The Hamptons Center for Rehabilitation and Nursing

Based on observations and staff interviews during the recertification survey, the facility did not ensure that Housekeeping and Maintenance Services maintained a sanitary, orderly and comfortable interior. This was evident on 6 (Units F, G, D, E, C, and A) of 7 resident nursing units. Specifically, resident equipment was not maintained in good repair by the housekeeping and maintenance services. Examples include but are not limited to: 1a) the left and right arm rests of a wheelchair in Room 286 R Unit G were torn; 1 b) the right arm rest of a motorized wheelchair for Room 207 of Unit D was in disrepair with sharp edges; 1 c) the right and left arm rests of a wheelchair for Room 233 R of Unit E were torn. The findings also include either the right or left or both arm rests of the wheelchairs for Rooms 124 R on Unit F, Rooms 246, 277, and 272 L on Unit G, Rooms 228 L, 233 L, 230 R, 231 L, and 231 R on Unit E, Rooms 149 R, 163 L, and 155 on Unit C and Rooms 114 L, 103 R, 115 R, 120 R, 113 R and 111 L on Unit A.
2) all rooms were not kept clean and orderly. This was evident during observational tour of an out of sample room on Unit D.

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

The findings include but are not limited to:

1a) During the initial observation tour of Unit G conducted on 8/18/11 at 10:15 AM, it was observed that the left and right arm rests of a wheelchair in Room 286 R Unit G were torn. This was brought to the attention of the Registered Nurse (RN).

The RN was immediately interviewed and stated that she was not aware of the wheelchair condition and that she will write a work order for the Maintenance Department on the wheelchair.

1b) During the initial observation tour of Unit D with the Registered Nurse (RN) Charge Nurse conducted on 8/8/11 at 10:25 AM, it was observed that the right arm rest of a motorized wheelchair for Room 207 of Unit D was in disrepair with sharp edges.

The RN was immediately interviewed and stated that she was not aware of the wheelchair condition and that she will write a work order for the Maintenance Department regarding the wheelchair.

1c) During the initial observation tour of Unit E with the Licensed Practical Nurse (LPN) Charge Nurse conducted on 8/2/11 at 9:15 AM, it was observed that the right and left arm rests of a wheelchair for Room 233R were torn.

The RN was immediately interviewed and stated that she did not know about the condition of the wheel chair and that the Certified Nursing Assistant (CNA) did not inform her about the condition of the arm rests of the wheelchair. The RN also stated that she will complete a work order for the Maintenance Department to look at the mentioned wheel chair.

The Maintenance Department Director was interviewed on 8/23/11 at 2:30 AM. The Director stated that a work order was done and completed for the wheelchairs as of this interview.

2) During an initial tour on Unit D, one out of sample room was observed to be dirty with food and non-food debris and was in need of cleaning.
Specifically, in Room 206 an observation of the resident area nearest to the window revealed that there were food crumbs on both the window sill and floor. The privacy curtain was visibly soiled and in need of cleaning. In addition, there were floor tiles underneath two urinals which appeared to be soiled and in need of cleaning.
An interview with the responsible housekeeper was conducted on 8/18/11 at 10:00 AM and revealed that the last time he had cleaned this room was the day before at 11:00 AM. He also stated that the laundry person was not in the facility and that he was also responsible for delivering clothing as well.
415.5(h)(2)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that Accident/Incidents (A/I) were thoroughly investigated to determine that neglect, abuse or mistreatment did not occur and to prevent further potential accidents or incidents. This is evident for 7 of 8 records reviewed in a total of 30 sampled residents (Residents #3, #24, #26, #27 and #30) and 3 (Residents #43, #44, and #45) of 3 out of sample residents reviewed for A/I. Specifically, 1) A/I Reports for Residents #27, #24, #30,
#26 did not contain documented evidence that assistive devices for fall prevention such as bed and chair alarms or non-skid socks were in place as documented in the Comprehensive Care Plan (CCP) and Resident Profile Form 2) A/I Reports for skin tears/bruises of unknown origin generated for Residents #27, #3, #43, #44 and #45 did not contain documented evidence that statements from a second Certified Nursing Assistant (CNA) that provided care to these residents who required a 2 person assist, was obtained to ensure that neglect, mistreatment, or abuse had not occurred. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1) Resident #26 has diagnoses including Sternal Fracture Status Post Chest Compression and Degenerative Joint Disease.

The Minimum Data Set (MDS) Annual Assessment dated 5/13/11 documented the resident as cognitively intact and requiring extensive assistance of one person for ambulation and that the resident uses a wheelchair as an assistive device.

