Nassau Extended Care Facility

Based on observations, record review, and resident and staff interviews the facility did not ensure that one of three residents who were reviewed for Dental Services and who were identified at risk, received timely dental services. Specifically, Resident #59 did not have a dental consult performed as ordered by the physician upon admission. The dental consult was performed more than six months after originally ordered, after the resident was downgraded from a regular diet, to a mechanical soft diet, then to puree diet and after the resident had a documented significant weight loss. This resulted in actual harm that is not immediate jeopardy.

The findings are:

Resident #59 has diagnoses including Rheumatoid Arthritis, Hypertension, Anemia and a history of Prostate Cancer.

The Resident Status Assessment dated 10/01/10 documented that the resident had cavities and was missing teeth.

The Admission Physician's orders dated 10/01/10 ordered a Dental Consult. The resident was placed on a Regular consistency No Added Salt (NAS) diet.

The Nutrition Assessment dated 10/04/10 documented that the resident's height was 75 inches, weight was 167 pounds with a Usual Body Weight (UBW) of 165-170 pounds. The resident was missing teeth and had no chewing difficulties identified. The resident feeds himself, had a good appetite and consumed 75% of Breakfast, Lunch and Dinner. The dietitian recommended a NO Concentrated Sweet (NCS)/No Added Salt (NAS) diet and Glucerna shakes 8 oz. daily.

A Dietary Order Form dated 10/6/10 documented to discontinue the current diet of NAS and to start a NCS/NAS diet and Glucerna shakes 8 oz. daily.

The Admission/14 day Minimum Data Set (MDS) 3.0 Assessment dated 10/11/10 documented that the resident's Brief Interview for Mental Status (BIMS) score was 12 (indicating moderately impaired decision making). The resident's weight was 167 pounds. Section L - Oral/Dental Status did not identify any problems.

A Dietitian progress note dated 11/19/10 documented that the resident was observed with difficulty chewing solid foods, and the Dietitian recommended downgrading the resident's diet to mechanical soft, NCS/NAS diet. The Dietitian documented that she would monitor tolerance, acceptance and follow up as necessary.

The MDS 3.0 Assessment dated 11/20/10 documented a BIMS of 14 (indicating that the resident was cognitively intact), limited assistance of one person for eating, the resident's height was 75 inches and the resident's weight was 161 pounds.

A Dietary Order Form dated 12/01/10 documented to discontinue the current diet and to start a NCS/NAS mechanical soft diet. The reason for the change documented, "requesting soft foods secondary to difficulty chewing solid foods."

A physician's order dated 12/01/10 (twelve days after the dietitians recommendation dated 11/19/10), documented to discontinue the current diet and start a NCS/NAS mechanical soft diet.

The quarterly Nutrition review dated 12/14/10 documented that the resident's weight was 165.8 pounds, no swallowing or chewing issues, and recommended to increase Glucerna shakes 8 oz. to twice a day because the resident's weight was stable at the lower end of the UBW range.

A physician's order dated 2/02/11 documented to send the resident to the hospital secondary to Shortness of Breath, Severe Anemia, and to Rule Out a Gastrointestinal Bleed. The resident returned to the facility on 2/07/11.

The physician's readmission evaluation dated 2/07/11 documented that the resident was admitted to the hospital for Severe Anemia and received a transfusion of blood.

The Nutrition Assessment dated 2/08/11 identified poor dentition and documented that the resident weighed 153.8 pounds, which indicated a significant weight loss. The Dietitian identified chewing problems and missing teeth. The recommendations included to increase Glucerna 8 oz. to three times a day.

A Dietary Order Form dated 2/08/11 documented to discontinue Glucerna 8 oz. twice a day and to start Glucerna 8 oz. three times a day to promote weight maintenance.

An interview was held on 3/02/11 at 10:09 AM with Resident # 59. The resident stated that he has chewing problems, that he has not seen a Dentist while residing in the facility. The resident stated that he needed to see a Dentist. The resident stated, "I need teeth". Visual observation of the resident's mouth revealed that he was missing some upper and lower teeth.

A nutrition progress note dated 3/02/11 at 1:25 PM documented that the resident weighed 145 pounds, an approximately eight pound (5.2%) weight loss since re-admission. The resident's intake was observed as fair to poor. The resident complained of difficulty chewing solid foods due to missing teeth, and stated he had a partial denture but has no idea where it is. The Dietitian spoke to the CNA and the CNA stated that she had never seen one (partial denture). The Dietitian requested a Dental Consult and recommended to downgrade the resident's diet to puree NCS/NAS. The Dietitian documented that she will monitor the resident and have weekly weights obtained.

A Dietary Order Form dated 3/02/11 documented to discontinue the current diet and start NCS/NAS/ puree diet due to multiple missing teeth. The Dietitian documented a request for a Dental Consult and puree diet for better tolerance, and identified weight loss.

A physician's order dated 3/02/11 requested a Dental Consult.

An interview with the LPN charge nurse on 3/07/11 at 9:15 AM revealed that the admission physician's orders dated 10/01/10 requested a Dental Consult. This LPN was the nurse who signed the physician's orders on 10/01/10. The LPN stated that she filled out the other consults requested by the physician however she must have forgotten and did not fill out the Dental Consult as the Dental Consult could not be found. The facility's procedure regarding Consults is as follows: when a consult is ordered the nurse who picks up the orders fills out the requested consult form and gives the form to the unit secretary. The unit secretary logs the consult into the unit's consult log then brings the consult form downstairs and places the form in a folder labeled for the consultant which is located in a mailbox near the receptionist desk. The consultant picks up the consult then sees the resident. The consult is then given back to the floor nurse and placed in the physician's box on the nursing unit for review. After the physician reviews the consult the consult is placed in the resident's medical record.

Review of the consult log book on 3/07/11 revealed no dental consult was filled out for Resident #59 upon admission. The LPN stated that the Dentist comes to the facility every Wednesday and that the resident will be seen by the Dentist this Wednesday 3/09/11.

