Woodland Pond at New Paltz

Based on observation, interview and record review, a resident who was dependent on others to perform her activities of daily living (ADLs) did not receive the assistance she required for nail care.

Resident #55 was admitted to the facility on 5/9/11 and had diagnoses including Dementia. The resident's most current 11/19/11 MDS (Minimum Data Set) assessment indicated that she was totally dependent on another person for personal hygiene.

The resident was observed at 3:30PM on 2/17/12 with soiled finger nails on both hands, particularly the left hand. The evening shift CNA (Certified Nurse Aide)was interviewed at that time and stated that the day shift showered the resident and cleaned the resident's nails.

The resident was observed sitting in her wheelchair in the unit dining room during breakfast at 8:30AM on 2/21/12. At that time, her fingernails were not clean, with brown soil under the nails, particularly of her left hand.

The day shift CNA assigned to the resident was interviewed at 11:45AM on 2/21/12. The CNA stated that the resident's fingernail care was provided by the overnight shift when they shower or bathe her.

The unit LPN (Licensed Practical Nurse) charge nurse was interviewed at 1:00PM on 2/21/12. The LPN stated that the resident's fingernail care was provided on the overnight shift with showers or as needed.

The resident's current CNA Kardex included instructions for the resident to get showers on the evening shift and for her to get nail care on shower days.

The resident's name was included in the list of residents on the "Overnight Shower List" located in the CNA ADL Book (CNA Care Guide binder). The resident's name was not included on the list for "Nail Care as Needed" in the CNA ADL Book.

CNA documentation of resident care was reviewed from 2/1/12 - 2/20/12 and indicated that no showers were documented as given to the resident on the day shift, that she received a shower on the evening shift one time on 2/1/12 and that she received showers on the night shift 4 times durning that 20 day period on 2/3/12, 2/6/12, 2/16/12 and 2/20/12. There was a period of 10 days, from 2/6/12 - 2/16/12, that indicated that the resident received no showers during that period of time.

415.12(a)(3)

Based on interview and record review, Admission MDS assessments (Minimum Data Set, the comprehensive assessment tools used as the framework for development of individualized care plans for residents of long term care facilities) did not accurately reflect residents' status for urinary continence at the time of their admissions.

This was evident for two of two residents reviewed for urinary incontinence (Residents #2 and #55) and resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #55 was admitted to the facility on 5/9/11 with diagnoses including Dementia.

The resident's 5/19/11 Admission MDS (Minimum Data Set) assessment indicated that she was always incontinent of urine and that no toileting program was being used for the resident.

The resident's Care Plan for Urinary Incontinence, initiated 6/30/11 and currently in use, identified the intervention to provide incontinence care for the resident every two hours and as needed. No toileting program was identified.

The current CNA Kardex care guide for the resident included instructions that the resident used the toilet. There were no instructions for the use of a toileting schedule.

The resident's day shift CNA (Certified Nurse Aide) was interviewed at 12:00PM on 2/21/12. The CNA stated that, back when the resident was admitted, she knew when she had to go to the bathroom and would tell the CNA that she had to go. The CNA stated that, back then, the resident would be dry when she said that she needed to use the bathroom and the CNA would take her to the toilet and she would urinate.

The CNA stated that, currently, the resident does use the toilet but that she was not toileted according to a schedule or toileting program. The CNA stated that the resident was usually, and some days always, incontinent now. The CNA stated that sometimes she will tell you that she has to go and sometimes she will wet herself already when she tells the CNA that she has to go.

The CNA was not observed to take the resident to the bathroom at any time from breakfast through lunch that day and stated that she was too busy to take the resident to the bathroom that day.

The unit LPN (Licensed Practical Nurse) charge nurse was interviewed at 1:00PM on 2/21/12. The LPN stated that the resident does use the toilet, was supposed to be toileted every two hours and that she had periods of continence and incontinence.

The DNS (Director of Nursing), who was responsible for care plan development and participated in the resident's care planning meetings, was interviewed at 1:45PM on 2/21/12. The DNS stated that she and the care plan team were not aware that the resident had a history of urinary continence or current episodes of continence. The DNS stated that the care planning team would have developed a care plan to attempt to maintain the resident's urinary continence or to prevent further decline if possible.

The MDS Coordinator was interviewed at 6:00PM on 2/21/12. She stated that she asked the CNAs about the resident's continence status when the resident was first admitted and that the aides said that the resident was always incontinent of urine.

2. Resident #2 was admitted to the facility on 10/12/11 with a fractured arm and discharged on 1/20/12. She had diagnoses including Alzheimer's disease.

The 10/12/11 Nursing Admission document revealed that the resident had urinary incontinence and used depends.

The 10/12/11 CNA (Certified Nurse Aide) Resident Profile and CNA Kardex had instructions that the resident should be toileted, was incontinent of bladder some times and that she used incontinence briefs.

A 10/13/11 Interdisciplinary Progress Note entered by an LPN stated that, "assistance given for toileting and incontinence cares, ... incontinent of urine."

According to the resident's 10/24/11 Admission MDS (Minimum Data Set, the assessment tool used as the framework for individualized care planning for the resident), she was always continent of urine, totally dependent on one person for toilet use and no toileting program was being used.

Review of the resident's Urinary Incontinence Care Plan that included interventions for toileting and incontinence care revealed that it was initiated six weeks after admission on 11/29/11.

The MDS Coordinator was interviewed at 6:05PM on 2/21/12. She stated that, when she completed the Admission MDS, she determined the resident's urinary continence status based on talking to the CNAs.

The MDS Coordinator stated that sometimes she would also interview and ask the resident about their continence status and refer to the paperwork from the hospital prior to admission, nursing entries in the facility Interdisciplinary Notes and the Care Plan. She stated that she likely made this determination based on what the CNAs told her at the time.

415.11(a)(2)

Based on observation, interview and record review, care plans were not revised when indicated for a resident who experienced bruising in order to prevent potential further bruising (Resident #55) and to address elevation of a resident's legs, according to Physician's Orders (Resident #14). This was evident for two of eighteen residents whose care plans were reviewed and resulted in the potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY

The findings are:

1. Resident #55 was was admitted to the facility on 5/9/11 with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypertension and a history of Breast Cancer.

