Wingate at Beacon

Based on interview and record review the facility did not develop Care Plans with measurable goals and objectives to address contractures, range of motion, use of protective footwear or toileting for 4 of 12 residents whose Care Plans were reviewed. (Residents #120, #147, #157 and #229). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Resident #147 has diagnoses of Hypertension, Dementia and Spastic Hemiplegia of the right upper extremity, according to the 8/10/11 MDS (Minimum Data Set) assessment. Further review of the MDS revealed that the resident had Functional Limitation in ROM (range of motion) of the upper extremity, shoulder, elbow, wrist and hand on one side of the body.

Observation, on 9/28/11 at 1:14 PM, revealed that the fingers of the resident's left hand were contracted and that she moved only her index finger and thumb minimally.

A review of the Nurse Practitioner's monthly notes from April, 2010 to August 2011 revealed that the resident had a contracture of the right hand /fingers.

A review of the Comprehensive Care Plan of 7/26/11 revealed that contractures are noted under "needs assist with ADL's" (Activities of Daily Living). This care plan had no measurable goals or objectives related to contractures and the care and services needed to address contractures in order to prevent decline.

An interview with the RN Unit Manager, on 9/28/11 at 1:30 PM, revealed that she had no explanation as to why no care plan was developed to address contractures.

2. Resident #120 was a long term resident of the facility with diagnoses including Dementia, Liver Cirrhosis, Diabetes, Hypertension, Hyperlipidemia and "Early Parkinson's" disease.

According to the 2/2/11 MDS (Minimum Data Set) assessment for a significant change in the resident's status, at that time the resident required the limited assistance of one person to transfer and walk in her room and the extensive assistance of two people to walk in the corridor. The MDS also identified that the resident had no impairment or functional limitation in ROM (range of motion) of her upper or lower extremities.

The resident had a Physical Therapy Evaluation on 6/17/11 and received therapy through 6/24/11 for ambulation training due to a decline in transfer ability and ambulation. No assessment of contractures or ROM was done at that time.

History and Physical Notes, Monthly Medical Evaluation Notes and Progress Notes completed by the Physician were reviewed from 3/7/11 - 9/5/11. Those notes revealed that the resident had a series of falls and was hospitalized from 6/24/11 - 7/2/11 for diminished mental status and a right hip fracture.

A Physical Therapy Evaluation was performed on 7/2/11 upon readmission for difficulty transferring and walking following right hip joint replacement. At that time, the therapist noted that the resident's ROM was within functional limits.

The resident was then reassessed for another significant change in status in the 7/9/11 MDS. At that time, the resident required the extensive assistance of two people to transfer and did not walk at all in her room or in the corridor. Again, that MDS also identified that the resident had no impairment or functional limitation in ROM of her upper or lower extremities.

According to the Physician's notes cited above, the resident was hospitalized again from 7/29/11 - 8/1/11 for evaluation of diminished food and fluid intake and further changes in mental status. At that time, she was diagnosed with Advanced Dementia. The resident had a Rehabilitation Screen completed on 8/2/11 upon readmission that determined that no evaluation was indicated at that time and her ROM was not assessed.

The Physician documented in the 9/5/11 Monthly Medical Evaluation that the resident experienced further overall decline in status and ordered a Physiatry Consult that was done on 9/13/11. The Physiatrist ( Physician who specializes in Rehabilitative Medicine) documented in the 9/13/11 Consultation Report that the resident had rigidity and contractures in multiple joints that was most likely from not being able to walk. The Physiatrist documented that the resident had pain that was not significant on passive stretching. The Physiatrist documented that the resident required passive stretching of her arm and leg joints on both sides and proper positioning to prevent deterioration of contractures.

There was no evidence in the Care Plans for ADLs, Mobility or elsewhere in the clinical record of (and the Physical Therapist (PT) and the RN Unit Manager were unable to produce) a Care Plan to address contractures and ROM prior to, or after, the Physiatrist's consult, findings and recommendations. The PT stated at 12:15PM on 9/29/11 and the RN stated at 4:00PM on 9/29/11 that no CP was developed that addressed contractures and ROM. The RN further stated that there was no available information regarding how ROM exercises should have been provided for the resident, for example. AROM, PROM, and what joints were involved, in order for the nurses to provide oversight and ensure that the CNAs properly perform ROM and positioning for the resident.

The CNA Care Card was initiated on 2/15/11 and reviewed and revised on 8/25/11. There were no instructions for providing ROM.

The CNAs documented, by checking boxes on the 9/11 ADL Flow Sheet, that AROM/PROM (Active/Passive ROM) was completed for the resident every day and every evening shift from 9/1/11 - 9/28/11. There was no indication whether the CNAs provided AROM, PROM or both and to which joints.

The resident was observed lying in bed from 8:10 AM - 10:30AM on 9/28/11. She was able to flex and extend the fingers of both hands fully upon command at that time. Her knees remained flexed at 90 degrees and were not tested at that time by the surveyor.

The CNA assigned to care for the resident was interviewed at 10:30AM on 9/28/11 and stated that she does not provide ROM to the resident during care or at any other time because the resident can move totally on her own and does not require ROM exercises.

The unit LPN was interviewed at 10:40AM on 9/28/11 and stated that the resident did not have contractures of any part of her body. She stated that the resident could straighten her legs completely and did so on her own.

The above CNA and LPN were then observed attempting to demonstrate that the resident had full ROM while the resident was in bed at 10:40AM on 9/28/11. The CNA and the LPN encouraged the resident to extend her legs. Those attempts were not successful. The resident did not extend her legs when encouraged. Her knees remained flexed. The LPN stated that the resident was able to extend her legs but that her behavior problems prevented her from cooperating. The LPN and CNA then attempted to extend the resident's legs themselves. They were not successful in straightening the resident's legs. Her knees remained flexed.

The resident was observed in the unit day room and the dining room from 11:30AM - 5:45PM on 9/28/11. Her knees were bent at 90 degrees continuously throughout those observations.

The resident was observed asleep in bed at 8:50AM on 9/29/11. she was turned on her right side and her knees were flexed to 90 degrees.

The CNA assigned to the resident that day was observed providing care to the resident at 11:05AM on 9/29/11. The CNA flexed the resident's knees five times for each knee to the point of resistance. The CNA raised the resident's legs five times each. The CNA stated that the resident moves her arms all over the place but that the CNA has to do ROM to her legs and move them all around because the resident does not move them herself and they are tightening up.

The Physical Therapy Assistant (PTA) and The Acting Director of Rehab (PT), were interviewed at 12:15PM on 9/29/11. They stated that the resident's contracture and ROM status had not been assessed by any therapist in the facility in order to develop a Care Plan. The PTA and the PT stated that the resident did not receive periodic evaluations of ROM and contracture status at scheduled intervals or on an as needed basis. The therapists stated that, when the nursing staff notices a change in functional status, or in what the resident can and cannot do, it triggers a screen for the therapist but that had not occurred.

The Physical Therapist evaluated the resident on 9/29/11 after surveyor request to determine the current status of contractures and recommendations. The PT determined that the resident had a change in contracture status with increased hip and knee flexor tightness on the right side. The resident was able to have her right knee and hip flexed to within functional limits, within the limits of the surgery, using active assisted ROM.

The PT recommended that skilled PT was indicated to increase ROM and to establish methods to reduce/prevent further muscle tightness.

3. Resident #157 was admitted to the facility on 6/06/07 and was alert and oriented to person and place. The resident had diagnoses including Cerebral Vascular Accident (CVA/Stroke) with hemiplegia (weakness/paralysis) of her left side, Diabetes Mellitus (DM) with renal involvement and Peripheral Vascular Disease (PVD).