The A/I Report dated 5/3/11 at 2:50 PM documented that the resident fell out his wheelchair while "trying to transfer self from the standard wheelchair to scooter". A statement obtained from a CNA, who provided care to the resident on the day shift when the incident occurred, contained no documented evidence that an alarm was in place and functioning. The A/I Report was signed by the Assistant Director of Nursing Services (ADNS) as designee for the DNS.

The Nurses' Notes dated 5/311 documented that "... I did not note a chair alarm in wheelchair at time, nor was it sounding so I instructed staff to place in wheelchair ..."

The CCP developed for At Risk for Falls dated 5/3/11 documented that the resident had a history of falls on 12/6/10, 12/13/10, 12/28/10, 9/6/10, 9/1/10 and 2/4/11. The CCP included interventions of bed and chair alarms that were initiated 5/3/11.

The Registered Nurse (RN) who submitted the A/I Report was interviewed on 8/23/11 at 10:00 AM. The RN stated that the bed or chair alarms should have been in place since the resident had a previous history of falls.

A Subsequent A/I Report dated 5/24/11 at 12:45 PM documented that the resident was found lying on the floor by the side of his motorized wheelchair. A statement obtained from the CNA that reported the incident contained documented evidence that at the time care was provided, alarms were "not applicable".

The two A/I Reports signed by the ADNS as designee for the DNS documented that there was no break in policy and protocol.

The CCP for Falls updated 5/24/11 did not include preventive devices such as chair and bed alarms as intervention.

The Resident Profile Form updated 5/25/11 documented chair and bed alarms for fall prevention.

The ADNS was interviewed on 8/23/11 at 2:00 PM and stated that the bed and chair alarms should have been in place.

2) Resident #30 has diagnoses including Gait Disorder and Exacerbation of Chronic Obstructive Pulmonary Disease (COPD).

The MDS Quarterly Assessment dated 5/13/11 documented the resident as moderately impaired in cognition and requires supervision and no set up help from staff.

The A/I Report dated 7/6/11 at 11:30 AM documented that the resident was found on the floor at bedside with no socks on. The resident sustained a right elbow open wound, 1 centimeter (cm) by 1 cm.

The CCP developed for At Risk for Falls dated 2/8/11 documented interventions that included to provide non-skid socks/slippers.

The undated Resident Profile Form documented non-skid socks as a fall prevention intervention.

The A/I Report was signed by the ADNS as designee for the DNS and documented that there was no break in policy and protocol.

The ADNS was interviewed on 8/23/11 at 2:00 PM and stated that the non-skid socks should have been in place.

3) Resident #27 has diagnoses including Status Post Open Reduction Fracture and Closed reduction of Left Shoulder.

The MDS Admission Assessment dated 6/30/11 documented the resident as severely impaired in cognition and requires total dependence on one person for assist with dressing, eating, locomotion and personal hygiene and two persons for assist with bed mobility, transfer and toilet use.

The A/I Report dated 8/4/11 at 3:00 PM documented that the resident was found on the floor next to her wheelchair and sustained a 4.5 cm by 1.5 cm skin tear. A statement obtained from a CNA who provided care to the resident on the day and shift the incident happened, contained no documented evidence that alarms were in place and functioning. There was no mention whether the non-skid socks were in use by the resident.

The Resident Profile Form dated "7/8" documented chair and bed alarms for fall prevention and non-skid socks.

The CCP developed for At Risk for Falls dated 6/23/11 documented interventions that included to provide bed and chair alarms.

The A/I Report Section II, Summary of Investigation, was signed by the ADNS as Risk Manager documenting that there was no break in policy and protocol.

A/I Reports for Resident #27 dated 6/30/11 and 8/9/11 regarding skin tears of unknown origin contained no documented evidence that statements from the second CNA who provided care to the resident as well as CNA's from previous shifts were obtained to ensure that neglect, mistreatment or abuse had not occurred.

The ADNS was interviewed on 8/23/11 at 2:00 PM and stated that the chair and bed alarms should have been in place. The ADNS also stated that there was no need to obtain the statement of a second CNA for this resident who required a 2 person assist, to complete the A/I Report.

The facility's policy dated 2/5/10 titled Resident Injury of Unknown Origin documented "...Employees who provided or assisted with resident care for the 24-hour period prior to the discovery of the injury are to complete staff member statements...".