The resident was observed to have a dark purple bruise that covered the entire outer surface of her left hand, from her wrist to her fingers, at 10:15AM on 2/16/12 and at 2:30 PM on 12/17/12.
The resident also had two small bruises on her right hand at those times.

Record review revealed an entry in the Interdisciplinary Notes by the RN at 7:34AM on 2/12/12 that stated, "The resident slept without complaints, however she was found to have a contusion on her left anterior hand."

Review of Accident/Incident Reports (A/I) revealed a report initiated on 2/18/12 concerning the bruise on the resident's left hand. The report stated that a CNA discovered the bruise at 6:30AM on 2/12/12 and that the event that precipitated the bruising was unwitnessed.

According to the A/I, a statement was obtained from the night shift CNA assigned to the resident who had reported the bruise to the RN. The CNA stated that the resident was last seen at 2:00AM and that the CNA noted the large bruise when she got the resident up in the morning.

The A/I noted that, "72-hour look back statements completed for unknown injury" were not obtained. No other statements were included in the A/I Report.

The A/I Recommendation to prevent recurrence was to use caution when handling the resident with cares and transfers. There was no evidence in the A/I, Interdisciplinary Notes, Physician Progress Notes, Physician's Orders or elsewhere in the paper or electronic clinical record, of an investigation to determine the possible root cause of the bruise in order to revise the resident's care plan to include interventions to prevent recurrence.

The resident's care plan was reviewed in it's entirety. There was no evidence that the care plan was revised to address the above recommendation or to initiate any other interventions to prevent recurrence.

The evening shift CNA (Certified Nurse Aide) was interviewed at 3:45PM on 2/17/12 and stated that she did not know how the resident got the bruises on her hands. The CNA stated that she did not provide any particular care to prevent bruising for the resident.

Bruises on the resident's hands were observed again in the same areas at 11:30AM on 2/21/12. The day shift CNA assigned to the resident, who came on duty at 7:00AM, was interviewed at 11:45AM on 2/21/12. The CNA stated that she had not yet cared for the resident that day. The CNA stated that she was not aware that the resident had bruises or what the source of bruising of the resident's hands was. The CNA stated that gentle care was provided to all residents, and no other particular interventions, were provided to the resident to prevent bruising.

The unit LPN was interviewed at 1:00PM on 2/21/12. The LPN stated that the source of bruising of the resident's hands was unknown. The LPN stated that she was not aware of a care plan in place to prevent bruising.

The Director of Nursing (DNS), who is responsible for for development and revision of care plans, was interviewed at 10:00 AM on 2/22/12. The DNS stated that she was not notified of the resident's bruising right away and did not become aware of it until a couple of days later. The DNS stated that no investigation had been done yet, as of that time ten days after discovery of the resident's bruising, to attempt to identify a possible cause of the bruise so that the care plan could be revised to prevent recurrence.

2. Resident #14 is an 89 year old male admitted to the facility on 4/09/10 with diagnoses that include 2 Stage Pressure Ulcers and End Stage Dementia.

Record review of Physicians Oders on 1/21/12 reveal that the heel was to be elevated while in the chair. Review of the Care Plans revealed that the Pressure Ulcer Care Plan was not reviewed and revised to reflect the Physician order to elevate legs while out of bed.

Observation of this resident on 2/17/12 revealed that he was out of bed in a chair with his feet on the floor.

Interview with the Licensed Practical Nurse at that time revealed that he was to have his legs elevated and she did not know why they were not.

415.11(c)2) (i-iii)

Based on observation and interview, residents' medications were not handled in a manner that prevented contamination. This was evident for two of ten residents during observation of medication administration (Residents #23 and #34) and for one resident during random observations (Resident #1) and resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. A Licensed Practical Nurse (LPN) wore gloves when she gave eye drops to Resident #23 at 9:00AM on 2/17/12, during observation of medication administration to the resident. The LPN touched the resident's skin with the gloves. Without removing the contaminated gloves, the LPN then handled one of the resident's pills with her gloved hand and placed it in the resident's mouth.

The LPN was immediately interviewed and stated that the gloves were "dirty" once she touched the resident and that she should have changed gloves before handling the pill.

2. During continued observation of medication administration at 9:35AM on 2/17/12, the same LPN as above wore gloves when she gave eye drops to Resident #34. The LPN removed the gloves and crumpled them up in one of her hands. She then used that hand, containing the contaminated gloves, to remove a pill from a cup containing the resident's medications. The LPN grasped the pill, touching it with the crumpled up gloves she had used to touch the resident's skin when administering the resident's eye drops. The LPN gave the contaminated pill to the resident.

The LPN was immediately interviewed and stated that she should have gotten a new glove before she touched the pill inside the resident's medication cup.

3. Another LPN was observed administering a pill to Resident #1 while the resident was in bed at 2:05PM on 2/15/12. The resident grasped, and then dropped, the pill from her hand into the bed linens. The resident stated to the LPN trainee that she could not find the pill. The LPN told the resident that she could see the pill in the linens and for the resident to feel for it. The resident felt around in the bed linens, found the pill, put it in her mouth and swallowed it in the presence of the LPN.

The LPN was immediately interviewed and stated that there was no concern related to potential infection because the pill had fallen into the resident's own bed linens which already had the resident's own germs in them. The LPN stated that she would have discarded the pill if it had fallen onto the floor. She stated that contact with the bed linens had not contaminated the pill.

415.19(b)(4)

Based on observation, interview and record review the facility did not ensure that the residents' environment was as free of accident hazards as possible. Specifically, a medication cart was left unattended with hazardous items on top of it . These items were accessible to cognitively impaired, wandering residents. This was evident on the facility unit for skilled nursing and specifically for Resident # 5.

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

Findings are:

Resident # 5 is a 51 year old female with diagnoses that include Mental Retardation with a BIMS of 3. This resident was observed sitting in her wheelchair next to the unattended medication cart on 2/22/12 at 9:00AM.

This resident was observed to be touching the doors of the medication cart to check if they were open. There was no staff present in the area of the medication cart or at the nurse station.