The Resident was observed sitting in the dayroom at 10:30AM on 9/27/11. She was wearing only socks on her feet at that time and she informed the surveyor that her shoes were lost. The resident was unsure of the time frame but stated that her shoes were missing for several weeks to months. The resident further said that the facility did not do anything about replacing them.

Review of the resident's Care Plan (CP) revealed no evidence that wearing protective footwear was addressed in the skin care or diabetic care plans or elsewhere in the clinical record.

An interview with the Certified Nursing Assistant (CNA) on 9/28/11 at 1:30PM revealed that the CNA had no knowledge that the resident ever had shoes. On 9/29/11 at 9:30AM in an interview with the Licensed Practical Nurse (LPN) who has worked on this unit and who works with this resident she stated that she never saw the resident wearing shoes.

In an interview with another CNA on 9/29/11 at 9:50AM, she stated that this resident never had shoes; she only had sneakers and these no longer fit the resident. This CNA stated that she reported this to a nurse at the time it was noted that the sneakers did not fit but she did not remember which nurse.

In an interview with the Nurse Practitioner on 9/29/11 at 10:05AM, he stated that the resident should be wearing protective footwear such as shoes/sneakers to protect her feet.

In an interview with the Unit Manager Registered Nurse (UMRN) on 9/28/11 at 4:00PM, she stated that she was not aware that the resident had no shoes but that she would initiate an Occupational Therapy evaluation to ensure that the resident's feet were protected by protective footwear because this resident has Diabetes Mellitus and PVD. The RN was not able to explain why the issue of footwear was not addressed in the resident's CP.

415.11(c)

Based on observation and interview, the facility did not promote resident dignity in dining. Specifically: 1. A soiled bath blanket was utilized as a clothing protector for Resident #65). 2. A Certified Nurse Aide was standing while feeding and/or assisting with feeding two residents including Resident #53 and 3. Residents #118 and #158 were not fed and or assisted with feeding in a timely manner. This was evident for 4 residents during two of two meals observed.

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

The findings are:

1. Observation on 9/28/11 at 11:31AM revealed that Resident #65 was sitting in his wheelchair in the corridor outside the unit dining room on the Putnam Unit. A bath blanket was being utilized as a lap robe to cover the resident's lap and legs. At that time a Certified Nurse Aide (CNA) used the end of the bath blanket to wipe the resident's "runny nose." The CNA then removed the bath blanket from the resident's lap, folded it in half, and put it on the resident's chest and around his neck. The CNA then took the resident into the dining room and utilized the soiled blanket as a clothing protector.

During an interview with the CNA, on 9/28/11 at 11:35 AM, as to why she was using the soiled blanket as a clothing protector for the resident, the CNA stated, "I should not have done that. I should have washed my hands." The CNA then left the dining room, stating that she was going to wash her hands, but left the soiled bath blanket around the resident's chest as a clothing protector.

2. During a lunch observation , on 9/26/11 at 12:30 PM in the Putnam Dining Room, a CNA was observed to be standing while alternating between feeding and assisting with feeding two residents. Resident #53 was seated to the right of the CNA and required assistance/feeding of the meal. Another resident, who required feeding, was seated to the left of the CNA. The CNA was standing while feeding and assisting these residents to eat.

During an Interview with the CNA , on 9/28/11 at 12:57 PM, as to why she was standing while feeding and or assisting these residents with feeding, she replied that she did it "rather than move my chair back and forth."

3. Breakfast observation on the Ulster Unit on 9/29/11 revealed that the nursing staff did not provide Residents #118 and #158 prompt assistance so that they could eat concurrently with their tablemate. Interview with the nursing staff during the meal revealed that Resident #158 is able to feed herself independently and Resident #118 had to be fed. Both residents waited to be assisted while their tablemate was being fed. Resident #158 was sleeping while she was waiting to be provided "set-up" assistance. Resident #118 sat idly while waiting to be fed. Once the tablemate began to eat, Resident #158 waited about 15 minutes to be assisted and Resident #118 waited about 30 minutes.

415.5(a)

Based on observation, interview and record review, the facility did not establish and maintain an infection control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Specific issues included:
1) The appropriate management of respiratory supplies to prevent infection). 2) Inappropriate use of a bath blanket protector during a meal. 3) Soiled privacy curtains . This was evident for 2 of 4 Units ( Orange and Ulster Units) and for Residents #65 and #151.

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

Findings are:

1. During envoirnmental rounds on 9/28/11 at 2:00pm it was noted that the Privacy curtain in Room 9 on the Ulster Unit was soiled with a brownish- substance.

In an interview with the Charge Nurse on the Ulster Unit on 9/28/11 at 2:15PM she agreed that the privacy curtain was soiled and should be removed.

Further envirormental rounds on 9/29/11 at 11:00am revealed that Privacy curtains in Rooms 3,5,8,10,14,16,17,20 on the Ulster Unit and Room 219 on the Orange Unit were observed to be soiled with a brownish substance.

In an interview with the contracted Housekeeping on 9/29/11 at 3:00PM he stated that he inspected all the privacy curtains on a monthly basis and changed them as needed. He had no explanation why the soiled privacy curtains had not been changed.

2. Resident #151 was observed entering his room, #G 19 A on the Ulster Unit, at 3:00PM on 9/26/11. The resident stated that he was going to put on his oxygen because he was feeling out of breath. The resident grasped a nasal cannula oxygen tubing that was draped across his bed with the nasal cannula end lying on the floor. An empty undated plastic bag for the oxygen tubing was noted to be on the floor at that time. The nasal cannula tubing had a piece of paper tape wrapped around it and was labeled 1 AM 9/18/11. The resident also had a nebulizer and tubing attached to a nebulizer device on his overbed rolling table. The nebulizer device was similarly labeled 1AM 9/18/11 and was lying on top of a plastic shopping bag unprotected from contamination.

The resident applied the nasal cannula to his face and connected the other end of the tubing to the oxygen concentrator. The face surface of the oxygen concentrator machine was dusty. The resident turned on the concentrator and set the flow rate. The resident then turned his wheelchair around to watch TV. The end of the oxygen tubing disconnected from the concentrator and dropped to the floor. The floor was soiled. The resident did not call for assistance or make any attempt to clean the end of the tubing. He reconnected the contaminated tubing to to the concentrator. A staff member arrived to escort the resident to a therapy session. The resident shut off his oxygen concentrator and removed the nasal cannula tubing from his head. He laid the tubing on his bed sheet with the nasal prongs in direct contact with the bottom bed sheet.

The regular unit LPN on the day shift was interviewed at 3:50 PM on 9/26/11. The LPN stated that the night shift nurses change the oxygen supplies and tubings weekly on Sunday nights. The LPN stated that the oxygen supplies and tubings should have been discarded after a week. The LPN stated that the nurses are expected to check the date on the oxygen supplies and should have noticed that they were in use beyond the 7 days.

The float LPN on the evening shift, who was also present during the interview, then discovered a nasal cannula with tubing and a nebulizer device with tubing, both labeled 9/25/11, located in a plastic shopping bag out of view. The LPN unit nurse stated that the night nurse must have provided new supplies for the resident last night which was Sunday night but did not discard the "old" supplies. The LPN stated that the nurse should have discarded the old supplies and that would have prevented the resident and staff members from using them beyond the seven day period.