415.4(b)(l)(ii)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that a physician not delegate a task when the regulations specify that the physician must perform it personally or when the delegation is prohibited under State law or by the facility's own policies. This includes, but is not limited to, delegating and supervising follow-up visits to interns. This is evident for 3 residents (Residents #15, 26 and 27) in a total of 30 sampled residents and 4 (Residents #34, 35, 36 and 37) out of sample residents reviewed for medical care supervision by a physician. This was evident on 5 (Units B, C, D, E and G) of 7 Nursing units. Specifically, Resident's #34, 35, 27, 15, 26, 36, and 37's medical records contained Progress Notes and/or Physician Orders signed by an intern. There was no documented evidence by the Attending Physician that the Physician Orders and/or Intern's Progress Notes were approved in writing. This resulted in no actual harm with the potential for more than minimal harm that is not immediately jeopardy.

The findings include but not limited to:

1) Resident #34 has diagnoses including Atrial Fibrillation.

The Physician's Order dated 7/30/11 contained documented evidence of an identification stamp and signature of an intern. The form did not contain documented evidence by the Attending Physician that the Physician's Orders were personally approved by the Physician.

The Physican Monthly Progress Note dated 5/24/11 contained documented evidence of a signature of an intern. The Form did not contain documented evidence by the Attending Physician that the Monthly Progress Notes were approved.

The signatures of the intern on the above documents were confirmed with the Registered Nurse (RN) Charge Nurse on 8/23/11 at 10:00 AM. The RN stated that there was no signature of the Attending Physician on either document.

2) Resident #36 has diagnoses including Chronic Obstructive Pulmonary Disease.

A Physician Progress Note dated 8/17/11 contained a signature of an intern. The Note did not contain a signature of the Attending Physician indicating that he personally reviewed and approved the intern's note.

The signature of the intern on the document was confirmed with the Unit RN on 8/23/11 at 10:20 AM. The RN stated that there was no signature of the Attending Physician on the document.

3) Resident #15 has diagnoses including Paraplegia.

The Resident's Admitting History and Physical Physicians Plan of Care Form dated 8/19/11 contained documented evidence of an identification stamp and signature of an intern. The Form did not contain documented evidence of a signature by the Attending Physician indicating that he personally approved the plan of care.

The Physician's Order dated 8/19/11 contained documented evidence of an identification stamp and signature of an intern. The Form did not contain documented evidence by the Attending Physician that he personally approved the document.

The identification stamp and signature of the intern on the above documents were confirmed with the Licensed Practical Nurse (LPN) Charge Nurse on 8/23/11 at 10:30 AM. The LPN stated that there was no signature of the Attending Physician on both documents.

The Medical Director stated that there is no regulation that the intern's orders and progress notes/history and physical notes of a resident require the Attending Physician's signature of approval. The Medical Director also stated that the interns are also physicians and have licenses from other states. The Medical Director further stated that the interns are under the Attending Physican's supervision under a program.

415.15(b)(4)(i)(ii)

Based on record review and staff interview during the recertification survey, the facility did not ensure that the resident's assessments accurately reflect the resident's status. This was evident for one (Resident #19) of thirty sampled residents. Specifically, Resident #19's Minimum Data Set dated 7/28/11 did not accurately document the resident's functional abilities. This resulted in no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.

The finding is:

Resident #19 has diagnoses which include Asthma and Hypertension.

The MDS dated 7/28/11 documented the resident required extensive assist of one staff for dressing, hygiene and bathing.

The Comprehensive Care Plan (CCP) developed for dressing, initiated 4/28/11 and updated 7/15/11 documented that the resident required supervision for dressing the upper body and was independent in dressing the lower body.

The CCP developed for personal hygiene initiated 4/28/11 and last updated 7/15/11 documented that the resident required supervision for personal hygiene.

The CCP developed for bathing initiated 4/28/11 and last updated 7/15/11 documented that the resident required supervision for bathing.

The MDS Coordinator was interviewed on 8/23/11 at 10:08 AM. The MDS Coordinator stated that she did not know why there are discrepancies with the MDS and the CCP. She stated that the CCP reflects the resident's true functional status.

415.11(b)

Based on record reviews and staff interviews during a recertification survey, the facility did not ensure that each resident's clinical record was complete, accurately documented and maintained in accordance with standards of practice. This is evident in 4 current resident records (Residents #9, #10,#19 and #21) and 2 (Residents #28 and #29) closed records in a total sample of 30 resident records reviewed. Specifically, 1) 4 (Residents #9, #10,#19 and #21) of 30 residents' Medication Administration Records (MAR) and Treatment Administration Records (TAR) did not have documented evidence of signatures that medications or treatments were administered on different dates and shifts as ordered by the physician. 2) Residents #28 and 29 had orders for Purified Protein Derivative (PPD, an intradermal test to determine if the individual is positive for Tuberculosis). The MAR May 2011 for Resident #29 documented no evidence that the first set of PPD was completed and read. The March 2011 MAR for Resident #28 documented no evidence that the second set of PPD was completed and read. 3) for Resident #19, the Social Work Interim Assessment form was incorrectly altered. T his resulted in no actual harm but had the potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1a) Resident #9 is 46 years old and was admitted to this facility on 6/28/11 with diagnoses that included Left Ankle Fracture and Seizures.