Upon observation of Resident #5 touching the medication cart, surveyor intervened with redirecting this resident. At that time, observation of the top of the medication cart revealed; 2 Lancets (small needles used to obtain blood from a finger for testing blood sugar), the Glucometer (a device used to test finger stick blood for the sugar level), 3 Testing Strips (on which the fingerstick blood is applied and then put into the Glucometer for reading the blood sugar level), and a box of Altoid Mints.

In an interview on 2/22/12 at 9:10AM with the Medication Licensed Practical Nurse (LPN) regarding the hazardous items on top of her unattended Medication Cart, she replied " I forgot to put them away".

415.12(h)(1)

Based on record review and interview the facility did not ensure (1) that the Quality Assurance Committee reviewed the facility's Abuse Prohibition policy and procedure in order to ensure that all 7 components of the protocol were addressed and implemented (Investigation and Protection) (2) that an investigation to rule out abuse was performed adequately or in a timely fashion for one of three residents with injuries of unknown origin (Resident # 55) ; and that the care plan was revised to prevent a repeat deficiency (#55) (This was evident during review of Abuse Prohibition policies and procedures and for 1 of 23 residents (#55)

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

The findings are:

1. Review of multiple facility policies and procedures for prohibition of abuse towards residents revealed that key elements, including comprehensive investigation of injuries of unknown origin to identify or rule out resident abuse and the protection of residents during investigations of possible abuse, were not adequately addressed.

The facility Policy and Procedure for Identification and Reporting of Possible Victims of Abuse, Neglect or Mistreatment, revised October, 2010, included an "Abuse Prohibition Protocol" section that outlined for seven key elements of the protocol. Two of the elements, specifically investigation of concerns of possible abuse and protection of residents from harm during and after an abuse allegation, did not include procedural steps, instructions or definition of how staff members

The Administrator and the Director of Nursing were interviewed on the afternoon of 2/22/12. They did not provide evidence that the facility had defined procedures, or made procedures available to staff members, that indicated the steps staff members were responsible for performing in order to investigate injuries of unknown origin in a comprehensive and timely manner to identify or rule out resident abuse and how residents would be protected during and after investigations.

Interview with the Director of Nursing on 2/22/12 at 3:30PM , during the Quality Assurance task, revealed no evidence that these policies/procedures had been reviewed by the Quality Assurance Committee.

The April, 2009 facility Policy and Procedure for Identification and Reporting of Possible Victims of Abuse, Neglect or Mistreatment, and the October, 2010 revision of that document, noted that bruises were a possible sign of physical abuse.

Review of Accident/Incident Reports revealed a report initiated on 2/18/12 concerning the bruise on the resident's left hand. The report stated that a CNA discovered the bruise at 6:30AM on 2/12/12 and that the event that precipitated the bruising was unwitnessed. The RN who completed the report noted that the bruise was a quarter size upon discovery and then diffused over the anterior hand.

According to the Accident/Incident Report, a statement was obtained from the night shift CNA assigned to the resident who had reported the bruise to the RN. The CNA stated that the resident was last seen at 2:00AM and that the CNA noted the large bruise when she got the resident up in the morning.

The A/I noted that, "72-hour look back statements completed for unknown injury" were not obtained. No other statements were included in the A/I Report.

There was no evidence in the A/I Report that abuse was ruled out for this unwitnessed injury. There was no evidence of an investigation to determine the possible root cause of the bruise in order to prevent recurrence.

There was no evidence in the Accident/Incident Report, Interdisciplinary Notes, Physician Progress Notes, Physician's Orders or elsewhere in the paper or electronic clinical record, that a Physician had been notified or that the resident had been examined by a Physician or Nurse Practitioner at any time subsequent to the discovery of the bruise on her left hand.

Review of Accident/Incident Reports (A/I) revealed a report initiated on 2/18/12 concerning the bruise on the resident's left hand. The report stated that a CNA discovered the bruise at 6:30AM on 2/12/12 and that the event that precipitated the bruising was unwitnessed.

According to the A/I, a statement was obtained from the night shift CNA assigned to the resident who had reported the bruise to the RN. The CNA stated that the resident was last seen at 2:00AM and that the CNA noted the large bruise when she got the resident up in the morning.

The A/I noted that, "72-hour look back statements completed for unknown injury" were not obtained. No other statements were included in the A/I Report.

The A/I Recommendation to prevent recurrence was to use caution when handling the resident with cares and transfers. There was no evidence in the A/I, Interdisciplinary Notes, Physician Progress Notes, Physician's Orders or elsewhere in the paper or electronic clinical record, of an investigation to determine the possible root cause of the bruise in order to revise the resident's care plan to include interventions to prevent recurrence.

The resident's care plan was reviewed in it's entirety. There was no evidence that the care plan was revised to address the above recommendation or to initiate any other interventions to prevent recurrence.

The evening shift CNA (Certified Nurse Aide) was interviewed at 3:45PM on 2/17/12 and stated that she did not know how the resident got the bruises on her hands. The CNA stated that she did not provide any particular care to prevent bruising for the resident.

Bruises on the resident's hands were observed again in the same areas at 11:30AM on 2/21/12. The day shift CNA assigned to the resident, who came on duty at 7:00AM, was interviewed at 11:45AM on 2/21/12. The CNA stated that she had not yet cared for the resident that day. The CNA stated that she was not aware that the resident had bruises or what the source of bruising of the resident's hands was. The CNA stated that gentle care was provided to all residents, and no other particular interventions, were provided to the resident to prevent bruising.

The unit LPN was interviewed at 1:00PM on 2/21/12. The LPN stated that the source of bruising of the resident's hands was unknown. The LPN stated that she was not aware of a care plan in place to prevent bruising.

The Physician was interviewed by phone at 9:00AM on 2/22/12. The Physician did not recall being notified of the resident's bruise but stated that the other doctor or the NP could have been notified. The facility did no provide evidence that a Physician or Nurse Practitioner was notified or assessed the resident.

The Director of Nursing (DNS), who is responsible for investigations to identify or rule out resident abuse, was interviewed at 10:00 AM on 2/22/12. The DNS stated that she was not notified of the incident right away and did not become aware of it until a couple of days later. The DNS stated that she then immediately contacted the RN on duty at the time the bruise was discovered. The DNS stated that the RN informed her that she had not started an investigation at the time the bruise was discovered because she did not think the bruise would have been caused by abuse and that the size of the bruise was not that big. The DNS stated that she then instructed the RN to perform an investigation immediately.