3. Observation on 9/28/11 at 11:31AM revealed that Resident # 65 was sitting in his wheelchair in the corridor outside the unit dining room on the Putnam Unit. A bath blanket was being utilized as a lap robe to cover the residents lap and legs. At that time a Certified Nurse Aide (CNA) used the end of the bath blanket to wipe the resident's "runny nose". The CNA then removed the bath blanket from the resident's lap, folded it in half, and put it on the resident's chest and around his neck. The CNA then took the resident into the dining room and utilized the soiled blanket as a clothing protector.

During an interview with the CNA, on 9/28/11 at 11:35 AM, as to why she was using the soiled blanket as a clothing protector for the resident, the CNA stated " I should not have done that. I should have washed my hands." The CNA then left the dining room, stating that she was going to wash her hands, but left the soiled bath blanket around the resident's chest as a clothing protector.

415.19(a)(1-3)

Based on record review and interviews, the facility did not identify quality deficiencies in order to develop and implement appropriate plans of action to correct the identified quality deficiencies as a function of a meaningful quality assurance program. Specifically, concerns in areas that impact on the quality of care and quality of life for residents including medication errors, contractures and an unkempt environment were not identified and appropriately addressed.

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

The findings are:

The Administrator, who chairs and provides direction for the Performance Improvement Committee, was interviewed at 4:00PM on 9/29/11 along with the DNS (Director of Nursing Services), who is another primary representative of the committee.

1. Random observations of medication administration revealed an error rate of 9.4% (See F 332).

The above interview revealed that the Consultant Pharmacist observes random nurses performing medication administration once or twice a year. There was no system in place to adequately monitor nursing performance or collect sufficient data that would have potentially identified concerns related to inaccuracy of medication administration.

2. Four of forty residents randomly selected during the standard survey were observed to have contractures. Three of those residents were reviewed for care to manage contractures including the provision of range of motion exercises, if indicated. Resident #120 did not consistently receive proper management of contractures including range of motion exercises. (See F 279 and F 317).

The same interview above revealed that there was no system in place to bring issues related to declines in residents' functional mobility to the committees attention, including increases in contractures and declines in range of motion.

3. Numerous privacy curtains in resident rooms were noted to be soiled during the standard survey. (See F 253).

During the above interview the Administrator stated that soiled curtains were identified as an area of concern six months ago and a system was put in place to change the curtains on a schedule. The Administrator stated that there has been auditing done to ensure that curtains have been changed according to the schedule but no evaluation of whether or not that plan has been effective.

415.27

Based on observation, interview and record review, medications were not administered in a manner that resulted in an error rate of less than 5%. Specifically: 1. Prescribed medications were not given as ordered and scheduled including eye drops for Residents #244, Calcium plus Vitamin D for Resident #120 and Saline Nasal Spray for Resident #82. 2. A combined Calcium plus Vitamin D supplement medication was ordered without a dosage prescribed for either of the two components and was given without clarifying the dosages for Resident #183. 3. Resident #184 was given the wrong dosage of an antidepressant medication.

This was evident for five of fifteen residents and five of 53 observed opportunities for medication administration and resulted in a 9.4% error rate with a pattern of potential for more than minimal harm that is not immediate jeopardy for Residents #82, #120, #183, #184 and #244.

The findings are:

1. During observation of medication administration on the Ulster unit between 4:30PM and 5:00PM on the evening of 9/26/11, an LPN was observed giving medications to five residents. The residents' current Physician's Orders were reviewed immediately after the observations and revealed that the LPN omitted giving one prescribed medication to three of the five residents. Specifically, Resident #244 had a 9/7/11 Order to be given one drop of artificial tears in each eye during the medication pass observed and the drops were not given. Resident #120 had a 9/5/11 Order to be given Calcium plus Vitamin D at 5:00PM and the LPN did not administer that medication. Resident #82 was supposed to receive two sprays of Saline Nasal Spray in each nostril at 5:00PM and the spray was not provided by the LPN.

The LPN was interviewed at 5:10PM on 9/26/11 about each of the three separate residents' medication regimens following the above observations. The LPN reviewed each of the residents current Physician's Orders and Medication Administration Records (MARs), one resident at a time. The LPN stated that she skipped each of the three medications, noted above to be omitted. The LPN stated that she should have seen that the residents were supposed to get those medications but that she did not see them listed on the MARs and "skipped" giving the medications.

2. An LPN was observed administering medications to Resident #183 at 9:45AM on 9/28/11 that included a chewable tablet of Calcium 500mg plus Vitamin D3 400 iu. The resident's current 9/5/11 Physician's Orders were reviewed immediately following the above observation and revealed that the resident was supposed to be given one tablet of Calcium plus Vitamin D3 daily at that time but, the dosage of Calcium and the dosage of Vitamin D were not specified in the order.

The LPN was then interviewed and asked what dosages of Calcium and Vitamin D were ordered for the resident. The LPN reviewed the Medication Administration Record and stated that no specific dosages were specified. The LPN was also asked about how she determined what dosage of Calcium and Vitamin D to administer to the resident since the dosages were not specified and there are numerous dosages for each medication. The LPN stated that she gives the combined Calcium plus Vitamin D tablets that are supplied by the pharmacy regardless of the dosage when there is an order for the combined drugs.

The resident's Physician was interviewed at 1:15PM on 9/28/11. The Physician stated that she thinks the facility uses a standard dose of Calcium 500mg plus 400 units of Vitamin D but the dose should be specified anyway. The Physician stated that there are a lot of residents receiving those medications and the orders should be clarified for all of them.

3. A LPN was observed administering medications to Resident #184 at 10:05AM on 9/29/11 that included Sertraline (Zoloft) 50mg .

The resident's current Physician's Order dated 9/16/11 were reviewed immediatedly after the observation and revealed the current order for Sertraline was 50mg - 3 tabs (150mg) by mouth once daily.

The LPN was interviewed at 10:10AM on 9/29/11. The LPN stated that she thought the medication dosage of the resident's Zoloft was decreased.

The Charge Nurse LPN was interviewed at 10:15AM on 9/29/11 and stated that the correct dosge was 3 -50mg tabs to equal the 150 mg dose ordered.

415.12(m)(1)

Based on observation and interview, equipment used in food preparation and, pipes and ceiling tiles above equipment used for food preparation and dish washing, were not maintained according to sanitary conditions. Additionally, a Dietary Aide did not wash her hands when indicated in order to prevent food contamination and a Licensed Practical Nurse and a Dietary Supervisor did not wash their hands when indicated during meal service .

This resulted in a pattern of potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During a tour of the kitchen at 10:30AM on 9/29/11, an accumulation of dust was noted on a pot rack suspended from the ceiling, as well as, on the handles of frying pans and serving utensils that were stored on the rack.

The exterior of the bread toaster had an accumulation of dust that was adhered to the greasy surface. An accumulation of greasy debris was noted on a rack in the toaster.

Multiple pipes above the stove and the toaster had an accumulation of dust.

Black mold-like residue was noted on the wall behind the dish wash washer and on the ceiling tiles above.

The Food Service Director (FSD) was interviewed at the time of these observations and stated that he was not aware that these conditions were present.

Additionally, a Dietary Aide mopped the floor in the dishwasher room. The Aide was then observed to dispose of her gloves and proceed to clean food trucks without first washing her hands. Interviews with the FSD and Diet Aide then revealed that both staff members were aware that it was indicated to wash hands after removal of gloves to prevent cross contamination of germs.

During the lunch meal in the Main Dining room on 9/26/11, an LPN (Licensed Practical Nurse) grasped a resident by both shoulders, touching the resident's sweater, as the LPN spoke to the resident. The LPN then grasped her own uniform pants with both hands, clenching the fabric in her fists. The LPN then poured coffee and tea for residents, handling the hot beverage pitchers, cups, tea bags, sugar packets and the half gallon container of milk, from which she repeatedly removed and replaced the cap. The LPN did not cleanse her hands with a sanitizing agent or wash her hands after touching the clothing of the resident and her own clothes.