The Physician's Order dated 6/29/11 documented left lower extremity vascular checks every shift; Phenobarbital (medication to provide sedative or hypnotic effect) 30 milligram (mg) by mouth at bedtime; pain observation each shift; check box if the resident verbalizes or exhibits signs and symptoms of pain.

The MAR dated 7/20/11 did not have documented evidence of a signature to indicate that the medication Phenobarbital 30 mg. by mouth at bedtime was administered.

The TAR dated 7/29/11 did not have documented evidence of signatures to indicate that the left lower extremity vascular checks were performed on each shift.

The TAR dated 7/30/11 and 7/31/11 did not have documented evidence of signatures to indicate that a pain observation on each shift was completed or a check in the box indicating that the resident verbalizes or exhibits signs and symptoms of pain was completed for Resident #9.

1b)Resident #19 is a 69 year old female who was admitted to this facility on 4/28/11 with diagnoses that included Schizoaffective Disorder and hypertension.

A Physician Order dated 5/5/11 documented Abilify (anti-depressant medication) 10mg. 1 tablet by mouth every day.

A Physician Order dated 8/10/11 documented Depakote ER (anti-seizure medication) 250 mg. in AM.

The MAR dated 5/5/11 at 9:00 AM did not have documented evidence of signatures to indicate that the medication Abilify 10mg. by mouth was administered to Resident #19 on 5/19/11 and 5/20/11.

The MAR dated 8/10/11 at 9:00 AM did not have documented evidence of signatures to indicate that the medication Depakote ER 250 mg. was administered to Resident #19 on 8/20/11 through 8/22/11.

The 8:00 AM-8:00 PM RN Supervisor was interviewed on 8/23/11 at 1:00 PM. The RN stated that after the resident is administered the medication, the MAR should be signed by the medication nurse.

The Medication Nurse was not available for interview.

2) Resident #29 has diagnoses including Status Post (S/P) Falls and Weakness.

The Physician Order dated 5/28/11 documented PPD 0.1 milliliter (ml) inject intradermally times 1, read in 48 hours. If negative repeat in 10 days. Read in 48 hours with diagnosis to rule out Active Disease.

The MAR May 2011 for Resident #29 documented no evidence that the first set of PPD was completed and read.

The Nurses' Notes for May 2011 did not contain documented evidence that the first set of PPD was completed and read as ordered.

The Medical Director was interviewed on 8/22/11 at 1:20 PM, he stated that when a medication or a treatment is administered to the resident, the nurse should sign the appropriate documents such as the medication administration record and the treatment administration record.

The Director of Nursing Services (DNS) was interviewed on 8/23/11 at 2:30 PM. The DNS stated that the MAR should be signed by the medication nurse after the resident is administered the medication.

The Facility's Policy dated 2/10/10 titled Medication Pass documented
"Immediately after medication is administered to the resident the nurse is to place his/her initials in each medication box, on the MAR, under the date and time the medication was administered. "

The Facility's Policy not dated titled Treatment Administration Record Documentation of Routine Treatment documented "the person administering a treatment initials the resident's TAR in the space provided under the date".

3) Resident #19 has diagnoses which include Schizoaffective Disorder and Delusion with Confusion.

The MDS dated 7/28/11 documented a Brief Interview for Mental Status (BIMS) score of 8.

The CCP developed for cognition initiated on 4/29/11 and updated 7/14/11 documented a BIMS score of 12.

The Quarterly Social Work Interim Assessment form dated 7/14/11 documented a BIMS score of 10.

During an interview conducted with the Social Worker (SW) on 8/23/11 at 9:30 AM regarding Resident #19 BIMS score, the SW was observed changing the 1 to a 0 and the 0 to an 8 on the Quarterly Social Work Interim Assessment form dated 7/14/11.

The SW was interviewed immediately, she stated that she should have put a line through the BIMS score of 10 with her initial and date.

The Director of Social Work was interviewed on 8/23/11 at 10:00 AM. She stated that the SW should not have incorrectly changed the BIMS score on the Quarterly Social Work Interim Assessment form dated 7/14/11.