An interview with the resident's regular 7 AM -3 PM shift Certified Nursing Assistant (CNA) on 3/07/11 at 9:40 AM revealed that Resident #59 requires assistance with feeding. The resident tries to feed himself but needs help. The resident has refused food in the past and was offered alternates, usually sandwiches. The CNA stated that the resident had complained of difficulty chewing in the past. The CNA stated that she did report resident's chewing difficulty awhile ago, that's why dietary changed his diet to mechanical soft. The CNA stated that she does not remember exactly who she told but dietary knew about it because they changed his diet. The CNA stated that the resident has both upper and lower teeth with some missing upper and lower teeth. The CNA stated that the resident did not come into the facility with any Dentures or partial plates. The CNA stated that the resident's diet was recently downgraded to puree.

An interview with Registered Dietitian (RD) on 3/07/11 at 9:45 AM revealed that she was not aware that the resident had not been seen by the dentist since admission in October 2010. The RD stated that the resident's Admission weight was 167 pounds on 10/04/10, and that the resident weighs 145 pounds as of March 2, 2011. The RD spoke to the resident on 3/02/11 and documented that the resident agreed to try a pureed diet because the resident was having difficulty chewing mechanical soft food. The RD stated prior to 3/2/11 she not know the resident was having problems with the mechanical soft diet, and she did not know the resident lost more weight since readmission on 2/07/11 when the resident weighed 153.8 pounds.

An interview with the the resident on 3/07/11 at 10:48 AM revealed that the resident is receiving a pureed diet now and likes it, the resident stated that it (pureed food) is better for him.

An interview with the physician on 3/07/11 at 12:38 PM revealed that the resident has a diagnosis of Prostate Cancer which could account for some of the weight loss. The MD stated that she did order a Dental Consult for the resident when first admitted and that the Dental Consult should have been performed by now. The MD stated that she was not aware that the resident had lost weight, that today was the first time she was made aware of the significant weight loss and that the resident had not been seen by the Dentist since admission 10/01/10.

Further interview with the physician on 3/07/11 at 1:05 PM revealed that the physician had reviewed the medical record and stated that although the dietitian had documented that the resident was having difficulty with chewing, she (the physician) was not made aware. The physician stated that the resident lost some weight from October 2010 through January 2011 but upon return to the facility in February 2011 the resident had lost a significant amount of weight. The physician further stated that when the resident was re-admitted in February 2011 she did not have the admission weight of 153 pounds available to her, that if she did she would have placed the resident on weekly weights. The physician stated that she did not order a Dental consult in February 2011 because she did not know that the resident was having difficulty chewing. Additionally, the physician stated that Dental consults are ordered upon initial admission and thereafter if the resident was having a dental problem. The physician stated that the resident would not routinely have a dental consult ordered upon readmission and that she was not aware that the resident was having a problem with chewing until today.

Interview with the Director of Nursing Services (DNS) on 3/08/11 at 2:35 PM revealed that the resident was seen by the Dentist today and that the Dentist stated that today was the first time he saw the resident. The Dental consult dated 3/8/11 documented that the oral exam was within normal limits and that Partial Upper/Partial Lower dentures were recommended.

415.17(a-d)

Based on observation, and staff interview during the annual survey, the facility did not ensure that 1) Acetaminophen suppositories were properly stored on 1 of 7 nursing units and 2) that medications intended to be in a locked cabinet were not locked in the cabinet on one of seven nursing units. This resulted in no actual harm with the potential for more than minimal harm.

The findings are:

1) During the initial tour of the facility on 2/28/11, it was observed that the medication refrigerator was at a temperature of 46 degrees Fahrenheit (F) at 9:15 AM on the 5th floor nursing Unit with one packet containing 8 Acetaminophen Suppositories. The manufacturer documented to store the suppositories at room temperature between 59 degrees (F) and 86 degrees (F).

The Licensed Practical Nurse (LPN) medication nurse on North unit was immediately interviewed at the time of the observation. The LPN stated that she was not aware that Acetaminophen suppositories should not be stored in the refrigerator. She checked with administration and immediately removed the suppositories from the refrigerator.

2) During tour of the facility on 2/28/11 at 9:05 AM on the 4 South nursing unit the medication cabinet and the medication refrigerator behind the nursing station were observed to be unlocked. The cabinet contained stock medication which included but was not limited to : Acetaminophen, Citromax, Gerri Tuss DM 16 oz (ounces), Antacid/Antigas 12 oz, Maalox 12 oz, and a tube of wound gel.
The refrigerator contained one vial of resident specific Lantus Insulin which was open and undated, one vial of stock Tuberculin which was open and undated and one vial of stock Fluaval which was open and undated.

The Licensed Practical Nurse Charge Nurse was interviewed on 2/28/11 at 9:20 AM and stated that the lock on the cabinet had been repaired a number of times and that when locked it becomes stuck. The LPN stated the cabinet should be locked. The LPN also stated that the pharmacy consultant had just been on the unit last week and had noted all the medication in the medication refrigerator that was open had been dated. The LPN further stated that the medication vials should be dated when opened.

The facility policy and procedure Titled Storage Medications last reviewed June, 2002 did not address dating of medication.

415.18(d)

Based on review of facility documentation and staff interviews during the recertification survey, the facility did not ensure that submission and receipt of a Criminal History Record Check (CHRC) was completed for 3 of 8 newly hired staff required to undergo a CHRC screening. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During review of the facility's newly hired staff for CHRC compliance, there were no New York State Department of Health results forms for three of seven Certified Nursing Assistants (CNAs), all with a date of hire documented as 2/8/11.

During an interview with the Administrator on 3/4/11 at 7:50 AM, she stated that the CHRC submissions for the three employees were not done and that her administrative assistant, is the Authorized Person and should have completed the 102, 103 and fingerprint appointment .

The Administrative Assistant was interviewed on 3/7/11 at 4:20 PM and stated that she was responsible for obtaining the forms 102, 103 and following up on appointments for fingerprinting for the newly hired staff. The Administrative Assistant further stated that the three newly hired staff fell thru the cracks and that it was difficult to keep up with staffing because the facility utilizes so many agency personal.

The facility Policy and Procedure titled Background Screening of Employees dated 7/5/07 and last reviewed 2/1/09 documented under Criminal History Record Check that CHRC will be conducted and is required of any person to be employed or used by the facility to provide direct care or supervision to the residents.