The LPN was interviewed at 12:55PM after she served hot beverages to twelve residents. The LPN stated that she should have washed her hands after touching the resident's and her own clothing before serving the coffee end tea. The LPN pointed out a handwashing sink in the room and a hand sanitizer dispenser. She said she could have used either to clean her hands.

The Dietary Supervisor was observed leaving the Main dining room and entering the adjacent kitchen during the lunch meal on 9/26/11. She was then observed to brush both of her hands up and down her pant legs, grasp her hair with both hands and scratch her nose. Without first cleaning her hands, the Dietary Supervisor opened a freezer and handled and removed containers of ice cream. She then washed her hands.

The Dietary Supervisor was interviewed at 1:10PM following the above observations. The Dietary Supervisor stated that she usually washes her hands after she touches anything that has germs on it. She stated that she did not wash her hands after contaminating them by touching her clothing, hair and nose because she is working at such a fast pace that her thought processes were not in action. The Dietary Supervisor stated that she should have washed he hands before opening the freezer and touching the ice cream containers.

415.14(h)

Based on observation, interview and record review, a resident's Care Plan for Activities was not revised in response to a significant change in her condition and the resident was not then provided with an adequate, ongoing program of activities that met her personal interests and current physical, mental and psychosocial needs. This was evident for one of two cognitively impaired residents reviewed for activities (Resident #120) and resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #120 is a long term resident at the facility. According to her Physician, in an interview at 3:30PM on 9/28/11, the resident has experienced a significant decline in her cognitive and physical status over the past several months and has been diagnosed with Advanced Dementia.

The resident was interviewed during her 11/5/10 Annual MDS (Minimum Data Set) assessment, prior to her significant decline in status, in order to determine her Activity Preferences . At that time, the resident was able to participate in the assessment process and identified that it was very important to her to listen to music she liked, keep up with the news, do things with groups of people, go out in the fresh air and participate in religious services. Also, at the time of that MDS, the resident required the limited assistance of one person to walk and move about on and off the unit.

The Resident Care Plan for Activites (CP) was initiated on 8/12/10 and most recently revised in 5/6/11. The CP noted that the resident would actively participate in 1-2 formal activites per week such as music programs, socials, cooking groups, BINGO, other games, special events, movies, crafts, sing-a-longs and Catholic Mass. The CP also identified that the resident would socialize and engage in conversation with peers daily.

The resident was reassessed using the 7/9/11 Significant Change MDS. At that time she was noted to have memory problems and severely impaired decision-making ability and was not able to participate in the interview portions of the assessment. The MDS identified that the resident was no longer ambulatory and had become totally dependent on others to perform her ADLs (Activities of Daily Living) including moving from place to place on and off the unit. Staff members completed the Activity Preference portion of the MDS and identified that it was very important for the resident to listen to music and be involved with groups, favorite activities and religious services.

The Director of Recreation documented in the Recreation Notes on 7/14/11 that the resident had experienced a change in behavior and mental status and a cognitive decline. The Director of Recreation stated that the resident was not able to activiely participate in programs of interest and became agitated at times in group settings. She further stated that the resident was verbally inappropriate and unable to engage in conversation.

The resident's CP was not revised to address her current physical, mental and psychosocial needs in accordance with the significant decline in her condition that was idnetified in the 7/9/11 MDS and the 7/14/11 Recreation Notes completed by the Director of Recreation.

The resident was seated in her recliner chair in the day room with the TV on from 1:00 PM to 4:00 PM on 9/26/11. She was not involved with watching the TV. No staff member engaged the resident in discussion or activity during that period of time. She was not observed to participate in the posted Peter Rabbit Visits on the Ulster Unit (where the resident resides) at 1:15PM or the Karaoke Soiree in the Recreation Room at 2:30PM.

The resident was observed in bed at 8:10 AM on 9/28/11. She was babbling and talking quietly to herself. The resident was easy to engage in interaction. She made eye contact and followed the surveyors simple commands to clench and stretch out her fingers and to grasp objects. The resident responded to questions in phrases, some of which seemed to follow the conversation and some that did not make sense.

A CNA completed morning care for the resident at 11:30AM on 9/28/11 and took her to the unit day room in her recliner chair and placed her in front of the TV. The resident was observed in that spot until 12:15PM. No staff member approached the resident during the period of time she sat in the day room to engage her in conversation or any type of activity.

The resident was then taken to the unit dining room in her recliner chair for lunch at 12:15PM on 9/28/11. She was returned to the day room with the TV on after lunch. Many residents were escorted to the music program in the MDR at 2:30PM on 9/28/11. The resident remained in the unit day room with the TV on, unengaged in the programs shown. The resident was still in the day room with the TV on at 5:15PM on 9/28/11. The resident was not engaged in watching the TV or any other activity during that time.

The CNA was interviewed at 9:30AM on 9/29/11 and stated that the resident mainly spends the day in the unit day room except for when she is being fed, receiving care or taking a nap. The CNA stated that she is not involved in the resident's program of activities.

The resident was seated in the recliner chair after breakfast in the day room on 9/29/11. She was present for the scheduled 10:45AM Sensory Group Activity. The recreation department staff member engaged the resident twice by calling out her name and asking her a question. The resident responded to her name being called. Ten minutes after the activity began, a CNA removed the resident from the room and put the resident to bed and cleaned and changed her. The activity was no longer in progress when the resident returned to the day room.

The Director of Recreation, was interviewed at 12:45PM on 9/29/11 and stated that she was familiar with the resident and her Care Plan. The Director of Recreation stated that the resident used to be more functional mentally and physically and participated in numerous programs. She stated that the resident has declined and now only participates in programs that take place on her own unit including music, reminiscing and trivia for example. She stated that the resident is able to sit in the programs and passively participate for stimulation but that she can't actively participate. The Director of Recreation stated that these activites occurred about three times a week. This was consistent with the Activity calendar.

The Director of Recreation also stated that the resident also gets a communion blessing every week. The Director of Recreation stated that the recreation staff spend time with the resident in one-on-one visits twice a week. She stated that one-on-one visits consist of sitting with the resident and talking to her about previous interests ranging from 5 - 10 minutes, depending on what the resident can tolerate.

The Director of Recreation stated that the resident's program of activities is provided by the Recreation staff members. She stated that it is not facility practice to include the involvement of CNAs, nurses or other staff members in the resident's program of activities.

415.5(f)1)

Based on observation, interview and record review, a resident's Care Plan for Activities was not revised in response to a significant change in her condition and the resident was not then provided with an adequate, ongoing program of activities that met her personal interests and current physical, mental and psychosocial needs. This was evident for one of twelve residents whose Care Plans were reviewed (Resident #120) and resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #120 is a long term resident at the facility. According to her Physician, in an interview at 3:30PM on 9/28/11, the resident has experienced a significant decline in her cognitive and physical status over the past several months and has been diagnosed with Advanced Dementia.

The resident was interviewed during her 11/5/10 Annual MDS (Minimum Data Set) assessment, prior to her significant decline in status, in order to determine her Activity Preferences . At that time, the resident was able to participate in the assessment process and identified that it was very important to her to listen to music she liked, keep up with the news, do things with groups of people, go out in the fresh air and participate in religious services. Also, at the time of that MDS, the resident required the limited assistance of one person to walk and move about on and off the unit.