415.22(a)(1-4)

Based on observations and staff interviews during the recertification survey, the facility did not ensure that resident's were cared for in a manner that enhances each resident's dignity. This was evident for 2 out of sample residents (Residents #41 and 42) during a medication pass observation; 1 of 2 residents observed for pressure ulcer dressing changes and 1 in a total of 30 sampled residents during observational tour. Specifically, 1) Residents #41 and 42 were observed having their blood pressure (B/P) and pulse taken while a recreation program was in progress with the other residents. The residents were not offered privacy prior to care. 2) Resident #17 who was observed for pressure ulcer dressing changes did not have a privacy curtain drawn and the room door was left opened. 3) Resident #18's urine collection bag was full of tea colored urine hanging along side the lower rail of the resident's bed. There was no cover on the urine collection bag. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy.

The findings are:

1) On 8/19/11 at 10:30 AM during a medication pass, the Licensed Practical Nurse (LPN) medication nurse was observed taking the blood pressure of Resident #41 and the blood pressure and pulse of Resident #42 while a recreation program was in progress . It was also observed that the LPN removed the left arm sleeve of Resident #41's outer sweater to obtain the blood pressure reading. The LPN did not offer to take the residents to a private area prior to care.

The LPN was interviewed immediately, she stated that she should have taken the residents to a private area prior to taking their blood pressure.

The Director of Nursing Services (DNS) was interviewed on 8/23/11 at 2:30 PM. The DNS stated that the LPN should have offered to take the residents out of the dining room to have their blood pressure taken.

2) Resident #17 has diagnoses including Right Hip Fracture.

During the left foot dressing change observation for Resident #17 on 8/19/11 at 6:25 AM, the LPN uncovered the blanket exposing the resident from the waist down to the feet. The resident wore a diaper. The resident resided in a room with a roommate present. The privacy curtain was not drawn and the room door was not closed during the dressing procedure.

The LPN was immediately interviewed and stated that she should have drawn the privacy curtain and shut the room door.

3) Resident # 18 has diagnoses that include Benign Prostatic Hypertrophy and has a Supra Pubic Catheter in place. An observation was made of Resident # 18 on 8/22/11 at 2:15 PM. The resident was asleep in bed and the urine collection bag was full of tea colored urine hanging along side the lower rail of the resident's bed. There was no cover on the urine collection bag.

The current comprehensive care plan dated 7/20/11 documented that the suprapubic catheter urinary drainage bag was to be covered to promote dignity and provide privacy.

An interview with the Charge Licensed Practical Nurse on 8/23/11 at 11:00 AM revealed that she could not explain why the urine bag was not covered to provide dignity on the afternoon of 8/22/11 but that the girls (Certified Nurse Aides) are usually good about doing that.

415.5(a)

Based on observations, staff interviews and record reviews during the recertification survey, the facility did not assure that the resident environment remains as free of accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents. This is evident in 2 observational tours conducted during the recertification survey. Specifically, 1) Resident # 25 with diagnoses including Dementia and Aspiration Precautions was observed in an unsupervised area with thin liquids within reach. In addition, the area surrounding the resident was in need of cleaning. 2) During the initial tour, the Beauty Parlor was not locked and liquid chemicals were in full view. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
This was a repeat deficiency.
The finding is:
1) Resident # 25 has diagnoses that include Advanced Dementia and is on Aspiration Precautions.
Observation on Friday, 8/19/11 from 1:15 PM to 1:45 PM following the unit lunch meal revealed the following: Resident #25 was seated in a geri-recliner chair in the sub-unit area without nursing staff supervision in the area. A family member was not present during that time.
There was a lunch meal tray still full of unoffered foods and fluids placed on the seat cushion of a near-by upholstered chair. The (dome) lid for the entree dish was placed on an arm rest of the upholstered chair and on the other arm rest of the chair, was an empty plastic wrapper.
The resident was poorly positioned in the geri-recliner leaning to one side.
The resident had a half consumed four ounce juice container within reach in front of her in which the aluminum foil cover was half opened and still remained on the juice container. The resident also had a hair comb in which she was observed, at one point combing her hair. In addition, there was a half eaten chocolate bar on the table near to the resident.
The resident's meal tray main entree was untouched. The slice of bread still had the wrapper on it and remained on the lunch tray. Other items, i.e., the coffee, dessert and margarine were all untouched.
There were no nursing staff in view despite this resident being left alone in the subunit area by herself.
Approximately ten minutes later an Licensed Practical Nurse (LPN) was observed walking past the sub unit area. The same LPN was asked by the surveyor to observe the area where resident #18 was seated.
An interview with the LPN on 8/19/11 at 1:50 PM was conducted. The LPN stated that she could not explain what she observed. She did explain that the resident should not have been left alone in this area. She also stated that she had been supervising in the floor dining room for the lunch meal and that she is a float nurse. She stated that she would have the area cleaned up and order a new lunch tray for Resident #25.
An interview with the Unit Charge Licensed Practical Nurse on 8/19/11 at 2:30 PM revealed that the son visits the facility often and that the family member never informed the nursing staff that he was leaving the facility and or the resident alone like this. The Unit Charge LPN further explained that the son visits regularly and had been with the resident during the lunch meal and that this area (the subunit) was where he and the resident spend time together.
The Administrator and the Director of Nursing Services (DNS) were interviewed on 8/19/11 at 3:00 PM and stated that the facility staff have been working with the family member who is part of the problem.
There was no documented evidence in the medical record that an effective plan had been developed to ensure resident safety during the meal time and when family visits and to ensure that the environment was free of accident hazards.
An interview with the DNS and the Administrator was conducted on 8/19/11 at 3:00 PM. The DNS explained that the nursing staff has been working along with the responsible family member to ensure that both the resident and family were satisfied with the current arrangement. They also explained that the area that the resident was left alone in was "his area". She also stated that the family member is capable of feeding his mother safely.
A second interview was conducted with the DNS on 8/23/11 at 2:30 PM. The Director of Nurses stated that she would be willing to initiate a care plan meeting to address the concerns identified with the family member. In addition, the DNS stated that this is the resident's living room and that the facility has tried to accommodate family wishes for visitation.