The investigation completed by the RN was reviewed with the DNS. The DNS stated that there was no investigation to attempt to determine if abuse or neglect were involved, suspected or ruled out. The DNS stated that there was no investigation done to attempt to identify a possible cause of the bruise so that the care plan could be revised to prevent recurrence.

Interview with the Director of Nursing on 2/22/12 at 3:30PM, during the Quality Assurance task, revealed no evidence that the Quality Assurance Committee had been notified of this injury of unknown origin or that an investigation had not been done to rule out abuse .

The Director of Nursing (DNS), who is responsible for for development and revision of care plans, was interviewed at 10:00 AM on 2/22/12. The DNS stated that she was not notified of the resident's bruising right away and did not become aware of it until a couple of days later. The DNS stated that no investigation had been done yet, as of that time ten days after discovery of the resident's bruising, to attempt to identify a possible cause of the bruise so that the care plan could be revised to prevent recurrence and ensure that the care plan was revised. Failure to review and revise the resident's care plan resulted in a repeat deficiency.

The A/I noted that, "72-hour look back statements completed for unknown injury" were not obtained. No other statements were included in the A/I Report.

The A/I Recommendation to prevent recurrence was to use caution when handling the resident with cares and transfers. There was no evidence in the A/I, Interdisciplinary Notes, Physician Progress Notes, Physician's Orders or elsewhere in the paper or electronic clinical record, of an investigation to determine the possible root cause of the bruise in order to revise the resident's care plan to include interventions to prevent recurrence.

The resident's care plan was reviewed in it's entirety. There was no evidence that the care plan was revised to address the above recommendation or to initiate any other interventions to prevent recurrence.

The evening shift CNA (Certified Nurse Aide) was interviewed at 3:45PM on 2/17/12 and stated that she did not know how the resident got the bruises on her hands. The CNA stated that she did not provide any particular care to prevent bruising for the resident.

Bruises on the resident's hands were observed again in the same areas at 11:30AM on 2/21/12. The day shift CNA assigned to the resident, who came on duty at 7:00AM, was interviewed at 11:45AM on 2/21/12. The CNA stated that she had not yet cared for the resident that day. The CNA stated that she was not aware that the resident had bruises or what the source of bruising of the resident's hands was. The CNA stated that gentle care was provided to all residents, and no other particular interventions, were provided to the resident to prevent bruising.

The unit LPN was interviewed at 1:00PM on 2/21/12. The LPN stated that the source of bruising of the resident's hands was unknown. The LPN stated that she was not aware of a care plan in place to prevent bruising.

The Director of Nursing (DNS), who is responsible for for development and revision of care plans, was interviewed at 10:00 AM on 2/22/12. The DNS stated that she was not notified of the resident's bruising right away and did not become aware of it until a couple of days later. The DNS stated that no investigation had been done yet, as of that time ten days after discovery of the resident's bruising, to attempt to identify a possible cause of the bruise so that the care plan could be revised to prevent recurrence and ensure that the care plan was revised. Failure to review and revise the resident's care plan resulted in a repeat deficiency.

Interview with the DNS , who is the contact person for Quality Assurance, on 2/22/12 at 3:30PM revealed that this incident of unknown origin was not brought to the Quality Assurance Committee.

415.27 (a-c)

Based on record review and interview, the facility did not provide a resident/resident representative with current and complete Liability Notice and Beneficiary Rights Appeal information in order to fully understand the extent of services that would or would not be covered by the resident's Medicare Part A benefit and for the resident/representative to make informed choices about continuing to receive services. Specifically, 1 ) the facility did not provide Advanced Beneficiary Notice to the resident/representative using the currently approved forms. Additionally, 2) the facility did not provide the resident/representative with the required Notice of Medicare Provider Non-coverage, or the necessary contact information to facilitate an expedited appeal by the State Quality Improvement Organization (QIO). This was evident for one of one residents who met the criteria for review of Liability Notice and Beneficiary Rights Appeals and resulted in the potential for more than minimal harm that is not immediate jeopardy (Resident #6).

THIS IS A REPEAT DEFICIENCY

The findings are:
Resident #6 was admitted to the facility from the hospital on 8/22/11. The resident received Physical, Occupational and Speech Therapies.
If a facility believes that Medicare will not pay for skilled nursing or specialized rehabilitative services, the facility must notify the resident or his/her legal representative in writing using either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (CMS form 10055) ornone one of the five uniform Denial Letters found in of the Skilled Nursing Facility Manual. The SNFABN and the Denial Letters inform the beneficiary of his/her right to have a claim submitted to Medicare and advises them of the standard claim appeal rights that apply if the claim is denied by Medicare. These claims are often referred to as "demand bills" and are reviewed by the Fiscal Intermediary (FI) or Medicare Administrative Contact (MAC).

According to the Advance Beneficiary Notice of Noncoverage (ABN) document provided to the resident's representative by the facility (CMS-R-131), the resident no longer would qualify for restorative rehabilitation therapy as of 10/18/11 and the facility believed that Medicare would not cover those services effective 10/18/11.

This document (CMS-R-131) has not been approved for use by the Centers for Medicare and Medicaid Services (CMS) since 3/1/09 and does not fulfill the facility's current requirement for notification, which requires use of one of the documents noted above.

Additionally, there was no evidence that the facility issued, to the resident, or representative, a Notice of Medicare Provider Non-coverage (CMS form 10123) for a termination of all Medicare Part A services for coverage reasons. The Notice of Medicare Provider Non-coverage, often referred to as an "Expedited Appeal Notice," informs the beneficiary/representative of his/her right to an expedited review by the Quality Improvement Organization (QIO) of a service termination, as well as providing contact information for the QIO.
The determination of the expedited appeal by the QIO has the potential to influence the resident's, or their representative's, decision to pursue a demand bill or not.

The facility representative for Liability Notice and Beneficiary Rights Appeals was interviewed at 2:30PM on 2/22/12. The facility representative stated that the CMS-R-131 document was the only written form used for the resident's/representative's notification.