The Resident Care Plan for Activites (CP) was initiated on 8/12/10 and most recently revised in 5/11. The CP noted that the resident would actively participate in 1-2 formal activites per week such as music programs, socials, cooking groups, BINGO, other games, special events, movies, crafts, sing-a-longs and Catholic Mass. The CP also identified that the resident would socialize and engage in conversation with peers daily.

The resident was reassessed using the 7/9/11 Significant Change MDS. At that time she was noted to have memory problems and severely impaired decision-making ability and was not able to participate in the interview portions of the assessment. The MDS identified that the resident was no longer ambulatory and had become totally dependent on others to perform her ADLs (Activities of Daily Living) including moving from place to place on and off the unit. Staff members completed the Activity Preference portion of the MDS and identified that it was very important for the resident to listen to music and be involved with groups, favorite activities and religious services.

The Director of Recreation documented in the Recreation Notes on 7/14/11 that the resident had experienced a change in behavior and mental status and a cognitive decline. The Director of Recreation stated that the resident was not able to activiely participate in programs of interest and became agitated at times in group settings. She further stated that the resident was verbally inappropriate and unable to engage in conversation.

The resident's CP was not revised to address her current physical, mental and psychosocial needs in accordance with the significant decline in her condition that was idnetified in the 7/9/11 MDS and the 7/14/11 Recreation Notes completed by the Director of Recreation.

The resident was seated in her recliner chair in the day room with the TV on from 1:00 PM to 4:00 PM on 9/26/11. She was not involved with watching the TV. No staff member engaged the resident in discussion or activity during that period of time. She was not observed to participate in the posted Peter Rabbit Visits on the Ulster Unit (where the resident resides) at 1:15PM or the Karaoke Soiree in the Recreation Room at 2:30PM.

The resident was observed in bed at 8:10 AM on 9/28/11. She was babbling and talking quietly to herself. The resident was easy to engage in interaction. She made eye contact and followed the surveyors simple commands to clench and stretch out her fingers and to grasp objects. The resident responded to questions in phrases, some of which seemed to follow the conversation and some that did not make sense.

A CNA completed morning care for the resident at 11:30AM on 9/28/11 and took her to the unit day room in her recliner chair and placed her in front of the TV. The resident was observed in that spot until 12:15PM. No staff member approached the resident during the period of time she sat in the day room to engage her in conversation or any type of activity.

The resident was then taken to the unit dining room in her recliner chair for lunch at 12:15PM on 9/28/11. She was returned to the day room with the TV on after lunch. Many residents were escorted to the music program in the MDR at 2:30PM on 9/28/11. The resident remained in the unit day room with the TV on, unengaged in the programs shown. The resident was still in the day room with the TV on at 5:15PM on 9/28/11. The resident was not engaged in watching the TV or any other activity during that time.

The CNA was interviewed at 9:30AM on 9/29/11 and stated that the resident mainly spends the day in the unit day room except for when she is being fed, receiving care or taking a nap. The CNA stated that she is not involved in the resident's program of activities.

The resident was seated in the recliner chair after breakfast in the day room on 9/29/11. She was present for the scheduled 10:45AM Sensory Group Activity. The recreation department staff member engaged the resident twice by calling out her name and asking her a question. The resident responded to her name being called. Ten minutes after the activity began, a CNA removed the resident from the room and put the resident to bed and cleaned and changed her. The activity was no longer in progress when the resident returned to the day room.

The Director of Recreation, was interviewed at 12:45PM on 9/29/11 and stated that she was familiar with the resident and her Care Plan. The Director of Recreation stated that the resident used to be more functional mentally and physically and participated in numerous programs. She stated that the resident has declined and now only participates in programs that take place on her own unit including music, reminiscing and trivia for example. She stated that the resident is able to sit in the programs and passively participate for stimulation but that she can't actively participate. The Director of Recreation stated that these activites occurred about three times a week. This was consistent with the Activity calendar.

The Director of Recreation also stated that the resident also gets a communion blessing every week. The Director of Recreation stated that the recreation staff spend time with the resident in one-on-one visits twice a week. She stated that one-on-one visits consist of sitting with the resident and talking to her about previous interests ranging from 5 - 10 minutes, depending on what the resident can tolerate.

The Director of Recreation stated that the resident's program of activities is provided by the Recreation staff members. She stated that it is not facility practice to include the involvement of CNAs, nurses or other staff members in the resident's program of activities.

415.11(c)(2)(i-iii)

Based on record review and interview, each resident's medication regimen was not free of unnecessary drugs. Specifically, resident #120 was receiving Vitamin D without a prescribed dosage. This was evident for one of ten residents reviewed for medication regimen and resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

A review of Resident #120's medication regimen revealed a current 9/5/11 Physician's Order for "Calcium 500 tab plus D" that did not specify the dosage of Vitamin D to be administered. The dosage of Vitamin D was also not prescribed in the previous 8/3/11 Physician's Orders.

The resident's Medication Administration Records for 8/1/11 - 9/28/11 reflected the Physician's Orders and did not indicate the dosage of Vitamin D prescribed for the resident.

The resident's Physician was interviewed at 1:15PM on 9/28/11. The Physician stated that she thinks the facility uses a standard dose of Calcium 500mg plus 400 units of Vitamin D but the dose should be specified anyway. The Physician stated that there are a lot of residents receiving those medications and the orders should be clarified for all of them.

415.12(l)(1)

Based on observation, interview and record review, the facility did not develop a Care Plan or provide appropriate services to address ROM (range of motion) for a resident with the new onset of contractures to determine if the contractures were unavoidable due to a decline in the resident's condition or whether the resident could regain her previous level of function and to prevent further limitations. This was evident for one of one residents reviewed for the new development of contractures and resulted in the potential for more than minimal harm that is not immediate jeopardy (Resident #120).

The findings are:

Resident #120 was a long term resident of the facility with diagnoses including Dementia, Liver Cirrhosis, Diabetes, Hypertension, Hyperlipidemia and "Early Parkinson's" disease.

According to the 2/2/11 MDS (Minimum Data Set) assessment for a significant change in the resident's status, at that time the resident required the limited assistance of one person to transfer and walk in her room and the extensive assistance of two people to walk in the corridor. The MDS also identified that the resident had no impairment or functional limitation in ROM (range of motion) of her upper or lower extremities.

The resident had a Physical Therapy Evaluation on 6/17/11 and received therapy through 6/24/11 for ambulation training due to a decline in transfer ability and ambulation. No assessment of contractures or ROM was done at that time.

History and Physical Notes, Monthly Medical Evaluation Notes and Progress Notes completed by the Physician were reviewed from 3/7/11 - 9/5/11. Those notes revealed that the resident had a series of falls and was hospitalized from 6/24/11 - 7/2/11 for diminished mental status and a right hip fracture.

A Physical Therapy Evaluation was performed on 7/2/11 upon readmission for difficulty transferring and walking following right hip joint replacement. At that time, the therapist noted that the resident's ROM was within functional limits.

The resident was then reassessed for another significant change in status in the 7/9/11 MDS. At that time, the resident required the extensive assistance of two people to transfer and did not walk at all in her room or in the corridor. Again, that MDS also identified that the resident had no impairment or functional limitation in ROM of her upper or lower extremities.

According to the Physician's notes cited above, the resident was hospitalized again from 7/29/11 - 8/1/11 for evaluation of diminished food and fluid intake and further changes in mental status. At that time, she was diagnosed with Advanced Dementia. The resident had a Rehabilitation Screen completed on 8/2/11 upon readmission that determined that no evaluation was indicated at that time and her ROM was not assessed.