Based on record review and staff interviews during the recertification survey the facility did not ensure that one of twenty six stage II sampled residents had Individualized Comprehensive Care Plans (CCP) developed to address their specific needs. Specifically, Resident #323 was admitted to the facility from the Hospital on a Nicoderm Patch. The resident was identified as using tobacco products at least daily, however no Comprehensive Care Plan (CCP) was developed upon admission or after a cigarette was found in the resident's room. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #323, with diagnosis including Right Occipital Hemorrhage and Hypertension, was admitted to the facility on 9/09/10.

The Admission Minimum Data Set 2.0 (MDS) Assessment dated 9/19/10 documented that the resident exhibited customary routine use of tobacco products at least daily. The resident exhibited no short or long term memory problems and was independent regarding daily decision making skills.

The Medication Administration Record (MAR) from the hospital dated 9/3/11 documented a physician's order for Nicotine Patch 14 milligrams (mg) topical times (x) fourteen days then decrease to 7 mg patch for two weeks then discontinue (D/C).

The admission physician orders dated 9/9/10 ordered a Nicoderm Patch 14 mg one patch daily. The Nicoderm Patch 14 mg, one patch daily, was ordered each month on the physician's order form until 2/21/11. On 2/21/11 the physician discontinued the 14 mg Patch.

A nurse's note dated 1/16/11 documented that the nurse received a call from the social worker to search the resident's drawer regarding the possibility of the resident having a cigarette in a drawer. A room search was done and one cigarette was found in the resident's drawer. The cigarette was removed by the nurse.

An interview was held on 3/8/11 at 11:20 AM with the LPN charge nurse. The LPN stated that the resident was admitted to the facility on 9/9/10 and was placed on Nicoderm patch 14 mg topical patch due to history of smoking. The resident was discontinued from the Nicoderm 14 gram Patch on 2/21/11. The LPN stated that she received a call from the Social Worker to check the resident's room for cigarettes because a family member called the facility, spoke to the Social Worker (SW), and reported seeing a cigarette in the resident's room. The LPN searched the resident's room and found a cigarette on the bedside table which the LPN removed. The Comprehensive Care Plan (CCP) was reviewed with the LPN. No CCP was developed for smoking. The LPN stated that she would have expected a CCP related to smoking developed for this resident after the cigarette was found in the resident's room.

An interview with the SW on 3/8/11 at 11:39 AM revealed that the resident's wife called her and reported that she (the wife) saw a cigarette in the resident's drawer then called the facility. The Social Worker stated that the resident does not smoke and that she was unaware of the resident's history of smoking. The SW stated that she called the nursing floor. The resident's room was searched, and a cigarette was removed. The SW stated that the recreation department is responsible for completing a smoking assessment and that she would expect a smoking assessment and CCP to have been developed after identifying a cigarette in the resident's room.

An interview was held on 3/08/11 at 12:15 PM with the Director of Recreation. The Recreation Director stated that the Recreation Department is responsible to perform a smoking assessment on all residents who are smokers. The Recreation Director stated that neither he nor the Recreation Supervisor who evaluated the resident upon admission were aware that the resident was on a Nicoderm Patch upon admission and if he had known a smoking assessment would have been done. The Recreation Director stated that he was not aware of the cigarette found in the resident's room on 1/13/11 and if he had been made aware he would have had the Recreation Supervisor complete a smoking assessment and develop a CCP for smoking.

An interview was held with the physician on 3/08/11 at 1:30 PM. The physician stated that the resident was on a 14 milligram (mg) Nicoderm Patch from the hospital and that the physician discontinued the Nicoderm patch on 2/21/11 because he felt the patch was not necessary. The physician stated that the resident has not exhibited a desire to smoke therefore the patch was discontinued.

415.11(c)(1)

Based on observations, staff interview and review of facility policy and procedure. The facility did not ensure that infection control procedures were followed to prevent the development and transmission of disease for two of four residents observed to have blood glucose monitoring during the medication pass. Specifically , the Licensed Practical Nurse (LPN) did not disinfect the glucose meter ( a device used to measure blood glucose (sugar) readings) between two residents. (Resident #184 and Resident #36). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #184 has diagnosis of Diabetes Mellitus, Renal Insufficiency and Macular Degeneration.

Resident #36 has diagnosis which include diabetes Mellitus , Multiple Sclerosis, Pulmonary Fibrosis and Thrombocytopenia.

During observation of medication pass on 3/1/11 at 4:50 PM on the 4 North unit the LPN medication nurse was observed to wash her hands, don gloves and prepare to monitor Resident #184 blood glucose. When the LPN completed the fingerstick monitoring for Resident #184 she proceeded to wash her hands don clean gloves and prepare to monitor Resident #36 blood glucose. The LPN medication nurse did not disinfect the glucometer between Resident #184 and Resident #36.

The LPN medication nurse was interviewed on 3/1/11 at 5:10 PM and stated that the facility provides disinfectant wipes and she should have disinfected the glucometer between Residents #184 and #36.

The Registered Nurse (RN) supervisor for the 4th floor nursing units was interviewed on 3/8/11 at 10;15 AM and stated that the glucometer should be cleaned between each resident and that the facility had provided and inservice approximately 5-6 months prior to inservice the nursing staff on the cleansing of the glucometer.

The policy and procedure titled Glucometer Cleaning dated January 2011 documented that Glucometers will be cleaned with a germicidal wipe after each resident use to prevent the spread of infection from blood born pathogens as per the CDC (Center for Disease Control ) guidelines.

415.19(a)(1-3)

Based on observation and staff interview, during the recertification survey, it was determined that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, on 3 of 7 nursing units toured syringes were noted to be left unlocked on the counter behind the nursing station.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During tour of the facility on 2/28/2011 between 9:00 AM and 10:20 AM the following was observed:

1) On the 4 South nursing unit 8 boxes of insulin syringes and 9 boxes of lancets were observed to be in an unlocked cabinet behind the nursing station at 9:05 AM.

The Licensed Practical Nurse Charge Nurse was interviewed on 2/28/11 at 9:20 AM and stated that the lock on the cabinet had been repaired a number of times and that when locked it becomes stuck. The LPN stated the cabinet should be locked.

2) On the 4 North nursing unit on 2/28/11 at 9:45 AM 2 boxes of insulin syringes were observed to be on the counter behind the nursing desk.

The Licensed practical Nurse Charge Nurse was interviewed on 2/28/11 at 9:46 AM and stated that the syringes belong up there pointing to the medication cabinet.

