the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, for one (Resident#11) of 10 residents reviewed the facility did not have social service notes available for review. The resident experienced an episode of depression and suicidal ideation and required treatment in the emergency room. This caused no actual harm but has the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following information.

Resident #11
The resident was admitted to the facility on 11/30/10 with a diagnosis of gout and diabetes mellitus. The Minimum Data Set ( MDS) assessed the resident having intact memory and no problems with decision making ability.

The nurse notes dated 12/31/10 documented the resident stated he was having thoughts of suicide and that he had these thoughts before.

The nurses note dated 1/1/11 at 12:30 am documented the resident stated he wasn't feeling right and he was more depressed than usual. The resident was sent to the emergency room for treatment.

There were no social service notes in the medical record.

During interview the Social Worker (SW) stated on 2/3/11 at approximately 4:00 pm that she has had numerous meetings with the resident but she has not written any notes regarding the resident. The SW stated she is new in her position and was a little overwhelmed.

10NYCRR415.5(g)(1)

Based on medical record review and staff interview the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight during the standard recertification survey. Specifically, for one (Resident # 75 ) of ten residents reviewed the facility did not complete weekly weights as recommended by the dietician. This caused no actual harm but has the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following information:

Resident # 75 :
The resident was admitted on 9/22/08 with a diagnosis of congestive heart failure, asthma, and diabetes mellitus. The Minimum Data Set dated 11/25/10 assessed the resident had moderate cognitive impairment and usually was able to understand and be understood.

The nurse notes dated 12/10/10 documented the residents weight for December 2010 was 214.8 and a reweigh was done and documented the residents weight as 216. The note documented the resident had an increase in edema ( fluid retention). The edema was especially evident in the body trunk area.

The Vital Signs Sheet dated 2010 documented the residents weight for November 2010 as 206 pounds. The December weight was doumented as 214.8 pounds.

The physician orders dated 12/13/10 documented to refer the resident to dietary services for a 8 pound weight gain.

The dietary note dated 12/20/10 documented the resident was referred due to an 8 pound weight gain. A nursing assessment revealed an increase in edema. The note documented that weekly weights were recommended.

The medical record was reviewed and there were no weekly weights found.

During interview the Director of Nurses on 2/3/11 at approximately 3:00 pm stated she could not locate the weekly weights.

The resident was admitted to the hospital on 1/5/11 with diagnosis of pulmonary edema and pneumonia.

10NYCRR415.12(i)(1)

Based upon observation and interview, it was determined that the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on two of two residential units and common resident areas, during the standard recertification survey. Specifically, the facility did not maintain ceiling tiles and resident closet doors in good repair, ceiling tiles that were free from stains, filters in resident heater/air conditioning units that were clean, and wall areas that were free from damage or scrapes. This resulted in no actual harm with the potential for minimal harm that was not immediate jeopardy, and was evidenced, but not limited to the following:

I. Nine resident rooms were noted in which closet doors were observed partially open and would not remain closed. These doors did not hold shut in place and were not a result of the clothing contents within. Three examples are:

1. Resident 25
This room was inspected at 1:35 pm on 2/5/11. The closet door did not remain closed when checked and was observed with missing areas of laminate on the front and edge.

2. Residents 15 and 16
The closet doors within this room did not remain closed when checked on 2/5/11 at 1:35 pm.

3. Resident 67
The closet doors within this residents room did not remain closed when checked on 2/3/11 during the morning initial tour.

The Director of Maintenance was interviewed on 2/5/11 at 1:35 pm who stated that environmental rounds will be conducted for closets in residents rooms.

II. Stained or broken ceiling tiles were noted as follows:

1. The second floor dining was noted with numerous stained and broken ceiling tiles during the initial tour on the morning of 2/3/11.

2. Resident 69
The ceiling tiles were noted stained during the initial tour on the morning of 2/3/11.

3. Resident 45 and 46
A ceiling tile within the room of these residents was observed water stained, bulging, and several drops of water fell when the tile was moved. This was noted on the initial tour on the morning of 2/3/11.

4. All of the second floor day room ceiling tiles, including the metal grid, were stained on 2/3/11 at 8:25 am.

The Director of Maintenance was interviewed on 2/5/11 at 1:45 pm and indicated that ceiling tiles are being replaced.

III. Eleven resident rooms were found to have in-wall heater units with filters that had accumulations of dust. Three examples noted during initial tour on the morning of 2/3/11, are as follows:

1. Room of residents 42 and 43.
2. Room of residents 65 and 66.
3. Room of residents 57 and 58.

The Director of Housekeeping was interviewed on 2/4/11 at 9:38 am and stated that housekeeping is responsible for the outside of the heater unit and is not sure which department is responsible for maintaining the filters. The Director of Maintenance was interviewed at 9:42 (same day), and stated that the cleaning of the filters on the first floor had been started and that there is no preventative maintenance program in place for the filters.

IV. The handrail power door button support located at the entrance to the facility was found to be wobbly and not securely held in place on 2/5/11 at 1:15 pm. The Director of Maintenance was interviewed at this time and was not aware of the handrail.

V. The following two resident rooms were observed to have cloth material being used to minimize drafts.

1. The room of resident 69 was observed with linen material being used to stop drafts in the window during the initial tour on the morning of 2/3/11. A family member was interviewed at this time who indicates that the window has been like that for a long time.

2. The room of residents 57 and 58 was observed with toweling stuffed into a hole above the in-wall heater units on 2/3/11 at 8:30 am. When the toweling was removed, a cold draft was felt.

VI. Wall areas were noted in disrepair as follows:

1. The second floor dining room was observed with peeling wallpaper during the initial tour on the morning of 2/3/11.

2. The baseboard molding in the corridor between rooms 224 and 225 was separating from the wall when observed during the initial tour on the morning of 2/3/11.

3. The walls within the room of residents 42 and 43 were scuffed and scraped when observed during the initial tour on the morning of 2/3/11.

The Director of Maintenance was interviewed during a tour from 1:15 to 1:45 pm on 2/5/11 and acknowledged the wall areas.

10NYCRR 415.5(h)(2)