The Physician documented in the 9/5/11 Monthly Medical Evaluation that the resident experienced further overall decline in status and ordered a Physiatry Consult that was done on 9/13/11. The Physiatrist ( Physician who specializes in Rehabilitative Medicine) documented in the 9/13/11 Consultation Report that the resident had rigidity and contractures in multiple joints that was most likely from not being able to walk. The Physiatrist documented that the resident had pain that was not significant on passive stretching. The Physiatrist documented that the resident required passive stretching of her arm and leg joints on both sides and proper positioning to prevent deterioration of contractures.

There was no evidence in the Care Plans for ADLs, Mobility or elsewhere in the clinical record of (and the Physical Therapist (PT) and the RN Unit Manager were unable to produce) a Care Plan to address contractures and ROM prior to, or after, the Physiatrist's consult, findings and recommendations. The PT stated at 12:15PM on 9/29/11 and the RN stated at 4:00PM on 9/29/11 that no CP was developed that addressed contractures and ROM. The RN further stated that there was no available information regarding how ROM exercises should have been provided for the resident e.g. AROM, PROM, and what joints were involved, in order for the nurses to provide oversight and ensure that the CNAs properly perform ROM and positioning for the resident.

The CNA Care Card was initiated on 2/15/11 and reviewed and revised on 8/25/11. There were no instructions for providing ROM.

The CNAs documented, by checking boxes on the 9/11 ADL Flow Sheet, that AROM/PROM (Active/Passive ROM) was completed for the resident every day and every evening shift from 9/1/11 - 9/28/11. There was no indication whether the CNAs provided AROM, PROM or both and to which joints.

The resident was observed lying in bed from 8:10 AM - 10:30AM on 9/28/11. She was able to flex and extend the fingers of both hands fully upon command at that time. Her knees remained flexed at 90 degrees and were not tested at that time by the surveyor.

The CNA assigned to care for the resident was interviewed at 10:30AM on 9/28/11 and stated that she does not provide ROM to the resident during care or at any other time because the resident can move totally on her own and does not require ROM exercises.

The unit LPN was interviewed at 10:40AM on 9/28/11 and stated that the resident did not have contractures of any part of her body. She stated that the resident could straighten her legs completely and did so on her own.

The above CNA and LPN were then observed attempting to demonstrate that the resident had full ROM while the resident was in bed at 10:40AM on 9/28/11. The CNA and the LPN encouraged the resident to extend her legs. Those attempts were not successful. The resident did not extend her legs when encouraged. Her knees remained flexed. The LPN stated that the resident was able to extend her legs but that her behavior problems prevented her from cooperating. The LPN and CNA then attempted to extend the resident's legs themselves. They were not successful in straightening the resident's legs. Her knees remained flexed.

The resident was observed in the unit day room and the dining room from 11:30AM - 5:45PM on 9/28/11. Her knees were bent at 90 degrees continuously throughout those observations.

The resident was observed asleep in bed at 8:50AM on 9/29/11. she was turned on her right side and her knees were flexed to 90 degrees.

The CNA assigned to the resident that day was observed providing care to the resident at 11:05AM on 9/29/11. The CNA flexed the resident's knees five times for each knee to the point of resistance. The CNA raised the resident's legs five times each. The CNA stated that the resident moves her arms all over the place but that the CNA has to do ROM to her legs and move them all around because the resident does not move them herself and they are tightening up.

The Physical Therapy Assistant (PTA) and The Acting Director of Rehab (PT), were interviewed at 12:15PM on 9/29/11. They stated that the resident's contracture and ROM status had not been assessed by any therapist in the facility in order to develop a Care Plan. The PTA and the PT stated that the resident did not receive periodic evaluations of ROM and contracture status at scheduled intervals or on an as needed basis. The therapists stated that, when the nursing staff notices a change in functional status, or in what the resident can and cannot do, it triggers a screen for the therapist but that had not occurred.

The Physical Therapist evaluated the resident on 9/29/11 after surveyor request to determine the current status of contractures and recommendations. The PT determined that the resident had a change in contracture status with increased hip and knee flexor tightness on the right side. The resident was able to have her right knee and hip flexed to within functional limits, within the limits of the surgery, using active assisted ROM.

The PT recommended that skilled PT was indicated to increase ROM and to establish methods to reduce/prevent further muscle tightness.

415.12(e)(1)

Based on observation, interview and record review residents with limitations in ROM (Range of Motion) associated with contractures did not receive appropriate treatment and services to prevent further decreases in ROM. This was evident for two of two residents with known contractures who were reviewed (Residents #147 and #157) and resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #147 has diagnoses of Hypertension, Dementia and Spastic Hemiplegia of the right upper extremity, according to the 8/10/11 MDS (Minimum Data Set) assessment. Further review of the MDS revealed that the resident had Functional Limitation in ROM (range of motion) of the upper extremity, shoulder, elbow, wrist and hand on one side of the body.

Observation, on 9/28/11 at 1:14 PM, revealed that the fingers of the resident's left hand were contracted and that she moved only her index finger and thumb minimally.

A review of the Nurse Practitioner's monthly notes from April, 2010 to August 2011 revealed that the resident had a contracture of the right hand /fingers.

A review of Nurse Practitioner notes from November 2010 through August 2011 revealed that the resident has a contracture of the right hand/fingers and refused to wear a splint. There was no documented evidence that the use of any alternate device to address the resident's contractures was considered in order to prevent decline.

An interview with assigned Certified Nurse Aide (CNA), on 9/28/11 at 1:55 PM, revealed that the CNA performs active range of motion (AROM) by lifting "a couple of fingers (the resident's); the resident cries and I report this to the nurse who takes over." The CNA stated that she was taught to do range of motion to the point of pain and "that's as far as I'm going."

An interview with the unit Licensed Practical Nurse (LPN), on 9/28/11 at 2:14 PM, revealed that when a CNA comes to her she "goes to the resident and is able to do limited passive range of motion while soaking the resident's hand and cutting her nails." The LPN stated that the CNA's come to her infrequently to perform ROM for the resident.

Monthly Medical Evaluation Forms, completed by the Physician were reviewed from 12/15/10 through 8/11/11 and revealed no evidence that the resident's contractures were noted or addressed. There was no current assessment of the resident's contractures in the Rehabilitation Notes or elsewhere in the clinical record to use to determine if there had been an increase in the degree of the resident's contractures.

There was no care plan with measurable and or objectives related to the care and services required to address contractures in order to prevent decline.

An interview with the Director of Nursing on 9/29/11 at 11:22 AM revealed that there was no system in place for periodic assessments of contractures by a Rehabilitation Therapist or other qualified health professional.

2. Resident #157 was admitted to the facility on 6/6/07 with diagnoses including Cerebral Vascular Accident (Stroke) with Left sided Paraplegia (paralysis), Diabetes Mellitus with Renal Involvement and Dementia with Depression.

Upon admission, the resident had contractures of the left elbow, hand and fingers. She received Physical and Occupational Therapy (PT & OT) and was discharged because she had reached her maximum potential in 2007 with orders to receive Range Of Motion (ROM) exercises to maintain flexion of her elbow, hand and fingers.

During an observation of the resident on 9/28/11 at 11:00AM, she was slumped in a chair with her left arm clutched to her chest and her left hand and fingers twisted inwardly. The resident wore no splint to maintain normal wrist and finger extension, no hand roll to extend her fingers nor other device to prevent decline in condition. With the resident's permission, the Certified Nursing Assistant (CNA) was able to extend the resident's fingers with careful manipulation.