The facility representative further stated that written notice of the right for an expedited appeal to the QIO, or contact information for the QIO, was not provided to the resident/resident's representative.

415.3(g)(2)(iii)

facility's Abuse Prohibition Protocol were not adequately developed or implemented. Specifically: the facility policies and procedures for abuse prohibition did not adequately address a) comprehensive investigation of injuries of unknown origin in order to identify or rule out resident abuse, neglect or mistreatment and b) the protection of residents during investigations of possible abuse. 2. Additionally, investigation to rule out abuse was not performed adequately or in a timely fashion for one of three residents with injuries of unknown origin that were reviewed (Resident #55). This resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Review of multiple facility policies and procedures for prohibition of abuse towards residents revealed that key elements, including comprehensive investigation of injuries of unknown origin to identify or rule out resident abuse and the protection of residents during investigations of possible abuse, were not adequately addressed.

The facility Policy and Procedure for Identification and Reporting of Possible Victims of Abuse, Neglect or Mistreatment, revised October, 2010, included an "Abuse Prohibition Protocol" section that outlined for seven key elements of the protocol. Two of the elements, specifically investigation of concerns of possible abuse and protection of residents from harm during and after an abuse allegation, did not include procedural steps, instructions or definition of how staff members Based on observation, interview and record review, 1. key elements of the ere expected to accomplish those required objectives.

The Administrator and the Director of Nursing were interviewed on the afternoon of 2/22/12. They did not provide evidence that the facility had defined procedures, or made procedures available to staff members, that indicated the steps staff members were responsible for performing in order to investigate injuries of unknown origin in a comprehensive and timely manner to identify or rule out resident abuse and how residents would be protected during and after investigations.

2. Resident #55 was was admitted to the facility on 5/9/11 with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypertension and a history of Breast Cancer.

The resident was observed to have a dark purple bruise that covered the entire outer surface of her left hand, from her wrist to her fingers, at 10:15AM on 2/16/12 and at 2:30 PM on 2/17/12.
The resident also had two small bruises on her right hand at those times.

Record review revealed an entry in the Interdisciplinary Notes by the RN at 7:34AM on 2/12/12 that stated, "The resident slept without complaints, however she was found to have a contusion on her left anterior hand."

The April, 2009 facility Policy and Procedure for Identification and Reporting of Possible Victims of Abuse, Neglect or Mistreatment, and the October, 2010 revision of that document, noted that bruises were a possible sign of physical abuse.

Review of Accident/Incident Reports revealed a report initiated on 2/18/12 concerning the bruise on the resident's left hand. The report stated that a CNA discovered the bruise at 6:30AM on 2/12/12 and that the event that precipitated the bruising was unwitnessed. The RN who completed the report noted that the bruise was a quarter size upon discovery and then diffused over the anterior hand.

According to the Accident/Incident Report, a statement was obtained from the night shift CNA assigned to the resident who had reported the bruise to the RN. The CNA stated that the resident was last seen at 2:00AM and that the CNA noted the large bruise when she got the resident up in the morning.

The A/I noted that, "72-hour look back statements completed for unknown injury" were not obtained. No other statements were included in the A/I Report.

There was no evidence in the A/I Report that abuse was ruled out for this unwitnessed injury.
There was no evidence of an investigation to determine the possible root cause of the bruise in order to prevent recurrence.

There was no evidence in the Accident/Incident Report, Interdisciplinary Notes, Physician Progress Notes, Physician's Orders or elsewhere in the paper or electronic clinical record, that a Physician had been notified or that the resident had been examined by a Physician or Nurse Practitioner at any time subsequent to the discovery of the bruise on her left hand.

The Physician was interviewed by phone at 9:00AM on 2/22/12. The Physician did not recall being notified of the resident's bruise but stated that the other doctor or the NP could have been notified. The facility did no provide evidence that a Physician or Nurse Practitioner was notified or assessed the resident.

The Director of Nursing (DNS), who is responsible for investigations to identify or rule out resident abuse, was interviewed at 10:00 AM on 2/22/12. The DNS stated that she was not notified of the incident right away and did not become aware of it until a couple of days later. The DNS stated that she then immediately contacted the RN on duty at the time the bruise was discovered. The DNS stated that the RN informed her that she had not started an investigation at the time the bruise was discovered because she did not think the bruise would have been caused by abuse and that the size of the bruise was not that big. The DNS stated that she then instructed the RN to perform an investigation immediately.

The investigation completed by the RN was reviewed with the DNS. The DNS stated that there was no investigation to attempt to determine if abuse or neglect were involved, suspected or ruled out. The DNS stated that there was no investigation done to attempt to identify a possible cause of the bruise so that the care plan could be revised to prevent recurrence.

415.4(b)

Based on observation, interview, and record review the facility did not: 1) provide apppropriate care and services to prevent further deterioration of a Stage 2 Pressure Ulcer. Specifically, a resident with a Stage 2 Pressure Ulcer of the left heel did not have pressure relief measures in place while out of bed. 2) the resident's Physician assessed this resident's Pressure Ulcers one to two times a month and relied on the Registered Nurse Unit Manager (RNUM) and Director of Nurses (DON) assessments weekly for treatment. This was evident for 1 of 1 resident reviewed for with a Pressure Ulcer (Resident #14).

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

Findings are:

1) Resident # 14 is an 89 year old male admitted to the facility on 4/19/10 with diagnoses that include: End Stage Dementia, Hypertension and 2 Pressure Ulcers: on Coccyx which has a Stage 2 and Left Heel which has a Stage 3.

Observation of Resident # 14 on 2/17/12 at 4:00PM, revealed this resident out of bed in a chair. This resident had his both feet placed on the floor. This resident had his legs extended with heels resting directly on the floor.

Record review of this resident's Physician Orders of 1/26/12 and revealed that his legs are to be elevated while out of bed to prevent pressure on heels.

Interview with the Licensed Practical Nurse at that time revealed, that this resident's heels were to be elevated off the floor and she did not know why they were not elevated.

2) Review of the Physician Progress Notes from 11/29/11 through 2/21/12 revealed that the Physician assessed the Pressure Ulcers on 11/29/11 upon resident's return from the hospital..assessed the Pressure Ulcer on Left Heel as" a new open area 0.5cm x 2cm" and assessment of "the coccyx as an open area which is brownish in color approximately 1cm x 2cm". No stage of these Pressure Ulcers were documented at that time.

