Elmhurst Care Center, Inc

Based on record review and interview, the facility did not have documented evidence that a resident's designated representative received financial quarterly statements for Resident #191. This was evidenced for 1 of 3 families interviewed during the recertification survey.

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

The finding is:

Resident #191 has diagnoses of Dementia, Hypothyroidism, and Hypertension.

The Minimum Data Set (MDS) 3.0 dated 5/1/2011 documented that the resident scored a 3/15 (severe impairment) on the BIMS (brief interview for mental status).

During an interview with Resident #191's designated representative on 7/18/2011 at 11:00 AM, she stated that the resident has a financial account with the facility and that she has never been informed of the account balance.

During an interview with the facility's Bookkeeper on 7/20/2011 at 1:00 PM, the Bookkeeper stated that the financial quarterly statements are mailed to families monthly. She further stated that she has no documentation to show that financial statements are mailed monthly.

415.26 (h)(5)(iii)

Based on observation, record review, resident and staff interview, the facility did not
ensure that residents have a right to choose when they want to wake up or to go to bed at night. This was evident for 2 out of 14 residents reviewed for choices in a sample of 44 residents with significant care concerns. (Resident #216 and #338)

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

The finding is:

1. Resident #216 is a 79 year old male admitted on 6/3/2011 for short term rehabilitation with diagnoses which include Chronic Heart Failure, Diabetes Mellitus, and Cerebro-Vascular Accident.

The admission Minimum Data Set (MDS) 3.0 assessment dated 6/13/2011 documented that the resident has intact memory and (in section F) that it is very important to him to choose his own bedtime. The resident also requires extensive to total assistance for all bathing, personal hygiene, grooming, and toileting.

During the individual resident interview (translated by the resident's family member) on 7/18/2011 at 1:24 PM, the resident stated that staff usually wake him up around 4:00 AM to provide morning care and afterwards they either leave him in bed fully dressed or transfer him to the wheelchair. The resident stated he felt this was too early and he would like not to be disturbed for at least two more hours; however his preferences were never discussed with him. The resident stated he "tried to tell them", but was not sure if he was understood as he does not speak English.

On 7/20/2011 at 5:00 AM, the resident was observed in his room, in bed , fully dressed, wearing a T-shirt, pants, and darco sandals. The light above his bed was on and the resident was observed with his eyes closed.

During an interview on 7/20/2011 at 11:55 AM, the regular dayshift Certified Nursing Assistant (CNA) stated that when she comes in at 7:00 AM she finds the resident fully dressed seated in his wheelchair.

2. Resident #338 is an 80 year old female admitted to the facility for short-term rehabilitation with diagnoses which include Arthritis, Chronic Knee Pain, and Hypertension.

The admission Minimum Data Set (MDS) assessment dated 7/14/2011 documented that the resident has intact cognition and (in section F) that it is very important to her to chose her own bedtime. It is also documented that the resident requires total assistance for all activities of daily living except eating.

During an interview on 7/18/2011 at 9:46 AM, the resident stated that staff usually wakes her up at 5:00 AM and takes her out of bed, while she would prefer to stay in bed undisturbed until at least 6:30 AM. Also, she is assisted back to bed at approximately 10:20 PM, while she would prefer to go to bed around 8:30 PM. The resident stated she was never asked about her preferences. Also, she stated she has never complained.

On 7/20/2011 at 5:25 AM, the resident was observed to be fully dressed, with eyes closed, seated in her wheelchair next to bed with the TV on.

In an interview on 7/20/2011 at 12:02 PM, the CNA, who was regularly assigned to the resident on dayshift, stated that the resident requires two person assistance for transfer with Sarita lift and when she comes in at 7:00 AM, she finds the resident fully dressed seated in her wheelchair.

During an interview with the Director of Recreation on 7/20/2011 at 12:10 PM, she stated that she completes the Section F of the MDS 3.0 "Preferences for Customary Routine and Activities". She further stated that she interviews cognitively intact residents and obtains information regarding their preferences, which she verbally communicates to nursing staff. She stated she interviewed both residents in order to complete Section F, but could not recall anything about their preferences regarding bedtime. She also could not recall to which nurse she communicated verbally the residents' preferences.