2) During the initial observational tour conducted on 8/18/11 at 8:10 AM, it was observed that the Beauty Parlor was not locked. The following were noted inside the Beauty Parlor:
- two bottles of Barbicides
-one bottle of Ajax Dish Detergent.

A Licensed Practical Nurse (LPN) who was in the vicinity of the Beauty Parlor was interviewed on 8/18/11 at 8:15 AM. The LPN stated that the Beauty Parlor should have been locked.

The Maintenance Director and Housekeeping Director were interviewed on 8/23/11 at 2:35 PM and 2:45 PM, respectively. Both Directors stated that the Beauty Parlor should have been locked when not in use.

The Material Safety Data Sheet (MSDS) for Barbicide documented that Barbicide causes eye burning sensation, watering or redness, and skin irritation on exposure. Barbicide on prolonged inhalation exposure may cause nausea, dizziness or disorientation.

The Material Safety Data Sheet (MSDS) for Ajax Detergent causes severe eye and skin irritation on direct contact and may be harmful if swallowed in large quantities.

415.12(h)(1)

Based on record review and nursing staff interview during the recertification survey, the facility did not ensure that all residents received ordered medications in a timely manner. Specifically, Resident #25 had at least ten different medications which were ordered at 9 AM and as per nursing staff interview, were not given until noon time. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The finding is:
Resident #25's Medication Administration Record (MAR) was reviewed on 8/23/11 at approximately 10:45 AM. All of the planned 9 AM medications were not signed by nursing indicating that the medications were not administered.
The following medications were documented on the MAR to be given at 9 AM: Cranberry Capsule, Ferrous Sulfate, Lopressor, Ditropan, Zoloft, Vitamin C, Promod and Ensure Plus.
An interview with the Medication Registered Nurse at that time stated that she had not given Resident #25 the 9 AM medication yet. She explained that she is a float nurse and she had not gotten to give the resident her medications yet. She also explained that she does not know the resident's on the unit.
An interview with the Charge Nurse (Licensed Practical Nurse) on 8/23/11 at 11:30 AM revealed that she (the resident) was out. She also stated that the resident had left the building with her son at either 7:30 and/or 7:40 AM. In addition, the LPN stated that the son was asked when he anticipated returning and he responded that he was not sure but by noon time. The Charge Nurse also explained that sometimes the son comes in even earlier to take the resident out on pass.
An interview with the day time Supervising Registered Nurse on 8/23/11 at 12:15 PM revealed that (the nursing staff) should have called the MD for an order to give the medications early (before the resident left the building at 7:40 AM) and not wait until the afternoon return.
A telephone interview was conducted with the Charge LPN on 8/23/11 at 1:00 PM. She stated that the resident returned to the facility at 11:50 AM.
415.18 (a)

Based on staff interviews and record reviews during an abbreviated survey, the facility did not ensure that each resident's legal representative or an interested family member was notified in a timely manner of an accident involving a resident which resulted in an injury requiring physician intervention in an Emergency Room (ER). Specifically, one (Resident A) of three residents reviewed for accidents sustained a fall with a bloody nose; the resident was transferred to the (ER) for an evaluation where she was diagnosed with a nasal fracture. Resident A's legal representative was not notified of the injury or transfer to the ER.
This resulted in no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.