Physician assessment on 12/3/11" coccyx with a gr 3 ulcer approximately 4 x 15mm no odor..no pus..necrotic noted at edges of the left heel,has beefy red opened area over majority of heel as sloughed skin".(no documentation regarding the Stage of the left heel pressure ulcer).

Physician Progress notes of 12/8/11 "asked to evaluate legs..history of edema..legs without edema..heel in bulky dressing".

The next Physician assessment on 1/12/12 revealed "left heel area approximately 3cm with beefy red outer surfaces and green tan center with positive odor..positive vascular flow, no evidence cellulitis..colonization..silver alginate dressing".(no documentation regarding pressure ulcer on coccyx or the stage of the left heel pressure ulcer).

Physician Renewal on 1/26/12 documentation under objective examination revealed: "there is a grade 2 wound on the left heel...the round wound itself is about 4 inches in redness and then there is a center diameter of a 4cm grade 2 wound at the left heel ...there is somewhat foul odor coming from the heel and lab culture will be ordered. There is also like a split coccygeal wound that measures about 3 inches at the coccyx in the buttocks crack there is some redness around that area and hydrogel and opsite is being applied daily and as needed. Assessment: Stage 2 pressure ulcer at the left heel and at the coccyx."

On 2/14/12 Physician Progress notes: " left heel with quarter size ulcer..drainage on alginate dressing..not reddened around lesion... heel ulcer stable MRSA."(no documentation regarding the pressure ulcer on coccyx or current Stage of the left heel pressure ulcer).

Observation and assessment of this resident's left heel pressure ulcer on 2/21/12 at 2:00PM by 2 NY State Surveyors revealed, that the left heel pressure ulcer is a Stage 3 due to the yellow slough noted in the center of the wound. The RNUM and DON had assessed the wound as a Stage 2 on the Weekly Wound Record.

Nurse Practioner (NP) was asked on 2/21/12 at 2:15PM by staff and surveyors to assess this resident's left heel pressure ulcer.The NP documented "50cent size grade 2-3 decubitus at left heel with one inch red abrasion on top of foot noted...continue Silver Alginate dressing daily.."

Interview with the DON and RNUM on 2/21/12 at 2:35PM revealed, that the Physician only assesses this resident's Pressure Ulcer 1 - 2 times a month, and does not accompany the RNUM and DON on "wound rounds".The Physician will assess the wound when requested by the nurses and that he relies on the nurses assessments. Weekly "Wound Rounds" are done by DON and RNUM and documented on the "Wound Care Record". There is no evidence of competency records for assessment of Pressure Ulcers for these Nurses.

415.12(c)(1)

Based on observation, interview and record review, a resident who experienced a decline in urinary continence status did not receive appropriate evaluation to attempt to determine contributory factors in order to plan interventions to potentially restore the resident's previous status for urinary continence or to prevent further decline or complications. This was evident for one of two residents reviewed for urinary incontinence (Resident #55) and resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #55 was admitted to the facility on 5/9/11 with diagnoses including Dementia.

The resident's 5/19/11 Admission MDS (Minimum Data Set) assessment, and subsequent MDS assessments for 8/19/11 and 11/19/11, indicated that she was always incontinent of urine, that she required extensive to total assistance of one person to use the toilet and that no toileting program was being used for the resident.

The resident's Care Plan for Urinary Incontinence, initiated 6/30/11 and currently in use, identified the intervention to provide incontinence care for the resident every two hours and as needed.

The resident was observed sitting in her wheelchair at 8:30AM, 9:45AM and 12:00PM on 2/21/12. The resident had a diaper on and there were no indicators of incontinence.

The day shift CNA was interviewed at 12:00PM on 2/21/12. The CNA stated that, back when the resident was admitted, she knew when she had to go to the bathroom and would tell the CNA that she had to go. The CNA stated that, back then, the resident would be dry when she said that she needed to use the bathroom and the CNA would take her to the toilet and she would urinate.

The CNA stated that the resident currently required extensive assistance to transfer to the toilet, "because she gets a little nervous, but she is pretty good." The CNA stated that the resident does use the toilet but that she was not toileted according to a schedule or toileting program. The CNA stated that the overnight shift got the resident out of bed before she came on duty at 7:00AM and that the resident stayed out of bed sitting in her wheelchair all day. The CNA stated that she tried to take the resident to the bathroom around the schedule of when she thought the resident would need to go, early in the morning and before and after lunch. The CNA stated that the resident was usually, and some days always, incontinent now. The CNA stated that sometimes she will tell you that she has to go and sometimes she will wet herself already when she tells the CNA that she has to go.

The CNA was not observed to take the resident to the bathroom at any time from breakfast through lunch that day and stated that she was too busy to take the resident to the bathroom that day.

The unit LPN (Licensed Practical Nurse) charge nurse was interviewed at 1:00PM on 2/21/12. The LPN stated that the resident gets out of bed at around 5:00AM or 6:00AM and stays out of bed all day. The LPN stated that the resident does use the toilet and that she had periods of continence and incontinence. The LPN stated that the resident also had episodes when she would say that she had to urinate and she would already be wet but the staff would toilet her and she would urinate more. The LPN further stated that sometimes the resident was continent from after breakfast until late in the afternoon and that the resident was better aware of when she had to urinate when she was in bed at night.

There was no evidence in the clinical record, including Physician Progress Notes, Interdisciplinary Notes, Consults, Care Plans or elsewhere, and the facility was unable to provide evidence, of evaluation or review to attempt to determine the possible medical, environmental or other contributory factors associated with the resident's incontinence in order to implement interventions to restore or prevent further decline in urinary continence.

The DNS (Director of Nursing), who was responsible for care plan development and participated in the resident's care planning meetings, was interviewed at 1:45PM on 2/21/12. The DNS stated that she was not aware that the resident had a history of urinary continence or current episodes of continence. She stated that she thought the resident was always incontinent so that she did not identify that the resident had a decline in urinary continence. The DNS stated that the care planning team was not aware that the resident had had periods of continence. She stated that would have prompted an evaluation to try to identify possible medical issues or contributory factors associated with times when the resident was wet versus dry in order to restore her previous level of continence if possible.