3) On the 2 North nursing unit on 2/28/11 at 9:55 AM 3 individual packaged insulin syringes and 2 boxes of insulin syringes were observed to be on the counter behind the nursing desk. Staff were observed in the area.

The Licensed Practical Nurse Charge Nurse was interviewed on 2/28/11 at 10:00 AM and stated that the syringes should not be left out and should be in the locked cabinet.

The Director of Nursing Service was interviewed on 3/8/2011 at 12:45 PM and stated that the syringes should not be left on the counter and should be stored in a locked cabinet.

The Storage of Medication policy and procedure last reviewed June 2002 documented under procedure 1. f. All medications including treatment items are stored in a locked cabinet or room inaccessible to residents and visitors .

415.12(h)(l)

Based on record review, and staff interviews during the standard survey, the facility did not provide the effective necessary social services for discharge planning for 1 of 2 residents reviewed for Community discharge. Specifically, there was no implementation of discharge planning services for Resident # 339 when Rehabilitation Services were completed and the resident no longer required skilled care. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #339 was admitted to the facility on 10/29/10 for short term rehabilitation with diagnoses which include Status Post Motor Vehicle Accident, History of Substance Abuse and Hypertension.

The admission Minimum Data Set (MDS) Assessment, dated 11/8/10 and 2/7/11, documented that there is no active discharge plan in place and that there was no determination made by the resident and Comprehensive Care Plan (CCP) team regarding discharge to the community. The MDS also documented that there has been no referral made to a contact agency in the community. The MDS documented that there was no active discharge plan for the resident to return to the community. The MDS also documented that there has been no determination made by the CCP team regarding discharge and that there is no active plan in place.

A CCP dated 11/4/10 documented that the goal was for the resident to be discharged when functionally stable with an adequate discharge plan through next review. The documented interventions were : inform the resident of the right to receive services in the least restrictive setting, inquire about the resident interest in talking to a local agency about returning to the community, involve family in discharge planning. The social worker documented on 2/16/11 that the resident remains uncertain about discharge plans.

An Occupational Therapy Discharge Summary (OTDS) dated 12/6/10 documented that the resident was receiving Occupational Therapy (OT) 5 times a week from 10/29/10 - 12/6/10 and that he was moderate to maximum assist with activities of daily living (ADL) on 10/29/10. On 12/6/10 the OT documented that the resident was completely independent and that OT was discontinued as resident reached his maximum potential.

A Physical Therapy Discharge Summary (PTDS) dated 12/7/10 documented that the resident was receiving restorative PT 5 times a week from 10/29/10 -12/7/10. The PTDS also documented that on 10/29/10 the resident needed maximum assistance with ADL care. The PTDS discharge note documented on 12/7/10 that the resident was independent, was able to walk up two flights of stair and that he was independent with ambulation, all goals met.

A Quarterly Social Work (SW) Assessment Note, dated 2/10/11, documented that the resident is a short term stay and that the resident would like to plan for a discharge to the community in April. The assessment also documented that the resident has an apartment in the community in which he will go to and has a support system in the community.

There was no documented evidence that the facility provided medically-related social services or did a comprehensive assessment of the resident for discharge to the community from 12/7/10 until 3/8/11 after completion of Rehabilitation and skilled services were no longer required.

An interview was held with Licensed Practical Nurse (LPN) Charge Nurse at 12:30 PM on 3/3/11. The LPN stated she believed that the resident is going home sometime in April but that she does not know the specific date.

An interview was held with the SW on 3/3/11 at 1:00 PM. The SW stated that the resident is waiting for money from a law suit and does not wish to return to the community until the lawsuit is settled "sometime in April" and does have an apartment in the community. The SW also stated that after the resident was discontinued from PT/OT the resident was independent in activities of daily living and ambulation. The SW also stated that she has not tried to plan a discharge after rehab was completed even though the resident no longer needed skilled care and that the resident has family in the community but that she did not explore the option of a discharge home with family or any other option.

An interview with the Director of SW on 3/8/11 at 12:00 PM. The Director of SW also stated that there is no documented evidence in the medical record that the facility tried to find alternate placement for the resident when rehab was completed and no longer needed skilled care. The SW also stated that she was aware that the resident goes out on pass with family from during the day and sometimes does not return until 12:00 midnight.

415.5(g)(1)(i-xv)

Based on record review and staff and resident interviews during the recertification survey, the facility did not ensure that all residents received the necessary care and services to maintain their highest practicable physical, mental and psychosocial well-being in accordance with their Comprehensive Assessment and Plan of Care. This was evident for 2 residents reviewed for Pain in a total of 70 sampled residents. Specifically, 1) Resident #279 was receiving pain medication, as needed (PRN), without adequate relief from the pain which effected the resident's emotional well being and without documented reassessments of the effectiveness of the medication. 2) Resident #361 was administered multiple doses of pain medication, as needed (PRN) without documented reassessments of the effectiveness of the medication.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #279 was admitted to the facility on 9/7/10 for short term rehabilitation with diagnoses of S/P Femoral Bypass, Degenerative Joint Disease and Chronic Back Pain.

A facility admission Pain Assessment dated 9/7/10 documented that the resident, on interview, stated that he had groin pain daily. The assessment did not include documented information regarding the resident's history of pain, medication effectiveness or level of pain.

The Admission Social Services (SW) Assessment dated 9/7/10 documented that the resident was pleasant, cooperative and motivated. The Assessment further documented that the resident had no history of substance abuse, was cognitively intact, and had no short or long term memory problems. The SW documented that the resident had no behavior problems and good discharge potential.

A Physician's Order dated 9/7/10 documented that the resident was to receive Percocet 5/325 milligrams (mg)-1 tablet every four hours as necessary (PRN) for Pain.

Monthly Physician's Progress Notes dated 9/7/10 through 2/24/11 documented that the resident was on Pain Management with Percocet. There was no documented evidence on the Physician's Progress Notes addressing the effectiveness of the pain medication.

The Comprehensive Care Plan (CCP) dated 9/15/10 documented that the resident was at risk for Pain secondary to Severe Degenerative Changes of the Thoracic-Lumbar Spine. Interventions included to: 1) assess for symptoms of pain, 2) report to MD if no relief, 3) provide opportunity to vent feelings,4) reassure and support resident, and 5) involve in activities.