Complaint ID Number: NY 00100447

The finding is:

Resident A was 84 years old and admitted to the facility on 01/06/2009 with diagnoses including Dementia.

The Minimum Data Set 3.0 (MDS) (an assessment tool) dated 04/04/2011 documented Resident A's cognition status as moderately impaired.

The Nursing integrated progress note dated 03/24/2011 7:00PM-7:00AM documented, that the resident "fell on the floor, with a bloody nose; family aware".
At 1:15 AM the note documented that "Resident A was found on the floor, doctor notified, ordered to send Resident A to the ER, daughter aware of same"; At 4:30 AM the note documented that the resident was returned from the hospital ER with a nasal fracture.

Resident Occurrence report dated 03/24/2011 at 1:45 AM documented "the designated representative was notified."

Memo to the file dated 05/06/2011 documented during a meeting with the Director of Nurses (DON) and Assistant Director of Nurses (ADON), Licensed Practical Nurse (LPN) A stated "to tell the truth I don't remember calling the family; I was afraid to tell before."

The facility investigation dated 05/06/2011 documented phone records were reviewed related to the phone call made to Resident A's daughter. There was no phone number dialed that was remotely close to any of the contact numbers on Resident A's chart.

The Occurrence Report for Resident A dated 02/05/2010 documented an accident is an unexpected, unintended event that can cause a resident bodily injury. The designated representative is to be notified of the accident.

On 05/10/2011 at 11:30 AM , an interview was conducted with the ADNS, she stated that an investigation was done after the daughter's complaint that she did not receive a call after Resident A's fall and was sent out to the ER. The ADNS stated "during the initial investigation the documentation and staff interview it looked like the call was made to Resident A's daughter." When the phone records did not show that the call was placed to the daughter, the LPN was re-interviewed and admitted that she documented that Resident A's family was called, but in fact the call was never placed. The ADNS stated that the family member should have been notified of the occurrence.

Interview with the 11:00 PM-7:00 AM LPN #2 was conducted on 05/26/2011 at 2:50 PM. LPN#2 stated that on 03/24/2011, Resident A fell around 1:00 AM and she wrote a note in the nurse's note stating that she (LPN) #2 called the family. LPN #2 also stated that after writing in the nurses notes she completely forgot to call the resident's daughter because it was very busy that night.

Interview with the Registered Nurse (RN) on 06/06/2011 at 3:10 PM was conducted. The RN stated that she was called to the unit by the unit LPN because Resident A fell. The RN also stated that she knew Resident A's family was very involved in the resident's care and would want to be notified about the incident. The RN asked the LPN to call the family member to notify them of Resident A's transfer to the ER. Later the RN questioned the LPN whether the family was notified and the LPN responded in affirmation. The RN stated that the family should have been notified of the incident.

415.3(e)(2)(ii)(a)

Based on observations, record review and staff interviews during the recertification survey, the facility did not ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs. This was evident for 1 (Resident #17) of 9 residents observed and reviewed for assistive device in a total of 30 sampled residents and one (Resident #40) out of sample resident. Specifically: 1) Resident #17 had an order for a knee separator. The resident was observed lying in bed on two separate occasions without the knee separator in place. 2) while in a resident's (Resident #40) room , the CNA did not address the resident's needs with regard to the nasal cannula timely. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #17 has diagnoses including Right Hip Fracture and Dementia.

The Minimum Data Set (MDS) Quarterly Assessment dated 5/31/11 documented that Resident #17 is severely impaired in cognition. The MDS also documented that resident is totally dependent on one person assist for Activities of Daily Living (ADLs). Additionally, the MDS documented that the resident had impairment of both sides of the upper and lower extremities that interfered with daily functions.

A Physician's Order for 8/4/11 documented knee separator when in bed and in wheelchair off for hygiene and skin checks every shift.

During an observation tour of the unit on 8/19/11 at 7:15 AM, it was noted that Resident #17 was lying in bed with bilateral lower extremities flexed at 90-degree angle without a knee separator in place. It was noted that both knees were in contact with each other.

Another observation of the resident's room was made on 8/22/11 at 8:30 AM with the Registered Nurse (RN) Charge Nurse and Certified Nurses Aide (CNA) responsible for Resident #17. There was no knee separator applied between the resident's knees.

The RN and CNA were both immediately interviewed and both stated that the resident should have the knee separator in place. The CNA stated that she should have placed the knee separator for the resident.

2) An observation was made on 8/19/11 at approximately 1:15 PM in Resident # 40's room. The resident was observed seated in a lounge chair in his room. The oxygen concentrator was turned on and the noise from the concentrator was easily heard once in the resident's room. Further observation revealed that the resident's nasal cannula and tubing was not in his nose but was laying on the floor tile along side of the resident's lounge chair.