415.12(d)(2)

Based on observation, interview and record review, schedules for waking, bathing and going to bed at night were determined for a resident by the facility without consultation with the resident's designated representative to identify personal choices or preferences. This was evident for one of twenty-one residents or representatives who were reviewed for schedule choices related to waking, bathing and going to bed at night (Resident #55). This resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #55 was admitted to the facility on 5/9/11 with diagnoses including Dementia.

The resident's 5/19/11 Admission MDS (Minimum Data Set) assessment, and subsequent MDS assessments for 8/19/11 and 11/19/11, indicated that she required extensive to total assistance of one person to transfer in and out of bed, bathe and get dressed. The MDS also revealed that the resident indicated that it was somewhat important for her to choose her bedtime. The MDS noted that the resident's representative was not included in the assessment.

A routine interview was conducted with the resident's representative at 4:00PM on 2/16/12. The resident's representative stated that she visits almost daily. She stated that she has been told by the staff that they get the resident up, wash and dress her early in the morning, at about 5:00AM because "she is a fall risk." The resident's representative stated that the staff have told her that the resident is put to bed late in the evening, also, because of her fall risk. The resident's representative stated that the staff has told her that they are afraid the resident will get out of bed so she is kept out of the bed from early morning until late evening to prevent her from falling. The resident's representative further stated that the staff has told her many times that the resident is tired a lot during the day and that they think it is because they are getting her up so early and keeping her out of bed so late.

The resident's representative stated that she did not support the decision for the resident to get up, bathe and dress that early. She stated that she did not want the resident to stay up without rest all day or to go to bed late in the evening. The resident's representative stated that she had not been included in decision-making about the resident's daily schedule.

The resident's current Care Plans were reviewed in entirety. The Falls Care Plan, initiated 5/12/11, had no identified interventions related to getting the resident out of bed early in the morning or keeping her out of bed late into the evening in order to prevent falls. The resident's fall history included a fall from bed on 1/17/12 and the use of a special mattress to prevent further falls was implemented at that time.

The Cognitive Loss Dementia Care Plan, initiated on 5/12/11, identified the intervention to maintain a regular daily schedule for the resident.

The Mobility, Impaired ADL Functioning Care Plan, initiated 5/12/11, identified the intervention to encourage the resident to make choices such as her time for bathing.

The resident's name was included on the list of "Overnight Get Ups" in the CNA ADL Book (Care Guide for Certified Nurse Aides) with instructions that, "The 6AM - 2PM Aide is to do overnight get ups before starting their AM shift." The resident's name was also included in the list of residents on the "Overnight Shower List" located in the ADL Book.

The resident was observed seated in her wheel chair at the nurses' station at 3:45 PM on 2/17/12. The evening shift CNA was interviewed at that time. The CNA stated that the resident is up all evening and that she is put to bed at about 9:00PM - 9:30PM because the staff does not want her to fall. The CNA stated that the resident does not like to stay lying in bed. The CNA stated that the resident gets up and sits on the side of the bed because she gets confused and thinks she has things to do like laundry. The CNA stated that the bed alarm sounds when the resident sits up on the side of the bed and the staff always hears it because the resident's room is close to the nurses' station.

The resident was observed in the small unit TV room at 9:50AM on 2/21/12. She was sleeping in her wheelchair at that time. She was observed sleeping in the same location at 10:20AM on 2/21/12 with her head and neck extended back and her mouth wide open. The resident was observed sitting in the TV room asleep in her wheelchair with a pillow behind her shoulders and neck at 10:50AM on 2/21/12. The resident was awake with the pillow removed at 11:10AM and asleep again with her head back at 11:30AM.

The day shift CNA assigned to the resident was interviewed at 11:45AM on 2/21/12. The CNA stated that the resident was showered or given a bedbath, gotten out of bed and dressed by the overnight shift. The CNA stated that the resident is up and dressed and in the wheelchair by the nurses' station when the day shift CNA comes in at 7:00AM. The CNA stated that she did not know if the resident tried to get out of bed because the resident is not in bed at all for the entire day shift.

The unit LPN (Licensed Practical Nurse) charge nurse was interviewed at 1:00PM on 2/21/12. The LPN stated that the resident was showered and gotten out of bed on the overnight shift at around 5:00AM or 6:00AM. The LPN stated that the resident takes her gown off and sits up on the side of the bed and her alarm goes off. The LPN stated that the resident did not stand up.

The (Director of Nursing) DNS was interviewed at 1:45PM on 2/21/12. The DNS stated that she was not aware that the resident was scheduled for getting out of bed and showering early in the morning and staying up out of bed until after 9:00PM. The DNS stated that it is not part of the resident's care plan to prevent falls or otherwise to keep her out of bed and that it was not appropriate for the staff to be keeping the resident out of bed from early morning until late evening. The DNS stated that the staff must have initiated that practice on their own outside of the care planning process.

The DNS stated that the resident's representative visited frequently and had attended Care Plan meetings. The DNS stated that getting the resident showered or bathed and out of bed early and keeping her up late were not reviewed in the care plan meeting, or informally with the resident's representative in order to determine preferences for the resident or for her input to be obtained.

The resident was observed asleep at the nurses' station with her head back against the wall from 2:45PM - 3:30PM.

The resident was observed in the dining room at 8:25AM on 2/22/12 seated at a table with three other residents and a restorative aide. The resident was asleep with her head and neck extended back and her mouth wide open.

415.5(b)(1-3)

Based on observation, interview and record review, a resident did not receive the necessary assistance for toileting and nail care according to her Care Plan and CNA Kardex (Certified Nurse Aide Care Guide). This was evident for one of eighteen residents whose Care Plans were reviewed (Resident #55) and resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #55 was admitted to the facility on 5/9/11 with diagnoses including Dementia.

1. The resident's 5/19/11 Admission MDS (Minimum Data Set) assessment, and subsequent MDS assessments for 8/19/11 and 11/19/11, indicated that she was incontinent of urine and that she required extensive to total assistance of one person to use the toilet.