Review of the Medication Administration Records (MAR) dated 9/7/10 through 9/15/10 documented that the resident had received 12 doses of the medication for the complaint of pain. There was no documented evidence on the MAR or in the medical record addressing the resident's level of pain before the administration of the pain medication or its effectiveness following administration.

The Physician's order dated 10/25/10 documented an order which increased the Percocet 5/325 mg to 2 tabs by mouth every four hours PRN. A review of the MAR dated 10/25/10-11/3/10 documented 22 doses of the Percocet administered with no documented pain levels prior to the administration and 20 doses without documented levels of effectiveness.

The Physician renewed the order for Percocet 5/325 mg-2 tabs by mouth every four hours, as needed 11/4/10 through 11/27/10. The MAR documented 51 doses of the Percocet administered without 50 documented levels of pain prior to the administration of the pain medication or following the administration of the pain medication.

The Minimum Data Set (MDS) Quarterly Review Assessment dated 12/13/10 documented that the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognitive skills with no memory problems or communication problems. The MDS further documented that there were no behavior or mood indicators. The MDS documented that the resident was independent in all Activities of Daily Living and required supervision and set up in dressing, eating,and bathing. The MDS also documented that the resident had received PRN Pain Medication in the last five days with a pain score on interview of 0.

The MAR dated 12/2/10 through 12/27/10 documented 38 doses of pain medication administered to the resident PRN with no documented level of pain or effectiveness of the medication for 29 doses.

A CCP dated 12/8/10 and titled Suicidal Ideation documented that the resident is alert and oriented, able to make his needs known. The CCP further stated that the resident felt there was no reason to continue living. Potential for the Depression did not include the Chronic Pain as documented in the resident's medical history 9/7/10.

During the resident interview on 3/1/11 at 11:35 AM, the resident stated that he had been "very depressed and disgusted" when he had voiced the suicide threat because of the pain and the slow progress that he was experiencing in his physical condition. The resident stated that he was residing on another unit (2S) at that time. The nursing staff were insensitive to his pain needs and certain nurses had made him wait for the medication. The resident stated that he was now on a different unit and he was not experiencing the same type of nurses. The resident stated that he still has back pain, but he is given the pain medication when he asks for it.

The facility Quarterly Pain Assessment dated 12/20/10 did not completely document the resident interview for the assessment and was incomplete for history of pain, trend and effect on daily living, as well as, pain symptoms and effectiveness.

The MARs dated 12/31/10 through 1/23/11 documented 17 doses of Percocet given per the physician's orders. There was no documented pain levels prior to the administration of the pain medication or level of effectiveness.

The CCP for Psychosocial Strength dated 12/13/10 documented that the resident had intact cognition with no behavioral symptoms. There was no documented evidence in the CCP that included the resident's history of Chronic Pain or identified the pain as a potential for psychosocial decline.

The CCP for Pain updated 12/10/10 did not include documentation of the residents pain medication regime, effectiveness of medication or reassessment of the plan of care.

The Psychosocial CCP dated 12/13/10 did not document the resident's history of chronic back pain with relation to the resident's psychosocial needs and behaviors.

A Nursing Progress Note dated 2/12/11 at 4:00 AM documented that the resident was ". . .demanding meds three times before time and abusive to staff. . .". The note documented that the Social Worker would be notified regarding the resident's behavior. There was no documented evidence in the resident's medical record that the SW interviewed the resident regarding the behavior related to the administration of the pain medication.

The resident was interviewed on 3/1/11 at 11:35 AM. The resident stated that he receives pain medication, Percocet 2 tabs every 4 hours as needed. The resident stated that he would ask every four hours for the medication and the nurses do not ask if it was effective and rarely ask the pain level. The resident further stated that when the pain medication was given on time, he reported to the medication nurse and the doctor that it was not effective. The resident stated that his pain is at a (scale rating of 1- no pain to 10- most pain) 9 when unrelieved and goes down to about 6 after medication. The resident stated that the nurses have discussed a Pain Management Consultation for him but he is unaware of when this will happen. The resident further stated that no non pharmacy interventions have been offered. The resident stated that he has a Diagnosis of Chronic Pain because of his spine injury. The resident went on to state that when he was on the other Unit, there were times when the nurses would make him wait for the pain medication and he would get frustrated. He stated that he reported pain at night and was told it was too soon, the Tylenol was usually never offered. The resident stated that he reported to the nurses that Tylenol did not really help, but nothing was ever done about it. During the interview the resident described an incident when he was on the 2S Unit. The resident stated that he had requested pain medication from the night nurse and was told that there wasn't any more. The resident stated that he called the security guard who notified the night Supervisor and the medication was brought to the unit. The resident stated that once he was moved to the new unit and was no longer on the 2S unit, the nursing staff were much more professional and he was satisfied with the interventions that were being attempted for better pain management.

The resident's Physician was interviewed on 3/4/11 at 1:00 PM. The physician stated that the resident was newly assigned to the physician on the unit and was currently unable to comment on the residents condition. A Pain Management Consultation was ordered during the time of survey.

During interview with the Registered Nurse (RN) Supervisor on 3/7/11 at 10:00 AM, the RN stated that before administering PRN pain medication, the nurse should assess the level of pain and assess again following the administration of the pain medication. This is usually documented on the back of the MAR. The RN stated that the facility Pain Assessment Criteria included that the resident will be assessed for Pain Management, by a Licensed Nurse on admission, quarterly and/or if the resident had a significant change and PRN when pain is suspected.

The facility's Pain Assessment Criteria documented that the resident will be assessed for Pain Management, by a Licensed Nurse on admission, quarterly and/or if the resident has significant change and PRN when pain is suspected.

The LPN/Med Nurse was interviewed on 3/7/11 at 10:15 AM and stated that the system at the time of the administration of the PRN medication on 2S included a Pain Assessment sheet which was kept with the MAR.

The LPN/Charge Nurse was interviewed on 2S at 10:45 AM, and stated that any of those sheets would have been sent with the resident's chart. The LPN further stated that the resident had a history of substance abuse and that is why he was always asking for pain medication.

The Director of Nursing Services (DNS) was interviewed on 3/7/11 at 1:00 PM and stated that pain assessment sheets should have been available in the chart. During a subsequent interview with the DNS on 3/7/11 at 3:30 PM she stated that there were no pain assessment sheets available for the resident and could not explain why there was no pain assessment documentation. The DNS stated that she would be investigating the problems with this resident's pain administration and assessments.