While in resident's room, a Certified Nurse Aide walked into the room in close proximity to the resident. The aide took the resident's completed lunch tray from the over bed tray table and left the room without taking notice of the resident's condition.

During an interview with the Certified Nurse Aide on 8/19/11 at 1:28 PM, she stated that she did not realize that the resident's nasal cannula tubing was lying on the floor when she walked into the resident's room. She also stated that if she had noticed that the tubing was on the floor, she would have fixed the tubing.

415.26(c)(1)(iv)

Based on staff interview and record review during the recertification survey, the facility did not ensure that a resident who is fed by gastrostomy tube receives appropriate treatment and services. This is evident for one (Resident #25) of 5 residents with tube feedings reviewed in a total of 30 residents. Specifically, Resident #25 is fed via a Gastrostomy tube (G-tube). Resident #25's Medication Administration Record documented Ensure Plus as a supplemental feed without the route via G-tube being written. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #25 has diagnoses that include Advanced Dementia and Aspiration Precautions.

An out dated order documented on 6/9/11 at 3PM reads: Ensure plus 240 cubic centimeter (cc) three times per day via G-tube.

The current Physician's order dated August 2011 and signed 8/5/11 documented under the title "Supplements" the following: Ensure Plus eight ounces three times daily- record the amount consumed.

The current diet order documented a Regular Diet of ground consistency. Resident should be seated upright at a 90 degree angle. No straw. No bread.

Review of the current Medication Administration Record (MAR) dated August 2011 documented an order for a supplemental feeding of Ensure Plus; eight ounces three times daily. Record the amount consumed on the MAR. Dx Supplement.

An interview with the Medication Nurse Licensed Practical Nurse (LPN) on 8/23/11 at 10:00 AM revealed that she would give the Ensure Plus via the gastrostomy tube. The LPN also stated that she would know to do that because all the resident's medications are given by the g-tube.

An initial interview with the Registered Dietitian on 8/23/11 at 11:00 AM revealed that the resident has been receiving the Ensure Plus Supplement via the gastrostomy tube since June 2011 and that the current 8/5/11 order must have been a transcription error.

415.12(g)(2)

Based on record review, medication pass observation and staff interview during the recertification survey, the facility did not ensure that residents were free from significant medication errors. This was evident for one out of sample Resident #39. Specifically, Resident #39 was not administered Diltiazem (a medication used to control rapid ventricular rate in atrial fibrillation or flutter) as ordered by the physician for three days. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The Finding is:

Resident #39 has diagnoses which include Atrial Fibrillation and Hypertension.

The Minimum Data Set (MDS) dated 5/27/11 documented the resident's cognition was severly impaired.

A Packing Slip from Specialty RX INC. dated 8/3/11 documented Diltiazem 240 milligram (mg) 30 pills were delivered to the facility on 8/3/11.

The Physician's Order dated 8/10/11 documented Diltiazem 240 mg. 1 capsule by mouth once daily.

The Routine Medication Administration form dated 8/3/11 documented Cardizem 240 mg. 1 tablet every day and dates 8/19/11-8/22/11 were initialed and circled. The comment section of the Routine Medication Administration form documented 8/10/11-8/22/11 awaiting to receive medication from pharmacy

A medication pass observation was conducted on 8/19/11 at 9:30 AM. During medication administration for Resident #39, Diltiazem 240 mg was missing from the medication cart.

The License Practical Nurse (LPN) medication nurse was interviewed immediately. The LPN stated that she would reorder the medication from the pharmacy.

In a subsequent interview with the LPN medication nurse on 8/22/11 at 1:10 PM the LPN stated that the Diltiazem was not received from the pharmacy and that the resident did not receive the medication from 8/19/11-8/22/11. When the LPN was asked if the Physician was notified of the missing medication, the LPN stated that the Physician was notified however she did not document this on the progress note.

The Physician was interviewed on 8/22/11 at 1:15 PM. The Physician stated that he was notified of the missing medication but could not recall when.

An interview was conducted with the Unit B charge RN on 8/22/11 at 3:00 PM. The RN stated that he was not notified that the resident's Cardizem was missing. The RN stated that he was made aware on 8/22/11 when the LPN called the Physician for an order to hold the Cardizem until received from the pharmacy. The RN further stated that he was not notified on 8/19/11 that the resident did not receive the Cardizem on that day.

An interview was conducted on 8/22/11 at 4:30 PM with the Pharmacist. The Pharmacist stated that a 30 day supply of the Cardizem was filled with the initial order received on 8/3/11 and that the refill date for this medication was 9/1/11.

415.12(m)(2)