Review of the resident's medical record revealed that the resident has had no PT, OT or other evaluation by a qualified health professional of the degree of her contractures since her discharge from rehabilitation therapy in 2007. (Further review revealed that the Nurse Practitioner (NP) had ordered an OT assessment on 9/27/11).

Review of the resident's Care Plan (CP) revealed that that the resident did not have specifications in the section of her CP that addressed ROM which specified how the repetitions/sets should be completed during cares and/or how often these should be done on a daily basis.

On 9/29/11 at 9:40AM in an interview with a CNA who cared for the resident, the CNA stated that the resident received limited ROM during cares but the CNA did not describe how the ROM was performed. The CNA stated that the resident's elbow and hand were always contracted and difficult to extend. The CNA stated that she did tell the Unit Manager Registered Nurse (UMRN) but doesn't remember when or if it was the current UMRN.

In an interview with the UMRN on 9/29/11 at 10:00AM, she said that she had not been informed regarding any changes in the resident's ROM by CNAs but that the NP had ordered an OT evaluation on 9/27/11.

In an interview with the NP on 9/29/11 at 10:05AM, he stated that he had ordered an OT consultation on 9/27/11 after a routine examination revealed a decrease in the resident's ROM and he was awaiting this evaluation.

In an interview with the OT on 9/29/11 at 11:30AM, she stated that residents were not periodically assessed for level of contractures. The OT stated that the facility policy was to re-evaluate residents only if requested by nursing, including residents with neurological impairments.

The OT was further interviewed regarding the training received by CNAs in order to provide the recommended follow up ROM exercises. The OT stated that the CNAs received this training at the time the resident was discharged from the rehabilitation services. (The resident was discharged from services in 2007). The OT stated that subsequent review or evaluation of the CNAs ability to perform ROM was not done.

The OT additionally stated that it is customary practice of OTs and/or PTs to recommend repetitions/sets of ROM exercises and the frequency ROM should be performed per day, but she did not explain why this had not been done for the resident.

415.12(e)

Based on interview and record review, the facility did not ensure that a resident's plan of care addressing nutritional concerns was implemented as written. This was evident for 1 of 4 residents (Resident #180) reviewed for nutrition. This has the potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY

The findings are:

Resident #180, with the diagnoses of Diabetes Mellitus and End Stage Renal Disease, was admitted to the facility on 8/17/11. According to the current Physician's Orders, the resident is dialyzed three times weekly and is on a Renal diet.

The initial Comprehensive Care Plan for Nutrition noted that the resident had a goal to adhere to therapeutic diet as evidenced by potassium level within the range of 3.5 to 5.5. The interventions to achieve this goal included Labs as ordered and to monitor for signs of hyperkalemia and hypokalemia.

On 8/17/11 the physican wrote an order for CBC (complete blood count) and CMP (complete metabolic panel that includes potassium level) to be obtained.

A review of a Communication Book used by the Dialysis Center and the facility revealed that on 8/24/11 the facility's Registered Dietitian RD requested that the Dialysis Center forward August labs. There was no documented evidence in the Communication Book that the Dialysis Center acknowledged the request or forwarded the lab results as requested.

On 8/30/11 a physician order was written to obtain lab work from the Dialysis Center.

On 9/30/11 in the morning the surveyor reviewed the resident's medical record and did not locate the results of the CMP and/or any lab work from the Dialysis Center. An LPN on the unit was then asked to locate the Lab work. After the LPN conducted a search, she informed the surveyor that she did not locate any lab work for the resident and that she would contact the Dialysis Center. This was done on 9/29/11 at 12:37 PM.

415.12

Based on record review and staff interview, the facility did not ensure that the services contracted for with a diialysis center pertaining to blood work were promptly implemented by the Dialysis Center for one resident (#180).

This was evident for one of one resident reviewed for dialysis services. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #180, with the diagnoses of Diabetes Mellitus and End Stage Renal Disease, was admitted to the facility on 8/17/11. According to the physician's orders, the resident is dialyzed three times weekly and is on a Renal diet.

The initial Comprehensive Care Plan for Nutrition noted that the resident had a goal to adhere to therapeutic diet as evidenced by potassium level within the range of 3.5 to 5.5. The interventions to achieve this goal included Lab as ordered and to monitor for signs of hyperkalemia and hypokalemia.

A review of a Communication Book used by the Dialysis Center and the facility revealed that on 8/24/11 the facility's Registered Dietitian RD requested that the Dialysis Center forward August labs. There was no documented evidence in the Communication Book that the Dialysis Center acknowledged the request or forwarded the lab results as requested.

On 8/30/11 a physician order was written to obtain lab work from the Dialysis Center.

On 9/30/11 in the morning the surveyor reviewed the resident's medical record and did not locate any lab work from the Dialysis Center. An LPN on the unit was then asked to locate the Lab work. After the LPN conducted a search, she informed the surveyor that she did not locate any lab work for the resident and that she would contact the Dialysis Center. This was done on 9/29/11 at 12:37 PM.

415.26(e)(i-iv)

Based on observation and interviews, the facility did not ensure that food is served at a proper temperature to residents. This was evidenced by complaints from three of nineteen residents interviewed about food temperatures, observations of delays in serving meals on the Ulster unit and the results of a test tray. This has the potential for minimal harm that is not immediate jeopardy..

The findings are:

1. Three interviews conducted during Stage I of the survey process revealed complaints that food is served cold.

2. On 9/28/11 the breakfast meal on the Ulster unit was observed. The trays contained in two food carts arrived in the dining room at the 8:05 AM. Seven nurses and CNAs distributed trays to the 24 residents in the dining room.

Resident #120 was observed lying in bed at 8:10 AM on 9/28/11, five minutes after the breakfast trays were delivered to the unit.

Seven staff members continued to distribute trays from the food carts to the residents in the dining room and set up the trays for the residents at 8:20 AM. Another resident arrived in the dining room at 8:20 AM. Two residents completed their meals and exited the dining room at 8:23AM.

The doors to the two food carts remained open throughout the process of serving the residents in the dining room. Resident #120 remained in bed at 8:28 AM without yet being served. The CNAs began delivering trays to residents in their rooms at 8:29 AM. The food cart doors were closed at that time.

Numerous residents were served in their rooms and assisted by the CNAs at 8:40 AM. Resident #120 was yet to be served. The resident's tray remained on the food cart in the dining room untouched until 8:55AM when the meal was delivered to her in her room, 50 minutes after the food carts arrived on the unit. A CNA then rearranged furniture and floor mats at the residents bedside, repositioned the resident in bed and set up the tray at 9:02 AM, 57 minutes after the trays had been delivered to the unit. The resident's breakfast consisted of farina, eggs, pancakes, milk and juice. The CNA fed the resident. She stated the resident was the last one to have breakfast.

The CNA was asked how she could tell that the bowl of farina was still hot. She stated that she does not check but she would know if the farina was still hot if the outside surface of the cereal bowl was hot. The CNA and the surveyor touched the outside surface of the bowl and it was cool. The CNA proceeded to feed the farina to the resident without attempting to heat it up. The CNA was asked how she knew that the eggs and pancakes were hot. She stated that they are kept warm in the food cart and by the metal hotplate inside the plate service container. The CNA and the surveyor touched the "hotplate." The hot plate felt cold to the surveyor. The CNA also stated that the plate was cold and proceeded to feed the pancakes and eggs to the resident without attempting to warm them.

After the CNA finished feeding the resident at 9:20 AM, the CNA stated that normally if food was cold she could bring it to the kitchen to be heated. She did not consider reheating the food today because she felt it had been staying hot since it was on the food cart until she served the resident. The CNA stated that she should have reheated it.