2) Resident #361 has diagnoses which include Lung Cancer
Gout, Hypertension and Chronic Obstructive Pulmonary Disease.

During an interview with Resident #361 on 3/01/11 during the day shift, the resident was observed to readjust his seating in his wheelchair, while he maneuvered himself the resident was observed to grimace, clench the arm of the wheelchair tightly and tighten his torso as he adjusted. When asked if he was in pain the resident stated that he would be fine once he was adjusted in the seat. When asked if he wanted to see the nurse he stated no.

The Admission Minimum Data Set (MDS) Assessment dated 2/18/11 documented that Resident #361 had a BIMS (Brief Interview for Mental Status) score of 12 indicating the resident was moderately impaired. The MDS also documented that the resident had mild depression, could understand and be understood.

The Physician's Orders dated 2/16/11 documented an order for Roxicodone IR 5 mg (milligrams) by mouth every 8 hours for pain prn (when necessary) and Tylenol (non-opiate analgesic) 650 mg every 6 hours PRN for complaints of pain.

A CCP dated 2/16/11 titled Cancer documented that Resident #361's had lung cancer and problems included at risk for: Weakness, pain, tiredness,weight loss, and depression from the cancer process. Interventions included but were not limited to: Assess for fatigue, pain; and Monitor for pain using pain scale.

A CCP dated 2/24/11 titled Pain documented that Resident #361 was at risk for pain secondary to lung cancer and gout. The CCP documented that the resident's strength included that he was able to communicate discomfort. Interventions documented on the CCP included but were not limited to: Assess symptoms of pain; provide pain meds (medication) as prescribed; and Monitor for adverse effects of meds.

The Medication Administration Record (MAR) dated 2/16/11 through 3/2/11 documented that a total of six doses of Tylenol PRN were administered, 2/18/11,2/21/11, 2/22/11, 2/23/11, 2/24/11 and 2/25/11. The back of the MAR did not document the results of the effectiveness of the Tylenol that was administered.

A review of the Nurse's Notes for 2/16/11 through 3/1/11 revealed no documentation that Tylenol PRN was given to the resident.

A facility Pain Assessment Form with instructions for Assessment to be completed on; admission, readmission, quarterly and with significant change documented on 2/16/11, 2/23/11, 2/25/11 and 3/1/11 under Assessment #1 with directions that included "using the numeric or verbal descriptor scale rate your worst pain over the last 5 days. Enter number or verbal response. If unable to answer enter unable. All 4 dates documented that Resident #361 voiced no complaints but that on 2/23/11, 2/25/11 and 3/1/11 that the resident answered yes to the question "does the current pain medication relieve the pain".

The Registered Nurse Nurse Manger for the 2 south unit where Resident #361 resides was interviewed on 3/8/11 at 10:20 AM and acknowledged that the back of the MAR for Resident #361 was not completed as required. She further stated that this was an area that they were falling short on.

The Director of Nursing Service (DNS) was interviewed on 3/8/11 at 12:40 PM and stated that the nurse who administered the medication should have documented the information either on the back of the MAR or on the pain scale form.

During a telephone interview on 3/8/11 at 2:20 PM with the 3:00 PM -11 PM Licensed Practical Nurse (LPN) who had administered a few doses of Tylenol to Resident #361 the LPN stated she would have to review the resident's medial record to determine if he was on a standing dose of Tylenol. She further stated that she could not recall if the resident had a pain level chart.

The facility's Pain Assessment and Management policy and procedure dated September 2009 and last reviewed February 2011, documented under #4 Pain Management flow sheet will be filled out by a Licensed Nurse. A Pain Management Flow Sheet is used to document and evaluate the regime for all residents on medication for pain.

415.12

Based on record review and staff interviews during the recertification survey, the facility did not ensure that all residents were provided with interventions to maintain documented declines of acceptable parameters of nutritional status. This was evident for one of one resident reviewed for Nutrition. Specifically, Resident #64 had a documented significant weight loss without a reweigh being done. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #64 has diagnosis which include Bowel Obstruction,Status Post Cholecystectomy with Hernia repair, Hypertension, Osteoarthritis, Rheumatoid Arthritis and Diabetes.

The Minimum Data Set (MDS) Assessment 1/13/11 dated documented that the resident had a BIMS Score of 12 indicating the resident was moderately impaired. The MDS also documented that Resident #64 understands and can be understood.

Review of the weight record for Resident #64 documented the residents weight in August 2010 was 187 lbs the next weight documented on the weight record was in October/2010 documenting that the resident weighed 162.8. The current weight in March/2011 was documented as 164 lbs.

Review of the Dietary Progress Notes dated 9/16/10 documented the resident's BMI as 26.6 and that her usual body weight was 187-193 pounds. The Dietician documented that the resident presented with a significant weight loss of 11.8% in 30 days. The Dietician further documented that the weight loss was unfavorable and un-planned. Resident #64s' weight was documented as 74.9 kilograms (164.78 lbs 9 pounds). The Dietician recommendations included ; nutritional supplement, extra nourishment in the form of dietary shakes, weekly weights X 4 weeks, to meet with resident to speak about favorite foods, and a 3 day calorie count. The dietician did not recommend a reweigh to ensure if the weight obtained was accurate.

During an interview with the Dietician on 3/7/2011 at 12:10 PM she stated that there should have been a repeat weight done to check the accuracy of the weight change. The Dietician further stated she had started the resident on a 3 day calorie count but the resident became ill and was transported to the hospital.

During an interview with the Director of Nursing (DNS) on 3/8/11 at 12:40 PM she stated that the Certified Nursing Assistant (CNA) that obtains the residents weight is responsible for reporting to the nurse a weight change. The DNS further stated that the nurse would report the weight change to the dietician and the dietician would recommend if the resident required a reweigh.

The facility policy and procedure titled Weight Change date 11/11/04 and last reviewed 11/8/2000 documented under Procedure #5. Whenever an unintended change in weight is identified (+/- 3 lbs) or +/- 5 lbs over 100 lbs) Nursing /Dietician must do the following:
a. resident must be reweigh within 24-48 hours.