During an interview on 7/20/2011 at 12:35 PM, the Registered Nurse (RN) stated that upon admission the residents are placed by nursing on schedules for assistance to go in and out of bed, which is then documented on the accountability records. The RN stated that "usually the residents would tell us if they object". The RN stated that residents would complain to the Social Worker, or nursing, or the Recreation Director and then the schedule would be adjusted according to the residents preferences. The RN was not aware of the residents' preferences or dissatisfaction with the times that they were scheduled to be taken out of bed or placed in bed.

415.5 (b)(1-3)

Section 12.3.1, NFPA25, states that each control valve shall be identified and have a sign indicating the system or portion of the system it controls.
Based on observation and interview, it was determined that the facility did not ensure that the signs provided on the sectional sprinkler control valves in various locations in the facility indicated the system or portion of the system each valve controls. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
The findings include:
During the annual LSC survey conducted on 07/18/11 and 07/19/11 between 9:00am and 3:00pm, it was observed that the signage provided on the sectional sprinkler valves in various locations in the facility lacked an indication of the system or portion of the system that each valve controls. For example the sectional sprinkler valves in each floor landing of stair case B (from the sub cellar to the 6th floor) and in the sub cellar by the electrical rooms/loading dock area lacked an indication of the areas each valve controlled.
In an interview on 7/19/11 at approximately 1:55pm, the administrator stated that arrangement has been made to provide signage indicating the system and/or portion of the system that each valve controls on the sectional sprinkler valves.
711.2 (a)(1)

Based on observation and staff interview, it was determined that the facility did not ensure that there is no impediment to the closing of corridor doors. Reference is made to doors held open with unapproved door hold open devices. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The findings are:
During the LSC inspection conducted on 07/19/11 between 9:00am and 3:00pm, corridor doors were observed held opened with unapproved door hold open devices. For example the door to the administrator's office in the cellar section was propped open with a plastic chock, the door to the medical records room in the sub cellar section was propped open with a plastic chock and the door to the business office was propped open with a carton.
In an interview with the administrator on 7/19/11 at approximately 10:50am, he stated that he will instruct staff to fix the door closer on his office door to ensure that the door can stay open if need be. He added that staffs would be informed to not prop open doors with unacceptable door hold open devices.
711.2 (a) (1)

Based on observation and interview, the facility did not ensure that exit components are enclosed with construction having a fire resistive rating of at least one hour. Reference is made to an unenclosed metal box, with an unknown fire rating mounted on the 3rd floor landing of the West side stair way enclosure. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The Finding is:
During the Life Safety Code inspection conducted on 07/18/11 and 07/19/11 between 9:00am and 3:00pm, an unenclosed metal box, with an unknown fire rating was observed mounted on the 3rd floor landing of the West side stair way enclosure. This box was not serving the stairway.

In an interview with the Administrator on 07/18/11 at approximately 12:50pm, he believes that the box belongs to the Homeland security and that he would try to find out the fire rating on the box. On 07/19/11 at approximately 2:20pm, he stated that he is still trying to obtain the information on the fire rating of the metal box and that it may belong to Time Warner.

711.2 (a) (1)

Section 5-2, NFPA 10, standard for portable fire extinguishers, states that at intervals not exceeding those specified in Table 5-2, fire extinguishers shall be hydrostatically-retested. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date.
Based on observation, interview and record review, it was determined that the facility did not ensure that the wet chemical type portable fire extinguishers (k- extinguishers) provided in the kitchen section are hydrostatically retested at 5 years intervals as per Table 5-2, NFPA10. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
The findings are:
During the LSC inspection conducted on 07/19/11 at approximately 2:00pm, it was observed that the wet chemical type portable fire extinguisher (k- extinguisher) provided in the kitchen section (meat side) was last hydrostatically tested March 2005. Further more, the k- extinguisher also provided in the dairy section of the kitchen lacked a sticker/tag indicating when it was last hydrostatically tested. Wet chemical fire extinguishers are to be hydrostatically retested at 5 years intervals as per Table 5-2, NFPA10.
In an interview with the administrator on the same day at approximately 2:05pm, he stated that both fire extinguishers noted should have been last hydrostatically tested at about the same time. He added that the fire extinguisher maintenance company would be called in to address the issue immediately
711.2 (a) (1)