The resident was again observed on 9/29/11 at the breakfast meal. The two breakfast meal trucks arrived on the Ulster unit at 7:55 AM and 8:05 AM on 9/29/11. The meal tray for Resident #120 was delivered to her in her room at 9:05 AM, one hour after the food had been delivered to the unit. A CNA (not the one referenced above) then set up the resident's tray and began to feed the resident, without first checking to see if the pureed French toast, eggs and hot cereal were still hot. When asked how the CNA would ensure that the food temperatures were acceptable before she fed the resident, the CNA stated that the cereal did not seem warm to her so she would keep the top on it until it was time to feed it to the resident. The CNA did not attempt to heat the resident's food before serving it to her.

2. Additional observation of the breakfast meal on the Ulster Unit revealed that the distribution of the trays in the dining room began at least 10 minutes after the trays arrived. The nursing staff were observed trying to locate trays for specific residents in a disorganized fashion. (Trays were removed and put back in there truck repeatedly). This resulted in prolonging the time the residents were served and/or assisted to eat.

Three residents were assigned to eat at a feeding table. One nursing staff member began to assist one resident while the other residents ( Residents # 118 and #158) remained unassisted for 15 - 30 minutes. The bowl containing the cereal served to Resident #118 felt cold to the touch before it was given to the resident to eat, at least 30 minutes after the unidentified tablemate began eating.

3. The temperature of the food served to the resident above was tested at 9:01 AM. The results obtained in Farenheit were as follows:

Cereal before cold milk was added - 100
Scrambled eggs - 100
French Toast - 100

These items were measured at the following temperatures on the tray line in the kitchen:

Cream of wheat - 168
Scrambled eggs - not done \\
French toast - 160

415.14(d)(1)(2)

Based on observations and interviews, the facility did not ensure the housekeeping services necessary to maintain a sanitary, orderly and comfortable environment. Specifically, shower/bathing rooms were cluttered or had drapes hanging askew, 2 bathroom sinks had large pieces of formica missing, one bathroom had a strong urine odor and peeling wall paper, and privacy curtains were stained with brownish colored substances in many rooms (Ulster Unit), and soiled and dragging on the floor in one room (Unit Orange). Floors were soiled in some bathrooms and bedrooms. Walls were scuffed with black marks on all units, (Dutchess, Orange, Putnam and Ulster). This resulted in no actual harm with the potential for minimal harm.

Findings include but are not limited to:

During observation of Room #19 at 3:10PM on 9/26/11, multiple issues were noted including the floor in the bathoom and bedroom were soiled, the radiator under the window was soiled, the silver base of the resident's rolling hospital style table was rusty and soiled, the front surface of the resident's oxygen concentrator was dusty, the walls and bathroom door were scuffed, the floor around the base of the toilet was soiled, as were the plastic baseboard strips around the resident's bathroom and bedroom.

During an environmental survey of the facility on 9/29/11 between the hours of 12:30PM and 3:45PM, the following observations were made:

Ulster Unit - Privacy curtains were stained with brownish substances in the following rooms: 03, 05, 08, 10, 14, 16, 17 and 20. The bathing room located near room 13 had drapes which were not hooked to the rod in the middle and therefore were hanging with large gaps in the center. Large portions of formica were missing from the vanities in rooms 05 and 17. Walls were scuffed with black marks in rooms 05 (upper and lower walls), 10, 13 and 20. There was a strong odor of urine in the bathroom of room 10, and the wall paper was peeling off the walls in the bathroom.

In an interview with resident #162 on 9/28/11 at 12:10pm, she stated that curtains were stained since my admission 2 1/2-3 months ago. She stated that they have not been changed and her son had told the staff about them.

In an interview with the Housekeeper Manager on 9/29/11 at 3:00PM, he stated that he inspects all the privacy curtains on a monthly basis and changes them as needed. He was unable to explain how the curtain in room 05 was not changed.

Putnam Unit - Carpets in the corridors leading to and on the unit were buckling. Room 112 has deep gauges and black scuff marks in the entry hall to the room and the wall paper is ripped. The wall paper in the bathroom is also ripped. An armchair in the visiting room adjacent to this room has a ripped arm and the stuffing is visible.

Dutchess Unit - Rooms 128, 131 and 140 had radiators with rusty colored areas and walls with black scuff marks.

Orange Unit - On 9/26/11, at 2:25PM it was noted that one of the 2 privacy curtains has 6 inches which drags onto the floor is soiled in room 219 and is stained. The other privacy curtain is stained.

The drapes in the bathing area near room G13 were hanging askew with large sections in the middle off their hooks. Walls were scuffed with black marks in rooms G05 (upper and lower walls), G10, G13 and G20. Large portions of formica were missing from the sinks in rooms G05 and G17. There was a strong odor of urine in the bathroom of G10 and the wall paper was peeling off the walls in the bathroom. The entry area to the room was covered with black scuff marks.

Room 112 has deep gouges in the entry hall to the room, wall paper is ripped. The wall paper in the bathroom is ripped as well. The armchair has ripped armrests and stuffing is visible. Rugs in hallway corridors are buckled and seams in the hall to right of nurses' desk which faces the desk are starting to fray.

In an interview with the Housekeeper Manager on 9/29/11 at 3:00PM, he stated that he inspects all the privacy curtains on a monthly basis and changes them as needed. He was unable to explain how so many curtains in these rooms were not changed.

In an interview with the Director of Maintenance on 9/29/11 at 3:40PM, he stated that the ripped wallpaper and scuff marks throughout the facility were not reported to him.

415.5(h)(2)

Based on observation, interview and record review, the nurse staffing information posted by the facility, to be available for residents and visitors to review, did not include all the required data.

This resulted in the potential for minimal harm that is not immediate jeopardy.

The findings are:

During the initial tour of the facility at 8:30AM on 9/26/11, nurse staffing information was located at the reception desk in the lobby. The data did not include all of the information that is required to be posted. The staffing data indicated the total number of licensed nursing staff members. This licensed nursing staff data did not differentiate the number of RNs (Registered Nurses)working per shift and the number of LPNs (Licensed Practicial Nurses), as required. Additionally, the total hours worked by RNs, LPNs and non-licensed CNA (Certified Nurse Aide)staff members, per job category, was not indicated.

The DNS (Director of Nursing Services) was interviewed at 9:15AM on 9/26/11. The DNS stated that the staffing coordinator posts the nurse staffing information throughout the week and the nursing supervisor posts the data on the weekends according to this standard format that has been used daily. The DNS and the Administrator, who was also present during the discussion, were not aware that the data posted was required to include numbers of RN staff members differentiated from LPN staff members and that the total hours worked for each category of staff member, RNs, LPNs and CNAs, was also required to be posted.

Based on observation and interview it was determined that the fire alarm system is not being maintained in accordance with NFPA 70 National Electric Code and NFPA 72 in that strobe lights o n four of four resident units are not synchronized.

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

Findings are:

On 9/27/11 beginning at 10:25AM during a test of the fire alarm system it was observed that the strobes (visible notification appliances) located between the Nurses' Stations and Day Rooms on four of four nursing units were not synchronized. These areas had t hree strobe lights flashing out of sequence in any field of vi sion.

I n an i nterview on 9/27/ 11 at 11: 2 0AM the Director of Maintenance stated that the problem would be addressed.

NFPA 72 (1999 edition) 1-5.4.6, 5-4.2.1, 3-8.2.3
NFPA 101 (2000 edition) 19.3.4, 9.6.5.1, 9.6.5.4
10 NYCRR 711.2(a)(1)