415.12(i)(l)

Based on observations, record review, resident and staff interviews the facility did not ensure that two of twenty six resident's Comprehensive Care Plans (CCP) were implemented in a timely manner. Resident # 59 had a Dental CCP developed, however interventions were not followed; specifically, a Dental Consult was not performed per physician's order. Resident #339 had a discharge CCP developed however there was no implementation of discharge planning services when Rehabilitation Services were completed and the resident no longer required skilled care. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #59 has diagnoses including Rheumatoid Arthritis, Hypertension, Anemia and a history of Prostate Cancer.

The Admission/14 day Minimum Data Set (MDS) 3.0 Assessment dated 10/11/10 documented that the resident's Brief Interview for Mental Status (BIMS) score was 12. A BIMS score of 12 indicated that the resident the resident had moderately impaired cognition. Section L - Oral/Dental Status did not identify any problems.

The Resident Status Assessment dated 10/01/10 documented that the resident had cavities and was missing teeth.

The Admission Physician's orders dated 10/01/10 ordered a Dental Consult. The resident was placed on a Regular consistency No Added Salt (NAS) diet.

The Nutrition Assessment dated 10/04/10 documented that the resident's height was 75 inches, weight was 167 pounds with a Usual Body Weight (UBW) of 165-170 pounds. The resident was missing teeth and had no chewing difficulties identified.

The Nutrition Assessment dated 2/08/11 identified poor dentition and documented that the resident weighed 153.8 pounds, which indicated a significant weight loss. The Dietitian identified chewing problems and missing teeth.

An interview was held on 3/02/11 at 10:09 AM with Resident # 59. The resident stated that he has chewing problems, that he has not seen a Dentist while residing in the facility. The Resident stated that he needed to see a Dentist, the resident stated, "I need teeth". Visual observation of the resident's mouth revealed that he was missing some upper and lower teeth.

A nutrition progress note dated 3/02/11 at 1:25 PM documented that the resident's weighed 145 pounds, an approximately eight pound (5.2%) weight loss since re-admission. The resident's intake was observed as fair to poor. The resident complained of difficulty chewing solid foods due to missing teeth, and stated he had a partial denture but has no idea where it is. The Dietitian requested a Dental Consult and recommended to downgrade the resident's diet to puree NCS/NAS.

A Dietary Order Form dated 3/02/11 documented to discontinue the current diet and start NCS/NAS/ puree diet due to multiple missing teeth. The Dietitian documented a request for a Dental Consult and puree diet for better tolerance, and identified weight loss.

A physician's order dated 3/02/11 requested a Dental Consult.

Review of Resident #59's medical record with the Licensed Practical Nurse (LPN) on 3/07/11 at 9:15 AM revealed that no Dental Consult could be found.

An interview with the LPN charge nurse on 3/07/11 at 9:15 AM revealed that the admission physician's orders dated 10/01/10 requested a Dental Consult. The LPN stated that she filled out the other consults requested by the physician however she must have forgotten and did not fill out the Dental Consult.

Review of the consult log book on 3/07/11 revealed no dental consult was filled out for Resident #59 upon admission.

An interview with the physician on 3/07/11 at 12:38 PM. The physician stated that she did order a Dental Consult for the resident when first admitted and that the Dental Consult should have been performed by now. The physician further stated that today was the first time she was made aware of the significant weight loss and that the resident had not been seen by the Dentist since admission 10/01/10.

2) Resident #339 was admitted to the facility on 10/29/10 for short term rehabilitation with diagnoses which include Status Post Motor Vehicle Accident, History of Substance Abuse and Hypertension.

The admission Minimum Data Set (MDS) Assessment, dated 11/8/10, documented that there is no active discharge plan in place and that there was no determination made by the resident and Comprehensive Care Plan (CCP) team regarding discharge to the community. The MDS also documented that there has been no referral made to a contact agency in the community. An MDS dated 2/7/11 documented that there was no active discharge plan for the resident to return to the community. The MDS also documented that there has been no determination made by the CCP team regarding discharge and that there is no active plan in place.

A Comprehensive Care Plan (CCP) dated 11/4/10 documented that the goal was for the resident to be discharged when functionally stable with an adequate discharge plan through next review. The documented interventions were: inform the resident of the right to receive services in the least restrictive setting, inquire about the resident interest in talking to a local agency about returning to the community, involve family in discharge planning. The social worker documented on 2/16/11 that the resident remains uncertain about discharge plans.

An Occupational Therapy Discharge Summary (OTDS) dated 12/6/10 documented that the resident was receiving occupational Therapy (OT) 5 times a week from 10/29/10 - 12/6/10 and that he was moderate to maximum assist with activities of daily living (ADL) on 10/29/10. On 12/6/10 the OTDS documented that the resident was completely independent and that OT was discontinued as resident reached his maximum potential.

A Physical Therapy Discharge Summary (PTDS) dated 12/7/10 documents that the resident was receiving restorative PT 5 times a week fro 10/29/10 -12/7/10. The PTDS also documented that on 10/29/10 the resident needed maximum assistance with ADL care. The PTDS discharge note documented on 12/7/10 that the resident was independent,was able to walk up two flights of stair and that he was independent with ambulation, all goals met.

A Quarterly Social Work (SW) Assessment Note, dated 2/10/11, documented that the resident is a short term stay resident and that the resident would like to plan for a discharge to the community in April. The assessment also documents that the resident has an apartment in the community in which he will go to and has support system in the community.

Nurses Notes dated 2/21/11 documented that the resident was out of the facility fro 8:45 AM and returned to the facility 12:00 midnight.

There was no documented evidence that the facility did a comprehensive assessment of the resident for discharge to the community from 12/7/10 until 3/8/11 after complete of Rehabilitation.

An interview was held with Licensed Practical Nurse (LPN) Charge Nurse at 12:30 PM on 3/3/11. The LPN stated she believed that the resident is going home sometime in April but that she does not know the specific date.

An interview was held with the SW on 3/3/11 at 1:00 PM .The SW stated that the resident is waiting for money from a law suit and does not wish to return to the community until the lawsuit is settled " maybe sometime in April" and does have an apartment in the community. The SW also stated that after the resident was discontinued from Rehabilitation Services the resident was independent in activities of daily living and ambulation. The SW also stated that she has not tried to plan a discharge after rehabilitation was completed even though the resident no longer needed skilled care and that the resident has family in the community but that she did not explore the option of a discharge home with family or any other option.