The resident's Care Plan for Urinary Incontinence, initiated 6/30/11 and currently in use, identified the intervention to provide incontinence care for the resident every two hours and as needed.

The resident's current CNA Kardex included instructions that the resident uses the toilet and is totally dependent on one person to use the toilet. There were no instructions for the use of a toileting schedule.

The resident was observed seated in her wheel chair at the nurses' station at 3:45PM on 2/17/12. The evening shift CNA (Certified Nurse Aide) was interviewed at that time. The CNA stated that the resident was not on a toileting schedule like some of the residents who were taken to the bathroom every two hours. The CNA stated that she changes the resident when she, the CNA, comes in at 3:00PM. The CNA stated that one person can take the resident to the BR because she can stand and hold the rail in the BR. The CNA stated that she will change the resident if she notices that she is wet but otherwise the resident is next changed when she is put to bed at about 9:00PM - 9:30PM. The CNA stated that she changes the resident either by taking her to the toilet or by changing her wet diaper in bed once she puts her to bed.

The resident was observed sitting in her wheelchair in the unit dining room, and then the unit day room, from 8:30AM - 12:00PM on 2/21/12. She was not observed to be toileted during that period of time. The resident was next observed being escorted back to the unit dining room for lunch, still without being toileted.

The day shift CNA was interviewed at 12:00PM on 2/21/12. The CNA stated that the resident currently required extensive assistance to transfer to the toilet, "because she gets a little nervous, but she is pretty good." The CNA stated that the resident does use the toilet but that she was not toileted according to a schedule or toileting program. The CNA further stated that she tried to take the resident to the bathroom around the schedule of when she, the CNA, thought the resident would need to go, early in the morning and before and after lunch.

The CNA stated that she was too busy to take the resident to the bathroom that day.

The unit LPN (Licensed Practical Nurse) charge nurse was interviewed at 1:00PM on 2/21/12. The LPN stated that the resident was toileted according to a scheduled toileting program every two hours and that incontinence care is provided at that time.

2. The resident's most current 11/19/11 MDS indicated that she was totally dependent on another person for personal hygiene.

The resident was observed at 3:30PM on 2/17/12 with soiled finger nails on both hands, particularly the left hand. The evening shift CNA was interviewed at that time and stated that the day shift showered the resident and cleaned the resident's nails.

The resident was observed sitting in her wheelchair in the unit dining room during breakfast at 8:30AM on 2/21/12. At that time, her fingernails were not clean, with brown soil under the nails, particularly of her left hand.

The day shift CNA assigned to the resident was interviewed at 11:45AM on 2/21/12. The CNA stated that the resident's fingernail care was provided by the overnight shift when they shower or bathe her.

The unit LPN charge nurse was interviewed at 1:00PM on 2/21/12. The LPN stated that the resident's fingernail care was provided on the overnight shift with showers or as needed.

The resident's current CNA Kardex included instructions for the resident to get showers on the evening shift and for her to get nail care on shower days.

The resident's name was included in the list of residents on the "Overnight Shower List" located in the CNA ADL Book (CNA Care Guide binder). The resident's name was not included on the list for "Nail Care as Needed" in the CNA ADL Book.

CNA documentation of resident care was reviewed from 2/1/12 - 2/20/12 and indicated that no showers were documented as given to the resident on the day shift, that she received a shower on the evening shift one time on 2/1/12 and that she received showers on the night shift 4 times durning that 20 day period on 2/3/12, 2/6/12, 2/16/12 and 2/20/12. There was a period of 10 days, from 2/6/12 - 2/16/12, that indicated that the resident received no showers during that period of time.

415.11(c)(3)(ii)

Based on observation, interview and record review, the nurse staffing information posted by the facility on a daily basis, to be available to residents and the public for review, did not include all of the required elements. This resulted in the potential for no more than minimal harm that was not immediate jeopardy.

The findings are:

The nurse staffing information posted by the facility on a daily basis, to be available to residents and the public for review, was observed on four days of the recertification survey. The posting identified the total number of licensed nursing staff on duty and did not differentiate between RN (Registered Nurse) and LPN (Licensed Practical Nurse) staff members, as required. Additionally, the total number of hours worked by RNs, LPNs and CNAs (Certified Nurse Aides) on duty was not posted for each of those categories of staff members.

The morning receptionist, who posts the nurse staffing information daily, was interviewed at 3:00PM on 2/21/12. The receptionist stated that she posts the staffing information daily using a standard format that was provided to her. She stated that she combines RN and LPN staffing in the licensed nurse category. The receptionist stated that she was not aware of the requirement to differentiate RNs from LPNs. She also stated that she was not aware that the hours worked by each category of staff were required to be posted.

The DNS was interviewed at 3:05PM on 2/21/12. The DNS stated that she was aware that RN and LPN staff members needed to be differentiated in the posting but that she was not aware that the hours worked by each category of staff needed to be posted.

2000 Life Safety Code section 19.3.2.6 requires that cooking facilities be protected in accordance with 9.2.3. Section 9.2.3 requires that commercial cooking equipment be in accordance with the requirements of NFPA 96, \i Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations . Section 8-3.1 states that: Hoods, grease, removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge.

This Requirement is not met as evidenced by:

Based on observation and interview, the facility did not insure that the hood ducts in the kitchen were properly maintained in accordance with NFPA 96 and cleaned at intervals frequent enough to prevent the build up of grease and dust in that an accumulation of grease and dust was noted on the surfaces of the hood duct located over the fryer and adjacent areas.

This resulted in no actual harm with the potential for minimal harm.

The findings are:

During life safety rounds of the kitchen conducted at 11:15 AM on 2/17/12, an accumulation of grease and dust was noted on the surfaces of the hood ducts located directly above the fryer as well as on surfaces adjacent to the fryer. In an interview at that time, the Dietary Supervisor stated that there had been heavy frying done the previous day, when fried chicken had been prepared and served. He also stated that the ducts are cleaned in house once per month. In a separate interview at approximately 11:25 AM the same day, the Food Service Director stated that the ducts had been pressure washed by an outside company in September 2011, and were due to be cleaned later this month.

10NYCRR 711.2(a)(1)
2000 NFPA 101 - 19.3.2.6; 9.2.3
1998 NFPA 96 - 8-3.1