An interview was conducted with the Director of SW on 3/8/11 at 12:00 PM. The SW also stated that there is no documented evidence in the medical record that the facility tried to find alternate placement for the resident when rehabilitation was completed and no longer needed skilled care. The SW also stated that she was aware that the resident was going out on pass with family from early morning until 12 midnight.

415.11(c)(3)(ii)

Based on record reviews and resident and staff interviews during the recertification survey, the facility did not ensure that of two residents who triggered for personal property had grievances related to personal property promptly resolved. Specifically,1) Resident #173 had complaints that personal clothing was missing which was not addressed by the facility in a timely manner and; 2) Resident #83 had reported a missing wallet to a facility staff member however no investigation was initiated. This resulted in no actual harm.

The findings are:

1) During an individual resident interview on 3/1/11 at 3:42 PM, Resident #173 stated that he was missing one pair of pants, one under shirt and three pairs of socks that was lost and not labeled.

The Licensed Practical Nurse (LPN) who reported the resident's missing clothing was interviewed on 3/7/11 at 11:15 AM and stated that the resident did complain to her approximately one week ago about his missing clothing. She stated that she called the laundry department and was not able to find his missing clothing. She was told by the laundry department that they will continue to look for the resident's missing clothing and will send the missing clothing to the resident if found. She did not notify social services because she assumed the resident spoke to his Social Worker (SW).

The Director of Social Services was interviewed on 3/7/11 at 11:18 AM and stated that she was never made aware of the resident's missing clothing. She stated that normally if there is missing clothing, a grievance form is filed. She was unable to find any grievance forms from the resident concerning missing clothing. She further stated that a grievance should have been initiated to check for the residents complaint of missing clothing.

The resident was interviewed in the presence of SW on 3/7/11 at 11:20 AM and stated that the family does his laundry and does not wish to label his clothing. He reported to the SW that his clothing was lost during the renovations of his room.

2) Resident # 83 has diagnoses including Diabetes and End Stage Renal Disease.

The quarterly MDS 3.0 dated 12/30/10 documented that the resident's Brief Interview for Mental Status (BIMS) score was 12 with no short term memory, long term memory, or behavioral problems identified.

An interview was held on 3/01/11 at 11:45 AM with Resident # 83. The resident stated that he lost a wallet about 4-5 weeks ago and that he told staff about the missing wallet. The resident stated that there was between $30-50 in his wallet and that as of 3/01/11 the wallet had not been found. The resident stated that everyone knows about the missing wallet, including the Certified Nursing Assistants (CNA), Nurses, Social Worker, and Administration.

A subsequent interview was held with the resident on 3/07/11 at 11:45 AM. The resident confirmed that his wallet was missing for about 4-5 weeks and that he told everybody. The resident stated that he could have lost the wallet anywhere, that he goes out of the facility and that it was reported as missing to the staff, including CNA's, nurses, all the way up to the top administration.

The interdisciplinary nursing progress notes were reviewed from 5/13/10 to 3/04/11. There was no documentation regarding the resident's missing wallet.

The Social Work progress notes and interdisciplinary progress notes were reviewed from 6/23/10 to 3/04/11. There was no documentation regarding the resident's missing wallet.

The facility Grievance Log from May 2010 - March 2011 was reviewed and revealed no documentation regarding the resident's missing wallet.

An interview was held on 3/07/11 at 11:49 AM with the resident's 7 AM -3 PM CNA. The CNA stated that the resident told her that his wallet was missing and that he also told his wife about the missing wallet. The CNA also stated that the resident told her that he had always kept his wallet in his pant's pocket.

An interview with the LPN (Licensed Practical Nurse) Charge Nurse on 3/07/11 at 12:03 PM revealed that she did not know anything about a missing wallet. The LPN stated that if she knew about the missing wallet she would have contacted the Social Worker and a room search would have taken place.

An interview was held with Social Worker (SW) on 3/07/11 at 12:11 PM. The SW stated that she was aware of missing laundry items however she knew nothing about a missing wallet.

An interview was held with Director of Nursing Service (DNS) on 3/07/11 at 2:15 PM. The DNS stated that she had no knowledge of the resident's missing wallet.

An interview with the 7 AM - 3 PM Registered Nurse (RN) Supervisor on 3/07/11 at 2:30 PM revealed that he had no knowledge of the resident's missing wallet.

An interview on 3/08/11 at 9:50 AM with the Administrator revealed that she was not aware of the resident's complaint of a missing wallet. The Administrator stated that the SW initiated the grievance procedure yesterday when the missing wallet was brought to her attention. The Administrator stated that once the CNA knew about the missing wallet the CNA should have told the nurse on the unit and then an investigation should have been initiated.

The facility's Policy and Procedure (P/P) related to Grievances dated 3/01/02 documented that every employee is empowered to receive a complaint or grievance, which is forwarded to the Social Work Department for coordination of the resolution and follow up. The also documented that grievances may be submitted orally and that upon receipt of a complaint or grievance, staff is required to report the issue to their supervisor.

4153(c)(1)(ii)

Based on observation, staff interview and record review, the facility did not ensure that the resident call bell system was fully functional in that call bell monitor screen on 1 of 7 nursing units did not function properly. The nursing staff observing the monitor was not able to determine which resident was pressing the call bell.

This resulted in no actual harm.

The findings are:

On 3/5/11 at 2:00 PM and 3/8/11 at 10:00 AM, the call bell screen behind the nursing station was observed to be blurry with static. It was unable to determine which resident room call bell was activated.

The Licensed Practical Nurse (LPN) was interviewed on 3/8/11 at 10:00 AM and was unable to determine which room was asking for assistance when looking at the call bell monitor. However, the LPN was able to observe the call lights in the hallway corridor and able to identify which room was pressing the call bell. The maintenance department was made aware on 3/8/11 at 10:03 AM and a maintenance worker immediately arrived on the unit and fixed the call bell screen. He stated that sometimes the screen malfunctions and the wire has to be adjusted.

In an interview on 3/8/11 at approximately 10:30 AM, the Director of Maintenance stated that the monitors are old, that he has been having a problem with the monitors for more than a week and has ordered new monitors to replace the old monitors. He further stated that staff should alert maintenance immediately to correct any issues with the call bell monitors.

10NYCRR 415.29